655 of tenderness, the vein may be felt solid with clot, andandE severely ulcerated. The contrast between the two limbs there is little or no oedema. If the intramuscular veinswasB striking and showed that even when the inferior cava are implicated there will be more pain and some deep has1 been obliterated, if the other veins are not interfered swelling, the limb feeling tight and heavy but showing’with,‘ a collateral circulation may be established quite little superficial oedema. If a main trunk is obstructed, assufficients for all ordinary purposes. But complete and the femoral, there will be more general cedema and the permanent] obstruction of the inferior vena cava may occur limb may become tensely swollen. There may still bewithout any marked development of the superficial veins ; as but little constitutional disturbance, and the chief danger iin a case examined at St. George’s Hospital where the to be apprehended is the detachment of clot. If the patient collateral4 circulation seemed to have been carried on almost is kept at rest these symptoms may gradually subside,entirely by the greatly enlarged azygos veins. The patient, the circulation through the veins involved may becomea woman, aged 50 years, died from pneumonia and post re-established and the limb after a time may completelymortem it was discovered that the inferior vena cava, from regain its normal condition. But in many cases some just above the entrance of the right renal vein to imme- of the affected veins are permanently obliterated, and when diately below the entrance of the hepatic vein, had been large trunks are involved they are often left with the converted into an impervious fibrous cord. The azygos veins walls thickened and lumen diminished by the adhesion and were greatly dilated and tortuous, but the veins of the shrinking of organised clot. I have found some of the surface of the body were not dilated or prominent.51 Dis- smaller veins of the calf blocked by firm adherent clot in sections of similar conditions in cases of obliteration of the cases where the limb appeared to have completely recovered vena cava were described many years ago by Dr. Matthew from attacks of phlebitis. The veins of the lower extremity Baillie ’2 and by Mr. Wilson.63 Uncomplicated peripheral are much more often attacked than those of the upper limb venous thrombosis does not cause gangrene. When this and those of the left more often than those of the right does occur it is in consequence of arterial as well as limb; the disease begins very commonly in the deep veins venous obstruction or else of the addition of inflammatory of the left calf. In this class of cases there is not so great disturbance. a liability to recurrence as in those of gouty origin. I have had the opportunity of observing several patients for varying periods up to ten years in whom there has been no recurrence after a severe first attack. A satisfactory subsidence and Lectures recovery is, however, not always the rule. The thrombus The Milroy ON may extend in the direction of the blood current and so to the larger trunks, causing increasing embarrassment to the EPIDEMIC DISEASE IN ENGLAND—THE circulation. Thus from the femoral vein coagulation may spread through the iliac to the inferior vena cava, or from the EVIDENCE OF VARIABILITY AND veins of the neck and upper extremity to the superior vena OF PERSISTENCY TYPE. cava, and thus to the heart. Professor G. M. Humphry de- OF scribed such cases with characteristic in a thesis on accuracy Delivered before the Royal College of Physicians of London on coagulation of the blood in the veins, published in 1859.58 March 1st, 6th, and 8th, 1906, I have seen a case in which the thrombus extended as high as the renal vein and in which recovery took place but with BY W. H. HAMER, M.D. CANTAB., of of the vena cava. M.A., permanent obstruction part When F.R.C.P. LOND. this occurs an enormous development of the superficial veins of the groin and abdominal wall usually takes place for carrying on the collateral circulation. A similar condition LECTURE 11.1 has been observed in connexion with obstruction of the Delivered on March 6th. superior vena cava, though this event is rare except in consequence of the pressure of intrathoracic tumours. MR. PRESIDENT AND GENTLEMEN,-Creighton gives the I exhibit a photograph showing the development of the earliest clear reference to influenza in these islands at 1173, superficial veins 21 years after obliteration of part of the when there was an evil and unheard-of cough (" tussis mala inferior vena cava. In this it took about ten patient years et inaudita ") at Melrose, while in this same year a certain for these veins to reach a troublesome degree of enlarge- dean of Paul’s on the continent the ment and it is only lately that the circulation has become St. travelling found completely compensated, so that now there is no difference whole world " infected by a nebulous corruption of the air in the size of the limbs at night and in the morning and the causing catarrh of the stomach and a general cough." 