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ELEMENTS

PATHOLOGICAL ANATOMY,

ILLUSTRATED BY

NUMEROUS ENGRAVINGS.

' IN MORBIS, SIVE ACUTIS, SIVE CHRONICIS, VIGET OCCCLTUM, PER HUMANAS
SPECULATIONES FERE INCOMPREHENSffilLE.' — BAGLIVI.

BY SAMUEL D. GROSS, M. D.,

LATE PROFESSOR OP GENERAL ANATOMY, PHYSIOLOGy, AND PATHOLOGICAL ANATOMY,

IN THE MEDICAL DEPARTMENT OF THE CINCINNATI COLLEGE :

AND NOW PROFESSOR OP SURGERY IN THE LOUISVILLE MEDICAL INSTITUTE, KY.

IN TWO VOLUMES. VOL. H.

i-rfJ DC

r-

BOSTON:
JAMES B. DOW, PUBLISHER,

X p PHILADELPHIA, BARRINGTON & HASWELL. NEW YORK, J. & H. G. LANGLEV.

LOUISVILLE, KY., JAMES MAXWELL.

1843.

Entered according to Act of Congress, in the year 1839, by

SAMUEL D. GROSS, M. D.,

In the Clerk's Office of the District Court of the District of Massachusetts.

WM. A. HALL & CO. S PRESS,
No. 12 Water street.

' :-^AiG STREt;,

r-.7;"5£URGH, PAc

Hecommnti)ations.

[From the New York Journal of Medicine and Surgery.]
" We had been looking forward for some time to the publication of Dr.
Gross's work on Pathological Anatomy, feeling assured that, if ably execu-
ted, it would confer a great benefit on the profession of this country.

" From the examination that we have already made, we are induced to
form the opinion that Dr. Gross is a laborious and careful investigator, an
honest, fair-minded man, with sufficient practical acquaintance with the
subject to distinguish the true from the visionary. That such a mind
should produce a work of the highest value on a subject so much neglected
in this country, is what might have been expected. And let it be justly
appreciated as an effort far better adapted to our present necessities than
the sublimer, but less intelligible efforts of genius could possibly have
been. We want a clear and simple statement of the actual knowledge
that has been acquired on this subject, by a careful comparison of the best
authorities, enlightened by sufficient personal experience to appreciate
what is true, and to reject what is false or imperfectly established. This
we believe Dr. Gross has accomplished.

" What strikes us as particularly useful, is the concise description of the
healthy condition of parts as introductory to the history of the morbid
changes they may undergo. Finally, the work is enriched with colored
plates and numerous wood cuts, Avhich are very well executed."

[From the Philadelphia JVIedical Examiner.]

"We have no better evidence of the importance attached to the study of
Pathological Anatomy, as an aid to diagnosis and treatment, than the pub-
lication of these volumes. The leading characters of the work, taken as a
whole, are, that it is clearly written, systematic, correct, and more complete
than other work supon the subject. Its accuracy and comprehensive char-
acter place it among the most valuable additions to medical literature. The
work is illustrated by nearly one hundred excellent wood cuts, a colored en-
graving of the inflamed mucous membrane of the alimentary canal, and
several other colored engravings. The illustrations are, therefore, as abun-
dant as is compatible with a price which would put the book into the hands
of the profession in general. It desei-ves an extended circulation, not only
for its own merits, but because no other work now in the liands of the pro-
fession can supply its place. We have spoken in high terms of it because
it possesses real and desirable excellences. It will rank among the stan-
dard productions of medical literature."

[From Bell's Eclectic Journal of Medicine.]

" The appearance of this work is creditable alike to its author and the
publishers ; — to the first for the ability and industry displayed in its com-
pilation and production ; to the second for their liberal venture in a com-
paratively new department on this side of the Atlantic. The merits of
these two parties, on the ground just stated, would entitle them to receive
from the medical public prompt and liberal encouragement by a large and
ready sale of their book.

" But, happily, another and a stronger motive will be operative in quick-
ening the attention and securing the support of this third party. It is the
positive benefit to themselves procurable by a careful perusal and study of
the pages of Dr. Gross ; and Ave may as well declare at once, that they Avill
be faithless to their trust if they AvilfuUy shut their eyes to his large collec-
tion of facts which are hardly less important by their not constituting a

body of doctrine." " We ought not to conclude without mentioning

the numerous wood engravings interspersed Avith the text, and Avhich give
a clearer knowledge of the author's Avritten descriptions. There is anoth-
er merit which belongs to the publishers, namely, the full and clear type in
Avhich the work is printed, and for Avhich every reader ought to thank them,
as Ave do."

^O^*^

Haommcniration©.

[From Dnnglison's American Medical Library and Intelligencer.]
"That a convenient work, in the English language, on Pathological
Anatomy, adapted to the existing condition of the science, was demanded,
will be admitted by all. This desideratum Pi-ofessor Gross has endeavored
to supply; and we can strongly recommend his 'Elements of Pathological
Anatomy ' to the attention of the pathological inquirer. In manuscript, the
production impressed us favorably, and the opinion is sustained, now that
it is placed before us in a more tangible form. We trust that the work
may see many editions, and we are satisfied that it will be the earnest en-
deavor of the able and industrious author to keep it a^ -porUt with the exist-
ing condition of the science. The student of Pathological Anatomy will
find these volumes entitled to his best attention."

[From the Boston Medical and Surgical Journal,]

" Not many weeks ago, a notice was given of the appearance of this fin-
ished and truly splendid production from the pen of Dr. Gross, of Cincin-
nati. In calling the attention of our many readers to the second examina-
tion of the claims which a native work has upon them for patronage, we
have ho other interest to serve than that of the whole profession, who can-
not be indifferent to the progress of any measures v/hich place in their
hands, and at their disposal, new powers, new agents, and unlooked for
prospects of success in the jaractice of physic."

" This great undertaking of elaborating two volumes, in which the whole
field of Pathological Anatomy has been surveyed under the skilful eye of a
master, cannot be passed by with indifference, or the work take its rest
upon the shelf, before its pages have been most carefully and minutely
studied. It is not, indeed, of a character to be easily forgotten."

" There is a large amount of matter brought to a focus on every leaf, and
where marginal diagrams are interspersed, we feel that Dr. Gross has neg-
lected no attractive method by which the text may be clearly and compre-
hensively understood in its details." " We are here put in pos-
session of not only a valuable treatise, but a beautifully-executed specimen
of copperplate printing, xylography and typography."

" In ostensibly constructing a guide-book for those less conversant than
himself with the intricacies of the labyrinth through Avhich he has been
travelling, he has raised a monument to his own fame that will transmit
his nsime to posterity, as a bright example of the triumphs of industry ;
while it will prove that the far west, in the infancy of our country, is a
genial region for intellectual attainments, and for the difflision of useful
knowledge."

[From ELISHA BARTLETT, M. D., Professor of the Theory and Practice of Med-
icine in the University of Transylvania, at Lexington, Ky.]

" It gives me jDleasure to add my testimony to that of other medical gen-
tlemen in favor of the value and excellence of Dr. Gross's work on Patho-
logical Anatomy. There are many points connected with this branch of
medical science, especially in relation to the diseases of our own country,
which arc yet far from being fully understood and settled ; but the work
of Dr. Gross is, on the whole, the best summary of Pathological Anatomy
in the language. ^^^^^^^ Bartlett."

Lowell, July 2d, 1840.

[From J, B. S. JACKSON, M. D., Boston,]

" I have frequently had occasion to consult Dr. Gross's work on Patho-
logical Anatomy, and I sliould consider it a very valuable accession to the
medical literature of tliis country. Besides the opinions of the best writers
on the subject, it contains many original observations which are highly
creditable to the talents and zeal of the author, and I hope it may meet
with the patronage it deserves. j_ ^ g_ Jackson."

JiijKfon, Jiiiif 251.11, 1810.

CONTENTS.

PART II.

SPECIAL PATHOLOGICAL ANATOMY.

CONTINUED.

CHAPTER I.

OF THE THYMUS GLAND.

Situation, Weight, Color, and Consistence. — Developement and Decay. —
Hypertrophy. — Thymic Asthma. — Scirrhus. — Tubercular Deposits, - 9

CHAPTER II.

OF THE THYROID GLAND.

Location and Organization. — Acute Inflammation. — Suppuration. — Goi-
trous Enlargement. — Sanguineous EtFusions. — Tubercular Deposits. —
Scirrhus. — Symptoms of Diseases of the Thyroid Gland, 13

CHAPTER III.

OF THE RESPIRATORY APPARATUS.

Section I. Lesions of the Air-Passages. — Inflammation of the Larynx. —
CEdema of the Glottis. — Ossification of the Laryngeal Cartilages. — Poly-
pous Growths. — Trachitis. — Inflammation of the Bronchise. — Dilata-
tion and Contraction. Section II. Lesions of the Lungs. — General Ob-
servations.— Structure and Functions. — Acute Inflammation. — Hepa-
tization. — Abscess. — Gangrene. — Chronic Irritation. — CEdema. — Em-
physema. — Apoplexy. — Encephaloid Disease. — Melanosis. — Serous
Cysts. — Hydatids. — Calcareous Concretions. — Hypertrophy. — Atro-
phy. — Tubercular Phthisis ; its History and Symptoms. Section III,
Lesions of the Pletira. — General Observations on its Arrangement, Struc-
ture. — Acute Inflammation. — Formation of Matter. — Gangrene. —
Chronic Pleuritis. — Ossification. — Accumulation of Gas. — Ulceration.
— Tubercular Deposits. — Symptoms of Pleuritis. — Position of the Pa-
tient.— Alteration of Respiratory Murmur. — jEgophony. — Dulness on
Percussion. — Friction Sound, --- --^..20

CHAPTER IV.

OF THE HEART AND ITS MEMBRANES.

Section I. Lesions of the Pericardium. — Inflammation. — Hydro-pericardi-
um. — Formation of Matter and Deposits of Lymph. — Sjonptoms. — ■

IV CONTENTS.

EfFusiou of Blood. — Accnmnlation of Air. — Serous Cysts. — Congeni-
tal Absence. Section II. Lesions of the Heart. — Situation, Shape, Color,
Weight, and Dimensions. — Cardiac Sounds. — Capacity of the opposite
Reservoirs. — Structure. — Malformations. — Acute Carditis. — Collections
of Pus. — Ulceration. — Inflammation seldom or never ends in Gangrene.

— Softening. — Induration. — Cartilaginous and Osseous Degenerations.

— Scirrhus and Encephaloid. — Fatty Transformation. — Atrophy. — Di-
latation. — Hypertrophy. Section III. Lesions of the Endocardium. — Acute
Inflammation. — Thickening. — Wart-like Excrescences. — Fibro- Carti-
laginous, Cartilaginous, and Osseous Transformations. — Polypous Con-
cretions, - - 115

CHAPTER V.

OF THE NASAL, MAXILLARY, AND FRONTAL CAVITIES.

I. Formation and Structure of the Nasal Cavities. — Deviations from the
Normal Standard. — Nasal Septum. — Inflammation of the Schneiderian
Membrane. — Epistaxis. — Different kinds of Polypes. — Obstruction of
the Mucous Follicles. — II. Maxillary Sinus. — Purulent Accumulations.

— Ulceration of its Lining Membrane. — Polypous Growths. — Carcinoma.

— Exostoses. — III. Lesions of the Frontal Simis, - - ------ 156

CHAPTER VI.

OF THE MOUTH, PHARYNX, AND CESOPHAGUS.

I. Diseases of the Lips. — Carcinoma, Encysted Tumors, and Congenital Fis-
sure.— Malformations of the Jaw. — II. Glossitis. — Ulceration, Hyper-
trophy, and Cancer of the Tongue. — Congenital Deficiences. — III. Sali-
vary Glands. — Parotitis. — Atrophy and Hypertrophy. — Scirrhus. — Cal-
careous Concretions. — Ranula. — Fatty Degeneration. — IV. The Teeth.

— Organization, Articulation, and Chemical Constitution. — Gangrene.

— Inflammation of their Internal Membrane. — Fungous Tumors. — Ex-
ostoses. — Denuding Process. — Deposits of Tartar. — Congenital Vices.

— V. The Gum. — Liability to Inflammation. — Epulis. — Ulcerative Ab-
sorption. — Mortification. — Alveolar Abscess. — VI. Diseases of the Ton-
sils. — VII. 77(.e Soft Palate and Uvula. — VIII. The Pharynx. — Diph-
theritis. — Polypes. — Sacculated Condition. — IX. Oesophagitis. — Ulcer-
ation. — Softening. — Stricture. — Scirrhus. — Congenital Malformations, 163

CHAPTER VII.

OF THE STOMACH AND BOWELS.

Section I. Organization of the Gaslro- Enteric Mucous Membrane. — Thick-
ness and Consistence. — Cellulo-fibrous Tunic. — Mucous Follicles. —
Glands of Brunner and Peyer. — Villosities. — Color of the Membrane;
how modified by Age, Digestion, and other circumstances. Section II.
.InflammcUion. — Anatomical Characters of the actite form of the Disease.

— Increased Vascularity. — Dryness. — Thickening. — Softening. — De-
position of Lymph. — Formation of Vesicles. — Effusion of Blood and
Serum. — May pass into Gangrene or become Chronic. Section III.
Softening ; of two kinds, from Inflammation and the action of the Gastric
Juice. — Experiments of Hunter and Carswell. Section IV. Diseases of
the Stomach. — Ulceration. — Hypertrophy and Atrophy. — Formation of
Pouches. — Cartilaginous Degeneration. — Carcinoma. Section V. Le-
sions of the Duodenum. Section VI. Affections of the small Bowels, properly
so called. — Ulceration of the isolated Crypts and of the Glands of Peyer.

— Tubercular Deposits. — Miltrlike Tumor of Monro. — Melanosis. —
Intussusception. — Hernia. — Atrophy and Hypertrophy. — Earthy Con-
cretions. Section VII. Lesions of the large Doivel and Anus. — Ulcers.

— Wart-like Vegetations. — Singular Contraction of the Colon. — Carci-

CONTENTS. V

noma. — Fissure of the Anus. — Organic StricUire of the Rectum. —
Hemorrlioids. — Fistula. — Prolapsion of the Bowel. — Congenital Vices.
Section VIII. Intestinal Worms. — Lumbricoides. — Oxyuris. — Trico-
cephalus. — Tgenia Solium. — Tsenia Lata, 191

CHAPTER VIII.

OF THE PERITONAEUM.

Is liable to different forms of Disease. — Acute Inflammation. — Deposition
of Lymph. — Effusion of Serum, Pus, and Blood. — Softening of the Sub-
serous Cellular Tissue. — Parts of the Membrane most apt to suffer. —
Developement of Vesicles. — Chronic IiTitation. — Agglutination of the
Bowels and formation of false Passages. — Tubercles. — Ascitic Effusions.

— Generation of Gas. — Heterologous Growths, -------- -294

CHAPTER IX.

OF THE BILIARY APPARATUS.

Section I. The Liver. — Situation, Color, Dimensions, and minute Structure
of the Liver. — Has two Envelopes. — Lesions. — Inflammation. — Suppu-
ration and Abscess. — Gangrene. — Softening. — Induration. — Hypertro-
phy and Atrophy. — Tubercles. — Carcinoma. — Melanosis. — Hydatids.

— Adipous Transformation. — The Liver Fluke, and other Worms. —
Cartilaginous Degeneration. — Osseous Concretions. — Sanguineous Ef-
fusions. — Restorative Powers of the Liver. . Section II. The Gall-Blad-
der. — Inflammation. — Ulceration and Rupture. — Atrophy and Thicken-
ing of its Coats. — Diseases of the biliary Ducts. — Alterations of the
Bile.— Gall-Stones, 307

CHAPTER X.

OF THE SPLEEN.

Normal characters of the Spleen. — Its Color, Weight, Dimensions, and Inti-
mate Organization. — Acute Splenitis. — Anatomical Characters. — May
pass into Suppuration or into Gangrene. — Softening. — Induration and
Hepatization. — Hypertrophy and Atrophy. — Tubercles. — Calcareous
Concretions. — Fibro-Cartilaginous and Osseous Matter. — Hydatids and
Serous Cysts. — Sanguineous Deposits, ------------ 343

CHAPTER XI.

OF THE PANCREAS,

Where situated, and how organized. — Weight and Dimensions. — Color. —
Has no special Envelope. — Is liable to pretty much the same Diseases as
the Salivary Glands. — Rarely the Seat of Acute Inflammation. — Is some-
times affected with Scirrhus. — Fatiy Transformation. — Serous Cysts. —
Tubercular Deposits, --- ---_..-.. -.357

CHAPTER XII.

OF THE URINARY APPARATUS.

Section I. Supra-Renal Capsules. — Their Structure and Diseases enveloped
in obscurity. Section II. The Kidneys. — Observations on their Normal
Characters and Congenital Vices. — Lesions of their Fibrous Covering. —
Nephritis, Acute and Chronic. — Abscesses. — Softening. — Induration. —
Gangrene seldom or never observed. — Bright's Disease. — Scirrhus and
Encephaloid. — Tubercles. — Serous Cysts. — Hydatids. — Fibro-Carti-
laginous, Osseous, and Fatty Degenerations. — Enlargement and Atrophy.

— Renal Calculi. — The Strongylus. Section III. The Ureter. — Liable

VI CONTENTS.

to Deposits of Tubercular Matter. — Effusion of Lymph, Thickening and
Attenuation of its Parietes, Avith Contraction or Enlargement of its Cavity.
Section IV. The Urinary Bladder. — Is rarely affected with acute Inflam-
mation, Suppuration, or Gangrene. — Hypertrophy of the Mucous and
Muscular Tunics. — Developement of Cysts. — Ulceration. — Encephaloid
Disease. — Neuralgia. — Calculous Concretions. — Healthy and Morbid
Urine. Section V. The Prostate Gland. — Situation, Weight, and Vol-
ume. — Is liable to various Forms of Disease, especially to Enlargement, 364

CHAPTER XIII.

OF THE MALE ORGANS OF GENERATION.

Section I. The Testicle. — Observations respecting its Coverings, Weight,
and Volume. — Diseases of its Vaginal Tunic. — Inflammation. — Hydro-
cele. — Hematocele. — Earthy Concretions. — Orchitis. — Malignant Affec-
tions of the Testicle. — Tubercles and Hydatids. — Hypertrophy and
Atrophy. Section II. The Spermatic Cord. — Encysted Dropsy. — Vari-
cocele. — Neuralgia. Section III. The Seminal Vesicles. — Their Lesions,
few in number and still involved in obscurity. Section IV. The Scrotum.

— Carcinoma. — Excessive Enlargement. — Is sometimes affected with a
peculiar sloughing Ulcer. — They contain foreign substances, such as
Teeth, Hair, and pieces of Bone. — Earthy Concretions. Section V.
The Penis. — Gonorrhoea. — Gleet. — Chordee. — Organic Stricture. —
Abscess along the Course of the Urethra. — Malformations of this Tube. —
Morbid Erection of the Penis. — Degeneration of the Pectinifonn Septum
and Fibrous Sheath. — Carcinoma. — Syphilitic Ulceration. — Experi-
ments of Ricord. — Herpetic AflTections. — Warty Excrescences. — Phy-
mosis and Paraphymosis, .__._ 40I

CHAPTER XIY.

OF THE FEMALE ORGANS OF GENERATION.

Section I. 77te Uterus. — Situation and Shape. — Observations on its Weight
and Volume. — Is composed of a peculiar Substance. — Liable to Malforma-
tions. — Retroversion. — Prolapsion and Inversion. — Is apt to suffer from
Inflammation, both of its lining Membrane, its serous Covering, and its
proper Tissue. — Remarks on Uterine Phlebitis. — Softening. — Indura-
tion. — Fibrous Tumors. — Different Species of Polypes. — Calcareous
Concretions. — Transformation of the Uterine Tissue into Cartilage and
Bone. — Malignant Diseases. — Encephaloid and Scirrhus. — The Cor-
roding Ulcer and Cauliflower Excrescence of Clarke. — Tubercular De-
posits. — Hemorrhage. — Accumulation of Air. — Obstructions of the
Mouth of the Womb. ■ — Hydatids. — Uterine Moles. Section II. The
Ovaries. — Normal Characters. — Their Disorders are numerous and im-
portant. — Serous Cysts and Hydatids. — Scirrhus. — Occasionally contain
Teeth, Hair, and Fragments of Bone. — Hemorrhage. — Remarks on the
Corpora Lutea. Section III. The Fallopian Tubes. — How organized. —
Are seldom affected with Disease. Section IV. The Vagina aiid Vulva.

— Liable to the same sort of Maladies as the other Mucous Structures. —
Polypes of the Vagina. — Enlargement of its Mucous Follicles. — Vices
of Formation. — The Great Labia. — Clitoris. — Nymphoe, and Orifice of
the Urethra. Section V. The Mammary Gland. — Structure, Volume,
and Color. — Is often the seat of Acute and Chronic Inflammation. — Its
Diseases, in many respects, resemble those of the Testicle and Ovary,
Section VI. Placenta. — Structure. — Inflammation. — Suppuration. —
Softening. — Cartilaginous Degeneration. — Ossification. — Hypertrophy.

— Sanguineous Effusions. — Umbilical Cord, 426

PART 11.

SPECIAL
PATHOLOGICAL ANATOMY.

CONTINUED.

PATHOLOGICAL ANATOMY.

CHAPTER 1.

Of the Thymus Gland.

Situation, Weight, Color, and Consistence. — Developenient and Decay. —
Hypertrophy. — Tiiymic Asthma. — Scirrhus. — Tubercular Deposits.

The thymus gland is situated in the anterior mediastinal
cavity, being in connection, in front, with the sternom and the
sterno-hyoid and thyroid muscles ; behind, Avith the trachea,
the pericardium, and the great vessels of the neck. Laterally,
it frequently overlaps the lungs, especially the right. In
the foBtus and in the new-born infant, it is of a light reddish
color, inclining to pink, and reaches from near the diaphragm
to the thyroid body ; but, as life advances, it assumes a yel-
lowish cast, and gradually diminishes in bulk ; so that, about
the time of puberty, there is scarcely any of it left. Consisting
of two lobes, which give it a forked appearance, the gland
is of an irregularly triangular shape, — the broader portion
being above, the narrow below. Its ordinary weight, at birth,
is about half an ounce. At this period, also, it is much larger,
not relatively, but actually, than in the adult. In the normal
state, it is about two inches and a half in length, an inch and
a half in breadth, and foi.ir fifths of an inch in thickness.

Of a soft, fleshy consistence, the thymus is invested by a
very thin, delicate capsule, which gives it a smooth, polished
appearance, at the same time that it sends a multitude of thread-
like processes into its interior, separating it thereby into nu-
merous lobules. Each of these little masses contains several
distinct vesicles, which are filled with a viscid, milky fluid,
analogous to that of the thyroid body, and which all open
into one general reservoir, which is as large, in proportion to
the volume of the gland, as one of the ventricles is to that
of the heart. The arteries of the thymus are furnished by the

VOL. II. 2

10 THYMUS GLAND. [cHAP. I.

inferior thyroid, pericardiac, and internal mammary. Its veins
terminate in the thyroid and the left innominata. Several
large lymphatic vessels traverse it ; and its nerves are derived
from the inferior cervical ganglia, the phrenic, and pneimio-
gastric.

The thymns gland is subject to very few diseases. The
principal lesions requiring consideration, are atrophy and
hypertrophy, together with the tubercular and scirrhous de-
generation. The organ, as was long ago remarked by Dr.
Baillie, appears to be very little disposed to common inflam-
mation ; abscesses are therefore of very infrequent occurrence,
and have been seldom noticed by authors.

The developement and decay of this organ have, of late,
received much attention from anatomists. It becomes visible
during the third month of gestation, and continues to grow
until the end of the second year of extra-uterine life. Be-
tween this period and the commencement of the second den-
tition, the gland remains nearly stationary in its size, under-
going, however, certain changes in its structure and consis-
tence, by which, whatever be their nature, it is probably
rendered unfit for the further performance of its functions.
It is only after the evolution of the permanent teeth that the
organ begins to experience any decided decrease : it now
rapidly diminishes in volume ; its vessels shrink ; its cells are
obliterated; and, as the juice by which it is moistened dries
up, its substance becomes hard and shriveled. At a still
later period, the gland loses its granular structure, and no
longer exhibits any traces of its lobular arrangement, — a soft,
dingy, cellular tissue being all that is left, and this, in time, is
wholly absorbed. The precise age at which the last traces
disappear does not seem to be accurately ascertained : many
highly respectable writers, as Hudson, Meckel, Hildebrandt,
and Burdach, fixing it at the twelfth year, whilst others,
amongst whom is Hoengsted, maintain that it is not completely
atrophied until thirty. Caldani and Sir Astley Cooper — the
latter of whom has recently published an excellent essay on
the structure of this gland — on the contrary, assert that it
never entirely disappears ; but that vestiges may always be
found, whatever may be the age of the individual. My own
dissections would lead me to the conclusion that this organ
varies very greatly, in respect to its disappearance, in different
persons, being atrophied very early in some, and in others not
until very late. In the generality of cases, it is completely

CHAP. I.] UYPERTKOPHY. 11

effaced between the twelfth and fifteenth years. Although the
changes here described are altogether of a physiological char-
acter, there is reason to believe that they are occasionally
expedited by accidental circnmstances, as the pressure of an
enlarged heart, a diseased lung, or an aneurisnial state of the
arteries at the base of the neck.

A not uncommon affection of this gland is hypertrophy.
This disease, which has recently attracted much attention in
Europe, was first accurately described by Dr. Kopp, of Ger-
many, under the name or thymic asthma, though it does not
seem to have been entirely unknown to other physicians.
Indeed, Richa and Yerdries, who wrote more than a century
ago, distinctly recognized inordinate developement of the
organ under consideration as a cause of asthma in children.
Since the appearance of the essay of Dr. Kopp, a very able
paper on the same subject has been published by Dr. Hirsch,
of Koningsberg, and also one by Dr. W. P. Montgomery, of
Dublin, besides several others which it is not necessary to
specify.

Thymic asthma is an affection peculiar to childhood, and
consists, as already intimated, in too great a developement of
the gland whose diseases we are contemplating. It gener-
ally comes on between the fonrtn and tenth months, lasts
from three to eight weeks, and is characterized by fits of
suffocation, during which the breathing is often completely
suspended, the countenance being livid, the eyes fixed, the
nostrils expanded, the hands cold, and the thumbs clenched.
These symptoms usually subside in a few minutes, when the
infant gradually recovers its accustomed cheerfulness. The
pathognomonic sign of this disease is a short, acute, hissing
inspiration, alternating with a weak, croup-like expiration.
Males are more liable to it than females ; and it is said to be
most common in subjects of a scrofulous diathesis.

The thymus gland in this disease is generally enlarged in
every direction-, but the most of all in thickness. The weight
commonly varies from six to eight drachms. In a few rare
instances, it amounts to nearly two ounces. When very
bulky, the organ compresses the lungs and trachea, inducing
that peculiar train of symptoms by which the complaint
under notice is characterized. Occasionally, the enlargement
is so great as to conceal the heart, and obscure its pulsations.
Morbid adhesions are sometimes formed between the gland
and the surrounding structures j and the large veins at the

12 THYMUS GLAND. [CHAP. I.

base of the neck are often so much obstructed as to prevent
the ready return of the blood from the brain to the heart.

The substance of the gland may be in a normal state, or
variously altered in color and consistence. Occasionally,
it is pale, soft, and pulpy ; but this, I presume, is rare, as very
few Avriters make mention of it. More commonly it is pre-
ternaturally red, and of a dense, fleshy consistence, with nu-
merous vessels running over its surface, and penetrating into
its interior. On cutting into it, a dirty milk-like fluid some-
times exudes from it.

The thymus is said to be occasionally the seat of scirrhus.
This, I very much doubt, for the reason, principally, that the
gland generally disappears long before the individual attains
the age at which the disease in question is apt to be developed.
Small calculi have sometimes been discovered in the thymus ;
and, in a phthisical child, fifteen months old, I found it
occupied with numerous tubercles. They were of large size,
and in a state of partial softening. The glandular structure
immediately around them Avas unusually hard, and of a deep
red color, from the great distention of its vessels. Writers
also mention the steatomatous degeneration of this organ ;
but of this I have never seen an instance.

CHAPTER 11.

Of the Thyroid Gland.

Location and Organizaiion. — Acute Inflammation. — Suppuration. — Goitrous
Enlargement. — Sanguineous Effusions. — Tubercular Deposits. — Scirrhus.
— Symptoms of Diseases of the Thyroid Gland.

The thyroid gland, lying at the anterior part of the neck,
extends from the inferior margin of the wings of the thyroid
cartilage to the level of the third piece of the trachea. In
front, it is covered by the common integuments and the sterno-
hyoid and thyroid muscles ; laterally by the platysma myoid,
omo-hyoid, and sterno-mastoid. Projecting outwards, it over-
laps on each side the primitive carotid artery and the internal
jugular vein, together with the pneumo-gastric, recurrent, and
great sympathetic nerves. These relations of the thyroid
gland should not be forgotten by the student of morbid anato-
my, as they will enable him to account for many of the
symptoms which attend excessive enlargements of this organ.

Of a dirty reddish color, the thyroid varies in size, not only
in different individuals, but in the same person, at different
periods of life : generally, however, it is comparatively larger
in children than in adults, and in women than in men. Its
average weight is about one ounce. Transversely it meas-
ures three inches and a quarter ; vertically, somewhat more
than two. Two lobes, united by a thin, narrow isthmus,
compose this body : they are convex in front, concave behind,
and larger below than above, where they slightly approxi-
mate each other..

Externally, the thyroid gland is invested by a very thin,
delicate capsule, composed evidently of condensed cellular
substance, to which it is indebted for its smooth and polished
appearance. The proper parenchyma consists of a number
of small irregularly rounded lobules, of a soft, spongy texture,
in which are contained many minute vesicles, filled with a
colorless, but occasionally thin, oily, yellowish fluid. Some
of the older anatomists, as Santorini and Schmidtmiiller, sup-

14 THYROID GLAND. [CHAP. II.

posed that they had discovered an excretory duct, by which
this fluid was conveyed into the trachea ; but it is scarcely
necessary to remark that this opinion has not been verified
by any of our best modern observers. I have myself often
searched for it, but have never succeeded in seeing it.

This organ is extremely vascular : it receives two arteries
on each side, one from the laryngeal branch of the external
carotid, and the other from the thyroid branch of the subcla-
vian. Its veins, which are very numerous, form frequent
anastomoses, and follow, for the most part, the course of the
arteries. The nerves are derived from the pneumo-gastric
and the cervical^ ganglia : its lymphatic vessels terminate in
the neighboring glands.

There are few organs more exempt from disease than the
one now under consideration. The principal affection to
which it is liable, in this country and in Europe, is broncho-
cele, goitre, or chronic enlargement : it is likewise susceptible
of acute inflammation, suppuration, scirrhus, and several kinds
of degeneration. Gangrene rarely, if ever, occurs.

Acute inflammatioji of the thyroid gland may be justly
ranked amongst the rarest affections of our species. Existing
occasionally as an idiopathic disease, it is generally caused
by external violence, local irritants, or lesion of some contig-
uous structure, as the larynx, trachea, or oesophagus. The
anatomical characters are very similar to those which take
place in inflammation of the other organs. The gland is soft
and succulent, considerably augmented in bulk, and of a dark
purple hue, — all its vessels being abundantly loaded with
blood. Sometimes its substance is remarkably tender, yield-
ing upon the slightest pressure of the finger ; and, in a few
rare instances, it is infiltrated with blood, sanies, or pus.
Matter is seldom found as a consequence of acute inflamma-
tion ; still more rarely is it deposited in the form of an ab-
scess. Of this, however, I have recently seen a most inter-
esting example, in a man forty-four years of age, who died of
pneumonitis after an illness of three weeks. On inspection.
Dr. Woodward and myself found the whole gland, with the
exception of a small portion of its inferior extremity, convert-
ed into a thin, delicate sac, containing nearly three ounces of
thick, cream-colored pus. The thyroid cartilage was com-
pletely denuded, and the matter had burrowed upwards un-
derneath the hyoVd bone on the left side, as far as the root
of the tongue. The most extraordinary cireumstance in this

CHAP. II.] INFLAMMATION BRONCHOCELE. 15

case was, that the patient never suffered the slightest uneasi-
ness in this part during his indisposition, and it was only by
accident that the lesion was discovered on the examination.

More frequently the suppuration follows on chronic inflam-
mation. To this description belongs the interesting case re-
corded by Allan Burns.* The suppuration took place in both
lobes : the matter was tardily secreted, and the integuments
became gradually distended, until they formed a large pouch,
which hung over the sternum, and contained several pounds
of pus. By retaining the sides of the cyst in contact, adhe-
sion was at length effected, and the woman recovered. The
purulent matter, from the effect pf the muscles and cervical
aponeurosis, is generally slow in working its way to the
surface. In some instances, as in the case mentioned by
Baillie, it finds its way into the trachea, and destroys the pa-
tient by suffocation. The quantity of fluid is occasionally
very great. Alibert saw a patient in the St. Louis hospital
of Paris, who had an enormous bronchocele, which was event-
ually relieved by discharging upwards of five pounds of
purulent matter.

Chronic enlargement of the thyroid gland, constituting
what is called bronchocele^ hypertro'pliy, or goitre, occurs at all
periods of life, from infancy to old age ; and, what is remark-
able, it is principally observed in the female sex. It is most
apt to appear during the first ten or twelve years after birth ;
and instances are not wanting, though they are rare, where
it was congenital. Of this Fodere, Sterndale, and Consbruch,
have each related examples. The disease is not confined to
the human subject. It has been noticed in the horse, cow,
sheep, dog, and other inferior animals.

There are certain localities in different quarters of the globe
in which this disease seems to be much more common than
in others, — for what reason is not known. In the United
States, it is often observed in the mountainous districts of
Pennsylvania, Virginia, New York, New Hampshire, and
Vermont : in England, it is very common in Derbyshire,
Norfolk, and, Surry ; and, in the valleys of the Alps, Apen-
nines, and Pyrenees, it not unfrequently prevails endemically,
almost all the native inhabitants being more or less affected
with it. The enlargement is often attended with a stunted
developement of the body ; and, in certain parts of Switzerland,

* Observations on the Surgical Anatomy of the Head and Neck, p. 215. 1823,

16 THYROID GLAND. [cHAP. II.

Savoy, Lombardy, and the Tyrol, it is apt to occur in combi-
nation with cretinism, — a state characterized by great de-
formity of the head, and entire absence of intellect.

Hypertrophy usually begins in the form of a small tumor,
on one or both sides of the trachea, which, gradually enlarging,
at length occupies the whole anterior part of the neck, from
the chin to the top of the breast-bone. In some instances,
the swelling is of frightful magnitude, extending upwards as
far as the ears, and downwards a considerable distance over
the chest. In a case mentioned by Alibert, the gland, of a
tapering, cylindrical shape, reached to the middle of the
thighs ; and other examples, not less remarkable, are related
by Milltemayer. In the early stage of the disease, the sub-
stance of the tumor does not seem to be very materially al-
tered : it is unnaturally vascular, slightly indurated, and still
elastic : as the enlargement progresses, however, it becomes
more and more firm, until ultimately it acquires the density of
a hepatized lung, or even of fibro-cartilage. The hypertrophy,
although it usually begins simultaneously in both lobes, sel-
dom proceeds equally, and occasionally it appears to be seated
chiefly in the isthmus of the organ, the remainder being but
little affected.

The internal substance of the tumor is liable to considera-
ble variety, depending upon its age and progress. When of
moderate standing, it is generally of a soft, gelatinous consist-
ence, emitting, on pressure, a ropy, glutinous fluid. In more
ancient cases, it is of a pale cinnamon tint, hard to the feel,
and interspersed with numerous cysts,* generally not larger
than a pea, containing a serous, glairy, or melicerous sub-
stance and occasionally pus, fibrin, or even pure blood.
Calcareous concretions are sometimes found in such enlarge-
ments, either alone, or in union with cartilaginous and osse-
ous productions. On a small goiterous tumor, which I removed
from a man fifty years of age, and which is now in my private
collection, there are several small steatomatous masses, with
a circular nodule of bone, about six lines in diameter. It is
of a deep yellow color, very compact in texture, and sur-
rounded by a thin, imperfect capsule. Occasionally the Avhole
organ is transformed into an osseous cyst, filled with various
kinds of matter, especially the jelly-like, the suety, and the

* These cysts arc notliing l)ut enlarged cells, which are dispersed through
the organ in the natural state.

CHAP. II.] BRONCHOCELE. 17

meliceric. I have a specimen of this kind in my cabinet :
one of the lobes has ahiiost entirely disappeared, whilst the
other is converted into a firm, solid capsule, as hard as bone,
though scarcely a line in thickness. On sawing through this
osseous tumor, which does not exceed the volume of a hen's
egg, I found it filled with a white, curdy, friable substance,
not unlike semi- concrete cheese.

The thyroid arteries are commonly much enlarged, and,
in some cases, the goiterous swelling seems to consist almost
wholly of a congeries of varicose veins. Under such circum-
stances it is by no means unusual to meet with considerable
sanguineous elusions, in various stages, so to speak, of mat-
uration,— some being quite fluid, some semi-concrete, and
others of a dense, firm consistence, like old apoplectic depots of
the brain. The blood is commonly poured into the enlarged
vesicles, but occasionally it finds its way into the connecting
cellular substance, which is, at the same time, more or less
lacerated. In some instances, it may be traced directly to a
ruptured vessel.

In the early stage of the disease, the skin over the affected
gland is perfectly natural, both as regards its color and
mobility ; but, by and by, as the hypertrophy increases, it
becomes dark, dense, vascular, and irregularly adherent.
The enlargement is usually very slow and gradual, years
often elapsing before it attains much bulk. Occasionally,
the gland, after having become partially hypertrophied, re-
mains stationary for a while, and then goes on increasing ;
or suppuration sets in, and the substance of the organ is ab-
sorbed, nature thus efi"ecting a sort of spontaneous extirpation.
Of this, some interesting cases are given by Petit. Hevin, and
Alibert.

Of the remote cause of goitre, nothing satisfactory is
known. By many it has been attributed to the use of impure
water, to innutritions diet, to the repulsion of cutaneous dis-
eases, and a vari.ety of similar circumstances equally hypotheti-
cal, and, for aught we know, unfounded. Concerning the
proximate cause of this singular malady our knowledge is of a
more positive nature. Some of the older writers supposed
that it arose immediately from an obstruction of a certain
number of passages which they imagined to lead from the
thyroid gland to the trachea; but, as no such openings exist,
the opinion must of course fall to the ground as untenable.
But, even granting that there were actually such apertures of

VOL. II. 3

18 THYROID GLAND. [cHAP. II.

communication, and that they were liable to be blocked up in
the manner alleged, still the circumstance could only be view-
ed in the light of an exciting, not in that of a proximate,
cause ; which invariably consists in inflammatory irritation
of the thyroid tissue, pursuing a slow, chronic march. That
this is the fact, is at once indicated by the morbid alterations
which this organ experiences during the progress of the en-
largement, and which can only be explained on the ground
which has been here assumed.

The thyroid gland is sometimes partially atrophied. In
several instances, I have found it less than one third the
ordinary bulk, having been reduced to a soft, spongy, dirty-
looking mass. The wasting, which is more common in men
than in women, is observed chiefly in advanced life. The
vessels supplying the atrophied gland are usually very much
diminished in volume, and many of the smaller branches
appear wholly obliterated. The nerves are also abnormally
delicate.

Tubercles are rarely found in the thyroid gland ; and the
same remark may be made concerning encephaloid, so com-
mon in some of the other viscera. The organ occasionally
becomes scirrhous ; but this, too, is very rare. When thus
affected, the gland seldom attains much bulk; it is of a light
grayish tint, and cuts like an unripe pear, from the intersec-
tion of fibrous filaments. The cells of the thyroid are said
to have been filled, occasionally, with hydatids ; but this is
probably an error, arising from confounding such appearances
with the sero-albuminous collections so common in goiterous
and other enlargements.

Of the symptoms of these diff'erent afl"ections, little need be
said in this place. Acute inflammation is commonly attend-
ed, it may be supposed, by pain, and tenderness on pressure,
with more or less constitutional disturbance, especially when
it passess into suppuration ; yet, that these are not invariable
results, appears sufficiently from the case which I have already
cited of thyroid abscess, where the patient did not evince
the slightest uneasiness in any part of the throat. When
the quantity of matter is considerable, a pendulous tumor will
gradually form in the region of the aff"ected organ, presenting
a distinct fluctuation, on the application of the finger, accom-
panied with hectic fever, and difficulty in breathing and
swallowing. Owing to the thickness and firmness of the
covering of the abscess, an early incision shoifld always be

CHAP. II.] ATROPHY TUBERCLES. 19

made ; otherwise its contents may work their way into the
oesophagus, or, what is worse, into the trachea, or the larynx.

Goiterous enlargements are always easily recognized, their
situation and history being commonly sufficient for determin-
ing their diagnosis. They prove troublesome chiefly by their
mechanical pressure on the windpipe, impeding respiration,
deglutition, and the return of the blood from the head. In
this manne,r may be induced headache, giddiness, apoplexy,
aphony, diseases of the heart and lungs, and, occasionally,
even death.

Scirrhus generally occurs in advanced age, and is charac-
terized by occasional darting pains in the region of the
affected part. It may be further distinguished by its great
hardness, and by the fact that it rarely attains much magni-
tude.

CHAPTER III.

Of the Respiratory Apparatus.

SECTION I.
Of the Air-Passages.

I. Lesions of the Air-Passages. — Inflammation of the Larynx. — CEdema of the
Glottis. — Ossification of the Laryngeal Cartilages. — Polypous Growths. —
Trachitis. — Inflammation of the Bronchiee. — Dilatation and Contraction. —
II. Lesions of the Lungs. — General Observations. — Structure and Functions.
— Acute Inflammation. — Hei^atization. — Abscess. — Gangrene. — Chronic
Irritation. — CEdema. — Emphysema. — Apoplexy. — Encephaloid Disease. —
Melanosis. — Serous Cysts. — Hydatids. — Calcareous Concretions. — Hyper-
trophy. — Atrophy. — Tubercular Phthisis ; its History and Symptoms. — III.
Lesions of the Pleura. — General Observations on its Arrangement, Struc-
ture. — Acute Inflammation. — Formation of Matter. — Gangrene. — Chronic
Pleuritis. — Ossification. — Accumulation of Gas. — Ulceration. — Tubercular
Deposits. — Symptoms of Pleuritis. — Position of the Patient. — Alteration
of Respiratory Murmur. — iEgophany. — Dulness on Percussion. ■ — Friction
Sound.

I. The larynx is liable to inflammation, oedema, abscess,
ulceration, ossification of its cartilages, and polypous growths.

Preternatural vascularity, and redness of the lining mem-
brane, either diftused or in patches, with tumefaction of the
mucous follicles and the secretion of a clear limpid fluid,
constitute the anatomical characters of acute laryngitis in its
earlier stages. By degrees, the redness increases in inten-
sity, and extends, on the one hand, down into the trachea,
and, on the other, up into the fauces, affecting, in some in-
stances, the tonsils, soft palate, and even the root of the
tongue. Various are the changes observed in the epiglottis.
In some cases it is thickened, infiltrated, and so erect as to leave
uncovered the mouth of the larynx ; in others, it is highly
vascular, clotted with lymph, and studded with enlarged
follicles. Within the larynx itself, the tumefaction is seldom
very conspicuous, except sometimes in the ventricles ; and it
almost always terminates at the junction of the trachea,
though, as was before mentioned, the redness often extends

SECT. I.] LARYNGITIS. 21

beyond it. In the progress of the disease, the natural secre-
tion becomes much altered : it is no longer thin, sparse, and
watery, but thick, tough, abundant, and of a yellowish
tinge.

Acute laryngitis, usually runs its course in from three to
five days. It is characterized by high inflammatory fever,
dyspnoea, cough, hoarseness, more or less pain, and expectora-
tion of thick, viscid mucus, often streaked with blood. The
disease almost always occurs in the prime of life, between
the years of puberty and forty-five, in which respect it differs
remarkably from croup, which, as will be presently seen, is
most common in young children.

It has been already intimated that one of the effects of
acute laryngitis is the effusion of serum into the submucous
cellular tissue. The infiltration, which is occasionally very
great, is always most abundant aronnd the edges of the glottis,
which are frequently elevated into white, glossy, pendulous
bags, resembling the gelatinous effusion which we sometimes
see under the epidermis, after the application of a blister.
This constitutes that form of the disease which was so ably
described by the late Dr. G. L. Bayle, under the name of
cedema of the glottis, in a memoir published at Paris in 1819.*
From the interesting cases recorded by this distinguished
writer, the affection would seem to be much more common
in adults, after the age of thirty-five or forty, than in early
life. Its progress is usually very rapid, and its termination
almost uniformly fatal, death being preceded by great anguish,
and symptoms of suffocation. Out of seventeen cases of
this disease, mentioned by Bayle, only one recovered. The
difficulty of breathing in this affection appears to result, not
so much from the absolute constriction of the chink of the
larynx, as from the manner in which the tumid and infil-
trated lips of the glottis are drawn in by the air, as it rushes
from the mouth into the lungs.

Occasionally, purulent matter is found in the larynx ; and,
in a few cases, small abscesses have been detected, situated
either in the ventricles of Morgagni, between the mucous
membranes and the muscles, or between this organ and the
pharynx. Bayle mentions several instances of this kind, in
each of which there was a discharge of half an ounce of
thick, creamy pus.

* See Nouveau Journal de Medicine, de Janvier, 1819. Also the Medico-
Chir. Rev. for September, 1823, p. 452.

23 AIR-PASSAGES. [cHAP. III.

In other cases, together with the inflamed condition of the
mucous hning, there is found an exudation of lymph, either
in dots, in patches, or in the form of a continuous lamella.
In simple laryngitis, this deposition is extremely rare ; but, in
that variety of the disease which is known by the name of
croup, nothing is more common. In this affection, which
differs further from ordinary inflammation by its being almost
exclusively confined to infancy and childhood, the effusion is
often very rapid, and moulds itself accurately to the shape of
the organ, to the walls of which it sometimes adheres with
considerable pertinacity. Although it is occasionally limited
to the larynx, yet the membrane usually passes into the
trachea and bronchiae, becoming gradually softer and more
delicate, until finally, in the binary and ternary divisions of
these tubes, it appears like a thin, mucous film. Upwards, it
sometimes extends over the fauces into the mouth, and even
into the nasal cavities. Such instances, however, are rare,
and it has never occurred to me to meet them.

Varying in thickness, in different cases, the membrane
seldom exceeds the third or fourth of a line, though in some
instances it is the eighth or tenth of an inch. It is of a light
grayish color, is composed chiefly of albumen and fibrin, in
combination with carbonate of soda and phosphate of lime ;
and is generally much stronger, more tenacious, and more
firmly adherent in the larynx than in the trachea and bron-
chial tubes, in the latter of which it is often loose or even float-
ing. The mucous coat beneath this lining is usually highly
injected, inflamed, and unnaturally rough, from the projection
of its mucous follicles. In slight cases, the color is of a light
red, and occurs in patches, streaks, or points : in more severe
ones, it is scarlet, brownish, or purple, and uniformly diffused.

To the presence of this plastic production, together with
the tumefaction of the lining membrane of the trachea and
bronchias, which so often accompanies the disease, is to be
imputed, in great measure, the impediment to the respiration
in croup. Sometimes portions of it are detached, and, by
sticking in the air-passages, cause suffocation. In other in-
stances, it is coughed up, either piece-meal, or in the form of
a dense, inspissated cylinder, and the patient recovers. The
organization of this membrane is admitted rather from an-
alogy than from any positive observation. The occurrence,
if possible, must be extremely rare.

Laryngitis sometimes becomes chronic^ or it may have a

SECT. I.] LARYNGITIS ; ULCERATION. 23

disposition to assume this type from the very beginning.
Such an alarming degree of prevalence has this form of the
disease assumed among our clergy, that it may almost be
viewed in the light of an epidemic. The inflammation is
confined exclusively to the mucous lining of the larynx, and
its peculiar characteristic is to terminate in ulceration. Slow
and insidious in its attacks, the first symptoms often are
merely slight hoarseness and cough, scarcely sufficient to
attract notice, which gradually increase, and, unless arrested
by treatment, destroy life, by inducing hectic fever, emaciation,
and general prostration. Often do we see the uvula elon-
gated, the tonsils and soft palate ulcerated, and the vocal
cords so much thickened as to encroach upon the glottis.
The lining membrane of the larynx is usually tumefied, its
glands enlarged, and its vessels engorged with dark blood.
In this way have perished, in the prime of life, some of the
brfghtest ornaments of the American church.

Inflammation of the larynx sometimes terminates in ulcera-
tion. This is very common in persons who are cut off by
tubercular phthisis. Of one hundred and two patients, M.
Louis found the epiglottis ulcerated in eighteen, and the rest
of the organ in twenty-three. The erosions in the former of
these structures were nearly always seated on the inferior
surface ; and, although they were generally superficial, yet
they sometimes extended into the substance of the cartilage,
destroying it partially in four cases, and completely in a fifth.
In the larynx, properly so called, the ulcers were usually
deep, from one to two lines in diameter, and of an irregularly
circular shape, with pale grayish-looking edges, occasionally
indurated and brittle. Their most frequent seat was, first, at
the junction of the vocal cords ; then these cords themselves ;
next, the base of the arytsenoid cartilages ; and, finally, the
interior of the ventricles of Morgagni. Sometimes the vocal
cords were partially destroyed, and the arytgenoid cartilages
stript of their natural coverings. A fact worthy of notice, in
connection with this subject is, that ulcerations of the epi-
glottis were remarked twice as often in men as in Avomen.*

The textures in the immediate vicinity of these erosions
are seldom much altered, either as respects their color or
their consistence. When the symptoms which precede
dissolution are denotive of high inflammatory action, the

* On Phthisis, p. 47. Boston, 1836.

24 AIR-PASSAGES. [CHAP. III.

mucous membrane is apt to be reddened and slightly soft-
ened ; but, in most cases, it is of a grayish hue, moderately
dense, or even indurated.

The signs, during life, of ulcerated larynx, vary, as might
be expected, according to the part that is affected, and also
according to the extent, depth, and number of the erosions.
When the vocal cords, the ventricles, or the aryiaBnoid car-
tilages are implicated, hoarseness, alteration of the voice,
pain, sense of heat and pricking, followed often by complete
aphony, are the ordinary and almost invariable manifestations.
The pain sometimes is quite severe, pungent, and lancinating,
the cough excessively distressing, and the patient dies, gradu-
ally worn out by hectic fever.

I have never seen the cartilages of the larynx ulcerated,
but this condition has been noticed by others, though the
instances wherein it has been found are rare. In the affec-
tion with which it usually occurs, in connection with ul-
ceration of the mucous membrane, it occasionally leads to
perforation, the symptoms which precede dissolution resem-
bling those of phthisis. The diseased cartilage is slightly
tumefied, and softened around the ulcers, the edges and base
of which are rough, and of a light brownish color. The
perichondrium commonly participates in the mischief, being
injected, dark, thickened, ragged, and bathed in unhealthy
looking pus. These ulcerations are most frequent in venereal,
mercurial, and phthisical affections, in which large portions
of these cartilages, or even entire pieces, are sometimes dis-
charged.

More frequent, perhaps, than ulcerations are the osseous
transfomiations which we sometimes meet with in the
laryngeal cartilages. The pieces in which this change, which
is natural in the aged, is most apt to take place, are the
thyroid and cricoid, of each of which I have seen a consider-
able number of specimens. When thus affected, these bodies
are usually very brittle, containing a considerable quantity
of thin, reddish, oily fluid. I have seen them, however, in a
few instances, quite hard and firm, like the most perfect bone.
Of ossification of the arytajnoid cartilages and epiglottis, I
am not aware that any examples have been recorded by
writers. The epiglottis may be affected, without the rest of
the larynx participating in the lesion. The simplest form of
disease is thickening of its mucous membrane, with ulcera-
tion of its inferior surface. The abrasions are generally

SECT. I.] LARYNX POLYPES. 25

small, superficial, and irregularly circular, their base, for the
most part, being formed by the submucous cellular texture,
though occasionally they extend into the substance of the
fibro-cartilage. Sometimes, indeed, this body is entirely
destroyed. Occasionally, the epiglottis is remarkably shriv-
eled and contracted, or singularly thinned and elongated,
its form being altered so as to represent the shape of a battle-
dore, the narrow extremity being at the mouth of the larynx.
This condition usually coexists with ulceration, and consti-
tutes what Professor Stokes has proposed to call the leaf-like
expansion of the epiglottis.*

The muscles of the larynx are also sometimes diseased.
In some cases, they are infiltrated with tubercular matter ;
but more commonly, perhaps, they are atrophied, and thus
cause various alterations of the voice, being no longer capa-
ble of producing proper tension of the f^bro-elastic structure
of the organ. The vocal cords, as they are termed, are
occasionally affected. Andral says that he has seen them
converted into a soft, inorganic pulp ; and he refers to cases
in which they had entirely disappeared, leaving the thyreo-
arytasnoi'd muscles bare. In chronic inflammation, it is very
common to find the ventricles of the larynx contracted ; so
that, in the advanced stages of the disease, they are merely
represented, as it were, by a superficial, transverse groove.
This narrowing seems to arise from hypertrophy of the mu-
cous and submucous textures, by which the edges of the cavi-
ties are gradually approximated.

Polypes are occasionally found growing within the larynx,
of the same nature as in other parts of the body. Forma-
tions of this kind, although quite rare, have been noticed by
diff"erent observers. Two cases are recorded by Lieutaud ; f
and the celebrated Dessault also met with them on several
occasions. Other examples are mentioned by Pelletan, Trous-
seau, Andral, and other writers. An instance, in which a
firm, elastic, whitish tumor of this kind adhered to the root
of the epiglottis, and finally produced suffocation, is related
by Mr, Mayo, of London. Tubercles and hydatids are also
sometimes found in the larynx ; the latter are very rare, and
the former generally coexist with pulmonary phthisis.

* On Diseases of the Chest, in Dunglison's American Medical Library, No.
14,1837.
t Historia Anatomico-Medica, lib. iv. ob. 63.

VOL. II. 4

26 AIR-PASSAGES. [cHAP. III.

II. The diseases of the trachea may be classed under the
heads 'of inflammation, ulceration, ossification, and structure.

Trachitis exhibits the same anatomical characters, in a great
degree, as inflammation of the larynx. The lining mem-
brane is crowded with multitudes of minute, florid vessels ;
its follicles are enlarged and unusually distinct, and its sur-
face besmeared with thick, ropy mucus. Purulent fluid is
occasionally found ; and, in some instances, as in croup, the
whole tube is lined with a layer of adventitious membrane.
Softening is seldom or never present, either in this aflection,
in laryngitis, or in inflammation of the bronchiae. In chronic
cases, the redness is less, though the vessels seem occasionally
to have a varicose arrangement ; and the mucous tunic often
presents several small ulcers, or is much thickened and in-
durated.

Ulceration of the trachea is very frequent in tubercular
phthisis, M. Louis having noticed this lesion in thirty-one
patients, out of the one hundred and two, who died of this
disease under his care. More common in the inferior than in
the superior half of the tube, and behind than in front, or at
the sides, the ulcers are generally of a circular shape, some-
times oval or oblong, and from the twelfth to the sixth of an
inch in diameter, with flat, reddened edges, as if they were
scooped out of the subjacent cellular tissue. In some in-
stances, the erosions are so small, close, and numerous, as to
give the whole of the inner surface of the trachea a sieve-
like aspect. Of this an interesting case is mentioned by
Andral. When large and deep, the ulcers may denude the
cartilaginous rings, invade their substance, and finally, destroy-
ing them, lead to perforation. In a few instances, there is a
complete removal of the mucous lining over nearly the whole
of its muscular structure, which, in such cases, is always
much thickened and indurated.

Ulcers of the trachea sometimes heal. Of this, an instruc-
tive case is mentioned by Mr. Porter, in his Surgical Pathology
of the Larynx. The patient recovered under the use of mer-
cury, and, after enjoying good health for upwards of a year,
died of another disease.

The signs of trachitis, whether simple or complicated Avith
ulceration, are often remarkably obscure. Pain, tightness,
and a sense of burning, just above and behind the sternum,
are occasionally the chief symptoms ; in general, however,
there are superadded embarrassment of breathing, accom-

SECT. I.] , BRONCHITIS. 27

panied with a peculiar mucous rhoncus. severe cough, and
copious expectoration of muco-purulent matter. The pain is
sometimes highly distressing, and is increased hoth by pres-
sure and by inspiration. The voice is seldom much altered.
Occasionally, the disease is almost completely latent ; and
cases occur in which the pain and uneasiness are entirely
referred to the larynx, the patient feeling no distress whatever
in the trachea, the actual seat of the disease.

The rings of the trachea, being of a fibro-cartilaginous
texture, seldom ossify. VYhen this deposition is found, it
usually takes place in small points, which, by coalescing, may
at length embrace the entire ring. Of this, I witnessed an
example, not long since, in a man seventy-five years of age.
The different tissues of the tube were remarkably dense,
inelastic, and brittle, requiring only slight traction to tear
them. All the rings were completely ossified. The trachea
is liable to become contracted by thickening of its lining
membrane from chronic irritation, forming a sort of stricture
several inches in length.

III. Acute bronchitis, although it may exist as an indepen-
dent disease, yet in most cases it is united with inflammation
of the trachea, the larynx, or pulmonary tissue, of which it
forms so important a component. The mucous coat is found,
on dissection, to be deeply injected, and of a bright crimson,
lilac, or purple color, diffused, or in patches of various sizes.
Rarely is it much thickened or softened ; but sometimes it
it is considerably augmented in firmness and density, so as
to tear no longer with the same facility as in health. Puru-
lent matter is occasionally observed ; and, in violent cases, it
is not imusual to find the smaller tubes filled with bloody
serosity, blended with froth or globules of pus. In the early
stage of this disease, there is always a suspension of the
natural secretion. In a short time, however, it is reestab-
lished ; and it is then found to be thin, transparent, and some-
what acrid. As the inflammation advances, it becomes thicker
and more abundant, assumes a yellowish color, with a slight
greenish cast, and adheres with so much firmness and tenaci-
ty to the bronchial tubes, as to be expelled with great diffi-
culty. Obstruction is thus created in the air-vesicles of the
lungs, and hence, on opening the thorax, these organs seldom
collapse.

In chronic bronchitis, a disease of. very frequent occurrence
in this country, the color of the mucous tunic is usually

28

AIR-PASSAGES.

[chap. III.

several shades darker, verging more on livid, violet, or ma-
hogany. Not unfrequently, however, the membrane is of a
light grayish tint, or even much whiter than in the normal
state. The thickening and augmentation of density are car-
ried much further than in acute bronchitis ; and the natural
secretions are usually very copious, opaque, of a deep yel-
lowish color, and almost always puriform. With these signs
of disease, we frequently find small ulcers, hypertrophy of
the mucous and other textures, and dilatation of the bronchial
tubes. Softening is rarely present, and never to any very
great extent.

The respiratory murmur, in this disease, is diminished in
intensity ; but the sonorousness of the chest is not sensibly
impaired, except in cases embracing a large extent of surface.
The cough, at first, dry, loud, and hoarse, becomes gradually
moist, loose, and more frequent ; the breathing is accompa-
nied with a mucous

rhoncus, most distinct
at the base or poste-
rior margin of the
lungs ; and the spu-
ta, which before were
thin, saltish, and
slightly glutinous, are
now opaque, yellow-
ish, and ropy. Occa-
sionally, they are
marked with dots of
blood, or mixed with
pus. In chronic bron-
chitis, the expectora-
tion is generally puri-
form, and sometimes
of a greenish, dirty
grayish, or brownish
color, from the ad-
mixture of black, pul-
monary matter. In
neither of these com-
plaints are the sputa
much offensive ; in
most cases, indeed,
they are perfectly in-
odorous.

Fig. 49.

SECT, I.] bronchitis; ulceration DILATATION.

29

Fiff. 50.

Ulceration of the bronchial mucous membrane is less fre-
quent than that of the trachea, and still less than that of the
larynx. Louis, in the whole of his researches, only met
with seven cases of this disease. From the observations,
however, of Hastings and Andral, it would appear that the
lesion is more common than is usually supposed. The ulcers
are generally small, clean, superficial, and of a dirty grayish
color, with somewhat tumid and reddened edges. They sel-
dom extend beyond the mucous and submucous textures,
and are rarely met with in the small bronchial tubes.

The symptoms of ulcerated bronchias differ little from
those which have been enumerated as characterizing trachitis.
There is, in general, however, more difficulty of breathing,
more deep-seated pain, more emaciation, and more hectic fever.

Dilatation of the bronchias is frequently met with in old
asthmatics, and in children after
severe attacks of hooping-cough.
The affection was first described
by Laennec, who has given a
number of interesting examples
in illustration of its pathology.
It presents itself under two varie-
ties of form. In the first, (Fig.
49,) the dilatation is uniform
throughout, and may attain the
diameter of a goose-quill or even
of a finger. Sometimes several
branches of the same trunk are
thus affected, each terminating
in a sort of cul-de-sac. In other
cases, the dilated tube regains its
normal caliber, and ends in the
usual way. In the second vari-
ety, (Fig. 50,) the bronchia pre-
sents a nodulated appearance,
like a varicose artery, or an ab-
sorbent vessel, forming a series of
globular swellings, on each side of
which the canal is of the natural
size. Occasionally, there is only
one such dilatation, which may
attain the magnitude of a cherry-
stone, a marble, or a walnut.

30 AIR-PASSAGES. [cHAP. III.

Yarions are the appearances of the raucous membrane in
this aflection. In the generaUty of cases, it is thickened,
injected, and indurated, with its siu'face covered with dense,
inspissated mucus. In others, especially in the second variety
of the disease, the membrane is transparent, and so extremely
attenuated, as to look like a shining vesicle. Occasionally,
again, all the component tissues are in a state of hypertrophy,
or they are indurated, rigid, and almost of a fibro-cartilaginous
consistence. Cases also not unfrequently occur in which
the mucous tunic is softened, and convertible into a grayish,
pulpy substance. When the dilatations are considerable, and
embrace a large number of tubes, the intervening pulmonary
tissue is hardened, probably from the effects of chronic irrita-
tion, imperfectly crepitant, and of a much lighter color than
natural.

