an opportunity of witnessing, in an old woman, an affection hitherto unknown to me. The patient had long suffered from dysuria, and there was found, after death, very extensive tuberculosis of the urinary organs. The upper part of the right kidney was in great part destroyed; the corresponding parts of the infundibula and pelvis in a state of cheesy ulceration; the remaining part of the renal pelvis and the right ureter studded throughout with small knots, partly grey and solid, partly white and ulcerous. Even in the cortical substance of the kidney there were found yellow knots. The urinary bladder was, in the upper part, thickly granular, with numerous little groups of grey knots; at the lower part, by the neck and urethra, it was hyperæmic, and studded with more isolated and finer grey tubercles. In the vagina there was found a similar eruption, mostly arranged in groups upon a base of red and injected mucous membrane, each single tubercle appearing as a fine grey pearl. They were sparingly distributed at the entrance of the vagina. They had not ulcerated in any part. Under the microscope they appeared to consist of granular masses, composed of soft cells,-a deposit which constitutes, in all cases, recently-formed tubercle. I saw none in the rectum or in the uterus of this patient.- Virchow's Archiv. 1853.

[Some time ago, Mr. Holmes Coote recorded a case of this disease in the lining membrane of the uterus.]-Med. Times and Gazette, June 11, 1853, p. 606.

143.-FURTHER RESEARCHES ON THE PATHOLOGY OF PHLEGMASIA DOLENS.

By Dr. ROBERT LEE, F.R.S.

[Various theories upon this disease existed until the memoirs of M. Bouillard, M. Velpeau, and the late Dr. Davis demonstrated that it consisted in an inflammation of the trunk and principal branches of the veins of the lower extremities. The following observations are taken from a paper read by Dr. Lee, before the Royal Medical and Chirurgical Society.]

In papers by the author, published in the fifteenth volume of the Transactions,' the actual condition of the iliac and femoral veins was ascertained, and he had been led to infer that inflammation of these veins gave rise to all the phenomena in puerperal women of phlegmasia dolens, and that it commenced in the uterine branches of the hypogastric veins, and subsequently extended from them into the iliac and femoral trunks of the affected side. Other cases had been recorded in the 'Transactions' of crural phlebitis following ulceration of the mucous membrane of the intestines. Experiments performed by Pirigott in 1839, and by Reunert in 1840, on dogs, showed that the action of chemical and mechanical irritants was limited to the vein on which the experiment was made, and the extension of the inflammation in the veins was not cominon; and Stannius, who had collected and tested all the facts bearing on the subject, doubted whether inflammation of venous trunks admitted of being excited by constitutional causes, independently of local irritation. A series of experiments on the veins of the lower animals, similar to those just mentioned, had recently been made, and a paper on phlegmasia dolens had been read to the Society during the present session, not founded on actual observation of the disease as it occurs in the human subject, but upon experiments on the veins of the lower animals in which phlegmasia dolens had never been observed. The object of the present communication was to submit to the Society the observations which the author had made during the last twenty-four years on inflammation of the crural veins. The paper contained the record of forty-three cases of phlegmasia dolens. The first nine cases were accompanied by post-mortem descriptions, and preparations illustrating the disease; and the author was led, from the whole of the facts thus adduced, to the conclusions he had formerly expressed, "that inflammation of the iliac and femoral veins gave rise to all the phenomena of phlegmasia dolens, and that the inflammation commenced in the uterine branches of the hypogastric veins, and from them extended to the iliac and femoral trunks of the affected side." The next series comprised the history of twenty cases, which the author thought furnished additional evidence in favour of this conclusion, though, in consequence of the recovery of the greater number of the patients, an opportu

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nity was not afforded of determining by dissection the actual condition of the crural veins. Nine cases followed, which demonstrated that phlegmasia dolens might occur wholly unconnected with pregnancy and parturition, and that in such cases the inflammation likewise commenced in the uterine branches of the hypogastric veins, and followed a course similar to what occurred in puerperal cases. of these the inflammation of the uterine veins was produced by cancerous disease of the os and cervix uteri; in others there was no organic disease of any kind preIn some viously existing. The concluding cases were five, in which crural phlebitis had followed inflammation of the saphena veins, and of the deep veins of the lower extremities, from fracture of the tibia and fibula, and the pressure of encephaloid tumours on the thoracic viscera. The author thought that these cases and dissections, as well as those of the distinguished authors whom he had quoted, proved, in the most conclusive manner, that inflammation of the iliac and femoral veins was the proximate cause of phlegmasia dolens; and that in puerperal women this inflammation commenced in the uterine branches of the hypogastric veins. It had likewise been demonstrated, by morbid anatomy, that phlegmasia dolens was a disease which might take place in women who had never been pregnant, and even in the male sex, and that, under all circumstances, the proximate cause was the same.

