Two CASES OF SCIRRHUS OF THE PANCREAS, WITH OBSERVATIONS ON THE DIAGNOSIS OF AFFECTIONS OF THAT GLAND. By F. BATTERSBY, F.R.C.S.I., &c. &c. (Condensed from the Dublin Medical Journal, May, 1844.)

Dr. Battersby was requested to visit Mrs. M., aged between 55 and 60, in Sept. 1843. She had enjoyed good health until two years previously, when she became subject to severe pains in the back, shoulders, and arms; these were supposed rheumatic. After a year there was discovered in the epigastric region a deep-seated pulsating tumor, size and shape of an orange, having a regular diastolic enlargement synchronous with the pulse, and a well-marked bruit de soufflet. The diagnosis then formed was aneurysm of the aorta. She also suffered from fluid eructations, and an obscure deep-seated pain. After a month, the tumor and pulsation disappeared-a new set of symptoms set in—scil. uneasiness over abdomen-stools passed with pain and forcing-great emaciation -complexion dingy and leaden-conjunctiva jaundiced-pain in abdomen, which was now prominent and tympanitic, particularly in the region of the cæcum-marked fulness in epigastric region, in which was felt a deep-seated, solid, and fixed induration. It had no pulsation, but a bruit de soufflet over it in the course of the aorta. Constipation aggravated her suffering, and bowels seldom moved without lavements and aperients-passage of stools very distressing and painful-stools consisted of watery, ropy mucus, deficient in bile. When solid, the fæces were not thicker than a small-sized finger. The body always bent forwards-no vomiting at any period-occasional eructations of a clear, watery fluid in small quantity, which was bitter-mouth always full of salivatongue pale and clean—no thirst-pulse 70, intermitting and variable-legs and thighs anasarcous.-Died Oct. 2d. Opiates and mild medicines were the only ones used. The ptyalism and eructations continued to the last. She always referred to the epigastrium as the source of all her suffering. The principal post-mortem appearances were, anasarca and ascites-large intestine very much contracted-great induration and thickening of the membranous structures within the abdomen: stomach very small, and its mucous membrane darkcoloured-its cardiac orifice much contracted by thickening and hardening of the cellular tissue around it-it was connected with the left extremity of the pancreas, which was universally hard and enlarged, and had lost every trace of its natural structure-near its centre was a thin, horny cyst, the size of a walnut; it lay over the aorta-its base was surrounded by a scirrhous formation. The inferior transverse portion of the duodenum adhered closely to the morbid pancreas, and was by it much contracted.

Here the pancreas was obviously the origin of a scirrhous affection, which, by extending to other parts, produced contraction of colon and of cardiac orifice of the stomach. Of all the usual symptoms of scirrhous pancreas, the only permanent ones present here were the epigastric induration and the emaciationthe others, scil. vomiting, jaundice, and epigastric pain, were either absent or obscured by more urgent symptoms, arising from contraction of the large intestines. Andral mistook a case for aneurysm of the aorta in a woman 54 years old, who complained of violent pains in the dorsal region, radiating to the left side of thorax; these pains affected the entire abdomen, and were lost in the region of the spleen. At the post-mortem, an enormous tumor was found in the position of the pancreas. Jaundice and vomiting are frequent attendants on scirrhous pancreas—they arise, the first, from obstruction or obliteration of the common or biliary ducts by pressure of the morbid growth, then seated in the head of the gland, which in the same way is often found to narrow very much the pylorus or duodenum. To compression of the vena portæ and cava we are to attribute the common occurrence of ascites and anasarca in organic affections