This lesion is said to be most common in the upper lobes
of the lungs : rarely is the entire organ affected. It is usu-
ally dependent upon chronic inflammation, and is sometimes
produced with much celerity. In whooping-cough, it has
been known to attain a very considerable size in the course
of a few months. A frequent, forcible inhalation of the
air, when the bronchise are enfeebled by disease, and ob-
structed with thick, ropy mucus, seems to be the immediate
cause of this dilatation. It occurs at all periods of life, and,
according to Guersent, is occasionally congenital.

The physical signs of this affection are, bronchial respira-
tion, loud mucous or gurgling rhoncus, and dulness on per-
cussion, from the condensation of the pulmonary tissue.
Seldom is there much dyspnoea ; the emaciation is not great ;
and the cough and sputa are similar to what we observe in
chronic bronchitis, which the dilatation so often accompanies
or succeeds.

There is another species of alteration of the air-tubes, the
reverse of that just described, which has of late attracted
the special notice of pathologists ; I mean obliteration of the
bronchiae. The first account of this singular lesion was
given a few years ago by Monsieur Reynaud, in a highly
interesting monograph, in the fourth volume of the Memoirs of
the Royal Academy of Medicine of Paris.* It would appear,

* An able translation of this paper, by my friend Dr. John W. Warder, of
this city, will be found in the Western Journal of the Medical and Pliysical
Sciences.

SECT,

!•]

BRONCHIA J OBLITERATION.

31

from the researches of this distinguished physician, that nar-
rowing and obhteration of the air-tubes are much more com-
mon than has hitherto been supposed by writers on thoracic
diseases ; but what the probable proportion is, in a given
number of subjects, is a circumstance which has not been
determined.

This lesion affects principally the smaller bronchise, espe-
cially when it is produced by inflammatory irritation, accom-
panied with the effiision of plastic lymph. In such cases, the
contraction is liable to be mistaken for an obliterated vessel.
When, on the other hand, it is caused by the pressure of an
external tumor, it occasionally involves the larger-sized
branches, or even one of the primitive trunks. Hypertrophied
lymphatic ganglions sometimes give rise to an obstruction
of this kind, followed by a gradual wasting of the correspond-
ing lung. The lesion under consideration is most common
in the superior lobe of the pulmonary organs, — a circumstance
which is easily explained by the great frequency of tuber-
cular disease here, with
which it often coex-
ists. The number of
tubes that may be thus
effected is variable ; occa-
sionally, only a single one
is obliterated ; at other
times, the^ lesion is ob-
servable in three or four ;
and, in a few rare cases,
all the branches of an
entire lobe are implicated.

Obliteration of the air-
passages presents itself
under two varieties of
form. In the first, (Fig.
51,) which is b'y far the
most common, the tube
is uniformly contracted
throughout its entire
length, being converted
into a firm fibro-cartilagi-
nous cord, from the sides
of which, numerous pro-
cesses are detachedjWhich

32

AIR-PASSAGES.

[chap. III.

ramify in an arborescent manner, and the diameter of which
scarcely equals that of a bristle. This variety, which may
be said to resemble the continuous stricture of the urethra,
usually affects the smaller div^isions of the bronchias, and is
almost always complicated with dilatation, the caliber of the
tube above the constriction being seldom perfectly natural.

In the second variety, (Fig. 52,) the obliteration occupies
only a very small portion of
the tube, and is observed
principally in bronchias of
the second and third order.
The affected part rarely ex-
ceeds half an inch in length ;
generally, indeed, it is not
near so long, and not un-
frequently it presents the |||
appearance as if the tube
had been compressed by a
narrow tape or ligature. In
this variety, the diameter of '
the bronchisB above and
below the obliterated point
may be natural, diminished,
or, as is more commonly the
case, increased. Several
tubes may present this spe-
cies of contraction in the
same lung.

The causes under the in-
fluence of which this lesion
takes place are various, but
may all be referred to the
following heads : 1. the formation of fibrinous concretions ;
2. thickening of the mucous membrane ; 3. external pres-
sure ; 4. the existence of accidental products within the tube.
Of these, the first and second are by far the most common,
and are both the immediate result of iniiammatory irritation.
The principle on which the one acts is similar to that which
obtains in the production of contraction and obliteration of
the arteries : the type of the other is to be found in the for-
mation of stricture of the urethra, the nasal duct, oesophagus.
Let us be understood. It is well known that the bronchial
tubes are liable to inflammation, followed not infrequently by

SECT. I.J BRONCHIA ', OBLITERATION. 33

an efFasion of plastic lymph. The substance thus poured
out being permitted to remain, it gradually contracts adhesions
with the mucous membrane ; and, in this way, an efTectual
barrier is formed, by which the ingress of the air is perma-
nently interrupted. Thus the function of the tube is an-
nulled ; and, in progress of time, it is converted into a firm,
fibrous cord, like an artery that has been tied with a ligature.

Thickening of the mucous membranes is observed in all
parts of the body in which these structures are found ;
and it is therefore not at all surprising that it should occa-
sionally produce narrowing and obliteration of the bronchise.
In the urethra, as is well known, it is a frequent cause of
stricture ; and, in the nasal duct, there is reason to believe it
a very common source of lacrymal fistula.

The third cause which has been enumerated, as liable to
produce obliteration of the air-passages, is external pressure.
This may be occasioned, as already stated, by a tuberculated
lymphatic ganglion, an aneurismal or other tumor, or, as
more generally happens, by pleuritic effusions, exerting a
permanent influence.

Lastly, obliteration of the bronchias is occasionally caused
by the presence of inspissated mucus, by deposts of tubercular
matter, or by the inhalation of particles of foreign substances.

The mucous membrane, near the point of obliteration, may
be normal, thickened, or attenuated : in some instances, it is
unnaturally red, softened, or incrusted with plastic lymph.
In the majority of cases, as Avas previously stated, the lesion
is associated with dilatation, either of the same, or of the
neighboring tubes. This is particularly apt to happen when
it implicates the larger trunks. The parenchymatous sub-
stance itself is variously altered. Frequently it is remarkably
emphysematous, or even rarefied ; as, on the other hand, it is
sometimes quite dense, solidified, and impermeable to the air.
The adjoining vessels are seldom much aflected, except when
the obliteration occupies a large extent of surface ; in which
case, the smaller branches are often very much diminished in
size, plugged up with fibrinous concretions, or transformed
into dense, thread-like cords, which are easily distinguished
by their dark grayish color.

The consequences of obliteration of the bronchise are ex-
ceedingly variable, and can only be pointed out in a very
general manner. When of limited extent, the lesion does not
produce any marked difficulty ; as the neighboring tubes, under

VOL. II. 5

34 AIR-PASSAGES. [cHAP. III.

such circumstances are always rendered sufficiently large to
compensate for the loss sustained by the afTected part. Should
it, on the contrary, be more considerable, the eifects will of
course be more serious. The corresponding portion of the
lung, for example, being deprived of air, will gradually fall
into a state of atrophy, its surface will become puckered, and
its substance rendered abnormally dry and dense, almost like
a piece of liver. Dalness, on percussion and diminution of
the respiratory murmur, will probably be found, when this
lesion shall have undergone more thorough investigation, to
be the principal physical signs of its existence.

The bronchiae are liable to ossification, by which many of
the more minute, and even some of the larger branches are
occasionally converted into hard, solid pencils, perfectly im-
permeable to the air. Andral gives a singular example of
ossification of these tubes. In dissecting the body of an old
man, he found the lung full of hard masses, which were com-
posed of an infinite number of bony spicules, arranged in a
beautiful arborescent form, with a cavity in each so small as
scarcely to admit a hair.* Laennec and some others speak of
having met with polypous growths in the bronchige ; but
the occurrence of these bodies in this situation is by no means
established.

SECTION II.

Of the Lungs.

I. The lungs are two soft, spongy bodies, and occupying
the lateral parts of the thoracic cavities, which they fill in such
a manner as to leave no space whatever between them and the
surrounding structures. Separated from one another by the
heart and mediastinum, they are attached below to the dia-
phragm by means of a fold of the pleura, and are retained in
their situation chiefly by the trachea and pulmonary vessels,
from the former of which they appear as if they were sus-
pended. In their shape, the Inngs are somewhat conical, the
apex being above, and the base, w-hich is cut off from before,

* Pathological Anatomy, vol. ii. p, 308.

SECT. II.] LtJNGS. 35

backwards, and from above downwards, resting on the dia-
phragm. Their volume always accurately corresponds with
that of the thorax and heart. Hence the quantity of air
which they are capable of containing must of coiu'se vary
considerably in different individuals, being greater in those
whose pulmonary organs are well developed than in those in
whom their growth has been impeded. The average amount,
however, has generally been computed at one hundred and
forty-five cubic inches, of which one fifth is probably renewed
at every inspiration. In a grown-up person, of ordinary
stature, the weight of the lungs is about three pounds, or, as
compared with the rest of the body, as one to forty-five.

If the lungs be artificially inflated, it will be found that
they differ a good deal in size, — the left being narrower, but
longer than the right, owing to the fact that the diaphragm,
from the obstruction caused by the liver, does not descend so
low in the latter as in the former direction. Each organ is
divided into several lobes, by a deep fissure, which runs ob-
liquely downwards and forwards, commencing on a level
with the fourth dorsal vertebra, and terminating at the ante-
rior magin of its base : the upper lobe of each is thus ren-
dered conical in its figure, whilst the inferior, which is also the
larger, is nearly quadrilateral. The left lung has only two
lobes, whereas the right has three, — the third being intermedi-
ate, in size as well as in situation, between the other two.

The outer surface of each lung is smooth and convex, es-
pecially behind : it accurately corresponds with the walls of
the thorax, with which it is always in contact, so that no air
can intervene between them ; and it is, moreover, perpetually
bedewed with a serous exhalation, which enables the organ
to move freely and easily upon the surrounding parts. In
consequence of disease, however, causing effusion of plastic
lymph, adhesions often exist in this situation, which are
sometimes so strong and extensive as to impede, in a very
serious manner, the free exercise of the pulmonary tissue.
The inner surface, which is slightly concave, particularly
that of the left lung, rests against the pericardium and
mediastinum, and receives, a little above its middle, the in-
sertion of the bronchial tubes and the pulmonary vessels,
forming, by their aggregate, what is called the 7^oot of the
lungs. The entrance of these structures takes place consid-
erably nearer the posterior than the anterior border of the
inner surface, and their position is such that the pulmonary

36 LUNGS. [chap. III.

artery is above, the two veins below, and the bronchise be-
hind and between them. This fact is of no httle importance,
especially in reference to the aerial tubes, and should not be
overlooked when engaged in sounding and ausculting the
chest.

The anterior margin of the lungs is thin and rather sharp,
and inclines obliquely downwards and forwards, covering, in
great measure, the pericardium, together with the organ
which it envelopes : that of the left side is slightly excavated,
towards the lower part, for receiving the point of the heari^
which is always exposed at this situation, even during the
most thorough distention of the air-cells. The postej'ior
margin is thick, rounded, and lodged in the groove formed
between the dorsal vertebras and the heads of the ribs, its di-
rection being nearly vertical.

The base of the respiratory organs is somewhat concave,
and rests on the upper surface of the diaphragm, whilst the
apex forms a rounded, narrow prominence, which ascends
between the scaleni muscles, the trachea, and the last cer-
vical vertebra. When the subject lies on the back, with a
block under his shoulders, it will be found, as a general rule,
that this portion of the organ ascends as high as an inch
above the level of the first rib, and occasionally, indeed, even
twice that distance. This is more particularly the case when
one lung, in consequence of disease of the other, is obliged
to perform as it were a double function. This arrangement,
a knowledge of which is of no little importance in reference
to the lesions of the pulmonary tissue, has not been sufficient-
ly dwelled upon by anatomists ; in fact, very few seem to be
aware even of its existence. How far it influences the pro-
duction of tubercles, which are so frequently observed in the
superior lobes of these organs, is a topic concerning which we
are still, in great degree, in the dark.

With respect to their color, the lungs vary not only in the
different periods of life, but also under different circumstances
of health and disease. Hence it is rarely that we find them
precisely alike in any two cases. In the fcetus, anterior to
respiration, the color of the lungs is of a uniform brownish
red. After this process has taken place, they acquire a light
florid complexion, which generally continues until about the
period of puberty, when it gradually passes into a grayish red,
intermixed with small lilac-looking patches. In progress of
time, as the individual grows older, the color is converted

SECT. II.] STRUCTURE COLOR. 37

into an iron gray, with narrow streaks of a still darker appear-
ance. These streaks here referred to are frequently quite
black ; and they appear to depend upon the deposition of a
peculiar pigment, which, as it is most abundant between the
lobules and their counecting cellular tissue, generally imparts
to the surface of the lung a singularly variegated aspect, —
some of the figures being triangular, some square, some hexag-
onal, and some lozenge-shaped. The matter in some instances
is poured out in small rounded spots, separated by intervals
of healthy tissue, and varying in diameter from that of a
mustard-seed to that of a five-cent ])iece. It is seldom ob-
serv^ed before the thirty-fifth or fortieth year ; and, notwith-
standing what Laennec has said to the contrary, can be
easily distinguished from melanosis, both by its color, and by
the peculiarity of its arrangement. It also imparts its tint
much less readily to linen and other articles than the latter
of these substances.

It is worthy of remark, that, in general anemia, the lungs
usually participate in the exsanguine condition of the system.
I have repeatedly examined the lungs of persons who had
lost an immense quantity of blood, either by the lancet or
otherwise, during their last illness ; and, in such cases, I have
invariably found them of a pale, blanched appearance ; nor
did they emit, on being incised, more than a few drops of
fluid. The pulmonary organs of the victim of the guillotine
have been said, by the French writers, to be unusually white ;
and the same phenomenon is generally observable in animals
that are bled to death, as I have convinced myself from per-
sonal observation. It is also deserving of notice, that, no matter
what may be the disease of which the individual dies, the
posterior part of the lungs is almost always of a much deeper
color than the rest, owing to the natural tendency which
the blood has to accumulate in the more dependent situations
of the body. The engorgement, which gives rise to this
difference of complexion, frequently commences during the
last struggles of life, and is probably not completed, in the
majority of instances, until a few hours after dissolution, or
until the blood is partially coagulated. Conjoined with this
state there is occasionally an oedematous appearance of the
pulmonary tissue, arising from the effusion of frothy serosity.
This phenomenon has been confounded with the infiltration
of the first stage of pneumonitis, from which, however, it is
easily distinguished both by its situation, which is always in

38 LUNGS. [chap. III.

the most dependent portion of the king, by the want of in-
flammatory redness, and by the absence of fibrin.

Tlie consistence of the kings, kke their color, varies accord-
ing to the period of hfe, and according to the liind of death.
Generally speaking, they have very little density, and hence
they may be very easily compressed, so much so, indeed,
that they will only imperfectly resume their original condi-
tion. In the fffitus, before respiration has taken place, they
are hard and firm, like the substance of the liver ; but, after
birth, they are soft, flexible, and elastic ; air-bubbles may
be pressed out of them ; and, when cut into, they distinctly
crepitate. Their specific gravity is likewise increased; and,
on being placed in water, they readily float on its surface.
Their texture, however, notwithstanding these properties,
possesses such a degree of tenacity as to render it by no
means easy to tear it.

The parenchymatous substance of the lungs being essen-
tially composed of the ultimate ramifications of the bronchial
tubes and the pulmonary vessels, it will be necessary to de-
scribe these parts before we proceed to contemplate its minute
structure. Externally, each of these organs is invested by a
reflection of the pleura, a delicate serous membrane, whilst
its interior is lined by a prolongation of the mucous tunic of
the wind-pipe.

Behind the arch of the aorta, opposite the third dorsal
vertebra, the trachea divides into two branches, called the
bronchicB, which incline laterally towards the inner surface
of the lungs, being separated from each other nearly at a
right angle. The right tube is larger but shorter than the
other : it is directed almost horizontally outwards, and enters
the corresponding organ on a level with the fourth dorsal
vertebra : the left, which is more oblique, is about an inch
longer than the right, and has therefore to descend somewhat
lower before it can reach the left lung. On arriving at its
place of destination, the right bronchia divides into three, the
left into two branches : and these, again, resolve themselves
into smaller tubes, so that, by continuing this division through
five or six successive stages, numerous canals are formed,
■which pervade the pulmonary organs, in every possible
direction, diminishing regularly in size as they augment in
number. An interesting fact with regard to the difierence of
the natural sound of respiration between the two lungs has
been recently pointed out by Dr. Gerhard, of Philadelphia.

SECT. II.] STRUCTURE DIVISIONS OF BRONCHIjE. 39

He has ascertained that the pecuhar blowing noise, observa-
ble at the right superior lobe, is owing to the greater caliber
of the corresponding bronchial tubes, which is nearly double
that of those on the left, where there is no such sound.

The bronchias and their primitive divisions are made up of
the same textures as the trachea, of which they may be re-
garded merely as so many prolongations. As their ramifica-
tions, however, become more frequent, the cartilaginous rings
gradually lose their annular form, and degenerate into small
irregular lamellae, which, succeeding each other less rapidly
than formerly, are placed in different parts of the circumfer-
ence of the canal, so as still to preserve its cylindrical shape.
The pieces thus by degrees become more and more scattered
and imperfect, until they at length completely disappear. The
other structures, however, are continued on to the ultimate
ramifications of the bronchise ; and, though, with the excep-
tion of the mucous membrane, they can be no longer discern-
ed, even with the aid of the microscope, there is every reason
to conclude, both from analogy and from the natural resiliency
of the lungs, that they still exist. The mucous lining in this
situation is extremely delicate, smooth, and polished, being
reduced to a thin, transparent film. By means of a good
glass, longitudinal folds may be seen on its free surface,
which is also studded with hundreds of minute follicles.
With regard to the tubes themselves, they spread out in dif-
ferent directions, with a caliber scarcely large enough to
admit a common bristle.

The lining membrane of the bronchise, as it passes from
the larger to the smaller ramifications, is supposed by some
pathologists to be transformed from the mucous to the serous
texture, or at any rate to undergo very important modifica-
,tions of structure. Such, amongst others, is the opinion of
Monsieur Reynaud, of Paris, and of Dr. Stokes, of Dublin.
How this notion originated it is difficult to determine, for it
is by no means necessary, I conceive, that, because these
tubes are occasionally the seat of plastic inflammation, they
should be lined with a serous membrane. The mucous
textures are not, it is true, very prone to this species of
irritation ; still the formation of fibrinous concretions is suffi-
ciently common, even in them ; and the effusion of lymph
in the minute bronchial ramifications should not therefore be
a matter of greater surprise than in the larynx, oesophagus,
nasal duct, uterus, or bowel. That the lining membrane is-

40 LUNGS. [chap. III.

somewhat modified in these situations I do not feel disposed
to deny, but that the change is so complete as is contended
for by certain writers, seems to me to be unfounded in fact,
and unsupported even by analogy.

The lymphatic vessels of the kmgs are exceedingly abun-
dant ; and here, as elsewhere, they are divided into two sets,
the one being superficial, the other deep-seated. In front of
the inferior extremity of the trachea, as well as around its
primitive divisions, are a considerable number of black, dirty-
looking bodies, called, from their situation, the bronchial
glands. In their size, they vary between a pea and a hickory-
nut, and most of them are of a rounded, flattened shape. Their
dark color would seem to be derived, according to Vauquelin,
from a deposition of pure carbon. They are evidently nothing
but lymphatic ganglions, which undergo various changes
during the progress of life, and which, in old age, almost al-
ways contain some earthy matter, either in a soft or solid
state.

The lungs are supplied with blood from two sources, the
pulmonary and bronchial arteries. The first is a short,
stunted vessel, about two inches in length, which arises from
the base of the right ventricle of the heart, and proceeds
obliquely upwards towards the left side of the chest, dividing
opposite the second dorsal vertebra into two large trunks,
one for the right, the other for the left lung, the former being
the larger and longer. On reaching the parenchymatous
substance, these two trunks separate into innumerable ramifi-
cations, which accompany those of the bronchial tubes to their
final termination in the air-cells, on the delicate walls of
which they become capillary, being spread out upon them in
the form of a beautiful net-work. These vessels have
nothing to do with the nourishment of the lungs : they are
designed simply to convey dark venous blood from the right
side of the heart, in order that it may be subjected to the
influence of the atmosphere ; and, having derived this benefit,
the fluid is sent, by means of appropriate veins, to the left
cardiac chambers, from whence it is transmitted to the ditfer-
ent parts of the body. Imperfect valves are said to exist in
these veins ; but of the truth of this assertion, recently made
by professor Meyer, of Bonn, I have not been able to satisfy
myself

The work of nutrition is delegated to another set of ar-
teries, called the bronchial. These vessels, which are ex-

SECT. II.] NERVES. 41

tremely small in comparison with the volume and weight of
the respiratory organs, are generally two in number, one on
each side ; but sometimes there are three, four, or even five.
In the majority of cases, they arise from the aorta, either
separately or by a common trunk ; but occasionally the right
is given off by the first intercostal or internal mammary
artery. Soon after their origin, they send some minute twigs
to the oesophagus, the pleura, and the pericardium ; and, on
reaching the root of the lungs, each divides into four or five
branches, which follow the ramifications of the bronchial
tubes, and freely anastomose Avith the pulmonary arteries.
The bronchial veins, which return the residual blood, unite
into several small trunks, which pass out at the root of the
organ, and open into the azygos and pulmonary veins : occa-
sionally, some of them terminate in the superior cava, or in
the oesophageal, or first intercostal veins, or even, as has been
observed by Winslow, Haller, and Hildebrandt, in the left
auricle of the heart.

The lungs are furnished with 7ierves from the pulmonary
plexus, which are made up chiefly by the par vagum, assisted
by a few branches from the great sympathetic. Some of
these nerves penetrate the parenchymatous substance in com-
pany with the divisions of the bronchiss, whilst the others
form an inextricable interlacement on their outer surface. It
was formerly supposed that the branches of the sympathetic
were appropriated exclusively to the bronchial tubes, and
those of the par vagum to the pulmonary vessels ; but the
recent researches of Reisseissen, and other anatomists, clearly
show that this opinion is erroneous.

The sources whence the hmgs derive their nervous supply
are worthy of being borne in mind, as they enable us to
explain many of their sympathetic derangements. Indeed,
there are no organs in the body which are so prone to suffer
in this way as the pulmonary. In cerebral affections, espe-
cially such as a^re characterized by symptoms of compression,
the lungs are almost always greatly oppressed^ performing
their functions in a tardy and imperfect manner ; and every
body knows how much they are involved in diseases of the
stomach, liver, and bowels. In chronic gastritis they often
become the seat of the most distressing cough ; and the
sympathetic irritation thus induced is frequently carried so
far as to give rise to the developement of tubercular phthisis.
The mere mention, however, of these connections must

VOL. II. 6

43 LUNGS. [chap. III.

suffice. The subject is one of deep interest to the practitioner ;
and, for a more ample account of it than our hmits will enable
us to furnish, we beg leave to refer the reader to the writings
of Dr. Philip* and Dr. Todd,-j- of England, in which he will
find much valuable and instructive information.

The different structures here described, as entering into
the composition of the pulmonary viscera, are united together
by cellular tissue, and so disposed as to form a series of small
lobules, of an irregularly angular figure, which, when care-
fully inspected, are found to consist of clusters of minute
cells, scarcely the hundredth part of an inch in diameter.
These cavities are of a spherical shape, and may be con-
sidered as the ultimate terminations of the bronchial tubes,
to which they are appended like bunches of little buds.
Their parietes, which are of great tenuity, and which Haller
has estimated as being about the thousandth part of an inch
thick, are probably formed exclusively by the mucous mem-
brane of the bronchiee, and naturally lie in close contact with
each other. Over their outer surface are scattered, in im-
mense pfofasion, the delicate capillaries of the pulmonary
vessels, and here, during life, the blood is constantly sub-
jected to the influence of the atmosphere, so as to be con-
verted from venous into arterial, which appears to be the
grand object of the respiratory function. Internally, the air-
cells are bedewed with a thin, mucous exhalation, the quan-
tity of which, in the twenty-four hours, including that of the
trachea and mouth, has been variously estimated from six to
twenty ounces.

It would appear, from the recent researches of Professor
Horner, X that the air-cells of the individual lobules, contrary
to the general opinion of anatomists, freely communicate with
each other laterally, precisely like the cavities of the bones,
or those of a sponge. The vesicles of different lobules, how-
ever, have no such connection, the intercourse between them
being established solely through the ramifications of the bron-
chial tubes. This arrangement is easily shown by distending
the air-cells with tallow, which, after the lungs have been
dried, is to be removed with spirits of turpentine. By this
process, their natural size is preserved, and they are seen to
communicate freely with each other. The aggregate of the

* On Indigestion, 1821.

t CyclopEcdia of Practical Medicine, article Indigeslion.

t Special Anatomy, vol. ii. p. li'i. Fourth edition.

SECT. II.] RESPIRATORY SOUNDS. 43

internal surface of the pulmonary vesicles is immense. Dr.
Monro * supposes that it is nearly thirty times greater than that
of the whole external area of the body ; and this evaluation is
probably not far from the truth, especially if there are, as he
conjectures, upwards of half a million of these little cavities
in every cubic inch of parenchymatous substance.

The parenchymatous structure, then, is composed of a
great variety of tissues, which are cemented together by
cellular substance. This substance is remarkable for its great
softness and delicacy. It is perfectly destitute of fat, but
often contains, as was previously intimated, a considerable
quantity of black pigment, which is generally most conspicu-
ous on the surface of the lungs, and which appears to be
simultaneously deposited with that of the bronchial glands.
It was formerly supposed that the interstices of this tissue
communicated with the air-cells ; but more careful observa-
tion has demonstrated that this is not the case. Externally,
the lungs are enveloped by a reflection of the pleura, which
is united to them by the same kind of cellular substance as
that w^hich pervades the interior of these organs, — a circum-
stance which accounts for the fact that inflammation of one
of these structures seldom exists long v/ithout involving the
other.

It only remains that we should make a few remarks on the
natural sounds of respiration, wnth reference to auscultation,
which closely connects itself with the present topic.

The entrance of the air into the respiratory passages pro-
duces a peculiar sound, which varies in its characters in the
larynx, the trachea, the bronchiae, and the pulmonary vesicles.
In the latter, the sound is somewhat soft and silky, and con-
stitutes what is called the respiratory or vesicular murmur.
In the other situations, the sound is more dry, and destitute
of that crepitating nature which accompanies the expansion
of the air-cells. This is the bronchial respiration of Laennec
and other writers.

Although the respirator}?' murmur may be recognized at all
points of the chest, yet there are some situations in which it
is much more distinct than at others. Thus it is particularly
loud in the arm-pits, in the space comprised between the
collar-bone and the trapezius muscle, below the mammary
gland, and at the inferior two thirds of the back part of the

* Elements of Anatomy, vol, ii. p. 93. Second edition. Edinburgh, 1831.

44 LUNGS. [chap. III.

chestj — regions where the thoracic parietes are naturally very
thin, and the lungs therefore comparatively superficial. Age
also exerts a considerable influence upon the energy of the
breathing murmur. It is always remarkably strong in chil-
dren, so much so as to have received the name of puerile
respiration, — a character which it sometimes retains nearly
throughout the whole of life. Towards puberty, the sound
in question gradually diminishes in intensity ; and, in old age,
it is often comparatively feeble. It is likewise more faint in
the corpulent than in the emaciated, and in men than in
women ; though, as respects the latter, the difference is usually
very slight.

The cause of the vesicular murmur is probably the rustling
of the air against the sides of the pulmonary vesicles, as it
passes in to fill the vacuum created by the elevation of the
ribs and the descent of the diaphragm. In expiration, the
fluid is expelled in a very gentle, uniform manner, without
harshly impinging upon the delicate reservoirs which embrace
it ; and hence the sound is always very difl'erent from that of
inspiration, being short, feeble, and of a blowing character.

The bronchial respiration is entirely free from the crepita-
tion which distinguishes the breathing murmur, and gives
the idea of air passing along capacious tubes. In the normal
state, it is only heard at the anterior and lateral parts of the
neck, except in very thin persons, in whom it may also be
perceived towards the top of the sternum, and in the inter-
scapular interval. In the minute bronchial tubes, it is con-
founded with the respiratory murmur, to such a degree as to
render it impossible to discriminate between them.

The number of respirations varies in difl'erent individuals,
and also in the same person at diflferent periods of life. An
adult breathes about eighteen times in a minute ; an infant,
about thirty-six times. At puberty, the number of respira-
tions is about twenty. In decrepitude the function is per-
formed in a more hurried manner, as well as with less regu-
larity, — the intervals between the respirations being at one
moment short, and at another long. In general, women
breathe a little more frequently than men, and individuals of
an irritable temperament, than those who are naturally tran-
quil or not easily excited. Healthy respiration is effected
with ease and freedom, in which there is nearly an equal
elevation of the ribs and depression of the diaphragm : each
side of the thorax is expanded to the same extent ; and there

SECT. II.] PNEUMONITIS ; FIRST STAGE. 45

is no sensible difference observable in regard to the intervals
of time occupied by the inhalation and expulsion of the air.

II. The pathological phenomena which are displayed in
the lungs, may be arranged under the follovs^ing heads : 1.
acute inflammation ; 2. abscess ; 3. gangrene ; 4. chronic
inflammation; 5. oedema; 6. emphysema; 7. apoplexy; 8.
encephaloid ; 9. melanosis; 10. serous cysts; 11. hydatids ;
12. calcareous concretions ; 13. hypertrophy ; 14. atrophy ;
15. tubercular phthisis.

Inflammation of the pulmonic tissue, now usually denomi-
nated pneumonitis, (from ni'svfjwv^ the lung,) is a very com-
mon and fatal disease in cold climates, prevailing not unfre-
quently epidemically. Commencing with all the symptoms
of an ordinary catarrhal afl'ection, it is soon followed by more
or less pain in the chest, difficult respiration, and convulsive
cough, with expectoration of a thick, ropy mucus, always
streaked, in bad cases, with blood. If the patient succumb,
as often happens in spite of the best directed efforts of the
physician, the anatomical characters will be found to vary
according to the extent of the inflammation, its severity, and
the length of time it may have existed. In this respect, the
disease may be considered as being divisible into three stages,
each of which had some features peculiar to itself. In the
first stage, the pulmonic tissue is marked by excessive en-
gorgement of blood ; in the second, it is dense, and hepa-
tized ; and, in the third, it is infiltrated with purulent matter.
Each of these pathological states will require brief consid-
eration.

In the first stage of the disease, the inflammation appears
to be wholly confined to the parenchymatous texture, the
only change observable in the bronchial tubes being the pre-
ternatural vascularity of their lining membrane. The lung
is externally of a dark, livid color, pits on pressure, and has
an unusually heavy and solid feel. With these changes, the
natural crepitus' and elasticity are impaired ; and hence, on
opening the chest, the organ seldom completely collapses.
The internal structure exhibits various shades of color, from
crimson red to livid black, occurring either continuously, in
large patches, or in small circumscribed spots, according to
the extent of the disease. When cut, blood freely issues
from the incision, mixed with white frothy matter ; the inter-
vesicular cellular tissue is infiltrated with a large quantity of
serosity ; and all the vessels, both arteries and veins, are in

46 LUNGS. [chap. Ill,

a state of the utmost engorgement. The hing, in this condi-
tion, still floats in water, owing to the fact that it still con-
tains air, and, by careful washing, may be made to resume its
spongy, vesicular structure, together with most of its normal
characters. In very violent cases, such, for example, as run
a very rapid course, we sometimes meet Avith small sanguine-
ous effusions, traceable to ruptured vessels ; and, another
effect, which is occasionally wrought in this stage of the dis-
ease, is a peculiar softening of the pulmonic tissue, first de-
scribed by Andral, who regarded it as the result of cadaveric
congestion ; but which the subsequent observations of Chomel,
and other pathologists, have clearly shown to be dependent
upon inflammatory irritation. The duration of this stage
is usually from one to five days.

In the second stage, the lung is hard and solid, being con-
verted into a heavy, inelastic substance similar to that of the
liver. The crepitus, so distinct in the sound state, is no
longer perceptible ; the organ does not collapse, or only slight-
15'', on opening the chest ; and if the affected part be torn
across, it will exhibit a large number of granulations, which
we have reason to suppose are nothing but the natural air-
cells filled with bloody inspissated lymph. These little
bodies are of a spherical shape, closely grouped together, and
so solid that, with proper patience, they may be lifted out of
their position. The parenchymatous texture, in this state, is
usually of a deep fleshy red, interspersed with various shades
of grayish, pink, brown, or even black : it is much more
friable than in the preceding stage, breaking readily down
under the finger ; and is so dry that blood no longer follows
the knife that is employed to divide it. By scraping the in-
cised surface, however, or pressing the part between the
fingers, a small quantity of sanguinolent fluid may be ob-
tained, mixed either with thin froth, or, as more frequently
happens, with purulent matter. There may also be observed
along the incision a considerable number of whitish-looking
points and striae, which correspond with unaltered portions of
blood-vessels and bronchial tubes. It is asserted by many
that the pulmonic tissue, when thus hepatized, is specifically
heavier than water ; but, although I have frequently tried
the experiment, I have never witnessed the circumstance,
and feel inclined, therefore, to regard it rather as an excep-
tion than as a general event. This stage seldom continues
beyond three or four days, when it passes into purulent in-
filtration.

SECT. II.] PNEUMONITIS ) THIRD STAGE. 47

We have just seen that the color of a hepatized lung is
liable to considerable variation. This is owing altogether
to the nature of the effused fluids on which the solidification
depends. When the product consists simply of plastic lymph,
the hepatized part is generally of a grayish white ; but, when
this substance is blended with hematosine, as it commonly is
Avhen the inflammatory irritation runs high, the color is
always more or less red.

In the third stage, the lung, although it exhibits the same
or even a greater degree of hardness, and the same granular
structure, as in the second, assumes a pale yellowish cast,
variegated with hepatized patches of red, gray, or even bluish.
Pus always exists in this state, appearing at first in small
isolated points, but which in a short time coalesce, and thus
impart to the pulmonic tissue a uniform citron color. If an
incision be made into the lung, it will be followed by the
escape of an opaque, ropy fluid, evidently of a purulent nature,
but almost void of smell, or at least much less offensive than
the matter of an external wound. As might be expected,
from what has been just stated, the parenchymatous structure
is extremely moist, soft, and lacerable, the slightest pressure
of the finger converting it into a yellowish, pulpy mass. The
smaller bronchial tubes, in the third stage of pneumonitis,
are completely obstructed ; the larger ones, on the contrary,
contain more or less purulent matter, and their mucous lining
is thickened, injected and of a brownish red color.

The anatomical characters of the three stages here de-
scribed frequently occur in the same lung, dividing it into
so many zones, which gradually and insensibly run into each
other. Much diversity prevails in regard to the extent of the
disease. In a few instances, I have seen it occupy almost
the whole lung ; most generally, however, it affects only a
single lobe, or small detached masses. We never find the
whole of both these organs hepatized at the same time, for
the obvious reason that an obstruction of this kind would be
incompatible with the respiratory function. The right lung,
according to Laennec, is more frequently involved than the
left, not only in pneumonitis, but in nearly all the morbid
affections to which these delicate structures are liable. This
view is strikingly confirmed by the interesting investigations
of Dr. Lombard, of Geneva. Uniting all the cases collected
by Chomel, Andral, and himself, he ascertained that, in nine
hundred and sixty-eight patients, one hundred and ninety-

48 LUNGS. [chap. III.

five had the disease in both lungs, — two hundred and sixty
in the left, and four hundred and thirteen, in the right.*
Various explanations have been proposed of this fact ; the
most plausible hypothesis, perhaps, is that of Lombard, who
supposes that the difference in the size of the pulmonary ar-
teries will account for the circumstance. But it may well be
doubted, I think, whether the right lung receives more blood,
in proportion to its volume, than the left : the question, at all
events, remains undetermined ; and, until something positive
be known, it will be well enough to refrain from conjectures,
as very little good is ever to be expected from them.

The different lesions of pneumonitis are accompanied by
appropriate symptoms, which indicate their presence, progress,
and mode of termination. In the first stage, when the pul-
monic tissue is infiltrated with bloody serum, all the vessels
are in a state of engorgement. The characteristic manifesta-
tions are, hurried respiration, dyspnosa, obtuse pain in the
chest, distressing cough, and inflammatory fever. The lung
being still permeated by the atmosphere, the chest, on per-
cussion, yields pretty much the same sound as in health ;
though, if the disease occupy a large extent of surface, it will
often want its natural clearness. If the ear be applied, a pe-
culiar sound, accompanying the usual respiratory murmur,
will be heard : it is a fine, crackling noise, resembling that
which results from rubbing a lock of hair between the fingers,
and is regarded, by most pathologists, as pathognomonic of
the first stage of this disease. This sound, it may now be
observed, is called the crepitating rhoncus. It is always more
distinct in proportion to the extent of the engorgement, and
is most easily recognized at the lower part of the chest, be-
neath the axilla, and in the interval between the scapula and
spinal column. The expectoration, in this stage, is white,
frothy, and small in quantity, — at first thin and transpa-
rent, afterwards remarkably viscid, and often streaked with
blood.

In the second stage, in which the pulmonic tissue is hep-
atized, and consequently impervious to the air, the chest
over the inflamed lung is dull, on percussion ; and, instead of
the crepitating rhoncus, there is a singular whiffing sound, not
unlike that which is produced by blowing through a narrow
quill. This is the bronchial respiration of Laennec and An-

* American Journal of the Medical Sciences, vol. ix. p. 202.

SECT. II.] PNEUMONITIS ; SYMPTOMS. 49

dral, and is always more audible in proportion to the solidifi-
cation of the parenchymatous structure. It seems to be
caused by the- air striking forcibly against the mucus in the
larger bronchial tubes, and hence it is usually most perfect at
the root of the lungs, where it is occasionally so loud as al-
most to amount to a Avhistle. The earliest indications of its
presence are to be detected a little above the centre of the
dorsal region, between the spine and scapula. Laennec, not
knowing that this sound uniformly exists in this stage of
pneumonitis, was disposed to undervalue it, as a diagnostic
sign ; but, at present, it is universally regarded by practition-
ers as the most important character which, in this respect,
we possess.

As usually coexisting with this altered state of the respira-
tory function, it will be necessary here briefly to advert to
that peculiar resonance of the voice which writers have dis-
tinguished by the term bronchophony^ (from ^(joyxog, the bron-
chia, and q:0)pri, the voice.) It does not occur in distinct words,
but in noes of various continuance, resounding, at the end of
the stethoscope, as if they came through little tubes. Always
loudest towards the root of the lungs, it is sometimes char-
acterized by a curious, vibrating tone, from the complication
of pleuritic effusion, which so often occurs in combination
with this disease. Like bronchial respiration, it is more dis-
tinct in pneumonitis than in any other affection, and hence is
occasionally of much value in determining the diagnosis.

The expectoration, in this stage, is still scanty, often not
exceeding a few ounces in the twenty-four hours. The
cough is hard, and the sputa, which are slightly yellowish,
and semi-transparent, are remarkably tenacious, streaked with
red, and blended with small air-bubbles. After a while, the
red streaks disappear, and the whole mass acquires a peculiar
rusty color, which, as it occurs in no other disease, may be
considered as absolutely pathognomonic of acute pneumonitis.
This tint arises from the intimate manner in which the blood
is incorporated with the ropy mucus of the bronchial tubes.

In the third stage, the bronchial respiration ceases, being
replaced by a coarse mucous rhonc^is, which is always loudest
at the root of the lungs, in the axillary region, and below the
great pectoral muscle. The chest offers the same flatness, on
percussion, as in the second stage, and there is also the same
want of respiratory murmur. The expectoration is more easy
and abundant, and the sputa, which are commonly of a

VOL. II. 7

50 LUNGS. [chap. III.

yellowish hue, are of a muco-purulent character : they are
not so tenacious as before, and frequently sink in water.
In some instances, they are thin, homogeneous, and brown-
ish, like the juice of prunes : this, however, is an occurrence
of great rarity, and always portends danger.

Considerable variety obtains in relation to the pain which
the patient experiences in this disease. In pure, uncompli-
cated pneumonitis, it is generally of a dull, aching character,
and sometimes it is even entirely absent. In a man, aged
forty, whom I attended, about eighteen months ago, with my
friend Dr. Woodward, there was not the slightest manifesta-
tion of pain throughout the whole course of the disease, a
period of upwards of three weeks ; and yet, upon examina-
tion, both lungs were found greatly disorganized, being al-
most universally engorged, with several of the lobes in a state
of purulent infiltration. For the most part, however, the
disease occurs in connection with pleuritis ; and then the pain
is often very distressing, sharp, and lancinating, shooting from
the atfected structure towards the shoulder, the axilla, and
corresponding arm.

The respiration, in pneumonitis, is performed chiefly by
the diaphragm, and is therefore short, hurried, and painful :
the frequency, on an average, is about twenty-fi.ve ; but, in
very severe cases, it often ranges as high as thirty-five, forty-
five, or even fifty in a minute. The cough is at first dry and
convulsive ; in the latter stages of the disease, it becomes
moist and less harassing, though it is still somewhat painful,
especially in children. The patient lies almost always on his
back, seldom or never on the affected side. The prostration
of strength, in this disease, is usually great and rapid.

Pneumonitis occurs at all periods of life, from the cradle to
the grave. Occasionally, indeed, it exists as an intra-uterine
disease.* It is incomparably more frequent, however, in in-
fancy and in old age than in the prime of life or vigor of
manhood. In the winter of 1836 — 7, when this disease be-
trayed somewhat of an epidemic tendency in Cincinnati, the
greatest number of persons affected, by far, were children un-
der three years of age. In London, Paris, and other Euro-
pean cities, during the same season, it appears to have been
remarkably destructive to old people.

The disease ordinarily begins in the inferior parts of the

* Cogny, Dissertation sur la Pneumonic, &c. des Nouveau-nes. Paris, 1827.

SECT. II.] pneumonitis; resolution: abscess. 51

lung, from whence it radiates in different directions, until it
involves a greater or less extent of tissue. This statement
accords with that of Laennec. and many of the best authori-
ties of the present day ; but it is opposed to the results of the
observations of Broussais, Chomel, and several other highly
respectable pathologists. In fifty-nine cases, Chomel found
the upper lobes affected in thirteen ; the inferior, in eleven ;
the whole of one lung, in thirty-one ; the posterior parts, in
two ; and the middle, in one.* The universal it}?- of this oc-
currence, on the whole, is perhaps not so great as was imag-
ined by Laennec : still, I feel perfectly satisfied, both from
my own, and the observations of others, that his statement is
applicable to the great majority of cases of this complaint,
whether occurring in old age, in infancy, or in youth.

Pneumonitis frequently terminates by resolution, especially
when it does not transcend the second stage. When this
event is about to take place, the preternatural vascularity
gradually disappears, the effused fluids are absorbed, and the
air-cells regain their primordial volume and figure. Some-
times the pulmonic texture continues for a while to be oedem-
atous, being characterized by slight dulness on percussion,
and indistinctness of the respiratory murmur. The progress
of a portion of hepatized lung is more tardy, a considerable
period generally elapsing before the granulations give way to
the developement of the air- filled vesicles. The first percep-
tible change is a diminution of color, accompanied by an
absorption of the lymph which gave rise to the solidification.
As the process advances, the pulmonic tissue becomes gradu-
ally more yielding and elastic, it loses its dryness, fragility,
and is infiltrated with a thin serous fluid, — characters which
closely assimilate it to the normal texture. In the third
stage, resolution is a rare occurrence ; but, should this take
place, the yellow color may be supposed to become hghter,
and the pus more liquid from the admixture of serum. Air-
vesicles afterwards appear, and continue to increase, while the
purulent fluid is reduced to small points, which progressively
diminish in number as the vesicular structure returns. All
these changes, as might be supposed, are accompanied by
corresponding changes in the physical signs of this disease.

The formation of abscesses, as an effect of pneumonitis, is
extremely rare. Laennec states that, in several hundred

* Laennec on the Chest, p. 20-1, note, by Dr. Forbes.

52 LUNGS. [chap. III.

examinations of persons who died of this disease, he never
met with more than five or six cases in which the pus was
concentrated into a focus. Precisely of the same import is
the testimony of the latest pathological anatomists of Europe
and this country. Broussais declares that he has met with
this termination only once ; Andral and Louis also consider it
as very infrequent ; and Dr. Horner, who states that he has
dissected more than fifteen hundred bodies, has observed it
in only two instances.* In my own examinations, I have not
been more fortunate, having hitherto seen pulmonic abscesses
only in two persons, the one an adult, aged forty, the other a
child of fifteen months. In this case, the abscesses, Avhich
occupied the inferior lobe of the right lung, were about
twenty in number, the largest of which scarcely equalled a
cherry-stone. No tubercles were found : the child had been
sick about four weeks.

Formerly the termination of pneumonitis by abscess was
considered as very frequent, — an error which no doubt
arose from mistaking tubercular excavations, which are of
such common occurrence in consumptive subjects, for collec-
tions of this kind. Of this, any one may convince himself
by a careful perusal of the works of Bonetus, Morgagni, and
other pathologists of the seventeenth and eighteenth centu-
ries. Even Dr. Baillie, so justly distinguished for the accu-
racy with which he generally conducted his researches, did
not escape this error.f The reason of the infrequency of this
mode of termination of pneumonitis will be explained by
and by.

The walls of these abscesses are formed by the pulmonic
tissue, which is usually infiltrated with pus, and in a state of
putrilaginous softening. In one of the cases to which I
before referred, the matter was bounded by a dark, flesh-
colored substance, very considerably indurated. Occasionally,
the abscesses are encysted, being enclosed by a thick, false
membrane : cases of this kind, however, are very rare, and I
have never met with them. Their size varies infirutely : in a
few instances, they have been found as large as an adult fist ;
but, in general, they do not exceed a nutmeg, hickory-nut, or
small apple. Frequently they communicate with the bron-
chial tubes, through which the matter is at length discharged,
when the cavity heals, and the individual recovers, the mode

* Pathological Anatomy, p. 241. t Morbid Anatomy, p. 42.

SECT. II.] PNEUMONITIS ; SUPPURATION. 53

of cicatrization being in every respect analogous to that
which takes place in the spontaneous cure of a tubercular
excavation, hereafter to be described. In old cases, the pus
is usually of a thick, creamy nature ; in recent ones, on the
contrary, it is apt to be semi-concrete, from the admixture of
an undue proportion of lymph. It may be remarked here,
that purulent depositions are commonly seated near the sur-
face of the lung, seldom deep in their structure.

Abscesses of the lungs can occur only in association with,
or as a consequence of, inflammation, whose limits are prop-
erly circumscribed ; in other words, the disease must be con-
fined to particular j)arts, lobes, or lobules. The rationale of
this is obvious. In universal pneumonitis, death must neces-
sarily ensue before the matter can break up the cellular tissue
and collect itself into a focus ; which need not be the case
when the inflammation is limited, — nature, properly assisted
by art, being often capable here of warding off this occur-
rence until after the establishment of the suppurative pro-
cess. Abscesses sometimes form in the substance of the
lungs, as in that of the liver, in consequence of severe wounds
and great surgical operations. Their origin here, whatever
it may be, is probably the same as in the latter organ. I
cannot think, with Andral, that the pus is formed in the
remote veins, and filtered into the pulmonic tissue in its
passage through the lesser circulation. Such an event may
occur, occasionally; but to suppose that it happens generally,
or even frequently, seems to me to be repugnant to the laws
of sound pathology.

Of the constitutional symptoms of pulmonic abscess, noth-
ing need be said in this place. As to the physical indica-
tions, they do not differ from those which appertain to the
third stage of pneumonitis, until the purulent matter has
been partly expectorated. In that case, the bronchophony is
replaced by a peculiar gurgling rhoncus, which becomes
more and more- hollow in proportion to the evacuation of the
liquid contents of the abscess, the voice, — if the stethoscope
be applied over the cavity, seeming to issue directly from
the chest of the patient. This is the pectoi^iloquous respira-
tion of Laennec and other writers. When the cavity is very
large, a metallic tinkling is sometimes heard, resulting from
a mixture of air, pus, and mucus, in the same way as this
phenomenon is developed in tubercular excavations.

The lungs are liable to become gangrenous, sometimes as

54 LUNGS. [chap. III.

an effect of acute pneumonitis, but more generally without
any assignable cause. The disease may occur in circum-
scribed spots, or it may invade an entire lobe, or even the
whole of one of these organs. It may be readily detected
by its intensely fetid odor, and by its greenish brown, dirty
olive, dark brown, or black color. The pulmonic tissue is
softened, and converted into an offensive putrilaginous mass,
not unlike decomposed blood. When cut, the part affected
often gives vent to a turbid, sanious fluid, of a greenish tint,
and. an almost insupportable smell : in rare cases, the sphace-
lated mass is dry and friable, like a rotten pear. When the
gangrene is circumscribed, an imperfect factitious membrane
may sometimes be discovered ; but, in most instances, where
there is a distinct line of demarcation, the living part is
preternaturally injected and infiltrated with sanguinolent
liquid, with cellular shreds and vascular filaments hanging
from its borders. By degrees, the putrid pulp finds its way
into the adjoining bronchial tubes, and is finally ejected by
expectoration. The cavity which is thus left, is either filled
up with lymph, or, as more commonly happens, its walls are
lined by a false membrane, which continues to secrete, for a
time, a thin, imperfect pus,

Laennec, who considers this disease as altogether of an
idiopathic nature, like hospital gangrene, seems disposed to
look upon it rather as exciting than following pulmonic
inflammation. This opinion is partly correct, partly erro-
neous; for it is now well ascertained that sphacelus is
generally a result of inflammatory irritation, more or less
intense in its character, though not always offering the usual
evidence.

Gangrene of the lungs seems to be of much more frequent
occurrence than was formerly supposed by pathologists. Dr.
Gerhard informs us that, in a single winter, he saw six cases
of it in the Philadelphia Almshouse ; and, in the same year,
the disease, it would appear, was extremely common in
Paris.* It is most prevalent in cold weather, and occasion-
ally betrays an epidemic tendency. It makes its attacks at
all periods of life ; but the aged, and especially such as are of
intemperate habits, are most prone to it. A singular fact
respecting gangrene of the lungs has been recently witnessed
by Dr. Guislain, a French physician. Out of thirteen insane

* On the Diagnosis of the Diseases of the Chest, p. 99.

SECT. II.] GANGRENE. 55

patients who died of inanition in the hospital at Gand, nine
were affected with this disease. In one case, both lungs
were involved ; and in nearly all of them the sphacelation
was confined to the posterior and upper part of these organs.*
How is this occurrence to be explained ? The present state
of our knowledge does not enable us to give a satisfactory
answer.

The only two specimens of gangrenous lung that I have
ever seen are preserved in our college museum. Of these, one
belongs to the circumscribed variety, and was taken from a
mechanic, forty years old, who died in this city in Septem-
ber, 1835, having had, six weeks before, an attack of con-
fluent small-pox. During the latter part of his illness, he
was attended by Dr. Wood, who describes his symptoms as
having consisted in severe thoracic pains, distressing cough,
recurring in irregular paroxysms, and expectoration of large
quantities of dark-colored, bloody mucus. He expired in
about a week after. On inspection, I found the left lung, at
the part corresponding with the interlobular fissure, reduced,
for about one inch in diameter, to a dark, pulpy, gangrenous
mass, so excessively offensive, that it was almost impossible
to remain in the apartment where we were conducting the
examination. The eschar, which reached as far as the sur-
face of the lung, communicated with a large bronchial tube,
and had been discharged in part by expectoration. The
pleura immediately over it was in a state of sphacelation,
and the matter was evidently prevented from escaping into
the chest by the adhesions which the lung had formed with
the wall of that cavity. The pulmonic tissue round the
gangrene was rather soft and injected, and the whole sur-
face of the organ was covered with a false membrane, thick,
dense, and highly vascular.

In the other specimen which belongs to the diffuse variety,
the gangrene involved nearly the whole of the right lung,
which was of a dark, dirty olive color, extremely soft and
friable, and exhaled a most intolerable odor. The pulmonary
pleura was perforated in several places, and a considerable
quantity of black, offensive matter was found in the corres-
ponding cavity of the chest. The disease, in this case,
supervened upon an attack of typhoid fever, and was marked
by a brownish, fetid expectoration, which set in a few days

* Gazette Medicale de Pari", January, 1836.

56 LUNGS. [chap. hi.

before death. The patient was a young printer, about
twenty-three years of age.

The progress of this disease, if at all extensive, is gener-
ally most rapid ; the respiration is much embarrassed ; the
cough excessively distressing ; and the patient often expires
in a state of asphyxia. The expectoration, which is of a
dirty black, green or brown color, is so horribly offensive,
that it may be considered as pathognomonic of the disease.
In case the slough is detached, the same signs of a cavity
may be produced, as in abscess of the lungs, already de-
scribed.

Chro?iic pneumonitis may be a sequel of the acute disease ;
but, in the great majority of cases, it seems to have a primary
and independent existence. Some there are who still doubt
whether there is such an affection as chronic inflammation of
the lungs ; and it must be confessed that, at first sight, the
skepticism is not without some degree of plausibility. The
older writers are entirely silent on the subject, nor do Ave
find any satisfactory information concerning it until the time
of the celebrated Laennec, who investigated it with his ac-
customed patience and accuracy. He considers the disease
as extremely infrequent,* — an opinion in which he has since
been joined by many of the most distinguished pathologists
of the French school. Chomel asserts that, although he
has annually, for the last sixteen years, examined about two
hundred bodies, he has seen only two well-marked examples
of it.f Andral and Louis also consider it as very rare ; and
of the same nature, precisely, is the testimony of some of the
most experienced British pathologists. What the sentiment
is on this point of American physicians, I am not informed,
as I have no means of ascertaining it ; and as for myself,
although I have in a few instances witnessed the disease, or
rather its structural effects, my observations are too limited
to enable me to draw any general deductions.

A chronically inflamed lung is hard, dense, and dry, yield-
ing little or no moisture on pressure ; it tears with a granu-
lated surface, pits under the finger, and cuts a good deal like
a sponge. Here and there a reticulated structure, caused by
some remains of the air-cells, is visible ; and scattered through

** " I am acquainted," says Laennec, " with only a small number of cases
which can be considered as examples of chronic peripneumony ; and they are
extremely rare." (Treatise on the Chest, p. 238.)

f Diet, tie Med. t. xvii. p. 252.

SECT, II.] CHRONIC PNEUMONITIS. 57

various parts of it, numerous tubercles may sometimes be
observed, of a pale grayish hue, semi-concrete, and easily
removable. The color of the indurated organ, being alto-
gether of an accidental character, varies in different cases.
Thus, it may be red, grayish, pale yellow, iron gray, brown-
ish, or even black, or these tints may be blended, and so the
part have a mottled aspect. In the College Museum is a
specimen, for which I am indebted to my friend Dr. Wood-
ward, of this city, which is of the color of flesh ; and another
which is of a light grayish, beautifully dappled witPi black
pulmonary matter. These, together with a specimen taken
from a young horse that died of pneumonitis, complicated
with chronic pleuritis, are the only instances, so far as I
now recollect, which I have seen of this affection. In neither
of them were there any tubercles. The pulmonary tissue
in all was remarkably dry. hard, tough, smooth, and shining
when incised, rough and granular when torn. The bronchial
tubes seemed to have been entirely closed : many of the
larger vessels were filled with red, clotted, friable blood, and
the smaller ones were either obliterated, or so incorporated
with the indurated mass as to have lost completely their
original features.

A lung in this condition is much diminished in volume,
sometimes almost one half, and occasionally sinks in water,
though this I consider as rare. All my specimens, notwith-
standing the induration in two of them, was very great, and
involved the v/hole organ, having been specifically lighter
than this fluid. Cases occur in which the disease is limited
to a few lobules ; but, in most of them, it affects one or more
lobes, and sometimes, as we have just mentioned, even the
entire lung. This kind of induration is occasionally seen
around pulmonary abscesses, and very commonly around tu-
bercular excavations.

This disease may pass into purulent infiltration, abscess,
and even gangrene. When fully formed, it is doubtful, I
think, whether it is susceptible of resolution, the various
textures being so firmly cemented together by lymph as to
render it impossible for the absorbents to effect their restora-
tion. When idiopathic, the progress of the affection is gradual,
exciting little attention until a large portion of the pulmonary
tissue has become impermeable to the air. Often there is
very little pain, cough, or dyspnoea. The chest sounds dull

VOL. II. 8

58 - LUNGS. [chap. III.

on percussion, and there is always a mucous rhoncus, with
occasional bronchial respiration.

The lungs are occasionally the seat of (Bclema, — a disease
which, as its name imports, consists in an effusion of serum
into their cellular texture. The anatomical characters vary
according as the lesion affects either the whole or only a parf
of the respiratory organs. When the entire lung is involved,
it does not collapse on opening the chest : it is denser and
heavier than in the normal state ; pits on pressure ; and, when
cut, exudes a large quantity of clear, yellowish serosity.
This fluid is intimately blended with the interstitial cellular
tissue of the organ, into which it is originally deposited, and
can be easily discriminated from that which is diffused during
the first stage of pneumonitis, by its being less frothy, and of
a lighter complexion. The lung, when thus affected, still
crepitates on pressure.

This disease, although of very common occurrence, does
not seem to have received much attention from the profession
until the time of Laennec, to whom thoracic pathology is
under so many obligations. Rarely is it idiopathic : on the
contrary, it is usually associated with other dropsical disor-
ders, occurring, for the most part, in worn-out cachetic indi-
viduals towards the close of painful and protracted fevers.
Sometimes it accompanies organic affections of the heart.
Chronic bronchitis likewise predisposes to it ; and it is the
cause of the embarrassment of breathing which so often ex-
ists as a sequel of measles, small-pox, and scarlet fever. The
oedema seldom lasts beyond a few days ; occasionally, how-
ever, it continues for several weeks or even months, when the
fluid is either absorbed, or the case proceeds to a fatal termi-
nation.

There are no physical signs which can be considered as
positively indicating the presence of this state of the lungs.
The sound, on percussion, is nearly as clear as in health ]
but the respiratory murmur is, in most cases, very much
diminished. A crepitating rhoncus, most distinct at the base
of the lungs, is usually perceived, resembling a good deal the
sound of effervescing champagne. The respiration is im-
peded ; there is slight cough ; and the expectoration is thin
and scanty.

Of emphysema there are two thirds — the vesicular and the
interlobular — the one consisting in a dilatation of the pul-
monic cells, the other in the extravasation of air into the

SECT. II.] VESICULAR EMPHYSEMA. 59

interstitial cellular tissue. These two forms seldom coexist ;
and the latter, compared with the former, is usually regarded,
though erroneously, as a most rare disease.

In the vesicular emphysema, the air-cells are preternatu-
rally dilated, and distorted in shape. Their size varies in dif-
ferent cases. In the great majority of subjects, they equal in
magnitude the head of a common pin ; in others, they are as
large as a currant ; in others, again, as big as a cherry-stone,
or even a French bean. When the cells are of the latter di-
mensions, which, however, is a very rare occurrence, it is not
improbable that several of them are thrown into one, by the
rupture of the intervening texture : in some instances, not-
withstanding, the enlargement evidently results from a single
vesicle ; the walls of which, instead of yielding to the dis-
tending cause, are expanded into thin, transparent bags. Oc-
casionally, all the cells disappear from one entire lobule,
leaving merely some vascular and cellular shreds. In this
manner, a capacious cavern is sometimes produced, which
projects beyond the surface of the lung, in the form of one or
more globules.

The lung, in this variety of the disease, seems to be aug-
mented in volume, and to have lost its natural resiliency. It
is considerably paler than the sound organ, less crepitous,
more dry and elastic, and does not collapse on opening the
chest. Its specific gravity, also, is increased ; the surface is
often studded with small vesicles ; and many of the minute
bronchial tubes are in a state of dilatation.

Vesicular emphysema may exist in both lungs at the same
time ; but whether this be the case, or whether it be confined
to one of these organs, it seldom involves a very large amount
of tissue, inasmuch as this event would be incompatible with
the due performance of the respiratory process. It is a very
common attendant on tubercles, aneurismal tumors of the
heart and aorta, enlargements of the bronchial glands, and
asthmatic disorders. Amongst the occasional causes may be
enumerated whatever has a tendency to overdistend the air-
cells of the lungs, as playing upon wind-instruments, sing-
ing, and loud screaming.

The principal signs of the disease are, habitual dyspnosa;
shortness of breathing ; slight cough, either dry, or attended
with a thin, frothy expectoration, mixed with more or less
mucus ; absence of the ordinary respiratory murmur ; and
a loud drum-like sound on percussion. When the emphy-

60 LUNGS. [chap. III.

sema is very extensive, the lung may be so much augmented
in bulk as to encroach very sensibly upon the heart and me-
diastinum, — forcing down the diaphragm, elevating the inter-
costal spaces, and giving the chest a vaulted appearance
contrasting singularly with its naturally compressed shape.
So remarkable is this conformation, under certain circumstan-
ces, that, according to Laennec, we may often with certainty
announce the existence of pulmonic emphysema from simple
inspection.*

The second variety, or interlobular emphysema, consists,
as was before stated, in the diftiision of air through the inter-
areolar texture, in consequence of the rupture of some of the
pulmonary vesicles. Of this lesion, I have observed a consid-
erable number of cases, and am disposed to believe that it is
exceedingly common in our Western States. So far as an
opportunity has been afforded me of judging, no period of life,
I should say, is wholly exempt from it. Males, between twen-
ty and thirty, have appeared to me to be particularly subject to
it, — much more so than at an earlier or later age, or than the
other sex. I have never observed this affection in new-born
infants ; but, in one instance, I noticed it in a child of seven
months, who died, under symptoms of pneumonitis, compli-
cated with hydrocephalus. Of nineteen cases of this disease,
of which I have kept a record, six occurred in association
with bilious and typhoid fever, four with dysentery, three
with hooping-cough, one with acute inflammation of the
lungs, four with tubercular phthisis, and one with infantile
cholera.

