angle between the middle and left portions of the central tendon of the diaphragm. Two perforations were about an inch in length, and two smaller about half an inch. They communicated with a purulent cavity above the diaphragm, which was situated to the left of the pericardium, and was formed by the margins of the base of the lung having adhered to the upper surface of the diaphragm. This cavity contained about ten ounces of foetid pus; the diaphragm reached nearly to the fourth rib on the left side. The liver weighed 86 ounces; the anterior surface of the left lobe was covered by a thick layer of purulent lymph, which extended to the suspensory ligament, beyond which the anterior surface of the liver was adherent to the abdominal parietes, and formed the right boundary of the large purulent cavity. The liver-tissue was greenish blue beneath the layer of purulent lymph, at other points it was pale and rather shining on section. The spleen was partly covered with purulent lymph; the kidneys were large, pale, and flabby. The lungs were free from disease, excepting the base of the left, which was slightly carnified. The heart was tolerably healthy, the valves were sound. Case 494, a woman aged sixty-three, who had purulent effusion into the right pleural cavity. Two years before death she had jaundice, and was never well afterwards. During the last fourteen months she had great pain in the loins and lower extremities, and was sometimes not able to walk for two or three weeks together. During the last fortnight before death she complained of cough, debility, and pain in the hepatic region. There was marked dulness on percussion about the base of the right lung, where the respiration also was deficient; the countenance jaundiced and haggard. On opening the right pleura an offensive gas escaped, and the cavity was found to contain four pints of a dirty yellowish fœtid fluid. The lung was pressed upward and against the spine; the costal and pulmonary pleura were covered with thick layers of purulent lymph. On removing the liver, it was found that the diaphragm had been perforated near the spine on the right side, and that the purulent fluid had been in contact with a portion of the thick posterior border of the liver. There was no appearance of any abscess of the liver; on section, the liver-tissue appeared granular. XII. LYMPHATIC AND LACTEAL GLANDS. 1. Cancer of Cervical Glands, 2 cases: Nos. 476, 533. 2. Cancer of Lumbar Glands, 5 cases: Nos. 382, 406, 413, 533, 556. 3. Cancer of Inguinal Glands, 3 cases: Nos. 394, 396, 433. Cancer of the cervical, lumbar, and inguinal glands, was always associated with cancer of some neighbouring organ. 4. Hypertrophy of Bronchial Glands, 4 cases: Nos. 407, 436, 437, 536.-In Case 407, a man aged fifty-one, who had cancer of the liver and stomach, the bronchial glands were very large and soft, as if from scrofulous deposit.-In Case 536, a little girl aged two years and a half, who was afflicted with general struma, the bronchial glands were enlarged by tubercular deposit to the size of a hen's egg, and produced pressure on the bronchi and consequent difficult breathing. 5. Colloid Cyst in Bronchial Gland, 1 case: No. 396. 6. Tubercle of Bronchial Glands, 6 cases: Nos. 437, 442, 493, 530, 532, 536. This number is doubtless below the actual proportion, although it includes one of the above cases of hypertrophy. 7. Tubercle of Mesenteric Glands, 1 case: No. 536. 8. Chalky Concretions in Mesenteric Glands, 1 case: No. 531. 9. Typhoid Deposit in Mesenteric Glands, 1 case: No. 391. XIII. BONES AND JOINTS. 1. Pus beneath Periosteum of Tibia, 1 case: No. 427. 2. Purulent Mucus in Sphenoidal Sinuses (Disease of Bone), 1 case: No. 456. 3. Disease of Bones within the Nose, 1 case: No. 397. 4. Pelvic Abscesses, 1 case: No. 486. 5. Cancer of Skull, 2 cases: Nos. 480, 498. In Case 480, the disease began in the antrum (Museum IV. 43); in Case 498, the primary disease was cancer of the liver, but the sternum, spine, and humerus, were also involved. In both these cases the dura mater was also affected. (See I. 1.) 6. Cancer of Antrum, 1 case: No. 480. 7. Cancer of Spine, 1 case: No. 498. 8. Cancer of Sternum, 1 case: No. 498. (Museum IV. 35d.) 9. Cancer of Ribs, 1 case: No. 382. (Museum IV. 35b.) 10. Cancer of Humerus, 1 case: No. 498. (Museum IV. 36d.) 11. Caries of Spine (Angular Curvature), 1 case: No. 500. 12. Lateral Curvature of Spine, 1 case: No. 381. 13. Necrosis of Vertebræ, 1 case: No. 388. 14. Disease of Hip-joint, 3 cases: Nos. 392, 426, 538. 15. Disease of Knee-joint, 3 cases: Nos. 445, 495, 506.-In Case 445, a man aged fifty, the cartilages were entirely destroyed; the bones were bare and rough, and yielded an offensive odour; there was partial dislocation, the lungs contained a quantity of tubercle, and the intestines were involved in tubercular ulceration.