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materials, but although they were in manyinstances hnng as soon as possible afterdeath,and the legs pulled with some force,no lesion of the arteries could be discovered.We do find, however, that the respiratory

passage occasionally presents varieties verymaterially influencing the effects of ligatureson the respiration. Unusual ossification ofthe larynx, an example of which is cited inthe instance of a woman who, having beenconvicted of harbouring thieves, was hung,and remained alive from nine until the nextmorning, and who, in consequence, had afree pardon ; and another in that of a Swiss,who had undergone the process of hangingthirteen times, and still lived. In the man’scase it w as ascertained by examination afterhis death that the windpipe had turned tobone;" and in the woman’s it was inferredthat life was saved by a similar state ofparts.

Pressure on the nerves I have not includedwith the causes producing sudden death,for although it may in many instances ofstrangulation contribute to the cessation ofrespiration, its effect is slow.

Sir Benjamin Brodie passed a ligaturennder the trachea of a guinea-pig, and tiedit tight on the back of the neck with a knot;the animal was uneasy, but, nevertheless,breathed and moved about; at the end offifteen minutes the ligature was removed ;on the following morning, however, the ani-mal was found dead. On dissection no pre-ternatural appearances were discovered inthe brain, but the lungs were dark and tur-gid with blood, and presented an appearancesimilar to that which is observed after thedivision of the nerves of the eighth pair.In relation to this experiment it may be

said, in the first place, that the author ofthe experiment did not positively concludethat the animal died from injury inflicted onthe nerves of the eighth pair ; and in thenext place, that even if it had died of suchinjury it would not have warranted the enu-meration of pressure on those nerves amongstthe causes of -vidden death.The circumstances intiuencinr the sud-

denness or slowness of death, independentlyof constriction from the cord, are, injuriesinflicted on other parts of the neck closelyconnected with the functions of vitality, asluxation or fracture of the cervical verte-

bræ, or rupture of the cervical ligaments.The existence of either of these injuriesmight certainly be regarded as evidencefavourable to the supposition that death hadbeen sudden, although their absence wouldnot prove, or even imply, that death hadbeen slow.

If, then, we have a case in which themark about the neck is faint, and resemblinga pseudo-morbid depression or discoloura-tion, we shall necessarily be led to inquirewhether there are indications of suddendeath to account for the faintness of the im-

pressions where the ligature has beenapplied.The immediate cause of death by hanging

has been ascribed by different physiologiststo different caoses, but these and other con-siderations connected with the snbject, ourtime does not permit ns to dwell upon atpresent.

CLINICAL REMARKS

ON A

CASE OF HÆMOPTYSIS WITHINCIPIENT TUBERCLES;

BY A. T. THOMSON, M.D.DELIVERED AT UNIVERSITY COLLEGE HOSPITAL.

JOHN MOULDINQ, a labourer, aged 39, wasadmitted into the hospital on the 16th ofJuly. He was of a sallow complexion andbilious temperament, had led a regular life,and lived in a healthy neighbourhood. Hisfather died of consumption; his mother isliving, and healthy. He stated that he hadnever suffered from any previous disease, astatement to which Dr. Thomson directedthe attention of the students, as demonstrat-ing how extremely difficult it was to pro-eure from patients an accurate history oftheir previous life. The students, he (Dr.Thomson) said, " would be convinced fromthe details of the autopsy, that he must haveat one time suffered a severe attack of pleu.risy." He said that about five weeksbefore his admission he began to be troubledwith a cough, tightness across the chest,difticulty of breathing, pain in the sides, andwith occasional spitting of blood, accompa.nied with extreme debility on the slightestexertion. Little was done to relieve thesesymptoms, which continued to increase inseverity until the Wednesday before hisadmission, when he suddenly brought up,by vomiting, he said, a large quantity ofblood, according to his own statement fullythree quarts. The haemorrhage soon lessen-ed greatly in quantity, but the sputa conti-nued tinged with blood, which was the casewhen he entered the hospital.The symptoms on his admission were

great emaciation and prostration of strength;a hot but moist skin, except on the palms ofthe hands, which were dry. He lay on hisback, which he said be was forced to do,owing to the pains which always superven-ed when he lay long upon either side, espe-

cially the left. He had headacb, which,however, was not constant ; his sleep was

! imperfect and unrefreshing and towardsmorning he was much disturbed by the

cough, which recurred with considerableviolence at that time; and he expectorated

rusty, serous sputa, mixed with streaks offlorid blood, and opaque clots. The breath-i ing was short and hurried; the pulse quick,