In twelve of these cases, the emphysema affected both
organs, though not to the same extent. In five it was exclu-
sively confined to the right lung, in two to the left. Nor does
every part of these viscera seem to be equally liable to this
disease. In nearly all the cases v/hich have fallen under my
observation, it was most distinctly marked along the inter-
lobular intervals and the free margins. In a few only was it
noticed at the base of the organ, and in not a single one at
the apex, or at the posterior part of the internal surface.
Why these differences should obtain, or, in other words, why
certain portions of the lungs should be more frequently
affected in this way than others, are circumstances in the
history of this lesion which, in the present state of the science,
we are totally incompetent to explain.

Treatise on the Diseases of the Chest, p. 162.

SECT. II.] INTERLOBULAR EMPHYSEMA. 61

When a lung is thus affected, the diseased part is easily
recognized by its peculiar whitish appearance, which con-
trasts singularly with the red-colored textures around it. It
distinctly crepitates under the pressure of the finger, the con-
tained air being readily pushed from one place to another, and
the serous covering of the viscus appears, as in truth it is, to
be lifted off from the parenchymatous substance. In this way,
I have repeatedly known thin, flattened bags to be formed
from two to three inches in length, by six or eight lines in
breadth, and as perfectly pellucid as the most delicate soap
bubble. In other instances, the pleura is raised into little
globules, so closely clustered together as to bear a strong
resemblance to a string of pearls. But whatever may be the
form or extent of the elevation, the parenchymatous texture
beneath is always more or less lacerated, of a pale color, and
generally reduced, especially in cases of long standing, to a
sort of net-work, consisting solely of vascular and bronchial
ramifications.

In this, as in the preceding variety, the lungs do not col-
lapse on opening the chest, and they also cover, to an unnatu-
ral extent, the surface of the pericardium, which, especially
when the emphysema is very great along the anterior mar-
gins of both viscera, is sometimes almost entirely concealed.
Occasionally, the air escapes into the cellular snbstance of
the mediastinal cavity, where it is either arrested, or it ex-
tends up the neck, and forms an irregularly flattened tumor,
which sensibly crepitates on pressure. In this way, the
fluid may reach over the whole body.

In this species of emphysema, the chest emits a loud noise
on percussion ; the respiration is much embarrassed ; and, on
applying the ear, a dry, crepitating rhoncus can be distin-
guished, with large bubbles, which, in connection with the
sudden supervention of dyspnoea, upon any violent effort of
the lungs, is the pathognomonic sign of the disease. Some-
times, as before- intimated, the air escapes into the mediastinal
cavity, and thence spreads over the cellular tissue of the
neck and upper extremities. When this happens, all doubt
as to the true nature of the complaint must of course vanish.
The most frequent cause of interlobular emphysema is the
forcible and prolonged retention of the air during severe mus-
cular efforts, as in lifting heavy weights, in parturition, in
hooping-cough, croup, and other affections of the respiratory
passages.

62 LUNGS. [chap. III.

Like the disease which we have just been considering,
pulmojiary apoplexy may be distinguished into two varieties —
the vesicular and the interlobular — the blood in the one being
retained in the air-cells, in the other, extravasated into the
connecting cellular tissue. The lesion, although incidentally
noticed by Haller, and other writers of the last century, was
first accurately portrayed by Dr. Hohntaum, of Erlangen, in
1817. A few years subsequently, a more detailed account
of it was published by Laennec ; and, since that period, it
has been ably described by other pathologists, both in France,
England, and Germany.

As might be expected, the anatomical characters of pulmo-
nary apoplexy vary, as the fluid occupies the vesicular or the
interstitial cellular texture. In the former case, the blood is
collected into round circumscribed masses, from the size of a
pea to that of a large apple. When incised, the section has
a deep red, granular aspect, of the consistence of a hepatized
hing, with numerous intersecting vessels and tubes of a much
lighter color. By scraping with the handle of the scalpel,
the clotted blood is removed from the air-cells, and the part
exhibits a beautiful honey-comb arrangement, the pits being
separated by irregular partitions.

In the second variety, the fluid ruptures the air-vesicles,
and is extravasated into the intervening cellular tissue, break-
ing it down into a ragged, shreddy substance, in appearance
not unlike a coarse sponge, saturated with dark blood. Large
cells and excavations may be thus formed, penetrating to a
considerable depth, and converting the lung, in some cases,
into a soft, irregular, fluctuating mass. Occasionally, the
apoplectic eflusion is so great as to lacerate the pleura, and
escape into the thoracic cavity. This, however, is rare ; and
I have never witnessed an example of it ; nor are there, so
far as is known to me, more than five or six instances of
the kind on record.

When the effusion is very profuse, as often happens when
it proceeds from a ruptured vessel of considerable magnitude,
death sometimes occurs in a few hours, — occasionally, indeed,
almost instantaneously. In other cases, the blood is dis-
charged by the mouth, or a portion of it remains, and gradu-
ally assumes new properties. If the individual is cut off
during the attack, the blood is found, upon inspection, to be
of a dark venous hue, and only partially or not at all coagu-
lated. In cases of an opposite character, however, it is uni-

SECT. II.] PULMONARY APOPLEXY. 63

formly clotted, more or less firm, and of a light brownish, pale
gray, dun, or drab color. These alterations are always more
conspicuous in proportion to the length of time that has
elapsed since the apoplectic attack, and, it need scarcely be
said, are dependent upon the absorption of the serum and
coloring matter of the extravasated fluid.

The tissue around the clot may be quite sound and crepi-
tous, but is more commonly pale and indurated. Sometimes
the clot acts as a foreign body, producing inflammation, soft-
ening, suppuration, or even gangrene. Should the efl"usion
be small, limited in extent, or not have caused much injury,
it may be entirely absorbed, and the vesicular structure
resume its normal characters. In other cases, again, though
this is extremely rare, nature makes an effort at reparation by
organizing the clot, or enclosing it within a cyst of false
membrane, as in apoplexy of the brain.

The blood, in pulmonary apoplexy, may flow from two
distinct sources, either from the mucous membrane of the
bronchiae, as a simple exhalation, or directly from a lacerated
vessel. When depending upon the latter source, the hemor-
rhage is often extremely profuse, and proves rapidly fatal.
Eighteen months ago, I examined the body of a man, thirty-
two years old, who died about twelve hours after an attack
of pulmonary apoplexy, in which he must have lost nearly a
gallon and a half of blood. The stomach contained nearly
a quart of this fluid ; the bronchiae, trachea, and larynx were
nearly filled with it ; and a large tubercular excavation in the
upper lobe of the right lung, capable of holding five ounces,
and from which the hemorrhage proceeded, was also occu-
pied with it. A loss of blood, of five or six pounds, is by no
means unusual in seizures of this kind.

Much dispute existed, at one time, concerning the proba-
bility of this disease emanating from simple exhalation of the
mucous membrane of the bronchial tubes. The subject is
amply discussed' by Bichat, who espoused the affirmative
side of the question ; and his opinion has been abundantly
confirmed by the more elaborate researches of modern patho-
logical anatomists. It is now well ascertained, indeed, that
the occurrence is not only possible, but much more frequent
than is generally imagined. The hemorrhage, though some-
times profuse, is seldom so great as when it proceeds from a
ruptured vessel.

Hypertrophy of the right ventricle of the heart, with con-

64 LUNGS. [chap. III.

traction of the mitral valves, seems to be the most frequent
cause, by far, of this lesion. In the cases examined by Dr.
Hope, amounting to a considerable number, upwards of two
thirds were referable to this source.* Similar is the evidence
"furnished by the dissections of Dr. Townsend, Andral, Bouil-
laud, Berlin, and other anatomists. Indeed, apoplexy of
the lungs may be said to have the same connection, pre-
cisely, with hypertrophy of the right side of the heart, that
apoplexy of the brain has with that of tlie left, — the tendency,
in both cases, being to throw the blood with more impetuosity
and force upon the respective organs. Should there be a
contraction of the mitral valve, the blood will stagnate in
the left auricle, and the pulmonary vessels be constantly
engorged from the obstacle in the venous circulation. When
this state is conjoined with thickening of the walls of the
right ventricle, nothing, it may be presumed, would be more
easy than the supervention of hemorrhage, whether as a
simple exhalation, or as the result of a laceration of one or
more vascular branches. The deposit of blood in the pulmo-
nary tissue is also a frequent attendant npon phthisis ; and,
in some instances, it is found to be accidental^ the fluid being
poured down the windpipe from an ulcerated artery of the
tongue, palate, or fauces, or from the bursting of an aneu-
rismal sac.

The pathognomonic signs of pulmonary apoplexy are, dul-
ness of sound on percussion, and extinction of the respiratory
murmur in the part which corresponds with the seat of the
disease, together with a crepitating rhoncus in the immediate
neighborhood. When these phenomena — the rationale of
which will readily occur to the reader — are conjoined with
hoemoptysis, no doubt can be entertained of the true nature
of the disease.

Encephalo'id seldom occurs in the lungs. This affection,
which constitutes the cancerous phthisis of Bayle, and the
medullary tumor of Laennec, may exist under several varie-
ties of form. Thus, it may be diffused through the inter-
vesicular tissue, in small, uncircumscribed patches ; or it
may be deposited in irregular spherical masses, varying in
size from a small pea to that of a full-grown foetal head ; or,
lastly, it may present itself in the character of an encysted
tumor, which, in fact, is most usually the case. In this

* Morbid Anatomy, p. 41.

SECT. II.] ENCEPHALOID MELANOSIS. 65

variety, the heterologous growth rarely exceeds a common-
sized apple, and the capsule surrounding it, although hard
and tough, is scarcely half a line thick, and of a white gray-
ish color • the adhesion between the two structures is usually
very slight, and the vessels which are so abundantly dis-
tributed upon the latter, can seldom be traced to any great
depth into the former. In some cases, the medullary matter
occupies only a single cyst ; in others, there are as many as
six or eight, united together into one lobulated mass. La-
ennec, who has given a very good account of this disease,
describes it as passing through three different stages. In the
first, the encephalo'id matter is of the consistence of concrete
lard, lobulated, and of a pale yellowish color ; in the second,
it has an appearance very much like that of the human brain ;
and, in the third, it is soft, moist and pulpy. Clots of blood,
of a deep red, brown, or blackish color, are frequently in-
termixed with this substance, altering its appearance and
consistence.

Of this disease I have never seen an example, and feel,
therefore, disposed to think it uncommon in the United
States. Dr. Morton has seen only a single case of it in a
great number of dissections ; * and Bayle v/itnessed it only
thrice in nine hundred subjects.f

No diagnostic signs of this disease have yet been pointed
out. If the tumors are numerous, or of considerable mag-
nitude, there will probably be dulness on percussion, with
diminution or absence of the vesicular murmur, pain in the
chest, dyspnoea, and that peculiar state of the complexion
which so often attends this lesion in other organs.

The lungs are liable to melanosis, though this may be
classed amongst the rarest affections which we meet with in
these organs. It is commonly seen in amorphous masses, in
small nodules, in thin, irregular laminae, or in minute dots.
The tuberiform variety, which is perhaps the most common,
occurs in globular, oval, or pyriform tumors, from the size of
a currant to that of an egg, or even a large apple. Some-
times they are encysted, the capsule by which they are en-
closed being composed of dense, cellular tissue, about half a
line thick. Their surface is either smooth, unequal, lobulated,
or studded with small tubercles, like a mulberry ; and their

* Illustrations of Pulmonary Consumption, p. 85. Plriladelpliia, 1834.
t On Phthisis.

VOL. II. 9

66 LUNGS. [chap. III.

consistence varies between that of tallow and that of a lym-
phatic gland, though occasionally they are quite fluid. The
circumjacent textures are generally sound, and the connec-
tion between them and the heterologous bodies is often so
slight as to require but little dissection to separate them from
each other.

Melanosis of the lungs, must, on the whole, be regarded as
a very rare disease in the inhabitants of this country. Of
the tuberiform variety, I have seen only two or three exam-
ples ; nor have I been more successful as respects the others.
The deposition, which is most frequent iu old people, espe-
cially in such as are of a strumous diathesis, seems to be
merely an excess of secretion of the black pigment, which
is sometimes so conspicuous in the organs at that period of
life. Andral relates the case of a man, fifty-nine years of
age, in whom the left lung was entirely converted into a black,
homogeneous substance, of such density, that the scalpel
would scarcely penetrate it : the whole appeared like a mass
of extravasated, black injection, after it has cooled.*

iSerous cysts, containing a thin, limpid fluid, are occasionally
found in the lungs. They are often seen in the inferior ani-
mals, as the ox, sheep, and goat, but are of very rare occur-
rence in the human subject. Morgagni gives only a single
instance of these accidental growths ; and Laennec seems
never to have met with them. I have never seen them in
this situation.

Equally rare are the hydatids which are sometimes seen in
the human lungs. Of a globular, ovoidal, or pyriform shape,
they are of variable magnitude, of a firm, semi-concrete con-
sistence, and usually, if not always, of the acephalocystic
kind. Their coats are of a light grayish color, sometimes
speckled with opaqne, yellowish dots; and their contents,
which are generally of a thin, limpid nature, like spring-
water, are often milky, brownish, or sero-sanguinolent. The
internal surface of the hydatid is frequently rough, and lined
by a thin layer of lymph. Seldom is the number of these
bodies great, or their size large. Occasionally, however,
there is a very large one, including several of smaller dimen-
sions. Dr. Geoffroy, a French writer, has furnished the partic-
ulars of the case of a young man, aged twenty-two, in whose
lungs were two enormous hydatids, each eleven inches long,

* Archives Generales for April, 1829.

SECT. II.] CALCAREOUS CONCRETIONS. 67

which adhered to the ribs and mediastinum, and reduced
these organs each into a thin, spongy cake, lying in the ante-
rior part of the thoracic cavity. Each contained about five
pints of thin, watery fluid ; and they were supposed to have
originated in the pulmonary tissue.*

These bodies, like the serous cysts to which I before ad-
verted, are extremely infrequent in the human lungs. Out
of nearly six thousand patients, says Andral, f admitted
into the wards of M. Lerminier, in six years, pulmonary
hydatids were seen only five times. In one of these cases,
the\?' occurred in the pulmonary veins ; but, in all the others,
they were developed in the midst of the parenchymatous
structure.

Neither hydatids nor cysts seem to give rise to any
pathognomonic symptoms. Oftentimes they acquire a con-
siderable magnitude without creating any pain, local suffer-
ing, or dyspnoea. It is only when they compress the delicate
substance of the lungs by their great size, that they inter-
fere with its functions. Sometimes they are ejected by
coughing ; and, in such cases, it is conceivalDle that the patient
may get well.

Of calcareous concretions, as occurring in the lungs, men-
tion is made by almost every writer, on morbid anatomy,
since the time of Bonetus. These structures, of which I
have seen several examples, are usually observed in small
rounded nodules, of a grayish white color, friable, semi-con-
crete, sometimes hard, consisting almost entirely of phosphate
of lime, with a minute proportion of animal matter, and the
carbonate of that salt.| Cases occur in which these concre-

* Bulletin de I'Ecole de Med. au 1805. (See Laennec, p. 381.)
t Clinique Medicale ; translated by Spillman, p. 553.

t Very recently these concretions were analyzed by Professor Sqarzi, of Bo-
logna, who found the following ingredients : *

Phosphate of .lime, ..------- 1.56

Carbonate of lime, ....---- 0.39

Carbonate of magnesia, -------- O.OG

A peculiar fatty matter, 0.06

Cholesterine, ...---.---- 0.66

Mucus, - 0.09

A yellow brown substance, .-..--. 0.03

Oxide of iron, .----_-.- 0.09

Silex, 0,03

Loss, 0.03

3.00
* American Journal of ths Medical Sciences, vol. x\. p. 542.

68 LUNGS. [chap. III.

tions are of a darker color, oval, cylindrical, or pyriform, hard
and grftty, or rough on the surface like a mulberry calculus
of the urinary bladder.

Their dimensions are very variable. From the size of a
mustard-seed they may attain, and even exceed, that of a
peach-stone : though, in the genera.lity of cases, they do not
surpass the volume of a currant, a pea, or a small cherry.
Their number is in an inverse ratio to their size. In the
French Dictionary of Medical Sciences is recorded the case
of a phthisical person, who, during eighteen months imme-
diately preceding his dissolution, expectorated upwards of
two hundred small stones ; and in another, mentioned by
Portal, between five and six hundred were coughed up.
Very frequently, these concretions coexist with tubercles.
They are always isolated ; and, although they may occasion-
ally be developed in the minute bronchial ramifications, they
are usually deposited into the inter-areolar tissue of the lungs,
the investing membrane of which they sometimes elevate by
their projection. I have never found them encysted, but
such cases have been detailed by authors, who describe the
capsule as being thick, dense, firm, of a grayish color, and,
in some instances, partially converted into cartilage or even
bone.

I am not certain that these bodies can give rise, by their
presence in the lungs, to any serious inconvenience. Bayle
thought that they might ; but his opinion has been success-
fully controverted by Laennec ; and, from having myself
several times found them in persons who, during their life-
time, had no embarrassment of breathing, I am disposed
to agree with this writer, in the belief that they are com-
monly harmless.

It is a law of the animal economy, that in proportion as a
part is exercised, so will be its size and strength. This is
strikingly exemplified in the muscular system, and also in
some of the other organs, as 'the lungs, testicles, kidneys, and
mammae. Under such circumstances, the organ increases in
bulk, its texture becomes more firm and elastic, and the air-
cells, although this cannot be demonstrated, are probably en-
larged, at the same time that their walls are thickened and
strengthened. The augmentation of volume is sometimes
extraordinary. More than once have I seen the hypertro-
phous lung permanently dilate the chest, force down the
diaphragm, displace the heart and mediastinum, and pro-

SECT. II.] ATROPHY. 69

ject up nearly two inches into the neck between the clavi-
cle and spinal column. In this way, although one lung may
be entirely gone, the individual may live for years in tolera-
ble comfort. Such seems to have been the case with the
lamented Godman, one of the brightest ornaments of our
profession. With one lung was he obliged to toil for his
daily substance, for nearly two years, undergoing a degree of
labor which has scarcely ever been equaled by any other
literary or scientific man, in the most perfect health.

Atrophy of the lungs, the reverse of the condition which Ave
have just described, is generally produced by accidental circum-
stances. In great emaciation of the body, such, for example,
as is witnessed in protracted fevers, or painful local disorders,
the lungs do not seem to participate in the decay, at all events,
not to any appreciable extent. That these organs experience
some changes in cases of wilful abstinence, when all the other
viscera are in a normal state, has been already seen ; * but what
these changes are, whether they consist in some structural
lesion, or in some derangement, simply, of the nutritive func-
tion, has not been accurately determined. In old age, the pul-
monary tissue becomes sensibly altered ; it no longer possesses
the same softness, the same pliancy, or the same color, that
it did in youth or adolescence ; on the contrary, it is dry,
imperfectly elastic, of a pale grayish tint, and comparatively
ill supplied with blood. Its absolute bulk and weight are
diminished, and the parietes of the air-cells are attenuated
and enfeebled.

But these are not the only causes of pulmonary atrophy.
In most cases, as was before intimated, it is dependent more
immediately upon causes, exerting a local influence, and
hence it is usually found in association with eff'usions of
water, lymph, pus, or air into the thoracic cavity, or with
tumors pressing upon the large bronchial tubes. In such
cases, I have repeatedly found the lung reduced to a mere
cake, scarcely more than an inch in thickness, by sev-
eral inches in diameter, with a dark, dense, inelastic struc-
ture, almost void of air-cells. This accidental atrophy,
which may occur at any period of life, in infants, in chil-
dren, and in adults, is usually connected, provided the patient
survives sufficiently long, with hypertrophy of the opposite
lung.

* See article Gangrene.

70 LUNGS. [chap. III.

Pulmonary phthisis. By far the most interesting disease
of the kings is phthisis, whether we consider the frequency
of its occurrence, the rapidity of its progress,* its almost
uniform fatality, or the obscurity which still envelopes its
Eetiology.f This affection, it need scarcely be remarked,
consists in a slow disorganization of the pulmonary tissue,
occasioned by the developement of tubercles. By the older
physicians, consumption was supposed to arise from a great
variety of lesions, which served, accordingly, as the basis of
a corresponding number of divisions, species, or varieties.
Even Bayle, whose treatise has been published within a
comparatively recent period, admits not less than six different
species of phthisis, — the tubercular, granular, melanotic, cal-
culous, cancerous, and ulcerous. This classification by the
French author has been adopted, with certain restrictions, by
the late Dr. Eberle, a writer who, in most of his productions,
has too servilely followed in the footsteps of his predecessors
and contemporaries. Such an arrangement, indeed, no matter
what may be the authority by which it is sanctioned or em-
braced, is not only unnecessary but absolutely subversive of
the best ends of science. Simplicity of arrangement, not
less than of language, should characterize all our writings ;
and none more so than such as relate to pathological topics.

It is now pretty generally acknowledged, that genuine
phthisis depends exclusively upon the presence of tubercles
in the lungs. Such at least is the sense in which the term
is received by almost every intelligent writer of the present
day, of whose works I have any knowledge. Nor is this
notion peculiar to the physicians of the nineteenth century.
P. Dessault, of Bourdeaux, in an able essay on phthisis, pub-
lished more than a hundred years ago, clearly states that
tubercles constitute the essence of consumption ; and the
same doctrine is warmly inculcated in the immortal work of
Laennec. Similar views have been promulgated, within the
last ten years, by Louis, Andrtil, and other anatomists, both
on the continent of Europe, in Great Britain, and in the
United States.

* This remark has reference, of course, only to the heterologous formations.

t " It has been calculated, by the late Dr. Young, Dr. Woolcombe, and others,
from the best data which the bills of mortality aflTord, fhat, in Great Britain and
Ireland, consumption causes one fourth part of the deaths that occur from dis-
ease." (Clark's Treatise, p. 8.) In this country, the mortality from this source, I
doubt not, is equally great ; though upon this point I cannot speak positively,
having no accurate data from which to deduce my conclusion.

SECT. II.] PHTHISIS. 71

The opinion now generally prevails, that the primary seat
of tubercular matter is in the air-cells and minute brouchial
tubes. For onr knowledge of this interesting and important
fact, we are mainly indebted to MM. Schroeder Yan der Kolk,
Cruveilhier, Magendie, and Professor Carswell, whose re-
searches in this and other departments of pathological science
are worthy of all praise. These distinguished anatomists
have fully decided the question — which many have hitherto
disputed — that the morbid product in question is, in the ma-
jority of cases, secreted by the mucous tissue of the lungs,
instead of being poured out into the interstitial cellular sub-
stance, as was maintained, until lately, by the French school.
That this doctrine concerning the site of tubercular deposits
is true, as a general rule, observation has fully convinced me.
Nevertheless, I am far from believing that it is applicable to
all cases ; for an instance occasionally occurs, where the
matter is evidently, in a great measure, if not wholly, con-
fined to the cellular texture. These cases, I acknowledge,
are rare, yet that they really exist, does not admit, I think, of
the slightest controversy or dispute. Independently of their
easy demonstrability, in this situation, analogy is strongly in
favor of the position here contended for. In the kidneys, for
example, how often does it not happen, that the heterologous
bodies are seated exclusively in the so called cortical tissue,
notwithstanding the amount of mucous structure within ?
They are also frequently seen in the bones, in the substance
of adventitious membranes, in the interior of the spleen, and
on the surface of the serous membranes, — parts which are
perfectly devoid of the tissue under consideration. The pres-
ence of this tissue is therefore not at all necessary to the
production of tubercles, nor is there any reason for conclud-
ing that these deposits should be invariably formed by it,
even where it abounds in an organ as it does in the lung.

The varieties of form in which this matter is deposited
were pointed out in a previous section. Referring the reader
to the general history of tubercle, I shall limit myself here
to the statement of a few leading facts, which will enable
him, it is hoped, more fully to comprehend the character of
the lesion before us.

Of the four varieties of tubercular deposits already de-
scribed, the m,iliary is unquestionably by far the most com-
mon. It occurs in at least forty-nine out of every fifty cases
of phthisis. The individual granules, in this form of the

73 LUNGS. [chap. III.

complaint, vary in volume between a mustard-seed and a fil-
bert : they are generally of a pale yellowish color, and of a
semi-concrete, friable consistence, like dry curds. A grayish
hue is not uncommon : occasionally they have a greenish,
vitreous aspect, and a degree of firmness amounting to fibro-
cartilage. This is especially the case in that variety of these
little bodies to which Bayle has applied the appellation of
gray granulations, and which this celebrated author consid-
ered, though erroneously, to be distinct from genuine tu-
bercles. Studied in the early stage of their developement,
the granules, of whatever appearance they may be, are always
soft and isolated ; by and by, however, they augment, in
consistence, and run into each other, forming, thus, larger no-
dules, of variable color, size, and shape. Not unfrequently,
the little masses are seen hanging from branch-like pedicles,
— a disposition strongly resembling that of the cauliflower.
Sometimes they contain particles of foreign matter, such as
grains of sand, especially in miners, masons, and grinders ;
and cases occur in which their central portions remain empty,
producing an arrangement, when divided, of internal depres-
sions. At other times, there is a distinct nucleus of inspis-
• sated mucus, around which the tubercular matter is depos-
ited, and which gives rise, as is supposed by Dr. Carswell, to
the appearance of central softening, so much insisted on by
Laennec.

The number of miliary tubercles is extremely variable.
In some instances, though this is rare, there are only a few, —
nay, perhaps, only a solitary one ; but, in the vast majority of
cases, there are hundreds and thousands, of all sizes, from that
of a pin-head to that of a hazelnut. All parts of the lungs
are liable to be aftected by them ; but, as will be shown here-
after, the superior lobes are their most frequent seat. Occa-
sionally, they are confined to the interior of the organs, the
external surface being entirely free from them. This, how-
ever, is rare.

These little masses sometimes appear encysted; hut this ar-
rangement, I am strongly disposed to believe, is in most instan-
ces altogether deceptive, as it probably depends entirely upon
the manner in which the tubercular matter is impacted in the
bronchial tubes. Such, at any rate, I have found to be the
case in my own dissections ; for, except on two or three oc-
casions, I have never been able to detect any thing like a
cyst, of new formation, similar to what has been described by
some of the French and German anatomists.

SECT. II.] PHTHISIS. 73

The sti^atiform variety is also very rare in the kings ; and
so Hkewise is the infiltrated. The former I have observed
only in a single instance, and then not in the human sub-
ject : the latter I have noticed several times, but never to
any considerable extent. The matter, in this form of the
disease, may he diffused through several contiguous lobules,
an entire lobe, or even the whole lung ; and, as in the miliary
variety, it generally occupies the air-cells, and the minute
bronchial tubes, the parietes of which are at the same time
somewhat thickened, and preternaturally brittle. Although
usually of a yellowish color, it often varies from a light gray
to a dark slate, arising from the intermixture of black pul-
monary matter, which occasionally imparts to it a variegated,
marbled tint. Its texture is homogeneous, opaque, and of a
firm, semi-cartilaginous consistence : when torn, it exhibits
a rough, granular surface, and seems to be entirely composed
of small, irregular bodies, which, from the peculiarity of their
arrangement, have been compared, not unaptly, to the eggs of
certain insects, placed in close contact with each other. The
tubercular infiltration is originally deposited in detached,
lozenge-shaped patches, which, in time, coalesce, and so in-
volve a considerable portion of pulmonary tissue : it is most
common around old caverns, and is occasionally seen in con-
junction with some of the preceding varieties, especially the
miliary.

The pulmonary tissue around these deposits is variously
altered. In the early stages of the disease, before the secre-
tion has made much progress, it is not unusual to find the
surrounding parts quite sound. This state, however, rarely
continues very long ; for, after the tubercles have existed for
some time, they invariably act as extraneous bodies, — ^ the more
so if they are very large or numerous, producing different
morbid changes, such as congestion, inflammation, softening,
induration, serous infiltration, and the formation of accidental
tissues, of a cellular, fibrous or cartilaginous nature.

Of these pathological conditions, none is more common than
congestion. Nor is this surprising, when we remember the
compressed and obstructed state of the pulmonary veins.
The blood, being thus prevented from finding a ready outlet,
must necessarily accumulate in the capillary vessels around
the morbid deposits, which, in consequence, often exhibit
quite a red appearance, the vessels being arranged in beau-
tiful arborescent lines, some of which are occasionally trace-

VOL. II. 10

74 LUNGS. [chap. Ill,

able into their substance. As the result of this engorged
condition, the puhnonary tissue is frequently infiltrated with
serous fluid, the quantity of which is sometimes so great as
to lead to great embarrassment of breathing, from the want of
the free admission of air into the lungs. Hoemoptysis is also not
uncommon. Pure uncomplicated congestion occurs much
oftener, according to my own observation, in children and
young persons than in the old, or in such as are greatly ex-
hausted by the disease. If it be allowed to go on unre-
strained, it produces, sooner or later, an effusion of lymph,
with consequent hardening and atrophy of the pulmonary
texture. Softening, gangrene, and ulceration are also occa-
sionally noticed, but much less frequently I apprehend, than
some have imagined.

The air-cells and minute bronchial tubes, the primary seats
of the morbid deposit, are usually more seriously affected
than the rest of the anatomical elements of the lungs. Not
only are they obliged to bear the brunt of the disease, but,
as might be anticipated, they must generally labor under
considerable irritation for some time, even before the matter is
poured out. Nor is it reasonable to presume that the irrita-
tion thus set up will wholly subside during the progress of
the secretion. As the matter accumulates in these reservoirs,
it presses upon them on all sides, by which, whilst their cal-
iber is enlarged, their parietes are generally attenuated, and
finally destroyed, by ulcerative absorption. Hence, when
caverns form, the bronchial tubes generally open into them
abruptly, as if they had been cut across with a sharp instru-
ment. Along with these changes, there is very commonly a
red and injected state of the lining membrane, which some-
times extends up into the trachea, and even into the larynx.

After having existed for some time, varying, on an average,
from one to nine months, the tubercular matter, whatever
may be the form in which it is deposited, manifests a dispo-
sition to become soft. The process by which this is effected
was pointed out in a previous section, to which the reader is
referred for an account of it. On the present occasion, I shall
content myself with a description of the changes which are
induced by it in the pulmonary tissue.

Of these changes, the most important is the formation of
excavations, caverns, or fistulous apertures. These were for-
merly considered, under the name of vomiccn, to be essential
to the existence of phthisis. It is now well known, however^

SECT. II.] PHTHISIS ; CAVITIES. 75

that it may prove fatal without them, especially that variety
of it which is vulgarly denominated, " galloping consump-
tion, " and which is marked by great fibrile disturbance. In
their size, these cavities are very variable ; but, as a general
rule, it may be said to be in direct ratio to their number. When
there is only one, it is occasionally as large as the fist, and
capable of holding half a pint or more of fluid : on the other
hand, when they are numerous, they rarely exceed a walnut,
and frequently they are not larger than a hazelnut, an al-
mond, or a pigeon's egg. In their shape, they are for the
most part irregularly rounded, sometimes ovoidal, and occa-
sionally angular. In respect to their number, not less than
in regard to their size and shape, much diversity obtains. It
is seldom that there are more than two or three, yet, in some
instances, the number is truly surprising. Not long ago, I
examined the body of an old man, sixty-two years of age,
whose right lung was literally one continuous chain of
excavations, the largest of which was scarcely as big as a
billiard-ball. Upwards of forty were counted. Many com-
municated together by short, fistulous tracks, and nearly one
half of them were completely empty.

The largest excavations are almost always found in the
superior lobes, inasmuch as the softening process usually
proceeds there to a much greater extent than elsewhere. It
also, for the most part, commences at this situation. Hence
nothing is more common, in making examinations, than to
meet with caverns in the summits of the lungs, with half-
softened tubercles further down, and with crude tubercles
and sound pulmonary substance at the base of these organs.
In the majority of cases, the cavities occur in both lungs.

When recent, the walls of the excavations are soft, and
lined by a thin layer of lymph, which is easily separated from
the surrounding parts : in more protracted instances, the false
membrane is dense, grayish, sometimes fibro-cartilaginous,
and from one fourth to one third of a line thick. Occasion-
ally several lamellae are thus deposited, — the one last formed
being always more delicate, more easily torn, and of a more
yellow color. In some instances, the excavation is entirely
destitute of a lining membrane, the parietes being formed by
indurated pulmonary tissue, having a raw, fleshy appearance,
not unlike the surface of a granulating ulcer.

The contents of these cavities vary, according to the period
they have existed- Such as are recent, generally contain

76 LUNGS. [chap. hi.

thick, cream-colored, inodorous matter, like common pus ;
whilst, in such as are of long standing, the fluid is of a thin,
bloody, sanious character, and often quite off"ensive. Creta-
ceous matter also is sometimes found in them, and occa-
sionally a substance resembling fibro-cartilage. It is only in
recent cases, and then very seldom, that the excavations
contain fragments of pulmonary tissue. The period required
for emptying themselves varies from, a few weeks to several
months, according to the size of the tubercular mass, the ex-
tent of the local disease, and the state of the system.

It is very seldom that we find the older caverns perfectly
smooth internally : their surface is almost always ragged and
uneven, and the irregularity is apt to be still further increased
by their being intersected in different directions by small cord-
like bodies, consisting either of condensed cellular substance,
or of impervious vessels. In their shape, these little bundles
bear a very close resemblance to the fleshy columns of the
heart ; their length is variable ; in thickness, they are from one
to two lines ; they are thinner at the middle than at the ex-
tremities ; and they are usually incrusted with yellowish
tubercular matter. It is a singular circumstance, and one
which has been noticed by every intelhgent observer, that
these excavations seldom, if ever, contain any remains of the
bronchial tubes. The pressure that is exerted upon these
structures by the tubercular matter, both internally and ex-
ternally, would seem to be sufficient to produce their speedy
absorption ; and hence it is extremely rare to find the slight-
est relic of them, even where the cavern is only partially
evacuated, or the heterologous deposit only slightly softened.
Nor does the cavity always communicate with the air-
passages. In some instances — and these are not unfrequent
— it is completely closed, so that its contents, being unable to
work their way out, either remain, or are finally absorbed.
More commonly, however, one or more bronchial tubes open
directly into it, and serve to carry off" whatever may be lodged
within. Occasionally the matter escapes into the pleuritic
sac, where, in a short time, it excites fatal inflammation. Dr.
Morton, of Philadelphia, describes an interesting case, where
the cavern, which was encysted, and situated in the apex of
the right lung, communicated, by a fistulous opening, with a
large abscess in the back.

It has already been stated that tubercular caverns are often
intersected by small vascular cords, the vestiges, evidently,

SECT. II.] phthisis; cicatrization. 77

of the arterial and venous branches that supplied the affected
structure. The changes which these vessels undergo, in
such cases, constitute one of the most interesting themes that
can engage the attention of the pathologist. Long before the
softening begins, their caliber is obliterated, as if nature, in-
tent on preventing hemorrhage, took care to anticipate the
ulcerative process. In the early stage of the disease, the
vessels are merely forced aside, and compressed by the tuber-
cular matter ; but, as the deposition advances, they gradually
become impervious, and are at length converted into hard,
fibrous cords, like the umbilical vessels of the infant after
parturition. Thus affected, they are greatly diminished in
volume, and no longer admit the finest injecting matter : even
air cannot be made to pass along them : in a word, they are
completely, effectually, permanently obliterated.

But for this provision, which is as admirable as it is benef-
icent, few individuals would survive the softening process.
As it is, with all the care that nature can exert, fatal hemor-
rhage is unfortunately of too frequent occurrence, arising from
the rupture of the affected vessel, in consequence of the ina-
bility of its walls to withstand the shock of the circulating
fluid. The blood occasionally finds its way from the cavern
by a fistulous opening into the oesophagus. Of this a most
interesting case is related by the late Dr. Mackintosh, of Edin-
burgh, in his excellent treatise on the Practice of Medicine.*
The patient was a child, which had labored for some time
tinder cough and anomalous symptoms, and died suddenly
from what was supposed to be hsematemesis. On inspection,
it was discovered that the blood contained in the stomach and
bowels had proceeded from a ruptured artery in an excava-
tion in the upper lobe of the left lung. From this a fistu-
lous passage was seen running high up into the OBSophagus,
along which the fluid flowed into the stomach.

One of the most interesting facts, in relation to these cav-
erns, is, that they are susceptible of cicatrization. That this
occurrence is rare, common sense alone, unaided by observa-
tion, is sufficient to convince us ; but that it occasionally takes
place is abundantly proved by the researches of Laennec,
Andral, Forbes, Carswell, Morton, and other pathological
anatomists. Indeed, every physician who is at all in the habit
of making dissections, must have met with examples of this

* Vol. i. p. 241, Philadelphia edition.

78 LUNGS. [chap. III.

kind. I have had occasion to observe it in a considerable
number of cases, and have taken care to preserve specimens
of it in my cabinet.

There are three ways in which the heahng may take
place, each of which is deserving of a brief notice. In one of
these, which is by far the most common, the cavern remains
open, and its surface becomes lined with a thin layer of plas-
tic lymph : this adheres more or less strongly to the surround-
ing textures, is gradually organized, and finally converted
into a membrane, which possesses all the properties of the
mucous tissue, excepting that it is devoid of mucous glands,
and therefore incapable of secreting genuine mucous matter.
Secondly, the cicatrization may be affected by the contraction
of the excavation, and the slow but steady agglutination of
its sides, through the intervention of dense cellular substance
of new formation ; and, thirdly, by an effusion of coagulating
lymph, or repeated depositions on the inner surface of the
cavity, forming a white bluish mass, more or less dense in its
structure, in which the bronchial tubes may be seen abruptly
terminating. In the last two varieties of cicatrization, the
contraction of the accidental tissue gives rise to a puckering of
the lung, which is most distinctly marked when the serous
envelope of the organ is forced to follow the retrocession of
the parenchymatous substance. These scars — for thus they
may be called — are most common in the apex of the lung :
and they may assume various figures, — oval, circular, linear,
arborescent, or stellated.

Although tubercles generally coexist in both lungs, yet it
is a singular fact that the left of these organs is commonly
more extensively involved than the right. This circum-
stance, which was long ago noticed by Bonetus, Morgagni,
and Stark, is fully confirmed by the recent observations of
Dr. Louis, though it is opposed by the high authority of
Laennec and Lombard, as well as by that of Dr. Mackintosh*
and Dr. Home, of Edinburgh.! It is also in accordance
with the experience of Dr. Morton, of Philadelphia. In

•* Principles of Pathology and Practice of Physic. Morton's edition, vol. i.
p. 436.

t This gentleman, in an able report on phthisis, published in the January
number of the Edinburgh Medical and Surgical Journal for the present year,
states that out of one hundred cases, he found both lungs equally affected in
twenty-live, the right most in thirty-eight, and the left in thirty-seven. In iive
cases in which one of these organs only was diseased, four were on the right,
and only one on the left.

SECT. II.] PHTHISIS ; LOCALITY. 79

eighty-six cases analyzed by this distinguished physician,
both lungs were equally affected in seven, the left most in
fifty-one, and the right in twenty-eight. This conclusion is
fully sustained by the results of my own dissections. With
the exception of twelve or fifteen cases, I have invariably
found the left organ more extensively implicated than the
right. In a few instances, the heteroclite deposit was con-
fined to one side. Upon what the difference here referred to
depends, is a point which has not been satisfactorily ex-
plained.

Not less strange is the fact that the morbid deposit is al-
most constantly more copious and perfect at the summit, than
at the base of the lungs. So true is this, that it may be laid
down as a rule, scarcely liable to a single exception. Yarious
explanations have been offered with a view of accounting for
this phenomenon ; but, so far as I know, they all rest upon
conjecture, and therefore scarcely deserve mention. That
the confined and compressed state of the superior lobes of the
respiratory organs should exert an injurious influence, predis-
posing these parts to disease, can scarcely be doubted ; but
that it is the only cause of the proneness in question, I am by
no means inclined to believe. Granting that the circum-
stances adverted to do joroduce a mischievous tendency, if
nothing more, it seems to me that the real cause consists in a
diminished supply of blood, and in a consequent debility of
the parts under notice. Owing to our erect position, the cir-
culation here is carried on with difficulty; the pulmonary
tissue is imperfectly nourished ; the proper stimulus resulting
from the due admission of the sanguineous fluid is withheld ;
and hence, wherever any cause exists that has a tendency to
produce tubercular disease, it generally exerts its baneful
effects upon this particular portion of the organ, in preference
to others that are more directly under the control of the san-
guiferous and nervous systems. This conjecture — for we
claim for it no other appellation — receives support from the
fact, now well established, that, in quadrupeds, the dorsal por-
tion of the lung, which, in reference to the eff"ect of gravita-
tion, may be said to correspond to the apex of the human
lung, is generally more extensively tuberculized than the rest
of the viscus.

Having thus briefly spoken of the localization of phthisis,
let us inquire, in the next place, whether tubercles ever exist
in any part of the body without being at the same time present

80 LUNGS. [chap. III.

in the lungs. This is a question which I should scarcely
deem it necessary to discuss, were it not for the extraordinary
assertion of Dr. Louis, that he has never, in a single instance,
seen an organ affected with these bodies independently of the
pulmonary tissue. Their existence in the respiratory organs
seems, says he, to be a necessary condition, a sort of sine
qua non, for their developement in other structures. In read-
ing this portion of his work, one would scarcely suppose that
the author was in earnest ; yet such is really the case. His
experience upon this subject is certainly at variance, in a very
high degree, with that of some of the most distinguished pa-
thological anatomists of the present day, as Laennec, Andral,
and Lombard. All these writers positively declare that they
have repeatedly witnessed tubercles in various organs when
none existed in the lungs ; and my own observations tend
precisely to a similar conclusion. In a boy, four years old,
whom I examined two years ago, a number of tubercles ex-
isted in the liver, but not a single one in the lungs ; and in a
child of twelve months, which I opened, last autumn, for Dr.
Woodward, of this city, although the spleen was literally
crowded with these bodies, none could be detected in the
respiratory organs. Similar phenomena were noticed last
summer, in dissecting the body of a man twenty-eight years
old. In this case, notwithstanding the closest scrutiny, the
lungs were found perfectly free from tubercular matter,
whilst the lymphatic ganglions of the abdomen, the right
kidney, and the seminal vesicles, were absolutely filled
with it.

Sex appears to exercise a considerable influence on the
production of phthisis. According to Louis, women are
more prone to it than men, in the proportion nearly of nine
to seven. This conclusion of the French author is fully con-
firmed by the more recent researches of several of his coun-
trymen. M. Chateauneuf, in a very interesting memoir,
states that, out of 1544 deaths from pulmonary consumption,
745 were men, 807 women. In the statistical tables of
Paris, published under the auspices of M. Charbol, in 1830,
we find that, out of 9542 cases of this disease, 5582 were
females, 3960 males. Upon this subject my own experience
is too limited to enable me to speak positively ; yet, so far as
it goes, it is decidedly in favor of the greater predominance of
this disease in men than in women : certain am I that I
have examined the bodies of five of the former to one of the

SECT. II.] ' PHTHISIS ] SEX. 81

latter. It is altogether probable that the mortality from this
cause varies in the two sexes in different regions. This,
indeed, is rendered ahnost certain by the calculations of Dr.
Clark, published in his excellent treatise on consumption.*
Thus, for example, in New York, the proportion of males to
females, in round numbers, is as ten to eight ; in Berlin, as ten
to eleven ; and, at Edinburgh, as ten to six.f In Sweden, the
proportion is nearly equal. In Prussia, if Berlin can be taken
as an illustration, phthisis in childhood appears to be much
more common among females than among males.

The period of life most liable to phthisis is between
twenty and forty. This fact, which was pointed out by
Hippocrates, has been amply confirmed by the united expe-
rience of hundreds of modern physicians. Of one hundred
and twenty-three patients observed by Louis, not less than
seventy-two died during this interval. These results are
confirmed by those of Bayle, Darwall, Home, Morton, and
other writers. In two hundred and eighty-one phthisical
persons, who died in the Philadelphia almshouse in three
years and a half, ending with the month of June, 1833, one
hundred and ninety-three perished under forty years of
age. Forty-two died between the ages of forty and fifty ;
twenty between fifty and sixty ; twelve between sixty and
seventy ; three between seventy and eighty ; two between
eighty and ninety ; one between ninety and a hundred. :]:
From the recent report of Dr. Home, showing the ages of
ninety-six persons treated in the Royal Infirmary of Edin-
burgh, it appears that sixty-six, or upwards of two thirds, died
between twenty and forty. The mortality below twenty
was eleven ; that above fifty, eight. '^ From a careful analysis
of the statistical reports of the principal cities of Europe, and
the United States, Dr. Clark has deduced similar conclusions.
The remarkable agreement of all the places, says this distin-
guished author, warrants the statement, that fully one half
of the deaths from consumption occur during the period above
specified, and that the mortality is at about its height at thir-
ty, and from that time gradually diminishes.

Dr. Lombard, of Geneva, has found that children are most
prone to tubercles between the ages of three and six, inclusive.

* London edition, p. 183.

t See Dr. Home's Report, Edinburgh Med. and Surg. Journal, No. 134.
t Morton's Illustrations of Pulmonary Consumption, p. 48, First edition.
§ Edinburgh Med. and Surg. Journal, p. 3, No. 134.
VOL. II. 11

82 LUNGS. [chap. III.

We have no correct data for estimating the frequency of phthisis
immediately under and above this period, but the number of
deaths is considerable. Infants are sometimes born with this
disease. Of this occurrence, several well-authenticated cases
are now on record ; that they are uncommon, however, can-
not be doubted ; and, thus far, it has not fallen to my lot to
meet with them. As was stated in a previous part of this
work, I have in several instances observed tubercles in very
young children ; and similar observations have been made by
some of my friends. Andral supposes that phthisis is most
frequent among females below the age of twenty ; but this
opinion, although supported by his own experience, and by
the statistical tables of Berlin,* requires further proof before it
can be received as true.

The duration of phthisis varies from a few weeks to
several years, the medium being about nine months. This
estimate is founded on the data furnished by Bayle and Louis,
which, in the main, agree with the calculations of Dr. Home
and Dr. Clark. The duration is greatly influenced by the
previous state of health, by the accompanying lesions, by the
mode of life, and, above all, by the season of the year. In
Edinburgh, most of the deaths from consumption occur in the
summer ; whilst, in London, according to Dr. Heberden, and
others, they are most frequent in the winter. In Glasgow,
the mortality is also greatest during the hot months ,• in Paris
and Milan, the proportion of deaths in the different seasons is
nearly equal.f In this country, we have no data on a suffi-
ciently extended scale to enable us to institute a comparison
on this subject. Should these ever be furnished, it will be
found, I doubt not, that in our Northern and Middle States, if
not everywhere, most persons die of this disease in February,
March, and April, or at the close of winter and the beginning of
spring. J Such at least is the result of my own observations,
confirmed by that of many of my most distinguished medical
friends. <§>

* Clark on Consumption, p. 175.

t M. Benoiston, Ann. d'Hyg. July, 1831, p. 19.

t With respect to the city of New York, actual observation has already proved
that the opinion expressed in the text is well founded. Prom the annual report of
interments for 1837, recently published by Dr. Henry G. Dunnel, it appears that,
of 1458 phtliisical subjects, 152 died in Februarv, 159 in March, 103 in April,
1.33 in May, 133 in June, 101 in Jidy, 109 in August, 119 in September, 72 in
October, 8S in November, and 97 in December. Thus about one third of the
mortality occurred at the close of winter and the beginning of spring.

§ Sec American Journal of the Medical Sciences for May, 1838.

SECT. II.] PHTHISIS J EXCITING CAUSES. 83

No occupation is exempt from this disease ; but that some
employments are more injm'ions than others, both observation
and experience have long since demonstrated. All sedentary-
pursuits, especially when conducted in crowded, and ill-
ventilated apartments, are decidedly detrimental, and. should,
therefore, if possible, be avoided. Masons, stone-cutters, car-
penters, grinders, painters, and cotton-weavers, are particular-
ly obnoxious to phthisis, probably from their being much ex-
posed to the inhalation of irritating matter. For the former
reason, sailors also suffer considerably ; and shoemakers are
often affected, from their constrained posture interfering
with the natural play of the respiratory organs. Living in
moist and filthy situations has a bad tendency ; and we have
the authority of Dr. Lombard for saying that the poorer
classes are twice as liable to phthisis as those in easy circum-
stances. This remark has reference solely to the inhabitants
of Europe, but may be extended, I am inclined to think, to
our foreign emigrants, many of whom die of this disease be-
fore they have resided many years in the United States.

Dress exercises an unfavorable, and oftentimes a highlj?-
disastrous influence upon the human frame. Tight lacing,
especially in young females, must be extremely injurious,
from the pressure it exerts upon the tender and delicate
organs of the chest, impeding their movements, stinting their
growth, and leading to structural derangement. Even when
the body has attained its full expansion, stays can seldom be
worn without detriment. But I have not time to dwell upon
this subject, and must therefore content myself by referring
the reader to the various works on hygiene and phthisis, in
which he will find ample information. He should also con-
sult the excellent paper on tight lacing, by the lamented
Godman, published as an appendix to his " Addresses."

Is the popular notion, that phthisis is contagious, well
founded ? This question has often been answered affirma-
tively, but never, at least so far as I know, in a single instance
upon satisfactory evidence. Morgagni was so fully impressed
with the idea that the disease is contagious, that he very
rarely examined a person that died of it, for fear as he says,
of contracting the infection. Professor Andral, in his com-
mentq;:ies on the treatise of Laennec, without attempting to
decide the point at issue, thinks it ought not to be treated too
lightly, alleging that it is by no means easy, in the present
state of our knowledge, to give a positive opinion concerning

S4 LUNGS. [chap. III.

it. Upon this subject I have no personal experience, yet I
cannot but beheve that the notion about the contagiousness
of phtliisis is perfectly idle and ill-founded. If, as sometimes
happens, the nurses and friends of consumptive patients con-
tract the disease, the circumstance is surely explicable upon
other and more philoso|)hical grounds. Loss of sleep, and
anxiety of mind, with the attendant impairment of the diges-
tive function, are amongst the most powerful predisposing
causes of the disease, and are alone suthcient, in many in-
stances, to kindle it into action. Strong though not conclu-
sive testimony in favor of the non-contagious character of
phthisis is likewise afforded by the experiments of Hebreard
and Lepellatin, of France. These physicians inoculated dif-
ferent animals with pus taken from scrofulous ulcers, without,
in a single instance, inducing the disease, or even any par-
ticular local derangement. The latter even tried the effects
of the matter upon himself, but with no better success.
Children have also been inoculated with impunity. Taking
all these circumstances into consideration, there is not even
a shadow of proof that consumption is contagious. Never-
theless, more extensive and diversified observation is still
wanting, before we can pronounce positively on the subject.

It rarely happens that consumptive patients reach the goal
of their existence, without other organs than the lungs be-
coming seriously involved in the disease. The affections,
which thus complicate the thoracic lesion, may be purely
accidental ; that is to say, they may supervene during the
progress of the complaint without having any direct connec-
tion with it ; but, in the plurality of cases, they are to be
viewed in the light of cause and effect, the presence of the
one being necessary to that of the other.

One of the most singular phenomena,, and at the same
time one of the most common, is the excessive emaciation^
which has been considered by some, though erroneously, as
pathognomonic of the disease. The weight of the body is re-
markably diminished ; and, with the exception of the glandular
structures, the brain, spinal marrow, and nerves, there is not
an organ, probably, that does not participate in some degree in
the general atrophy. The fat is every where absorbed ; the
muscles are pale, flabby, and attenuated ; the cellular tissue
is deprived of its moisture ; the skin is thin and blanched ;
the hairs grow slowly, and many of them drop off ; the nails
are soft and incurvated ; the parietes of all the hollow viscera

SECT. II.] PLEURA. 85

are much reduced in thickness ; the boiieS; although they
retain the same length, shrink in circumference, are specifi-
cally lighter than natural, and have an unusual degree of
"whiteness ; the marrow is almost wholly removed, and in
place of it there is commonly a considerable quantity of oily
serosity. Even the cartilages, ligaments, and tendons are in
some cases sensibly diminished. The blood also is altered.
It is exceedingly thin and pale, from the dej&ciency of fibrin
and hematosine ; coagulates imperfectly when drawn ; is often
buffed, and even cupped. These changes are always more
conspicuous of course, during the latter stages of the disease,
in persons who have suffered for a long time. Along with
these changes, the whole contour of the body is altered.
Every depression is rendered more conspicuous, and every
osseous eminence stands out in bold relief. The chest is
remarkably altered in shape ; it is fiat and narrow, instead of
being round and protuberant ; the intercostal spaces are sunk
beyond the level of the ribs, and form long deep grooves ; the
shoulders are tilted forward ; and the clavicles are unusually
prominent, leaving a deep hollow between them and the
upper ribs. During life, there is a peculiar stoop, which is
almost characteristic of the disease.

We have already noticed the changes which take place in
the pulmonary tissue. Let us now proceed to examine the
lesions of some of the other organs.

The pleura is very rarely free from disease. Indeed, this
can only be the case so long as the tubercles are few, small,
and confined to the interior of the pulmonary tissue ; for, as
soon as they become numerous, large, and affect the exterior
of the organ, they must ncessarily act as irritants, and thus
lead to structural derangement of the serous investment.
Hence we generally find extensive adhesions, both inter-
lobular, costal, diaphragmatic, and even pericardiac. The
intervening substance varies in its consistence from that of
recent lymph "to that of fibro-cartilage, according to the
period of its existence. Generally it is pretty thick, and of
the nature of cellular tissue, being harder and firmer in some
places than in others. When there are large excavations,
there are almost always extensive adhesions ; tubercles are
sometimes disseminated through the false membranes ; and,
during the latter stages of the disease, the morbid deposit is
often accompanied by effusions of serous fluid, the quantity
of which varies from a few ounces to several pints. This

86 LUNGS. [chap. III.

secretion, there is reason to believe, frequently takes place
only a day or two before death. It need scarcely be re-
marked, that as the superior lobes are usually most affected
with tubercles, so they generally adhere most firmly to the
walls of the chest.

One of the most distressing accidents which occur during
the progress of phthisis, is 'perforation of the pleura. This
usually takes place suddenly, 'vn the advanced stage of the
disease, and almost always destroys life within the first few
days, from the violent iufiammation that is excited by the
extravasation of acrid fluids and the entrance of the atmos-
phere. In such cases, there is commonly severe pain in the
region of the affected part, with much oppression and anxiety.
When the symptoms are more mild, life is occasionally pro-
tracted for several weeks ; and Dr. Stokes, of Dublin, men-
tions an instance where the patient survived five months.
The perforation may happen in either pleura, but has hitherto
been observed principally in the left side, — a circumstance
which may be readily explained, by the more frequent occur-
rence of tubercles in the left than in the right lung.

The air-passages are variously affected in phthisis. The
ramifications of the bronchise, as before stated, are frequently
obliterated, very much contracted, or otherwise altered, in
their form and dimensions. The mucous membrane of the
principal tubes, as well as that of the smaller ones, is gener-
ally reddened, opaque, and thickened ; occasionally softened,
encrusted with specks of lymph, or even ulcerated. Appear-
ances nearly similar, are often seen in the trachea ; and here
it is also more common to find erosions. Occasionally there
is extensive destruction of the mucous membrane, with great
thickening of the muscular fibres ; and, in rare cases, the
ulcerative action has been known to produce serious mischief
in the cartilaginous rings. The larynx and epiglottis are also
frequently studded with ulcers: Louis found them thus
affected in one fifth of his cases, Bayle in one sixth. An-
dral detected disease, of some kind or other, in as many as
three fourths of his examinations. He also found the muci-
parous glands often very much enlarged, and the lining
membrane variously altered in color and consistence. A not
uncommon lesion was a considerable degree of softening.*

That the huirt should be affected in pulmonary consump-

* Clinique Medic^le, p. 488.

SECT. II.] PERITONEUM SPLEEN LIVER. 87

tion, is no more than what might be expected, from its close
proximity to the kuigs ; yet that this does not so often
happen as has been imagined, my own dissections warrant
me, I think, in saying. Even in protracted cases, I have
frequently been nnable, notwithstanding the closest scrutiny,
to detect any thing more than a pallid and slightly softened
state of the muscular fibres, with an entire absorption of adi-
pous matter. In the great majority of persons examined by
Louis, the organ is stated to have been unusually small, being
not more than two thirds of the normal volume. The most
common lesion which I have noticed was hypertrophy of
the ventricles ; and, what is remarkable, this was generally
more frequent, as well as more perfectly marked, on the left
side than on the right. Occasionally, also, I have observed a
diseased state of the mitral and aortic valves ; and, in some of
my examinations, there were numerous flakes of lymph, with
partial adhesions of the pericardium, the result evidently of
recent inflammation of its serous investment. In a few cases,
the pericardium was distended, and pushed out of place by
an immense quantity of sero-albuminous matter. The large
vessels attached to the heart are usually healthy.

The most common appearance observed in the peritonceum
is sero-albuminous fluid, which is always most copious when
there is disease of the spleen, liver, heart, or mesenteric
glands. The phenomenon, however, is extremely rare. The
membrane is sometimes thickened, opaque, discolored, or
studded with tubercles, in various stages of maturation. A
small quantity of thick cream-colored matter is occasionally
found, not unlike what occurs in phlegmonous abscesses.

The spleen, in phthisis, is seldom much involved. Louis
observed tubercles in one sixth of his cases ; Home in one
fiftieth, or twice in one hundred subjects. From never hav-
ing found these bodies in persons who died of other diseases,
the former of these writers is disposed to consider them as
peculiar to this afi'ection. This conclusion is decidedly at
variance with my own observations. In two cases, at least,
have I witnessed this state of the spleen unconnected with
phthisis. An alteration of volume and consistence is by no
means infrequent ; but whether these pathological conditions
are foreign to or dependent upon the present affection, is a
point which remains to be settled. My own belief is, that
there is no connection whatever between them.

The liver is variously affected. In France, the most fre-

88 LUNGS. [chap. III.

quent alteration is the fatty degeneration. Louis established
its existence in one third of his cases of phthisis, whilst he
met with it only nine times in two hundred and thirty per-
sons who died of other diseases. He also found it much
more common in women than in men, in the proportion
nearly of four to one. This state of the liver is probably
much more frequent in some localities than in others. In
my own dissections, I have rarely met with it ; in the exami-
nations of Dr. Home, of Edinburgh, it also occurred com-
paratively seldom ; * and Dr. Clark f affirms, that it is much
less common in England than in France. That peculiar
change, called cirrhosis, is, according to my own experience,
much oftener associated with phthisis than any other. The
waxy degeneration, which is probably only an advanced
stage of the adipous, and in which the organ acquires a
brownish, yellowish color, with a strong resinous lustre, a
dense but friable consistence, and a homogeneous aspect, I
have never noticed, in a single instance, as a complication of
the present disease. The hepatic tissue is sometimes exten-
sively softened ; at other times, it is preternaturally firm ;
whilst, in a third series of cases, though these are very rare,
it contains tubercular deposits, serous cysts, hydatids, or car-
cinomatous growths. With these various alterations, the
volume of the liver may be natural, augmented, or dimin-
ished. The former I believe to be the most common. The
gall-bladder is ordinarily exempt from this disease.

It is seldom that we find the urinary and genital organs
much affected in this disease. In a few instances, I have
observed tubercles in the kidneys, the ovaries, the prostate
gland, and the seminal vesicles. The uterus is almost inva-
riably sound. On two occasions I have met with ulcers in
the urinary bladder, and on one with a small deposit of tuber-
cular matter in the submucous cellular tissue. The pancreas
is rarely affected. I have found tubercles in it only in a
single case,^ — that of a negro boy about nine years old. Louis
and Home, seem to have entirely overlooked this organ in
their examinations.

During the latter stages of phthisis, aphthas are very apt to
appear in the mouth. They are generally considered, and I
believe correctly, as the immediate forerunners of dissolution ;

* Report on Plitliisis Puhuonalis, op. cit. ji. 29.
t Op. cit. p. 1G2.

SECT. II.] PHTHISIS ; STOMACH. 89

sometimes, hoAvever, they exist a considerable time before
the occurrence of this event. In many cases they are ex-
tremely numerous, covering both the tongue, the inside of
the cheeks, and the fauces. Occasionally, though this is
rare, they are also observed in the nose, the ears, and even on
the vulva. When first seen, they present the appearance of
minute chalk-colored specks, resting upon a red florid base.
By and by these white crusts fall off, exposing a great num-
ber of small ulcers, the primary seat of which is in the
muciparous glands. The suffering caused by these aphthas is
sometimes intense. The pharynx and oesophagus are rarely
affected in phthisis.

The stomach often sympathizes with the -disorganization
of the lungs. One of t?ie most common lesions is softening,
with diminished thickness of the mucous coat. These changes
are sometimes produced after death by the action of the
gastric juice ; but more frequently they are caused, by in-
flammatory irritation, and are usually most conspicuous along
the great cul-de-sac of the organ. The mucous membrane
is occasionally ulcerated, thickened, extensively reddened, or
mammillated. Another lesion that is pretty often met with
in Europe, especially in France, but which I have nex^er
observed, is great distention of the stomach, the organ reach-
ing sometimes down to the brim of the pelvis. This condi-
tion, which is usually accompanied with a blanched and at-
tenuated state of the different tunics, is supposed by Louis to
be peculiar to phthisis, as he has very rarely witnessed it in
other maladies. On this subject, as just stated, I have no
personal experience. One thing, however, appears to me
certain, that the explanation of this author, which ascribes
the dilatation in question to the effect of the repeated shocks
induced by coughing, is wholly inadmissible ; otherwise, it
would not only be much more common in phthisis, but often
attend other thoracic affections.

But of all the -organs there is not one which is so frequently
or so extensively affected in phthisis as the alimentaj^y tube,
properly so called. The parts more particularly liable to
suffer are the inferior third of the ileum, the coecum, and the
ascending portion of the colon. The most common lesions
here by far are ulcerations ; and it is rarely that we examine
a subject in which they do not occur in considerable num-
bers. In the small bowel they are usually situated over the
Peyerian glands, which they sometimes entirely destroy,

VOL. II. 12

90 LUNGS. [chap. III.

forming large, ragged ulcers, resting upon the muscular fibres.
In the large intestine, the erosions occur irregularly, and sel-
dom attain a great size, except when several of them coalesce.
The subjoined table, compiled from different sources, will
place this subject in a more familiar attitude :

Authors.

•No. of Patients.

Locality.

Small Intestine.

Large do.

