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present day, considered as furnishing anything like satisfactoryevidence of the existence of a poison. Time was, indeed,when they were regarded as almost infallible; but that dayhas passed by, and every authority will now agree, that how-ever exquisitely developed, they can never justify an opinionin favour of more than high probability." Let it not for amoment be supposed that I wish to undervalue such evidence;there are many cases in which it may be fairly stated to bepreeminently important; there are some of the irritantpoisons, for example, whose effects are so abrupt in their com-mencement, so violent in their action, so rapid in their course,and so fatal, that the symptoms alone generate probability ofthe very highest kind, and provoke the strongest suspicion.But assuredly, ptyalism cannot be placed in this catalogue,exhibiting itself, as it does, in the course of many maladies,and being itself undoubtedly an idiopathic disease; nay more,presenting itself constantly, in its most violent form, in thevery disease under which it was affirmed this child hadlaboured-scarlet fever.
Still less to be relied upon than the symptoms duringlife, are the morbid appearances presented on examinationninety hours after death. Inflammation, ulceration, the
presence of pus, the destruction of the tissues, though pro-duced by mercury and many other poisons, are they not
equally the effects of natural disease ? The truth is, morbidappearances can seldom be much relied upon, and never when
they show the presence of disease that might be generatedspontaneously, or may be produced by medicinal agents. But
perhaps I am urging these points too strongly, and it maytherefore appear unfairly, as the medical witness particularlysaid, " I rest my opinion upon the mercurial foetor of the saliva-tion, which could not be mistaken." Now this I consider amost important question, deserving every careful considera-tion, and, indeed, the principal question I wish to bring for-ward in this paper.
Inquiries, as is well known, have taken place beforecoroners, in cases where death has been produced by, or sup-posed to have been the result of, salivation from mercury ad-ministered to children, and the inquiry is just as likely to takeplace wnen tne attendance nas oeen given oy tne aU1y quan-fied, as by the unqualified practitioner. Upon what authority,then, let me ask, is it stated that the faetor of mercurial saliva-tion is distinctive, and cannot be mistaken. I trust I shall notbe considered as speaking disparagingly of my medicalbrethren, when I venture on the assertion, that the experienceof no man, in private practice, however extensive that may be,is sufficient to decide this question in the affirmative, unlessthe opinion tally with the voice of authority, or the receivedexperience of the profession. For my own part, I am notashamed to avow that I have often been unable to dis-tinguish the foetor of the salivation which accompaniessevere sore throat, from the foetor of mercurial ptyalism,and I should be very backward, indeed, to decide positively,from the smell alone, between the ptyalism of mercuryand the ptyalism of malignant disease. Is this matter,let me ask, a thing already settled by experience andobservation ? for in pathology, facts, and facts only, formthe basis and superstructure of our knowledge. If it besettled, my paper, perhaps, is superfluous, and the evidenceof the medical witness beyond my criticism; if it be not settled,I think I cannot be in error in supposing it to be deserving ofdiscussion. We are so familiar with salivation from mercuryand its unpleasantfcetor,that,finding the symptoms present,themind readily makes the inference that the drug has been ad-ministered ; but let us not, under such circumstances, mistakestrong probability for infallible proof. Why should the fcetorof mercurial ptyalism be supposed to differ from that knownoccasionally to be produced by the preparations of copper,gold, arsenic, bismuth, and other agents ? and why should itbe expected to differ from the foetor of salivation, as it accom-panies natural diseases Assuredly, it is not the mineral thatsmells; for mercury, in its simple and compound forms, isalmost without odour. No; the foetor belongs to the abnormalstate itself; it is not an axiom in our science that a diseasevaries with its exciting cause. Quite the contrary. Whatavails it whether a subtle poison, floating in the atmosphere,placed upon the tongue, or introduced into the stomach, pro-duce the specific change ? Of what consequence is it whetherinoculation, contagion, or any other cause, provoke the malady ’IThe disease is still the same, varied or modified, not with re-ference to the peculiarity of its exciting cause, but with re-ference to the peculiarities of the constitution it chances tcinvade. Reasoning, then, upon the subject, appears to me tclead to an inference opposed to the medical evidence on thepresent occasion. Analogy, if I may be allowed to use it,
does not support the proposition; and facts, as far as I canmeasure them, do not prove it.
My communication is already so long that I feel ashamedof intruding further on your valuable space; but allow meone line more, to ask, if it be not well known that gangrene ofthe mouth occurs to children in the course of fever, small-pox, &c. ; and if it be not also admitted that it is most diffi-cult, if not impossible, to distinguish the disease from thatproduced by over-doses of mercury; and is it not on record,that medical men have, under such circumstances, beencharged with causing death by mercury, when, on inquiry,proof positive has been furnished that not a grain had beenadministered ?