[Dr. Mackenzie observed that the facts alleged were, that certain lesions of the crural veins were developed in the progress of phlegmasia dolens; but he dissented from the conclusion that these lesions constituted the essence or proximate cause of the disease.]

The disease known as phlegmasia dolens was a very complex malady. It was one which was characterized, not only by a morbid condition of the veins, but by a morbid condition of the sensory, the motor, the lymphatic, and the secretory organs of the affected extremity also; and accordingly, in all well-marked cases of the disease, there was exquisite sensibility of the limb, especially in the track of particular nerves, loss of motor power, amounting sometimes to perfect immobility of the extremity, inflammation and obstruction of the lymphatic vessels and glands, and a general hot, tense, and elastic swelling of the limb, not simply arising from oedema, but possessing rather the character of active exudation than of passive effusion. Now, could all these lesions depend upon or be deduced from mere inflammation and obstruction of the principal vein of the extremity? Were they ordinarily observed in cases of simple, uncomplicated phlebitis? Or, if not, was there anything in the anatomical or physiological characters of the veins to justify our deducing them à priori from it? And if we replied to these questions, as he submitted that we must, in the negative, he should ask whether those who adopt this theory have undertaken any particular investigation for the purpose of determining this point? In other words, have they reproduced the lesion of the veins in a simple, uncomplicated form, and observed such consequences to follow? Now, to these questions, we must also reply in the negative, and it must be added that the whole matter rested purely on assumption. It had been assumed that, because the crural veins were found obviously diseased in fatal cases of phlegmasia dolens, that such lesions constituted the proximate cause of the disease. No further steps had been taken to establish the truth of this doctrine, and that, therefore, had been taken as a matter of assumption which ought to have been made a matter of demonstration. Further, he would observe, that the clinical history of the disease, and the progress of symptoms, did not support this theory. It was quite true that in some cases the first irritations commenced in the region of the femoral vessels, but in others it was far otherwise; in some they commenced in the back, in others in the hip, sometimes in the calf of the leg, and more frequently in the popliteal region. Again, one leg might be affected alone, or both lower extremities concurrently; or the disease, after having attacked one, may pass on to the other, or a superior extremity might be affected; and he had lately met with a case in which, after symptoms of the disease had successively declared themselves in the left lower and upper extremities, the malady ultimately established itself in the right arm, the whole right upper extremity being hot, swollen, and tense, the surface exquisitely painful, with loss of motor power, and a tense, corded condition of the basilic vein. Now, it appeared to him that these facts were inconsistent with the theory, that the proximate cause of the disease was essentially inflammation of the crural veins. They pointed to the existence of some more general and diffusive

cause, in regard to which it was probable that phlebitis itself was but a secondary affection. Again, he would point to the general experience of the profession as being opposed to this theory. It was now upwards of thirty years since it was first promulgated by his friend and teacher, the late Dr. David Davis; and, although the facts upon which it rested were well known, it was yet very far from being generally adopted. Thus, in this country, Dr. Burns affirmed, that the nerves were as much affected as the veins. Others regarded the lymphatic vessels as being principally affected; while many, dissatisfied with these restricted views of the pathology of the disease, preferred the theory of the late Dr. Hull, that it consisted in a general inflammation of the several organs and structures of the affected limb. So again, on the continent, the greatest difference of opinion existed respecting its nature and pathology; and while many affirmed that it consisted essentially in inflammation of the lymphatics, and others that it was a specific inflammation of the cellular tissue, nearly all agreed that, in its general characters, it differed widely from ordinary phlebitis. Now, this diversity of opinion existed, notwithstanding that all were aware of the facts upon which the phlebitic theory of the disease rested; and it afforded a powerful argument against it, because it tended to show that, when tested by general experience, and considered irrespectively of particular facts, and free from bias, it failed to account rationally for all the known phenomena of the disease, and consequently could not be regarded as its proximate cause. Then, in the sequelæ of the disease, circumstances were met with which are inconsistent with this theory. We know, for instance, that after an attack of the disease, the crural veins are generally left impervious or obliterated, and yet successive attacks of the disease may occur in the same extremity. Now, if it be true that the first attack left them in the condition described, it was difficult to understand how these versels, having functionally ceased to exist, could again take on functional activity, and become the seat of active inflammation. So also it happened after an attack of the disease that the limb would be left for many years, or even for the remainder of life, in a weak, sensitive, and irritable condition, being easily affected by atmospheric and constitutional influences. It was easy to reconcile these facts with the notion that the nerves had been injured or damaged by the attack, but not with the idea that the veins alone had been affected. On all these grounds, then, it appeared to him (Dr. Mackenzie) that the phlebitic theory of the disease was either defective or erroneous. But assuming for a moment that it was correct, he would observe that it left much which was still to be explained. We had yet to learn the nature of that peculiar inflammation of the veins met with in this disease, which was so exceptional, and so different from ordinary phlebitis. Did it depend upon some peculiar disposition on the part of the venous coats to take on diffusive inflammation, or did it depend primarily upon the blood? If we adopted the first of these theories, we were bound to state the nature of the peculiarity, and the laws of its development. For to be satisfied with merely giving it a name, and to speak of it as a specific" inflammation, was not to advance our scientific knowledge, but rather to take refuge, or to hide our ignorance, under the shadow of a name. If, on the other hand, we accepted the latter view, and regarded the venous inflammation as dependent upon some morbid condition of blood, then, indeed, we might reasonably account, not only for the peculiarities it presented, but for all the several lesions of other organs, and the structural changes with which it was associated. Upon this view, also, we might reconcile the conflicting opinions respecting the nature of the disease which had been held by different pathologists, and the varia tions which it manifested in its symptoms and progress in different cases. But, in accepting this view, we must forego the theory that phlebitis was the proximate cause of the disease, and regard it, as it really was, as a secondary rather than a primary phenomenon; related to the other lesions of the extremity, not so much in the order of cause and effect, as in being, like them, a parallel effect of some more general and diffusive morbific agent.-Med. Times and Gazette, June 4, 1853, p. 583.