-Case 495, a man aged twenty-four, in whom excision of the knee had been performed. On examination, the wound was in a suppurating condition, and yielded a most offensive odour. Fibrinous deposits occurred in the lungs and liver.-Case 506, a lad aged nineteen; amputation of the thigh had been performed for ulceration of the cartilages of the knee. On examination, no purulent deposits were found; the saphenous and femoral veins were perfectly healthy; the lymphatic glands of the groin and pelvis enlarged and soft. There was hypostatic congestion of the lungs; also fatty degeneration of liver, granular kidneys, and adherent pericardium. 16. Fracture of Skull, 2 cases: Nos. 518, 521. 17. Fracture of Tibia and Fibula, 1 case: No. 403.-A lad aged fourteen years and a half; the fracture was compound and comminuted. He died of hepatization of the lungs. 18. Fracture of Neck of Femur, 1 case: No. 450.-A woman aged eighty-one; the fracture was external to the capsule, passed through the anterior intertrochanteric line, and the fossa at the base of the great trochanter; the trochanter was split downwards; the fractured bone was surrounded by a large quantity of purulent matter. XIV. EXTERNAL APPEARANCES, SKIN, ETC. 1. Burn of Scalp and Hand, 1 case: No. 429. 2. Burn over Knee, 1 case: No. 477. 3. Ulcer of Leg, 1 case: No. 547. 4. Gangrene of Leg, 1 case: No. 465. This was produced by fibrinous plugging of the common iliac artery. (See IV. 5.) 5. Erysipelas, 4 cases: Nos. 386, 405, 534, 544.-Case 386 occurred after excision of a cancerous tumour of the breast. 6. Abscess in the Neck, 1 case: No. 388. 7. Fistula in Ano, 2 cases: Nos. 438, 528.-Both these were associated with phthisis. 8. Amputation of Arm, 1 case: No. 519.-A man aged fortyfour; death was caused by pleuritis and carnification of the lung. 9. Amputation of Thigh, 1 case: No. 506.-This was performed for disease of the knee-joint. (See XIII. 15.) 10. Excision of Knee-joint, 1 case: No. 495. (See XIII. 15.) 11. Psoriasis, Secondary Syphilis, 2 cases: Nos. 390, 526. 12. Jaundice, 2 cases: Nos. 408, 491. (See VII. 23.) 13. Anasarca (general Dropsy), 2 (extreme) cases: Nos. 516, 537. ART. II. An Experimental Inquiry into the Function of the Supra-Renal Pathology of the Supra-renal Capsules. COMPARATIVELY little attention has been paid to the pathology of the supra-renal capsules. All that we as yet know is, that they, like other organs, are liable to a variety of organic changes, such as cancerous, calcareous, and tuberculous deposits, as well as fatty and fibrous degeneration. With regard to their functional derangements, we know absolutely nothing. As it happens that at the present moment the question of the connexion existing between bronzed skin and supra-renal capsular disease is agitating the whole medical world, both here and abroad, and as I consider it still sub judice whether or not bronzing of the skin ought to be regarded as a pathognomonic symptom of diseased supra-renal capsules, it may perhaps be advisable for me to add a few remarks upon the subject. Since the publication of Dr. Addison's interesting monograph 'On the Constitutional and Local Effects of Disease of the Supra-renal Capsules,' many cases similar to those he described have been reported, both in home and foreign journals. At the present moment the facts of the case seem to be the following:-A certain number of cases have been observed where bronzing of the skin and disease of the supra-renal capsules have been found associated together, and from that it has been concluded by some that the one was dependent on the other state. Now, let me ask if the mere fact of supra renal capsular disease and brouzing of the skin being found associated together, is sufficient to justify us in regarding the latter as a pathognomonic symptom of the former? Add to these textural changes the functional symptoms of anæmia, debility, languor, feebleness of the heart's action, and irritability of the stomach, and have we then incontestable evidence that bronzing of the skin so accompanied is the result of supra-renal capsular disease? Do we require no further data to be laid before us ere we pronounce judgment? Surely every one will agree that this is but one side of the question, and that before we can decide it, the other must also be examined. In order to consider the subject properly, it will be necessary for us to proceed in a categorical manner. The principal points to be ascertained are-Firstly, Is supra-renal capsular disease invariably accompanied by bronzed skin? and, secondly, is bronzed skin always associated with disease of these organs? At the time when Dr. Addison published his monograph, as well as in October, 1856, when a review of it appeared in this Journal, a number of cases had been recorded in which a bronzed condition of the skin was found concomitant with total destruction of the suprarenal capsules; one or two cases where partial disease of these