Percy-street, Bedford-square, June, 1846.
On Diseases of the Liver. By GEORGE BUDD, M.D., F.R.S.,Professor of Medicine in King’s College. London: Churchill.1845. 8vo, pp. 401.
Remarks on the Dysentery and Hepatitis of India. By E. A.PARKES, M.B., late Assistant-surgeon H.M. 84th Regiment.London: Longmans and Co. 8vo, pp. 271.
UNAVOIDABLE circumstances have prevented an earlier noticeof the first of these volumes. We do not regret the delay,as it affords an opportunity of reviewing some of the mostimportant statements which the work contains, in connexionwith the results of inquiries on similar subjects, by the authorof the second of the above-named volumes. Diseases of theliver-" liver complaints"-were, some years ago, more fashion-able than in more recent times-facts to which the verdantstreets of our once fashionable spas bear desponding testimony.The rise and progress of physical diagnosis, in diseases of thechest, have, to a certain extent,withdrawn attention from thoseof the abdomen; whilst our improved pathological knowledgehas made spinal irritation, hysteria, or a deranged gastricmucous membrane, responsible for many errors at one timeattributed to the liver. In a physiological and a pathologicalpoint of view, more has been done by advancing science for thisorgan than for any other in the body. The microscope hastraced its existence downwards in the scale of created beingsfar beyond a point where man’s unaided powers had failed tofind it, and thus, by its universality, established its importance.The structure, too, of this complex organ has, by perseveringgenius, been exposed and simplified ; whilst its secretion-theconstituents of which were at one time pronounced to be sonumerous, that our knowledge of its nature was as obscure asthat of the structure of the organ whence it came-has, bymodern research, been proved to be composed of but somethree or four elements. Of this advanced knowledge, Dr.Budd has availed himself. He has given to the profession awork which will render its members acquainted with nearlyall that has hitherto been done in reference to the structure.,functions, and diseases of this important organ and its ap-pendages. Dr. Parkes’s volume, with its unpretending title, isalso a valuable contribution to this department of scientificmedicine.The first-named author has extended his inquiries to all the
diseases of the liver. Dr. Parkes, availing himself of theopportunities afforded by his appointment as assistant-surgeonto one of her Majesty’s regiments serving in India, has con-
. fined his attention to those diseases which are presented inthat climate. The result is a work which, conferring ines-
’ timable advantages on all, whether those who suffer, and those’ whose duty it is to afford relief, must be a source of great’ satisfaction to the honourable director-general of the army, towhom the present volume is dedicated, and to whose dis-
! crimination in selecting a distinguished student for an unso-’ licited appointment, the profession is indebted for this the first) result of his labours. But to proceed to our more immediate. subject.
Dr. Budd commences with an Introduction, which treats of, the general anatomy and physiology of the liver, and he ac-
companies his descriptions with many practical remarks on the which such a condition requires; but whenever from any causepathology and treatment of its diseases. In reference to the -as a hot climate, gross living, indolent habits, constipation-structure of the liver, the following paragraph will clearly ex- a more abundant secretion of bile is requisite to purify the
., . ’ . 0 blood, the liver is inadequate to its office, and they becomepress the views entertained by the author blood, the liver is inadequate management of such cases, we
°‘ In consequence of the arrangement of the minute vessels, have two objects to fulfil,—1st, to enjoin those conditions andif we cut into a liver in which, as is usual after death, the rules of life that render a plentiful secretion of bile less need-branches and twigs of the hepatic vein and the capillaries im- ful; and 2nd, to endeavour to render the liver itself moremediately terminating in them, are full of blood, while the active.branches and twigs of the portal vein and the capillaries im- "The chief conditions to diminish the quantity of mattermediately springing from them are empty, the cut surface will which the liver is called on to excrete, are, a light diet, withbe mapped out into small, tolerably equal, and somewhat pent- water for drink; active exercise; early rising; and a cool, orangular, spaces, having the outline, formed by the portal temperate climate. Acids have been supposed to act in thetwigs, pale, and the centre, into which a twig of the hepatic same way, and have been much in repute as a remedy in livervein enters, red. The small masses, of which these pentagonal disorders, particularly in India, where, from the circumstancesspaces are sections, have been termed lobules of the liver. mentioned, a remedy having this mode of action is especiallyThey have been described by Malpighi, Kiernan, Muller, and required.others, as isolated from each other, and each invested by a " Various medicines seem to fulfil, to a certain extent, thelayer of areolar, or, as it used to be named, cellular, tissue. second object, that of rendering the liver more active, and in-The injected preparations of Mr. Bowman show, I think, creasing in this way the secretion of bile. Mercury, iodine,clearly, that this opinion is erroneous,-that the lobules are muriate of ammonia, and taraxacum, have undoubtedly an ac--not distinct, isolated bodies, but merely small masses tolerably tion of this kind."-pp. 34, 35.defined by the ultimate twigs of the portal vein and the in- The first chapter of Dr. Budd’s book is devoted to the subjectjected oruninjected capillaries immediately contiguous to
