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ART. I-CASE OF FIBRO-SCIRRHOUS TUMOUR,-CONTINUANCE FIFTEEN YEARS,-DEATH,-NECROSCOPY,-REMARKS.

BY JOHN S. Rohrer, M. D., OF PHILADELPHIA.

HISTORY.-Miss S., of delicate and slender frame, aged fifty-four years, died on the 7th August, 1840. She was of scrofulous habit, and subject to glandular swellings of the neck. Fifteen years previous to her decease, she first observed a tumidity of her abdomen, which produced a sensation of fulness and distention. From this time her catamenia ceased to flow, and were never afterwards restored. The abdomen continued to enlarge, which circumstance, and the sudden suppression of the accustomed secretion, caused some apprehension on the part of her too solicitous friends, calculated to reflect upon her heretofore fair and unsullied character. In due time, however, her faded complexion and emaciated form, together with an increase of her malady, dispelled their ill-grounded suspicions, and convinced them that there was no rational cause either to affect the matron's pride, or raise the virgin's blush. Previous to this she enjoyed good health. Her skin soon became sallow, and, towards the termination of her complaint, of an earthy hue. Her appetite was generally good. During the long period of the gradual developement of the tumour, she was not prevented until within six weeks of her death, from attending to her accustomed daily avocations. Towards the close of her malady there was some cough; difficulty in moving about; a "sense of bearing down;" occasional abdominal pain; dyspeptic symptoms; swelling of the feet and legs; paroxysms of chills and fever. Her body was much emaciated, and it was with great difficulty that her feeble and exhausted frame could sustain the enormous load with which she was obliged to move about. Her bowels were constipated, and great pain was produced by evacuating their contents; her urine could not be voided without an assistant to push up the tumour from the brim of the pelvis, for the purpose of allowing the urine to escape from the neck of the bladder.

August 7th, 1840. Necroscopy five hours after death.-There are scrofulous enlargements of the glands of the neck, behind the ears, and under the chin, most of which are cicatrised, and a few ulcerated.

The lungs on the anterior surface are of a dark red colour, and upon pressing portions between the fingers, numerous little hard bodies are felt, varying in size from a millet seed to a garden pea. The anterior lobe con

tains many of these tubercles clustered in bunches, and forming a considerable mass. They resemble the miliary tubercle of Laennec. Other portions have the natural spongy structure and the crepitous feel.

Upon opening the cavity of the abdomen, an irregular ovoid tumour is seen anterior to the intestines, and occupying the hypogastric, umbilical, and epigastric regions, extending into the pelvis, and filling its entire cavity. After carefully removing the tumour from its different attachments, it weighed forty-five pounds, and measured from the apex to its base twentyone inches, through its lateral portion nineteen inches, and from the front to its back surface, through the centre, nine inches.

The liver, spleen, pancreas, and kidneys were normal.

The tumour had a covering of the peritoneum, which kept it in its situation, and bound it firmly to the parietes of the abdomen, to the intestines, pancreas, spleen, uterus, and bladder. The whole length of the colon was attached to it by strong adhesions. The uterus lay in front, and the broad ligaments were stretched over it at the lower portion where it emerged from the pelvis, and adhered firmly to its lower surface. The Fallopian tubes and ovaries were normal, and could be traced in front of the lower portions of the tumour on each side of the uterus, strongly attached to it. The bladder was also in front of the tumour, and fastened to it. This viscus, as well as the uterus, was pushed above the brim of the pelvis, and the necks of both were very much elongated. Many blood-vessels supplied the tumour from these attachments.

The tumour appears to have originated either in the cavity of the pelvis or abdomen, and by its gradual enlargement pushed the peritoneum before it, which gave it a covering and supplied it with blood-vessels. The external surface presented a smooth and uniform appearance. Upon making a section through the middle portion, a crepitus is produced by the edge of the scalpel. The internal substance exhibits a variety of appearances, generally of a whitish colour, but some portions of it have a blueish, others a dusty gray and yellow colour.

The whole appears to be a mass formed by the aggregation of tumours or lobules in their progressive developements. The consistence and structure varies, portions being of a loose structure and containing cells. The greater mass is hard and intermixed with cartilaginous and bony maller. The upper portion of the tumour is composed of a homogeneous substance of almost cartilaginous consistence, and mixed with a substance of less density of a whitish colour. Lower down it represents a dense substance resembling a section of pork. Throughout the greater part its consistence varies from that of fresh pork to boiled udder or brain. A large quantity of this carcinomatous matter throughout the whole tumour is accumulated in cells. In some places the lardaceous substance forms a homogeneous mass of considerable bulk. Fibrous matter, mixed with glandular substance, is seen throughout the whole tumour. Red points can also be traced in different parts, of the colour and consistence of the fibrine of blood.

Portions of it again are composed of almost entire osseous matter; spicula of bone are seen at different points, of an inch in length and a line in thickness.