104, full and jerking ; the tongue was

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covered along the middle of its entire tettgthwith a dry, fenowish crust, and the edgeswere red, and also dry. The bowels were

constipated, and the arine was copious andhigh-coloured.As Dr. Thomson did not see him until the

day after his admission, his bowels hadbeen freely opened before his visit. On questioning him respecting the haemoptysis,it was difficult to determine satisfactorilyfrom his statement, whether it had proceed-ed from the stomach or the lungs; but ashe stated that it had appeared immediatelyafter coughing, was accompanied with asensation of suffocation, and was ejectedwith great violence, the Doctor had no hesi. itation in deciding that the hæmorrhage was pulmonary. Besides the influence, he ob-aerved, of heemorrhage from the lungs tocause sickness, we might suspect that owingto the large quantity of the blood, a portionof it might have passed into the stomach,and been thence rejected by vomiting, a cir-cumstance which led the patient to supposethat it came from the stomach. On percus-sion the resonance was clear on the rightside, but dull on the left.On the 11th the patient was bled to the

extent of sixteen ounces, and ordered to take,every fourth hour, a pill, containing threegrains of acetate of lead, and to wash itdown with a draught, consisting of onedrachm of distilled vinegar and one ounceof water.The spitting of blood had disappeared on

the 19th, but he complained of griping, andthe tongue was still harsh and dry, althoughthe pulse was much freer.-He was directedto omit the use of the acetate of lead, and totake in its stead a grain of calomel, in theform of pill, every six hours, and in the in-tervals the following draught :-

Infusion of cusparia, an ounce and ahalf;

Dilute sulphurit acid, fifteen minims.Neither of these medicines were taken, for800n after the visit of the physician deliriumsupervened, and soon rose to such a heightof fury that the patient required restraint.He became at the same time greatly ex-hausted ; the breathing more embarrassedand shorter than before; the speech inco-herent, with difficulty of deglntition, andpicking of the bed-clothes and convulsions.At noon on the following day he expired.The bod) was opened twenty-four hours

after death. Signs of decomposition werealready apparent, bnt the rigidity still ex-isted. On opening the chest extensive oldadhesions were observed on both sides, but

’ more particularly on the right side, towardswhich the heart was pushed over. Thefalse membrane which formed the coheringmedium between the serous surface, dis-played a granular aspect, which evidentlydepended on the deposition of tubercles.The pericardium contained much serous

fluid; the sabstance of the heart was softand pale; the valves on the left side con-siderably thickened, but not those of theright; and the coronary vessels were con-gested.The lungs, on both sides, were greatly

congested, of a deep red colour throughout,heavy, and much indurated in the centrelobes; the left luog weighed two poundsten ounces; there was ioterlobular emphy-sema on the margin of the superior lobeposteriorly, and evident traces of pneumoniain the lower lobe. The apex of the superiorlobe on the right side was firmly adherent,and there wu also a small cavity in itsanterior portion. This lung weighed threepounds six ounces; both lungs were full ofmiliary tubercles, which were congregatedin masses at the roots of the lungs, andwhere the indurations were considerable.The stomach was congested in the cardiacportion, slightly softened and thin, but natu-ral in every other part. The liver washealthy ; the spleen large and soft. Thiswas evidently a case of bronchial hæmor-rhage, depending in a great degree on mecha-nical obstruction to the circulation, from themasses of granular tubercles at the roots ofthe lungs; but they were in no place ad.vanced to a state of softening ; for even thecavity in the anterior portion of the rightupper lung was not of an ulcerated charac-ters. The extent of the tubercles was gene-ral throughout the lungs.

In this case there was an hereditary trans-mission of the tubercular diathesis, thefather of the patient having died of phthisis;and, although the mother was still alive andhealthy, yet it was sufficient that one of theparents was affected, for the transmission ofthe predisposition to the offspring. It wasextremely difficult to say how long the tuber-cles had existed. or whether tbey existed atall before the patient began to cough. Itwas probable, although we were not told 80in the history of the case, that he had caughtcold, and inflammation being set up, in ahabit predisposed to phthisis, the tubercu-lous matter was deposited, and the irritativeprocess set up, that led to haemoptysis.As was most common, although the granu-

lar tubercles w ere seen throughout the wholeof the lungs, yet they appeared in greatestquantity, and in aggregated masses, in thesuperior and posterior portion of the upperlobes on both sides.