The first chapter of Dr.Budd’s book is devoted to the subjectthem. The ultimate twigs of the vein are, as it were, hairy of congestion of the liver. He copies, with a proper acknow-with capillaries, springing directly from them on every side, ledgment, Mr. Kiernan’s views and diagrams,-he describesand forming a close and continuous network. The lobules ap- mechanical congestion depending on disease of the heart andpear distinct isolated bodies only when seen by too low a power lungs, and states that a similar result has a different origin-clearly to distinguish the capillaries."-?. 6. viz., in morbid states of the blood, and in ague. The chapterWe have no hesitation in withholding assent from the is still exceedingly unsatisfactory, containing no information
latter view. The first-named authorities have produced the as to the method by which a congested liver can be recognisedmost satisfactory evidence of the subdivided structure of the during life, and being recognised, how it is to be relieved. Itsliver. From the pig’s liver macerated in acetic acid, the lobules conclusion brings us to the subject of hepatic inflammation ;can indeed be picked out separately. It is quite true that and here we come into immediate contact with the views ofthe microscope shows more uniformity in the injected speci- Dr. Parkes. Both authors treat the subject at great length-mens than the naked eye can perceive; this is but a result of at too great length to admit our entrance on it in the presentthe injection of the capillaries ramifying in the portal canals. number. We shall return to it, probably, in our next, andThe liver in man, and in almost all animals, is composed of conclude now with an outline of Dr. Parkes’s views on dysen-separate lobules, and we are greatly mistaken if pathological, tery. They are highly original, and may be stated in a seriesas well as physiological proofs will not, ere long, be produced of propositions. The first recognised fact, already prettyin support of this opinion. The arrangement of the blood- generally known, is, thatvessels, lymphatics, and other tissues, is described; the com- "There exists, on the inner coat of the large intestines, aposition, quantity, and other matters connected with the secre- series of solitary glands peculiar to that particular mucoustion of bile, are discussed’; one of the purposes of this latter membrane. They are evident in many diseases of the liver,function being the separation from the blood of certain hen they become enlarged, as in cirrhosis, accompaniednoxious and effete principles.
with ascites:’-p. 4." There has been much debate among physiologists, whether The author considers that they are not merely mucous fol-
the principles of bile are formed in the liver, or are not rather licles; they have some resemblance to the solitary glands ofmerely separated by this organ from the blood, in which, the small intestines, and are found equally distributed overunder this supposition, they are supposed to exist, ready-made the whole mucous membrane of the large.for secretion Data are yet wanting for the complete solution The second statement is, that " inflammation and ulcerationof this question. But it is quite clear that the colouring mat- of these glands are the earliest morbid changes in dysentery," ters of the bile exist in the blood, since if they be not sepa- of these glands are the earliest morbid changes in dysentery,"rated from it by the liver, as sometimes happens when the and those changes are described. The description we requiresecretion of bile is suppressed, the person is speedily jaun- to extract at length; it does not admit of condensation, and isdiced:’-p. 28. deserving of perusal in its entire form.On this point Dr. Parkes makes the following remarks :— "The first alteration in the glands is an enlargement of" I have never seen any reason to believe that the non- them, and a change in their contents. The contained sub-