organs occurred, and in these bronzing of the skin was sometimes present, sometimes absent; but not a single case was at that time on record in which total destruction of the supra-renal capsules existed without manifest discoloration of the skin. And still farther, no case of bronzing of the skin had been published in which the capsules were found healthy. So that the conclusions come to by these gentlemen at the time they wrote might be considered as legitimate. At the present moment, however, the case is very different, several cases have been reported in various journals where extensive and even total destruction of the supra-renal capsules existed unaccompanied by any discoloration of the skin. In proof of this I may cite the following 12 examples: Professor Friedreich relates a case of extensive amyloid degeneration of the supra-renal capsules, without a trace of bronzing of the skin. He says that the organs were of the normal size, but unusually hard. On being cut into, the brown cortical pigment-zone was found entirely absent. On microscopical examination, this part of the organ was seen to be full of fat granules. The medullary substance was even in a still more advanced stage of degeneration; the greater part of the cells being transformed into homogeneous glittering masses-a fact, as the author remarks, of particular importance in connexion with the absence of any discoloration of the skin.* Virchow's Archives, April, 1857, p. 389. Professor Friedreich, in the same paper, mentions still another case, in which the supra-renal capsules were found of twice their normal size, and extensively affected with amyloid degeneration. The microscopical characters were similar to those mentioned as occurring in the other specimens, and yet there was no discoloration of the skin. At one of the meetings of the Bath and Bristol Association, Mr. Davis reported two cases that he had met with of extensive disease of the supra-renal capsules, without any bronzing of the skin.* The one patient died of heart, the other of kidney, disease. Professor Virchow writes me, that he has met with several cases of tubercular deposit in one or both supra-renal capsules, unaccompanied by bronzed skin. He mentions one case in particular, in which both capsules were completely destroyed by cancerous deposit, without the slightest discoloration of the skin having been observed. I have myself examined one case of complete degeneration of the supra-renal capsules without any bronzing of the skin having been noticed. The patient died in the Middlesex Hospital, and his supra-renal capsules were kindly forwarded to me by Dr. Van der Byl. The capsules at first sight appeared healthy. On being cut into, however, the sinuses in the medullary part were found all united into one, so as to form a tolerably large cavity, which contained a dark grumous-looking liquid. On this fluid being examined with the microscope, it was seen to contain a number of blood corpuscles, pigment granules, oil globules, and broken-up nucleated cells, most probably, part of the débris from the medullary substance, which was found no longer to possess its normal histological structure. The cortical portion of the capsules was of a dingy yellow colour, soft, and exceedingly friable; so much so, that on attempting to make a thin section of it with the knife, it crumbled away before the cutting edge. On placing a small portion under the microscope, there was neither the slightest trace of loculi nor fibrous matrix visible; nothing but a confused mass of cells, granules, and fatty matter could be detected. In fact, it was almost entirely composed of fat globules and granules. For the following notes of the case I am indebted to Dr. Van der Byl: "The patient (a man aged forty) was of thin make of body and sallow complexion, with several cicatrices of scrofulous abscesses about the hips, axillæ, and neck. His lungs were attacked with inflammatory disease. Most of the internal organs contained a large quantity of fat. The heart, on microscopical examination, showed the existence of many fatty molecules, although the transverse striæ were visible in the greater number of the fibres. The liver weighed 11 pounds 13 ounces, and had a pale-yellowish appearance. The lobules were not distinguishable. [The cells of the liver were crowded with fatty matter.-G. H.] The spleen weighed 25 ounces, and resembled waxy spleen,' &c. &c. No bronzing of the skin was observed." At the late meeting of Naturforscher und Arzte,' at Bonn, Dr. * British Medical Journal, Feb. 28th, 1857. For the benefit of those not accustomed to examine the supra-renal capsules microscopically, I may remark, that about fifty per cent. of the human supra-renal capsules have their cells more or less filled with oil globules, so that great caution is required in their examination, otherwise many healthy organs may be regarded as diseased. |