Dec.21rI*]TZgAIX.DJCd.&W.,thiesystematrg*i?Howcanyoukawwho'thehangesar - PDF document

Dec.21rI*]TZgAIX.DJCd.&W.,thiesystematrg
Dec.21rI*]TZgAIX.DJCd.&W.,thiesystematrg*i?Howcanyoukawwho'thehangesaretoWetreated,how)mosbdproductsareto.beremovd,howzinuredorgansaretoberepaired,howdamage-tthe-fissuesolossoflifeistobeprevented,unlessyouknow,and,kowthoroughly,*batthenoxmalprocessesarethatgooninthehumanbody?Youmatfirstunder-standthenaturalprocess,beforehopingtocomprehendthechangesproducedbydisease.Ourknowledgeof,bothhasoflateyearsgrgalyincreased,owingnotonlytomoreaccurateobservationbothinheaLthandsickness,butfromwhat,wehaveobservedofthefunctionsofthevariousorgansofthebody,fromthevariationsordiseasesproduq¢dbyexperiments.Now,however,"inresponsetoperhapsawUll-meaning-butcertainlyfoolish,portionofthecommunity,ledastraybyignorant.4f-iateresteditinerantlecturers",*alawhasbeenpassedwhichmakesfitpenaltoinflictpainonanimalsiftheintentionbetobenefitman-kind;whereasexquisitetorturemaysafelyheinflictedeithertogratifythepalateoftheepicure,toamusethewealthy,orrender-enjoymenttothemob.Wemust,therefore,themoreearnestlyan4carefullyinves-tgatethegrandexperimentswhichNatureherselfperforms,andseeifwecannotlearnsomethingfromthem.IcannotdobetterherethanquotethewordsofDr.BarnesinhisaddresstotheBritishMedicalAssociationatManchesterin1877,thereportofwhich,andhispaperontheRelationsofPregnancytoGeneralPathologyinthefirstvOlumeofthe,TransactionsojtheAmericanGynmrcologicalSociety,willamplyrepayyouforthetimespentintheirperusal."Alldiseaseisthe.reactionofthelivingeconomyundertheinfluenceofconditionsaccidentallyapplied.Theseaccidentalconditionsareinrealityexperiments.Pregnancytakingplaceinahealthywomanmayberegardedasanexperimientperformedunderthemostsimpleconditions,fromwhichthecomplicationswhichdisturbandthwartobservationsinmanareeliminated.Howisthis?Iwilltrytoconveytoyou,inasfewwordsaspos-siblq,theideasworkedoutbyhim.Inthehealthyfemalq,intheun.impregnatedcondition,,thefunctionsoflifeareequallybalanced;toeachpartthenerve-forceandblood-supplynecessarytocarryonitsfunctionsaresupplied,andnomore;but,whenimpregnationtakesplace,allthisbecomeschanged.Thenerve-forceisaltered.Thecerebral,ganglionic,andspinalsystemsdevelopenewforce.Theemotionalsystemofthefemale,atalltimesgreaterthanthatofrnan,nowbecomesmoresensitive.Sheisnowmoreresponsivetopsychicalandphysicalimpressions.Theuterusanditscontentsgrow;forbothrequiremoreblood,andmorenutritivematerialintheblood,andhenceincreasedblood.flowandalteredqualityand-consistency.;tosupplythisincreasedflow,augmentedhydraulicpowerisrequisite,andwe,findcardiachypertrophyandincreasedvasculartension;-increasedgrowthandactivitypredicateincreased,waste,and,therefore,increased-eimination.Theglandularsystemis,therefore,affected;themostnotableiglandulargrowthisthatofthebreasts;but,althoughthechangesinthemareobvioustoall,theotherglandsarelikewisedis-tuirbed.Thusnotonlyisthewombaltered,buttheentiresystemsympathises,asit-were,withit.Ifthebodybehealthy,iftherebenoweakspotinit,thesechangesfinallyculminateinthatexplosionofnerve-forceandmusculareffortwhichwedesignatelabour.But,afterthisculmination,weseeanolesswoncerfulphysiologicalfunctionper-formed,bywhichtheenormouslyincreaseduterusisremoved,andoutofitsdZbrisanewoneformedbytheprocesswecallinvolution.Now,althoughinthenormalconditionthesechangesfollowaregularcourse,yet,iftherebesomelesionwhich,underordinaryconditions,maynotbesufficienttoaffectthenormalfunctionsofthebody,itmay,andoftendoes,causeabreak-downundertheseverestraintowhichthesystemissubjected,andthuswemayhaveconvulsivemania,failureoftheheart,albuminuria,clotsofbloodintheheartorvessels,esta-blishingthemorbidconditionsknownasembolism,thrombosis,andphlegmasiadolens.Asallthesechangesoccurwithinadefiniteperiod,wecanwatchthisexperimentfromitsinceptiontoitsconclu-sion.Howmuchmaywenotlearnwithregardtothecausationofsimilardiseasesintheunimpregnatedstateandinthemale,andallwithregardtothemorbidconditionproducedinthevariousorgans?Thediseases,ofthefemalegenitalsystemnapartfrompregnany,teachuslessohsofnolessimportance.Theiproductionofepilepsyandothernervousafections;thecacheiafequentlyresultingfromdefectsofmenstruationormorbidovarinaconditionsi;thechangesofstructproduinproducroduebuterinedisplacements-aeallpregnantwithinstrution.TimewouldifalmetItelliotheknowledgetobegaindaboutchorea,jaundice,hepaticdiswdrs,glyeoguzia,Addisonsdisewdi&aderngements,syphilis,and;hereditarnila;or,tocom,-wemefromtheverybegiuning,_.theje1fpedIeIdiontheiconstitutionfithedcildfromdefects-of.iutritiarmodrii-Wfthemothe*SpencerWells,AddressinSurgerY,z877.ButIhaitesAMiwottghltahowiyouwhatavastfildhereliesopenforyourstudy$,andfhowimportantAsthebeaxingofpregnancyEnduterine-Vathologya-dphysiology-ontstudyofmedicineandsuv.gety.;Iave,I:beieve,provedthatobttetricsandgynaecologyarenotasepar£ebranch,nomereignoblespecialty,butanintegral-patofthegreatscienceofmedicine,demndingyourmostearmestatten.tion,andwhchwillamplyrepaythetinieandlabouryoudevotetothem.Andnow.,gentlemen,inconclusion,astheemergenciesofthisbranchofyourproihsi'onarezogxave,theaccidentssosudden,theresultsofignorante.ormalpraxissodisdstrous;as,whateverlineofpracticeyoumayadopt,youmustbelargelyocctipiedwithdiseaseofwomen;asthe.lifeordeathofthemotherandchildmayatanymomentdependlonyourknowledgeandskill;asthe,happinessormiseryoffamilies,andthehalthandusefulnessofmanyawomanwillrestonyou;astheresponsibilitiesaregreat:Ientreatofyoutostudynow,-now,whilstyouhaveampleleisure,-now,whilstyouhavenoresponsibilities,-toprepareyourselvesforthehouroftrial,that,thenitcomes,youmaynotbefouxidwanting.AndItrustthatnoneofyouwilleverfeeltheagony,thedeepremorse,thattimewillhardlyeverefface,ofknowingthatyouhave,caused,byyouridlenessorcarelessness,thedeathofahumanbeing,orthatyouhaverenderedaonce'happyhomedesolateoraparentchildless.Wemaydoourbestandwemayfail;wemaymakemistakes,aye,andfatalonestoo;todosoismerelytoprovethatwearehuman;butwecanhavethesatisfactionofknowingthatithasnotoccurredthroughanydefaultofours;thatwehaveworkedhard,andhaveavailedourselvesofallthemeansofinformationwithinourreach.Butthissourceofconsolationisdeniedtothemanwhohasneg-lectedtomasterhissubject;whohasmerelyacquiredtheminimumamountofinformationtopasshisexamination;andwho,whenfacetofacewithanemergency,isunabletocopewithit.Althoughisa-nocentinthesightofman;althoughperchanceguiltlessintheeyeofthelaw,yethestandsconvictedbyhisownconscience,andonhissoulreststhebloodoftheinnocentandhelpless.Ibeseechyou,then,toleavenocauseforjsuchafterremorse.RememberalsothatIcannotmkeyoulearn;Icanonlysho*youtheway;youmustwalkinityourselves.Inonecourseoflea-tures,Ioouldnottellyouatitheofwhatyoushouldleam;youmustreadthework-softhegreatmasterswhohavedepartedandofthosewhoremainwithus;and,aboveall,whenyouhave.theopportunity,youmusttesttheinformationyouthus.gainbythebedside.Thus,andthuralone,willyoubeable,whenyougoforthintotheworld,towintheconfidenceandrespectofthepublic,andtofeelthat,whateverbetheresultofyourlabours,youhave,asirasinyoulies,doneyovkduty,andyouwillrespectyoursel-vesandfearnoman.CASEOFCIRRHOSIS-INABOYAGEDELEVENYEARS':JAUNDICEOFNEARLYTHREEYEARS'DIJRATION.ByARTHURW.FOX,M.B.,PresidentoftheBathPathologicalSociety;PhysiciantotheEasternDispensaryandBellott's(MineralWater)Hospital,Bath.ONJanuary2nd,1878,J.D.,agedii,wasadmittedasapatientundermycareattheEasternDispensary.Hecomplainedofnopain,butsoughtadviceonaccountofhisbeingjaundiced.Whenfouryearsold,hehadasevereillness,whichendedinhispassingalargeroundworm.Hisfathernoticedthatafterthishi;stomachwasalwgysunusuallybig.Hehadhadscarletfever,measles,andchicken-pox.Formorethantwoyears,hehadbeenjaundiced,andhadbeenmorethanonceanin-patientattheUnitedHospital.Thejaundicecameongradually.Therewasnohistoryofchillorindul-genceinalcohoLHehadabrotherandtwosisterslivingperfectlyhealthy.Hismotherwasadrinker.;shehad-hadthreemiscarriages,Shepresentednosignsofsyphilis,norcouldanyhistoryofsuchbeelicited.Hisfatherneverhadsyphilis.;b4tfromboyhoodhadsufferedfromdiseasedriglittibia,whichhadexfoliated;otherwisehewas.he4lthy..His.gneralappearancewasthatofaboyofgreatintelligence.Heboreanexcellentcharacter.Hishairwpsdark;hisiridesbrowzTheconjunctivaeandbodywere,deeplyjaundiced;theskinunusuallyhairy.Therewassomeemaiation.HehadclubbingofthefingoX.en4s;anecch}ymosi$ontheleftlg,,andtwopetechialspotsonth4e,jwtribrsurfce.ofthechest.Therewassomeenlargementofthebandsin,theinguinalregionsandleftaxilla,andasmallsubcutaneous914THEBRITISAMEDICAL7OURKAL.[(c.21,1z878pa-likebodyontheextensorsurfaceoftheleftforearm.Theteethdatendencytoaserratedconditionofthelowerborderofthetwoupperincisors;thegumswereinclinedtobleed;thetongueclean.Hisappetitewasfair

;hewasthirsty,Hisbowelswereopenfourorfiv
;hewasthirsty,Hisbowelswereopenfourorfivetimesaday.Thestoolsweresometimesformed,atotherswerepulta-ceous;alwaysofalightyellowcolour.Thishadbeenthecase,hismothersaid,fortwelvemonths.Hehadfrequentlyvomitedblood.Hisabdomengenerallywasdistended,withmarkedprominenceoftheupperpart.Theliver-dulnessintherightmammarylinebeganatthesixthrib;intherightaxillaryline,attheeighthrib;intheverti-calnipple-line,itextendedthreegoodfingers'breadthbelowthecostalmargin.Thesurfacewassmoothandhard;themarginslightlyrounded.Therewasnotendernessonpalpation.Therewasadis-tinctsulcusbetweentheliverandalargetumourwhichoccupiedtheleftsideoftheabdomen.Thistumourdescendedfrombelowtheleftcostalmargindownwardsandforwards,crossingthemiddlelinejustbelowtheumbilicus.Thelowerborderreachedapointnearlyaninchbelowalinedrawnhorizontallythroughthesuperiorspinousprocessesoftheilium.Theanterioredgewassharpandnotched;theleftborderslightlyrounded;thesurfacesmooth.Itwasabsolutelydulluponpercussion,anddescendednearlyaninchandahalfwithafullinspiration.Therewasnoevidenceoffluidinhisperitonealcavity,neitherwasthereanyvisibleenlargementoftheveinsofhisabdo-minalwall.Hiscirculatoryandrespiratorysystemswerenormal.Hisurinewasamber-coloured.Gmelin'stestshowedthepresenceofbile-pigment,butnottoanyamount.Therewasnoalbumennorsugar.Fromthistimetothedateofhisdeath,onMay7th,hegotgraduallyworse.Hisabdominalveinsbecameenlarged,andfluidwaspouredoutittohisperitonealcavity,hislegssubsequentlybecominganasarcous.Theascitesvariedinamountfromtimetotime,butneverwassuffi-cientlygreatastoembarrasshisbreathing.Towardsthecloseofhislife,heoccasionallycomplainedofabdo-minalpain,butitwasneversevere.Hisjaundicewaspersistentthroughout.Hisurineremainedmuchthesameaswhenfirstseen,specificgravityranginigbetweenI007andioio,ofadeepyellowcolour;bile-pigmentwasalwayspresent,butnevertoanygreatex-tent;neveraiiyalbumen.Ononeoccasion,Ifoundafewgranularcasts.Hismiddaytemperaturevariedbetween99deg.Fahr.andIOOdeg.Fahr.;generally994deg.Fahr.;onceitreachediooldeg.Fahr.Heneverhadanyperspirationsnorrigors.Hispulserangedbetween8oandI2o,buttendedmorefrequentlytothelatternumbertowardstheendofhislife.Ecchymosesandpetechialspotswereoccasionallyvisibleonhisskin;thesmallpea-likebodyuponhisleftforearmcom-pletelydisappeared.Hehadrepeatedattacksofhematemesis.Duringthelasttwoorthreedaysofhislife,hevomitedlargequantitiesof-blood.Forthelastnineweeks,therewasasystolicmurmnuraudiblealloverhiscardiacregion,itspointofmaximumintensitybeingsituatedatthepulmonaryorifice.Duringthelastthreeweeks,hislegs,especiallytheleft,wereaffectedbyconstantcoarsetremor.Hediedcomatose.Thenecropsywasmadethirty-sixhoursafterdeath,onMay8th,inmypresence,byDr.Maunsell,thenresidentmedicalofficertothedis-pensary.Thebodywasemaciated.Rigormortiswasabsent.Theperitonealcavitycontainednearlysixpintsoffluid.Theliverwasmuchenlarged;unfortunatelytherewasnopossibilityofweighingtheorgan;itgaveonetheimpressionofanunusuallybigliverthatwasundergoingcontraction,andthecapsulehereandtherethickened;thegeneralsurfaceoftheliverwasfinelygranular.Upontheupperpartoftherightlobe,thatportionwhichwasupunderthecostalmarginduringlife,weresomeroundedeminencesaboutthesizeofasmallpea.Thetissueoftheliverwastoughandleathery.Uponsection,itwasdeeplybile-stained,andpresentedtheusualappearanceofcir-rhosis.Therewasnoamyloidreaction.Thegall-bladdercontainedbile;theductswerepatentandbile-stained.Theportalveinwasnatural.Theglandsintheportalfissureweremuchenlargedanddeeplypigmented.Thespleenwasenormouslyenlarged,gorgedwithblood,andsomewhatfriable.Thekidneyswereratherlarge;thecap-sulesseparatedeasily;thesurfaceofeachwaslobulated;onsection,bile-stained;thestructure,tothenakedeye,wasnormal.Theperi-cardiumwasnatural.Theleftventriclewassomewhatthickened;thecavitiesandvalvesoftheheartwerenormal.Theleftlungwasnormal;therightcontainedasmallspotofcretaceousmatterattheapex.Themediastinalandbronchialglandswereenlarged.Themicroscopicexa-minationoftheliver,spleen,heart,andkidneyswasmadebyMr.E.Lawrence."Specimenswerefirsthardenedinspiritandwater,after-wardsinsolutionofchromicacid.Theliverpresentedanabnormalamountoffibroidovergrowth,especiallyintheinterlobularspaces,withmoreorlessamorphousgranularmatter,somefewcellsonlycontainingoilymatter.Thespleenwascongestedthroughout.TheMalpighiancorpusclesweresomewhatincreasedinsize;thetrabecuaiwererathermorefibrousthanusual.Thehearthadaveryslighttraceoffattyde-generation;themuscularfibreswereinclinedtobreak.Therewasnofatdepositedbetweenthemuscularfibres.Thekidneywascon-gested,otherwisenormal."REMARKS.-Whenthisladfirstcomeundermynotice,Ifeltincon-siderabledoubtastothenatureofhishepaticandsplenicenlargement,therebeinganabsenceofalltheusualfactorsofcirrhosis.Hislarge,painless,andseeminglysmoothliver,whencoupledwithhisunusuallybigdensespleen,ratherinclinedmetoregardhiscaseasoneoflarda-ceousdisease,withenlargedglandsinhisportalfissure;butagainstthisviewwastheapparentintegrityofhiskidneysandotherorgans,andthefactoftherehavingbeennoneoftheusualcauseswhichgiverisetolardaceousdisease;besides,therewasaslightamountofpyrexiapresent,whichisnot,accordingtoDr.Murchison,asymptomoflardaceousdiseaseanymorethanarejaundiceandascites,unlesstherebeenlargedglandsintheportalfissure.TheintensejaundiceintheboywasinfinitelymorepersistentthaninanycaseofcirrhosisthatIhavehithertometwith,andwasprobablydue,1imagine,tothepressurewhichmusthavebeenexercisedduringlifeuponhisbile-ductbytheenlargedglands;notsufficient,however,toentirelyoccludeit,astherewasalwaysacertainamountofpigmentpresentinhismotions;while,ontheotherhand,hisurinenevershowedanygreatamountofthesame.Dr.Fagge,inGuy'sHospitalReports,I875,referstoacaseofcirrhosiswheretherewaspersistentjaundiceforsevenyears,thepa.tientdyingatlastofhsematemesisandheremarksthat,whencir-rhosisisassociatedwithjaundice,"theliverisnotcontracted,asarule,butisincreasedinsize".Thepointofparamountinterestincon-nectionwiththiscaseisitsetiology.Theboywascertainlynotadrunkard,neitherwasthereanyhistoryofcongenitalsyphilis,orofhishavingreceivedachill.Afterhisdeath,Iwasinformedthat,duringthelasttwoorthreemonths,hehada"craving"forbeerandporter,andIrememberhisaskingmeforsomeeightorninedaysbeforehedied.Itappearstomeratherunlikelythataboyofhisageshouldevincesucha"craving"forstimulants,unlesshehadpreviouslyin-dulgedinthem.Hismotherhadbeenachronicdrinkerforyears,and,duringthewholeofthetimethatshewaspregnantwithhim,andtheyearthatshesuckledhim,shedrankmoreorlesstoexcess,fre-quentlybeingintoxicated.Now,Gintracremarks(Dr.Taqueton"Here-dityinAlcoholism",LondonMedicalRecord,Jan.15,I878),thatthechil-drenoffemaledrunkards,iftheysurvivetheirbirth,areoften"idiots,imbeciles,insane,orepileptic",theconsequencesof"congestionorhae-morrhageintothemembraneornervoussubstance".Why,therefore,maynotcirrhosisinchildrenbetosomeextentoneofthemanifestationsofalcoholicheredity?For,asDr.Taquetobserves,"thatalcoholcarriesintothecompositionofthefecundatingmaterialmodificationsofwhichweareignorant,mustbeadmitted".Ibelieve,however,withDr.WickhamLegg(St.Bartholomew'sHospitalRepors,I877:CasesbearingonLiver-Disease),thatcirrhosismayoccurindependentlyofalcohol,andmaybemerelythelocalexpressionofsomegravegeneraldisease.Apartfromsomeoftherecordedcases,suchasthelateDr.Hillier's,Dr.Hayden's,andthecaseofachildagedthreeyears,mentionedinDr.Payne'seditionofDrs.JonesandSieveking'sPathologicalAnatomy,wheretherehasbeennohistoryofalcohol,howcanweotherwiseaccountforthisconditionoccurringinanimals?forDr.Walshestates(DiseasesoftheLungs,fourthedition,Art.Cir-rhosis)that"theliverofthecowexhibitsasperfectspecimensofcir-rhosisasareeverseeninthehumanviscus".ONSPINALEPILEPSY.ByALEXANDERM.McALDOWIE,M.B.,HousePhysiciantotheNorthStaffordshireInfirmary.THEterm"spinalepilepsy",appliedbyBrown-Sequardtoparoxysmalconvulsionslimitedtothelowerextremities,withpersistenceofcon-sciousnessandsensibility,hasbeenobjectedtobythoseauthoritieswhoregardepilepsysolelyasanidiopathicaffection,andwhoexcludeallcon-vulsionsresultingfromlesionofthecerebro-spinalcentres,allexcentricconvulsions,and,inshort,allconvulsionsoccurringwhenanydefiniteexcitingcausecanbeshowntoexist.Bytheseauthorities,epilepsyisclassedamongst-thepurelyfunctionaldiseases,alongwithhysteria,neuralgia,andsomeothernervousaffectionsinwhichnolesionshaveasyetbeendetected;and,withthem,includedunderthegenerictermneuroses.Inthisrestrictedsense,epilepsycouldnotcorrectlybeap-pliedtotheconvulsionsdescribedbelow.Butwiththislimitedmeaningattachedtoit,thewordbecomesmerelyanexpressionofourignoranceofthenatureoftheaffection;forwemayfairlyassumethatsome