Notwithstanding the statement of the pa.tient that he never had any previous dis-

ease, the existence of old adhesions demon-strated that there had been pleurisy at someformer period ; and it confirmed an opinionwhich he, Dr. Thomson, bad long held, thateven severe attacks of pleunsy seldomfavoured the deposition of tuberculonsmatter in the substance of the lungs. Thefebrile symptoms, the cough, the tightnessacross the chest, with dyepnoea, the rusty

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serous sputa, streaked with blood, the stateof the tongue, the high coloured urine, allindicated the existence of pneumonic inflam-mation at the time of his admission into thehospital.The pain which existed and obliged the

patient to lie on his back, being greatlyaugmented when he lay on either side,especially the left, was independent of ex-tension of inflammation to the pleura, not-withstanding the assertion of Andral, in his" Clinique Medicale," that pain was alwaysindicative of such an extension ; in severalcases the lecturer had not observed the leasttrace of recent inflammation in the pleura,although pain, similar to that in the caseunder consideration, was present. He wasparticular in pointing out this fact, as thejustly high authority of Andral might in-duce many to adopt his opinion, which,however, as a general rule, was evidentlynot correct. It was the inflammatory condi-tion of the lungs, probably, which favouredthe deposition of the tuberculous matter,which, although the predisposition existed,was not previously present. The situationof the largest deposit of tubercles near theroots of the lungs, causing the induration ofthe middle lobes, and compressing the trunksof the pulmonary veins, se as to obstruct thefree return of the blood to the heart, readilyexplained the congestion of the organ, and

the haemoptysis which occurred a weekbefore his admission into the hospital.

Notwithstanding the amount of the bloodlost on that occasion, no lesion was found,nor was it necessary, the exhalation fromthe mucous membrane of the bronchi andthe air-cells, being fully adequate to its pro-duction, even if the quantity were as greatas the patient had stated, which, however,was probably exaggerated, would lead usto believe. If, as the lecturer believed, thetubercles preceded the haemoptysis, thesuddenness of the discharge might havebeen owing to the increased effort of theright ventricle to overcome the obstruction,augmenting the quantity of the blood thrownupon the obstructed portion of the lungs, toan extent sufficient to effuse it upon themucous membrane of the bronchi and theair-cells.From the appearance of the lungs, and

the partial induration of the middle lobe,he anticipated pulmonary apoplexy, in thestrict meaning of that term ; that was, bloodextravasated into the broken-down tissueof the lungs, and deposited in masses similarto those which occurred in cerebral apo-plexy. Nothing of the kind, however, wasobserved ; there were no partial depositions,but a general congestion of the bronchialcapillaries of the greater part of the lungs ;and blood exuded on the lining membraneof the bronchi, which, when wiped off, leftthe surface pale. The large quantity ofblood ejected when the haemoptysis occur-

red, must have relieved the general conges.tion for a time ; and as little or no beemor-rhage subsequently happened, the sputabeing merely tinged with blood, whilst thecause of the vascular engorgement stilll’e.mained, the blood again accumulated, andhad the patient lived, a second haemorrhagewould, most probably, have been the result.Pneumonia was not a necessary accompa-niment of this condition of the lungs; butin the case under consideration, its presencecould not have been easily demonstrated,in consequence of the bloody serum, fullof air-bubbles, which Rowed out on cut.ting into the congested lung, whilst thecut surface was of a dark chocolate red-

colour ; and in the lower lobes, where thelungs where still crepitous, the serum wasmost abundant and very frothy. In themiddle lobe hepatisation was the cause ofthe induration; the lung was solid andinelastic to the touch, and no longer crepi.tous ; but this condition might have result-ed, independent of inflammation, from thecongestion which was the result of the ob.struction to the pulmonary circulation whichtubercles might produce. It was chiefly in, the lower lobes that the traces of the pneu-monic inflammation were most evident inits early stage ; but the central part of the

lungs was decidedly that most diseased,both in reference to the tubercular depositsand the inflammation in its advanced stage.It was the capillary vessels of the pulmo-nary veins which were the seat of the in-flammatory action; but from the very gene-ral congestive condition of the lungs theinflammation probably extended to the ter-mination of the bronchial arteries, wherethey were supposed to anastomose with thepulmonary.The delirium which supervened, with the

general depression of the bodily powers,was not very uncommon in pneumonic in-flammation, and was always a very hazard-ous symptom. When it became furious, asin the present case, it very rapidly exhaustedthe patient and brought on a fatal collapse.Indeed the general typhoid characters whichso rapidly displayed themselves on the 15th,were natural consequences of the impededcirculation preventing the due change of theblood from taking place in the lungs.The miliary tubercles, in the case under

consideration, whilst they might be regardedas subsequent to the inflammation set up inthe lungs, were, nevertheless, the cause ofthe hæmoptysis,—a state of things whichinfluenced, or should modify greatly, thetreatment of such cases where it was sus-

pected, or could be proved to be present. It ’

neither required, nor did it admit of the de.pletion which was demanded in true pulmo-nary apoplexy, and when haemoptysis occur-red in persons not predisposed to phthisis,nor labouring under it at the time. Theexistence of tubercles was the most striking