of the pancreas. The great emaciation observed in scirrhus of the pancreas is explained by the great influence which diseases of this organ exercise over the functions of digestion and assimilation. Dr. B. next directs attention to one of the symptoms observed in the above case, viz. the ptyalism. He here gives numerous cases and authorities to prove that a reciprocal influence subsists between the pancreas and salivary glands. Fourcroy has observed, that, in obstructions of the pancreas, the salivary glands separated more saliva than usual. This is referred to the effect of sympathy. Certain instances of metastasis of inflammation are attributed to this sympathy. Augmented pancreatic secretion has been observed to be followed by a certain form of diarrhoea, and this in connexion with the salivary glands. While diarrhoea alternating with salivation is a consequence of inflammatory derangements of the pancreas, in scirrhus of the gland, on the contrary, continued constipation is almost always present, and is attended by salivation; which, coming on at a more advanced stage of the disease, is a symptom almost constant. This "balancement" of the secretion of the buccal and abdominal salivary glands is further illustrated by what occurs during pregnancy, in which salivation accompanied by constipation, is very frequent. The diarrhoea without fever, of pregnancy, in which the stools contain great quantity of serosity, may have its origin in augmented pancreatic secretion. Hence we see the close relations and intimate sympathy existing between the abdominal and buccal salivary glands. Dr. Battersby refers cases of pyrosis with rejection of limpid fluid, alternating with diarrhoea, to chronic alterations of the pancreas-in this view he is supported by Andral.

ON TUBERCULAR LEPROSY. By A. S. SKENE, Esq. (From the London Medical Gazette, June 14, 1844.)

Frances Savoy, aged 46, a married woman, with a family of six children.March 28th. She presented the following appearance:-The whole surface of the skin seemed as if smeared with oil. The entire face studded with tubercles varying in size from that of a pepper-corn to that of a bean-the larger ones, about the lower part of the face, enlarged the lips and cheeks. Nose much enlarged; alæ pendulous, with ulceration and thickening of the mucous membrane -eye-brows devoid of hair, cilia nearly gone. The whole of the inside of mouth and fauces studded with tubercles of various sizes-voice husky and nasal. Breath very fætid-many tubercles on the upper and lower extremities-respiration short-cough-sleeps and eats well-has little or no pain. Disease commenced about 44 years ago. Her husband sleeps with her, and is in perfect health. One of her boys, eight years of age, has the disease.

Tranquil Robichaeux, a boy aged 15. March 29, 1844, he presented the following appearances :

Entire face much swollen, and surface of skin as if smeared over with oilstudded with tubercles, very large, about the lower part of the cheeks and lips. Tip of the nose pendulous, and occupied by a livid, shining tubercle--lips much enlarged, full of tubercles on the inside. Tongue thickened, and protruding between the lips-palate and fauces thickly covered with tubercles. Uvula and tonsils tuberculated; one mass of disease, in fact, extending down into the pharynx. Cough-breath very fætid-voice a mere whisper-no hair or brows or eyelids. Calf of left leg and the right instep ulcerated-incipient ulceration at the roots of the nails-tumors in either groin-four large ulcers on left thigh. Sensibility of the diseased parts much impaired. Sleeps indifferently-appetite good. Disease commenced about six years ago. His uncle died of the disease in a shocking state about a month ago.

This disease, as described in the above cases, is identical with the tubercular leprosy which prevailed throughout Europe during the Middle-ages. The new locality for it forms a part of the province of New Brunswick. It is chiefly confined to the East side of the land lying between the bay of Chaleur and the estuary of the Miramichi River, and more particularly to the Settlements on the Neguac and Tracadie Rivers. No positive information could be obtained regard ing the original appearance of the disease in this quarter: all that could be known was, that the first case occurred in the year 1817, in a woman named Ursale Landré, one of a family of 19 children. This woman married and came to rereside in Tracadie. She had five children. After the birth of her youngest child, she fell into a bad state of health, and continued so for six or eight years. Blotches appeared on her face, extending over the upper part of the trunk and extremities. After some time, distinct lumps came on the face and inside of lips and throat-hair of eye-brows and eye-lashes disappeared-voice became hoarse. She died in 1829. Her husband died of it in two years after.

The points still at issue, connected with this disease, relate to,-1st, its peculiar nature; 2nd, the pathology; 3rd, the causes; 4th, the diagnosis; 5th, the prognosis, and 6th, the treatment. With respect to the first point, the primary cause of all the symptoms seems to be a morbid principle, sui generis, known only by its effects, which most probably resides in the blood-the most promi nent symptoms being a perversion of nutrition, with a secretion of new products in the tissues of organs. The extrinsic causes cited by authors are indigence, including filth, exposure to extreme temperatures, scanty or unwholesome food, with miasmata generated in the soil or subsoil. With respect to the other points, nothing either definite or satisfactory has been ascertained.