In the centre of the tumour is a large cavity containing a fluid of the consistence of cream, intermixed with shreds of cellular tissue, detached bloodvessels, and a curdy matter of a grayish colour. There are other smaller cavities containing serum.

I will not further attempt to enter into details, but will content myself with saying, that after a minute and careful examination of the different structure and consistence of the tumour itself, and a comparison with Professor Carswell's "Illustrations of the Elementary Forms of Disease," I am satisfied that in this interesting specimen, the scirrhous, lardaceous, mammary, medullary, and hæmatoid forms are all combined.

Chestnut street, Nov. 22, 1840.

J. S. ROHRER, M. D.

ART. I.-FUCHS ON THE INFLUENCE OF PROFESSONS ON HEALTH.'

Professions, in medical statistics, may be considered certain determined combinations of external circumstances to which classes of men are exposed. Their influence is much more powerful and obvious in India, where they are hereditary, than in Europe; yet several professions in Europe have a remarkable effect in modifying the extent of sickness and death to which their members are liable. Before this full effect can be determined, extended series of observations, made by different individuals, must be collected; and the observations must embrace all essential_facts, capable, like other facts in physical science, of being compared. To determine the relative health of any profession or class of men, and the deleterious influence of any circumstance in which they may be placed, the facts required are simple and few; but it is very rare that they can all be obtained, or at least are all furnished by writers. In the first instance, it is necessary to ascertain the number of individuals in each profession between the ages of 10-20, 20-30, &c., and then the total cases of disease, the average number constantly sick or the days of sickness, and the deaths in a determined time; from which data the annual diseases and deaths in 1000, and the average proportion of sick at all ages may be deduced. The sicktime and mortality in an assumed unit of lifetime thus becomes a determined quantity, which may be compared with any other quantity. To give an example: in the island of Corfu2 the average force of the British troops was 1974-5 during the six years 181621; equivalent to 11,847 (1974·5×6) years of life, 620 of which were years of sickness. The total number of cases treated amounted to 14,098. Whence it is found by direct proportion that in a year 1000 soldiers living suffered 1190 attacks of sickness; that 52 of them were on an average constantly ill, and that 27 died. Of 1000 cases treated, 23 terminated fatally. A table in which these results were compared with those presented by other classes of men, would constitute a law of health for professions: it would teach the medical practitioner how many patients in a known population he may expect to attend; the general on how many effective men he may count in a campaign; the government how the labouring, manufacturing, agricultural, and higher classes are affected by political or economical measures. The sick-clubs and self-supporting dispensaries can only be firmly established by a knowledge of the quantity of sickness in the class they embrace; and if they enter every individual, distinguishing the age on their books, they will soon be in possession of a mass of useful facts.

The observations of Professor Fuchs were collected from the reports of a trades' institution in Würtzburg, to which each workman employed contributed weekly, in order to obtain a certain sum in sickness. These reports, published since 1788, distinguish the contributions of each trade; the deaths and attacks of sickness occurring in each trade have been distinguished from the first and from these contributions and payments the learned professor has been enabled to ascertain that, since the foundation of the society in 1786 (49 years), the average number of contributions has been 1186; the

1 British and Foreign Medical Review, October, 1840, p. 373.

Ueber den Einfluss der verschiedenen Gewerbe auf den Gesundheitszustand und die Mortalität der Künstler und Handwerker in den Blüthenjahren, &c. Von Dr. C. H. Fuchs.

A Statistical Memoir on the Influence of Various Professions on the Health and Mortality of Mechanics and Artisans in the Prime of Life; founded on the Tables of the Institution for Sick Mechanics in Würtzburg from 1786 to 1834. By Dr. C. H. Fuchs, Professor of Medicine in Würtzburg. Berlin, 1835. 8vo.

2 Hennen's Medical Topography of the Mediterranean. We have not been fortunate enough to meet with all these data in any other work, foreign or English. This article was written before the appearance of the army medical reports.

same as if 58,125 members had lived and been occupied in their respective arts one year in Würtzburg: 275 cases of sickness and nine deaths occurred on an average annually; for the total attacks of sickness in 49 years amounted to 13,268; the deaths to 445. Of 10,000 contributors, 2,282 fell sick, and 76 died, yearly; and of 10,000 cases treated, 327 (1 in 29.8) ended fatally. The value and defect of Professor Fuchs's method of inquiry are sufficiently obvious; but we shall compare it with what was said before, to impress the right method more forcibly on future observers.