Bayle,*

100

Paris,

67

Louis, f

112

((

78

70

Home, 1

66

Edinburgh,

30

38

Tubercles are likewise not uncommon, and there is every
reason to believe that they often form the primary seat of in-
testinal ulcerations. These bodies, as will be shown hereafter,
are usually situated in the submucous cellular substance,
where they are sometimes seen in great numbers, either
isolated or grouped together. Their occurrence, I presume,
is not so common in this country as in France. Louis found
them in thirty-six out of ninety-five cases.

It is a pretty common opinion that phthisis frequently gives
rise to anal fistula, establishing thus, as it were, a sort of an
issue, which, by diverting from the affected organ, retards, as is
supposed, the progress of the original malady. Respectable as
the authority certainly is by which this notion is sanctioned;
it is entirely at variance with the experience of every intelli-
gent observer of the present day. The circumstance, I am
convinced, is in great measure, if not wholly, accidental; at
any rate, I can truly say that it has rarely occurred in my
practice, nor have I witnessed it more than once in my dis-
sections of phthisical subjects. Nor do I stand alone in this
opinion. The more ample testimony of Laennec,*§> Andral,
and Horner, || is equally strong and conclusive. The former
of these authors, who treated an immense number of con-
sumptive patients, positively declares that anal fistula was
not only very rare in his practice, but that, when present, it
seldom exerted any appreciable influence on the progress of
the pectoral complaint. Dr. Clark also states that, although
he has often met with this affection, he has not been able to
trace any connection between it and phthisis, further than its

* Recherches sur la Phthisic Pulmonaire, p. 59.

t Louis, op. cit. p. 81.

t Report on Phthisis, op. cit. p. 28.

§ Op. cit.

11 Path. Anatomy, p. 256.

SECT. II.] PHTHISIS ; LYMPHATIC GANGLIONS. 91

probable dependence on abdominal venous plethora, which so
frequently precedes the latter malady.*

It is rare for phthisis to run its course without some of the
lymphatic ganglions becoming diseased. Those of the mes-
entery, of the bronchise, and of the pelvis, appear to be much
oftener affected than those of any other region ; yet the cer-
vical and axillary are also not unfrequently found in a dis-
ordered state. The most common lesion is the tubercular
deposit, which is generally conjoined with hypertrophy, in-
duration, and vascular engorgement. In adults, according to
my own observations, this heterologous formation is most fre-
quent in the bronchial ganglions ; in children and young
persons, in the mesenteric, meso-coecal, and meso-colic. Louis
considers the tuberculization of the lymphatic ganglions as
peculiar to phthisis ; and he even goes so far as to affirm that
this morbid change 7iever exists, after the age of fifteen, with-
out the lungs being similarly affected. This sweeping as-
sertion has been contradicted by M. Broussais. It is certainly
in opposition to the results of the experience of our best
authors, and we hold it to be utterly untenable upon patho-
logical grounds. Indeed, nothing can be farther from the
truth.

The brain and its envelopes are found in various diseased
states. Sometimes there is unnatural vascularity of the cere-
bral pulp, accompanied occasionally with softening of the for-
nix and great commissure. Tubercles are also observed in
different situations, either solitary in some part of the enceph-
alic mass, or spread generally over the arachnoid membrane,
which is not unfrequently opaque and thickened. In many
cases there is effusion of limpid fluid, either in the ventricles,
or between the arachnoid and pia mater, at the base or top of
the brain. This effusion probably takes place, in most in-
stances, only a short time before death, inasmuch as the intel-
lectual faculties generally remain sound until within a few
hours of dissolution.

From the foregoing account it is obvious that the diseases
which complicate phthisis are both numerous and distressing.
That they are more common in some localities than in oth-
ers is highly probable ; but further researches are needed be-
fore we can deduce any satisfactory conclusions in regard to
this and some other topics. In the mean time, all our micro-
scopic examinations should be conducted with the utmost

* Op. cit. p. 163.

92 LUNGS. [chap. III.

scrutiny, taking care not to overlook a single organ, however
distantly it may be connected by structure and sympathy
with the suffering viscera ; for in this way alone can we hope
to add any thing substantial to the pathological anatomy of
phthisis.

I shall only further illustrate this subject by making a few
cursory remarks on the nature and symptoms of phthisis. It
is not deemed necessary to reiterate here what was said in a
previous chapter, concerning the doctrine of the inflammatory
origin of tubercle.* The subject has been discussed at suf-
ficient length. Since writing that part of the work, I am
happy to find that similar views have been promulgated by
some of the most eminent pathologists of Europe. That the
doctrine of the inflammatory nature of tubercular phthisis
will be generally embraced by the profession, it requires, I
think, no prophetic vision to foresee. Every one who has
carefully investigated the subject must be fully convinced
that it is the only true one, and it is only surprising that there
should ever have been any other. We do not deny those
who have no personal experience in this matter the right of
forming an opinion : we assume no such authority ; but we
conscientiously believe that those who entertain a diff"erent
view are, in ninety-nine cases out of a hundred, completely
disqualified from coming to a just and rational conclusion
concerning the point at issue. This is strong language, we
grant: and we shall be very happy to modify it as soon as
our physicians shall make themselves better acquainted with
the principles of morbid anatomy, and the laws of abnormal
action.

Dr. Armstrong and others have expressed the belief that
tubercles of the lungs are probably never found without a
constitutional or hereditary predisposition to them. That
such a predisposition frequently exists, and exerts more or
less influence over the developement of these bodies, is a
point concerning which it would be unreasonable to doubt ;
that it is not ailways present, however, seems to me fully
borne out by the general experience of the profession. Per-

* Professor Horner, of the University of Pennsylvania, after referring to the
opinion entertained by some liighly respectable authorities, that the develope-
ment of pulmonary tubercles is not produced by inflammation, holds the follow-
ing language : " For my own part, I am not disposed to adopt this opinion. I
rather view tubercles as a form of chronic inflammation, to which evidently all
parts of the boily are liable ; but especially the langs, from the peculiarity of
their texture, and the quantity of lymphatic vessels entering into their composi-
tion." (Treatise on Pathological Anatomy, p. 258.)

SECT. II.] PHTHISIS J SYMPTOMS. 93

sons whose constitutions are perfectly sound, and in no wise
tainted by what is called the striimoiis diathesis, nevertheless
often fall victims to pulmonary phthisis, after having labored
only a short time under general debility, such as results from
a severe attack of bilious fever, typhus, cholera, bronchitis,
pneumonitis, profuse hemorrhagic discharges, and other ex-
hausting affections. Thus, although the various organs and
textures of the body may have been originally strong and well-
built, yet, being worn out by disease, the lungs may finally
take on tubercular action, of a character so destructive as to
make the whole frame yield to its influence. This is a point,
however, upon which it behooves us to speak with caution,
as further observation is still necessary before we can come
to any positive conclusion.

That a morbid condition of the system frequently precedes
and accompanies the developement of this disease, may be
gathered from the foregoing remarks. To this condition of
the body various appellations have been applied, such as tu-
bercular cachexy, strumous habit, and scrofulous diathesis.
Persons are often born with it ; at other times it is acquired,
and this may happen during any period of life, from infancy
to old age. Those in whom it prevails are generally distin-
guishable by certain external marks. In one class, which is
perhaps the most numerous, the skin is remarkably fair and
delicate, the hair light, the countenance full and pasty, the up-
per lip tumid, the eyes blue, and the lids fringed with long
lashes, the expression serene and placid, the mind unusually
intelligent, and the nervous system highly excitable. In
another class, which may be named the brunette, the com-
plexion is dark, the iris of an opaque brown, the cornea glis-
tening, the mind dull and sluggish. Occasionally the skin is
extremely fine, the hair of a raven black, and the intellect at
once sprightly and intelligent.

Children in whom the tubercular cachexy exists, are gen-
erally weak and ill-formed, and all the physical functions are
imperfectly executed. The circulation is unusually feeble ;
and hence the extremities, especially the hands and feet, are
almost always cold ; digestion goes on imperfectly ; the bow-
els are either sluggish or too loose ; the urinary and cutane-
ous secretions are deranged ; the muscles are soft and flaccid ;
the joints appear as if they were too large ; the belly is habit-
ually tumid ; the head disproportionably bulky ; the upper lip
unnaturally full ; and the countenance has a swollen, sickly,

94 LUNGS. [chap. III.

and disgusting aspect. Cutaneous eruptions are not uncom-
mon, especially behind the ears ; the eyes are extremely sub-
ject to chronic inflammation ; and the nose, which is usually
dry, from a deficiency of mucous fluid, is the seat of frequent
hemorrhages.

With respect to the diagnostic character's, phthisis may be
divided into three stages, the duration of which is too varia-
ble to enable us to lay down any definite rule. In the fi.rst
stage, the more prominent symptoms are the following :
1. More or less cough, either dry, or attended with thin,
frothy expectoration ; 2. pain in the side of the chest, at the
infra-clavicular region, or between the shoulders, or at all
these points simultaneously ; 3. hasmoptysis ; 4. slight dim-
inution or alteration of the respiratory murmur ; 5. dulness
of sound, in some part or other of the chest on percus-
sion. Along with these phenomena, which may be consid-
ered as positively indicating the existence of crude tubercles,
there is generally progressive emaciation, loss of strength,
capricious appetite, dyspnoea, and great sensibility to atmos-
pheric impressions.

A very important sign of incipient phthisis, one, indeed,
that may be regarded as in some degree pathognomonic, was
discovered, a few years ago, by that excellent observer, the
late Dr. James Jackson, Jr. of Boston, a physician who, had
he been spared, would have been an ornament alike to his
profession and to his country. While pursuing his studies
in Paris, under the guidance of the celebrated Louis, he as-
certained that there is always, in the early stage of the
present disease, a well-marked bronchial sound on expiration,
before the same phenomenon is observable on inspiration, or
even before the entire disparition of the breathing murmur.
This circumstance, j'-oung Jackson supposes, is easily explica-
ble. Although there already exists, at this period, a consid-
erable deposit of solid matter around the bronchia, yet, as the
greater portion of the affected lung is still permeable to the
air, it follows that the respiratory murmur, on inspiration,
completely masks the noise of the descending atmosphere,
which would otherwise be transmitted through the surround-
ing denser medium. On expiration, however, the order of
things is changed. The air, on passing through the bronchia,
produces the same sound as on its introduction ; and, as there
is now no vesicular expansion to mask it, it is easily trans-
mitted through the diseased structure to the ear of the exam-

SECT. II.] phthisis; symptoms. 95

iner.* Other explanations, might be offered of this phenome-
non, but the one given by its lamented discoverer is at least
ingenious, if not strictly true.

In the second stage, the cough becomes more violent and
paroxysmal ; the expectorated matter, instead of being thin
and frothy,^ is muco-purulent, and often streaked or mixed
with blood ; the breathing is hurried ; the pulse is more fre-
quent ; the fever is of a hectic character ; and the sound on
percussion is more dull. Excavations now take the place of
the crude tubercles ; and hence there is generally, in addition
to the phenomena first enumerated, bronchophony, crackling
rhoncus, pectoriloquy, and cavernous respiration.

In the third, or concluding stage, there is an aggravation of
all the previous symptoms. The emaciation is now excessive ;
the attacks of dypnoea are not only more frequent, but often
much more distressing, bordering on suffocation : the perspi-
ration is extremely copious, especially towards morning ;
aphtha appear in different parts of the mouth ; the legs and
feet are osdematous ; and the patient is harassed with con-
stant diarrhoea, which usually persists until dissolution. The
latter symptom, which is rarely absent, occasionally manifests
itself in an early stage of the disease. It is usually associated
with, and dependent upon, intestinal ulcerations. There are
two other phenomena which are of a good deal of importance,
I conceive, as diagnostic signs of phthisis : I allude to the
incurvated state of the finger-nails, and to the glistening, pearly
lustre of the sclerotic coat of the eye. The former is some-
times wanting ; the latter seldom if ever. Hence it is a
symptom of no inconsiderable value.

Cough is a very uncertain symptom of phthisis. It is gen-
erally most harassing towards the close of life. At first, it is
very slight, dry, and short ; but, as the disease advances, it
becomes more severe, and, in the majority of cases, occurs in
distinct paroxysms, which are particularly distressing during
the night, or early in the morning. In some instances, it is
entirely wanting. Hence its uncertainty as a diagnostic sign.

Much variety obtains with regard to the color, quantity,
and consistence of the expectorated matter. In the early stage

* A Memoir of James Jackson, Jr. M. D. with extracts from his Letters to liis
Father ; and Medical Cases collected by him. By James Jackson, M. D. Boston,
1835, p. 129. We cannot omit this opportunity of expressing the gratification
•we have received from the perusal of this interesting work. It is a manly and
just tribute from a bereaved father to the memory of a worthy son.

96 LUNGS. [chap. III.

of phthisis, there is either an entire absence of fluid, or it is
remarkably scanty, thin, and spamous. At a later period, the
quantity considerably increases ; but it still retains the whitish,
semi-transparent appearance of the bronchial secretion.
These characters are observable until softening takes place,
and caverns begin to form, when the sputa become streaked
with opaque specks, from the admixture of broken down tu-
bercular matter,* and are ejected in distinct, rounded masses,
with irregular and indented edges. The color of these
masses, is somewhat yellowish, with various shades of ash,
and even green : they sink, in part, in water, and they are
generally enveloped by a thin, ropy, and more transparent
fluid, which is nothing but common bronchial mucus. In
the concluding stage of the malady, the sputa assume a dirty,
cineritious aspect : they are much more tenacious, and they
usually run together. The quantity of matter expectorated,
varies remarkably in different instances, and is seldom com-
mensurate with the extent of the pulmonary lesion. In rapid
cases, from ten to twenty ounces are sometimes discharged
in the course of twenty-four hours, even before the dis-
ease has made much progress. Occasionally the matter is
ejected suddenly in large quantities, as when a tubercular
abscess gives way ; and, under such circumstances, the patient
has been known to be sufl"ocated by it, from his inability to
•clear the bronchial tubes.

The sputa, especially in the latter stages of the complaint,
are generally of a nauseous odor, and at times quite fetid.
Their taste is variable ; very often they are quite insipid ; at
other times they are saccharine, and, in a few rare cases, sa-

* This matter generally appears in the form of small, whitish, opaque flakes,
the size of which varies from that of a clover-seed to that of a pea. Hippocrates,
who seems to have been acquainted with their existence, compares them to
grains of hail, and he distinctly states that they are indicative of pulmonary
phthisis. Their appearance, as has been observed by Bayle, resembles a good
deal that of boiled rice. According to the recent observations of M. Bonnet, of
Lyons, these flakes, which are essentially composed of fibrin, are insoluble in
water, in alcohol, or ether. He has also ascertained that the immediate princi-
ples of tubercular matter are the same as those which exist in other kinds of pus.
An emulsive, fatty substance is often found in the sputa of phthisical subjects;
but this is not peculiar to this disease, inasmuch as it forms a part of the secre-
tion of all the mucous membranes, both in health and in disease. M. Bonnet
supposes that pus, of whatever nature, always derives from it its opacity and
yellowish tinge. — London Medical Gazette, December, 1S37. See also an ac-
count of Mr. Brett's able paper on the ph)^sical and chemical characters of ex-
pectorated matter, which was read last autumn before the British Medical Asso-
ciation at Liverpool. His results, in the main, agree with those obtained by the
French author above quoted.

SECT. II.] PHTHISIS J SYMPTOMS. 97

line. Fragments of pulmonary parenchyma, bronchial tubes,
and false membrane, similar to that of croup, are sometimes
mixed with the ejected matter ; and occasoiiially, though this
is also extremely rare, the patient coughs up small calculous
concretions. The sources of the expectorated fluid are three,
the bronchial mucous membrane, softened tubercles, and ex-
cavations.

Hemoptysis, on the whole, is rather a frequent symptom.
It may take place at any period of the disease, but is most
common during the early stages. Sometimes it is the first
circumstance which excites alarm. Age and sex appear to
exert a considerable influence on the production of hemop-
tysis. Females are more liable to it than males, in the pro-
portion, according to Louis, of three to two. The former are
more commonly attacked after the age of forty, whilst the
latter seem to be equally subject to it before and after that
period. The quantity of blood varies in difl'erent cases, from
half an ounce to a pint or more ; in some instances, it merely
streaks the sputa, and in others it comes away in large
mouthsful. Several years ago, I saw a case, in which up-
wards of a gallon was discharged in the course of a few
hours. The hemorrhage in this instance, as in almost every
other where it is profuse, proceeded from an opening of one
of the branches of the pulmonary artery, which had traversed
a large excavation in the superior lobe of the right lung.
Bayle, Laennec, and Andral have reported similar examples.
When less copious, besides the source just mentioned, the
blood may be furnished, first, by the bronchial mucous
membrane ; secondly, by the air-cells ; and, thirdly, by the
parietes of tubercular caverns, the surface of which, as was
before intimated, is occasionally thickly studded with minute
vascular granulations. The blood of hemoptysis is commonly
florid ; occasionally it is dark and clotted ; and at other times
it is mixed with frothy, mucous, or purulent matter.

Pain is another symptom which is not much to be relied
upon. It is rarely present in the early stage of the com-
plaint ; and cases occasionally occur in which it is entirely
absent. The situations in which it is most commonly ob-
served, are the subclavicular regions, the side of the chest,
and the interval between the shoulder-blades. Coughing,
deep inspiration, and lying on the aff"ected side, often though
not constantly increase it. The cause of this symptom is
inflammation of the pleura ; for, so long as this membrane

VOL. II. 13

98 LUNGS. [chap. hi.

remains unaffected, there is generally little or no pain. The
dyspnosa, when present — which, however, is not always the
case — is usually referred by the patient to the central part of
the chest, and is rarely noticed except when he takes exer-
cise.

Although phthisis is generally indicated by well-marked
symptoms both of a local and constitutional character, yet
cases occasionally occur in which there are no phenomena
whatever by which it is possible to recognize its existence.
To such cases, which are by no means infrequent, the term
latent has been applied. This form of consumption, Dr.
Clark thinks, is more common after the middle period of
life, — an opinion which is at variance with my own, and the
experience of some other writers. Every instance of the
kind which has fallen under my observation was under thirty-
five years of age.

Various states of the system have a manifest tendency to
disguise phthisis. Pregnancy almost always retards its pro-
gress, and masks its symptoms. No sooner, however, is the
delivery over, than the disease redoubles its vigor, and rapidly
advances to a fatal termination. '' Persons laboring mider con-
sumption rarely abort, though labor pains frequently occur
about the seventh or eighth month. A lady, the mother of
a very large family, had consumption arrested by eight suc-
cessive pregnancies. The disease returned in a very marked
form after each delivery. As she did not give suck, impreg-
nation speedily recurred, and her temporary comfort was thus
insured. Death followed too closely upon her last delivery
to admit of the relief which pregnancy in so many previous
instances had afforded." * Diabetes, dyspepsy, and diarrhoea
will frequently suspend the influence of this affection, and
even cause it to be entirely overlooked both by the patient
and by his attendant. Mania occasionally produces the same
effect. Dr. Rush mentions f two cases in which madness
alternated with phthisis, and for the time wholly suspended
every symptom of the thoracic complaint ; and numerous
cases of a like nature have been recorded by more recent
observers. In three cases, which at this moment occur to
my recollection, and of which I have kept notes, although
the lungs were extensively tuberculized, and in two of the

* Ingleby's Practical Treatise on Uterine Hemorrhage, p. 8i). London, 1832.
+ Med. Inq. and Obs. vol. ii. p. 51. Philadelphia, 1818.

SECT. III.] PLEURA. ' 99

subjects contained pretty large caverns, yet there was not
the slightest indication of pulmonary disease during life, not
even cough, expectoration, pain in the chest, or embarrass-
ment of breathing. One of the individuals, a colored man,
twenty-nine years of age, labored for six weeks under all the
symptoms of an ordinary bilious fever, with a pulse seldom
higher than ninety-six in a minute. On inspection, I found
an excavation of the size of a walnut in each superior lobe,
with numerous tubercles in other parts of the organ, and a
large abscess between the serous and muscular tunics of the
rectum. It contained about half a pint of thick, offensive
matter, and its walls were in such a state of softening as to
yield to the shghtest traction. In the second case, there was
extensive ulceration of the mucous membrane of the ileum
and colon ; and, in the third, that of a young married lady,
whose body I examined along with my friend Dr. Richards,
of this city, complete tubercular disorganization of the right
kidney. Who can doubt that in these instances the disease
of the abdominal and pelvic viscera acted in the manner of a
revulsive, counteracting that of the lungs, masking its symp-
toms, and protracting its progress ?

SECTION IIL
Diseases of the Pleura.

The serous membrane of the chest, like that of the other
splanchnic cavities, forms a shut sac, which is reflected, on
the one hand, over the lung, and, on the other, over the
diaphragm and the ribs. Hence the distinction of pulmonary,
diaphragmatic, and costal pleura, so frequently referred to
by anatomists and pathologists. Inferiorly, this membrane
reaches, in front, to the cartilage of the seventh rib, and,
laterally, within an inch and a half of the margin of the
sternum ; whilst, superiorly, it extends into the neck, forming
a narrow pouch, which lies in the hollow between the clavicle,
spinal column, and scalene muscles. This portion of the
sac, which is designed to receive the apex of the lung, is
often from one to two inches in height, especially when one
of the respiratory organs is in a state of hypertrophy, to com-
pensate for the partial loss of the other.

100 PLEURA. [chap. III.

In regard to delicacy of structure, the pulmonary pleura
considerably exceeds the costal and diaphragmatic, and it is
also united by much softer cellular tissue. That this is the
case, is abundantly proved, both by anatomical demonstration
and by the facility with which this substance is permeated
by the air in emphysema, and the water in oedema, — no such
appearance being ever perceptible in the subserous cellular
texture of the thoracic parietes. Indeed, so great is the
quantity of this substance in the latter situation, and so close
the aggregation of its component filaments, that Stokes and
Cruveilhier are inclined to regard it as of a fibrous nature, — an
opinion which is entirely at variance with the result of my
own observations. Careful examination has convinced me
that the parietal subserous cellular tissue is not fibrous, as is
supposed by these distinguished writers, but merely con-
densed cellular substance, spread out in the form of a lamella,
similar, in many respects, to the transverse fascia of the
abdomen, so well described by Sir Astley Cooper in his ex-
cellent treatise on hernia. Semi-transparent and of a dull
whitish aspect, the lamella under consideration is highly ex-
tensible and elastic, and, withal, so firm and resisting as to
require a good deal of force to tear it. Its thickness, which
nowhere exceeds that of a sheet of common writing paper,
varies in different portions of its extent, being much greater
between the ribs than upon their surfaces, where it is quite
thin and delicate. The connection between it and the pleura
is so slight, that the latter can in general be easily pealed off
in large-sized patches ; but, externally, the adhesion is very
close and strong, particularly as it passes over the intercostal
aponeurosis, from which it can be separated only with a knife
or by protracted maceration. On the ribs, this structure, as
was just remarked, is comparatively thin and spongy, and,
in fat individuals, always contains a considerable quantity of
adipous matter. Considered in reference to its situation, the
lamella which we have here briefly described, may be called,
with great propriety, the internal thoracic fascia. It is much
more distinctly developed in the horse and ox than in the
human subject, and performs a very important part in all dis-
eases of the pleura, especially in such as are of a chronic kind,
in which it often becomes hypertrophied and abnormally
dense. It supports the tender ramifications of the vessels, both
arterial and venous, as they proceed towards the substance of
the serous membrane ; and the filaments of which it is com-

SECT. III.] ORGANIZATION. 101

posed are interwoven with each other in every possible direc-
tion, forming thereby an inextricable net-work.

In the normal state, the pleura is perfectly colorless, no
vessels of any kind being anywhere perceptible. Nor does
it possess much animal sensibility. In several cases in which
the chest was punctured by the elder Monro, he introduced a
curved probe, and rubbed the point of it against the pleura,
without the patient experiencing the slightest pain or uneasi-
ness. He also repeated the experiments of Haller, of prick-
ing and even lacerating the membrane, after removing the
intercostal muscles, with precisely the same results.

Although, to the naked eye, the free surface of the pleura
is perfectly smooth, yet this is rather apparent than real ; for,
when carefully examined with the aid of a magnifying-glass,
it is found, like the rest of the serous membranes, properly so
called, to be studded with an immense number of the most
delicate villi, which give it somewhat of a rough aspect.
Concerning the precise nature of these minute eminences we
have no positive information. In chronic inflammation, they
are frequently rendered visible to the naked eye, and impart
a rough, gritty sensation to the finger.

Excepting the arachnoid tunic of the brain and spinal
cord, none of the serous sacs, in the normal condition, contain
any fluid. This, I know, many have doubted ; but reiterated
examination of the inferior animals, as well as of persons who
came to their end by sudden death, has fully persuaded me
of the entire truth of the proposition here stated. Naturally
the serous textures are lubricated merely by a sort of vapor,
which is designed to facilitate the movements of the organs
over which they are reflected, and which is evidently an
emanation from the capillary vessels distributed through their
substance.

With respect to their structure, the serous membranes may
be regarded as a modification of the cellular tissue, since they
may all be resolved into this substance by difl"erent mechani-
cal and chemical processes. They are highly extensible and
elastic, and, notwithstanding their tenuity, they possess no in-
considerable share of strength and firmness. By stretching a
portion of peritonaeum over a hoop, Scarpa found that it did
not give way until a weight of fifteen pounds was placed on
its surface. Their extensile properties are well displayed in
pregnancy, dropsy, and hernial protrusions.

The proper serous membranes are only six in number :

102 PLEURA. [chap. 111.

1. the arachnoid tunic of the brain and spinal cord; 2. the
hning of the heart and pericardium ; 3. the two pleurse ; 4.
the peritonaeum ; 5. the vaginal coat of the testicle. To
these some have added the amnios, one of the envelopes of
the foBtus, the membrane of Jacob, and certain structures of
the internal ear, which all bear a considerable resemblance to
the serous tissue, but the precise nature of which is still un-
determined.

The diseases that will be treated of in the present section
are, inflammation, with its ordinary consequences, and malig-
nant growths. The first of these affections may be acute or
chronic, partial or general ; that is, it may be limited to a
small portion of the pleura, or pervade the entire membrane.
Occasionally, too, though this is unusual, it attacks both sacs
simultaneously. When the inflammation affects the pulmo-
nary pleura, it often extends to the parenchymatous structure
of the lungs, — a circumstance which gave rise, amongst the
older practitioners, to the opinion that it was impossible for
pleuritis ever to have an independent existence. The first
writer that controverted this doctrine was Baldi, who pub-
lished a work on Thoracic Diseases, at Paris, in 1640. A
similar view was advanced, about forty years after, by the
celebrated Hoffmann, of Germany ; and, in 1740, precisely a
century from the period the subject was first broached in
France, the question was finally settled by the writings of
Triller, a physician of Prussia. Since that time, fact upon
fact has been accumulated, and the subject no longer admits
of the slightest disputation.

The anatomical characters of acute •pleuritis consist in a
change of color of the affected membrane, with an increase
of its secretion, an altered state of the subserous cellular
tissue, and a change in the form and volume of the lung,
invested by the inflamed texture.

As soon as the pleura is irritated, the subjacent capillary
vessels become injected with red blood, and spread out in
every possible direction, anastomosing freely with each other.
In this way they form, at first, beautiful dendritic lines, and
afterwards, as the disease progresses, a close and intricate
mesh-work, the intervals of which are often much smaller
than the most delicate pin-head. The color produced by this
capillary injection is usually a bright red ; and, although it
generally occurs in small patches, with sound portions inter-
vening, yet in many instances, it is diffused over a considera-

SECT. III.] pleurisy; anatomical characters. 103

ble extent of surface, occupying the greater part of the entire
membrane. In very mild cases, we have sometimes the
speckled, dotted, or punctiform redness ; as, in those of an
opposite character, we sometimes have the blotched, echy-
motic, or bloodshot appearance. In the early stage of the
disease, the capillary vessels upon which this discoloration
depends, seem to be confined, as already intimated, to the
subjacent fascia ; but, by degrees, as the inflammation ad-
vances to completion, they extend into the substance of the
pleura, as any one may convince himself by peeling off this
membrane, and inspecting it by the aid of a good glass, or
by holding it simply between the eye and the light.

In most cases of acute pleuritis, there is an effusion of se-
rosity into the subserous cellular texture, which is sometimes
so great as to give the affected membrane an osdematous
aspect. This infiltration, which usually begins at a very
early stage of the disease, is always more abundant under
the pulmonary than under the costal or diaphragmatic pleura,
from the more considerable laxness of the connecting tissue.
The serous membrane itself is not at all thickened, though
the contrary, I know, has been asserted by numerous pa-
thologists.

In acute pleuritis, as in the corresponding disease of the
arachnoid, pericardium, and peritonaeum, there usually occurs,
in the nascent stage of the complaint, if not an entire sup-
pression, at least a considerable diminution, of the natural
secretion ; so that the membrane, instead of being moist and
lubricated, as in the normal state, is rendered somewhat dry
and harsh. But this state continues only for a very short
period, when it is followed by an effusion of serum and
lymph. Some of the French pathologists suppose that this
effusion takes place the very moment the inflammation sets
in ; or, in other words, that they proceed with equal pace.
The truth of this position, however, is by no means estab-
lished ; indeed, it may well be doubted, I think, whether it holds
good under any circumstances, further than as an exception
to a general rule ; for it is satisfactorily ascertained, that a
diminution, if not an entire suspension, of the exhaling pro-
cess, is one of the very first effects of acute pleuritis, as it is
of acute inflammation of every other serous membrane in the
body.

The quantity of fluid poured out in this affection varies
from a few drachms to several quarts. Generally thin,

104 PLEURA. [chap. III.

watery, and colorless, it is sometimes reddish, and slightly
flocciilent ; or it resembles unclarified whey, and contains
masses of lymph, pus, or blood. Occasionally, the fluid is of
a yellowish, viscid character, not unlike copal varnish or thin
olive oil. An exhalation of pure blood is sometimes wit-
nessed ; but this is much more infrequent than in acute peri-
carditis, or in acute inflammation of the serous membrane of
the abdomen.

It is very seldom that genuine pus is secreted in this dis-
ease, yet such cases sometimes take placp, with very great
rapidity. In the winter of 1837, two cases occurred to me,
one in a boy, nine years old, and the other in a child of ten
months, in both of which upwards of a pint of thick cream-
colored matter v»''as found in the pleural cavity after an illness
of only about two weeks. Piso relates several instances of
acute pleuritis, in which the patients died on the fifteenth,
and some even as early as the ninth day, with their chests full
of pus ; and similar examples are recorded by Andral, Towns-
end, and other pathologists.

Concurrently with this eff'usion of serosity, there is a depo-
sition of lymph, occurring either in small globules, in patches,
or in continuous layers. At first, this substance is quite soft,
so that it can be easily scraped ofl" with the finger-nail ; but,
after it has existed for a few days, it is found to have a con-
siderable degree of tenacity, and to exhibit the usual mani-
festations of incipient organization. The precise period at
which this process begins cannot be satisfactorily indicated,
as it must vary in diff'erent cases ; yet, as a general propo-
sition, it may be affirmed to be from forty-eight to seventy-
two hours from the invasion of the disease. The color of
this deposition is usually a pale lemon, but not unfrequently
it is a milky white, light gray, or even reddish, from the
admixture of blood.

If the inflammation be early arrested, the eff'used fluid is
gradually absorbed, and the contiguous surfaces of the serous
membrane, being covered with lymph, are brought into con-
tact, and speedily cemented together. The adhesions thus
formed, are at first very slight and easily broken ; but, in pro-
cess of time, they are converted into cellular tissue, and be-
come proportionally strong and resisting. When extensive,
they often greatly embarrass the movements of the lungs, at
the same time that they exert a very serious influence upon
the size and figure of the chest.

SECT. III.] GANGRENE. 105

If, Oil the other hand, the disease be allowed to progress,
until the effusion amoimts to several quarts, it requires to be
let out by puncturing the chest, the absorbents being no
longer capable of taking it up. The v/ound thus made
occasionally" heals kindly; and, if the fluid does not reaccumu-
late, the patient has a chance of getting well, the parts con-
tracting adhesions, as in the preceding case, and the lung
becoming again dilated by the introduction of the air. It
deserves to be mentioned that, when the quantity of fluid
is considerable, the adventitious membranes are apt to be
quite thick, and to have their outer surface pitted like a honey-
comb. Of the manner in which the lung is aff"ected in this
disease, I shall speak more particularly under the head of
chronic pleuritis.

Gangrene is one of the rarest results of acute pleuritis.
As a primary afl"ection, I have never seen an instance, and
Laennec met only with a single case in the whole of his
long experience. Nor have others been more successful.
Most commonly it is produced by external violence, and occa-
sionally it is propagated from the pulmonary tissue. The
afl'ected parts may be readily distinguished by their softened,
pulpy condition, by their dark grayish, brownish, or blackish
color, and by their disagreeable, fetid odor. In some in-
stances, the affection appears to begin in the adventitious
membranes, from whence it gradually spreads to the other
structures, such as the pleura, the lungs, intercostal muscles,
and even the ribs.

The symptoms of acute pleuritis, as might be expected, are
much influenced by the extent of the disease, and by the
length of time it has existed. In general, there is inflamma-
tory fever, Avith violent pain in the side, dyspnoea, a hard,
dry congh, and inability to lie on the afl'ected side. Having
lasted for a day or two, these phenomena are followed by
others, such as dulness of sound on percussion^ bronchial
respiration, a peculiar modification of the voice, and, finally,
a complete absence of the respiratory murmur.

The pain is usually circumscribed, no matter what may be
the extent of the inflammation, and is of a sharp, stitch-like
character, increased by coughing, by deep inspiration, by
pressure on the intercostal spaces, or by lying on the afl'ected
side. The situation where it is most commonly felt is the
mammary region, whence it often shoots along the axilla, the
clavicle, top of the shoulder, upper part of the back, or even

VOL. II. 14

106 PLEURA. [chap. III.

the arm and fore-arm. In the latter case, the pain seems to
be reflected along the course of the intercosto-hiimeral nerves,
from their participating, probably, in the disease of the serous
lining of the chest, immediately beneath which they lie.

In acute pleuritis, the countenance is generally expressive
of deep suffering, and the respiration is short, hurried, and
jerky, from the inability which the patient experiences in
inflating the lungs with air. These phenomena, together
with the dry, hacking cough, and the sharp, lancinating pain,
may be regarded as pathognomonic of this, one of the most
frequent and distressing complaints with which we have to
contend in this country.

When acute inflammation of the serous membrane of the
chest continues beyond a few weeks, it becomes chronic j
but it is by no means always thus preceded ; for. in many
instances, it exists as an original affection, stealing on in
a slow and almost insensible manner. In whatever way,
however, it may arise, the anatomical characters do not differ
essentially in the two diseases, especially as far the effusions
are concerned.

In chronic pleuritis, the membrane acquires a slight degree
of morbid thickening, its color is of a more obscure red, and
the subserous cellular tissue is hypertrophied and indurated.
This, however, is not always the case ; for, in some instances
I have found this substance so soft and brittle that the pleura
could be peeled off, almost entire, with the utmost facility.
The effusion, which is generally much more abundant, as
well as less limpid, than in the acute disease, is almost always
mixed with lymph. Hence, when evacuated, and allowed
to stand at rest, it usually separates into two parts ; one thin
and viscid, like serum, floating on the top ; the other, which
consists of fragments of albumen and serum, sinking to the
bottom. Most commonly, perhaps, the effusion is of a light
lemon color, of the consistence of thin oil, and destitute, or
nearly so, of odor. Frequently, however, it is of a dark
greenish hue, sero-purulent, and almost insupportably often-
sive. Cases also occur in which it contains blood, and now
and then it is strictly purulent, possessing all the properties
of genuine pus. The quantity of effused fluid is sometimes
almost incredible. In a subject, fifty-two years old, I drew
off, not long ago, fully two gallons of sero-purulent matter,
from the right pleural sac : it was of a white yellowish color,
and intolerably offensive. Occasionally, when the distension

SECT. III.] PLEURISY ] CONCRETIONS. 107

is very great, the fluid has a tendency to work its way out,
either through the bronchial tubes, through the intercostal
spaces, or even through the diaphragm. Of the latter mode
of escape, an interesting case is given by Andral, and another
by Le Dran, in his surgical observations. When the patient
survives, as sometimes happens, the passage along which the
pus travels becomes lined with an adventitious membrane, as
are fistulous tracks in other parts of the body.

The adventitious membranes of chronic pleuritis do not
materially differ from those that are produced by the acute
form of the disease, excepting that they are generally thicker,
more extensive, denser, and more firm. Oftentimes they consist
of a number of distinct layers, the outer of which are always
much softer than the internal, or those which are formed first.
Repeatedly have I seen from three to five such lamellae ; and,
on several occasions, it has occurred, to me to meet with
small compartments, formed, by sheets of lymph, and filled
with a thin, glairy fluid, not unlike the white of egg. Oc-
casionally these cavities contain thick pus, and even pure
blood. Soon after their deposition, these false membranes
become organized, and consequently subject to the samic dis-
eases as the natural tissues ; for example, to the efl\ision of
serosity, lymph, pus, or blood, gangrene, tubercles, and, lastly,
fibrous, cartilaginous, and osseous transformations. Their
vascularity is sometimes very considerable, as is shown by the
red dots which are seen upon their free surface, as well as
by the clots of blood found in their cavities. Thus, then,
when these abnormal textures are organized, it is sufficiently
clear, from w^iat has been stated, that they perform the office of
secretion ; and, from the fact that the effused fluids sometimes
entirely disappear, it is equally manifest that they possess,
in a very eminent degree, the faculty of absorption.

Small, bony concretions, very much like those of the joints,
are sometimes found floating loosely about in the effusion.
How these bodies originate, has long been a problem with
pathologists ; but the most plausible explanation, perhaps,
that can be offered concerning them, is to suppose that they
are attached, at first, to the surface of the pleura, in the form
of fibrin ; secondly, that they are organized ; thirdly, that,
their nutrition being perverted, bony matter is deposited ;
and, fourthly, that, after this process has continued for some
length of time, the vessels supplying them are obliterated,
and they drop off". Instead of being osseous, these concre-

108 PLEURA. [chap. hi.

tions are sometimes of a fibrous, fibro-cartilaginous, or gristly
consistence, and of a white pearly color, with a tolerably
smooth surface.

Gases sometimes accumulate in the chest, being either
secreted there by the serous membrane, generated by the de-
composition of effused fluids, or introduced from without, in
consequence of a wound, a fistulous aperture, or the bursting
of a tubercle. In the two former cases, they often have the
odor of sulphureted hydrogen, and, on the chest being punc-
tured, escape^ with a loud hissing noise. When very abun-
dant, these gases seem to be incapable of absorption ; and their
presence, therefore, may occasionally become a source of
much inconvenience, by the pressure which they exert upon
the lungs. Dr. Davy, of Edinburgh, has analyzed the air
collected from a patient who died of pneumo-thorax, and
found the following proportions: carbonic acid, 12.5; ni-
trogen, 85.5 ; oxygen, 2. Professor Apjohn, of Dublin, in a
similar experiment, found, in one hundred parts. 8 of carbonic
acid, 10 of oxygen, and 82 of nitrogen.

Ulceration of the pleura, though occasionally observed, is
yet to be considered as very rare, and hitherto I have wit-
nessed only a single instance of it. The patient was a female,
fifty-five years of age, who died of hydro-thorax, complicated
with pulmonary tubercles. On opening the chest, which
contained an immense quantity of sero-purulent effusion, five
ulcers, of an oval shape, were seen upon the left costal pleura,
the largest of which was about an inch and a half in diameter :
their surface, formed by the subserous cellular tissue, was
bathed with bloody matter, and their edges were red, indu-
rated, and slightly everted. The parts around were of a
brownish color, deeply injected, and considerably incrusted
with lymph. The lung contained hundreds of tubercles, in
every stage of developement ; and in the upper lobe was a
large excavation, the margins of which firmly adhered around
the principal ulcer of the pleura. Such erosions, perhaps,
seldom or never heal. In fact, it is doubtful whether they are
susceptible of it.

Another affection which is sometimes noticed, and which
is also very rare, is ossification of the pleura. The bony mat-
ter, which usually appears in thin, narrow plates, is probably
always preceded by cartilage, as is shown by the fact that
.these substances often occur together, the former being en-
circled by the latter. Laennec states that he once met with

SECT. III.] pleurisy; tubercles. 109

a cartilaginous incrustation of the serous membrane of the
chest as large as the hand, and more than half an inch thick
in the centre. The costal pleura seems to be the part most
frequently affected by these transformations, though the
pulmonary and diaphragmatic portions are not exempt from
them. Their original seat is the subserous cellular tissue,
the involvement of the serous membrane itself being entirely
secondary.

Tuhe7xles are also rarely met with, — seldom if ever, except
in connection with adventitious membranes and liquid effu-
sions. I have seen two instances of this disease, in both of
which the tubercles were very large, — most of them of the
size of a hazelnut, of an opaque, whitish appearance, and sur-
rounded by inspissated lymph : they adhered with great firm-
ness to the costal pleura, which was itself considerably thick-
ened, and to the knife they offered all the resistance of the
fibro-cartilaginous tissue. Laennec, who supposes that these
bodies generally originate in the false membranes, describes
them as varying in size from a millet-seed to a hemp-seed; as
being of a grayish or yellowish color, semi-transparent or
opaque, and as lying in close proximity to each other, with the
intervening structure in a state of high vascularity. Tubercles
are sometimes developed with great rapidity. Thus, Andral
states that he has seen the abnormal membranes studded with
these bodies in persons who died of acute pleuritis of only
fifteen days' standing.

Schirrhus and encephalo'id are sometimes found in the
pleura ; but their occurrence is so very unusual that it is un-
necessary to say any thing about them in this place. The
same remark may be made respecting those cysts which
have occasionally been noticed in this situation, and of which
such an interesting case has been given by the late Baron
Dupuytren of France.*

The lung, as might be anticipated, is variously affected in
pleuritis, both acute and chronic. When the effusion is very
considerable, the organ is sometimes so much compressed,
that, without a careful examination, it might be regarded as
totally destroyed. Repeatedly have I seen it reduced to the
smallest possible size, lying like a thin cake, scarcely bigger
than a child's hand, in the back part of the chest, beside the
spinal column. When thus atrophied, the parenchymatous

* Cruveilhier, Essai sur I'Anatomie Path. Paris, 1816.

110 PLEURA. [chap. Ill,

texture is peculiarly hard and dense, void of crepitus, pale,
and almost bloodless, the vessels being flattened, and, in some
instances, partially obliterated. If the lung continue in this
state for a considerable period, it becomes hepatized, or, as is
more generally the case, tuberculized, and entirely unfitted
for the purposes of respiration. On the contrary, should the
fluid which has occasioned the compression be speedily ab-
sorbed, the pulmonary tissue will gradually expand, and
finally be as pervious to the air as ever. The only exception
to this rule, so far as 1 know, is where the organ is tied firm-
ly down, as I have several times witnessed, in the hollow
between the spine and ribs, by shreds and layers of lymph ;
in which case, if I may so express myself, it will remain
permanently strangled.

Nor is the alteration confined to the lung. Whenever the
eff"usion is great, the aff'ected side becomes manifestly larger ;
the intercostal spaces being not only remarkably wide, but
projecting occasionally considerably beyond the level of the
ribs. The diaphragm, also, is more or less depressed, and the
heart is often thrust from its natural situation, either to one
side, or down into the epigastric region. The extent of the
dilatation varies in different cases, but does not in general
exceed two inches. The best way of ascertaining how
much enlargement there is, is to adopt the plan suggested by
Dr. Townsend, of Dublin, which consists in measuring both
sides with a tape, carried from a central point in the sternum
under the mamma to the spinous process of the corresponding
vertebra. The eye alone, however, is often quite sufficient to
detect the difference, even when it amounts only to six or
eight lines.

Sometimes the reverse of this phenomenon is observed, the
chest, instead of being dilated, being considerably contracted.
This diminution, which results from the complete absorption
of the effused fluid, and from the conversion of the adventi-
tious membranes into fibrous, cartilaginous or bony matter, is
generally accompanied by a loss of resonance in the affected
side, and by a very marked alteration of the respiratory mur-
mur, — effects which usually continue for a long period after
the cure of the disease, and not unfrequently during the re-
mainder of the patient's life. A very rapid contraction of
the chest sometimes takes place after the operation for em-
physema. Dr. Townsend mentions the case of an individual,
aged twenty years, in whom, in the space of nine days, the

SECT. III.] CHRONIC PLEURISY. Ill

circumference of the diseased side diminished nearly three
inches by the faUi ng in of its osseous parietes.

Chronic pleui'iiis as has heen aheady stated, is the conse-
quence, most generally, of the acute form of the disease ;
yet sometimes it is primary, and then its approaches are often
so obscurely marked that it may have existed for a considera-
ble length of time, and extensive effusion taken place, before
the patient is led to suspect the slightest mischief When
chronic pleuritis is the relic of acute, the individual does not
gradually or suddenly regain his health as is usual after
active depletion ; on the contrary, he remains weakly, feels
some oppression in the chest on lying down, experiences
shortness of breath on ascending a flight of stairs, and has a
slow fever at night, followed, towards morning, by copious
perspiration. The cough is irregular, short, and tickling, and
the pain is commonly not severe, the stitch which marks the
acute disease being seldom present, or, if present, only occa-
sional in its occurrence. Sometimes, indeed, the disorder
maybe said, so far as this symptom is concerned, to be per-
fectly latent, the pleura being greatly disorganized, and even
profoundly suppurated, without the person having ever com-
plained of the least pain. Baglivi and Morgagni have trans-
mitted the history of several cases of this kind ; and similar
testimony is borne by numerous writers of a more recent date.
This is an important fact, which renders it highly imperative
upon us always to watch our patients after an attack of acute
inflammation, and not to neglect the stethoscope whenever
there is the slightest suspicion of lurking disease.

When the individual, laboring under chronic pleuritis, sits
up, he is often free from any marked inconvenience ; but no
sooner is he asked a succession of questions, or requested to
cough, or to walk across the room, than the chest begins to
heave, the respiration becomes hurried, and there is a sense of
tightness and oppression, from which it will take some time
to recover. Firm pressure on the abdomen or on the affected
side will produce the same result. But one of the most re-
markable symptoms in chronic inflammation is the position
which the patient assumes in bed : in the acute disease, he
lies invariably almost on the sound side ; in that under con-
sideration, on the contrary, he lies on the affected side, on
the back, or in an intermediate posture.

Such are the more prominent phenomena which denote the
existence of chronic pleuritis. It only remains for me, there-

112 PLEURA. [chap. Ill;

fore, in connection with this topic, to speak of the physical
signs of this malady, — a subject which has been so happily
elucidated by the labors of the immortal Laeimec, that little
has been left to be done by succeedhig pathologists. These
signs, which are to be drawn from a stethoscopic examination
of the patient, do not differ in any respect in the two forms
of the disease which we have been considering, except that
in the chronic there is less frequently that shrill, jerky, tremu-
lous sound, which, from its resemblance to the voice of the
goat, has received the name of agophony.

In the early stage of pleuritis, there are no physical signs
to indicate its existence ; but, as soon as effusion has taken
place, they become at once prominent and expressive. Thus,
when a stratum of liquid intervenes between the lungs and
the walls of the chest, there must necessarily be dulness on
percussion, with diminution or absence of the respiratory
murmur. This will be the case even when the quantity of
effusion is small ; but, should it be abundant, the lungs will
be greatly compressed, and the respiration be bronchial, from
the fact that the air can no longer gain admission into the
vesicular structure.

The dull sound is, in most cases, originally observed at the
inferior part of the affected side, from whence it gradually
ascends as the effusion becomes more copious ; and as it
changes, likewise, with the position of the patient, it thus de-
termines very accurately the level of the extravasated fluid.
The principal exceptions to this rule are, where the lungs
have contracted extensive adhesions, and the fluid occnpies
almost the entire cavity of the thorax. Examples of these
occurrences are not unfrequently met with in our dissections.
In the fifth volume of the Dublin Hospital Reports, two
remarkable instances of empyema are detailed by Professor
Stokes, in both of which the lungs were attached from their
summit to their base by a vertical adhesion of several inches
in breadth. Similar instances have been published by other
writers, and of the influence which they exert over the
physical indications of pleuritis, every one must be fully
aware. Dulness of sound alone cannot be regarded as
pathognomonic of the disease, as it may arise from other
causes than from effused fluid ; for example, from hepati-
zation of the lungs, or from an excessive developement of
tubercles ; still it should never be overlooked, inasmuch as,
when taken in connection with other signs presently to be
noticed, it will much aid our diagnosis.

SECT. III.] PLEURISY J- PHYSICAL SIGNS. 113

The alteration of the respiratory murmur is always in
direct ratio to the thoracic effusion, being deep and feeble when
the quantity of fluid is moderate, but entirely wanting when
it is very abundant, except along the spinal column, where it
is still somewhat audible over a space of a few inches in
breadth. Sometimes the respiratory murmur survives the
dulness of sound for several days ; and, not the least remarka-
ble circumstance connected with this subject, is, that the
crepitation after having ceased in all other parts, except along
the dorsal vertebrae, often continues to be heard under the
clavicle, from the adhesions between the pulmonary and
costal pleura in this situation in phthisis. This continuance
of the breathing murmur towards the root and apex of the
lungs, with its disappearance, either gradually or uddenly,
from other parts of the organ, is generally sufficient to dis-
tinguish pleuritis from inflammation of the substance of the
lung, in which the diminution or absence of this sound is
invariably preceded by what is termed the crepitating rhoncus,
and in which are ordinarily to be observed traces of the ad-
mission and expulsion of air.*

Another physical sign which we may sometimes recogn'7e
in pleuritis, especially in the acute form of the malady, is a
'pecniiav friction sound, not unlike what is produced by rub-
bing against each other two pieces of sole-leather. The
cause upon which this depends is easily explained. In the
normal state the contiguous surfaces of the pulmonary and
costal portions of the pleura are constantly bedewed with a
thin, viscid exhalation, by which they are enabled to glide
smoothly and imperceptibly over each other ; but, as soon as
they become inflamed, they pour out plastic lymph, which
adheres to them in different places, and renders them so
rough as to thwart their physiological object. Thus the
movements of the lung are materially impeded, and the sound
which attends them is heard both during inspiration and ex-
piration. We n'eed scarcely remark ■ that this sign can only
be detected ^o long as there is no effusion of serosity. Hence
it is usually most distinct in the early stage of the disease,
or after the accumulated fluid has been absorbed.

iEgophony is commonly most distinct towards the inferior
parts of the chest, in the interval between the nipple and the
spine ; but it changes its place whenever the patient assumes

* Laenuec on Auscultation, p. G5.
VOL. II. 15

114 PLEURA. [chap. III.

a different position, and seems constantly to follow the upper
level of the fluid. It does not exist either in the very early
or in the more advanced stage of pleuritis ; is heard only so
long as the effusion is moderate, or a few lines in depth ;
disappears when it becomes more abundant ; reappears when it
diminishes ; and finally ceases altogether, when it is ab-
sorbed. This phenomenon, considered by some writers,
though erroneously, as pathognomonic of pleuritis, has been
variously accounted for. Ijaennec ascribes it to the trans-
mission of the voice through the compressed lung and the
fluid which is interposed between this organ and the wall of
the chest ; whilst others, with more plausibility, suppose that
it depends upon the air not penetrating beyond the larger
bronchial tubes, — an opinion which is strengthened by the fact
just mentioned, that, whenever the quantity of effusion is so
great as to exert a considerable degree of pressure upon the
pulmonary tissue, the aegophony is entirely absent, reappearing
as the matter is absorbed and the pressure diminishes.

Besides these signs, which may be regarded as unequivocal
evidences of pleuritis, fluctuation can often be distinctly felt
through the intercostal spaces ; and, on some occasions, a
splashing noise is to be heard within the chest, resembling
that produced by agitating a cask partly filled with water.
Another test of thoracic effusion, first suggested, I believe, by
Bichat, is the effect of pressure on the corresponding side of
the abdomen. The diaphragm, with the fluid resting upon
its upper surface, is thus thrust into the chest, and, the lung
being greatly compressed, an insupportable sense of suffocation
is produced. The value of this test, however, has been re-
cently disputed by Chomel and Townsend, who assert that
in most of the cases in which they have employed it, the
result was the very opposite to that just stated. Important
diagnostic signs may also be drawn from the figure of the
chest, and from the fixed position which the ribs assume
when this cavity is much dilated or contracted.

When the effusion is combined with gaseous matter, or
when the latter exists alone, the physical signs are very nearly
as they have just been described, excepting that there is often
a remarkable tympanitic clearness on percussion, and a pecu-
liar metallic tinkling during the act of respiration. This
sound, which resembles that of the .Tews-harp, may also be
easily imitated by the dropping of a pin into a tumbler, or by
touching gently a sonorous vessel with a quill.

CHAPTER IV.

Of the Heart and its Membranes.

SECTION I.

Of the Pericardium.

I. Lesions of ike Pericardium. — Inflammation. — Hydro-pericardinm. — For-
mation of Matter and Deposits of Lymph. — Symptoms. — Etfusion of
Blood. — Accumulation of Air. — Serous Cysts. — Congenital Absence. —
II. Lesions of the i?mr^. — Situation, Shape, Color, Weight, and Dimen-
sions. — Cardiac Sounds. — Capacity of the Opposite Reservoirs. — Structure.
—- Malformations. — Acute Carditis. — Collections of Pus. — Ulceration. —
Inflammation seldom or never ends in Gangi'ene. — Softening. — Indura-
tion. — Cartilaginous and Osseous Degenerations. — Scirrhus and Encephaloid.
— Fatty Transformation. — Atrophy. — Dilatation. — Hypertrophy. — III. Le-
sions of the Endocardium. — Acute Inflammation. — Thickening. — Wart-like
Excrescences. — Fibro- Cartilaginous, Cartilaginous, and Osseous Transforma-
tions. — Polypous Concretions.

The first disease of which we shall speak is pericarditis.
This is unquestionably of much more frequent occurrence
than is generally supposed by the profession. Most com-
monly induced by vicissitudes of temperature, and by exter-
nal violence, it often exists in combination with rheumatic
affections of the fibrous tissues, with pneumonitis, pleurisy,
and the autumnal remittent fevers of the United States and
other countries. In the acute variety of the disorder, the
leading anatomical characters which are to be observed in
such as die, are^ preternatural redness of the lining mem-
brane, effusion of serum, and exudation of lymph.

It is rare to find the redness very bright ; most generally it
inclines to a purple or light brownish tint. Presenting itself
under a great variety of forms, it is sometimes seen in small
dots, sometimes in arborescent lines, sometimes in considera-
ble patches. In all these cases, the surface of the pericar-
dium has a mottled appearance, from the intervening portions
of the membrane retaining their natural color. Not unfre-
quently, however, the part is almost free from this, the vascu-

116 PERICARDIUM. [CHAP. IV.

larity, even when the inflammation is very intense, being
extremely slight, or having so far disappeared, when the
inspection is made, as to he scarcely visible. Yery rarely is
the redness uniformly diffused over the whole bag ; when
this happens, the inner surface exhibits a stained appearance,
as if the color had been dyed into it.

When the disease becomes chronic, or is so from the onset,
the redness diminishes in intensity, and assumes a mahogany,
brownish fawn, or cinnamon tint. The eff"used lymph, of
which we shall presently speak, often acquires the same
color, and the heart itself is usually of a bluish-white appear-
ance. Neither in this, nor in the acute variety of the disease,
does the serous membrane undergo much change. Its thick-
ness and consistence are precisely as in health ; and although
its surface is often roughened, yet this is altogether an adven-
titious circumstance, produced by the deposition of lymph.

Soon after the disease is fairly established, the lining
membrane pours out a thin, watery fluid, either of a clear,
limpid appearance, or of a light citron color, slightly inclining
to greenish. This fluid is coagulable by heat, alcohol or
acids, and is to be regarded simply as an increase of the
natural secretion. In many cases, it contains fragments of
lymph ; in others, it is mixed with pus, or even with pure
blood ; or all these substances are found atl the same time.
The eftlision of blood is always indicative of high inflamma-
tory irritation : it may be a simple exhalation from the lining
membrane, or it may proceed from a rupture of some of its
vessels. The quantity of serum thrown out during the first
two, three or four days, is generally considerable, amounting
often to ten or fifteen ounces. After this, as the violence of
the disease subsides, it gradually disappears by absorption, so
that in the course of a week or two scarcely any of it is left.
In chronic pericarditis, the serum has usually a singularly lac-
tescent, puriform character, and is much smaller in quantity
than in the acute form of the disease. When the fluid
remains unabsorbed, it gives rise to what is called hydro-
pericarditis. The quantity in such cases is sometimes very
great. Corvisart relates one in which it was eight pounds.*

The quantity of purulent matter thrown out in chronic
pericarditis is sometimes astonishingly great. In the case of
a colored man, thirty years old, mentioned by Dr. Wright, an

* Organic Diseases of the Heart, p. G3. Philadelphia, 1812.

SECT. I.] PERICARDITIS. 117

I

eminent physician of Baltimore, the quantity is said to have
exceeded a gallon. It was of a uniform consistence, and of
a light yellowish color, exhibiting all the qualities of lauda-
ble pus. The pericardium, from the lining membrane of
which this immense accumulation of matter proceeded, was
excessively dilated, and both lungs, in consequence, were
thrust high up into the thoracic cavities. The heart was of
the ordinary size, and not particularly diseased.* In the acute
form of the complaint, pus is rarely observed, and never to
so great an extent as in the chronic.

Contemporaneously with the effusion of serous fluid is the
exudation of lymph, which is at first of a pale straw color,
and of a soft, viscid consistence, but which in a short time
acquires a light grayish, opaline tint, and a firm tenacious
character. Though occasionally deposited in small, detached
patches, it commonly forms a continuous layer, which is
spread over the opposing surfaces of the pericardium, both on
the heart and on the origin and termination of the great ves-
sels. The thickness of the false membrane seldom exceeds
a line, from which it may vary, in some instances, to nearly
an inch, being generally much more considerable than the
false membrane of pleuritis. The adherent surface is smooth,
and accurately adapted to the parts upon which it reposes ;
the other is rough, flocculent, and often marked with small
depressions, which give it a singularly reticulated aspect, not
unlike a piece of lace-work, a sponge, or a honey-comb.
This appearance, which is seen only in recent cases, results
from the incessant movements of the heart, and may be
pretty closely imitated by pulling apart two plates united by
a thick layer of butter.

After this membrane has been for some time formed, it
becomes organized, — vessels shooting into it from the sur-
rounding parts in the same manner as in the adventitious
structures in other situations. In this way, it may become
the seat of subsequent attacks of inflammation, or of tuber-
cles and various other transformations. Whilst the process of
vitalization is going on, the exudation is gradually deprived
of its more fluid ingredients, until at length it is completely
converted into dense, grayish cellular tissue, cementing the
contiguous surfaces closely and inseparably together. Of this
I have seen a number of specimens, two of which are now

* American Journal of the Medical Sciences, vol. xii. p- 33.

118 PERICARDIUM. [CHAP. IV.

in my museum. When the lymph is very thick, it sometimes
assumes a laminated arrangement ; in other cases, it is drawn
out into transverse wrinkles, or into long, slender filaments.

In chronic pericarditis, the false membrane sometimes con-
tains plates of cartilage, and even small specks of bone.
Occasionally we meet with compartments, filled with pus,
serum, or puriform fluid ; and cases also occur, and this not
unfrequently, in which the lymph is studded with tubercles.
In a preparation which I took from the body of a colored
man, ninety years old, the adventitious membrane, which is
about a third of an inch thick, contains from fifteen to
twenty of these bodies, some of which are as large as a
common cherry-stone. They are of a light straw color,
quite hard and dense in their texture, and seem to be firmly
embedded in the substance of the abnormal tissue.

The muscular substance of the heart, in this disease, often
remains wholly free from inflammation ; sometimes, however,
it is found to be considerably changed in its color and con-
sistence,— circumstances which would lead us to infer that
it had participated in the derangement of its investing mem-
brane. The organ is, in some instances, partially atrophied,
from the pressure, probably, which it sufl^ers from the effused
fluid. When it has been long united with the pericardium
by lymph, it is not uncommon to find hypertrophy and dila-
tation of the ventricles, with ossification of some of the
valves, and softening of the muscular tissue. These dis-
orders are brought about, no doubt, by the great exertions
which the heart is obliged to make, in consequence of its
restrained and shackled condition. Unable to act with its
accustomed freedom, its fleshy fibres are in a state of constant
congestion, and its chambers in a state of constant distention ;
whence results, on the one hand, hypertrophy, and, on the
other, dilatation of the auricles and ventricles.

Pericarditis has been observed at all periods of life, though it
is undoubtedly most common after the age of forty, in persons
who are naturally predisposed to gouty and rheumatic afl^ec-
tions. The late Dr. Billard was led to suppose that it occurs
most frequently in new-born infants. In seven hundred au-
topsic examinations which he made at the Foundling Hospital
of Paris, ho observed seven well-marked cases of this disease,
two of which proved fatal in less than forty-eight hours after
birth. In one of the children who died thus early, the
adhesions between the pericardium and the heart were so

SECT. I.] PERICARDITIS ] SYMPTOMS. 119

strong as to lead to the belief that the malady had existed
for some time prior to birth. In the other six cases, the adhe-
sions were much weaker, and there was also a considerable
quantity of sero-albuminous effusion.* Pericarditis, when
occurring at this tender age, generally runs its course with
great rapidity, and without affording any signs which can be
considered at all as diagnostic. The little patients, according
to Billard, appear to suffer violent pains, the respiration is
greatly embarrassed, the muscles of the face are continually
contracted, and there are occasional paroxysms of impending
suffocation,

"There are few diseases," says Laennec, "attended by
more variable symptoms^ or of more difficult diagnosis, than
pericarditis. Sometimes it appears with all the symptoms of
a very violent disease of the chest, obviously calculated to
carry off the patient in a few days. At other times, it proves
fatal without leading us in the least to suspect its existence.
Again, we find cases marked by all the symptoms usually
attributed by pathologists to this disease, and in the subjects
of which, after death, we discover no traces of its presence.
I have myself," continues this celebrated individual, " fre-
quently fallen into both errors, and I have seen the same
thing happen to the most skilful practitioners." f One of the
great difficulties connected with the diagnosis of this affec-
tion, is the circumstance of its being generally complicated,
as was before remarked, with pleuritis, inflammation of the
lungs, or some other thoracic disorder, which masks its pecu-
liar character, and deceives the physician.