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144.-DEFICIENT MENSTRUATION COMMONLY TERMED CHLOROSIS. By DR. W. S. OKE, Physician to the Royal South Hants Infirmary.

[Dr. Oke observes:]

It has fallen to my lot to have had extensive experience in the treatment of this disease; and I can confidently affirm, that, where this atonic condition of the system is not complicated with any co-existing organic disease, the following simple treatment has seldom, if ever, failed of complete success. One of the pills (a) is to be taken every other night, and two of the pills (b) three times a day:

(a) B. Hydrargyri chloridi gr. xij; pilula aloes cum myrrhâ gr. xlviij; syrupi, q. s. Misce et divide in pilulas xij.

(b) B. Pilulæ ferri comp. 3 iij. Divide in pil. xxxvj.

If there be diarrhoea, the pills (c) are to be taken instead, leaving out, of course, the aperient:

(c) B. Pilulæ ferri comp. 3 iij.; pulveris opii gr. iv.; syrupi, q. s. Misce et divide in pilulas xxxvj. quarum capiat duas ter die.

It occasionally happens that an individual cannot swallow medicine in the form of pills, in which case (d) may be prescribed with equal success:

(d) B. Misturæ ferri comp. 3 viij.; decocti aloes comp. iv. Misce. Capiat iss. ter quotidie.

If necessary, the bowels may be regulated by the powder (e) taken in jelly: (e) B. Hydrargyri chloridi gr. j.; aloes socot. pulv. gr. iij.; pulv. cinnamomi comp. gr. ij. Misce. Fiat pulvis noctibus alternis sumendus.

Amongst the better classes of society, the patient is often sent to the sea-side, or some other place, for change of air, without the aid of medicine; but this is at best a tedious remedy, if it be a remedy at all; whilst the treatment above recommended will bring about convalescence in six weeks or two months, without any change of locality.-Association Med. Journal, May 6, 1853, p. 392.

145.-Neuralgic Menstruation, commonly termed Dysmenorrhea. By Dr. W. S. OKE. [Frequently the menstrual secretion commences with and is accompanied by pain in the abdomen, back, and hips, varying in its degree of intensity. Frequently this may be alleviated by the hip-bath, opiates, belladonna, digitalis, purgatives, electricity; or, if inflammatory, by cupping over the sacrum; in other cases, however, no relief is obtained from any of these measures.]