681

feature of the case under review, and theimportance of determining this fact couldnot be doubted; but, when tubercles wereassociated with pneumonia the physicalsigns were obscure, so that little assistanceto our diagnosis could be obtained, eitherby percussion or auscultation, and we wereobliged to rest our opinion chiefly upon thehistory of the case, and the local and con-stitutional symptoms. Although the symp-toms of pneumonia, of a subacute kind,were obvious, the hereditary tuberculartaint which existed led him to fear that iftubercles were already present, which hestrongly suspected, much depletion and theemployment of the lancet to an extent au-thorised by simple pulmonary congestion,should be avoided; and it was on thisaccount that one venesection only was order-ed, and that he trusted more to the acetate Iof lead for checking the haemoptysis thanhe should have done had no suspicion oftubercles existed in his mind. After thebleeding the spitting of blood ceased, andthe pulse became more free ; under such cir-cumstances its repetition was uncalled for,and consequently it was not ordered.

Still, however, as the congestive state ofthe lungs remained, and the depressed con-dition of the vital powers, conjoined withthe state of the tongue, which had much ofthe character of that of typhus, he was dis-posed to try the influence of calomel, chieflyas affording the best means of resolving thecongestion by its influence on the loaded

capillaries; at the same time he was anxiousto support the strength. The rapid mannerin which the furious delirium supervened,prevented the medicines ordered with thisintention from being administered.He considered the case instructive chiefly

from the addition which it afforded to the

proofs of bronchial haemorrhage being theconsequence, not the cause, of tuberculous

deposits in the lungs, and the powerful in-fluence of predisposition in the formation oftubercles at a period of life beyond that inwhich they usually appeared, when inflam.mation was set up in the lungs from whatevercause. It also pointed out, in a strikingdegree, the manner in which the accumula.tion of miliary tubercles near the roots ofthe lungs caused mechanical obstruction tothe pulmonary circulation, adequate to theformation of congestion, and the consequenthaemorrhage, which might almost be re-

garded as an effort of the constitution torelieve the obstructed condition of the organ.The case also illustrated the rapid manner inwhich the disease might proceed to a fataltermination, even when there was no returnof the haemoptysis.

REMARKABLE CASEOF THE

EFFECTS OF LIGHTNING.BY JOHN DAVIES, ESQ.,

Surgeon to the General Infirmary at Hertford.

ON Wednesday, June 26th, 1839, during aviolent thunder-storm, between eleven andtwelve o’clock in the morning, WilliamAncient, a ploughman, together with his

master, Mr. Cannon, and Mr. Cannon’s son,a boy about eleven years old, were standingunder a large, tall, elm tree, in the parish ofTewin, in this county, about five miles fromHertford ; they had not been there manyminutes when the tree was struck by light-ning, and when the whole three personsalready named were struck down senseless.About two poles off, under another tree,there were three other persons, and fourhorses. The horses were all struck down,but soon got up again, and ran away into themiddle of the field. The men felt a strongshock, but were not struck down. In a fewminutes after, they discovered their master,his son, and Ancient, lying on the groundunder the neighbouring tree. The boy soonrecovered from the shock, but he was agood deal scorched on different parts of thebody.Mr. Cannon spoke to the men who came

up to him, but he has no recollection of any-thing that occurred up to the time of hishaving his wounds dressed, about half anhour after the accident. He was a gooddeal scorched on different parts of the body,and there was a very deep and extensivelaceration of the right heel and sole of thefoot; but as he did not come under my care,it is not necessary to follow out his case.William Ancient, the ploughman, was

standing with his back against the trunk ofthe tree when he was struck; his masterand the boy being about a yard or so infront of him. When discovered he waslying insensible in the hedge, under thetree. I understand that he could not moveany of his limbs, and that his skin was of apurple colour. The medical man who sawhim ordered spirits of turpentine to be ap-plied to the scorched parts; which was theonly medical treatment he received untilbrought into the infirmary.On Friday, June 28, in the afternoon, Wil-

liam Ancient was brought into the GeneralInfirmary, at Hertford. A degree of reactionhad then taken place; there was a slightflush in the face; he was quite delirious,and his talk was perfectly incoherent. AsI was from home, Mr. Towers, the medicalresident, applied tincture of iodine to theparts that were most scorched and lacerated,and administered five grains of calomel,followed by a simple saline mixture. Thecalomel was repeated early next morning.