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The ages of neither class were certainly known; and this table only shows the attacks of sickness and deaths at the ages specified; the attacks of sickness are however probably the same at all ages between 10-70. A material defect in the German professor's researches, it will be perceived, is the omission of the average proportion of sickness; investigated in the friendly societies of Great Britain by Dr. Price and the Highland Society, a defect which the data already before him will probably supply. It is almost unnecessary to remark, that the excessive mortality and sickness of the soldiers is in part owing to the climate and fevers of the Mediterranean. The mortality and sickness of soldiers in times of peace is in their native climate greatly above the average; of the English infantry eighteen in a thousand die annually, while the mortality of the entire population is only ten in a thousand at the corresponding age. The mortality of the Würtzburg artisans is apparently low; Dr. Fuchs states that the ages of the different classes were nearly the same, on an average between 15 and 35 years, and this may be fairly brought within the narrower mean of 20-30; at which period of life the mortality in Carlisle was 7·54 per 1000, differing to a trifling extent from 7-60. With Dr. Fuchs we are disposed to place considerable reliance on this general result, although the body of artisans in the society were to a certain extent selected; and we subjoin for comparison the deaths in 1000 at the same age in England and Wales, in Belgium, and in Sweden; England and Wales.

10.1

Belgium.
9.1

Sweden.
8.9

Wurtzburg.
7.6

Carlisle.

7.5

The proportion of 32-7 deaths in 10,000 cases treated, the professor thinks highly favourable; but on what grounds we do not know. Nearly the same mortality (334) has been observed among the sick of the British troops in Bengal; and in Corfu, only 230 died in 10,000 treated. At the same time the attacks of sickness suffered by 1000 persons in Würtzburg, Corfu, and Bengal, were in the proportion of 228, 1190, 1713.

The mean mortality of the Würtzburg artisans, expressed in parts of 10,00, being 76; the mean frequency of sickness 2282; when the same operation has been repeated for each profession, on a sufficient number of individuals, their relative mortality, and what Professor Fuchs has called their morbility, may be determined by comparison with the mean standard.

Before examining the professions separately, it is necessary to observe that: 1. The institution, and consequently the calculations, only embrace the incorporated trades; day labourers, hackney coachmen, and some others,

'Burke on the Mortality of Troops in India, 1826-32. Edinb. Journal, No. 109.

are consequently excluded. 2. That only journey men and apprentices belong to the institution. And this is so far for the advantage of the calculation, as the sick are nearly of the same age (15-35); besides, for obvious reasons, a profession exercises its baneful influence far more intensely on journeymen and apprentices than on their masters, who often only superintend without working at their business, and so avoid its discomforts and dangers. 3. Formerly several trades, for example, watchmakers and gunsmiths, carpenters and slaters, &c., formed one united company, and were placed together in the accounts. Professor Fuchs had no means of separating these associated trades, and was himself compelled to combine several of the smaller allied trades, in order to obtain more probable results. 4. Members having syphilitic diseases, and, up to the year 1828, also itch, were not entered on the books.

The second and third columns of the following tables, showing the total deaths and diseases of each profession, were calculated from the payments made in the 49 years; but the contributors belonging to each profession were only known from 1818 to 1834; and the numbers in the tables were obtained by first ascertaining the relation of the sick to the contributors during these seventeen years, and calculating from the relation so obtained the number of contributors in the earlier period. For example, of 920 weavers who contributed between 1818 and 1834, exactly 269 had an attack of sickness; and, as during the 49 years 480 of the weavers fell ill, the following proportion gives the total number of weavers who had contributed, 269: 920 :: 480: 1642; which last sum is entered in the first column of the table.

We purposely withhold the arrangement of these 54 trades in the elaborate table of Professor Fuchs, according to their greater or less mortality and morbility, and all the professor's reasonings on their relative salubrity. Professor Fuchs is apparently ignorant or forgetful of the well-established physiological fact, that the fluctuations of mortality between 15 and 35 are limited to nearly 7-20 in 1000 of those who remain in their native climate, or he would not reason seriously with the great anomalies of the fifth column before his eyes. These anomalies are principally due to the paucity of observations, which may be sufficiently augmented if proper returns were obtained from all similar institutions; on this account the paper before us deserves attention. It is one of the numerous series of observations which we hope to collect in this Journal, from which our readers, or perhaps ourselves at some future time, may deduce rational, well-founded generalisations. It may, however, be observed, that in this arrangement, and in that which follows, those classes in which the morbility exceeds 2282, the mortality 76, are considered unhealthy; on the contrary, those professions are considered salubrious in which the proportions fall below the average.

The influence of a profession on health is the result of several appreciable agents, to determine the exact value of which is the next step in the inquiry. For this purpose Dr. Fuchs has grouped all the professions in the table according to the locality in which they are carried on; the temperature and moisture connected with their exercise; the materials employed; the muscular force required; the position and necessary movements of the body; the aliment insured to their followers; the amount of wages; their influence on the education and the state of mind of their members. This has the further advantage of increasing the number of facts in each category, and diminishing the chance of error from differences of age. The first column shows the extent of the observations or the number of yearly contributors in the group; the second the attacks of sickness in 10,000 persons living one year; the third the annual deaths in 10,000; and the fourth the deaths in 10,000 cases treated. It is right to observe that the morbility is diminished disproportionably in some professions, where the contributors were well off, and resorted less frequently than others to the institution; all the deaths were recorded. To catch the eye more readily, an * has been affixed where the mortality and morbility were above, at where they were below the

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