ILEO-COCAL OBSTRUCTION.

The following fatal case of this disease was that of a medical student in Philadelphia, under the care of Dr. Dunglison.

Dr. Southwick, on the 18th of March, had an attack of bilious colic, with pain, flatulence, and bilious vomiting. Warm fomentations and opiates were prescribed, with enemata. 19th. Pain and vomiting abated-some meteorism and tenderness of abdomen-Seidlitz powder and castor-oil. Pulse natural. No evacuation. 20th. Castor-oil and ol. terebinth. Dr. Dunglison called in, and diagnosticated subacute peritonitis with cœcal obstruction. Ordered ten grains of calomel and two and a half of opium immediately-turpentine and castor-oil injections, and if no evacuations before next morning, to have 20 leeches applied. 21st. No evacuations-great decrease of the tenderness and meteorism. Twenty-five leeches over the ileo-cœcal region-castor oil mixture every two hours. In the evening a warm bath. 22nd. At two o'clock in the morning a profuse fluid fæcal evacuation, followed by several others-vomited several times-great dulness over the ileo-cœcal region-" death-like sickness." 23rd. Vomited a large quantity of fluid matters, with stercoracious odour. 24th. Pulse rose to 125-150-160, with great restlessness and anxiety. We need not pursue the details of treatment. He died at four o'clock of this day.

On dissection, the whole abdomen was tympanitic. A quantity of fæcal matter was found extravasated. Universal marks of inflammation were every where visible, with agglutination, and effusion. There was a binding down of the lower portion of the ileum, causing an obstruction there, and the appendix cæci had burst and discharged fæces into the general cavity.

We fear that the slowness of the pulse prevented early depletion in the above case. These abdominal, and especially cocal inflammations, are equally insidious and dangerous.-Medical Examiner, April, 1844.

INTERNAL ANEURISMS.

In the Philadelphia "MEDICAL EXAMINER," of April 20, 1844, three cases of internal aneurism are related, of which we shall notice two.

Case 1.-Was a female aged 34 years, a hard-working woman and intemperate. She entered hospital, Dec. 28, 1843, presenting dyspnoea, especially increased about three o'clock every morning, relieved by expectoration. She had a harassing cough and much expectoration. Auscultation revealed the "cantus avium omnium" of Lænnec, that often shews a combination of bronchitis and empyema. She had little fever, increase of pulse, or pain. Much dulness about the region of the heart, with a roughened first sound. Her history threw no light on the nature of the malady. On the 15th January pneumonia took place in the lower lobe of the right lung, which terminated fatally in two days.

Post Mortem.-There appeared an aneurismal tumour, two inches in diameter, issuing from the arch of the aorta, which had not burst, but was filled with laminated coagula. The coats of the aorta were much thickened about its origin, with depositions obstructing the orifice of the left carotid artery. The aneurism was closely adherent to the œsophagus, and pressed on the trachea. One of the mitral valves was atrophied.

Case 2.-A female cook, aged 40 years, entered hospital, 26th January, 1844, complaining of cough, expectoration frothy-pain in the left axilla. Had cough for three months, but only kept her bed during the last fortnight, though her breathing was short for six years. Percussion clear on left side, but dull on the right. The breathing cannot be heard in the upper part of the right lung, except by great exertion of the patient. The resonance of the voice there approached bronchophony. The heart itself did not present any particular phenomenon. At the junction of the second rib with the sternum, there was distinct pulsation and heaving, together with some elevation of the part, and the sounds of the heart were here (right side) as audible as in the region of the heart itself. No aneurismal thrill could be heard or felt. January 31, she was seized with a great difficulty of breathing, and next morning was in a distressing state, and spat much blood and mucus. She lingered till the 4th February, when she expired. Post Mortem.-Right lung compressed, and its space occupied by a large tumour caused by effused blood from an aneurism of the arch of the aorta, which had given way. The arch itself was much dilated, and lined with scales of bone. We have a patient under our care at the present time who has suffered much from cough and dyspnoea, and in whom we recognize a distinct pulsation under the right clavicle. We have little doubt of an aneurism of the aorta.