The pain in acute pericarditis is generally of a pungent,
burning, lancinating kind, and, as in acute pleuritis, often
extends to the top of the shoulder and upper-arm : it is aug-
mented by a full inspiration, by stretching the left side, or by
pressure over the praecordial region or between the fifth and
sixth ribs. The patient lies almost always on his back ; he
is harassed with a dry, hacking cough ; the respiration is
hurried and irregular ; the countenance is expressive of deep
anxiety ; the features are contracted ; there is cardiac palpita-
tion, with a peculiar disposition to faintness ; and the pulse
is always frequent, and generally, at the onset, full, hard, and

* Traite des Maladies des Enfaiits Nouveau-nes, p. 624. Paris, 1837.
+ Treatise on Thoracic Diseases, by Forbes, p. 675.

120 PERICARDIUM. [CHAP. IV.

jerky, the stream of blood being sent with a peculiar thrill.
This state of the artery, however, usually continues only for
a few days, when the pulse becomes very small and frequent,
or even insensible.

, In some instances, a sound similar to the creaking of new
leather is heard, which, however, seldom lasts longer than a
few hours, and cannot therefore be considered as of much
value. Very recently. Dr. Watson, of London, has called at-
tention to a symptom which, in most cases, furnishes a cer-
tain ground of diagnosis. It consists in a superficial murmur^
heard equally during the systole and diastole of the ventricle.
This murmur appears to be produced by the rubbing of the
contiguous surfaces of the pericardium, roughened by lymph,
and is designated by Dr. Watson by the term to and fro
sound. The noise is not always to be recognized, however,
with the same degree of distinctness : it is loudest when there
is no serous effusion, and often entirely disappears when the
quantity of fluid is great, becoming again audible as it dimin-
ishes. In this respect, it is analogous to segophony. Very
generally a systolic murmur is also heard, produced, it is
probable, by a roughened state of the valves.

When there is much accumulation of fluid, whether in.
consequence of acute or of chronic pericarditis, the precordial
region sounds dull on percussion, and often becomes preter-
naturally prominent, in the same manner as the thorax does
in pleuritic effusion. The projection is sometimes evident
over a space of four or five inches in length, by three and a
half in breadth. The pulsations of the heart are often per-
ceptible on inspection, always irregular, tumultuous, and ob-
scure. If, with these phenomena, the patient is unable to lie
on his back without being threatened with instant suffocation,
and is subject to frequent paroxysms of swooning, no doubt
can be entertained of the true nature of the complaint.

It is surprising how large a quantity of fluid may occasion-
ally exist in the pericardium, and yet the patient scarcely
manifest any symptoms of uneasiness. In the case detailed
by Dr. Wright, to which I previously adverted, although the
pus amounted to four quarts, there was not the slightest ap-
pearance of impeded cardiac action ; the pulse Avas free, mod-
erately full, and regular ; there was no embarrassment of
breathing, no distress of countenance, no syncope, no proc-
cordial pain, no cedema of the extremities. The patient could
lie equally well on either side, and, the day before he died.

SECT, I.] PERICARDITIS ; SEROUS CYSTS. 131

walked abont the wards of the hospital with apparent ease.
The formation and accumulation of this immense quantity of
purulent fluid were obviously the work of time, and had
commenced long before the man's last illness.

The signs of adhesion of the pericardium are generally very
obscure. Perhaps the most characteristic symptom is an ab-
rupt, jogging motion of the heart, recognizable by the hand
or stethoscope placed over the prsecordial region. When the
lesion is joined with hypertrophy of the left ventricle, a bel-
lows-murmur is occasionally heard, and not unfrequently the
apex of the organ strikes with so much violence against the
costal cartilages, as to produce a marked prominence.

We have already mentioned, that, in cases of violent peri-
carditis, there is sometimes an effusion of pure Mood. In most
cases, the fl.uid, amounting frequently to upwards of a quart, is
coagulated ; occasionally, however, it is liquid, exceedingly
dark, and almost destitute of fibrin. On examining the pe-
ricardium, in persons who succumb under this lesion, it is
generally impossible, after the most diligent search, to dis-
cover any ruptured vessels, from which the blood might have
flowed. Whence, then, does the fluid proceed ? In one way
alone can this question be satisfactorily answered : taking into
consideration the fact just stated, that the vessels of the peri-
cardium always retain their integrity, and the analogy afford-
ed by the serous textures in other situations, under like cir-
cumstances, it may be concluded that the blood, in these
cases, is the result simply of a process of exhalation, depend-
ent upon an altered condition of the capillaries of the lining
membrane. When the effusion occurs in cachectic personSj
as it appears often to do in Russia and some other countries,
it is not improbable that the blood itself is considerably mod-
ified in its properties, being preternatural] y thin, black, and
manifesting no disposition to coagulate.

Cases have occurred, though very rarely, in which a large
amount of air has been accumulated in the cavity of the peri-
cardium. Commonly conjoined with sero-purulent efiiision,
its presence may sometimes be detected, according to Laen-
nec, by an unusually clear resonance at the lower part of the
sternum, or by a sound of fluctuation produced by the beats
of the heart, and by strong inspirations. Its chemical nature
is not known. Dr. Horner has never seen an instance of this
aeriform accumulation, nor have I myself met with it.

Serous cysts are occasionally found in the pericardial cap-

VOL. II. 16

122 HEART. [chap. IV.

sule. Dr. Monro refers to a specimen of this kind, preserved
in the museum of the university of Edinburgh, in which the
morbid growth is nearly six inches long : the heart was of
enormous size, and the patient had labored for several years
under the usual symptoms of hypertrophy.

Finally, the pericardium is sometimes entirely absent.
Such an anomaly is no doubt rare, and has been supposed to
exist when it actually did not, from the deceptive appearance
produced by the adhesion of this capsule to the outer surface
of the heart. The pericardium is sometimes partially trans-
formed into bone ; and, in one instance, observed by Dr. Bar-
low, of London, the ossification was complete. The foreign
matter is probably deposited originally in the serous lamella,
from whence it gradually extends to the fibrous membrane.

SECTION 11.
Of the Heart.

I. The heart, situated in the central part of the thoracic
cavity, is placed in such a manner that its base looks oblique-
ly upwards and backwards to the right side ; the apex ob-
liquely downwards and forwards to the left. Interposed
between the great arterial and venous trunks, it has the same
relations to the surrounding structures as the pericardium, by
which it is enclosed. Anteriorly, it corresponds to the thy-
mus gland, the breast-bone, and several of the costal carti-
lages; posteriorly, to the bronchial tubes, the oesophagus, and
descending aorta ; laterally, to the inner surface of the lungs
and the phrenic nerves. Inferiorly, it rests on the tendinous
centre of the diaphragm, which forms the floor of the chest,
nearly on a level with the fifth rib, and thus separates it from
the abdominal viscera. It is important to remember that, ex-
cepting in a few rare instances, the pericardium is not entirely
covered by the lungs, but that a portion of it remains in im-
mediate contact with the walls of the thorax. This portion,
which is of a lozenge shape, corresponds to the anterior sur-
face of the right ventricle, and is seldom more than an inch
and a half in extent.

In the normal state, the apex of the heart beats against the

SECT. II.] SITUATION SHAPE. 123

fifth costal cartilage, or against the interval between the fifth
and sixth, near their junction with the ribs. The left ven-
tricle is situated in advance of the right, which is behind the
other, and in great measure concealed by it. The auricles,
forming the base of the heart, mount as high up as the inter-
val between the third and fourth costal cartilages, and are
placed almost entirely under cover of the sternum. The
valves of the pulmonary artery are situated a little to the left
of the median line of the breast-bone, on a level with the in-
ferior border of the third rib : those of the aorta are directly
behind, and consequently concealed by them.

The organ, instead of being situated obliquely, is some-
times placed, like the heart of a quadruped, in a line with the
sternum ; and, occasionally, though rarely, it is found to pro-
trude externally, through an opening in the chest. Cases
have been observed where it lay in the epigastric region, on
the outside of the ribs, and in the substance of the liver,
Boudelocque examined the body of an infant, in which there
were two distinct hearts, one of which occupied the abdomen,
the other the thorax. Instances are also recorded in which
the organ was situated in the right side of the chest. These
cases are usually associated with transposition of the abdom-
inal viscera.

The situation of the heart is also influenced by diseased
states of the lungs, aneurismal enlargements of the aorta, and
by collections of water or purulent matter within the pleura
or abdomen. In ascites, the organ is sometimes remarkably
filled up ; and in hydro-thorax, it is frequently thrown en-
tirely out of its natural position, so that the impulsion of its
apex can be felt on the right side instead of on the left.

In its shape, the heart is somewhat conical, the base being
above, and the apex, which is formed entirely at the expense
of the left ventricle, below. The division between the four
chambers of which it consists is indicated externally by two
grooves, one of them running transversely, the other nearly
vertically. The color of the heart is of a florid red, in a
healthy adult individual ; but it assumes a paler aspect as we
advance in life ; and, in certain morbid states of the system,
especially in dropsical affections, it is frequently quite
blanched. It is a remarkable fact that the internal fibres are
generally of a much deeper red than the exterior. With re-
gard to its consistence, the organ is sufficiently firm to resist
the pressure of the finger. After death, the auricles, from the

124 HEART. [chap. IV.

tenacity of their walls, are always in a collapsed state ; and
the same is the case in respect to the right ventricle. The
parietes of the left ventricle, on the contrary, are so thick as
to prevent the obliteration of the corresponding cavity.

In the new-born infant, the position of the heart is nearly
vertical, so that it lies more along the median line, as in some
of the inferior animals. Its color is also of a brighter red,
its muscular fibres are more distinct, and the walls of the
ventricles are proportionally stouter, as well as more nearly
alike in regard to their thickness.

The weight and volume of the heart vary much in different
individuals, as well as at the different periods of life. Numer-
ous attempts have been made to fix upon some standard of
comparison, by which we might judge with some degree of
certainty, of its dimensions, but with so little success, that
the results that have been furnished can be regarded only as
affording approximate evidence. Thus Lobstein estimates
its weight at nine or ten ounces ; Cruveilhier at six or seven ;
and Bouillaud at eight or nine. In ten examinations, made
with a view of throwing additional light upon this piece of
healthy anatomy, I ascertained the average weight to be eight
ounces and a half; the minimum seven, and the maximum ten
and a half. Laennec merely observes that the heart ought
to be about the size of the fist of the subject ; a means of
comparison, which, although somewhat vague, will usually
be found, according to my own experience, to be very near
the truth.

The average length of the ventricles, including the apex
of the organ, is four inches ; of the auricles, one inch and
three quarters. The mean circumference, measured around
the auriculo-ventricular groove, is nine inches and a half ;
the breadth four inches. The thickness of the ventricles
varies in different parts of their extent. Thus, the thickness
of the right is scarcely two lines at the middle, whilst it is
nearly two and a half at the base, and about one and a
quarter at the apex. So also of the left ventricle ; whilst it
is seven lines in thickness at the centre, it is only six at the
base, and four and a half at the apex. Of the right auricle,
the mean thickness is one line ; of the left, one line and a
half. The thickness of the inter-ventricular septum also
varies in different parts of its extent, being at its maximum
at the middle, where it is six lines and a half, and at its mini-
mum at the apex, where it is nearly the sixth of an inch

SECT. II.] ' MEASUREMENTS. 125

less. The mean thickness of the inter-auricular partition is
one line and a half.*

The above measurements are founded upon a careful ex-
amination of twelve hearts taken from male and female sub-
jects, between twenty-five and forty, and which were, in
every respect, so far at least as I could determine, perfectly
sound. They differ in some particulars from those of Bouil-
laud and Lobstein, which is not surprising when it is remem-
bered that the weight and dimensions of the organ in ques-
tion, whether considered as a whole, or in reference to its
several parts, are remarkably influenced by sex, stature, age,
and individual peculiarities ; so that upon this point it is ex-
tremely probable that the results of any two writers will
never perfectly coincide. It would appear from the interest-
ing researches of Dr. Bizot,-j- of Geneva, that the dimensions
of the heart are in direct proportion to the breadth of the
shoulders, and that the organ is always bigger, not relatively,
but absolutely, in persons of middle stature or under, than in
those who are distinguished for their tallness.

The mean circumference of the mouth of the aorta, meas-
ured in the same subjects, was two inches and three quar-
ters ; of the pulmonary artery, three inches and a sixth. Of
the left auriculo-ventricular orifice, the average circumference
was four inches ; of the right, four inches and a half.

By placing the ear over the prsecordial region of a healthy
individual, two distinct sounds may be heard, followed by a
period of rest. The first, supposing the pulse to be sixty in
a minute, lasts about half a second, the other about a fourth,
and the interval of repose the remaining quarter of the second.
The first sound, which is dull and prolonged, coincides with
the contraction of the ventricles ; the other, which is sharp
and clacking, with their dilatation.

* Professor Lobstein, of Strasbnrgh, attributes the following mean dimensions
to the healthy adult heart : length, from the base to the apex, five inches and a
half; breadth, at the base, three inches ; thickness of the Avails of the right ven-
tricle, at the upper part, two lines and a quarter, at the lower, half a line; of the
left, seven lines superiorly, and four inferiorly ; thickness of the right auricle,
one line, and of the left, half a line. (Traite d'Anatomie Pathologique, t. ii.)

M. Bouillaud, of Paris, found the mean circumference of the organ, measured
around the base of the ventricles, to be eight inches and three quarters ; the mean
length, from the root of the aorta to the apex, nearly three inches and two
thirds ; and the same, as the mean breadth, measured at the base. The average
thickness of the right ventricle, stated in round terms, is, according to the same
authority, two lines and a half, and that of the left, seven lines; of the right
auricle, one line, and that of the left, one line and a half. (Traite Clinique des
Maladies du Cceur, t. i. p. 52.)

t Mem. de la Societe Med. d'Observation de Paris, t. i. p. 276.

126 HEART. [chap. IV.

Concerning the causes of these sounds, there is still con-
siderable difference of opinion, notwithstanding the numer-
ous attempts that have been made to investigate them. From
the experiments of Dr. Hope, an account of which is to be
found in the recent edition of his excellent treatise on the
Diseases of the Heart and Great Vessels, it would appear
that the first sound is of a compound character, being pro-
duced partly by the shutting of the auriculo-ventricnlar valves,
partly by the vibratory action of the muscular and tendinous
fibres, and partly by the collision of the blood in its passage
through the lower cardiac chambers. In regard to the second
sound, the most probable conclusion is, that it depends upon
the flapping to of the sigmoid valves at the mouth of the
aorta and pulmonary artery. At all events, it has been fully
ascertained that it is stopped, and succeeded by a peculiar
hissing noise, on transfixing one or more of these folds with
a curved needle, and thus confining them against the walls
of the vessels, so as to arrest their action. Similar efforts
follow, though in a less striking degree, the compression of
the aorta and pulmonary artery, whereby the column of blood
is prevented from falling back against the sigmoid valves.

The cardiac sounds vary greatly in intensity in different
individuals. Ordinarily they are not audible, except at the
prsecordial region, if the ear be more than an inch and a half
from the chest. The absence of adipous matter, the thinness
of the ventricles, and the energetic contraction of the muscu-
lar fibres, together with the force with which the valves are
thrown into action, are so many causes whose direct tendency
is to augment the loudness of the sounds under considera-
tion. It is worthy of remark, moreover, that the sounds are
transmitted in a much more intense form through hepatized,
tubercular, or compressed portions of lung than through such
as are healthy.

It is extremely difficult, especially for one who has not
had much experience, to distinguish between the normal
sounds of the two sides of the heart. Nor is it possible to
define their exact limits, except in a general manner, which
is, that they are audible in almost every part of the chest,
but much more distinctly so at the praecordial region, and at
the left side of the sternum, near its junction with the third
costal cartilage, than in any other situation.

The capacity of the opposite reservoirs of the heart does not
seem to be precisely alike, although, if we take into considera-

SECT. II.] CAPACITY. 127

tion the fact that the same amount of blood flows through both,'
it might reasonably be inferred that the reverse was the case.
The two auricles are evidently larger than the ventricles,
especially the right, the size of which is generally about one
fifth greater than that of the left. This disproportion in the
capacity of the auricles is by no means imaginary, as some
anatomists have asserted ; nor can it, properly speaking, be
dependent, as has been alleged by others, on the particular
kind of death ; for, although the walls of the left chamber
are more uniformly muscular, as well as a little thicker, than
those of the right, yet if these cavities be carefully distended
with wax, the right will always be found to be considerably
larger than the left. This fact, indeed, is so familiar to those
who are in the habit of making preparations of this organ,
that it would be idle to dwell upon it.

With respect to the ventricles, the capacity of the right
has usually been supposed to exceed that of the left, — an
opinion which appears to be almost coeval with the earliest
records of anatomy. Santorini, whose experiments on this
subject are worthy of an attentive perusal, however, arrived
at an opposite conclusion ; and the same is the case with the
observations which have since been made by Lower, Weip,
Moor, Lieutand, Sebatier, and other inquirers. Haller and
Meckel assert that the difference, whenever there is any, is
always attributable to the species of death, the results of
their researches leading them to believe that either the one
or the other of these reservoirs may be rendered more capa-
cious, just according as the blood is arrested, during the last
struggles of life, in the lungs or in the aorta. Opposed,
again, to this conclusion are the observations of Seller and
Legallois, v/"ho, by distending the heart with mercury, invaria-
bly found that the right ventricle was larger than the left, no
matter on which side of the organ the blood accumulated
during death. This statement is likewise borne out by the
examinations of .Bouillaud, and is in perfect accordance with
the results of my own researches. Legallois endeavors to
account, very correctly, as I think, for this difference of
capacity, on the well-known fact that the parietes of the
left ventricle are much stronger and more muscular than
those of the right, in consequence of which they are much
less liable to become dilated ; the corresponding cavity thus
presenting always the same size, whereas the other, from the
same cause, is constantly subject to enlargement. The abso-

128 HEART. [chap. IV.

lute capacity of these reservoirs has not been very accurately
determined ; but it will be sufficiently near the truth to state
that, in their normal condition, they are capable of lioldiDg a
hen's egg. The auricles are obviously a little larger, as
above stated.

The outer surface of the viscus is covered, as was pre-
viously stated, by a reflection of the serous lamella of the
pericardium, from which it obtains its smooth and polished
appearance ; whilst its several chambers are lined by a mem-
brane of a similar nature, which is continuous, on the one
hand, with that of the hollow veins and of the pulmonary
artery, and, on the other, with that of the aorta and of the
pulmonary veins. In the healthy state, this membrane is
perfectly white and pehucid : it is scarcely thicker than the
arachnoid tunic of the brain, and it adheres so firmly to the
muscular substance that it can be detached only in very small
shreds. Like the inner coat of the vessels, it is readily dis-
colored by imbibition ; and, in certain morbid affections, it is
rendered rough, opaque, and uneven, acquiring the consist-
ence of the fibrous layer of the pericardium. In its structure,
this serous lining differs considerably in the two sides of the
heart, — that of the right half being very extensible, resisting,
and but little liable to ossification, whilst that of the left half
is almost inextensible, remarkably brittle, and extremely
prone to bony deposits. This membrane, it may now be
observed, is named the endocardium, and plays a very impor-
tant character in the diseases of the heart. No vessels or
nerves have been traced into its substance.

The endocardium is arranged in certain portions of its
extent in the form of folds, the principal of which are situ-
ated at the mouth of the aorta and pulmonary artery, the
orifice of the inferior hollow vein, and the auriculo-ventricu-
lar apertures. In their shape, they are nearly all semilunar ;
and they are composed each of two distinct lamellas, con-
nected together by short, dense cellular substance. In addi-
tion to this, there is in the duplicature of the aortic and
pulmonic valves, at the centre of their free margin, a small,
firm tubercle, called the corpuscle of Arantius, after a profes-
sor of Bologna, who first described it. The precise nature
of this little body is not determined, but it ap])ears probable
that it is of a fibro-cartilaginous structure. Tlie auriculo-
ventricular valves, or, as they arc more commonly termed,
the mitral and tricuspid, are united, on the one hand, to the

SECT. II.] ITS STRUCTURE. 129

slender tendons of the fleshy pillars, and, on the other, to the
contour of the corresponding orifices by a whitish, fibrous
zone, which is particularly distinct on the side of the auricles.
Thus the heart would seem to be composed of five entirely
different anatomical elements, — the muscular, the serous, the
fibrous, the fibro-cartilaginous, and the tendinous.

The heart contains scarcely any cellular substance, being
composed essentially of muscular fibres. In many cases,
especially in fat persons, there is a considerable quantity of
adipous matter, which is generally most abundant along the
course of the coronary arteries, at the origin of the great
vessels, and on the surface of the right ventricle. In a
number of instances, I have seen the whole organ incrusted
with this substance, forming a smooth yellow lamella, from
the third of a line to a line and a half in thickness, and yet
the muscular fibres be perfectly sound.

The proper cardiac substance is much more firm and dense,
as well as of a deeper red, than that of the voluntary mus-^
cles, and is composed of numerous fibres, lying in close con-
tact with each other, and running, for the most part, in an
irregularly spiral direction from the base to the apex of the
organ. In the auricles, the walls of which are much thinner,
as before stated, than those of the ventricles, they are ar-
ranged into two planes, one of which is external, the other
internal. In the A'^enous portion of the right auricular cavity,
the fibres exhibit a smooth, uniform appearance, whilst in
the proper ear-like appendage they are disposed in small par-
allel bundles, constituting the so called pectineal muscles :
here numerous intervals are left between them, at which the
two serous membranes of the heart are almost in immediate
contact. In the left auricle, the two muscular strata are
somewhat thicker, and also more uniform in their mode of
arrangement : the fibres may be said to begin at the entrance
of the pulmonary veins, and to take nearly all a transverse
course, with the "exception of the more deeply seated, which
cross each other in almost every conceivable direction. The
inter-auricular septum is likewise of a muscular nature, and
the layer of which it is composed is considerably thicker
and stronger than those forming the walls of the auricles.

The fleshy fibres of the ventricles are interwoven with
each other at right angles, and they are all arranged — at least
if we may credit the assertion of Wolff, Gerdy, and others,
who have particularly investiga.ted this subject — in the form

VOL. II. 17

130 ^ HKART. [chap. IV.

of loops, the convexities of which look towards the apex of
the organ. In the left ventricle, the fibres are disposed in
six layers, and in the right only in three, which accounts for
the comparative thickness of their walls. The superficial
strata run obliquely downwards, backwards, and towards the
left side ; the middle take precisely the opposite direction ;
and the deep-seated ones, which form the fleshy columns of
the heart, are for the most part longitudinal. After all, it
must be confessed that it is extremely difficult to determine
the exact arrangement of these fibres, let us adopt what
method we may ; and instead, therefore, of saying that they
follow one particular course more than another, it may be
boldly affirmed that they begin at all points, and extend iri
all directions, forming thus a net-work which it is utterly
impossible for any ingenuity to unravel.

The heart is supplied with blood by the two coronary
arteries, the branches of which are distributed through every
part of its substance : they take their origin just behind the
sigmoid valves, and, as might be supposed, pursue a most
tortuous course. The coronary vein is very large, and em-
bogues into the right auricle. The lymphatics, which are
quite numerous, follow, for the most part, the direction of the
blood-vessels. The nerves are derived principally from the
cervical ganglion of the trisplanchnic ; but a few filaments are
also furnished by the pneumo-gastric, which accounts for the
sympathetic relations which subsist between the lungs and
the central organ of the circulation. Scarpa and Munninks
have fully demonstrated, that the branches of these nerves
are extensively distributed to the fleshy fibres of the heart,
and not merely, as was contended by Behrends and some
others, to the cardiac vessels.

II. The heart, like other organs, is liable to malformations.
These, though not frequent, are so various as to render it ex-
tremely difficult to classify them according to philosophical
principles. Any generalization, indeed, that may be ofl"ered
must necessarily, in the present state of the science, be im-
perfect, and susceptible of future improvement. The follow-
ing, without pretending to any thing more than ordinary
accuracy, will be found to embrace an account of the more
interesting varieties hitherto noticed. Before we proceed to
indicate this arrangement, it should be stated that the differ-
ent congenital deficiencies of which we shall speak, may be
conveniently viewed in reference, first, to the parietes of

SECT. II.] MALFORMATIONS. 131

the organ ; secondly, in respect to its internal septa ; thirdly,
in relation to its valves ; and, fourthly, in regard to the origin
and termination of the great vessels.

(I.) 1. The heart consists only of one auricle and one ven-
tricle. This malformation is rare. Cases, however, are re-
lated by Kreisig, Burns, Billard, Breschet, and other authors.
The organ gives origin to a single vascular trunk, which
presently divides into the aorta and pulmonary artery. The
type of this imperfection is to be found in fishes, in Avhich
the single heart and artery, with its branchial arches, are
permanent parts. This malformation, it need scarcely be
observed, is always hostile to the prolongation of life. The
infant generally dies Avithin the first twelve days.

2. Both auricles are wanting ; or there are two ventricles,
with one auricle ; or, finally, two auricles, with one ventricle.
These cases are likewise extremely rare ; but in a few in-
stances the patient attained the age of manhood.

3. The auricles have a sort of supernumerary appendage.
Of this species of malformation, D^ Haen and Billard have
each recorded an instance.

4. The apex of the heart is bifurcated, or there is a deep
groove marking the junction of the ventricles. The former
of these appearances naturally exists in the human embryo,
and constitutes the type of what is found in several species of
mammalia, as the dugong and manatee.

(Tl.) The second series comprehends the malformations of
the internal partitions, of which the most frequent and im-
portant are those of the inter-auricular septum. The aper-
ture which naturally exists at this part is generally closed
within the first few days after the establishment of the
respiratory function, by a fold of serous membrane situated at
the left side of the heart. This valve is sometimes defective,
perforated, or entirely absent. More frequently, however,
there is an arrest in the developement of the muscular sub-
stance, eventuating in the formation of an imperfect partition.
The septum thus produced is seldom more than three lines in
diameter, but occasionally the deficiency is complete. This
malformation frequently coexists with patescence of the ar-
terial duct. Although the individuals usually die within
the first six months, yet cases are mentioned where life was
protracted to the twentieth, thirtieth, fortieth, and even fiftieth
year.

A congenital opening between the two ventricles is by no

132 HEART. [chap. IT.

means common ; at any rate very few such cases have been
recorded by writers. The form of this aperture is generally
rounded, with smooth, pohshed margins ; and, in the majority
of instances, it is situated at the superior part of the septum,
not far from the origin of the great vessels. With this vice
there is frequently patescence of the arterial duct and oval
foramen, with contraction of the pulmonary artery. The
essence of this imperfection exists in the heart of the alligator,
in which the ventricles naturally communicate with each
other during life. Infants thus affected, usually die soon after
birth. Dr. Pulteney relates the case of a patient who reached
his fourteenth year.

The symptoms which indicate the existence of these mal-
formations are such as might be expected to arise from the
admixture of venous and arterial blood in the chambers of
the heart. The individual is always in ill health, the respira-
tion is disturbed, the circulation disordered, and the tempera-
ture of the whole body diminished. With these phenomena,
which are present to a greater or less extent, according to the
size of the opening, there is a peculiar bluish discoloration of
the skin, which is most conspicuous in the face, lips, eyelids,
nose, and ends of the fingers, and which may be regarded as
pathognomonic of the malformations in question.

(III.) The valves rarely exhibit congenital imperfections.
Sometimes they are deficient in numbers, but more frequent-
ly they are too short, reticulated, or perforated, so as to serve
as an incomplete barrier to the regurgitating fluid. The
sigmoid, mitral, and tricuspid valves have all been found
stretched fiat across their respective orifices, with one or more
apertures in their substance. The Eustachian valve is more
frequently deficient than any other.

(IV.) The fourth class of malformations relates to the origin
and termination of the great vessels, which often exist with-
out any accompanying imperfections of the heart. Of these,
several varieties may be enumerated.

1. The aorta arises from both ventricles. This state is
commonly accompanied with patescence of the oval foramen
and arterial duct, the latter of which occasionally ends in a cul-
de-sac in the substance of the heart. The pulmonary artery
is either contracted, obliterated, or entirely absent. Death en-
sues at various periods, from the first day to the fourteenth
year. The symptoms are such as denote a mixture of venous
and arterial blood, namely, lividity of the prolabia, palpita-
tions, and paroxysms of suffocation.

3ECT. II.] MALFORMATIONS. 133

2. The pulmonary artery springs from both ventricles.
This is also a very rare variety of malformation. The oval
foramen remains open ; and the vessel sends off the descend-
ing aorta, the ascending arising in the ordinary way.

3. The aorta arises from the right ventricle, and the pul-
monary artery from the left. In this transposition, the veins
generally retain their normal disposition. Nor do the oval
foramen and arterial duct always remain open.

4. Both vessels originate from the same ventricle. This
is extremely rare. Several well-authenticated cases, how-
ever, are on record. The internal septa of the heart are usu-
ally imperfect in this variety of malformation.

5. The arterial duct opens directly into the right ventricle,
the aorta and pulmonary artery exhibiting nothing unusual
in their size or mode of arrangement. This deviation has
been observed only three or four times.

In regard to the venous trunks, the deviations from the
normal standard are not less singular. Thus, the right auri-
cle has been known to receive the pulmonary veins, and the
left the superior or inferior cava, or both. Meckel relates an
instance where the coronary vein opened into the left ventri-
cle ; and Breschet records another, where the hepatic veins
emptied directly into the right auricle. The latter cavity
also sometimes receives the azygous vein. Le Cat narrates a
case in which this vessel divided, near the heart, into two
branches, of which one terminated in the right and the other
in the left auricle.

These cases of congenital absence of the heart are extreme-
ly rare, and never occur without being associated with other
vices of conformation, of which the most common is deficien-
cy of the brain. Such a state, whether simple or compli-
cated, it need scarcely be said, is inconsistent with the con-
tinuance of life. A double heart has occasionally been ob-
served, but in no instance, perhaps, without a monstrous con-
dition of the majority of the other organs.

III. The lesions of the muscular structure of the heart
may be arranged under the heads of inflammation, suppura-
tion, ulceration, gangrene, softening, induration; cartilaginous,
osseous, and fatty transformations ; scirrhus, encephaloid, me-
lanosis and tubercles; hypertrophy, atrophy, dilatation, and
rupture.

1. Acute carditis is an extremely rare disease, especially
that variety of it which invades the whole organ. In the

134 HEART. [chap. IV.

majority of instances, it is conjoined with inflammation of the
investing capsule ; in others, however, it exists as an inde-
pendent affection, and runs its course without any particular
complication. Of general carditis, very few well-authenti-
cated cases are upon record. The disease seldom assumes
that acute type which generates pus ; in which respect it
offers a striking analogy Avith inflammation, as it appears in
the voluntary muscles. Of this mode of termination, how-
ever, several examples have been related by the British and
French pathologists. In the third volume of " the London
Medical Gazette," Dr. Latham has given the particulars of a
most interesting and instructive case of this kind, which he
observed in a boy twelve years of age. '' The whole heart,"
says he, " was deeply tinged with dark-colored blood, and its
substance softened ; and here and there, upon the section of
both ventricles, innumerable small points of pus oozed from
among the muscular fibres. This was the result of a most
rapid and acute inflammation, in which death took place after
an illness of only two days." Meckel saw a case, in a man
fifty years old, in which the muscular substance of the heart
was considerably infiltrated with purulent matter ; the fibres
were of a bright red color, rough, unequal, and clean, as if
they had been dissected from their cellular tissue.

Much more frequently, the disease is only partial, affecting
particular parts of the organ. Here, as in the other varie-
ty, the inflamed structure is always unnaturally red, being
crowded with small crimson points, of an arborescent, stella-
ted, or punctuated configuration. Occasionally, as when the
irritation is very severe, we meet with spots of extravasated
blood, of a bright red, violet, or purple tint, which impart to
the surface of the organ a singularly speckled aspect. In-
flammation of the muscular substance of the heart is rarely
if ever attended with any tumefaction. Why this should be
the case, will be at once perceived when we reflect upon the
intimate and almost inseparable connection of the fleshy
fibres ; for, of all the muscles in the body, the heart is the
one which has the least amount of cellular matter. Hence,
serous infiltration, which is so common in some other struc-
tures of the system, can have no place in the organ now
under consideration. When the inflammation is seated su-
perficially, the affected part is often covered with globules,
shreds, or patches of lymph, poured out by the visceral por-
tion of the serous membrane of the pericardium, from a propa-

SECT. II.] CARDITIS ; SUPPURATION ] ULCERATION. 135

gation of the disease. Its coDsistence is often much dimin-
ished ; and not unfreqnently the muscnlar fibres are bathed
in imperfectly elaborated j)us. The diagnostic signs of car-
ditis, if any there be, are still involved in obscurity, no pa-
thologist having ever succeeded in pointing them out. Dr.
Bouillaud, the most recent and elaborate writer on the dis-
eases of the heart, positively asserts that he has never seen
an instance which was not complicated with pericarditis or
endocarditis ; and he frankly acknowledges that, in the three
cases which came under his notice, the signs of the two lat-
ter affections were all that attracted his attention. Nor have
any other authors, so far as I am acquainted with their works,
been more successful.

When the disease passes into suppuration, the pus may
either be diffused through the muscular texture, or be col-
lected into an abscess. Of this, numerous examples are
related by the older anatomists, and not a few by those of a
more recent date. Corvisart found an abscess of more than
an inch in length, near the apex of the right ventricle of the
heart of a young man of nineteen. Laennec met with two
instances of cardiac suppuration, in one of which the pus was
deposited amongst the fleshy columns of the left ventricle ; in
the other, it formed an abscess, about the size of a bean, in its
substance.

Collections of pus are occasionally found within the heart.
Of this, a case has been already given from Laennec, and
another has recently been reported by Dr. Mareshal, a French
physician. It occurred in a ^''oung girl, ten years of age.
The heart, both ventricles of which were very much dilated,
contained three distinct abscesses, each about the size of a
small nut. Of these, one was seated in the left ventricle,
near the centre of the inter-ventricular partition, the other
two in the right. They were of a white grayish color ex-
ternally, and filled with a dirty, yellowish looking fluid, of
the thickness and consistence of cream. Cases of a similar
character are narrated by Mr. Wardrop,* and various other
authors on morbid anatomy. The muscular substance around
such collections is generally red and softened.

Circumscribed carditis is sometimes attended with ulcera-
tion. The lesion is more frequently found on the internal
than on the external surface of the organ, and commonly

■^ See his edition of Baillie's Morbid Anatomy.

136 HEART. [chap. IV.

supervenes upon inflammation seated originally in the lining
or investing membrane. The external ulcer has been de-
scribed by some of the older pathological anatomists. I have
never seen a case of the kind, but in one, the particulars of
which have been communicated to me by my distinguished
friend, Dr. Harrison, the whole outer surface of the heart
heart was abraded by ulceration, the appearance being very
similar to that species of ulceration, denominated the cutane-
ous, by Mr. John Hunter. The pericardium was much
indurated and thickened, and contained several ounces of
purulent matter. In other respects, both the heart and its
capsule were sound. The right lung was completely hepa-
tized, the left partially. In the abdomen was contained about
half a gallon of sero-purulent fluid ; the liver was somewhat
enlarged, unusually vascular, and adherent in different parts.
All the other organs were in a normal condition. The sub-
ject of this case, so extremely interesting from the large
extent of the ulceration, was a boatman on the Ohio river,
thirty-five years old, who was admitted into the Louisville
hospital in April, 1825. He died in about a fortnight there-
after, having suffered incessantly under dyspnoea, and dry,
convulsive cough, with inability of lying on either side,
dropsy of the abdomen, and oedema of the extremities.

These ulcerations sometimes extend deep into the sub-:
stance of the heart, leaving merely a thin stratum of mus-
cular fibres. The cardiac texture around is generally very
hard, pale, and so friable as to break down under the slightest
pressure of the finger. The matter with which these ulcers
are bathed, is of a bland, homogeneous nature, like laudable
pus in other situations : in a few instances, it is mixed with
bloody serosity.

2. Is it possible for the muscular structure of the heart
ever to become gangrenous 1 Many writers suppose that it
is not, alleging as a reason, that, as this organ is so essential
to life, this termination of inflammation is always anticipated
by death. Others, however, not only admit the possibility of
it, but cite numerous cases in confirmation of their opinion.
Leaving out of the question the more doubtful testimony of
Bonetus, Morgagni, Lieutaud, and other authors of the seven-
teenth and eighteenth centuries, the results of the observa-
tions of modern writers, are, I think, abundantly sufficient to
settle the point. Portal, Goulay, and Kennedy relate each
a well-marked example of this disease. The gangrenous

SECT. II.] GANGRENE. 137

substance, says Portal, is of a dark color, relaxed, softened,
infiltrated with ichorous serosity, and quite offensive to the
smell. Not unfreqaently, it is of a livid, brownish, or green-
ish hue, and emits an odor like that of a piece of flesh in a
state of partial decomposition, which constitutes the essential
characteristic of this lesion. In most cases, the mortification
occurs in superficial, dark-colored patches, not more than a
line or two in depth ; but more rarely it pervades the entire
organ. The most interesting case of this kind, perhaps, on
record, is that by Dr. Kennedy, of Glasgow, an account of
which was published in the London Medical Repository for
April, 1S24. The cardiac tissue, which exhaled quite a
putrid odor, was throughout remarkably flaccid, of a black
color, like venous blood, and easily perforated with the finger,
The left ventricle, particularly, was very livid, and scarcely
of the consistence of the cerebral substance. No blood ex-
uded from any of the ruptured vessels of the heart, and all
the chambers were perfectly empty. The inner surface of
the pericardium was of a dark red color, and in its cavity
were found about four ounces of a fetid, yellowish lluid, of
a serous nature.

It appears from the dissection, which was made eight hours
after death, that there existed a remarkable tendency to
gangrene, not merely in the heart, but in various other organs
and textures of the body, especially the omentum, small in-
testines, uterus, and skin of the upper extremities. The sub-
ject of this extraordinary case was a woman somewhat past
the prime of life. The symptoms were of the most violent
character. Long before death the pulse disappeared altogether
from the wrists. There were stinging pains, with a sense of
burning, in the region of the chest ; difficulty of breathing ;
palpitations of the heart ; frequent disposition to syncope ;
tumefaction of the limbs, and almost complete immobility of
the joints. Towards the last, broad, livid spots appeared on
different parts of the surface, with here and there a large and
sphacelated wheal, and the patient expired finally in a state
of deep coma.

In a case of partial gangrene, narrated by M. Gaulay,* a
French physician, two blackish-looking streaks, more than a
line in depth, were observed on the anterior surface of the
heart, extending from its base to its summit. The whole

* Journal de Med. Chir. et Pharm. Janvier, 1807. ^^ "

VOL. II. 18

138 HEART. , [chap. IV.

organ was extremely flaccid, soft, lacerable, and of an un-
pleasant odor ; it was of the usual volume, and had contracted
extensive adhesions with the pericardium, in the interior of
which, was a small quantity of serosity. During the three
days preceding dissolution, the patient, a female, fifty years
of age, labored under the most frightful dyspnoea ; the pulse
was very small, unequal, and intermittent ; and, at intervals,
the heart beat with the utmost violence, though, at times, its
movements were scarcely perceptible. The liver, pancreas,
and spleen were considerably enlarged, and in a state of
scirrhous induration.

Such is a brief outline of these two interesting cases of
cardiac gangrene. That they are true examples of this rare
disease cannot, I think, be doubted ; such, at all events, must
be our conclusion, both from the phenomena that were ex-
hibited during life, and from the appearances that were re-
vealed on dissection.

3. The heart, like other organs, is liable to softening,
which may be either partial or general, though the latter of
these occurrences must be considered as extremely rare. It
may coexist with various other lesions, such as hypertrophy
of the walls of the organ, or dilatation of its cavities, or it
may take place as an independent affection. Occasionally,
the softening is limited to the outer surface of the heart, the
inner surface, or to the fleshy columns ; and not unfrequently
it is found in small isolated points, running insensibly into
the healthy texture. No unnatural odor attends this lesion,
in which respect it differs remarkably and characteristically
from that which we have just described.

The cardiac substance, in a state of softening, is extremely
flaccid, tears with great facility, and is of a deep red color.
The finger can be pushed through it in every direction, and
when the ventricles are opened, they often collapse to so great
a degree, as to lose entirely their natural figure. This, how-
ever, is by no means a uniform, or even perhaps a general
occurrence. Much oftener, indeed, have I seen the softened
organ accurately retain its natural form. The color of the
cardiac tissue in this affection is variable. Most commonly,
perhaps, as was before stated, it is of a deep red ; but occa-
sionally it is claret, marone, red-brown, violet, or purple. In
other cases, again, though very rarely, it is of a faint grayish
hue, cineritious, pale yellow, or almost white, as if the organ
had been macerated for some days in water. These diflerent

SECT. II.] INDURATION. 139

shades of color appear to be so many modifications dependent
upon corresponding grades of inflammatory irritation.

Softening of the heart often occurs in connection with
tubercles of the kings, chronic pleuritis, and adynamic fevers.
In one instance, I found it in an old man who died of apo-
plexy, after an illness of about five days. The lesion is not
peculiar to the human subject. In the horse I have met
with it several times. In a remarkable case, occurring in a
young colt that died of pleuro-pneumonitis, accompanied with
an enormous accumulation of fetid water in the chest, the
cardiac substance was of a red-brown color, and so soft that
I could easily push the handle of the scalpel through both
ventricles in every direction.

Doubts seem to be still entertained by many writers,
whether softening of the heart ought to be uniformly as-
cribed to inflammatory irritation, or to some disorganizing
cause of another character. Laennec, who first directed the
attention of the profession to the disease before us, consid-
ered it as a peculiar afl"ection, produced,- as he thought, by
some aberration of nutrition, by which the solid elements of
the muscular tissue are diminished in proportion as its fluid
elements are augmented.* This singular notion, which
merely expresses the vague sentiments of its author, has been
successfully controverted by M. Bouillaud. By him, soften-
ing of this organ, under whatsoever form it may appear, is
attributed to the effects of inflammation, either of an acute
or chronic character ; and with this opinion my own belief
entirely agrees. Many symptoms have been pointed out by
pathologists as attending this disease ; as yet, however, none
have been enumerated that can be in the least relied upon
as pathognomonic.

4. Leaving the subject of softening of the heart, we come,
in the next place, to that of induration, — a state which, like
the preceding, is, in all probability, induced by inflammation,
though generally of a much more chronic character. The
affection seldom occupies more than a part of the organ, com-
monly one of the ventricles, which is at the same time in a
state of hypertrophy. Sometimes it is confined to its outer
or inner surface, to the fleshy columns, or to the inter-ven-
tricular septum ; and not unfrequently it is blended with
softening. In a case detailed by Bertin, there was induration

* Treatise on Diseases of the Chest, by Forbes, p. 623.

140 HEART, [chap. IV.

of the left, with mollescence of the right ventricle ; and, in
a second, some of the fleshy columns were hard, and others
soft. Universal induration is perhaps never met with ; such
an occurrence, in fact, would be incompatible with the exer-
cise of the functions of the heart.

The degree of induration is subject to considerable variety,
running through numerous stages, from the fibrous to the
cartilaginous, and even the osseous. In some instances, it
appears in the form of incrustations, and seems as if it had
commenced, in the first instance, in the serous covering of
the organ. The muscular substance is not always heightened
in color ; sometimes, indeed, it is even unnaturally pale.
When incised, it is found to be so firm as to grate under the
knife. Corvisart states that he has occasionally heard a
peculiar creaking sound, like that emitted by new sole-
leather, on cutting through an indurated heart ; but this has
never been perceived by Laennec, Bertin, Hope, Andral, or
myself, and may therefore be regarded as very rare. The
organ, if placed on a table, generally retains its rounded form,
and, if struck with the scalpel, sometimes sounds like a dice-
box or hollow horn.

The diagnosis of induration of the heart, like that of
mollescence, is still involved in obscurity, it being quite im-
possible in the present state of our knowledge, to distinguish
it from hypertrophy, with which it is so often associated.
When these atfections coexist, the impulse of the heart is
often augmented to such a degree, that it can be seen and
heard at soine distance from the patient ; if, on the other
hand, the induration is uncomplicated, very extensive, or of
long standing, the strength of the organ is apt to fail, and, as
a consequence, the pulse at the wrist becomes sometimes
nearly imperceptible. How far the assertion of Laennec,
that the firmest heart always imparts the strongest impulse,
is correct, I will not pretend to decide ; I can only say, that,
so far as I know, his opinion has not been verified by other
observers.

5. The cartilaginous and osseous transformations of the
muscular structure of the heart, being often associated with
induration, may be noticed here. Both these lesions are ex-
tremely rare ; and, thus far, I have not been so fortunate as to
meet with them. Corvisart has seen the apex of the organ,
in its entire thickness, and the fleshy columns of the left
ventricle, converted into cartilage. Haller, Albertini, Bertin,

SECT. II.] SCIRRHUS ENCEPHALOID. 141

and others, have observed partial ossifications ; and the late
Mr. Allan Burns, of Glasgow, found the ventricles of the
heart of an old woman of sixty so completely changed that
they resembled the bones of the cranium. This case, the
most remarkable perhaps on record, was attended with terri-
ble dyspnosa, great prsecordial anxiety, and lividity of the
countenance. The patient was unable to lie in any other
than a semi-erect position ; and, for a few days before her
death, the pulse, although previously regular, became ex-
tremely feeble and intermittent. On dissection, the pericar-
dium was found of an opaque, dusky color, excessively loaded
with fat, closely adherent to the substance of the heart, and
studded with ragged, projecting spicules of bone, which gave
it a very rough and irregular aspect. Both ventricles were
completely ossified, excepting about a cubic inch at the apex,
the new tissue forming a broad, solid belt, as firm as the
cranium. The auricles v/ere sound, only a little thicker than
usual, and so also were the great vessels.

A case nearly as remarkable as the preceding is to be
found in the '' Journal de Medicine " of Paris, for January,
1816, where it was reported by Dr. Renauldin, a French
physician. It occurred in a man thirty-three years of age, who
had been afflicted for a long time with embarrassment of
breathing and cardiac palpitation. The left ventricle was
converted into a petrifaction, which, in some parts, had a
sandy aspect, in others, resembled a saline crystal. The
fleshy columns, also ossified, were much increased in their
dimensions, and looked like so many stalactites. The
present Professor Monro, of Edinburgh, states, that he has in
his possession a most remarkable specimen, in which the
whole of the heart, with the exception of the left auricle, is
converted into a mass of bone.*

6. Scirrhus and encephaloid have been found in the sub-
stance of the heart, but their occurrence here is extremely
rare. The latter of these lesions generally exists in the form
of small spherical tumors, varying between the size of a
pea and an egg, which stud the outer surface of the organ or
project into its cavities. Cases occur in which it is seen in
layers several lines in thickness, or wherein it is infiltrated
into the muscular texture, converting it into a yellowish sub-

* See his Morbid Anatomy of the Gullet, Stomach, and Intestines, second ed.
p. 300.

142 HEART. [chap. IV.

stance. Recamier has found the heart partially converted
into scirrhous matter, like the skin of bacon ; and a case is
mentioned in the Memoirs of the Royal Society of Medicine
of Paris, for 1776, in which a carcinomatous ulcer, more than
three inches in diameter, occupied the whole posterior sur-
face of both ventricles. The cardiac tissue around was in-
durated and scirrhous : and the bottom of the ulcer was
formed by a thin stratum of muscular fibres, so soft and friable
as to break down under the slightest pressure of the finger.
The heart itself was greatly enlarged, and the pericardium
had almost entirely sloughed away. The subject of this re-
markable case was a woman twenty-two years old : she
complained of sharp, lancinating pains, darting from the left
side of the chest towards the centre of the sternum, had fre-
quent attacks of swooning, and was obliged constantly to re-
main in a semi-erect posture, with the head bent upon the
chest, and the body slightly inclined backwards and towards
one side. A singular case of scirrhus of the heart is men-
tioned by Billard. It occurred in an infant only three days
old, and consisted of three tumors, which were firmly em-
bedded in the muscular substance of the organ.

In the fatty transformation, the heart is converted into a
substance having all the physical and chemical properties of
grease. The apex is the part most commonly affected, but
in some instances the infiltration pervades the entire organ,
changing it into a pale tawny structiu'e. In the few cases
which I have observed as this lesion, the muscular substance
was remarkably soft, thin, flabby, and greasy to the touch.
It is most common in old age. Its causes are unknown.

8. The heart, like the rest of the muscular system, is
liable to atrophy ; but this affection is much less frequent than
the one which we have just noticed. The wasting is occa-
sionally very great. Burns gives several cases in which the
volume of the adult heart was not larger than that of a young
child ; and in one instance it scarcely exceeded that of a new-
born infant. Similar examples are detailed by Bertin,
Bouillaud, Hope, Carswell, and other writers.

It is rare, however, that the atrophy is either so general or
so extensive. In the majority of cases coming under my
own observations, I have found it limited to particular parts
of the organ, more commonly to the right ventricle, the right
auricle, and inter-auricular septum. The color and consist-
ence of an emaciated heart are seldom much altered ; fre-

SECT. II.] ATROPHY. 143

quently, indeed, they remain perfectly natural, or are even
augmented. It has been said that, when the atrophy is very
great, the organ often presents a puckered and shriveled ap-
pearance, like an old withered apple ; but such a condition I
have never witnessed, and feel disposed to doubt the possi-
bility of its occurrence. The cardiac chambers in this affec-
tion may remain natural, be diminished, or dilated, very much
as in hypertrophy. Conjoined Avith dilatation, the walls of
the heart are sometimes so thin as to exhibit quite a translu-
cent, web-like aspect, and so weak as to be liable to break on
the application of the slightest force.

Atrophy of the heart usually occurs in persons who are
worn out by lingering and exhausting diseases, terminating in
general emaciation of the body. Hence it is not unfrequently
found in connection with organic affections of the lungs and
bowels, dropsy, diabetes, cancer, and other incurable disorders.
Excessive bleeding, especially when united with great ab-
stinence, ossification of the coronary artery, and protracted
compression from enlarged lymphatic glands or effused fluids,
may also be so many causes of atrophy of the heart. In one
instance I found it connected with permanent closure of the
inferior cava and extensive disease of the abdominal organs,
with collection of water in the peritonaeal sac. There are no
symptoms which can be regarded as diagnostic of this affec-
tion. The pulse is generally faltering, and the cardiac im-
pulse scarcely perceptible.

Occasionally we find that the chambers of the heart, in-
stead of being diminished in size, are dilated, so that their
capacity is much greater than in the normal state. This
condition of the organ, which was described by the celebrated
Corvisart under the name of passive aneurism, may be either
general or partial, that is, it may exist in all the cardiac
cavities at the same time, or be limited to the auricles, the
ventricles, or to one of these reservoirs alone, which is, in
fact, most commonly the case. Universal dilatation is ex-
tremely infrequent, and thus far I have never seen an instance.
The heart in this state seems to be sometimes much increased
in weight. In a case mentioned by Burns, in which all the
chambers, both auricular and ventricular, were equally dilated,
the organ was larger than that of an ox, and weighed two
pounds, its muscular substance being throughout of the
usual thickness.

Dilatation of the heart may be conveniently arranged under

144 HEART. [chap, IV.

several species. The first species consists of dilatation with
hypertrophy ; that is, one or more of the chambers of the
heart are enlarged, and the corresponding walls thickened :
the second species is the simple dilatation, in which the
cavities are augmented, whilst the corresponding parietes re-
tain their normal state : the third consists of dilatation with
atrophy ; that is, one or more of the cardiac reservoirs are en-
larged, and the corresponding walls attenuated : a fourth,
and much the rarest variety of all, that which truly deserves
the name of aneurism, is where there is a pouch or blind sac
leading from, and communicating with, the affected cavity.
These different forms, especially the first three, sometimes co-
exist in different parts of the heart, or even in different parts
of the same chamber ; and several of them are very common-
ly found in conjunction with hypertrophy.

In dilatation with atrophy there is often softening of the
muscular structure, with an alteration of color, which, instead
of a florid red, is either pale gray, cinnamon, brown, or purple.
The emaciation varies in different cases, being sometimes so
great that the most substantial portion of the organ is scarcely
more than the eighth of an inch in thickness. The fleshy
columns are stretched and attenuated ; and occasionally,
though very rarely, the muscular structure is so much un-
folded that the Avhole heart looks like a membranous pouch.
Extreme emaciation is more common in the right than in the
left ventricle, in the right than in the left auricle, — a circum-
stance easily accounted for by the natural difference of thick-
ness existing between the two sides of the organ. Formerly
this species of dilatation was regarded as a very frequent
lesion ; but more recent observation has shown that this
opinion is erroneous.

The fourth species of dilatation, consisting, as we have
seen, in the formation of a pouch in the walls of the heart,
is also extremely rare, not more than ten or twelve cases of
it being found on record. Of these, two have been related
by Dr. Berard, a French writer, in each of which the dilata-
tion formed a tumor about the size of a duck's egg.* The
aneurismal sac, especially when of longstanding, usually con-
tains several layers of dense, tough fibrin, perfectly similar to
those of aneurism of the limbs, with a small, rounded orifice
communicating with the corresponding chamber of the heart.

* Disscrlatiou .sur plusieiirs points de Patlioloijie, &c.

SECT. II.] ATROPHY. 145

In nearly all the cases which have hitherto been recorded,
the dilatation was seated in the walls of the ventricle ; in one,
mentioned by Dr. Hope, it occupied the substance of the
auriculo-ventricular septum. Occasionally the parietes of
the tumor seem to consist only of the outer and inner lining
of the heart, the muscular texture around being softened.
Such was the case with the left ventricle of the celebrated
French tragedian Talma, who died from almost total oblitera-
tion of the rectum.* The remaining species of this disease
it is unnecessary particularly to describe, as in one of them
the walls of the heart are always natural, in the other hyper-
trophied.

The causes of dilatation of the heart are, valvular disease,
narrowing of the auriculo-ventricular orifices, contraction of
the mouth of the aorta or pulmonary artery ; and, in short,
whatever has a tendency to impede the passage of the blood
from the auricles into the ventricles, or from the ventricles
into the great arteries connected with their base. For the
functional and physical indications of cardiac dilatation, the
reader is referred to the various treatises on diseases of the
heart.

9. On the subject of rupture of the heart, very little need be
said in concluding our remarks on the different lesions of the
cardiac tissue. This accident is generally the result of
softening, excessive deposition of fat, ulceration, or chronic
inflammation, and seldom occurs except in persons above fifty
or sixty years of age. From whatever cause proceeding,
laceration of the heart is almost always followed by immediate
death. Of ten patients mentioned by Berlin, eight died in-
stantaneously, and the other two after a few hours. The
cause of these disastrous consequences appears to be not so
much the extent of the hemorrhage, as the great and sudden
shock sustained by the nervous system, together with the
mechanical compression of the cardiac chambers. If the
patient survives the accident several days, the rent is general-
ly plugged up by a clot of fibrin, in the same manner as
sometimes happens after the reception of a wound. In some
instances there would even seem to be an effort made at
cicatrization. A species of partial rupture of the heart is men-
tioned by Laennec, Bertin, and Corvisart, consisting in a lace-
ration of the fleshy columns and the tendons of the valves.

* Revue Medicale, Janvier, 1827.
VOL. II. 19

146 HEART. [chap. IV.

Tuhercles are very rare. Dr. Bonillaud, of Paris, who has
written two large vohimes on the diseases of the heart, af-
firms that he has never met with tubercles in this organ ;
and he is inclined to believe that they are more rare here
than in almost any other part of the body. Andral and
Laennec never saw more than three or four instances. Re-
cently Dr. Townsend, of Dublin, has pubhshed a case in
which this heteroclite deposit was situated in the substance
of the left auricle, between the outer and inner membranes,
and so compressed the pulmonary veins that they would
scarcely admit the smallest probe. The right auricle and
ventricle were greatly dilated ; but in other respects the
heart was sound. The bronchial glands and lungs contained
some tubercles, and were otherwise diseased. The patient
was a male, sixty-two years old.*

10. Melanosis, serous cysts, and vesicular worms have also
been seen in the muscular structure of the heart ; but their
occurrence is so infrequent, and their mode of origin so im-
perfectly comprehended, that it is unnecessary to say any
thing further about them in this place.

Examples of this disease have been recorded by Houlier,
Ptolfinck, Fauton, Valsalva, Morgagni, Bonetus, Dupuytren,
Duvernoy, and Andral. In a case mentioned by the latter
author, a serous cyst was embedded in the substance of the
left ventricle ; it was filled with a thin, limpid fluid, and was
about the size of a Avalnut,

11. Hypertrophy is an excessive growth of the muscular
substance of the heart, resulting, as the name literally implies,
from increased nutrition, without any obvious change of tex-
ture. The true nature of this affection, of which there are
three varieties, was first pointed out by the late Dr. Berlin,
of Paris, in 1811. In the first and most simple variety, the
walls of the heart are merely thickened, the cavities retain-
ing their natural dimensions ; in the second, they are aug-
mented in bulk, and the corresponding chambers dilated ; in
the third, they are thickened and the cavities contracted.

In the majority of cases, the abnormal growth is confined
to the walls of the ventricles, of which the left is more prone
to suffer than the right. Seldom do the auricles participate
in it; on the contrary, they generally remain sound;, even
when the rest of the heart is enormously enlarged, — a cir-

* Dublin Journal of Medical and Chemical Science, Janiiaiy, 18-33.

SECT. II.] HYPERTROPHY. 147

cmnstance which probably depends upon the paucity of
their muscular fibres. Occasionally the hypertrophy exists
only in particular parts, as the base, apex, inter-ventricular
septum, or fleshy columns.

A hypertrophous heart is usually more firm and red than
natural ; but these are not essential characters ; and, when
present in a high degree, they constitute the affection which
has been already noticed under the name of induration. The
increase in the thickness of the walls of the organ varies in
different cases, being sometimes two, three, or even four
times the ordinary volume. In a remarkable instance of gen-
eral hypertrophy, conjoined probably with dilatation, related
by Dr. Wright, of Baltimore, the heart, after being injected,
weighed five pounds, three ounces, its circumference at the
base being seventeen inches and a half, near the apex twelve
inches and a half, and its length, from the top of the right
auricle to the point of the left ventricle, thirteen inches,* An
example of general hypertrophy of the heart, not less extra-
ordinary than the one just m.entioned, I had occasion re-
cently to observe in a boy, seven years of age, whose body I
examined along with my friends Dr. Wood and Dr. Ridgely,
of this city. The organ was of an obtuse conical shape, and
considerably larger than we usually find it in the adult, its
weight being ten ounces and. a half after the removal of the
great vessels. The thickness of the wall of the right ven-
tricle was three lines ; of the left, six lines and a half. The
mter-ventricular septum was also unnaturally stout, and the
parietes of the auricles were nearly double the normal dimen-
sions ; the cardiac chambers had a corresponding increased
capacity ; the pericardium adhered every where very closely
to the outer surface of the heart ; the mitral valves were
rough and indurated ; and the endocardiac lining of the left
auricle and ventricle Avas very much thickened, opaque, and
of a dense, fibrous consistence. The child had labored under
all the symptoins of disease of the heart for about eight
months. All the other viscera were sound. In such cases,
the organ is very apt to become altered in its figure ; it loses
its elongated, conical appearance, and assumes a globular
shape ; and, instead of lying obliquely in the chest, as it natu-
rally does, it is made to take a transverse position ; and in this
way it may encroach so much upon the left lung as to force

* American Journal of the Medical Sciences, vol. xii. p. 54.

148 HEART. [chap. IT.

it high up into the thoracic cavity. When great enlargement
is accompanied with adhesion of the pericardium, the heart
is secured by the attachments of tlie membrane in a higher
situation than its weight would otherwise dispose it to as-
sume ; and, being thus impacted between the spine and fore
part of the chest, it sometimes occasions a preternatural prom-
inence of the prascordial region, — a circumstance first pointed
out, I believe, by that distinguished pathologist and acute
observer, Dr. Hope, of London.

The left ventricle, as was before intimated, is much more
liable to hypertrophy than the right, and often grows to a
very considerable bulk. In my own dissections, I have never
seen the thickness exceed an inch and a quarter ; but cases
are recorded in which it amounted to an inch and a half,
an inch and three fourths, and even two inches. The
situation of the greatest increase is commonly somewhat
above the middle of the ventricle, opposite the attach-
ment of the fleshy columns. From this point it dimin-
ishes rather suddenly towards the aortic orifice, and grad-
ually towards the apex, where it is reduced to less than one
half. Generally speaking, the fleshy columns participate,
though occasionally, especially when there is much dilatation,
they appear to be flattened out and emaciated. When the
hypertrophy is very great, the ventricle may not only occupy
the left prcecordial region, but extend far under the sternum,
where its impulse and sound may be mistaken for those of
the right.

In hypertrophy of the right vetitricle, whether alone or
coexistent with that of the left, the greatest thickening is
generally near its base, where it often amounts to twice the
natural bulk. Increase of substance without dilatation is
much more infrequent in the right than in the left ventricle ;
and, what is remarkable, the growth is much oftener noticed
in the fleshy columns than in its walls, being sometimes so
curiously interlaced as to traverse the cavity in every direc-
tion, subdividing it into various compartments, and, in some
cases, almost filling it up. When the ventricle in question
is alone hypertrophied, it may descend lower than the other,
and so form the summit of the organ.

Hypertrophy of the auricles is almost invariably conjoined
with dilatation, but the two other forms are not, however,
without example. The thickening seldom exceeds twice
the natural size, and, as it is even then inconsiderable, it may

SECT. II.] HYPERTROPHY. 149

be easily overlooked by a superficial observer. Sometimes
the pectinate muscles are the only structures in which the
hypertrophy shows itself: more comro.only it is uniformly
ditfusecl throughout the walls ; and, as these are naturally
thicker in the left auricle than in the right, it is in the latter
that the increase generally attains its greatest height.

Hypertrophy of the walls of ;the ventricles generally re-
sults from great and habitual accumulations of blood in their
cavities, produced by disease of the semi-lunar valves, or
contraction of the mouth of the aorta and pulmonary artery.
In the same Avay rriay arise hypertrophy of the auricles ; or it
may be occasioned, more directly, by a narrowing of the auri-
culo-ventricular apertures, preventing the ready ingress of
blood from one chamber of the organ into the other. Hyper-
trophy of the right side is also frequently dependent upon dis-
ease of the lungs, as tubercles, emphysema, and hepatization
of their tissue.