secretion or the non-separation of the bile from the blood will stance becomes thicker, and now resembles flour and water inproduce jaundice. I have never seen jaundice in any case of appearance and consistence. In all probability this conditionhepatic abscess, and, in fact, in no case in which secretion has occurs every day, and giving rise to slight diarrhoea, relievesbeen totally arrested. I therefore, with all respect, differ itself, and the glands return to their normal condition. Thatfrom those pathologists who suppose that the liver merely alternation of constipation and slight diarrhoRa, with derangedseparates the biliary principles from the blood, as the kidneys secretion, which is often termed torpor of the liver, may bedo urea. In these cases of complete suspension of secretion, something of this kind, and at any rate is always best treatedcephalic symptoms are uncommon, contrary to what we should by a reference to the colonic mucous membrane.expect, if the opinions of Dr. Alison be well founded."-p. 191. " If, instead of relieving themselves by secretion, the glandsThere is much force in the observation; but, before entirely
continue enlarged for some time without being acutely in-flamed, that appearance is presented which has been incor-
adoptmg this view, we should wish to see it made the subject rectly compared by Ballingall and others to a variolous erup-of further inquiry. The quantity of bile secreted by different tion. I have seen this several times, and the resemblance isindividuals varies. In many it is deficient; the power of the about as great as might have been anticipated from the looseliver to secrete is too feeble, and disease is the consequence, nature of the statement. The characteristic marks of the
as shown in the following observations by Dr. Budd :- variolous eruption are, a slough or disorganization of the cutis’
vera, (phlyctidium,) with vessels radiating from a central"People who inherit this feebleness of the liver, if we may point or stigma, which by its adherence to the cuticle, else-
so term it, or in whom, in consequence of disease, a portion of where raised by a peculiar pus, produces the umbilicus. It isliver has atrophied, or the secreting element of the liver has needless to say, that in dysentery there is no process of thisbeen damaged, may suffer little inconvenience as long as they sort; there is the simple gland, easily dissected and isolated,are placed in favourable circumstances, and observe those rules with an occasional dark point on the summit, or side, of unde-
termined nature. I make this comparison, as an otherwiseaccurate observer, Dr. Murray, of the Bengal Horse Artillery,has insisted strongly on the coincidence between small-poxand dysentery, and even appears to think that this connexionwill both establish and explain the contagious nature of thelatter disease in certain cases, (Calcittta Transactions.)
" If a greater degree of inflammation be present, the vesselsaround the gland become enlarged and conspicuous, and forma ring or halo, spreading a short distance into the mucousmembrane.
" This condition presents the earliest symptoms of dysen-tery-viz., slimy stools, increased in number without blood,causing perhaps slight griping and tenesmus when passed, andgenerally unattended by pain on pressure.
" Immediately after this, and in severe cases, during thevery first days, ulceration begins, and is always denoted byslimy and gelatinous stools, streaked with blood, and attendedby tormina, tenesmus, and pain on pressure, varying accordingto the seat of the diseases, and its intensity.Ulceration begins in three ways:-" (a.) In the glands themselves." (b.) Around the glands."(c.) By effusion of a fluid beneath intermediate mucous
membrane.’-pp. 6-8.These several forms of ulceration are fully described, and
on their progress a classification of the stages of dysentery isfounded.
" First period.-Of enlargement, and commencing ulcerationof solitary glands." Second period.-Of complete and spreading ulceration." Third period.-Of cicatrization. [Or,]"Fourth period.-Of abortive cicatrization, commonly called
chronic dysentery, a disease which is a resultant of continuedsub-acute inflammation and ulceration, combined with inef-fectual efforts to produce the usual cicatrizing process."The observations on the cicatrization of ulcers are of great
interest. The author proves that this process takes place withgreat rapidity and completeness. The ease of a young man
who, recovering from dysentery, died suddenly from sun-stroke, affords an apposite example of the facts stated.
It is impossible to follow the author through the lengtheneddescriptions which he gives of the various complications ofdysentery with disease of the liver, with scurvy, with remit.tent fever, &c., all of which statements are illustrated by cases:neither have we time to dwell on the symptoms of this diseasenor on its treatment. Suffice it for the former to say, that
scybala are by no means necessarily present in true dysentery;and for the latter, that it must vary with the character of thedisease. We do not regret the necessity which requires us,
. for the present, to bring our remarks to a close, as we are satis-fied that there are few whose practice leads them to feel aninterest in the subject of hepatic disease, or in dysentery, whowill not make themselves acquainted with the contents of boththe volumes, the titles of which head this notice.
ROYAL MEDICAL AND CHIRURGICAL SOCIETY.MAY 26TH.—MR. PERRY IN THE CHAIR.
CASES OF MELANOSIS, WITH OBSERVATIONS. By HOLMES COOTE,Esq., Fellow of the Royal College of Surgeons, Surgeon tothe North London Ophthalmic Institution.