OBSERVATIONS ON THE CLIMACTERIC DISEASE, WITH CASES. BY HENRY KENNEDY, M.B. &c. &c. One of the Medical Officers of St. Thomas's Dispensary.

[Dublin Journal, May 1844.]

It is now more than twenty years since Sir Henry Halford published his Paper on the Climacteric Disease, and for many a long year we have directed our attention to the malady in question, but not with the most satisfactory results. We occasionally see people, at all ages, droop in general health, but without any tangible or appreciable disease of any particular organ-exhibiting a declension of all the powers of life-a deterioration of all the vital functions-and this state continuing for many months, ending in death, or a gradual restoration to health.

Generally, however, some one organ, as the heart, the lungs, the kidneys, or the stomach gives way before the fatal termination arrives, and appears to be the immediate cause of death. That such a break-up of the constitution takes place more frequently at 63, than at 53-43, or 33, might be naturally expected; but beyond this, we verily believe that there is nothing about the "GRAND CLIMACTERIC" except the force of imagination. Dr. Kennedy believes that the malady in question is a substantive disease; but that it is not confined to the climacteric period, as he has seen it not unfrequently between the age of twenty and thirty years. But this is not all. Our author observes :-" Were I to speak from my own experience, I should say that the persons who pass through life without having laboured under it, once, if not twice, are the exceptions to the general rule." The following sketch will shew that the climacteric disease is just what is familiarly called being "out of health," or "out of condition," for a longer or shorter period.

Climacteric disease in general commences in a very gradual way. From three to six weeks may pass over, the individual not feeling quite well, and yet not making any distinct complaint. I have known it happen too, though it is not common, that the patient was observed by his friends to be looking ill for a considerable time before he made any complaints whatever. In the great majority of cases, however, the remarkable change the countenance undergoes is not observed till a later period of the disorder. Pains of one form or other are among the most common symptoms ushering in the attack: these may be of a darting and transient character, passing through the entire frame, or they may be more fixed and confined to a certain part. In the former case they are set down as rheumatic or gouty pains, according to the habits, or, it may be, the wishes of the individual; while in the latter nothing remarkable is to be observed about them, except that in general they are in a very marked degree periodic. Another very common symptom complained of in the earlier stages of the disorder is weakness, which is referred in general to the knees, the patient expressing himself in the usual way, by saying that these parts feel as weak as water. It is not alone when the patient is walking about that this weakness is complained of; on the contrary, they suffer from it while lying on a sofa, and I have seen it complained of to such a degree that it was described as amounting to absolute pain. It is also worthy of remark, in connexion with this sense of weakness, that it does not seem to be increased by any exercise the individual may take. In one instance, which will be given in detail, this symptom recurred for several days, and at a particular time of each day, before any other symptom showed itself, the individual during this period wondering what could be the cause of such weakness.

"It has been already stated that the disease under notice generally commences in a gradual way. To this, however, there are some remarkable exceptions, and this is an important point to keep in mind. I have known the disease commence with what may be called acute symptoms. Thus a common bilious attack has been followed at once by the usual symptoms, and well-marked climacteric disease has been established within fourteen days. A case of this sort will be detailed. A common cold, or influenza, have been already mentioned as ushering in the attack. But probably the most important of this class of cases is where the disease commences with head symptoms of so acute a character as to throw the medical man entirely off his guard. Under such circumstances a wrong view is very apt to be taken of the case, and erroneous treatment adopted in consequence. This will be alluded to again.

"After the pains, which have been before spoken of, have existed some time, other symptoms make their appearance, in quicker succession too than the commencement of the disease would lead one to expect. The appetite begins to fail; this soon increases to a total loss of it; and finally, should the attack be a well marked one, an utter aversion for all sorts of food succeeds. With this there is