An increase of the muscular substance of the heart neces-
sarily implies an increase of power ; and hence one of the
most prominent effects of this state would be to force the
blood with more vigor and velocity upon the different tissues
and organs. Let us suppose that the individual is laboring
under hypertrophy of the left ventricle. He would have a
strong, bounding pulse, frequent attacks of headache, bleed-
ing at the nose, ringing in the ears, and perhaps ultimately
die of cerebral apoplexy, — all these circumstances depending
not so much, as it is supposed by some, upon the increased
amount of blood sent through the systemic circulation as
upon the power with which it is impelled by the overgrown
ventricle of the left side of the heart. In the same manner,
hypertrophy of the right ventricle may bring about engorge-
ment of the pulmonary tissue, with all the train of secondary
effects, such as apoplexy, oedema, and dyspnoea, which are
known to result from habitual accumulations of blood.

The physical signs of hypertrophy consist in increased
impulsion of the heart against the walls of the chest, dimi-
nution of the natural sound, and dulness on percussion. In
the simple form of the disease, as well as in that with dilata-
tion, the sound is sometimes nearly lost, or converted into an
obscure purring.

150 ENDOCARDIUM. [cHAP. IV.

SECTION III.
Of the Endocardium.

Of the anatomy of this membrane we have already spoken.
It only remains, therefore, that we should point out its lesions.
Of these, the most important is acute inflammation, techni-
cally called endocarditis.

Encodarditis is anatomically characterized by redness,
thickening, and opacity of the affected membrane, with depo-
sition of lymph on its free surface. Redness alone cannot
be considered as indicative of inflammation, as the same
appearance is produced by cadaveric imbibition. The color
varies from a slight rose to a scarlet, violet, or even brownish
tint, and ordinarily occurs in small circumscribed spots,
which are always most conspicuous on the valves. Some-
times it is universal, and, on the other hand, is an instance,
occasionally, in which it is entirely wanting. The redness
seems to depend rather on a tinging of the endocardium than
on true capillary injection ; and, although it seldom extends
into the subjacent cellular texture, it cannot be easily washed
away.

In acute inflammation, the endocardium is rarely much
thickened ; under the influence of chronic irritation, on the
contrary, it often acquires the density and consistence of a
fibrous membrane. In the healthy state, it will be remem-
bered, it is perfectly smooth, polished, and so firmly adherent
that it can be detached only in very small shreds ; but, under
protracted disease, it becomes opaque, rough, of a milky
white, and can be easily raised in considerable patches.
Occasionally the thickening is entirely dependent upon hy-
pertrophy of the subjacent cellular tissue, or it may be pro-
duced by a layer of adventitious membrane.

In very acute cases, there may be softening of the endo-
cardium, with an infiltration of pus, serosity, or bloody mat-
ter into the subjacent cellular texture. Ulceration also is
sometimes observed, and may proceed to such a degree as to
lead to perforation of the muscular substance.

Endocarditis, although noticed by previous observers, was
first accurately described by Dr. Bouillaud, in his elaborate
treatise on the Diseases of the Heart, published at Paris in

SECT, III.] ENDOCARDITIS. 151

1835. The extensive investigations of this distinguished
pathologist induce him to assert, in opposition to many able
writers, that this disease is quite as common as pericarditis ;
that it is often produced by the same causes, and that it fre-
quently coexists with and cannot be distinguished from it.
The characters which he assigns to this affection, but which,
as they are not invariably present, cannot be viewed as diag-
nostic, are, increased cardiac impulse, prsecordial dulness on
percussion, and violent palpitations, accompanied with a dis-
tinct bellows murmur, and sometimes with a metallic tinkle,
isochronous with the ventricular systole. The beating of the
heart against the side of the chest is usually very strong, some-
times like a hammer, extensive, and superficial, being recog-
nizable both by the eye and hand. There is seldom much pain
or dyspnoea, unless the lesion is coincident with pericarditis
or pleuritis, or there is much obstacle to the circulation. In
the acute stage, the disease may terminate fatally in a very
few days, the principal cause of death being the formation of
extensive fibrinous concretions, which fill up the cardiac
cavities, and obstruct the passage of the blood.

It has been already stated that one of the morbid effects
of endocarditis is the deposition of lymph upon the inner
surface of the lining membrane. Though sometimes poured
out as a distinct lamella, this substance more commonly
occurs in the form of small granulations, varying in size
between a pin-head and a cherry-stone. These bodies dis-
play a peculiar preference for the mitral and aortic valves,
especially for their free borders, to which they adhere with
considerable tenacity when old, though when recent, as they
are then soft, they are easily detached : they are of a light
pink color, whitish or yellowish, somewhat darker internally
than externally, and are sometimes so clustered together as
to give the surface on which they grow a rough, granulated
aspect, not unlike that of a fungous ulcer. These bodies,
are oftentimes ©rganized ; and in their nature they may be
considered as strictly analogous to the tubercular concretions
which are so frequently met with on the surface of the peri-
cardium, pleura, and peritonaeum, in chronic inflammation.

Somewhat similar to these tubercular concretions are
those wa7^t-like excrescences of the heart, the existence of
which was first clearly indicated by Laennec, who has
described them under the name of globular vegetations.
Commonly of a spherical shape, they are of a pale straw

152 ENDOCARDIUM, [CHAP. IV,

color, smooth externally, and encased by a distinct cyst ;
their size varying between that of a pea and a pigeon's egg.
These singular bodies sometimes exist in considerable num-
bers, both in the auricles and ventricles, to the inner surface
of which they adhere by narrow footstalks, occasionally more
than a third of an inch in length. The capsule, which is
usually about a fourth of a line thick, firm and organized, is
filled with a dark grayish-looking, semi-fluid substance, some-
what similar to coagulated blood, or the lees of red wine. In
some instances, the surface of these excrescences is rough,
mammillated, raspberry-like, or divided off into numerous facets
resembling those of a crystallized garnet. Oftentimes they
are so closely grouped together, as to present the appearance
of a cauliflower.

These globular vegetations are, on the whole, of very rare
occurrence ; and their origin seems to be still involved in
considerable obscurity. From the fact, however, that they
generally coexist with chronic endocarditis and inflammation .
of the aorta, I am led to the conclusion, that they are caused
by a deposition of bloody lymph, which assuming, perhaps
in consequence of the constant movements of the circulating
current, the form and color above described, in time becomes
perfectly firm, dense, and organized. Corvisart supposes that
they are of a syphilitic origin ; but the opinion is evidently
groundless.*

These bodies do not give rise to any characteristic symp-
toms, yet Dr, Bouillaud seems to be inclined to suspect their
existence, when there is a well-marked bellows sound, unac-
companied by any other indication. When seated on the
valves, especially if very large and numerous, they must
necessarily interfere with their action, and materially diminish
the auric ulo- ventricular orifices and the mouths of the great
vessels.

As consequences of chronic inflammation, it is by no means
uncommon to meet with, fibro-cm-tilagmo us and osseous de-
generations of the endocardium. The most frequent seats of
these lesions are the circular zones around the auriculo-ven-
tricular orifices, together with the adjacent valves. They

* Sec Corvisiirt, Essay on Organic Diseases of the Heart, p. 172; and Mor-
gagni, on the Seat and Causes of Disease. The latter aathor saw a ease in a girl
of sixteen, in wliicii tlie valves of the pulmonary artery were so indurated and ossi-
fied, that their agglutinated edges scarcely left an opening as large as a lentil
for the passage of the blood.

SECT. III.] ENDOCARDITIS. 153

may occur at all periods of life, butUhe age which seems" to
be most prone to them is between forty and sixty. Occa-
sionally they are seen in children ; and Bonillaud mentions a
case in which he found them in an infant of only ten months
old. Like the tubercular and warty excrescenceSj just de-
scribed, these transformations are much more common in the
left side of the heart than in the right, though they are by
no means confined to it, as is thought to be the case by
Bichat and some others.* The cause of this remarkable dif-
ference is not well understood. That it depends upon some
diiference of organization of the endocardiac lining of the op-
posite chambers of the viscus cannot, I presume, be reason-
ably doubted. The arteries, we know, are extremely liable
to these degenerations ; and, as their internal tunic is contin-
ued into the left cavities of the heart, whilst the right are
lined by a prolongation from the internal coat of the veins, it
is highly probable that the same cause which operates in the
production of these lesions in the former of these structures,
is of the same character as that which produces them in
the latter, and conversely. Bertin ascribes the difference
to the nature of the fluid which traverses the two sides
respectively, the left receiving blood of a more vital, acrid,
and stimulating quality than the right ; and Dr. Hope sup-
poses that it depends upon the greater energy of action of
the left ventricle, by which the endocardiac lining, with the
corresponding valves which are framed out of it, is more
severely strained.f A somewhat similar notion is entertained
by Professor Cruveilhier, of Paris.

In the fibro-cartilaginous transformation, the endocardium
is often remarkably thickened, corrugated, opaque, and of a
pale milky color. Not unfrequently, indeed, the membrane
is of the consistence and tenacity of tendon, or of a truly car-
tilaginous hardness, with a creaking sound on being cut. In
this advanced stage, bony depositions usually occur, forming
granules, patches, scales, or nodules, of various sizes, rough,
opaque, whitish, or yellow. The ossifications, in most cases,
assume a very irregular shape ; and occasionally they pen-

* For a most interesting case of this disease, illustrated by several very graphic
wood cuts, the reader is referred to the tifieeiith vokime of the American Jour-
nal of the Medical Sciences, where it has been detailed by Professor Jackson, of
Philadelphia. It occurred in a man aged My-four, and was complicated with
pericarditis, dilatation of the heart,'^and cedema of the larynx and fauces.

tHope, on^the Diseases of the Heart/ p. 311.

VOL. II. 20

154 ENDOCARDIUM. [cHAP. IV.

etrate deeply into tlie muscular substance of the heart itself.
For the most part, they are seated on the valves, which are
often perforated with holes, torn, reticulated, or almost en-
tirely detached, though these morbid appearances are by no
means common.

The tissue in which the ossific deposition begins seems to be
the cellular, which binds the endocardium to the muscular sub-
stance, and which is evidently somewhat of a fibrous nature,
especially where it connects the folds which constitute the
valves. From thence it gradually extends to the endocardi-
um itself, and occasionally even to the muscular substance.

Amongst the most serious lesions resulting from cartilagi-
nous and osseous degeneration of the valves of the heart, is
the contraction of the auriculo-ventricular and arterial orifices.
In its extreme degree, the point of the little finger, or even a
quill, can scarcely pass. Sometimes the valves become con-
solidated with each other, leaving merely a small rounded,
oval, or elliptical aperture, through which the blood is forced
with so much difficulty that hypertrophy and dilatation, with
various other diseased conditions, are sooner or later the in-
evitable consequences. Cases occasionally occur in which
the valves form adhesions with the walls of the heart, giving
rise to pretty much the same symptoms as those which result
from contraction of the orifices.

The diagnosis of induration of the valves with contrac-
tion of their orifices, has been very happily elucidated, within
the last few years, by Dr. Bouillaud, who considers it quite
as easy and certain as that of stricture of the urethra or rec-
tum, by the most skilful surgeon. The most important phys-
ical signs upon which our reliance is to be placed, are the
bellows, rasping, or sawing sound; a peculiar vibratory sen-
sation imparted to the hand ; and an irregular, intermittent,
and tumultuous action of the heart. When these phenomena
are present, it is in the highest degree probable that the lesion
is the one in question ; and the suspicion is fully confirmed,
when to these signs are added those of impeded circulation, —
such, for example, as discoloration of the countenance, con-
gestion of the lungs, dyspnoea, bleeding from the nose, and
beating of the jugular veins, synchronous Avith the pulse.

Polypous concretions are sometimes found within the heart ;
more generally in the right side than in the left, — for what
reason, it is not very easy to say. Many of these bodies
are formed during the last agonies of life, and do not ma-

SECT. III.] ENDOCARDITIS. 155

terially differ from the buffy coat of the blood ; but there
are others which are evidently organized, and which adhere
quite intimately to the walls of the heart, especially to the
fleshy columns and tendons of the valves, around which they
are often intricately coiled. In their early stage, they are
attached solely through the medium of coagulating lymph ;
after a while, however, as they become older, and more fully
developed, they adhere by true cellular tissue, at the same
time that they receive an abundant supply of vessels from
the parts with which they lie in contact, and into which they
are as it were ingrafted. In this advanced state, tliey are
generally of a pale grayish color, dense, highly elastic, and
distinctly fibrous in their texture. Sometimes the centre of
these concretions is softened, and occupied with purulent
matter ; in other instances, it contains small vesicles, clus-
tered together, and filled with a semi-concrete liquid. Their
size varies in different cases : very often they are confined
to the right or left side of the heart • but, in many instances,
they extend into the great vessels, especially into the inferior
and superior hollow veins. In their shape, they may be
cylindrical, conical, pear-like, flattened, or irregular. The
symptoms to which these concretions give rise, are such, gen-
erally, as might be expected to result from obstruction thrown
into the way of the circulation : there are none which can
be regarded as strictly characteristic.

CHAPTER V.

Of the Nasal, Maxillary, and Frontal Cavities.

I. Formation and Structure of the Nasal Cavities — Deviations from the Normal
Standard. — Nasal Septuin. — Inflammation of the Schneiderian»Membrane. —
Epistaxis. — DiflTerent kinds of Polypes. -^ Obstruction of the Mucous Folli-
cles.— \l. Maxillary /S'i?tMs.-^ Purulent Accumulations. — Ulceration of its
Lining Membrane. — Polypous Growths. — Carcinoma. — Exostoses. — III.
Lesions of the Frontal Sinvs.

I. The interior of the nose is covered throughout by a
mucous membrane, which is continuous, on the one hand,
with that of the fauces, and, on the other, with that which
lines the various sinuses of the skull. Anteriorly, it is insen-
sibly blended with the skin, and at the inferior meatus it
extends up into the nasal canal, spreading over the lacrymal
sac, and terminating at length on the surface of the eye in
forming the conjunctiva. Thus the Schneiderian membrane,
as it is called, has a very extensive distribution, as well as
important sympathetic relation^! ; upoii which, however, we
have not time to dwell in this place.

In its structure, the Schneiderian membrane resembles the
mucous textures generally ; its color, however, is naturally of
a deeper and uniform red ; and it is thicker also in some places
than in others. Its free surface has a fleecy villous appear-
ance, as may be seen by floating it in water ; and it is every
where studded with minute crypts, from which proceeds the
mucus of the nasal cavities. The other surface is rough,
and reposes upon a fibrous membrane, being connected to it
by cellular tissue, the density of which varies in different
parts of the organ.

The parietes of the nasal cavities are developed by several
distinct points, the union of which is effected at the mesial line.
The regularity of this formation is much influenced by that
of the olfactory nerves, the imperfection of which appears to
be always attended with a corresponding imperfection of the
parts over which they preside. Cases are recorded in which
these nerves were entirely absent, and in which, as a conse-

CHAP, v.] INFLAMMATION. 157

quence, there was a complete deficiency both of the septum
and of the floor of the nostrils.

The external nose, properly so termed, is very rarely absent
as a connate vice. A much more common defect is congeni-
tal malformation of the nasal septum. Of this quite a num-
ber of examples have fallen under my own notice, and others
have been reported by authors. The defect to which I allude
is generally confined to the cartilaginous portion of the septum,
but may also implicate the vomer and the nasal lamella of
the ethmoid. It consists, for the most part, simply in a lateral
curvature, obstructing more or less the corresponding cavity,
and leading to indistinct enunciation. The cartilage is occa-
sionally thickened, perforated, or tuberose, and the external
nose deformed ; but these are rather accidental than necessary
attendants. On the whole, it may be confidently affirmed,
that there are few persons in whom the part in question is
perfectly vertical.

The most common disease of the Schneiderian membrane
is inflammation, the anatomical characters of which are the
same as in the rest of the mucous system. With the in-
creased redness, there is generally at first a suppression of the
natural secretion, which, in a short time, however, is not
only restored, but becomes extremely abundant, watery, and
so irritating as to excoriate the parts with which it comes in
contact. When the inflammation begins to decline, as it
usually does in a few days, the secretion assumes a thick
yellowish or greenish appearance, is less acrid, and gradually
regains its natural standard, both as regards quantity and
quality. The sense of smell is very much impaired, — often
lost. Both cavities are usually affected, and in many in-
stances the disease invades the neighboring parts, as the
conjunctiva, the fauces, and the frontal sinuses. Dark-col-
ored spots, evidently caused by the effusion of blood into the
submucous cellular tissue, are sometimes observed, and the
same fluid is occasionally discharged along with the altered
mucous secretion. The Schneiderian membrane between
these spots is of a deep florid hue, verging upon purple.

The duration of this affection varies from a few days to
several weeks, when it either subsides, passes into suppura-
tion, or assumes the chronic type. Submucous abscesses
occasionally form, and are eventually followed by ulceration,
with an escape of their contents. More frequently, the mat-
ter is discharged along with the mucous secretion, unaccora-

158 NASAL CAVITY. [CHAP. V.

panied with any breach of continuity. In the chronic stage
of the disease, the membrane loses its spongy texture, in-
creases in thickness and density, and can generally be easily
detached, owing to the brittleness of the subjacent cellular
tissue. Ulceration sometimes succeeds, and in its progress
involves the osseous structure, producing what is called
ozoana, — an affection which is frequently attended with a
profuse muco-purulent discharge, of a character the most
intolerably fetid. In secondary syphilis, the ulceration is liable
to commit the most extensive ravages, destroying the greater
part of the nasal septum, the lateral cartilages, and the turbi-
nated bones, and so producing the most unsightly deformity.

Another affection of the nose is hemorrhage, which re-
ceives the name here of epistaxis. Owing to the great vas-
cularity of the Schneiderian membrane, this is an extremely
common occurrence, much more so than in any other part of
the body, and is most frequently observed about the age of
puberty. In females, it is sometimes vicarious of the men-
strual flux. The blood rarely proceeds from both nostrils. In
general, only a few ounces are lost at a time. When arising
spontaneously, it is almost always the result of exhalation.

The Schneiderian membrane is a common seat of polypes.
Persons of all ages are subject to the formation of these
heterologous growths, but their occurrence is most frequent in
adults and old people, — occurring both in man and in the
lower animals, especially in the horse and the dog. They
often display a malignant tendency, and are generally regen-
erated when extirpated. In regard to their structure, polypes
may be divided into three species, the gelatinous, the fibrous,
and the vascular.

The gelatinous polype generally grows from the mucous
membrane over the turbinated bones, never from the median
septum. As its name indicates, it is of a soft jelly-like con-
sistence, smooth, of a white greenish color, shghtly transpar-
ent, and striated with a few scattering vessels. Most com-
monly it has a narrow, elongated neck, with a broad bulbous
part hanging forward into the nostril. It readily breaks
under the pressure of the forceps, is void of sensibility, and
is composed of a thin, mucous pelhcle, enclosing a soft cellular
substance, the cavities of which are occasionally filled with
watery fluid. This species of polype seldom exists singly,
and is often met with in great numbers together. One nos-
tril is very rarely aflected alone. It is most common between

CHAP, v.] POLYPES. 159

the age of twenty and forty, may attain a large size, and
usually expands in damp foggy weather.

I'he fibrous polype is distinguished by the extreme firmness
of its texture, which nearly equals that of tendon. Great
effort is required to detach it ; and, when cut into, it exhibits a
faintly striated arrangement, being composed of whitish fila-
ments agglutinated by a dense fibrinous substance. Although
it sometimes grows in both nostrils, it almost always exists
singly, and is most common in young adults. When touched
it blends profusely, and often acquires a very great bulk,
protruding externally, descending into the fauces, and press-
ing upon the walls of the nasal cavities in all directions.

The third and last species of polype requiring to be no-
ticed is the vascular, which, in comparison with the other
two, is extremely rare. Young persons are most subject to
it, and it occasionally grows to a very large size. Of a red
florid color, it is soft and erectile, bleeds from very slight
causes, the hemorrhage issuing from every part of its surface,
and is composed essentially of vessels, some of them of con-
siderable magnitude. It is rarely of a malignant character,
and does not often return when extirpated.

Of the difl'erent species of polypes now described, the
fibrous is by far the most liable to degenerate into malignant
disease. When thus affected, it becomes extremely friable,
bleeds profusely when injured, and often assumes the char-
acter of genuine fungus hcematodes, encroaching without
limitation upon the bones of the nose and face, and gradually
but surely sapping the foundations of life. The malignant
growth exudes a fetid, purulent, or bloody matter, is attended
with severe pain, usually occurs late in life, and invariably
returns when extirpated. Small cysts, containing a glairy,
mucous fluid, are sometimes found in these polypes ; and in
a specimen now in my possession, removed from the nose of
an elderly gentleman in this city, there are five large tuber-
cles, of the same nature exactly as those that are found in
the lungs and other organs.

There is a disease of the nasal cavities, which, as it is
often mistaken for polypes, requires brief notice in this place.
It is observed chiefly in weakly children and in females of a
relaxed constitution, and consists in an elongation of the
Schneiderian membrane, produced by the eff"usion of serum
into the subjacent cellular substance. A tumor is thus
formed of a red vascular appearance, and of a soft, spongy

160 ^MAXILLARY SINUS. [cHAP. V.

consistence. The parts on which it grows are the turbinated
bones, of which the superior is more frequently affected than
the inferior. Both nostrils are sometimes affected. The
tumor may exist for a long time, but is always amenable to
proper treatment.

The mucous follicles of the nose, like the same structures
in other situations, are liable to obstruction of their orifices,
leading to the formation of encysted tumors. They have an
irregular, bulbous shape, a light grayish color, a soft, gelati-
nous consistence, and hang within the nose like so many
little bladders. No pain attends these tumors ; they easily
break under pressure, discharging a thin, glairy fluid, like the
white of eggs, and are extremely apt to reappear after they
have been removed, either at the same place, or in the parts
immediately around.

II. The maxillary sinus, situated in the body of the upper
jaw, is subject to different maladies, the most important of
which, by far, is inflammation of the lining membrane, oc-
casioned by cold, the irritation of a carious stump, or exten-
sion of disease from the nasal cavities. The anatomical
characters of this lesion have not been accurately described,
but it is presumable that they do not differ from similar
affections in other parts of the mucous system. The puru-
lent matter, which is often quite abundant, is of a thick,
cream-like consistence, and almost always highly offensive,
apparently from its long sojourn in the antrum. When the
inflammation is protracted, the lining membrane becomes
thickened, the natural outlet is partially or entirely closed,
the dimensions of the sinus are increased, ulceration is set
up, and great mischief is frequently done to the maxillary
bone. The first manifestation of this malady is a dull, aching
pain, which gradually augments in intensity, and at length
assumes a throbbing, pulsatory character : very often it ex-
tends towards the forehead, in the direction of the frontal
sinus, and in most cases it is accompanied by a sensation of
weight and tightness. In a short time the cheek becomes
red, hard, and full ; and, on raising the lip, the gum is found
to be abnormally tumid just above the fangs of the teeth.

When the natural outlet of this cavity is shut, an immense
accumulation of raucous fluid occasionally takes place, form-
ing a tumor which exhibits all the outward features of carci-
nomatous disease. In this affection, the maxillary sinus is
brought in the same relations as a mucous crypt laboring

CHAP, v.] CARCINOMA EXOSTOSIS. 161

under an obstruction of its orifice. The normal secretion
still goes on, but being unable to find an outlet, it is pent up,
and thus forms a species of encysted tumor. The fluid is
usually of a thick, glutinous consistence ; but occasionally it
is thin and glairy, like the white of an egg, or the contents
of a ranula.

Polypes, of the same nature as those of the nose, some-
times grow in the antrum. They are generally attached to
the mucous membrane by a pretty broad base, and increase
with more or less rapidity, until they fill the whole chamber.
In time, they encroach upon the surrounding parts, as the eye,
nose, mouth, and face, thrusting them out of their natural
position, and thus occasioning considerable deformity. In
color, they are ordinarily florid, from their excessive vascu-
larity ; and in consistence they vary from the softness of flesh
to the firmness of fibro-cartiiage, cartilage, and even bone.
A profuse discharge of fetid, sanions matter usually accom-
panies this disease, and the part is the seat of constant pain,
commonly of a dull, aching character.

Another afiection, which is sometimes observed in this
chamber, is carcinoma, generally, if not invariably, of the
encephaloid kind. The young appear to be most obnoxious
to it, but the old are by no means exempt from it. The
disease usually begins, I presume, in the lining membrane,
or perhaps in the submucous cellular texture ; and, as it pro-
ceeds, it invades the osseous frame-work of the face, leading
finally to the most hideous deformity. In a case which re-
cently fell under my observation, in a man fifty- seven years
of age, the tumor, although scarcely of eleven months' stand-
ing, was of enormous size, encroaching, on the one hand,
upon the roof of the mouth, and, on the other, upon the nose,
eye, and forehead. The progress of this malady is gener-
ally rapid, and its result always unfavorable. When removed
with the knife, it is sure, sooner or later, to reappear at the
cicatrix, or in so-me neighboring part.

Exostoses occasionally grow in the antrum. In a speci-
men which I had an opportunity of examining a few years
ago, there were from eight to a dozen of these excrescences,
varying in volume between a mustard-seed and a grain of
wheat, which they also resembled in shape. In a iew rare
instances, these exostoses acquire a very large magnitude, so
as to fill not only the antrum, but encroach very much upon
the neighboring organs. In a case recorded by Sir Astley

VOL. II. 21

162 FRONTAL SINUS. [cHAP. V.

Cooper, the bony masses projected into the orbits of the eyes,
and eventually produced fatal compression of the brain.

III. It is seldom that the frontal sinus is the seat of
disease. This cavity is lined by a reflection of the pituitary
membrane of the nose, in the lesions of which it sometimes
participates, especially in the catarrhal affections which are
so common in this country. The inflammation occasionally
terminates in the eflusion of purulent matter, which com-
monly finds a vent through the nostrils, though in a few rare
instances, it has worked its way out through the bones and
soft parts, leaving a troublesome fistulous opening. When
chronic, the disease is generally attended with thickening of
the mucous membrane, together with a discharge of thin,
fetid matter, and a diminution of the sense of smell.

It is rare that the frontal sinus contains calcareous concre-
tions ; nevertheless, a few such cases have been recorded by
authors. A most instructive one is to be found in the first
volume of the Gazette Medicale de Paris. It occurred in a
female who had daily suffered, for several years, from an
obstinate and distressing headache, which commenced in the
left frontal sinus, and gradually involved the whole of the
corresponding side of the cranium. Under the influence of
sternutatories, three or four calculi, about the size of a small
bean, were discharged from the nose, followed by a very
oflE'ensive suppuration, and finally by a complete cure. On
analysis, these concretions were ascertained to consist of phos-
phate and carbonate of lime, magnesia, slight traces of soda,
oxide of iron» and animal matter.

CHAPTER VI.

Of the Mouthy Pharynx, and Oesophagus.

I. Diseases of the Lips. — Carcinoma, Encysted Tumors, and Congenital Fis-
sure. — Malformations of the Jaw. — II. Glossitis. — Ulceration , Hypertrophy,
and Cancer of the Tongue. — Congenital Deficiencies. — III. Salivary Gkmds.

— Parotitis. — Atrophy and H3'pei'trophy. — Scirrhus. — Calcareous Concre-
tions. — Ranula. — Fatly Degeneration. — IV. The Teeth. — Organization,
Articulation, and Chemical Constitution. — Gangrene. — Inflammation of their
Internal Membrane. — Fungous Tumors. — Exostoses. — Denuding Process.

— Deposits of Tartar. — Congenital Vices. — V. The Gu7n. — Liability to
Inflammation. — Epulis. — Ulcerative Absorption. — Mortification. — Alveolar
Abscess. — VI. Diseases of the Tonsils. — VII. The Soft Palate and Uvula. —
VIII. The Pharynx. — Diphtheritis. — Polypes. — Sacculated Condition. — IX.
(Esopha,gitis. — Ulceration. — Softening. — Stricture. — Scirrhus. — Congenital
Malformations.

I. The lips afford a subject of interest to the morbid anato-
mist chiefly on account of carcinoma, encysted tumors,
and congenital malformations. Cancer is sufficiently com-
mon here, especially in oldish subjects, and usually begins in
the follicular structure of the part, which becomes hard and
thickened, and soon tends to ulcerate. The sore thus formed
is often very deep, with fiery and everted edges, and gives
vent to a thin, sanious, and eroding fluid. When removed
by excision, the disease commonly returns. If permitted to
progress, it gradually eats away the lip, and involves theg-um,
together with the periosteum, and the substance of the jaw.

When the orifice of one of the labial glands becomes acci-
dentally obstructed, mu-cus accumulates in it, converting it
into an encysted tumor. The swelling seldom exceeds a
hazelnut, but, in a few instances, I have found it as large as
an almond. Its form is usually spherical, its appearance semi-
transparent, and the fluid it contains is thick and glairy, like
the white of eggs.

The congenital malformations of this structure are usually
comprehended under the title of hare-lip, from their supposed
resemblance to the lip of the hare. The most simple form
in which it is presented is that of a fissure, extending from
the border of the lip to its connection with the gum. Gen-

164 MOUTH. [chap. VI.

erally seated to oae side of the mesial plane, more frequently
on the left than the right, it exists either by itself, or is com-
plicated with malformation of the jaw, palate, or nose, or of
all these parts together. The margins of the abnormal cleft
are more or less rounded off ; and, as they are covered with
mucous membrane, they are usually of a reddish color. In
double hare-lip there are two such fissures, separated by an
intermediate portion of lip, which varies much in size and
shape, being sometimes broad and quadrangular, but more
commonly narrow, elongated, and tit-like. The cleft, wheth-
er single or double, is occasionally more or less oblique. The
defect, it need scarcely be observed, always depends upon an
arrest of the natural developement of the part concerned.

" The malformation to which the upper-jaw is liable consists
in a projection of the central part that holds the cutting teeth,
forming a tumor from which the teeth grow out at a right
angle to their ordinary direction. In most cases of this kind,
the projection comprehends an equal portion of both superior
maxillary bones, the portion, namely, which, in the lower ani-
mals, is occupied by two distinct pieces, the ossa incisiva.
It forms a round knob, connected by a narrow neck to the
septum of the nose, covered with a firm substance, similar to
the gum, and having at its anterior part a similar shaped but
smaller sized appendage, which seems to consist of the tis-
sue that should have constituted the lip. The fissures on
each side of this knob meet together behind it, and are there
continued single through the palate backwards. Instead of
this conformation there is sometimes merely an overlapping
of one edge of the split gum over the other, and the degree
to which the projection thus formed takes place is extremely
various."

II. The tongue is liable to be affected with inflammation,
suppuration, ulceration, hypertrophy, cysts, and cancer.

Glossitis may exist as an idiopathic affection, but is most
generally induced by salivation, by mechanical injury, or cor-
rosive substances. The idiopathic variety, to which these
remarks are intended more particularly to apply, is a most
formidable malady, in reference both to its local as well as to
its constitutional effects. The organ is extremely painful,
and swells sometimes so enormously as to threaten the patient
with speedy sufl'ocation : all its vessels are engorged with
blood ; and its surface, which is at first of a bright red, is
soon coated with viscid mucus, or, when the inflammation

CHAP. VI.] TONGUE ] GLOSSITIS. 165

runs high, even with a layer of lymph. Now and then the
disease is limited to one half of the tongue, the raphe form-
ing a pretty distinct line of demarcation between it and the
unaffected side. Glossitis terminates either in resolution, in
suppuration, or in gangrene. The disposition to disappear is
sometimes manifested as early as the third day, but mostly
not until about the sixth. When matter forms it is generally
deep-seated, and requires free incisions for its evacuation.
The termination of glossitis in gangrene is extremely rare,
and has hitherto been noticed only in persons of a debauched
habit and worn-out constitution.

The mucous membrane of the tongue and cheek is liable
to several forms of ulceration. In psoriasis there are whitish
excoriated patches, not unfrequently half an inch in diame-
ter ; and in children nothing is more common than to see
these parts studded with small milky-looking vesicles. These
blebs, which are technically called apthm, are of an irregularly
spherical figure, and vary in size from a pin's head to a small
pea. When punctured, their contents are found to consist
of two parts, one of a fibrous, the other of a serous nature.
Apthee are frequently connected with gastro-enteric irritation ;
and there is reason to believe that they often extend through
the oesophagus, as far as the cardiac extremity of the stomach.
In several instances, however, in which I made a careful in-
spection with a view of ascertaining this point, I failed in
tracing the vesicles beyond the fauces, although the tongue,
the inside of the cheeks, and the roof of the mouth were liter-
ally covered with them.

Flat, shallow ulcers, with hard and thickened edges, are
occasionally observed on the tongue, cheeks, and fauces, in
secondary syphilis, and in persons who have been excessively
salivated. The parts are foul and clammy ; the saliva acrid
and abundant ; the gums spongy, and disposed to ulcerate.

The tongue being composed of different structures, hyper-
trophy may be I'iraited to its muscular substance, to its mu-
cous covering, or to its papillae. The former variety, although
sometimes congenital, commonly appears soon after birth,
and is now and then witnessed in adults, either without any
assignable cause, or as the result of glossitis. Of this nature,
seems to have been the case published by Dr. Harris, of
Philadelphia, of a girl twenty-four years of age. Commenc-
ing when she was quite young, the intumescence was at-
tended, at first, with great pain and difficulty of deglutition,

166 MOUTH. [chap. VI.

and gradually progressed, until the organ protruded four inches
beyond the incisor teeth, measuring one inch and three
fourths in thickness, by six inches and three fourths in cir-
cumference. The projecting portion was extremely dense,
of a dark chocolate color, and constantly covered with a
thick, tenacious mucus. The part within the mouth was
entirely free from disease, excepting the lenticular papillse,
which were about five times the natural size.* In another
case, recently reported by the same distinguished surgeon,
the hypertrophy was congenital, and was attended with un-
usual shortness of the branches of the lower-jaw, with great
separation of the incisor teeth.f Hoffman, an old physician,
of Stockholm, removed a tongue of this kind from a girl, ten
years old, which protruded four inches, and was two inches
thick.J An interesting case, of a similar description, but
where the swelling was considerably less, is recorded by Dr.
Wells, in the Western Journal of the Medical and Physical
Sciences for July, 1833. The patient, likewise a girl, was
six years of age, and had formerly suffered much from in-
flammation and ulceration of the mucous membrane of the
tongue. The organ, preternaturally dense and rigid, hung
down two inches and a half beyond the teeth of the upper-
jaw, being a little more than two inches in breadth. This
lesion, like that next to be mentioned, is generally caused by
inflammatory irritation ; and, upon a careful examination of
the principal cases of it on record, I am disposed to believe
that it is much more frequent in the female than in the male.
Enlargements of this kind are sometimes remarkably vascu-
lar, being pervaded by plexuses of dilated vessels, and subject
to temporary erections, from the preternatural influx of blood.
Dissection shows that the fleshy fibres of the tongue have
lost their normal color, and that they are converted into a
dense semi-cartilaginous substance, with scarcely a trace of
the primitive structure.

With respect to the mucous membrane, the hypertrophy,
as might be expected, is usually limited to one or more points,
though, in a few instances, it has been known to extend over
the entire organ. The affected part varies in thickness from
the twelfth to the third of an inch, and exhibits a rough,

* American Journal of the Medical Sciences, vol. vii. p. 17.

t Op. cit. vol. XX. p. 1.5.

t Acta Literaria et Scient. Suecice. 1732, t. iii.

CHAP.

VI.] HYPERTROPHY. 167

grayish appearance, the prominence being occasionally di-
vided by deep fissures. The enlargement has little or no
pain in it, and the sense of taste is almost always partially
destroyed.

The papillcB, situated on the dorsal surface of the tongue,
have a narrow base, and a broad, mushroom-like head. From
a deranged state of the stomach, or from local injury, they
are capable of becoming considerably enlarged, so as to form
preternatural tumors, of a deep florid color, which may be
mistaken for cancerous excrescences. From these, however,
they are readily distinguished by there being no real ulcera-
tion of the tongue, and by the absence of any decided pain.
The size which such tumors may acquire varies from that of
a pea to that of a nutmeg.

Still more rare than the lesion just described is atrophy of
the tongue. This is generally associated with inflammatory
irritation, and may reach such a height as to leave behind
it nothing but a dense, whitish mass, with scarcely a vestige
of muscular tissue.

A singular disease of the tongue, first noticed, I believe, by
Mr. Earle, of London, is occasionally met with. It consists
in very minute semi-transparent vesicles, occupying the mus-
cular substance of the organ, the mucous membrane of which
they not unfrequently elevate in the form of little tumors.
The precise nature of these vesicles is not well understood.
In the case mentioned by Mr. Earle, they grew in clusters,
and were so sensitive as to bleed profusely on the slightest in-
jury. The clusters, in some places, were separated by deep
clefts, which discharged a fetid, irritating sanies.

This organ is not unfrequently the seat of cancer, — a dis-
ease which, though most common in old persons, is some-
times observed in the young. It commences in the form of
a hard, inelastic, puckered tubercle, situated towards the an-
terior part of the tongue, by the side of the mesial plane.
The ulcer whi-ch follows is excavated, foul, and uneven ;
the edges are thick and contracted ; the base and surround-
ing substance hard and gristly. In time, the disease affects
the gums and cheeks, and the erosion thus produced often
presents a frightful aspect. The breath is intolerably fetid ;
the patient is harassed with lancinating pain ; the neighbor-
ing lymphatic ganglions swell ; and profuse hemorrhages su-
pervene from the ulceration of one or more vessels. In some
instances, the disease begins in a fungous excrescence, at

168 MOUTH. [chap. VI.

the side of the tongue, which extends rapidly over the sur-
face, and assumes all the characters of encephaloi'd. In
whatever manner it may appear, there is reason to believe
that carcinoma is originally located in the follicular struc-
tures, from which it gradually spreads to the other tissues.

The tongue, finally, is liable to cougenital malformation.
Thus, it may be bifurcated at the tip, as in the snake and
the lizard ; be extremely small, and nipple-shaped, as in
parrots ; be double, or even entirely absent. The frosnum is
sometimes too long, or too short, or unusually thick, and of
a dense, fibro-cartilaginous consistence.

III. The salivary glands, situated to the number of three
on each side of the jaws, although differing in size and
shape, all agree in being of a pale ochrey color, not un-
like the cineritious substance of the brain, and in being com-
posed of minute granules, aggregated into lobules and lobes,
and connected together by firm, cellular tissue. They are
provided each with an excretory duct, by which the fluid
they secrete is poured into the mouth ; but none of them
have a proper envelope ; and hence the reason, perhaps, why
they are so little subject to disease.

All the salivary glands are not equally liable to morbid
alterations. The parotid is infinitely more frequently affected
than the others, and the disease to which it is most subject
is mumps, — an infectious, inflammatory complaint, occurring
sometimes endemically. Both organs are usually involved.
The swelling, which is often considerable, reaches its height
about the end of the fourth day ; after which, it gradually
subsides, and, in a week from the time of the invasion, is
entirely gone. One of the most singular features of the
disorder is its liability to be translated to other organs, as the
testicle in the male sex, and the breast in females. It rarely
occurs more than once, and youth is its favorite period of
attack.

In whatever way induced, the anatomical characters of the
disease are generally the same. That is to say, the substance
of the affected gland is preternaturally red, its density is
augmented, its lobules are rendered more distinct, and the
connecting cellular tissue is infiltrated with serosity. In
severe cases, fibrin and blood are often effused, giving the
part a bloodshot appearance. Added to these phenomena, the
capillary vessels, both arterial and venous, are excessively en-
gorged, and the minute excretory ducts are so much com-

CHAP. VI.] SALIVARY GLANDS J DISEASES. 169

pressed, as to be no longer permeable to the most diffusible
injecting matter. The salivary fluid is also more or less
altered. When the inflammation is at its height, the secre-
tion is either very much diminished, or else entirely sus-
pended : by degrees it is restored, and is then often discharged
in immense quantities, as is exemplified in mercurial saliva-
tion. In this aff"ection, which appears to be propagated from
the gums and cheeks, as there are always manifestations of
it there, before it involves the glandular structures about the
jaws, the salivary fluid is remarkably thin, pellucid, and of a
strong, disagreeable taste. Much of this is owing, doubtless,
to the follicular secretion of the mouth, which, under such
circumstances, is poured forth in great abundance, and of a
very fetid quality.

Parotitis, under favorable circumstandes, may terminate
in supjpm^ation. Of this I have noticed several instances,
in one of which an opportunity was afl'orded me of making
an autopsic inspection. Both glands were considerably en-
larged, unnaturally dense, of a grayish, gristly appearance, and
pervaded throughout by purulent matter, collected here and
there into little abscesses, the largest of which did not ex-
ceed the volume of a hazelnut. The pus was white, thick,
and tenacious, like that of a scrofulous lymphatic ganglion.
The weight of the right parotid was one ounce two drachms ;
of the left, one ounce one drachm. The glandular substance
was very little injected, a small straggling vessel being only
here and there perceptible. The patient was sixty^eight
years of age, and died of disease of the liver and the duode-
num, for which he was attended by my friends Drs. Drake
and Rives. The parotitis came on ten days before death ;
and, what is remarkable, the man never coniplained of the
slightest pain from this source.

Gangrene has been known to seize on the parotid, and to
proceed until it had entirely destroyed its substance. This
termination, however, is extremely rare, and has hitherto been
observed chiefly in cases in which the surrounding textures
were extensively involved by the inflammation.

The salivary glands, especially the parotid, are subject to
atrophy. This is usually induced by some morbid growth
in their immediate vicinity, which, by causing the absorption
of their substance in proportion to its own enlargement, at
length usurps their place. Hypertrophy, an aflfection much
more common than the one just adverted to,, is generally as-

voL. II. 22

170 MOUTH. [chap. VI.

sociated with induration, the effect of which is to render
the glandular structure hard, dense, and sometimes almost of
a gristly consistence.

True scirrhus is occasionally met with in the parotid, as
are also encephaloi'd and melanosis. The occurrence, how-
ever, of these malignant growths is rare in this country, and
is seldom witnessed, except in persons passed the prime of
life. The size of the organ, in these affections, is sometimes
really surprising. In a case in which it was removed by Dr.
Prieger, of Germany, on account of a carcinomatous disease,
it weighed two pounds and three quarters. The patient was
a female, thirty-five years of age. Tubercles, I believe, have
never been observed either in this or in the other salivary
glands.

I am not aware that authors have recorded any examples
of the fatt'y degeneration of the salivary glands ; but an in-
teresting case of this kind has recently fallen under my own
observation, in a man forty-two years of age. The disease
involved the right parotid, which was enlarged to nearly
three times the normal bulk, and had been gradually coming
on for several years, unattended with pain or tenderness on
pressure. After the extirpation of the organ, which was suc-
cessfully accomplished by my friend, Professor Parker, who
is well known to the public, as an excellent anatomist and
surgeon, it was found to be completely transformed into adi-
pous matter, quite greasy to the touch, remarkably friable,
and of a pale bluish color, not unlike the buffy coat of the
blood. The granular texture was still recognizable, but the
connecting cellular tissue appeared to be entirely destroyed.
When pressed between the fingers, a clear oily fluid oozed
out, and which, when the gland had remained some time in
alcohol, collected in considerable quantity on the surface of
that liquor. A similar transformation, as will be shown here-
after, is occasionally witnessed in the pancreas, Avhich bears
so close a resemblance to the parotid, that it has been de-
scribed by many under the name of the salivary gland of the
abdomen. Whether the sublingual and submaxillary are sus-
ceptible of a like change, I am not able to say, as there are
no cases of it on record.

The ducts, both of the parotid and submaxillary glands,
are sometimes the seat of calcareous concretions, which are
named salivary calculi. Their volume varies from that of
a clover-seed to that of a large almond : their number is

CHAP. VI.] TEETH. 171

usually small. They are of a pale yellowish color, oval in
their shape, and have a finely tuberculated surface. Their
composition is phosphate and carbonate of lime, agglutinated
together by a small quantity of animal matter.

The principal disease of the sublingual gland is ranula,
which is generally supposed to depend upon the dilatation of
one of its ducts, but is in reality an encysted tumor. The
swelling is usually occupied by a thick, glairy fluid, like the
white of eggs, but sometimes is watery, or of a pultaceous
consistence : occasionally, it resembles the synovial liquor of
the joints, and contains particles of gritty matter, probably
a mixture of phosphate and carbonate of lime. The size of
the tumor varies from that of a pea to that of the fist ; its
form is irregularly oval, and its parietes are thin, and for the
most part translucent. The submaxillary gland is sometimes
similarly affected.

IV. Although the teeth bear a very striking resemblance to
the bones, yet as they differ from them essentially in their
mode of developement, and the uses which they subserve in
the economy, to say nothing of the peculiarity of some of
their diseases, it will be necessary to consider them separately.
To enter minutely upon this matter would be foreign to the
design of this treatise, and I shall therefore, after making a
few remarks concerning the structure and composition of
these organs, content myself with a very rapid outline of their
more interesting lesions.

The total number of teeth in the adult is thirty-two, of
which eight are named incisors, four cuspid, eight bicuspid,
and the remaining twelve molar. Although these four classes
are arranged in perfect uniformity in each jaw, yet they differ
widely from each other in size and form, as well as in their
use and articulation. Anatomically considered, each tooth
has a body, a neck, and a root : the first, which is also called
the crown, being the part which is incrusted with enamel ;
the second, that, which is embraced by the gum ; and the
third, that which is implanted into the substance of the jaw.

In the interior of every tooth is a canal, which represents
very faithfully its outward form, being larger in the crown
than in the root or fang, at the extremity of which it termi-
nates in a minute foramen. The whole of this cavity is
lined by a very delicate membrane, which is highly vascular
and exquisitely sensitive, and which is intimately connected
with the growth and preservation of the organ, into the com-

172 MOUTH. [chap. VI.

position of which it enters. The vessels and nerves penetrate
the aperture at the bottom of the fang, and ramify over this
membrane in every direction ; but whether any branches are
spent upon the substance of the tooth, is still a mooted point.
After a successful injection with size and vermilion, neither
the enamel nor the bony part appears to be reddened.
Nevertheless, it is not only highly probable, but almost cer-
tain, that these structures are organized ; otherwise it would
be difficult, if not impossible, to explain the sympathetic con-
nections between them and the rest of the system, and the
various changes which they experience in consequence of
disease. Their vitality, however, is no doubt of a very low
grade ; and hence they readily yield to such agents as have a
tendency to destroy them.

The nerves of the teeth are derived from the ganglionic
portion of the fifth pair, filaments of which may be traced
through the cavity of the fang into the substance of the
lining membrane. The arteries, which are accompanied by
corresponding veins, are furnished by the internal maxillary
branch of the external carotid. The existence of absorbents
has been ably controverted by Mr. John Hunter, but not
successfully, as there is every reason to believe that these
vessels exist here as in other parts of the body, though
doubtless in less abundance.

The mode of articulation by which a tooth is fixed in its
socket, is termed gomphosis. The fang, however, through
the intervention by which this is effected, does not lie in im-
mediate contact with the walls of the containing cell, but is
separated from them by a very delicate vascular membrane.
This is merely a prolongation of the periosteum of the max-
illary bones, which, after covering the alveolar processes, dips
down into each socket, the parietes of which it lines. From
the bottom of the cavity it is reflected over the root of the
tooth, which it entirely invests as far as the neck, at which
part it is intimately united with the gum. Thus, the mem-
brane here spoken of not only adds materially to the firmness
of this articulation, but it may be said to answer to the osseous
portion of the organ which it covers, — the same purpose that
the periosteum does to the bones of the skeleton, preserving
its connection, and contributing to its support.

Two distinct substances enter into the formation of the
teeth, diftering widely from each other in their structure, as
well as in their chemical composition. The first, of which

CHAP.

VI,] TEETH. 173

the mass of the organ mainly consists, is of an osseous nature,
extremely hard, compact, and indestructible : it is of a dull
yellowish color, and is made up of a cartilaginous frame-work,
the cells of which are occupied by earthy matter, upon
which the solidity of the teeth essentially depends. The
chemical composition of the bony substance, as ascertained
by Berzelius, is as follows :

Animal matter, ....... 28.

Phosphate of lime, . , . . . . 62.

Fluate of lime, .,..,.. 2.
Carbonate of lime, ...... 5.5

Phosphate of magnesia, . . . . .1.

Soda, with muriate of soda, .... 1.5

100.0.

The enamel covers the crown of the teeth, forming an in-'
crustation for it, the thickness of which varies in different
parts of its extent. In the grinders it is always more abun-.
dant on the triturating surface than at the sides, the reverse
being the case in regard to the front teeth. As it approaches
the neck, it becomes gradually thinner, and finally terminates
almost imperceptibly. The enamel is the hardest animal
substance with which we are acquainted : it is of a pale
milky color, semi-transparent, and glistening, and consists of
minute fibrous crystals, disposed in a radiated direction in re-
gard to the centre of the organ to which it is attached. This
arrangement is very obvious when the enamel is broken.
The following is the result given by the celebrated chemist
above mentioned, whose analysis appears to have been more
elaborate than that of any other experimentalist :

Animal matter, ....... 1.

Soda, with muriate of soda, .... 1.

Phosphate of lime, ...... 85.3

Fluate of lime, ...... 3.2

. Carbonate of lime, ...... 8.

Phosphate of magnesia, . . . . . 1.5

100.0.

"When a tooth is steeped in diluted muriatic acid, it becomes
flexible, but retains its form : the earthy matter is dissolved,
and leaves the animal substance with Avhich it was in-
corporated.

Although a tooth is not sensibly vascular, yet, if it be taken
from the jaw of a living person, and immediately replaced in

174 MOUTH. [chap. VI.

its former socket, it will contract adhesions to the raw surface,
and be permanently retained. The singular experiment of
Mr. Hunter is well known. This ingenious physiologist
transferred a tooth from its cavity into an incision, made on
purpose, in the comb of a cock, to which it became so firmly
united that, on killing the animal some time subsequently, and
injecting its head, the fluid ran freely into the internal mem-
brane of the transplanted organ. No better proof, surely,
could be offered, of the vitality of a structure, than the result
of such an experiment. If the same operation be performed
with a tooth that has been some time drawn, it acts as an
extraneous substance, and the socket makes an effort to throw
it off.

The most common disease of the teeth by far is gangrene,
a lesion which is strictly analogous to necrosis of the osseous
tissue. Commencing invariably in the bony substance of the
crown immediately under the enamel, it presents at first the
appearance of a minute, opaque, brownish speck, which grad-
ually extends towards the centre of the organ, assuming at
length a blackish color, and becoming so soft and brittle as
to be crushed on the slightest touch. Thus a large cavity is
exposed, which perhaps had not previously been suspected to
exist. Advancing in the manner here described, the gan-
grene frequently destroys the entire crown, or converts it
into a dark, pulverulent substance, without a single trace of
its primitive texture. The roots are usually the last to die,
and it often happens that they retain their vitality long after
the other parts have fallen into complete decay. Deprived of
life, they act as extraneous bodies, exciting ulcerative absorp-
tion of the gum and alveolar processes, whereby they lose
their connection, and are finally dislodged.

The teeth most liable to this disease are the last grinders,
probably from some defect inherent in their constitution in
consequence of their late developement. The upper central
incisors are also frequently affected ; and so likewise the first
molar teeth, particularly those of the under jaw. The lower
incisors, on the contrary, are rarely attacked. Every part of
the crown appears to be equally liable to gangrene ; and it
sometimes happens, though this is infrequent, that the disease
begins at several points simultaneously. Generally tardy in
its progress, there is at first seldom any pain or even uneasi-
ness ; by and by, however, when the internal cavity is laid
open, the lining membrane becomes exceedingly tender, and

CHAP. VI.] INFLAMMATION. 175

productive of excruciating suffering, which is either continu-
ous, paroxysmal, or remitting. The proximate cause of den-
tal gangrene is inflammation.

Persons of a tubercular constitution are very subject to
this species of decay, which often sets in at a very early
period of life, and proceeds until nearly every tooth is de-
stroyed by it. The upper incisors of children are frequently
attacked in this way within a short time after their appear-
ance, and occasionally, indeed, when they are still partially
covered by the gum. There would likewise seem to be a
hereditary proclivity to this disorder. " It often happens,"
says Mr. Bell, in his admirable work on the Anatomy,
Physiology, and Diseases of the Teeth, " that this tendency
exists either in the whole, or great part of a family of chil-
dren, where one of the parents had been similarly affected j
and this is true to so great an extent, that I have very com-
monly seen the same tooth, and even the same part of the
tooth, affected in several individuals of the family, and at
about the same age."

The internal membrane of the teeth is occasionally affected
with inJianvmatio7i, the other anatomical elements of these
organs being apparently in a sound state. The disease, as
might be anticipated from the confined situation of this deli-
cate structure, is generally accompanied with the most excru-
ciating pain, of a throbbing, pulsatile nature, and, if allowed
to go on, almost always leads to the formation of an alveolar
abscess. In other cases, there is a pretty abundant deposit
of fibrin, both within the canal of the affected organ and
around its roots, the latter of which exhibit a singularly
shreddy aspect, the plastic lymph hanging from the thick-
ened periosteum in all directions. Occasionally, again, though
this is not very common, purulent matter is poured out, form-
ing an abscess analogous to what is sometimes observed in
the interior of a bone. When the quantity of fluid is con-
siderable, it is very apt, from its confined situation, and con-
sequent pressure, to produce mortification of the lining mem-
brane, with absorption of the parietes of the cavity. By
this means the pus gradually escapes at the extremity of the
fang, the foramen of which is much enlarged. Ulcerative
inflammation is next set up in the alveolar process and gum,
which continues its ravages until the enclosed matter, now
extremely offensive, obtains an outlet, the affected tooth
meanwhile losing its vitality, and presenting a dull yellow-
ish, dark, or brownish color.

176 MOUTH. [CHAF. VI.

The exposure of the internal membrane from gangrene,
fracture, or other causes, not unfrequently leads to the forma-
tion of fungous tumors, varying in volume between that of a
pin-head and an ordinary pea. Of a pale reddish color, they
are of a soft, fleshy consistence, and are essentially' composed
of a plexus of vessels, connected together by delicate cellular
substance, and traversed by minute nervous filaments. From
their excessive vascularity, these growths are liable to bleed
upon the slightest touch ; and although they are occasionally
as insensible as healthy gum, yet in the majority of cases
they are the seat of the most exquisite pain. The period
required for their developement varies from a few months to
several years ; but, from the great sujffering which they induce,
they are seldom permitted to remain for any length of time.
They appear to arise, for the most part, from the lining mem-
brane of the fang, from which they proceed more or less
rapidly until they fill the whole cavity of the organ. Occa-
sionally, there is reason to believe that these growths spring
directly from the dental nerve, which becomes exceedingly
vascular, elongated, and thickened. The teeth most fre-
quently affected with this disease, are the central incisors
and the large grinders. In the case of a young lady observed
by Dr. Hullehen, of the State of Virginia, there were two
fungous tumors of this kind, which were the seat for several
months of periodical hemorrhage, vicarious, as was supposed,
of the menstrual flux.*

When we consider that, with the exception of the enamel,
the teeth are essentially composed of the same anatomical
elements as the bonesy it is not surprising that they should be
the seat of exostosis. The substance which is thus added
differs from the preexisting structure principally in being of a
denser consistence, and in presenting a yellowish transpa-
rent aspect, not unlike chalcedony. The deposit ordinarily
takes place at the root of the organ, but in some instances it
affects the body, and may even extend as high up as the
crown. Analogy would lead us to infer that the new matter
is furnished exclusively by the vessels of the periosteum ; and
this doubtless happens in the generality of instances. The
progress of this disease is usually very tardy, a long time
elapsing before the bony tumor attains much bulk.

There is a singular affection of the teeth, which has been

* Western Journal of the Medical and Physical Sciences, No. 38. p. 558.

CHAP. VI.] CALCAREOUS CONCRETIONS. 177

described by Mr. Hunter under the name of " the denuding
process," and the precise nature of which is still unexplained.
It consists in the gradual removal of the enamel, generally
without the slightest discoloration or any diseased appearance.
I have most frequently observed it in the incisors, especially
the inferior, but it occasionally attacks the whole dental arch.
As the denuding process advances, the crown of the tooth is
slowly worn away, the enamel first disappearing at the top,
and subsequently at the sides, until the greater part is re-
moved. The organ in the mean while changes its color,
gradually becoming more yellow, and finally, when the enamel
is completely destroyed, assuming a brownish aspect. The
most curious circumstance in the history of this lesion is the
beautiful provision by which the cavity of the tooth is pro-
tected from exposure. This consists in a deposit of new
bony matter, perfectly hard and solid, but so transparent
that nothing but the closest examination could detect it.
Thus a sort of permanent plug is formed, which effectually
protects the delicate structures within, and which exactly re-
sembles the transparent layers of an segose pebble, surround-
ed by a more opaque mass. In what this lesion essentially
consists it is not easy to determine, though it is not improba-
ble, I think, that it depends upon some original or acquired
defect of the enamel, whereby it is made to yield more readi-
ly to the mechanical attrition to which the teeth are con-
stantly subjected. It is witnessed at nearly every period of
life, but is most common by far in old people.

The teeth, from want of cleanliness, as well as other causes,
are very apt to become the seat of calcareous concretions.
When first deposited this substance possesses the character
of a soft, friable, porous paste, which by degrees acquires the
consistence of hardened mortar, and often scales off in large
masses, having the shape of the organ around which it was
formed. Its usual color is a dull whitish yellow, though in
some cases it is dark brown, blackish, or even greenish. The
specific gravity of this matter is 1.571. From the analysis of
Pepys it would appear to be composed principally of phosphate
of lime, in association with a small quantity of cartilage and
fatty substance.

The accumulation of this substance often takes place with
great rapidity, so that in a short time the dental arches are
almost completely incrusted with it. Calculous and gouty
persons are particularly liable to it ; and it is also frequently

VOL. II, 23

178 MOUTH. [chap. VI.

witnessed in lying-in females. It is ordinarily deposited, at
first, around the necks of the teeth, just beneath the free
margin of the gum. As it increases in quantity it produces
the most disastrous elfects, exciting irritation in the soft parts,
which leads to absorption of the gum and alveolar processes,
until the teeth, deprived of their support, are loosened and at
length drop out.

Various notions have been entertained respecting the source
of this substance. Some believe that it is derived directly
from the mucous secretions of the mouth, vitiated by chronic
irritation ; but the more plausible opinion is, that it is fur-
nished solely by the salivary glands, and that it is held in
solution by the fluid which it is the office of these organs to
elaborate. This view of the subject is not only supported by
the analogy which obtains in the formation of urinary calculi,
but by the fact that this substance is always deposited in
greatest abundance upon the superior grinders, and the in-
ferior incisors, — teeth which lie in the immediate vicinity of
the mouths of the salivary ducts, and by the circumstance,
moreover, that it is composed of the same elements as the
fluid just referred to.

The teeth experience important changes in consequence of
age. As we advance in life they gradually lose their white-
ness, and assume a peculiar yellowish tint, which is often re-
markably conspicuous in old people. They become likewise
more brittle, and the enamel exhibits an irregularly abraded
appearance. These changes are produced by certain altera-
tions which take place in the anatomical constitution of the
teeth, from the obliteration of many of their vessels, followed
by a diminished supply of blood.

The temporary teeth, which are only twenty in number,
are surrounded each by a membranous cyst, which often in-
flames during dentition, and thus gives rise not only to much
local uneasiness, but occasionally to great disturbance in
other organs, especially the stomach and bowels. The gum
at the same time becomes red and tumid, and there is general-
ly an inordinate secretion of salivary fluid. When the tooth
is fully formed, the sac is no longer of any use, and is there-
fore gradually absorbed.

Lastly, the teeth are liable to certain congenital vices in
regard to their dcvelopement, situation, and direction. In
persons afl'ected with hare-lip and cleft palate, the upper
incisors arc almost always badly formed, and thrust out of

CHAP. VI.] gums; epulis. 179

their natural position. Instances also occur in which some
of these organs are firmly united together by osseous matter ;
and Albinus has related a case where the crown of the eye-
tooth was turned towards the maxillary sinus, the situation
of the fang being reversed.

V. Another structure which requires mention here is the
gum. This substance, after having covered the alveolar
processes of the maxillary bones, to which it adheres with
great firmness, encircles the necks of the teeth, forming a
partition between every two adjoining organs, which extends
up as high as the enamel. In its texture, the gum is some-
what peculiar, — less hard and dense than cartilage, but more
so than the other parts of the mucous membrane of the
mouth, of which it is essentially constituted. No follicles
are discoverable in it, though it is highly probable, I think,
that they exist here as elsewhere. This substance is highly
vascular, and of a beautiful vermilion color : it possesses
very little sensibility in the normal state, but becomes ex-
tremely painful and irritable when inflamed. In old age,
when the teeth fall out, it parts with its florid complexion,
and acquires the density of cartilage, compensating, in some
degree, for the loss of the dental arches.

Of the occurrence of ordinary inflammatory aff"ections to
which the gum, in common with the rest of the mucous
system, is liable, it is not my intention here to speak ; but
there are several lesions which are either peculiar to this
situation, or are produced by irritation of diseased teeth, of
which it Avill be necessary to treat with some degree of
minuteness.

One of the most formidable diseases of the gum, though
fortunately not a very common one, is epulis^ as it is termed,
which is generally in the form of a small wart-like excres-
cence, of a reddish color, and of a hard, gristly consistence.
Its growth is seldom rapid, nor is it attended, at first, with
any decided pain or inconvenience. After having remained
for some time, it loses its solid feel, becomes soft and spongy,
bleeds upon the slightest touch, and throws out an abundance
of irregular cauliflower-like processes. Ulceration now com-
mences, the morbid mass rapidly augments in volume, and
there is a constant discharge of fetid, purulent matter. At
this stage of the disease, the gum has a remarkably red and
spongy aspect, the teeth drop from their sockets, and the
lymphatic ganglions in the neighborhood are more or less

180 MOUTH. [chap. VI.

contaminated ; the pain is also very great, and the system
labors under hectic. If the tumor be excised, it almost in-
variably returns, especially if a part be left behind, and re-
quires a fresh operation. Epulis never occurs in those situa-
tions of the gum from which the teeth are perfectly removed ;
nor is it usual to see it without some disease of these organs,
or of the sockets in which they are contained. Its most
frequent though not constant seat is on the transverse pro-
cess of the gum, where this structure projects between the
incisor teeth.