Case. A lady, aged twenty-six, well formed, and of dark complexion, from a disappointed attachment had become deficient in her menstruation; and the diminution was accompanied with hysterical paroxysms, and the most intense pain of the uterine region, as soon as the secretion commenced. This state of extreme suffering continued for some years, and rendered her existence quite wretched. She had consulted a variety of medical men, and many remedies had been tried, to remove or alleviate her pains. She had been locally bled, had frequently used the warm hip-bath, with purgatives, opiates, antispasmodics, &c.; but all these means had fallen short of any permanent relief. The only remedy which had given her any respite was large doses of the liquor opii sedativus, although it always disordered her system. In such a case as this, as all ordinary remedies had been found unsuccessful, and reflecting that the indication of cure was clearly to subdue the morbid action of the uterus, and restore its normal secretion, I resolved to combine some preparation of iron with a sedative which would not contract the secernent cavity of the uterus; accordingly, she was immediately placed under the following treat

ment:

B. Pilulæ ferri compos. 3ij; extracti conii 3j. Misce et divide in pilul. xl. quarum capiat duas ter quotidie.

This plan was steadily observed through the interval up to the next period, after which she wrote to me, stating that it had passed with an increased secretion, and without suffering or hysteria. The treatment was persisted in for some months with complete success; and two years have elapsed without any return of suffering. I considered this an important case; and, as others of a similar character came under my notice, they were placed under the same treatment, and almost always with a successful result. Opium, in one shape or another, will doubtless, in

large doses, afford temporary relief to the severity of the pain in dysmenorrhoea; but as it tends to cause contraction of the uterine cavity, and, therefore, rather restrains than encourages the menstrual discharge, it is not a desirable remedy.

I do not wish it to be understood that the above treatment is recommended for the relief of all cases of dysmenorrhoea. When the symptoms indicate an inflamed condition of the internal membrane of the uterus, manifested by the discharge of fibrinous shreds and febrile disturbance of the system, such treatment is, of course, inadmissible, and the case must be treated according to its indications by local bleeding, by the warm hip-bath, digitalis, saline aperients, &c.

Dysmenorrhoea, as well as leucorrhoea, may be sometimes also caused by the local irritation of ulcers, either within or near the os uteri; and has been successfully treated by the application of the nitrate of silver, through the speculum—an instrument which has brought to light local causes of uterine disease, which had long escaped detection by the ordinary means. When, therefore, in dysmenorrhoea, the symptoms are found to resist general methods of cure, and when the intermenstrual mucous discharge from the vagina is ascertained to be purulent and mixed with streaks of blood, it may be fairly inferred that the painful character of the menstrual period is kept up by epithelial ulceration, too far within to be discovered by common observation, and too superficial to be detected by the finger. In such a case, the speculum should be employed without hesitation, in order to decide the question, and allow of the application of such local remedies as may be required. 'The speculum is, undoubtedly, a most useful instrument for the diagnosis and treatment of diseases of the distal end of the vagina and the os uteri; but where the symptoms are derived from induration and enlargement of the cervix uteri, the speculum might overlook what the finger will not fail to discover. Such cases are of no uncommon occurrence. The enlargement is most frequently found on the posterior part of the cervix, and in my experience is very difficult of cure, even when it is not of a malignant character. On the other hand, the practice of frequently introducing the speculum, to have ocular proof of the condition of the os uteri, before a fair trial of other remedies has been made, whatever may be the patient's class in society-whether she be in her own dwelling, or in a public institution-whether in a mansion or in a cottage-ought, in my judgment, to be considered an abuse of a most useful instrument, and condemned as a demoralizing procedure.-Association Med. Journal, May 6, 1853, p. 392.

146.-Profuse Menstruation, commonly termed Menorrhagia. By Dr. W. S. OKE. [This condition may occur at any period of life, and be caused by either a plethoric or debilitated condition of the system, or by some local irritation of the uterus, as by a polypus growth.]

When menorrhagia takes place in plethoric habits, it is manifestly remedial, and ought not to be hastily restrained. In such a case the plethora is the object to be kept in view, rather than the discharge; and it will be best treated by a cooling diet, the recumbent position, and the mixture (a).

(a) B. Magnesia sulphatis 3 vj.; infusi rosa comp. 3 vss.; syrupi simplicis 3 ss.; acidi sulphurici diluti 3 ss. Misce. Fiat mistura, cujus capiatur fluiduncia ter quotidie.

But when the discharge has continued for a considerable length of time, producing an anæmic condition and great debility, the indication of cure will clearly be to restrain the uterine flux as speedily as possible by general and local means. The system may be strengthened by (b).

(b) B. Confectionis rosa 3 ss.; infusi rosæ comp. 3iij.; decocti cinchonæ 3iij. Misce et cola.

Colaturæ adde,

Acidi sulphurici diluti 3j.; tincturæ opii mxxx. Fia mistura, cujus capiat quartam partem ter quotidie.

Opium, in menorrhagia from this cause, is a valuable remedy, as it is found to increase the force of circular muscles; whilst henbane, hemlock, and belladonna relax them. Hence it is that the former contracts whilst the latter dilates the iris; and hence, also, the great use of opium in restraining profuse and dangerous