2 outline of the muscles is easily perceptible. Sir Thomas There can be no room for doubt as to the character of the Watson,59 in his lectures on the Principles and Practice of coqueluche of 1510 whatever be thought of the five " sweats " Physic, has described, in his inimitable manner, two cases already discussed or of agues (such as the "hot agues of illustrating the effects of obliteration of the vena cava and 1540") occurring during the first half of the sixteenth has given diagrams which show the collateral circulation. century. In 1557-58 occurred the epidemic which Dr. John One of these was the case of a man who exhibited in a Jones ("Dyall of Agues ") compared to the true sweat of remarkable degree the results of obliteration of the 1551 ; it was "a new burning ague," and one-third part of vena cava an of the innominate superior by aneurysm the population taste the general sickness." In 1562 there was The shows the the artery. diagram means " whereby blood an outbreak of the "new acquaintance." Mary Queen of from the head found its at descending way length through Scots was attacked by it in Edinburgh in this year. In many circuitous channels to the heart." The second case 1580 the " gentle correction " appeared, and in 1596-98 there related Sir Thomas Watson was that of a woman in whom by was prevalence of a malady which was in all probability three inches of the inferior vena cava were the " obliterated by influenza. Fuller describes the "ague " of 1558 as a dainty of a tumour of the a of pressure liver, great development mouthed disease which passing by poor people fed generally the veins of the thorax and abdomen superficial contributing on principal persons of greatest wealth and estate," and, to the collateral circulation. Thomas draws Sir Watson indeed, "ague" may now be said to have replaced the attention to the tortuosity of the veins in which the direction formerly fashionable "sweat." of the current is retrograde. " Influenza " seems to have been first to an 60 applied Mr. C. Mansell Moullin has recorded a case of throm- epidemic in Italy, in 1729 ; at any rate, it is introduced in an bosis of the inferior vena cava a fall on back following the account of that outbreak given in a London periodical in and over-extension of the spine. The vein was obliterated from 1830. The word first appeared in England in 1743 but did not a point immediately below the entrance of the renal vein and the left common and external iliacs and the femoral 61 Post-mortem and Case Book, 1896, No. 145. vein were blocked. The right leg was scarcely cedematous ; 62 Transactions of the Society for the Improvement of Medical and the left was six inches more in circumference, hard, brawny. Chirurgical Knowledge, vol. i., p. 127. plate v. 63 Ibid., vol. iii., p. 65. See also Dr. Peacock in the Transactions of the Royal Medical and Chirurgical Society, vol. xxviii., p. 1, on 58 On Coagulation of the Blood in the Venous System during Life. Thrombosis of the Vena Cava Superior, with reference to other by George Murray Humphry, M.D., F.R.S. Macmillan, Cambridge, published cases. 1859. 1 Lecture I. was published in THE LANCET of March 3rd, 1906, p. 569. 2 59 Lectures on the and Practice of vol. Some suspicion attaches, Creighton thinks, to a " rheumy in- Principles Physic, ii., p. 350, " 1857. firmity " at St. Albans in 1427 and to the " pestilentia volatilis recorded 60 Transactions of the Clinical Society of London, vol. xvii., p. 115. by Fordoun in Scotland in 1430 and 1432. 656 " come into common use until the beginning of the nineteenth References to "a crisis by sweat after a few days" century. In the seventeenth century influenza was, says (Fothergill) ; "sweats which came on spontaneously" Creighton, variously designated "new disease," " new ague," (Haygarth) ; " considerable sweats " (White) ; "a plentiful " strange fever," "new delight," "jolly rant, "great cold," easy sweat " (Glass) ; and "warm copious sweats " (Reynolds) "unusual cold," "unusual transient fever," &c.; in the occur in connexion with this epidemic. Glass’s account is eighteenth century "catarrh" was commonly applied to it. particularly interesting : he refers to attacks in institutions ; As Robert Boyle says: "The term new disease is much he speaks of "a spontaneous sweat being the natural remedy abused by the vulgar, who are wont to give that title to of the fever"; he even uses the identical expression, "aa almost every fever that in autumn especially varies a little in Diary fever " applied by Caius to the sweating sickness of its symptoms or other circumstances from the fever of the 1551 ; finally, he refers to horses and dogs being attacked, as foregoing year or season." do Haygarth and Pulteney also.