Epulis is merely a species of local hypertrophy, varying
in volume, between that of a pea and an egg. It is invested
by a prolongation of the mucous membrane of the gum, and
is intersected by fibrous filaments, which add much to its
density and cohesive power. Vessels enter it at every point,
and, in some cases, the tumor appears to be almost entirely
made up of them. Besides these anatomical elements, which
constantly exist, there is occasionally, in the truly malignant
form of the disease, a deposition of encephalo'id matter.

The most frequent lesion of the gum is ulcerative absorp-
tion, produced by the accumulation of tartar around the necks
of the teeth. The pressure that is thus exerted, excites in-
flammatory action, leading to great thickening, sponginess,
and discoloration of the gum, with erosion of its substance.
In this way the teeth are entirely denuded at their necks,
and, as a necessary consequence, they often drop from their
sockets, or become so loose as to be useless.

The gum, in common with the rest of the mucous mem-
brane, is liable to sloughing, from excessive mercurial action,
and probably also from causes which exert their influence
chiefly through the constitution. Of this nature appears to
be that variety of mortification which has been so ably de-
scribed by the older writers under the name of " black
canker," and by Coates* and others of our own times, under
that of the " gangrenous ulcer " of the mouth. This disease
prevailed quite extensively, some years ago, in the marshy
districts of New Jersey and Pennsylvania, attacking, for the
most part, weakly children, between two and five years of
age. Although it may begin at any part of the mucous

* Description of the Gangrenous Ulcer of the Mouths of Children. By B. H.
Coates, M. D. one of the physicians of the Philadelphia Children's Asylum.
North American Medical and "Surgical Journal, vol. ii. 1826.

CHAP, VI.] ABSCESS. 181

membrane, yet, in by far the greater number of cases, it
makes its appearance at the edges of the gum, over the neck
of the central incisors of the lower-jaw, in the form of a
w?iitish, cineritious, or reddish ulcer, which varies in diame-
ter, from half a line to the eighth of an inch. In this state,
the disease may continue for several weeks, or even months ;
but more commonly it extends its ravages, affecting either a
large portion of the dental arches, or passing down in the
direction of the sockets of the teeth, which, together with
their periosteum and the alveolar processes, are thus gradu-
ally deprived of their vitality. The soft parts, in the mean
while, assume a dirty blackish appearance ; and, on being de-
tached, they leave a ragged, sloughing ulcer, which is the
seat of a foul, sanious discharge, of so excessively acrid a
nature as to excoriate whatever texture it may happen to
come in contact with. In this manner, the disease appears
to be frequently propagated to the mucous membrane of the
cheeks and lips, where it generally spreads with great rapid-
ity, until the parts are completely perforated, or a black gan-
grenous spot manifests itself upon the external surface.

The true pathology of this disease is still enveloped in
obscurity. It is almost wholly confined in its attacks to
young, weakly subjects ; and, from the researches of Dr.
Coates and others, it would seem occasionally to display an
endemic tendency. Out of two hundred and forty children
observed by this physician in the Philadelphia Asylum, up-
wards of seventy were more or less affected with the primary
ulcer at one time. In the early stage of the complaint, there
is little or no pain, the system is free from excitement, and
the appetite and strength are scarcely at all impaired. When
the sloughing process, however, has fairly commenced, the
child suffers much local distress, and is harassed with con-
stant fever. Dissection has thrown no light on this singular
variety of gangrene.

Another disease, which is deserving of mention here, is
alveolar abscess, or, as it is familiarly termed, gum-boil. Al-
though this may be produced by a great variety of causes,
yet the most common by far is the irritation of toothache,
or the existence of a dead fang. This, acting as an extrane-
ous body, excites inflammation in the periosteum of the
alveolar cavity, followed by an effusion of plastic lymph,
which becomes condensed into a sac, in the centre of which.

183 MOUTH. [chap. VI.

pus is formed. This sac, which is commonly of an ovoidal
figure, closely embraces the root just above its extremity,
which is, as it were, bathed in the purulent matter.* The
quantity of pus cannot of course be great ; but the pressure
which it exerts upon the investing parts always induces
ulcerative absorption, by which it gradually makes an outlet
through the gum, generally opposite the base of the dead
fang.

YI. The tonsils are two small bodies, about the size of an
almond, situated between the arches of the soft palate. They
are of an elongated, oval shape, of a firm, glandular consist-
ence, and are composed of a great number of mucous folli-
cles, connected together by short, cellular substance. The
internal surface of each presents several small apertures,
which lead into cells, that secrete a viscid, mucous fluid.
They are of a reddish-gray color, and exceedingly vascular
in their texture.

Tonsilitis, vulgarly called quinsy, is a very common com-
plaint in cold and variable climates, which is announced by
a sensation of dryness, heat, and pain in the fauces, with
difficult deglutition, and a high grade of febrile excitement.
On inspecting the throat, the organ is found to be considera-
bly swollen, and of a uniform, cherry-red color. The natural
secretion is at first suspended, but after some time augments
in quantity, becoming remarkably tenacious, and assuming a
pale, cream-like aspect. Seldom is the disease wholly con-
fined to the tonsils. In the generality of cases, it extends to
the root of the tongue, the uvula, and the curtain of the
palate, and occasionally even to the Eustachian tube, giving
rise to pain in the ear, and partial deafness.

Tonsilitis often terminates, in a few days, in suppuration,
the pus being always fetid, and not unfrequently blended
with flakes of lymph. The matter is commonly deep-seated,,
and occasionally works its way out under the angle of the
jaw. Now and then small ulcers form on the inflamed or-
gan. These are commonly preceded by minute, yellowish
pustules, which, bursting, expose to view a very red and
painful sore. Patches of whitish lymph sometimes coat the
tonsils, resembling superficial sloughs.

Gangrene, as a termination of this disease, is extremely

« Bell, on the Teeth, p. 210. Philadelphia, 1830.

CHAP. VI.] TONSILS ] ULCERATION HYPERTROPHY. 183

rare. The event is announced by the fetidness of the breath,
the livid state of the parts, and the dark, sanious discharge
from the throat. On examining the tonsils after death, they
will be found pulpy and disorganized, and of a deep gray,
ash, or mahogany color. Ulceration and sloughing of these
parts are very common in some of the exanthematous fevers,
and in none more so than in scarlatina.

In syphilitic affections of the throat, the tonsils are often
the seat of ulceration^ of which several forms have been
recognized by authors. The first is the excavated ulcer,
which exhibits the appearance of a deep hollow, as if a por-
tion of the organ had been scooped out, with a dirty ash-
colored bottom, and red, elevated margins. In the second
form, Avhich usually coexists with papular eruptions on the
arm and shoulder, the ulcer is narrow and superficial, some-
times, indeed, a mere fissure ; but the edges are often irregu-
lar, indented, and apparently coated with lymph. The tonsils
in both these cases, are considerably enlarged, and preter-
naturally red ; yet there is rarely much pain, or difficulty of
swallowing. A third form is the phagedenic, which com-
mences in a small aphthous speck, surrounded by a deep
erysepelatous blush, and rapidly proceeds over the organ to
the neighboring parts, involving them often in one common
slough.*

A not unusual effect of chronic inflammation is hyper-
trophy of the tonsils ; the disease, however, is sometimes con-
genital, and occasionally it would appear to be hereditary,
being handed down through several generations. When in-
duced by repeated attacks of quinsy, it is commonly associat-
ed with induration, which is sometimes so great as to have
received the name of scirrhus. Genuine scirrhus, however,
has probably never been observed here. At all events, if
such a case exists in the records of pathological anatomy, I
have not met with it.

E^icysted tutnors, supposed to be of the nature of acephalo-
cysts, may be developed in the tonsils. These were first
observed by the late Professor Dupuytren, of Paris, in the case
of a person on whom he operated in the Hotel-Dieu. The
gland had acquired a considerable magnitude, and exhibited
all the appearance of ordinary hypertrophy. On cutting into
it, he was surprised to find a large quantity of clear limpid

* London Cyclopsedia of Practical Medicine, vol. iv. p. 186.

184 MOUTH. [chap. VI.

fluid escape, which was ascertained to proceed from a loose
cyst, of an opaline tint, and as elastic as a hydatid. No other
surgeon, I believe, has noticed these tumors, and little is
known respecting them. May they not depend upon the ob-
struction and consequent dilatation of some of the tonsilitic
follicles ?

The tonsils are sometimes the seat of calcerous concretions,
closing up the mouths of their follicles. Their composition
is phosphate of lime, agglutinated by a small quantity of ani-
mal matter. They have usually a light brownish color,
spherical figure, and finely tuberculated surface. Their vol-
ume seldom exceeds that of a mustard-seed.

VII. The lesions of the soft palate do not differ, on the
whole, from those of the tonsils, and any labdred description
of them would therefore be superfluous.

Polypes sometimes grow from this part. Sir Astley Cooper
relates* two cases of this kind, in one of which the excres-
cence was attached over the palato-pharyngeal muscle, and
hung down like a sausage into the fauces : it was of con-
siderable size, soft, and of a florid color.

Split-palate is a congenital defect, analogous to hare-lip,
with which it generally coexists. It occasionally afTects
only the soft parts, in which case there is no lack of substance,
but the opposite halves recede from each other at an angle of
about thirty degrees. When the maxillary and palate bones
are involved, the fissure always corresponds with the mesial
plane, and is sometimes so great as to throw the buccal and
nasal cavities into one large sinus. In cases of this kind,
there must be an entire absence, of course, both of the vomer
and of the perpendicular lamella of the ethmoid. Even the
cribriform plate of this bone may be deficient, the olfactory
nerve wanting, and the cerebrum considerably malformed.

Of the diseases of the uvula, too little is known to enable
us to give any satisfactory account of them. Like the soft
palate, it originally consists of two lateral pieces, which, in
some instances, remain ununited at the raphe, thus forming a
congenital defect parallel to hare-lip and split-palate. This
malformation, however, rarely exists singly. The most com-
mon lesion of the uvula, undoubtedly, is hijpertroplLy, in
which it becomes both longer and more bulky. Its structure
also is sensibly altered, being much harder than in the natural

Lectures by Tyrrell, p. 318.

CHAP. VI.] PHARYNX. 185

State ; its vessels are much enlarged, and its color is a light
grayish, instead of a florid red. The consequences of such
changes are but too well known. The part becomes trouble-
some in deglutition and talking, and causes a disagreeable
tickling at the root of the tongue, attended with an annoying
cough and frequent retching.

Gangrene rarely affects the uvula. In anginose inflamma-
tion, it is often completely incrusted with a thick membra-
nous lamella, which is detached either piecemeal or in the
form of a nipple-shield, a thimble, or the finger of a glove.
In syphilitic sore throat, the uvula is sometimes entirely de-
stroyed ; at other times, it is perforated at its base.

Yin. The lesions of the pharynx resemble, for the most
part those of the tongue and tonsils ; but there are several
which are peculiar, and which therefore demand separate
consideration.

Acute pharyngitis is characterized, ordinarily, by redness
and tumefaction of the afl'ected part, with a secretion of thick,
grayish mucus. In the more severe forms, however, there is
additionally, an efl"usion of lymph, which appears either in
small patches, or, as is more frequently the case, as a contin-
uous layer over the whole surface of the reservoir. Hence,
on the one hand, the exudation generally extends upwards
over the tonsils and the soft palate ; and, on the other, down-
wards into the CESophagus, the larynx, the trachea, and even
the bronchial tubes. Much diversity obtains in regard to the
color and consistence of these adventitious membranes.
When first formed, they are usually of a light yellowish tint,
and so soft that they can be easily wiped off" with the finger ;
in a short time, however, they become grayish, and acquire
considerable tenacity, forming pretty hard incrustations. In
very intense cases, blood is apt to be exhaled, which, mixing
with the exudation, imparts to it a dark brownish hue. The
mucous membrane itself is of a deep livid complexion ; the
subjacent cellular tissue is infiltrated with serosity ; and all
the vessels are engorged to snch a degree that it is impossi-
ble either to inject them or unload them by pressure and ab-
lution.

This disease, which has been so ably portrayed by Dr.
Bretonneau, of Tours, is by no means an uncommon at-
tendant on small-pox and scarlet fever, but also occurs very
frequently as an idiopathic affection in children, especially in
such as are naturally weak, or who have become so by indis-

voL. II. 24

186 (ESOPHAGUS. [chap. VI.

position or impoverished, diet. The symptoms, as might be
expected, are generally severe ; and, when the exudation
extends down the air-passages, death is often induced
by suffocation, precisely as in pseudo-membranous croup.
Bretonneau, it should be observed, has bestowed upon this
inflammation the title of diphtheritic, a Greek term, indica-
tive of the pellicular, membranous, or skin-like excretion to
which it gives rise.

The pharynx is occasionally the seat of tubercles, of scir-
rhus, and of encephaloi'd. When the latter of these growths
attain a considerable magnitude, as they sometimes do, they
are apt to prove troublesome by their mechanical obstruction.
Mayo records a case where a scirrhous tumor, attached to the
laryngeal surface of the pharynx, gradually filled the passage,
and at length produced death by inanition. Polypous growths
are seldom met with in this situation. The only instance,
indeed, of which I have any knowledge is that related by
Professor Monro, of Edinburgh. It adhered to the fore part
of the pharynx by a narrow root, and was of such a length
that whenever the patient retched, it was thrown forward
against the incisor teeth.

The pharynx is liable to become sacculated, a blind pouch
being sometimes formed at its junction with the oesophagus.
This is most apt to happen at the posterior part, and the dis-
order is chiefly inconvenient, as having a tendency to entrap
particles of food in their descent from the mxouth to the
stomach. A bag capable of holding several ounces has been
thus formed.

IX. The diseases of the asophagus, though much less
numerous than those of the mouth and fauces, are not less
dangerous in their tendency, or less interesting to the student
of morbid anatomy. Amongst the most important of these
lesions may be mentioned diphtheritic inflammation, ulcera-
tion, softening, stricture, and scirrhous degeneration. In its
structure, the oesophagus very closely resembles that of the
intestinal canal, excepting that it is furnished with a distinct
epidermis, which abruptly disappears at the cardiac extremity
of the stomach. Its inner surface is of a whitish color, lon-
gitudinally wrinkled, and perforated by a great number of
follicles, situated beneath the proper mucous coat.

Simple asophagitis is marked by the usual symptoms of
redness, pain, and tumefaction, with dryness of the part, and
difficulty of deglutition. In violent cases, as, for example,

CHAP. VI.] ULCERATION, 187

when the inflammation is caused by corrosive poisons, there
is an abrasion of the cuticle, and an effusion of lymph. The
diphtheritic form of the disease is often witnessed in hydro-
phobia ; and there is reason to believe that it is sometimes
caused by a suppression of the cutaneous perspiration. A
remarkable instance of this is mentioned by Dr. Abercrombie,
of a gentleman who caught cold in travelling to Edinburgh.
The fauces were of a slight red color, and he complained of
great soreness of the throat, with hoarseness of the voice,
and considerable difficulty of swallowing. His case at
length assumed a typhoid character, and at the end of
about three weeks from the commencement of the disease
he died. On examination, the whole of the cesophagus was
found to be lined by a soft adventitious membrane ; and a
similar exudation was traced over the pharynx and epiglottis.

Last winter. Dr. Bamford sent me the stomach and oesopha-
gus of a boy, thirteen years old, who suddenly expired in con-
vulsions after an illness of three days. The patient complained
of severe pain in the fauces, and had great difficulty of swal-
lowing, every attempt of the kind being followed by spasm of
the throat, especially when the substance was of a fluid nature.
On inspecting the oesophagus, I found it lined throughout by
a thin layer of lymph, closely adherent to the natural mucous
coat, which was itself highly injected, and of a bright red
color. The stomach was perfectly sound, the inflammatory
appearances terminating abruptly at the cardiac orifice. Dr.
Mount, who attended the lad, and was present at the exami-
nation, informed me that he traced the adventitious mem-
brane also around the mouth of the larynx and over the
whole of the fauces.

These membranes rarely become organized. When the
inflammation subsides, they gradually lose their moisture
together with their adhesive properties, and are either vomited
up in small tubular fragments, or swallowed and digested,
or passed by stool. Andral refers to a case where an exu-
dation of this kind was found in the oesophagus of a new-
born infant. It lined the tube for about a third of its extent,
and seemed to be almost identical with its substance.*

Ulcers of the oesophagus most frequently occur at the
upper part of the tube, near its junction with the pharynx.
They may be of various forms and dimensions ; and, in the

* Pathological Anatomy, by Townsend and West, vol. ii. p. 172.

188

(ESOPHAGUS.

[chap. VI.

generality of cases, their edges are smooth and but httle
thickened. When, however, as it sometimes happens, they
are associated with scirrhns, the surrounding structure is very
much elevated, and often consists of a dense fleshy sub-
stance, interspersed with gristly matter. These ulcers some-
times lead to perforation, though this is of rare occurrence.

Abscesses sometimes form between the coats of the oesoph-
agus, and, by compressing the trachea, affect the breathing.
When very large, they encroach upon the caliber of the gul-
let, and impede deglutition. Dysphagia also sometimes results
from enlargement of the thyroid gland, projection of the dorsal
vertebrse, and aneurism of the aorta. In a man, forty-nine
years of age, whom I examined in 1827, the oesophagus and
aorta communicated by a large aperture, through which
more than half a gallon of blood suddenly passed into the
stomach, and thus caused death. The principal symptoms
were dyspnoea, spitting of blood, and pain in the inferior part
of the chest, in the region of the gullet.

Softening of the oesophagus, of the same nature as that of
the stomach, is sometimes observed. One of the most com-
mon effects of this lesion is a perforation of the walls of the
tube, and an escape of fluid into the thorax. The opening
usually occurs near the cardiac extremity of the oesophagus,
in connection with an inflamed, softened,
or perforated state of the stomach, though
occasionally there is no appreciable altera-
tion whatever in any of the surrounding
textures. No age seems to be exempt from
this lesion, and in one or two instances it
has been observed even in the new-born
infant.

Stricture of the oesophagus almost always
results from inflammatory thickening of the
submucous texture, with more or less altera-
tion of the proper linings. A sort of ring,
of variable depth and firmness, is thus
formed, (Fig. 52,) which encroaches upon
the channel, and produces great difliculty
in swallowing, aggravated frequently by
spasmodic exacerbations. In a case which
I examined some years ago, the tube was
so much contracted, that it would scarcely
admit a common-sized quill. The stric-

CHAP. VI.] MALFORMATIONS. 189

ture, which was about half an inch deep, and of gristly firm-
ness, was seated within three inches of the cardiac extremity
of the stomach, and the patient literally died from inanition.
The ordinary place of stricture, however, is not so low
down, but near the junction of the tube with the pharynx.
In the early stage, the disease is curable by the use of bou-
gies ; but, if it be neglected, the contraction progressively
increases, and the oesophagus finally ulcerates, and opens into
the posterior mediastinal cavity, the trachea, or the lungs.
The part above the stricture is sometimes sacculated. Monro
describes a case, in which the enlargement was so great that
the patient could retain nearly a pint of fluid for ten minutes,
and in the mean time converse with his friends ; and in an-
other, mentioned by Purton, the sac was capable of holding
two quarts.* Occasionally the stricture is of a spasmodic
nature, being produced by the contraction of the circular
fibres of the oesophagus. In this case, the difficulty is
generally temporary, and may be easily overcome by a
bougie.

The walls of the oesophagus are sometimes of a scirrhous
hardness, or almost cartilaginous, and even ossified. Cases
of this kind are referred to by Bonetus, Morgagni, and some of
our modern writers ; but there is reason to believe that they
are of very infrequent occurrence, especially when unasso-
ciated with stricture.

The oesophagus, finally, is liable to various congenital
malformations. These, although not of frequent occurrence,
constitute a very interesting subject of study to the patho-
logical anatomist. Nevertheless, a bare enumeration of them
is all that we can hope to do, with any prospect of success,
in the present state of our knowledge. The following
arrangement will be found to embrace the most important
deviations which have hitherto been observed : 1. the oesoph-
agus terminates in a cul-de-sac, either within a few inches
below the pharynx, or at a short distance above the cardiac
extremity of the stomach ; 2. it is obliterated, contracted, or
converted into a solid cord ; 3. it is unnaturally dilated, or
even double ; 4 it is totally deficient, the pharynx ending in
a blind pouch, and the stomach having no cardiac orifice ; 5.
it communicates with the trachea. Of the latter variety, a

* London Medical and Physical Journal, December, 1821.

190 (ESOPHAGUS. [chap. VI.

highly interesting and instructive case was observed by Dr.
Martin, of Marseilles, in an infant, that died thirty-six hours
after birth. On dissection, there was found to be an entire
absence of the pharyngeal extremity of the oesophagus ; but
an aperture existed in the trachea, just above its bifurcation,
through which a probe could be passed into a thin, membra-
nous, elastic tube, of the diameter of a small quill, that led
to the stomach, and thus established a communication be-
tween the cavity of that organ and the air-passages.

CHAPTER VII.

Of the, Stomach and Bowels.

SECTION L
Organization of the Gastro-Enteric Mucous Membrane.

I. Organization of the Gastro-Enteric Mucous Membrane. — Thickness and
Consistence. — Cellulo-fibrous Tunic. — Mucous Follicles. — Glands of Brun-
ner and Peyer. — Villosities. — Color of the Membrane j how modified by
Age, Digestion, and other circumstances. — II. Infiammation. — Anatomical
Characters of the acute form of the Disease. — Increased Vascularity. — Dry-
ness. — Thickening. — Softening. — Deposition of Lymph. -^ Formation of
Vesicles. — Effusion of Blood and Serum. — May pass into Gangrene or become
Chronic. — III. Softening ; of two kinds, from Inflammation and the aclion of
the Gastric Juice. — Experiments of Hunter and Carswell. — IV. Diseases
of the Stomach. — Ulceration. — Hypertrophy and Atrophy. — Formation of
Potiches. — Cartilaginous Degeneration. — Carcinoma. ^— V. Lesions of the
Duodenum. — VI. Affections of the smalt Boivels, properly so called. — Ulcera-
tion of the isolated Crypts and of the Glatids of Peyer. -^ Tubercular Deposits.

— Milt-like Tumor of Monro. — Melanosis. — Intussusception. — Hernia.

— Atrophy and Hypertrophy. — Earthy Concretions. — Vll. Lesions of the
large Bowel and Anus. — Ulcers. — Wart-like Vegetations. — Singular Con-
traction of the Colon. -»- Carcinoma. — Fissure of the Anus. — Organic Stric-
ture of the Rectum. — Hemorrhoids. — Fistula. — Prolapsion of the Bowel.

— Congenital Vices. — VIII. Intestinal Worms. — Lumbrfcoldes. ^^ Oxyuris.

— Tricocephalus. — Taenia Solium. — Taenia Lata.

Previously to describing the different lesions of the sub-
diaphragmatic division of the ahmentary tube, it will be use-
ful to direct the attention of the reader, for a few moments, to
the appearances which it presents in the normal state, as a
knowledge of this kind will the better enable him to discrimi-
nate what is sound from what is morbid. The remarks,
however, which I shall make, are designed to have more
especial reference to the mucous membrane ; upon which, as
is well known, the violence of almost all gastro-enteric affec-
tions is mainly spent.

In the sound state, the alimentary tube is perfectly smooth,
semi-transparent, free from adhesions, more or less vascular,
and covered internally with a thin, ropy mucus. The thick-

192 MUCOUS MEMBRANE. [cHAP. VII.

ness of its walls varies in different portions of its extent,
being greatest in the duodenum, the stomach, upper half of
the jejunum, and the rectum, and least in the ileum, the
lower half of the jejunum, and the colon. In the latter situa-
tions, indeed, the tenuity is generally so considerable that the
bowel on being spread out upon a printed sheet enables us to
distinguish the letters, owing, doubtless, to the almost entire
absence of mucous folds and villosities.

' With regard to the stomach, the thickness of the mucous
coat varies remarkably in the cardiac and pyloric divisions.
In the former it is comparatively thin and delicate, especially
around the oesophageal orifice and in what is called the great
cul-de-sac : but, as we proceed towards the right side, it
gradually augments in thickness, becomes more and more
opaque, and is studded with an immense number of follicles,
upon which these differences seem mainly to depend.

But there is no portion of the alimentary tube in which the
mucous membrane is so thick and opaque as in the upper
two thirds of the duodenum. From thence on it becomes
gradually thinner and thinner, until it reaches the lower divis-
ion of the small bowel, where it is so delicate as to give the
tube a semi-transparent appearance, except along the glands
of Peyer. In the colon, the thickness of the mucous lining is
considerably less at the right side, and at the commencement
of the arch than in the descending portion or in the left half
of the arch. The thickness appears again to diminish in the .
sigmoid flexure ; but, on arriving in the rectum, it suddenly in-
creases, and continues so to do until a short distance before it
terminates at the margin of the anus.

The mucous membrane of the stomach and bowels has no
epidermic covering, in which respect it differs essentially from
that of the oesophagus. The existence of such a structure
has, it is true, been admitted by numerous and highly re-
spectable anatomists, from the time of Haller until the present
moment. The peculiar manner in which the oesophagus is
inserted into the stomach has induced many to believe that
the epithelic lining of that tube terminates at the cardiac ex-
tremity of that viscus precisely in the same manner as the
corresponding covering of the vagina at the lips of the uterus.
Haller and Bichat, acknowledging that it is impossible to
demonstrate the epidermis of the alimentary canal, neverthe-
less maintain that we may infer its presence from the mem-
braniform substances which are occasionally discharged from

SECT. I.] ORGANIZATION, 193

the bowels. This supposition, however, may be very easily
controverted by the fact that all such excretions are the prod-
uct of inflammatory action, one of the eff'ects of which is an
effusion of sero-albuminous matter, Avhich, having acquired a
certain degree of consistency, is gradually detached from the
free surface of the mucous tunic, and finally expelled in the
form of a distinct membrane, not unlike that of croup.

Exudations of the kind here adverted to are by no means
uncommon, either in the gastro-pulmonary, or in the genito-
urinary division of the mucous system. I shall hereafter
have occasion to refer to cases in which they were noticed
even in the urinary bladder, the vagina, and the uterus ; and
shall therefore content myself, for the present, with remarking
that these membranous productions, no matter in what part
of the. body they are found, are always of a similar nature,
both as respects their physical properties and their chemical
constitution.

Taking into consideration, therefore, the fact that these
concretions are always the result of inflammatory action, and
the circumstance, moreover, that they are essentially different
from the epidermis iu their appearance and composition, it is
obvious that they cannot be adduced in favor of the opinion
of the existence of such a structure in the gastro-enteric divis-
ion of the mucous system. Did this membrane really exist
here, is it not reasonable to suppose that it could be displayed
by the same process that it can in the mouth, the oesophagus,
or the vagina ? But this has never yet, at least so far as I
know, been done, the most careful dissection, maceration, and
boiling having alike failed in accomplishing it.

The natural consistence of the mucous membrane of the
alimentary tube is liable to considerable variation ; but it may
be stated, as a general rule, that it is in direct proportion to
its thickness. Thus it is much more firm in the pyloric half
of the stomach than in the cardiac ; and it is in that situation,
also, that it has the greatest degree of thickness. In the
duodenum the rule does not hold good ; for, although the mu-
cous membrane is thicker and more opaque here than in any
other portion of the digestive canal, yet, owing to the presence
of the glands of Brunner, which are remarkably large and
numerous, as well, perhaps, as to some peculiar mode of or-
ganization, the structure in question is exceedingly brittle,
and can seldom be raised except in very small fragments.
Lower down, the consistence of the membrane progressively

VOL. II, 25 .

194 STOMACH AND BOWELS. [cHAP. VII.

increases, so that, in the inferior third of the jejunum and in
the ileum, it may be torn from its connection, in pieces varying
from three hues to half an inch in length. In the large
bowel, the cohesive property again diminishes, and the mem-
brane can be detached only in small shreddy patches. It need
hardly be remarked that the normal consistence of the mu-
cous coat of the alimentary tube is much less in the infant
than in the adult. At what period of life it attains its maxi-
mum developement in this respect, is a point concerning which
we cannot communicate any positive intelligence, as it is a
question which has not yet been determined.

The mucous membrane of the digestive organs is amongst
those tissues which do not readily yield to putrefaction. The
softening that is produced under the influence of this cause
is always a very gradual process, and there can therefore be
little danger of confounding it with that which results from
the action of the gastric juice, or from inflammatory irritation.
The changes in the surrounding organs, as well as in the
other tunics of the alimentary tube, which must always, to a
greater or less degree, participate in the putrefaction, would
be alone suflicient to enable us to distinguish the diflference,
and prevent any difficulty in relation to the subject.

The tissue which serves as a bond of connection between
the mucous and the muscular coats of the alimentary canal
is of a cellulo-fibrous nature, and deserves to be attentively
considered, from the important character which it plays in the
dii'erent lesions of this part of the body. In the normal
state it is of a pale grayish color, very thin, yet so dense and
tenacious as to be capable of very great resistance. Sending
a great number of minute processes between the muscular
fibres, it is attached to the middle much more firmly than to
the mucous tunic, and seems to consist of a very close, dense
net-work, the filaments of which may be separated from each
other by protracted maceration, by boiling, and careful dis-
section. It is this structure concerning which so much is
said by the ancient anatomists under the name of the 7iervous
coat.

This coat — for so indeed it deserves to be considered —
is much more distinct in carnivorous animals than in her-
bivorous, or than in the human subject. In the small
bowel of the lion and the bear, it forms a thick, opaque
lamella, of a whitish color, and of a fibrous consistence,
which adds very much to the strength of the tube, and re-

SECT. I.]

MUCOUS FOLLICLES.

19c

ceives the larger ramifications of the vessels, preparatory to
their distribution to the mucous membrane.

The mucous membrane of the stomach and bowels is fur-
nished every where with minute glands^ crypts, ox follicles,
(Fig. 53,) the study of which, in a pathological point of
view, is of the very highest impor-
tance. In the normal state, these
little bodies are always recognized
with great difficulty, but are ren-
dered very evident in certain morbid
conditions, especially in chronic diar-
rhcEa, cholera, dropsy, and pulmo-
nary phthisis. Seated in the sub-
mucous cellular tissue, they are cov-
ered over by the proper mucous
corion, and are of an irregularly
oval, rounded, or spherical shape,
presenting each a minute orifice
leading to a blind cavity. These
glands, although they are found
throughout the entire mucous sys-
tem, have been most frequently ex-
amined in that part of the alimentary
canal, where they occur in vast mul-
titudes. In most situations, however,
they are so much flattened, that they
do not project sensibly upon the free surface of the mucous
membrane, on which account they often appear to be much
less numerous than they actually are.

In children, the gastro-intestinal follicles are naturally more
developed than in adults, and consequently are much more
easily recognized. In order to discern them distinctly, the
mucous tunic must be thoroughly cleansed, and then held
between the eye and the light, when they will appear like
minute dots, of an opaque grayish color, and with a delicate,
central aperture, the margins of which are often quite dark.
The difficulty of distinguishing these hJtle bodies will be
much lessened if the part to be examined be previously
steeped in warm vinegar, as was first suggested, I believe, by
Willis. I have frequently tried this method, and always
found it decidedly advantageous. Their structure, so far as
it can be ascertained by careful microscopic inspection, seems
to be very simple, being made up entirely by a congeries of

196 STOMACH AND BOWELS. [cHAP. VII.

vessels, connected together by the most dehcate celhilar tex-
ture. Their internal cavity, which can occasionally be beau-
tifully displayed by inflation with the blow-pipe, is perfectly
smooth and uniform, and constantly bedewed with a thin
mucous secretion.

In the stomach alone, the number of these glands amounts,
according to the recent calculations of Professor Horner, to
one million two hundred and sixty-six thousand ; or, in
other words, estimating the area of the inner surface of this
organ at ninety square inches, he supposes that each cubic
inch has fourteen thousand and four hundred follicles. In
the intestinal tube, their number appears to be still greater.
Allowing the area of the whole canal to be two thousand
square inches, and that there are about twenty-two thousand
of these little bodies on every inch, it would follow that the
entire number, in the small and large bowels, is from forty-five
to forty-eight millions. If this evaluation be correct, the
mucous follicles must be infinitely more abundant than is
generally imagined : as all microscopic observations, however,
are liable to great deception, and more especially as all these
bodies can never be discerned at the same time, so as to
enable us to count them, it is not improbable, I think, that
the distinguished anatomist to whose name I have adverted,
has fallen into error, his estimate far transcending the natural
limits.

In their size, the mucous follicles vary in different parts of
the gastro-enteric membrane. In the stomach, the largest
are about the twelfth of a line in diameter, the smallest about
the twentieth of a line. In the duodenum, where they are
denominated the glands of Brunner, after a German anato-
mist who first described them, their volume is much greater,
most of them being a line in diameter ; and they are generally
so prominent, especially for the first four inches of that tube,
as to give the free surface of the lining membrane a peculiar
granulated aspect. In the mesenteric portion of the small
intestines, their dimensions are greater than in the stomach,
but less than in the large bowel, where they are also more
easily recognized.

Besides these isolated crypts, there are other mucous folli-
cles which are limited to particular portions of the intestinal
tube, and which have recently attracted the special attention
of pathologists, from the appearances which they present in
certain diseased states of the system. I need scarcely say

SECT. I.J

peyer's glands.

197

Fig. 54.

that I allude to the glands of Peyer, or, as they are now

very generally called by the French writers, the elliptical

plates. (Fig. 54.) They occur almost exclusively in the

lower half of the ileum, none having yet

been observed, except, in a few instances, in

the jejunum or duodenum. Their number

is very variable ; but, as a general rule, it

may be stated that there are from eighteen

to twenty-five. More than these I have

never seen, and but rarely so many. Louis

tells us that there are from twenty to thirty ;

and Lelut asserts that he has several times

counted from fifty to sixty.

The shape of most of these glands is ellipti-
cal ; whence the epithet which has been ap-
plied to them by the French anatomists. Not
a few of them, however, are circular, and not
unfrequently they are remarkably angular.
They are uniformly situated opposite the
attachment of the mesentery, and are from one half to two
inches in length, by five or ten lines in width, becoming
larger and more numerous as they approach the coscum.
Considerably elevated above the circumjacent parts, they im-
part to the finger a rough, mammillated sensation, and are
easily distinguished by their opaque, grayish appearance.
Often they are studded with minute dark-colored points,
which indicate the mouths of the follicles which compose
them, and of which there are in each patch, according to its
dimensions, from twenty to several hundred. Dr. Lelut, a
writer whose name I have already quoted, affirms that, by
dessication, a thousand of these crypts may occasionally be
demonstrated in a single gland.

The seat of these glands, like that of the isolated follicles,
is in the submucous cellular tissue. What their precise struc-
ture is, is a point which has never been satisfactorily deter-
mined by anatomists. That it is different from that of the
glands of Brunner it is perfectly reasonable to suppose ; other-
wise why should they display such peculiarity of- arrange-
ment, and be confined exclusively to one particular portion of
the alimentary tube ? Another argument, which may be
adduced in support of their dissimilarity, is the fact that they
are extremely prone to disease, and that they are frequently
affected, nay, almost totally disorganized, and yet the isolated

198 STOMACH AND BOWELS. [CHAP. VII.

follicles remain quite sound. Ignorant, thus, of their true
nature and character, how can it be presumed that Ve should
know any thing of their functions ? Are not the thousands
and thousands of isolated folHcles which every where stud
the lining membrane of the ileum sufficient to furnish all
the mucus that is required to lubricate its surface ? Or does
this portion of the digestive canal, so differently organized
from the rest, perform some peculiar office, and consequently
demand some peculiar secretion ? All these are questions
which, desirable as it would be, cannot be solved in the pres-
ent state of the science.

Another distinguishing trait of the gastro-enteric division
of the mucous membrane is the circumstance of its being
covered with numerous villosities, which give it the feel and
aspect bf a piece of velvet. These are minute, delicate little
bodies, which, although seen by Assellius and others, were first
accurately described, in 1721, by an anatomist of the name
of Helvetius. Extremely numerous in the small intestines,
especially in the duodenum and upper half of the jejunum,
they are supposed by some to be wanting in the stomach and
the colon ; which, however, is not the case, as any one may
assure himself by careful examination with the microscope,
or even, in certain pathological conditions, with the naked
eye.

The villosities are best seen by inverting a portion of
bowel, and then immersing it in clear water, when they can
be made to move gently amidst the fluid, in the form of minute
processes, projecting from the free surface of the mucous mem-
brane. About the fifth of a line in length, they are much
larger in the upper than in the lower portion of the digestive
tube, and, when injected, or rendered turgid, as they naturally
are during chylification, they acquire almost double the ordi-
nary volume. They are arranged very compactly, and, as
there are about four thousand upon every square inch, Meckel
supposes that the whole number of them may be estimated
at more than one milion, — an evaluation, doubtless, far short
of the truth. In their shape, some of these bodies are coni-
cal, some cylindrical, some bulbous. Their vascularity is
extremely great, the base of each being encircled by a most
delicate wreath of blood-vessels and lymphatics. Of their
minute structure, as it has no relevancy to the subject before
us, I forbear saying any thing on the present occasion.

Organized in the manner here stated, the gastro-enteric

SECT. I.] COLOR OF THE MUCOUS MEMBRANE. 199

mucous membrane is most liberally supplied with blood-
vessels, with nerves, and with lymphatics. If we examine
a portion of bowel, and. carefully trace its vessels as they creep
along beneath the peritonseal covering, it will be seen that,
as they approach the submucous cellular tissue, they gradu-
ally decrease in size as they augment in number, until finally
they resolve themselves into a beautiful capillary net-work.
These ultimate ramifications, which are divided to an infi-
nite degree of minuteness, being much smaller than the finest
hair, are spread over the adherent surface of the mucous
corion, where they intersect one another in every conceivable
direction ; thus giving the intestine, when they are filled with
size and vermilion, the appearance almost of a piece of scarlet
cloth. The intervals of this vascular net are occupied by
follicles and villosities, which are themselves, as before inti-
mated, most abundantly supplied with vessels and nerves,
every thing relating to their organization being of the most
delicate and exalted character.

How the capillaries of the mucous membrane terminate
is a problem which, although it has engaged a large share
of the attention of the anatomists of all ages, has not yet
been satisfactorily solved. The thin sero-mucous fluid with
which it is constantly moistened, induced Haller, and since
his time Bichat, Soemmering, and others, to infer the exist-
ence of arteries with open mouths, or, in other words, ex-
halant vessels. But, as no such vessels have yet been dis-
covered, or satisfactorily demonstrated, the most philosophical
explanation that can be offered, in the present state of our
knowledge, is, that the capillary arteries in question commu-
nicate directly with the capillary veins ; and this doctrine, I
conceive, is amply sustained not only by the phenomena
which are witnessed in the mucous membrane of the stomach
and bowels of living animals, but likewise by what is ob-
served in minute artificial injections.

But concerning no one subject is it of so much importance
to have correct ideas as of that which relates to the natural
color of the gastro-enteric mucous membrane. Much as this
point has occupied the attention of anatomists, it is to be
feared that our information is still very far from being satis-
factory. Nor, indeed, considering the difficulties attending
the investigation, could this be expected to be otherwise.
Seated beyond our visual reach, it is only by accident, as it
were, that we can at all approach the mucous membrane in

200 STOMACH AND. BOWELS. [cHAP. VII,

the healthy state ; and, although every opportunity has been
diligently embraced to ascertain its normal appearances, yet
so discrepant are the statements of the observers who have
distinguished themselves in this field of physiological inquiry,
that it is often extremely difficult to reconcile them, and
sometimes impossible to draw from them any useful deduc-
tions.

That the color of the gastro-enteric mucous membrane
should vary in the different periods of life, no one can doubt ;
nor, considering that the physical cause of it is the accumu-
lation of blood in the capillary vessels, can it appear strange
that it should be influenced by the state of the general sys-
tem, and by the state of vacuity, or repletion of the organs
which this texture serves to line. Thus, then, may it be
safely assumed as a general proposition, that the color of the
villous coat of the stomach and bowels is different in the
child from what it is in the adult ; that it is deeper in the
strong and robust than in the weak and sickly ; and that it is
several shades lighter when these reservoirs are empty than
Avhen they are distended with food.

In the foetus, and the child soon after birth, the color of
the mucous coat is of a light rose, interspersed with small
milky spots ; in the adult, it is more of a whitish appearance,
but still preserves some degree of its reddish tint ; towards
middle life, it assumes a dull grayish aspect, which continues,
gradually increasing, until finally, in decrepitude, it becomes
quite cineritious.

During digestion, the mucous membrane of the stomach
is of a light red color, approaching almost to vermilion,
especially in the young subject, from the second to the tenth
year. (PI. I, Fig. 1.) The duodenum, and occasionally even
the jejunum, participate in this increased vascularity, which
always diminishes in proportion as the process of chymifi-
cation advances to completion. Except from this circum-
stance, this portion of the small intestine never presents that
red dye which has been ascribed to it by different writers.
Although this redness uniformly exists, to a greater or less
extent, during digestion, yet there is no doubt it is essentially
modified by the quality, as well, perhaps, as by the quantity
of the food.* (PI. I, Fig. 2.) Dr. Gendrin, of Paris, ascer-

*' Dr. Beaumont, of the United States army, who had the rare opportunity of
inspecting the gastric mucous membrane through a fistulous channel in the ab-

Fig. 2.

lU,..'i.

Tig. 6.

'mu-mii^^iiiimmmmti

Fio.16

C>r^.-^ jirA

Fig.l7.

Tig. 13.

Fig. 12

Tic/ 9-

s

ri^.io

Z WBoLives i.itli'^.So

SECT. I.] COLOR OF MUCOUS MEMBRANE. 201

tained that if two dogs, of the same size and age, be fed,
the one upon milk, and the other upon fatty broth, highly-
seasoned with salt and pepper, and both be killed an hour
after, the mucous membrane of the stomach of the latter will
be of a mnch deeper red than that of the former, at the same
time that the augmented vascularity will extend much further
down the small bowel. From this circumstance, which exerts
so great an influence upon the rest of the alimentary tube,
the ileum and colon experience little or no variation in their
appearance.

The redness which supervenes during digestion is re-
markably lessened, but never completely effaced by exsangui-
fication. Of this, any one may convince himself by opening
an animal during the process of chymification, and cutting
across the aorta and vena cava, the latter especially, which, as
is well known, has always the effect; when divided, of giving
the surface of the alimentary tube a pale, blanched appear-
ance.

The color of the gastro-enteric mucous membrane is con-
siderably influenced by the kind of death. In general, the
rosy tint very much diminishes, so that we commonly find
in young children that have died of protracted diseases, an
unnatural pallor, amounting sometimes almost to a milky
whiteness. In persons who are drowned, hung, or otherwise
asphyxiated, the inner surface of the stomach and bowels is
often of a crimson color, occurring either continuously or in
large patches. Dr. Yellowly, of England, who has devoted
much attention to this subject, states that he has observed
this condition of the mucous coat of the stomach successively
in five executed criminals ; and Professor Monro, of Edinburgh,
informs us that he has repeatedly, under similar circumstances,
seen the gastric lining of a tile red. In a mulatto woman,
who was executed in Kentucky, in the winter of 1835, and
whose body I had an opportunity of inspecting soon after
the event, the whole mucous surface of the alimentary tube
was so deeply injected, as to present a deep lake color, espe-
cially distinct in the stomach, and in the inter- valvular spaces
of the jejunum. Similar phenomena I have had occasion to
witness in a female who was destroyed by manual strangula-

domen, states that the color of the inner surface of St. Martin's stomach, when
emptj', was usually of a pale pink ; but that, on the application of food, the ac-
tion of the vessel became augmented, and the color of the villous tunic consid-
erably heightened.

VOL. II. 26

202 STOMACH AND BOWELS. [cHAP. VII.

tion, in a man who hinig himself, and in dogs and rabbits
asphyxiated for experimental purposes.

In an individual who died very suddenly from ossification
of the coronary arteries, and whose abdominal viscera seemed
to be in every respect sound, Professor Horner found the
mucous coat of the stomach thrown into numerous folds, the
sides and summits of which were of a bright brownish color,
produced apparently by thousands of microscopic points of
blood, detained in the capillaries : in the depressions between
the wrinkles, the organ was of a dull pearl color. The
jejunum was of a still deeper hue, and of a more uniform
tinge than the stomach. The mucous coat of the colon was
of a dull grayish color. In another person, who died within
half an hour after eating a hearty meal of soup, bread, and
potatoes, the lining membrane of the stomach was, through-
out, of a red crimson hue, and that of the intestines of a hght
brownish.

If an animal be kept without food for three or four days,
and then killed, the stomach and bowels will be found to be
of a red rose color ; the mesenteric vessels considerably dis-
tended with blood ; the isolated follicles enlarged ; and the
villous membrane unnaturally rough, softened, and easily
detached. Not unfrequently, indeed, the color of these organs,
under such circumstances, will be of a cherry red, bright lake,
or vermilion. If the abstinence, however, be prolonged for
a considerable period, then the mucous membrane, partici-
pating in the general anemia of the system, will be apt to
be pallid, though cases occasionally occur, even in the human
subject, in which the reverse of this obtains.

Various substances, when taken into the stomach, have the
property of imparting to the mucous membrane a deep red
color, which may be mistaken for the effect of poison. Of
this nature, are the infusions of logwood and red poppy, to-
gether with black currants, the tincture of cardamom, and
the compound spirits of lavender. A knowledge of these
facts is of much importance in a medico-legal point of view :
as a person, after having swallowed freely of some one or
other of these substances, might suddenly expire, and from
the mucous membrane of the stomach and bowels being
found of a red tinge, the suspicion might arise that he had
been poisoned. Of this, a most instructive case is recorded
by Fodere, in his learned treatise on juridical medicine.

It was stated in a previous })art of this work, that the

SECT, II.] GASTRO-ENTERIC MUCOUS MEMBRANE. 203

nitrate of silver, when taken internally for a long time, had
the effect of staining the external integument with a gray-
slate color. Similar results follow in regard to the mucous
membrane of the alimentary canal. In a case examined by
Dr. Rayer, of Paris, where the substance in question was
taken for thirteen months, for the cure of epilepsy, conse-
quent on disease of the brain, the internal surface of the
whole alimentary tube, together with the interior of the
mouth and sides of the tongue, was of a gray slate color. In the
stomach the tint was extremely deep, and uniformly diffused ;
in the bowels, it was somewhat more faint, but still quite
appreciable, and was interrupted here and there by minute
vascular specks. The skin exhibited a precisely similar hue.
The above case is by no means a solitary one.

In traumatic fever, caused by wounds of the head or ex-
tremities, the mucous membrane often assumes a bright red-
dish color, which, although it does not seem to be always
associated with derangement of the digestive passages, cannot
be easily removed by exsanguification. This fact, which
seems to have been first experimentally ascertained by Dr.
Gendrin, has been fully corroborated by the later researches
of Mr. Swan, of London. The numerous observations of
this distinguished anatomist have proved, in the clearest
manner, that the insertion of any of the mineral poisons, or
even mercurial frictions, on the back of a dog, after shaving
off the hair, communicates a red color to the villous coat of
the whole alimentary tube.*

SECTION II.

Of Inflammation of the G astro -Enteric Mucous Memhrane.

With these preliminary observations concerning the healthy
structure and appearances of the gastro-enteric mucous mem-
brane, designed to enable the young pathologist to avoid
some of the many difficulties which beset this most interest-
ing field of inquiry, I proceed, secondly, to take up the sub-
ject of its morbid anatomy. In entering upon this important

* Monro, Morbid Anatomy of the Gullet, Stomach, &c. p. 313.

204 GASTRO-ENTERIC MUCOUS MEMBRANE. [cHAP. VII.

topic, I do not deem it necessary to consider the lesions of
each portion of the ahmentary tube separately ; to do so, in-
deed, would only lead me into useless repetitions, and compel
me at each step to recount what has been already stated.
Possessing the same structure, the stomach and bowels, small
as well as large, must be liable to the same diseases, whether
acute or chronic, whether simply inflammatory or organic ;
and therefore, for all practical purposes, there can be no
reason whatever why they should not be all described under
one general head. Nevertheless, the method that will be
pursued in the following pages will be somewhat different
from that which the plan here stated might be presumed to
indicate. Thus, after having discussed the subject of acute
inflammation, together with its several terminations, with
reference to the gastro-enteric mucous membrane generally,
I shall proceed to speak of the various organic lesions as
they affect each section of the alimentary passages in par-
ticular. Adopting this method, I shall be enabled the better
to point out, what may be deemed of no trifling utility, the
pathognomonic symptoms, so far as they are known, of those
chronic affections of the stomach and bowels which are such
a stumbling-block to the young practitioner.

The signs which anatomically characterize acute ijijiam-
mation of the mucous membrane of the alimentary tube are,
increased vascularity, loss of transparency, dryness, thick-
ening, softening, deposition of lymph, and the formation
of small vesicles, with alteration of the natural secretion and
effusion of serum into the submucous cellular tissue. How far
each of these phenomena is to be regarded as denotive of
diseased action, I will now endeavor, as concisely as possible,
to point out.

The first perceptible effect produced in the inflamed mem-
brane is a change of color, resulting from an augmented flow of
blood to the affected part. The shades of tint induced by this
species of irritation are extremely numerous, but may be
properly referred to modifications of red, brown, slate, and
black. Of these, the first is by far the most common in acute
inflammation, whilst the other three are more usually the
product of a chronic process, in which the coloring principle
of the blood, perfectly incorporated as it were with the mu-
cous texture, is variously altered in its properties, either from
simple stagnation in the miimte capillaries, or from contact
with the acid and gaseous contents of the alimentary tube.

SECT. II.] inflammation; redness. 205

The inflammatory redness, although sometimes widely dif-
fused, usually occurs in small irregular patches, separated by
considerable intervals of sound membrane. Yarying in diam-
eter from a few lines to several inches, they often project
sensibly beyond the level of the circumjacent parts ; and, in
violent cases, are always of a bright red color, looking a good
deal like so many pieces of scarlet velvet. Connected with
this augmented vascularity, are commonly to be observed
certain changes in the mucous and subjacent textures. In
the early stage of the disease, there is perhaps merely a slight
degree of opacity, with a rugose condition of the free surface
of the membrane. Afterwards, however, as the inflammation
progresses, the reddened patches lose their tenacity, and be-
come covered with a thick, ropy mucus, elevated into small
vesicles, chapped, or fissured, or studded with flakes of lymph.
Should all or several of these phenomena be present, no
doubt can be entertained concerning the true nature of the
disease : they are signs which no one can mistake, and which
are as unequivocal as though they were drawn in characters
of gold.

But it is not always that the inflammatory redness is thus
distinctly marked ; and hence much difficulty is sometimes
experienced in discriminating between it and that which is
natural. Attention has been already directed to the well-
ascertained fact, that stimulating viands or drinks received
into the alimentary canal produce an efiiux of blood to the
vessels of this cavity, by which the color of the mucous
membrane is often so greatly heightened as to exhibit an ap-
pearance not unlike what is observed in inflammation. This
circumstance should be constantly borne in mind in making
post mortem examinations, otherwise the most serious mis-
takes must frequently be the consequence. How, then, are
these two conditions to be distinguished from each other ?
for upon the correct decision of this point hinges the pathol-
ogy of a large number of the diseases of the stomach and
bowels. The answer is obvious, — by comparison.

Thus, the inflammatory redness has rarely that uniform tint
which is to be observed in the sound membrane ; on the con-
trary, it is usually somewhat mottled, and, instead of termin-
ating, as does the other, by insensible gradations, it almost
always stops abruptly. Most frequently the inflammatory
discoloration occurs in small irregular spots, situated at differ-
ent points of the circumference of the tube ; whereas that

206 GAisTRO-ENTEKIC MUCOUS MEMBBAx [CHAP. VII.

resulting from simple congestion is commonly diffused over
a large extent of surface, or is confined to the most depending
parts. Another important trait is to be derived from the con-
dition of the abdominal vessels. In inflammation, the dis-
tended capillaries seem as it were lost, or, in other words,
cannot be traced to any particular trunk ; the reverse of
which obtains when the redness is c'adaveric, or caused by
mechanical obstruction. The blood, too, in the former case,
cannot be pushed about so easily from one place to another,
from the great firmness with which it is impacted in the mi-
nute vessels, added, perhaps, to some preternatural viscidity
of its fibrin, or to the abstraction of some of its aqueous prin-
ciples. For the same reason, also, maceration produces its
effects much more slowdy than in the sound state, and minute
injections seldom succeed so well, many of the vessels giving
way in consequence of the difiiculty of displacing their con-
tents. These characters are not, of course, so well marked
in incipient as in confirmed inflammation ; still they almost
always exist to a greater or less extent.

Besides these diagnostic signs, it may be further stated
that the mucous membrane, when inflamed, is always deci-
dedly opaque, from the engorgement of the capillary vessels,
which exhibit the appearance of a fine net-work, more dis-
tinct generally at the adherent than at the free surface of the
mucous tunic. In the healthy state, on the contrary, or even
when there is a slight degree of congestion, such as occurs,
for example, under ordinary circumstances, during chymifica-
tion, the membrane is diaphanous, or at least very nearly
so ; and if a portion of it be detached, and held before the
light, it will be found to have a uniform rose color.

The inflamed part offers considerable diversity in regard to
the mode of its vascularity. Most commonly, it is arbores-
cent, the vessels being spread out like the branches of a tree.
(PI. I, Fig. 3.) This species of injection, however, is never
indicative of high inflammatory action, unless when conjoined
with softening of the mucous tissue, or deposition of lymph
upon its surface. Hence it either soon disappears, with-
out producing any appreciable symptoms, or it loses its den-
dritic arrangement, and becomes capilliform. A fine exam-
ple of the present variety of vascularity is often to be noticed
in the conjunctiva, when, from any transient cause, its mi-
nute vessels are made to convey red blood.

The capilliform injection (PI. I, Fig. 4) always denotes,

SECT. II.] inflammation; VASCULARITy. 207

as just intimated, a much higher grade of irritation than the
dendritic, to which it succeeds. In this variety, the capilla-
ry vessels, excessively crowded with blood, intersect each
other in such a manner as to form a most intricate net-work,
often particularly conspicuous around inflamed ulcers, the
isolated follicles, and the glands of Peyer. It is attended
frequently with softening of the subjacent cellular tissue,
and can be completely removed by maceration in water for
twenty-four hours.

Either alone, or conjoined with one or another of the prece-
ding varieties of vascularity, we occasionally find a singularly
speckled, appearance of the mucous membrane. (PI. I, Pig. 5.)
When the dots are numerous, the affected surface looks very
much like the section of an inflamed brain. It may also be
imitated, with great nicety, as has been observed by Andral
and Hope, by scattering fine grains of powdered vermilion
upon a moist sheet of white paper. The appearance is much
more frequent in the stomach than in the intestines, though
at times it is found in nearly every membrane of the body.
I have seen it, in the same individual, in the pleura and
pericardium, the stomach and bowels, the spleen, mesentery,
and omentum. The specks are sometimes very closely set
together ; and they vary in diameter from the smallest pin-
head to that of a mustard-seed, and in color from a light
rose to a deep cherry red. This species of vascularity, which
does not point out an intense degree of irritation, uniformly
proceeds from slight extravasation of blood, caused by the
rupture of a considerable number of capillary vessels, in con-
sequence of the impulse with which the fluid is forced into
them at the onset of the inflammation. When it is conjoined,
as very often happens, with the diffused redness, the dots
generally occupy a considerable extent of surface, and occa-
sionally run into each other so as to give the part a striated,
streaked, or linear disposition.

In the highest degree of inflammatory action, as in that,
for instance, resulting from the administration of some of the
acrid poisons, spots of extravasated blood, of considerable
magnitude, are not unfrequently met with. (PL I, Fig. 6.)
In such cases, the fluid seems to be poured out originally into
the submucous cellular tissue, whence it extends into the
proper villous membrane, forming patches of a dark livid
hue. Dissection does not always reveal the true cause of
these extravasations. Very frequently, they can be traced

208 GASTRO-ENTERIC MUCOUS MEMBRANE. [cHAP. VII,

directly to one or more ruptured vessels ; in many cases,
however, the capillaries of the part seem to be in a state of
the most perfect integrity : how far, under these circum-
stances, we are authorized to ascribe the phenomenon in
question to simple vascular exosmosis, it is not easy to deter-
mine. Judging from what we observe upon the free surface
of the mucous and other membranes, where blood is often
thrown out in considerable quantities, without any laceration
of the vessels, it is not unreasonable to conclude that the
ecchymoses here adverted to may occasionally have a similar
origin.

This blood-shot appearance, indicative of the most intense
irritation, is often attended with thickening and softening of
the villous tunic, together with a deposition of lymph upon
its free surface, an effusion of serosity into the subjacent
cellular tissue, and the secretion of an inspissated and tena-
cious mucus, or even of purulent matter.

The brown, slate, and black color, with their various inter-
mediate shades, are usually ascribable to a process of chronic
irritation, or to inflammation of long standing. They are
seen, however, occasionally in cases of a high degree of
acuity ; in such, for instance, as result from corrosive poisons,
violent diseases of the bowels, and the more severe forms of
bilious fever of warm climates. The black color is often
witnessed in protracted diarrhoea and dysentery, and is always
characteristic of profound morbid action.

An interesting question here arises, — can an inflammatory
redness exist, and yet wholly disappear after death ? Bichat
and Broussais, together with some others, think that it may ;
and, as the doctrine is of much importance, from the danger-
ous use which may be made of it in pathology, it demands a
brief examination in this place. Those who have advocated
the possibility of this occurrence, have adduced the fact, that
in many cases the traces of erysipelas will greatly diminish,
if not entirely disappear after death ; and the same circum-
stances, it is well known, is often observed with respect to
the redness of tonsilitis, and other inflammatory affections of
the throat. This condition has been explained by some on
the assumption that the injection of the capillaries ceases
as soon as the irritation causing it becomes extinct ; whilst
others have endeavored to account for it by supposing that,
during the agonies of dissolution, the vitality of the affected
part is so much diminished that it has no longer the power of

SECT. II.] INFLAMMATION ; VASCULARITY. 209

attracting the blood in preternatural quantity. In. regard to
cutaneous diseases, this is unquestionably true ; but, even
here, cadaveric pallor of parts previously inflamed is far from
being a general phenomenon, the redness oftentimes remain-
ing long after death, especially in high grades of erysipelas,
in scarlet fever, in measles, and in old irritable ulcers.

But is this comparison strictly applicable to the mucous
coat of the stomach and bowels? Much as the skin and
lining membrane of these hollow organs are related to each
other by similarity of structure and function, and intimately
as they are associated by sympathy, it is well known that
their capillary injection is widely different under inflamma-
tory irritation. Even in the highest grade of erysipelas, the
blood can be easily enough forced out of its vessels, so as to
give the part a pallid aspect, but nowhere can this be done,
so far as we have opportunities of observing the fact, in con-
firmed inflammation of the mucous membrane. Pressure to
a highly-irritated tonsil, or to a prolapsed rectum, never dis-
places the sanguineous fluid to so great an extent as in the
skin, because it is impacted much more firmly into the
minute vessels, the coats of which will often yield rather than
allow their contents to pass along them.

Nor is this all. The blood has not that natural tendency
to recede from the mucous membrane during the last strug-
gles of life that it has to recede from the skin : on the con-
trary, so far from this being the fact, we uniformly find the
fluid accumulate in the interior of the body ; and, in many
instances, if indeed it does not occur always, there is reason
to believe that this process goes on for some time after the
heart has ceased to act, and the vital principle fled. The
redness, therefore, of the inflamed membrane, so far from
diminishing on the approach of death, would have a tendency
rather to become heightened ; and this, indeed, may occasion-
ally happen ; though, taking all the facts which have been
adverted to into- consideration, I would be disposed to assume,
as a general proposition, that the color remains precisely
what it was during life.

Yet, although this subsidence does not take place in the
generality of cases, it may, nevertheless, occur under certain
circumstances. Thus, a high degree of irritation accompa-
nied with deep redness, may exist in the lining membrane of
the stomach ; but a severe dysentery supervening, a powerful,
revulsion will be the result, in consequence of which the

VOL. If. 27

210 GASTRO-ENTERIC MUCOUS MEMBRANE. [cHAP. VII.

original disease, with its attendant vascularity, will in great
measure subside; so that, on inspection, no trace whatever
of gastritis shall be discernible. The same circumstance
may occasionally occur in persons that are cut off, in the
course of a few hours, by violent attacks of cholera morbus.
In several instances of this kind, where, from the intensity of
the symptoms, no doubt could be entertained whatever, of the
existence of the most severe inflammation, I have not been
able to detect the slightest vascularity of the mucous mem-
brane after death. Life, in such cases, seems to be destroyed
by some lurking poison, exerting its baneful impression pecu-
liarly upon the nervous system, without leaving any visible
alteration in the organs whence it radiates its influence.

Enough, surely, has been said, to enable the reader to dis-
tinguish the different kinds of inflammatory redness, not only
from each other, but also from that which appertains to the
mucous membrane in the normal state. As the discussion
of this subject has been carried to considerable length, I shall
content myself, in concluding this article, with a brief analysis
of the other anatomical characters which are to be found,
either alone or conjointly with this discoloration, in the acute
variety of gastro-enteritis. These, it will be remembered,
consist in opacity, thickening, softening, vesicular eruptions,
and vitiated secretions.

One of the earliest effects, in addition to the alteration of
color, of acute inflammation of the mucous membrane, is a
diminution of its natural transparency. Even when there is
but a slight degree of redness, the irritated spots lose, in great
degree, their diaphanous aspect ; but, should the discoloration
be deep and uniform, the opacity will be complete, owing to
the extreme injection of the capillary vessels.