THE author, after relating several cases of melanosis, gives abrief historical notice of the works in which a description ofthe disease is contained. He then observes, that " melanosisin the human subject occurs as a primary disease only in theeye and in the skin. In the horse it is s’een chiefly about theanus, parotid gland, or spleen. Mr. Spooner, of the RoyalVeterinary College, has never met with it but in horses of alight colour, most of whom were becoming white from age."After some remarks upon the necessity of not confounding Itrue melanotic tumours with other dark-coloured swellings, the author gives a brief account of the chemical composition ’iand microscopical anatomy of true melanosis. He argues fromthe latter, that melanotic tumours, though sparingly, if at all Isupplied with bloodvessels, are not unorganized, the cells which compose them having their periods of growth, maturity,and decline. He denies the correctness of regarding melanosis Ias a variety of cancer. He enumerates many points in whichthe two diseases essentially differ. Melanosis of the eye com-
mences between the choroid and the retina; the tumour, push-ing the contents of the globe on one side, makes its way exter-nally by irregular periods of increase. Melanotic tumours of £the skin are either cutaneous or subcutaneous.The development of internal disease, to which the fatal ter-
mination of the case is owing, is marked by general lassitude,and undefined pains over the trunk and limbs. The patient isexhausted by sickness and diarrhoea, but in most cases retainshis mental faculties to the last.
Secondary melanotic accumulations are found in all struc-tures, except the cornea, synovial membranes, tendons, andaponeurotic expansions. The liver often attains an enormousmagnitude: in one case, examined by Mr. Lawrence, it weighedseventeen pounds and a half. From a table of fifteen accu-rately-watched cases, it would appear that the average dura-tion of life, after the removal of the primary disease by opera-tion, does not amount to more than thirteen months. Theauthor concludes by endeavouring to show that the operation,though justifiable for the purpose of relieving a patient from asource of suffering, ought not to be held out as a means oferadicating the disease, or of materially prolonging life. Herests these conclusions very much upon examinations made byhimself, having found, by the aid of the microscope, that, inone case, melanotic matter existed in the bloodvessels, in ap-parently healthy muscles, nerves, and other tissues immediatelysurrounding the primary tumour.Mr. WniTE CoopER referred to one of the cases recorded in
the paper before the Society, and said, that subsequent to theoperation that patient was the subject of extreme dyspepsia.The eye itself was well, but the patient was much attenuated,and subject to distressing pyrosis. He feared that she labouredunder disease of some internal organ, probably of the stomach,similar to that removed from the eye.The PRESIDENT observed, that in the case alluded to, the
melanotic disease was situated externally to the eye. This hebelieved was a very unfrequent seat of the affection, and askedif any chemical examination had been made of the contents ofthe tumour.Mr. COOPER had not examined the tumour chemically; but
under the microscope it exhibited all the characters of mela-nosis. It commenced from a small red point, it was suppliedwith vessels from the canthus, and had progressed with greatrapidity. Mr. Fergusson had seen the case previous to theoperation, and had recommended the removal of the tumour
. as affording the only chance of saving the patient. It wasaccordingly removed; the operation was attended with muchhaemorrhage, but the wound healed rapidly, and in a fortnight,the eye, to all appearance, was well. A considerable portionof the conjunctiva covering the cornea was removed in theoperation; but there was no consequent opacity.Mr. FERGUSSON had a full recollection of the case, and had
a firm impression that the tumour was melanotic. He cer-tainly concurred in opinion as to the necessity of an operation;but he was by no means sanguine as to the result of that pro-ceeding. It was gratifying to him to hear of its success,which was contrary to his experience generally in these cases;for he had hitherto found, that when this disease was situatedin the vicinity of the eyeball, it invariably returned, and, at alater or earlier period, destroyed the patient. The first casedetailed in the paper was peculiar in regard to the appear-ances observed in the portion of optic nerve removed, whenit was placed under the microscope, as it exhibited blackspots similar to those observed in other parts of the tumour.He feared that a similar condition of the nerve left behindwould obtain. Had Mr. Coote seen this patient since thepaper had been written? Had he also any peculiar viewsrespecting the term " malignant" as applied to these tumours?That term, in his (Mr. Fergusson’s) opinion,was strictly applic-able to this disease. The result of these cases, in general,bore out the correctness of this opinion; for the average du-ration of life, after the operation of removal, as proved by thepaper, was but thirteen months, and the disease was not amuch longer period in proving fatal, even after its first ap-pearance. He therefore looked upon this as a malignantdisease.Mr. CooTE had not seen the subject of the first case detailed
in his paper since the operation. He had, however, heard,that for some months subsequently to that proceeding, therewas a dark, sanious discharge from the orbit; the veins of thepalpebræ were enlarged, and the integuments stained of adark colour. IIe had little doubt that if the blood from theseveins had been examined, it would have been found to bemelanotic. He had divided the optic nerve with a cleanknife; the spots alluded to by Mr. Fergusson had been clearlydetectable under the microscope, and he feared, from this