At the onset of the disease, the secretion of the membrane
is somewhat augmented in quantity, but thinner and less
viscid than in the normal state ; the mucous folhcles are
also perceptibly engorged, and more prominent than usual,
being encircled by a beautiful vascular wreath. When the
inflammation is at its height, the secretion is almost sup-
pressed, and the membrane consequently dry, as happens
in inflammation of the Schneiderian lining of the nose ; but,
as this period is always of short duration, the secretion is
soon reestablished, and often discharged in considerable
abundance, being of a thick, ropy consistence, and of a
grayish opaline color ; occasionally, also, it is of a greenish

SECT. II.] inflammation; dryness; thickness. 211

tint, or dark and sanious. The orifices of the mucous folhcles
are enlarged and patulous ; and if, under these circumstances,
the membrane be carefully washed, it will be found to ex-
hibit a granulated aspect, not unlike a pale fungous ulcer.
Towards the decline of the disease, the secretion sometimes
assumes a puriform character, and is often quite copious, — a
phenomenon v/hich was long ago adduced by John Hunter
and his disciples, as exemplifying suppuration without solu-
tion of continuity.

Dryness of the mucous membrane, as a result of inflamma-
tion, is much less usual than in some of the other textures of
the body. The phenomenon is by no means uncommon, for
instance, in the arachnoid tunic of the brain, and is always
indicative there of a very intense degree of irritation. The
same circumstance is occasionally witnessed in the alimentary
tube, and sometimes to a very considerable extent. Thus, in
a case mentioned by Professor Horner, the whole ccEcum was
so dry as to be almost crisp, like a bladder that has been sus-
pended for some time in the air. Most commonly, however,
this lesion occurs in small spots, from one to six lines in
diameter.

The surface of the inflamed membrane loses much of its
natural softness ; it becomes rough, from the turgid condition
of its villosities and folhcles, and, in very intense cases, it is
not unusual to find it chapped, cracked, or fissured.

Increase of thickness is a pretty constant attendant on acute
inflammation, the tumefaction appearing either cotemporane-
ously Math, or soon after the redness. Effusion of serum into
the submucous cellular tissue, added to injection of the capil-
lary vessels, seems to be the main cause of this anatomical
character, which is never so well marked in the stomach and
bowels as in the larynx, conjunctiva and fauces. Occasion-
ally, the thickening proceeds almost wholly from the mucous
follicles, which may be so much enlarged as to give the sur-
face of the affected membrane, as already stated, a rough,
granular appearance.

At an early period of the attack, the density of the mem-
brane is commonly somewhat augmented ; but, in its progress
to its height, as well as during its decline, it is always pre-
ternaturally softened. In this condition, which is deserving
of a considerable share of attention, both the mucous and sub-
mucous textures are frequently infiltrated with serum, muco-
purulent matter, or even with blood ; at the same time that

212 GASTRO-ENTERIC MUCOUS MEMBRANE. [cHAP. VII.

they become so pulpy and disorganized as to allow themselves
to be scraped away with the finger-nail or the handle of the
scalpel. Inflammatory softening, as I shall endeavor to show
hereafter, is much more common in some parts of the alimen-
tary tube than in others, or, what is remarkable, is seldom
attended with any decided redness, the part, which is opaque,
and elevated, having every appearance as if the blood had
ceased to penetrate it for some time prior to the extinction of
life. Thus, then, whenever the irritation is of a high grade,
the submucous cellular tissue uniformly participates in the
disease.

A singular vesicular eruption is sometimes met with in this
disease. It is indicative of the very highest grade of inflam-
matory action, and has hitherto been noticed chiefly in
dysenteric affections and Asiatic cholera. The eruption con-
sists in the developement of minute spherical vesicles, very
little elevated, but discharging, when punctured, a small
quantity of clear limpid fluid. Their walls are perfectly
transparent, and few of them exceed the diameter of a grain
of mustard. Yery often these vesicles occur in thick clusters,
hundreds of them being found upon a surface not larger than
a square inch.

No part of the alimentary tube seems to be exempt from
this eruption. It is observed, however, by Professor Horner,
who has repeatedly witnessed it in Asiatic cholera, that it
manifests a peculiar predilection, so to speak, for the valves of
the jejunum, along the roots of which it is sometimes per-
fectly confluent, like the eruption of small-pox. In the ileum
and colon, they are more scattered, and consequently much
less numerous. Dr. Abercrombie has seen the whole surface
of the large bowel thickly covered with these vesicles.

Generally this vesicular eruption is associated with a
chapped or excoriated condition of the mucous membrane,
preternatural vascularity, deposition of lymph, and effusion of
sero-albuminous, bloody, or purulent matter. How it is pro-
duced, it is not very easy to determine. I cannot agree with
Professor Horner, in supposing that they consist simply in
an elevation of the epidermis of the stomach and bowels,
for the obvious reason that no such structure as that exists ;
and it will be much more reasonable, therefore, to conclude
that it is formed directly by the mucous corion itself, in con-
sequence of some specific inflammatory irritation, not unlike
what we see in erysipelas and anthrax. The subject, how-

SECT. II.] inflammation; lymph. 213

ever, is still open for discussion, and will no doubt receive
the serious attention of pathologists.

We now come to the consideration of lymphy exudations,
(PI. I, Fig. 7,) as signs of inflammatory action. In the
stomach and bowels, the deposition of this substance is much
less frequent than in the supra-diaphragmatic portion of the
alimentary canal. In children, the mouth, pharynx, and
(Esophagus are sometimes completely lined with it ; but even
in them it is far from being common, and seldom extends
along the rest of the digestive tube. In attestation of the
truth of this remark, it will be sufficient here to state, that
out of two hundred and fourteen cases of aphthous disease
that occurred in 1826, in the Foundling Hospital of Paris,
Billard noticed only three in which there were false mem-
branes in the stomach, and only two in which they existed in
the intestines.

After puberty, these exudations are equally uncommon, as
well in the stomach as in the intestines ; bat much more so
in the former than in the latter of these organs. In the
stomach, I have witnessed this phenomenon only in a single
instance, but in the rest of the alimentary tube repeatedly,
both in children and in adults. By Dr. O'Brien and Dr.
Cheyne, of Dublin, it is described as a frequent appearance
in the epidemic dysentery of Ireland ; and by numerous ob-
servers, such as Horner, Ferris, Corbyn, Gendrin, Gerardin,
and Gaimard, it has been noticed in Asiatic cholera. This
exudation is of very common occurrence in the large intes-
tine of persons who die of dysentery and bilious fever in the
Western States. I have noticed it in a very great number
of cases, in every part of the tube, but more particularly in
the rectum, and ascending portion of the colon. The ileum
is also frequently affected in these diseases, but I have never
observed the exudation extend into the jejunum, duodenum,
or stomach.

The inflammation giving rise to this lymphy exudation
appears occasionally to assume a sort of epidemic type. Of
this. Dr. Gendrin makes mention. In the spring of 1817,
an abdominal phlegmasia, as he informs us, prevailed exten-
sively in Paris, in which nothing was more common than to
see pseudo-membranous matter discharged both by the mouth
and anus. In most of the patients who were admitted into
the wards of the Hotel-Dieu, the inflammation, especially
during the -declme of the epidemic, commonly affected at

214 GASTRO-ENTERIC MUCOUS MEMBRANE. [CHAP. VII.

first the stomach and small bowels, from whence it gradu-
ally descended into the colon and rectum. In a large pro-
portion of those who died of this disease, the pyloric half of
the stomach was covered by an adventitious membrane, and
the whole gastro-enteric lining of an erythematous red color.
The mucous corion was sensibly thickened as well as soft-
ened ; and, in many places, there were small brownish-looking
zones, likewise studded with albuminous matter.

The membranous exudation usually takes place, in the
first instance, in small whitish specks, separated by con-
siderable intervals : these, gradually coalescing, form large
patches; and these, again, continuous lamellae, which often -
cover a very great extent of surface. A few years ago, I met
with a specimen, in a young man who died of acute ente-
ritis, after an illness of two weeks, in which nearly the whole
of the lower half of the ileum was lined by a false mem-
brane, in many places fully half a line in thickness : it ad-
hered with considerable firmness to the surface beneath,
which was extensively fissured, and of a dark, gangrenous
color. The patient, in this case, sutfered under all the symp-
toms of the most intense inflammation.

Is this substance susceptible, when thrown out upon the
surface of the stomach or bowel, of becoming organized ?
Upon this subject the opinions of anatomists can scarcely be
said, in any way, to accord. Dr. Gaimard and Dr. Gerardin,
two Russian physicians, affirm that, in cholera subjects, they
have several times seen the finest capillary vessels shooting
into it from the natural membrane ; but no other writers, so
far as I know, have been so fortunate. That the thing is
possible, may be readily supposed from what occasionally
happens in the larynx, the womb, and urinary bladder : that
it is extremely infrequent, must be equally plain, especially
when we take into consideration the heterogeneous contents
of the ahmentary tube, and the tendency which they would
have to thwart a process of such delicacy and refinement.
Whether organized, however, or not, the adventitious mem-
brane is always sooner or later detached, either in small
semi-concrete masses, or, as sometimes happens, in long,
lobular pieces.

I will not stop here to discuss the question, agitated by
some highly respectable pathologists, whether these exuda-
tions are the result of a peculiar disease, the essential nature
of which is still unknown, or whether they are the eftect

SECT. II.] inflammation; suppuration. 215

simply of acute inflammation. I will merely observe that
it is a well-ascertained fact, that such depositions are nev-
er present without some of the phenomena which indicate
the existence of phlegmasial disturbance. Nay, indeed, it
can scarcely for a moment be supposed that the mucous
membrane, either of the alimentary canal, or of any other
part of the body, could pour out lymph-like matter, and yet
not be inflamed. Standing in the light of cause and efi'ect,
the thing is impossible.

Does any one deny this, let him remove this lymphy ex-
udation, and carefully inspect the natural membrane. He
will find, as might be anticipated, that the affected part is
Jiighly vascular, reddened, thickened, more or less softened,
chapped, or perhaps even excoriated ; the villosities, of a
deep crimson hue, are turgid with blood ; the follicles en-
larged and prominent ; and the submucous cellular texture
weakened and extensively infiltrated with serous or other
fluids. Thus have we not only the anatomical characters of
acute disease, but of the most intense inflammation.

When acute inflammation runs so high as to give rise to
bloody infiltrations beneath, and within the substance of the
mucous coat, or even to small ecchymoses, it occasionally
terminates in purulent effusions. Under such circumstances,
it is by no means rare to meet with considerable abscesses,
either in the walls of the digestive passages, or in the con-
tiguous portions of the mesentery, produced by an extension
of the irritation, and opening most generally into the bowel.
The mucous membrane thus bathed and infiltrated with pus,
is commonly of a reddish gray color, very soft, and yielding,
being sometimes wholly disorganized, and converted into a
dirty-looking, pultaceous substance. Frequently, considerable
quantities of pus are thrown off by the inflamed tunic, with-
out any solution whatever of continuity. Rarely does it
come away pure, but is almost always mixed with vitiated
mucus, bloody; and fecal matter.

Blood, either pure or mixed with the mucus and other
contents of the alimentary tube, is oftentimes thrown out in
violent attacks of this disease. This exhalation, for such
in truth it generally is, is almost constantly present in
dysentery and yellow fever, both of them high grades of
inflammation, affecting, in the one case, the mucous coat of
the colon, in the other, the mucous coat of the stomach. No
doubt can be any longer entertained that the matter of black

216 GASTRO-ENTERIC MUCOUS MEMBRANE. [cHAP. VII.

vomit is merely a transudation of blood, altered in its phys-
ical and probably also in its chemical properties, by contact
with the gastric acid. That it is a secretion from the vessels
of the stomach, is an opinion which was promulgated by the
late Dr. Physick, during ihe yellow fever in Philadelphia, in
1798, and which is the conclusion now generally embraced
by the medical profession in different parts of the world.
The quantity of this singular looking matter, once supposed
to be nothing but vitiated bile, is sometimes excessively great ;
and yet, upon examination, no structural lesion whatever, ex-
cepting lymphy exudation, and perhaps softening of the mu-
cous membrane, is to be found in the organ which is its seat.

The changes which the blood experiences, when brought
in contact with the acid and gaseous contents of the stomach
and bowels, are curious and important. When thus effused,
the fluid is speedily deprived of its natural color, and con-
verted into a soft, black substance, resembling thin pitch.
(PI. I, Fig. 8.) Very much the same appearance is some-
times observed when the blood becomes stagnant in the
villous and follicular structures of these organs, from the in-
fluence, probably, of the same cause. This discoloration
will be much greater always, there is reason to suppose, in
proportion to the quantity and vitiated condition of the gastric
juice. Hence the reason, perhaps, why it generally has that
peculiar coffee-ground appearance in yellow fever.

Thus, then, an exhalation of blood, either pure, or vari-
ously altered by the gastric contents of the alimentary tube,
is another effect of acute inflammation of the mucous mem-
brane, and this by no means, an infrequent one. The red-
ness which accompanies it is generally patch-like or diffuse,
and not unfrequently there are considerable-sized ecchymoses.
Conjoined with these appearances, may be softening, excoria-
tions, and thickening of the villous tunic, with vesicular
eruptions, and depositions of lymph. It should be observed
here, that it does not necessarily follow, when abrasions exist
on the mucous coat, that the blood should issue merely from
them. Very often, indeed, there is reason for believing that
they have nothing at all to do with the hemorrhage.
I Produced by the same process is the thin rice-water secre-
tion, which forms so prominent a feature of Asiatic cholera
and violent diarrhoea. The essential character of this secre-
tion is sero-albuminous, and the quantity poured out is often
very great, several quarts being occasionally discharged in

SECT. II.] ABSORPTION. 217

the course of a few hours. For the most part, the fluid is
inodorous, whitish, and of an aqueous consistence, with nu-
merous flakes of lymph floating through it, which frequently
impart to it a turbid, milky aspect ; in diarrhoea, it is seldom
so pure as in cholera, and it is also more apt to be offensive,
from the union of feculent matter and vitiated mucus. It is
partially coagulable by heat, alcohol, and acids.

The most prominent lesions connected with this sero-
albuminous secretion are, softening of the villous membrane
and hypertrophy of the follicles, with occasional depositions
of lymph. What is remarkable, there is sometimes a com-
plete absence of redness of the lining membrane, both of the
stomach and bowels, — a circumstance which may be satis-
factorily accounted for, by supposing that the immense rice-
watery discharges relieve the vascular engorgement prior to
dissolution, so that, upon inspection, no discoloration what-
ever is perceptible.

The function of absorption, so vigorously carried on by
the mucous membrane in the normal state, is generally much
diminished, sometimes totally suspended, in acute inflamma-
tion. The distinguished Dr. Gendrin, of Paris, in order to
satisfy himself concerning this interesting circumstance, re-
peatedly applied poisonous substances, such as strychnine and
prussic acid, to the mucous membrane of the nose and vagina
of animals, in which these tubes had been previously irritated
by tincture of cantharides and other fluids, and he invariably
found that no injurious results were manifested by their con-
tact. He farther ascertained that the more corroding poisons
produced their specific effects only after they had wrought
their way through the inflamed textures to which they had
been originally applied.

In addition to this interruption of the absorbent faculties,
there is almost always, when the inflammation runs high, a
suspension of the digestive process, so that if food be taken
into the stomach it will either immediately be thrown off by
vomiting, or it will pass into the bowels, and be finally evac-
uated by stool. Highly interesting as these facts are, in a
physiological point of view, they are still more so in a practi-
cal light, as showing the extreme folly of employing any but
the very blandest kinds of food and drink in the treatment of
gastro-enteric diseases. It is to a knowledge of them, doubt-
less, that Broussais and his followers are mainly indebted for
the success which is said, in France, to characterize the

VOL. II. 28

218 GASTRO-ENTERIC MUCOUS MEMBRANE. [CHAP. VII.

exhibition of diluents in phlegmasial disorders of the stomach
and bowels, in the almost total absence both of medicine and
food.

Inflammation of the lining membrane of the alimentary
tube frequently produces, even when it is entirely confined
to the mucous corion, a well-marked injection in the other
tunics. When the disease is very extensive and intense, the
vascular injection may not only pervade the whole thickness
of the stomach, small or large bowel, but even reach to the
mesentery. Under such circumstances, the distended state
of the neighboring vessels, the purple discoloration and arbo-
rescent appearance of the peritonasal covering, either alone or
in conjunction with globules or flakes of adherent lymph,
generally afl"ord abundant evidence of the probable extent of
the internal lesions. The mesenteric glands are sometimes
swelled and inflamed, though seldom so much as in ulcera-
tion.

In active inflammation, the digestive tube is ordinarily
dilated ; which continues only so long, however, as the
irritation is limited to the mucous lining ; for, as soon as it
extends to the muscular tunic, the canal becomes invariably
contracted ; sometimes to so great a degree as to render it
impracticable to evacuate its contents.

One of the most singular circumstances connected with
acute inflammation of the digestive passages, is the develope-
nient of gas which we occasionally meet with. This phe-
nomenon has been variously explained by difi^erent patholo-
gists ; some supposing that it arises merely from a species of
fermentation of the fluids which may be contained at the
time in the stomach and bowels ; others, that it is the result
of a peculiar secretion, with the nature of which we are still
unacquainted. Without denying the truth of these explana-
tions, both of which are, perhaps, to a certain extent well
founded, it may yet be doubted, I think, whether they are
sufiicient to account for the fact that this evolution of gas is
present in some cases and absent in others. With a view of
deciding this question, Dr. Gendrin irritated a portion of
bowel in several dogs by caustic, alcohol, or boiling water,
and then intercepted the inflamed part between two liga-
tures, having previously exhausted the air with a syringe. In
two out of five of the animals thus treated, the gut was dis-
tended, in twelve hours after the operation, with an inodor-
ous gas, the inflammation in both being rendered evident by

SECT. II,] INFLAMMATION ; TOLLICULAR ENTERITIS. 219

the lively redness of the villous tunic ; in the other dogs,
although the discoloration was equally conspicuous, and pro-
duced by the very same substances, no air wha!tever was to
be found. Is it probable that this fluid is disengaged from the
blood-vessels of the aftected part ? This is not unlikely, when
it is recollected that carbonic acid gas is evolved in great
quantity from the same source, in the lungs during respiration.

Not unfrequently we find that the disease, instead of invad-
ing the villous texture, properly so termed, begins in and is
confined exclusively to the mucous follicles, which occur
every where in such profusion in the alimentary tube. As
an independent lesion, it was particularly described, in 1811,
by two distinguished Parisian anatomists, Dr. Petit and Dr.
Serres, who denominated the accompanying constitutional
disorder entero-mesentei'ic fever. Dr. Bretonneau, of Tours,
to whom we are likewise indebted for a very valuable me-
moir upon this interesting affection, more recently published,
calls it dothin-enteritis^ from a Greek compound, literally sig-
nifying furuncular inflammation of the intestines. Both
these appellations, however, as well as that oi follicular en-
teritis, lately proposed by Professor Andral, are objectionable,
on the ground of their not being sufliciently specific, since
the disease is by no means confined, as these terms would
lead us to infer, to the bowels, but also occurs in the stomach.

The subject of follicular inflammation is much agitated,
at this moment, by the profession, in relation to the pathology
of typhous fever. From the investigations of Louis and
Choniel, well known as two of the most shrewd and diligent
cultivators of morbid anatomy, of the present day it clearly
appears that this formidable malad^'- is either caused by or
gives rise to inflammation of the intestinal follicles, especially
the glands of Peyer, which finally terminates in their destruc-
tion. How this question will be ultimately settled it is im-
possible to foresee ; I have very little doubt, however, that it
will be in favor" of the opinion which attributes typhoid fever
to a primitive lesion of the mucous glands ; and in this belief
I am justified by the severe constitutional disturbance which
is so constantly present whenever these bodies are seriously
affected.

In the inceptive stage of this variety of inflammation, the
isolated follicles look like little boils, moderately projecting
beyond the level of the surrounding surface. (PL I, Fig. 9.)
Varying in size from a small pin-head to a mustard-seed, they

220 GASTRO-ENTERIC MUCOUS MEMBRANE. [cHAP. VII.

are generally of a spherical shape, soft, and of a reddish
glossy aspect, each being marked by a minute, central aper-
ture, indicating its natural orifice. At this period of the dis-
ease, the glands are already quite injected ; and, if they be
closely examined, it will be found that they are encircled by
a beautiful wreath of vessels, so fine as to be almost undis-
tinguishable by the naked eye. At a more remote stage,
their color is of a light brown ; their bulk is considerably aug-
mented ; and their surface, instead of being lubricated, as
before, by an abundant mucus, is nearly dry, their secretory
functions being in great degree suspended. This state,
however, which soon disappears, is followed by a copious
flow of fluid. When, as often happens, the villous membrane
between the follicles participates in the disease, it gradually
loses its natural characters, and exhibits some of those appear-
ances which have been pointed out as denoting acute inflam-
mation. The glands themselves are often very much soft-
ened, or so greatly disorganized as to give the surface of the
digestive tube a singularly cribriform aspect.

Not unlike the preceding are the changes which the glands
of Peyer undergo in acute inflammation. (PI. I, Fig. 10.)
In the normal state, these bodies, it will be remembered, are
seldom very distinct ; when affected, however, by disease,
they are rendered quite prominent, being considerably raised
above the surrounding surface, in the form of elliptical, ovoi'd-
al, or circular patches, from a few lines to several inches in
diameter. In this state, they are of a bright florid color, from
the injection of their capillaries ; and their surface has an un-
even, granular, or honey-comb appearance, from the projec-
tion of their follicles. The submucous texture is also con-
siderably thickened, and the intervening membrane more or
less altered, according as it participates or not in the inflam-
mation. Ulceration often follows this process.

Acute inflammation, whether affecting the villous or the
follicular textures, or both at the same time, may either ter-
minate by resolution, or it may pass into the chronic form, or
else proceed to disorganization. When it goes on favorably,
the infiltrated fluids are gradually absorbed ; the vascularity
diminishes ; the natural secretions are restored ; the absorbing
faculties become more and more vigorous ; and, at length, the
functions of the part are entirely reestablished, — the only al-
terations which remain being a thickened, and occasionally
a slightly indurated state of the mucous and submucous tex-

SECT. II.] GANGRENE. 221

tures. If the follicles have been principally involved, the
affected surface exhibits, after the lapse of some time, numer-
ous dark dots, which have been compared, not unaptly, to
those of a newly-shaved beard.

With regard to acute inflammation, it may be observed, in
conclusion, that its relative frequency is much greater in some
parts of the alimentary tube than in others. The inferior
half of the ileum, the stomach, and the commencement of
the colon, are, without doubt, most commonly engaged, either
alone or conjointly. This latter circumstance has given rise
to the term g astro-enteritis, in such frequent use amongst
the French pathologists, but which is not always applicable,
inasmuch as the coincidence is by no means universal, or
even perhaps general.

Although acute inflammation occasionally terminates in
gangrene, yet this effect is by no means so common as was
at one time supposed by pathologists. By a reference to the
works of the older anatomists, it clearly appears that they
were constantly in the habit of compounding high discolora-
tion, whether proceeding from simple congestion, effusion of
blood, or melanotic deposition, with mortification of the mu-
cous texture. Since, however, a more accurate method of
investigation has been introduced into science, it has been
abundantly established that this lesion is of very rare occur-
rence, being scarcely met with in one case out of ninety-nine
of gastro-enteric disease. This remark applies, of course,
solely to the idiopathic variety of inflammation, and not to
that which is occasioned by strangulation, intussusception,
external violence, or corroding poisons.

It is now well ascertained that some parts of the mucous
membrane of the alimentary tube are much more liable to
gangrene than others. The inferior half of the ileum is the
section most commonly affected, and next in point of fre-
quency stands the colon, particularly the ascending portion.
It is an extraordinary fact that the stomach, jejunum, and duo-
denum are seldom implicated. Why these structures should
enjoy this remarkable immunity, both from this and other
affections, has never been explained ; but such as has just
been stated is the fact, no matter what may be the cause of it.

Large portions of the mucous membrane are sometimes de-
prived of their vitality. Professor Horner refers to a case in
which the gangrene implicated nearly the whole, both of the
small and large bowel ; and, in several instances which have

222 GASTRO-ENTERIC MUCOUS MEMBRANE. [cHAP. VII.

come under my own observation, I have seen the greater
portion of the ileum and colon involved. But, generally, the
lesion is much less extensive, occurring in small patches, of
an irregular shape, and from one to several inches in diameter.
The textures primarily affected are, the mucous and follicular,
from which the disease may gradually spread to the other
tunics, converting them into soft, dark-colored sloughs, inca-
pable of resisting the slightest distention from fecal matter.
Hence it not unfrequently happens, if the patient lives suffi-
ciently long, that the intestinal tube gives way in one or
more places, and discharges its contents into the abdominal
cavity, as in perforation from ulcerative action.

The color of the sphacelated part is variable. (PI. I, Fig. 11
and 12.) Occasionally we find it of a dark-drab, dirty-ash,
or greenish tint ; but more commonly it is of a mahogany-
brown, black, or livid, from the imbibition of the ichorous
matter, which is often poured out in such abundance during
the height of the inflammatory stage of the disorder. The
mucous membrane which surrounds the slough is generally
very considerably injected, and of a red mulberry color, in-
dicative of excessive irritation.

With this change of color, the mucous membrane is con-
siderably altered in its consistence, being so much softened,
indeed, that it can be removed by simply passing over it the
handle of the scalpel. In many instances, the gangrenous
part is remarkably offensive : frequently it is covered with
flakes of lymph, and occasionally, though this is very rare,
there are little phi yc tense, not unlike those which are wit-
nessed in mortification of the skin and cellular tissue. An
emphysematous condition of the submucous cellular tissue is
also sometimes found ; but this, in the majority of cases, is
to be regarded rather as the result of putrifaction than of in-
flammation.

When the gangrene seizes upon the glands of Peyer,
which, however, is not often the case, the sloughs are of a
dark brownish color, soft and fetid, very much as in the pre-
ceding case ; and, on being detached, deep excavations are
formed, with loose, ragged edges. Although in the generali-
ty of cases these excavations do not extend beyond the sub-
mucous coat, yet occasionally they invade the whole thick-
ness of the ileum, and thus give rise to perforations and faial
effusions. Sometimes, even when the gangrene stops short
at the mucous and subjacent cellular textures, considerable

SECT. II.] GANGRENE. 223

blood-vessels, branches of the mesenteric arteries and veins,
are laid open, and the patient falls a victim to the hemorrhage.
Appearances very similar to these are to be observed when
the gangrene invades the isolated follicles, except that the
surrounding parts are usually less red and injected.

I shall close this subject with the following case, which
came under my notice about eighteen months ago. A
colored man, twenty-seven years old, of a stout, athletic
frame, was affected for three days with all the symptoms of a
severe bihous colic, for which he was attended by Dr. Dodge,
of this city. At the end of this period, when I saw him, in
consultation, the tongue and extremities were quite cold, the
pulse almost imperceptible at the wrist, and the stomach ex-
cessively irritable, with a constant disposition to vomit, in-
tense thirst, and a countenance expressive of the most intense
distress. The abdomen was somewhat tympanitic, and the
bowels, although perfectly torpid, were almost free from pain.
In this condition the patient continued for about forty-eight
hours, when there was an appearance of slight reaction,
though still no evacuation from his bowels. In a short time,
however, the symptoms again became worse, and he expired,
in a state of complete collapse, on the seventh day from the
attack.

On examination, the great omentum, excessively loaded
with fat, was found glued to the colon and right side of the
abdomen, the points of attachment being in a black, fetid,
gangrenous condition. The mesentery and small bowel Avere
gorged with dark blood, and the latter adhered extensively to
the bladder and rectum by a thick mass of lymph. The
ccECum, vermiform appendage, and inferior fifth of the ileum
were externally of a livid color, and internally black in
patches from one to two inches in diameter. Here and
there, the surface of the mucous membrane was covered with
flakes of lymph, and the same substance was found in con-
siderable abundance upon the exterior of these portions.
The whole intestinal tract was much distended with gas
and feculent matter ; and the stomach, which contained
about a pint of thin, greenish liquid, presented well-marked
signs of inflammation, especially at the great tuberosity. All
the other abdominal viscera were natural.

Chronic inflammation of the mucous membrane of the
alimentary tube is much more frequent than acute, of which
it may be either the consequence, or it may exist as an origi-

224 GASTRO-ENTERIC MUCOUS MEMBRANE, [CHAP. VII.

nal and independent disease. It is very common in dispepsy,
diarrhoea, dysentery, and infantile cholera, of which and of
almost all protracted fluxes of the bowels, it is the principal
cause, these affections themselves being merely the symp-
toms. Though not so immediately dangerous as acute in-
flammation, this disorder is usually very diflicult to be dis-
lodged, from the strong hold which it takes of the part, and
from the insidiousness of its attack, weeks, nay months some-
times elapsing before it induces any decided constitutional
disturbance.

The anatomical characters of chronic inflammation differ,
in many essential points, from those of the acute variety of the
disease. As a general proposition, it may be stated that the
appearances vary according to the duration of the malady,
and the nature of the exciting cause, together with several
other circumstances which it is unnecessary to specify.
Thus, when the disease is of recent standing, we usually find
the mucous membrane of a dusky red, inclining to mahogany ;
whereas, in the opposite state, especially when the attack is
one of considerable intensity, it is of a livid, purple, or mul-
berry aspect. Though occasionally the discoloration is
diffuse and uniform, yet in the great majority of cases it
occurs in small patches, stripes, or bands, leaving the inter-
vening surface of the natural hue. As in the acute form of
the disease, so in this, the color, whatever be its nature, is
closely identified with the mucous texture, and therefore al-
ways removable with much difficulty by maceration ; artifi-
cial injection, also, is no longer practicable, at least not to
any degree of minuteness. The vessels upon which this
discoloration depends are generally disposed in arborescent
lines, and, what is remarkable, and serves to distinguish this
from mere congestive vascularity, is, that they cannot be
traced to any particular trunks, but seem as if they were lost
in the midst of the inflamed tissues.

But it is not always that the diseased membrane is height-
ened in its color. Often, indeed, it is preternaturally pale, as
if it had been bleached and drained of its fluids, and in such
cases, also, it is generally very flabby and relaxed. Examples
of this kind have been reported by Andral and Louis, and
have repeatedly been witnessed in my own dissections : they
occur with considerable frequency in chronic diarrhoea and
in infantile cholera.

A very common appearance in this disease is a slaty bluish

SECT. II.] CHRONIC INFLAMMATION. 225

or blackish discoloration, occurring in spots, from the size of
a five cent piece to that of a dollar. (PI. I, Figs. 13, 14.) The
parts in which it is most frequently met with are the colon
and the rectum, where it is sometimes difiused over a large
extent of surface. In the stomach and small bowel, where it
is usually more limited, it is commonly most distinct along
the temporary folds and winking valves, for what reason it is
not easy to say. The discoloration which runs through a
great variety of shades, from a light slate to a jet black, is
seldom witnessed except in cases of long standing, or in such
as are characterized by a considerable degree of intensity,
and it probably always results from an extravasation of blood
into the submucous cellular texture. Its seat, however, is
not, as might be supposed, confined to this substance: often,
indeed, it involves in a special manner the mucous membrane,
the follicles, and even the villosities ; and cases are not
wanting, though they are uncommon, in which it penetrates
all the tunics at the same time, tinging the tube externally of
a greenish, brownish, or sooty dye.

In chronic inflammation, the substance of the mucous
membrane is generally thickened, and its density augmented,
so that it can no longer be torn with the same facility as in
the normal state. The mucous follicles (PI. I, Fig. 15) are
also more or less enlarged, forming, in many instances, hard,
granular bodies, which project considerably above the level of
the surrounding parts. Nor is the hypertrophy — for such it
really is — alv/ays confined to these structures. The villosi-
ties, small as they naturally are, are often involved in the dis-
ease, and sometimes attain quite an astonishing developement.
Owing to these alterations, the surface of the mucous mem-
brane is usually rough, and occasionally even cellulated, like
a honey-comb. This, however, is by no means a uniform
occurrence ; for cases are frequently witnessed, and even those
of long standing, in which the part is perfectly smooth and
polished, not a. gland or villosity being any where perceptible.

When, as sometimes happens, the disease passes into the
acute form, the mucous texture undergoes still farther
changes, or, more correctly speaking, it assumes very differ-
ent characters. It loses its hardness and tenacity, and is con-
verted into a soft, thick, puJpy substance, which is infiltrated
with various kinds of fluids, such, for example, as serosity,
pus, or blood, either alone, or in combination. If the morbid
action be of long continuance, the mucous tunic is apt to

VOL. II. 29

226 GASTRO-ENTERIC MUCOUS MEMBRANE. [CHAP. VII.

give way, and to form ulcerations, which extend, by degrees,
to different depths in the tube. If, on the other hand, the
disease retrogrades, the membrane, aUhough it loses its dark
complexion, yet it remains preternaturally soft, spongy, and
tumid.

In chronic as in acute inflammation, the vessels of the
part always retain their unnatural volume for some time after
the main disease has subsided ; and cases are occasionally
observed in which the veins have quite a tortuous and vari-
cose disposition, forming thick whorls underneath the mucous
tunic. This appearance is particularly apt to attend chronic
inflammation of the stomach, colon, and rectum.

On some occasions, fungous excrescences are to be noticed,
hanging from the free surface of the membrane like so many
little warts ; and nothing is more common than to find the
submucous cellular tissue indurated and hypertrophied. But
of these lesions, as well as of ulcerations, we shall speak more
particularly in the following pages, under the head of organic
diseases, which will presently engage our attention.

The secretions in this disease present several important va-
rieties. Most generally they consist of a thick, ropy, inodor-
ous mucus, discharged in considerable quantity by stool ; not
unfrequently, however, they are of a thin, gleety nature, and
the cases are not uncommon wherein they are serous, sanious,
purulent, or fibrinous. Occasionally, again, though I believe
this is very rare, the evacuations are thin, greasy, and of a
singularly cadaverous smell.

SECTION III.

Of Softening of the G astro -Enteric Mucous Membrane.

Softening of the mucous membrane of the alimentary
tube, a subject already incidentally referred to in the preceding-
section, was first described, as a distinct pathological condi-
tion, in 1829, by the celebrated Dr. Louis, of Paris, a gentle-
man to whom morbid anatomy is under so many obligations.
Since that period, the disease has attracted the attention of
numerous observers both in Europe and in this country, and,
as might be expected, our knowledge concerning its anatomi-

SECT. III.] SOFTENING. 227

cal characters, however deficient it may be in relation to its
symptoms, is ah'eady of a very high order, nearly, indeed, if
not quite perfect.

Softening of the mucous texture from inflammation, that
variety to which we shall at present restrict our remarks, is
most commonly noticed in the lower third of the ileum, the
coecum, the right and left portions of the colon, the stomach,
and the rectum, — the frequency of its occurrence being in the
order, very nearly, here enumerated. In the majority of
cases, it is confined to particular parts of the digestive tube ;
but, in some rare instances, it extends through its entire
length, from the cardiac orifice to the anus. Although oc-
casionally the softening seems to be limited to the mucous
corion, villosities, or follicles, yet most generally it occurs in
all these structures at the same time, converting them into a
pulpy, homogeneous substance. Under certain circumstances,
it is supposed to be capable of invading all the tunics of the
stomach or intestines, proceeding successively from ,the mu-
cous membrane to the subjacent cellular texture, and from
the latter to the muscular and serous layers, so as to give rise
to perforations with a discharge of the contents of these
reservoirs. This opinion, however, has been contradicted by
some very able pathologists, under a belief, in all probability
well-founded, that, when the lesion is thus extensive, it de-
pends, not on inflammation, but on the chemical action of the
gastric juice. The reasons for this belief will be more fully
adverted to in the course of this article.

Inflammatory softening is usually somewhat gradual in its
progress, running through several well-marked stages before it
attains its full developement. In the first stage, the mucous
membrane is remarkably brittle, and breaks as soon as it is
seized with the forceps, allowing itself no longer, as is the
case in a sound state, to be detached in small, narrow strips ;
in the second, the cohesive powers are so far destroyed, that,
by merely sweeping the finger over it, it may be converted
into a soft, grayish pulp, very analogous to thick cream ; and,
in the last stage, the disorganization is such that the mucous
. membrane may be easily removed by a small stream of water
poured upon it from the height of a few inches. When the
softening has attained this degree of developement, it is not
uncommon to find considerable portions of the mucous mem-
brane detached, by the passage simply of the fluid contents
of the alimentary tube ; and in this way may be produced

228 GASTRO-ENTERIC MUCOUS MEMBRANE, [cHAP. VII.

numerous abrasions, of a circular, oblong, or linear configura-
tion, and from the size of a split pea to that of a Spanish
dollar, or even the magnitude of the hand. The edges of
these abrasions are generally clean and even, and their sur-
face is formed by the submucous cellular tissue, itself often
in a state of partial disorganization. The denuded patches,
especially when small and circular, have occasionally the ap-
pearance of ulcers ; but, as has been justly remarked by Pro-
fessor Cars well, in all cases of doubt, the handle of the scal-
pel, carried lightly over the part, will enable us to determine
their true nature. If the membrane sloughs away to a very
great extent, as sometimes happens, the margins of the sore,
instead of being rounded, as in the former case, will be irreg-
ularly levelled off, running insensibly into the surrounding
parts. In cases of this description, too, it is not unusual to
find shreds of the mucous membrane stretched across the de-
nuded surface, so soft as to render it impossible to lift them
with the forceps.

Considerable diversity prevails in respect to the color of the
softened membrane, different shades of tint marking different
cases, and even the same case in different regions. (PL I,
Fig. 16.) In the generality of instances, the membrane is
of a pale bluish aspect, one or two degrees lighter than in the
normal state ; and not unfrequently it is of a dead white,
like milk or cream. This variety of softening is very com-
mon in consumption, in mesenteric disease, and in all affec-
tions attended with mu(^h emaciation.* In other cases, again,
the membrane presents various shades of red, brown, or pur-
ple, or, perhaps, even retains its natural hue. Occasionally
the discoloration is rigidly limited to the part affected, and this
is especially the case in the pale variety ; but in most instances
it extends to the neighboring parts, which at the same time
exhibit all the phenomena of ordinary inflammation.

The blood-vessels in this disease have a singularly flattened
appearance, and many of them are partially obliterated, no
doubt from their participating in the softening. Injecting
matter can no longer be forced into them, and their contents
often escape so as to form small dark-colored ecchymoses, re-
sembling the black spots observable in the stomachs of those
who die of yellow fever.

The lesion now under consideration is an exceedingly

* Carswell, London Cyclopaedia of Practical Medicine, vol. x. p. 15.

SECT. III.] SOFTENING ; SYMPTOMS. 229

common one in this city, so much so, indeed, that I rarely
make an examination without meeting with it. AUhough it
is occasionally limited to some particular portion of the ali-
mentary tube, yet, in by far the greater n amber of subjects,
it occurs simultaneously in the stomach, the ileum, and large
bowel. In some instances, it involves an immense extent of
surface, one third, a half, or even two thirds, of the gastro-
enteric lining. It may be the only disease, or it may exist
with other aifections, such as ulceration, extenuation, or thick-
ening ; but, however this may be, the anatomical characters
do not differ from those we have just pointed out. Inflam-
matory softening of the mucous membrane is frequently wit-
nessed in bihous and typhoid fevers, in dyspepsy, in phthisis
and pneumonitis, in diarrhoea and dysentery. I have like-
wise noticed it repeatedly in infantile cholera, especially in
the chronic form of that disease, of which it often constitutes
the principal evidence. In nearly all the dissections which I
have made of subjects who died of this malady, the soften-
ing was particularly observable in the mucous lining of the
colon and stomach. In a few instances it was also noticed
in the lower half of the ileum.

The symptoms of this disease do not differ materially from
those of other gastro-enteric affections. Generally, with
more or less protracted indisposition, there are epigastric
pains, with loss of appetite, nausea, vomiting, disorder of the
bowels, failure of the strength, and progressive emaciation.
These phenomena are particularly distinct when the lesion is
confined to the stomach, when the patient, besides, often ex-
periences a degree of tightness at the upper part of the abdo-
men, as if a bar or heavy weight were stretched across it. The
pains are always augmented by pressure, and, during their
existence, the countenance is usually expressive of much un-
easiness, very dull, and haggard. But these symptoms are
not pathognomonic, and I therefore forbear any further re-
marks concerning them.

The species of softening now described is caused, it will
be remembered, by a process of inflammation, either acute or
chronic, and may occur in any part of the mucous system,
not only of the alimentary tube, but of the rest of the body :
it is characterized, moreover, by the circumstance of its being
limited to the mucous textures, and by its 7iever affecting the
muscular and peritonseal tunics. Another variety, resulting
from a very different cause, and which frequently produces

230 GASTRO-ENTEAiC mucous membrane. [chap. VII.

extensive erosions and perforations, remains to be noticed.
I need scarcely say that I allude to the softening occasioned
by the ^-astric juice, or, more correctly speaking, the gastric
acid. (PI. I, Fig. 17.)

The celebrated John Hunter, it is well known, communi-
cated, at an early period of his professional career, his obser-
vations on the chemical solution of the mucous and other
coats of the stomach, in a paper first published in the London
Philosophical Transactions,* and subsequently in his work
on the animal economy. He describes this species of softening
as a digestion of the tunics of the stomach, produced by the
solvent powers of the gastric juice after death ; and the reason
which he assigns why this effect does not occur during life,
is the constant resistance of the vital principle to its action.
These observations were confirmed shortly afterwards by
Spallanzani, of Italy, Dr. Adams, of London, and Mr. Allan
Burns, of Glasgow, the latter of whom contributed some very
valuable information on the subject, more particularly rela-
ting to the chemical solution of the stomach in individuals
who died of protracted diseases ; for it should be recollected
that Mr. Hunter, having met with this lesion only in healthy
animals, and in persons who had been suddenly deprived of
life, by external violence, he advanced the opinion that a state
of perfect integrity immediately prior to death was absolute-
ly essential to its production. Very important additions have
since been made by Baillie, Chaussier, Josger, Gairdner, Cars-
well, and other writers, some of whom agree in the opinion
of the great British anatomist, that the effect under consider-
ation is the result of the action of the gastric acid ; whilst
others maintain that it is an idiopathic affection ; and some,
again, especially Cruveilhier and Louis, that it is caused by
a high state of inflammatory irritation, which, occasioning a
slow and protracted effusion of serosity, produces infiltration,
distention, and ultimate disorganization of the delicate tex-
tures of the mucous membrane, leading finally to complete
perforation of the intestinal tube.

It is not of little consequence that correct views should be
entertained in regard to this subject, as it is one of much im-
portance, not only in pathology, but also in juridical medicine.
The French anatomists, it seems to me, have attributed en-
tirely too much to inflammation ; and, in their eagerness to

*yol. Ixii. p. '1'14.

SECT. III.] SOFTENING AFTER DEATH. 231

deride the doctrine of John Hunter and his disciples, have
lost sight of the physical and chemical properties of the gas-
tric acid, which, it cannot be denied, is often fully compe-
tent to the production of extensive mollescence of the mucous
membrane. When it is remembered, indeed, that softening,
with erosion and perforation of the stomach and intestines, is
frequently found after death in persons who, during life, do
not evince the slightest gastro-enteric derangement, — that it
occurs at any period of existence, alike almost in infancy, in
manhood, and decrepid age, — and, finally, that it is witness-
ed equally almost in those who are destroyed suddenly by
external violence and those who die from chronic diseases, —
we are fully warranted, I think, to conclude that, if the gas-
tric acid is not the sole agent in the production of this lesion,
it is certainly the most frequent and efficient cause of it.

But there are other reasons, of a still more cogent and un-
answerable character, which justify us in attributing this
effect to the agency of the gastric acid, and to nothing else.
Mr. Hunter, in the paper already referred to, distinctly ob-
serves that the power of this fluid is not confined to the
stomach alone, but that, after dissolving this organ in the
usual place, which is at the great cul-de-sac, it would gradu-
ally extend to the spleen, intestines, and diaphragm, eroding
them, and reaching as far sometimes even as the lungs. The
truth of this statement derives additional force from the re-
searches of Professor Carswell, who, with a view of finally
putting this question to rest, instituted a series of the most
patient experiments, which he modified in almost every pos-
sible shape, and the results of which go directly to substan-
tiate the doctrine of the solvent powers of the gastric acid.
The queries which this distinguished philosopher wished
more particularly to solve were the following : first, are the
lesions noticed by various authors, under the appellations of
softening, erosion, perforation, and digestion of the coats of
the stomach, t-he same, or different morbid effects ? second-
ly, are they produced during life or after death ? if in the
latter case, are they the result of the chemical action of the
gastric acid? and, thirdly, what are the conditions and prop-
erties of the fluid to which they are to be ascribed ? *

In the prosecution of these researches, Professor Carswell
ascertained the interesting and important fact that these le-

* Cyclopaedia of Practical Medicine, vol. iv. p. 17.

232 GASTKO-ENTERIC MUCOUS MEMBRANE. [cHAP. VII.

sions can frequently be produced at pleasure, simply by re-
moving the stomach of a healthy animal, cleaning it of its
contents, and putting in contact with it a small quantity of
gastric acid. In one instance, he placed the stomach of a
recently killed rabbit, containing digested food, under a glass
globe, and taking care to keep it moist wnth a little tepid wa-
ter, he observed, in a short time, that the fundus of the organ
became pale, then soft, thin, and transparent, and finally, at
the end of four hours, there was a perfect dissolution of all
the tunics, followed by an escape of the chyme. When the
softening was allowed to take place in the abdomen, and the
gastric acid came in contact with the surrounding organs, as
the liver, diaphragm, spleen, or intestines, the same lesion
was frequently observed in them as in the stomach, portions
of these structures being more or less macerated and broken
up. In a few of the experiments, the mollescence extended
as far as the cesophagus, pleura, and lungs.

From the foregoing facts, Professor Carswell justly con-
cludes that softening, erosion, and perforation of the alimen-
tary tube, whatever may be their extent, seat, or form, are
caused by the solvent properties of the gastric acid, and not,
as has been asserted by the French pathologists, by inflam-
matory irritation ; and, lastly, that whenever observed to-
gether, these lesions are invariably produced after death.
Results similar to those of the British anatomist, it may be
here stated, were obtained as early as 1818, in a set of exper-
iments on the same subject, by Dr. Camerer, a German phy-
sician. In one of these experiments, a drachm of gastric
acid, taken from two children who died of mucous molles-
cence, was introduced into the stomach of a man, soon after
death, and kept at a temperature of 170 of Fahrenheit for the
space of twelve hours. At the expiration of this period, the
mucous and muscular coats were found to be dissolved
through to the peritonaeum, wherever the fluid got in contact
with them. The same liquid, conveyed into the stomach of
a living rabbit, produced no sensible effect ; but, after the an-
imal was killed, its corroding properties soon manifested
themselves. This observation, it will be perceived, striking-
ly illustrates the influence of the vital principle, so often ad-
verted to by Mr. Hunter when speaking of the digestion of
the coats of the stomach.

The rapidity with which softening, erosion, and per-
foration of the stomach may take place in the human sub-

SECT. III.] SOFTENING AFTER DEATH. ^ 233

ject, is well illustrated in a case which I had an opportu-
nity of examining, about a year ago, along with Dr. Mount.
It occurred in a female infant, seven weeks old, who was
found dead one morning in her mother's arms, having expired
apparently without a struggle. A month previously, this child
had had a severe cough, which continued for eight or ten
days, when it gradually abated. It was also harassed, every
evening for several weeks, with regular paroxysms of retching
and vomiting, attended with occasional colicky pains, and
latterly with diarrhoea.

On inspection, nine hours after death, numerous apoplectic
effusions, from the size of a currant to that of a pea, were
discovered in the pulmonic tissue, which, together with the'
universal engorgement, the injected condition of the bronehias,
the distention of the right cavities of the heart, and the ab-
sence of any structural lesion, save a slight degree of hepati-
zation of the inferior lobe of the left lung, made it sufficiently
clear that the child had died of suffocation. In the great
cul-de-sac of the stomach existed a rounded opening, with
ragged edges, about the size of a Spanish dollar, through
which had escaped a small quantity of mucus and gastric
acid. The concave surface of the spleen was of a pale color,
and the contiguous portion of the omentum was slightly
softened, and the latter in two places perforated. The mucous
membrane around the opening in the stomach was of the
natural complexion and consistence, nor was there any where
the slightest appearance of disease.

The question may be asked here, — why is it that these
effects, so conspicuous in some cases, do not occur, to a greater
or less extent, in all ? Professor Carswell, who, as was before
hinted, has endeavored to solve this problem by an appeal to
direct experiment, thinks that the difference depends upon
some altered condition of the gastric juice ; or, in other words,
that in proportion precisely to the acidity of this fluid will
be its solvent- and eroding properties. The accuracy of
this conclusion is sufficiently confirmed by the fact, that if
the liquid in question be neutralized by a small quantity of
magnesia, no softening whatever will happen in the stomach
of an animal that has been just killed. The sour smell of
the gastric juice is often remarkable, and the effect which it
has, under certain circumstances, of setting the teeth on edge,
as it is vulgarly termed, is familiar to every one. The pres-
ence of free muriatic acid in this liquid has been fully estab-

voL. II. 30

234 GASTRO-ENTERIG MUCOUS MEMBRANE. [cHAP. VII.

lished by the researches of numerous chemists, and its
macerating and corroding properties were long ago pointed
out by Spallanzani, Stevens, and other physiologists.

With respect to the situation of this species of softening,
it is a matter of some moment to know that it always takes
place at the great cul-de-sac of the stomxach, in consequence
of its depending position favoring the accumulation of the
gastric acid, as well, perhaps, as from this fluid being secreted
here in larger quantity than elsewhere. The only exception
to this rule arises where there is an enlargement of the spleen,
or some tumor pressing this part of the organ up, and thereby
rendering the pyloric extremity the lowest point. When
there is softening of the intestines, with erosion and perfora-
tion, it invariably occurs in the loops lodged in the epigastric
region, in close proximity with the stomach. Under no cir-
cumstance, at least so far as my own observation extends, has
this variety of mollescence been noticed in the more depend-
ent portions of the digestive tube, or in the urinary bladder.

The exte7it of the lesion is very variable, being either lim-
ited to a small portion of the stomach and bowels, or occupy-
ing the whole surface of the former, with a considerable por-
tion of the latter. Occasionally, it is observed entirely in the
intestines, which can only be explained on the assumption that
the gastric acid, having left the stomach, has accumulated in
inordinate quantity in the latter organs. When the softening
is accompanied with perforation, it may extend, as was before
stated, to the oesophagus, liver, spleen, diaphragm, and even
the lungs, all of which viscera may therefore be affected in
the same individual, and exhibit various degrees of dissolu-
tion.

Not unworthy of brief notice is the form which the soften-
ing presents in different parts of the digestive tube. When
confined to the fundus of the stomach, the lesion generally
occurs in irregular patches, varying much in size, the edges
of which are formed by the mucous membrane, and their
surface by the subjacent cellular texture. Very generally the
margins of the erosions are thin, soft, ragged, and transparent.
When the softening penetrates beyond the muscular tunic,
the margins are beveled outwards, and terminate in delicate
and irregular processes, which exhibit a tattered, shred-like
appearance on being immersed in water. The same form
precisely is perceived when the lesion affects the peritonasum.
This patch-like softening usually takes place whenever the

SECT. IV.] STOMACH. 235

mucous membrane happens to be stretched ; but should it be
thrown into folds, it will assume a different shape, and occur
in stripes and bands of a light bluish tinge, forming thus a
striking contrast with the sound surface, which is either of
the natural color, rosaceous, or of a light vermilion. These
stripes and bands, it should be stated, always have the sit-
uation and direction of the mucous wrinkles, the inter-
vals between them being very slightly or perhaps not at all
changed in their consistence, — a circumstance which maybe
easily recognized by floating the parts in clear water. Occa-
sionally, though I believe very rarely, the softened membrane
is of a light orange hue ; and the vessels traversing it, pro-
vided there be any, which is not always the case, are filled
with black blood, which, as I have repeatedly witnessed, is un-
susceptible of any change upon its exposure to the atmosphere.
Redness of the affected texture is never observed ; its exist-
ence being incompatible with the chemical action of the
gastric acid.

The degree of softening presents several important varie-
ties. At first the membrane has very much the same con-
sistence as in moUescence from inflammation ; but, as the
process advances, it is gradually converted in a grayish,
pulpy substance, which can be easily removed with a sponge
or by a stream of water, leaving the submucous cellular
tissue of a dark silvery color. Instances occur, especially in
young children, in which the membrane is reduced to the
consistence of a hot solution of starch, arrow-root, or isin-
glass.

SECTION IV.

• Of the Diseases of the Stomach.

That ulceratio7i of the stomach should occasionally occur,
is not at all surprising when we take into consideration the
great extent of its surface, the delicacy of its organization,
the variety of its functions, its important sympathetic connec-
tions with other organs, and the heterogeneous nature of its
contents. Yet, that this event is much less frequent than was
at one time supposed, is abundantly proved by the general ex-

236

STOMACH. [chap. VII.

perience of the profession. Extensively as I have been en-
gaged in pathological researches, it may be safely asserted
that I have never met with this lesion in more than three or
four instances. Nor have I been wanting in proper precau-
tions with regard to the cleansing and minute inspection of
the mucous coat. True it is, my observations were not con-
ducted formerly with so much patience and accuracy as they
have been for the last three years ; still, every thing confirms
me in the belief that ulceration of the stomach is decidedly
amongst the rarest diseases to which this important organ is
subject.

Ulcers of the mucous membrane of the stomach are seldom
either large or numerous. Most generally, indeed, there is
only a single one, which is then of considerable size. Occa-
sionally, however, they are extremely numerous, as in the
case mentioned by Dr. Louis, of Paris, in which there were
as many as eighty. When they are seated in the glands of
Brunner, as was probably the case in the instance just re-
ferred to, they are almost always much smaller than when
they affect the intervening texture, their magnitude rarely
exceeding that of a split pea. In the other variety, they
often attain the size of a Spanish dollar, especially when
solitary ; and instances are not wanting in which they were
n uch larger.

Not less variable are the shape and depth of these erosions.
Their most common appearance is that of depressed breaches
of continuity of the mucous corion, of a roundish form, with
edges slightly elevated above the level of the internal sur-
face. Not unfrequently, however, they are remarkably irreg-
ular, their margins hard and thick, fissured, or even granu-
lated. Appearances like these are especially observable in
old chronic cases, but are very rare in such as are recent.
In several instances I have seen the edges partially under-
mined, so that, upon being floated in water, they presented
that ragged, shreddy aspect, which is so often witnessed in
erosions of the small intestines.

The bottom of the ulcer may be formed by the cellular
tissue, or it may erode through this and the muscular layer,
so as to lie upon the peritonaeal covering. In the latter case,
it is not uncommon for perforations to take place, and for the
contents of the stomach to escape into the abdominal cavity
or into some one of the neighboring organs. Most generally
a communication is established with the arch of the colon,

SECT. IV.] ULCERATION. 237

the walls of which are firmly cemented with those of the
stomach, as the erosive process extends by means of lymph.
In this way, the individual may sometimes live for years,
with very little inconvenience. Oftentimes the bottom of the
sore is hard and thickened, from the hypertrophous condition
of the subjacent textures, or, as more rarely happens, from a
deposition of small patches of lymph. Its color is usually
pale ; but cases are sometimes observed in which it is of a
light rose tint, brownish, or crimson, every capillary vessel
being loaded with florid blood. Under no circumstances,
scarcely, is the base of the sore of so deep a hue as the
edges.

One of the most interesting and instructive circumstances
connected with ulceration of the mucous membrane of the
stomach is, that the sores thus induced occasionally undergo
a process of reparation, similar to the cicatrization of ulcers
in other parts of the body. (PI. I, Fig. 18.) The possibility
of such an occurrence has been questioned by some very
able pathologists, — more, perhaps, however, from their having
been governed by speculative views than by actual observa-
tion. The facts published by the French, English, and Ger-
man writers leave, indeed, no longer any doubt upon the
subject. Reil, Meckel, Troillet, Andral, Graves, and Cruveil-
hier have each given well-marked examples of it. The
latter of these distinguished anatomists has delineated several
cases in which ulcers of the stomach, of considerable size,
were completely healed, with the contiguous mucous corion
in a contracted and puckered state. The cicatrix was always
of a bluish color, and of a dense, fibrous texture, very difier-
ent from the characters of the natural tissue.* In 1832, I
examined the body of a young lady, about thirty-three years
of age, who had been laboring for a long time under all the
symptoms of chronic gastritis, attended with extreme ema-
ciation. In the posterior wall of the stomach, nearly midway
between the great tuberosity and the pyloric extremity, was
an old ulcer, about the size of a five franc piece, the edges of
which were puckered, thickened, and completely cicatrized.
All the tunics were destroyed ; and the contents of the organ
were prevented from escaping by the manner in which it was
glued to the anterior surface of the pancreas, which thus
formed the bottom of the erosion. The rest of the stomach

* Anatomie Pathologique de I'Home, Livraison, x. p. 7, plates 5 and 6.

238 STOMACH. [chap. VII.

was perfectly soundj excepting that its coats were much
thinner than usual, and remarkably blanched. A case, in
many respects similar, has been described by Professor Re-
camier, of Paris.

Another equally conclusive instance of this sort of repara-
tion is furnished in the case of the celebrated Beclard, author
of the well-known "Elements of General Anatomy." When
this individual died, a completely cicatrized ulcer, about the
magnitude of a quarter of a dollar, was discovered in the
small curvature of the stomach, a few lines from the cardiac
extremity. Its surface, considerably depressed, was traversed
by a central band of white fibrous matter, on each side of
which was a shallow cavity, formed by the peritonasal tunic.
The rest of the organ was perfectly healthy.

It thus clearly appears, from the foregoing observations, that
ulcers of the mucous membrane of the stomach, even when
of considerable magnitude, are susceptible of healing. Such
a reparation, however, is always difficult, from the surface of
the sore being constantly exposed to the irritating contents
of the organ, by which the salutary efforts of nature as a
necessary consequence, must be very frequently bafiled. The
first step in the process seems to be the effusion of fibrin, by
which the loose margin of the ulcer is tied to the subjacent
parts. By degrees, a similar substance is deposited upon the
bottom of the sore, which in time is transformed into a gran-
ulating surface, bathed with a thin muco-purulent fluid.
Thus, day after day, the process proceeds until the cicatri-
zation is completed, the ulcer in the mean time diminishing
in size, and acquiring a bluish, puckered appearance. The
new product, it should be observed, although it occasionally
attains the consistence and thickness of the natural mem-
brane, is yet essentially different, being less smooth, less vas-
cular, more easily destroyed by subsequent attacks of disease,
destitute of follicles, and incapable, therefore, of secreting
real mucus.

The portions of the stomach most liable to ulceration are
the cul-de-sac and great curvature, from their being more
constantly in contact, perhaps, with our food and drink. No
part of the organ, however, is exempt from it.

The signs which denote the existence of gastric ulceration
during life, are not always well marked. Occasionally, in-
deed, the disease is entirely latent, manifesting no phenomena
whatever by which we can recognize its presence. Most

SECT. IV.] ULCERATION ; HYPERTROPHY. 239

commonly, however, the patient complains of the ordinary
symptoms of chronic gastritis, such as nausea, with occa-
sional vomiting, difficult digestion, colicky uneasiness, gnaw-
ing pain in the epigastric region. With these signs are
usually conjoined, when the ulcers are large, deep, and nu-
merous, great emaciation, considerable fever especially in the
evening, constriction of the features, and coldness of the
extremities. In many cases, there are repeated attacks of
vomiting of blood ; and a symptom upon which Professor
Cruveilhier lays a good deal of stress, is the existence of a
dorsal stitch^ or a severe and steady pain in the neighborhood
of the lower vertebra of the back. Occasionally, large-sized
vessels are exposed by the ulceration ; and, in this way, ex-
hausting and fatal hemorrhage may take place.

The period which elapses from the commencement of the
inflammation until the supervention of ulceration, must vary,
of course, in different cases and under different circumstances,
so as to render it impossible to lay down any definite rules.
In general, however, it will not be going too far to say that
erosions do not begin to form under several weeks after the
establishment of the disease which gives rise to them. Nay,
very often there is reason to suppose that the antecedent
inflammation is not only remarkably tardy in its progress, but
of an extremely low character.

Hypertrophy of the stomach is by no means so uncommon
as was formerly supposed by pathologists. Excepting the
peritonasal, it may invade all the tunics simultaneously, or be
confined to a single one, which is, in fact, most generally the
case. Sometimes the enlargement particularly attacks the
mucous follicles, giving the internal surface of the organ a
rough, tnammillated fulness, the widened orifices of the
glands identifying the seat of the affection. This state of the
mucous membrane of the stomach is of very frequent occur-
rence in chronic inflammation : I have several times met
with it as a complication of diabetes, and Louis has often
observed it in pulmonary phthisis. The mammillated promi-
nences, which are generally of a rounded, conical shape, and
from the size of a currant to that of a filbert, strongly resemble
the granulations of an old ulcer, and are occasionally separat-
ed by deep narrow grooves, running in different directions.
Their length is subject to much variety. In some instances,
it does not exceed half a line ; but, in others, it has been
known to be more than a third of an inch. In my own dis-

240 STOMACH, [chap. VII.

sections, I have invariably found this mammillated appear-
ance of the mucous coat most conspicuous in the inferior half
of the organ.

The mucous membrane in this affection is usually of a
pale reddish color, like the surface of an indolent ulcer ; occa-
sionally, however, it is almost white, and still more frequently
it is grayish. In most cases, it is abnormally firm and thick,
allowing itself to be raised in large shreds. The villosities,
also, are sometimes much augmented in size, and truly hyper-
trophous. There are no diagnostic signs of this disease. In
some of M. Louis's patients, there was merely an impairment
of the appetite ; in others, epigastric tenderness, with nausea
and vomiting.

To the same class of lesions are to be referred those singu-
lar looking laarty excrescences which are sometimes to be
observed upon the mucous membrane of the stomach. Their
shape is generally rounded ; their size inconsiderable ; and,
in most cases, they adhere by a narrow footstalk, of consider-
able length. Much diversity prevails in regard to their inter-
nal structure, which is sometimes fibrous, sometimes fungous,
and sometimes vascular and erectile. Their color varies in
different cases. For the most part they are grayish, but
occasionally reddish, brownish, or blackish.

Hypertrophy of the jibro-cellular tissue is characterized
by considerable thickening and induration, with or without
change of structure of the other tunics : the areolar texture
is destroyed, and replaced, as it were, by a dense albuminous
substance, which may be so firm as to prevent the stomach
from collapsing when opened. There is some variety in the
color of the affected part. Occasionally it bears some resem-
blance to a mixture of bees-wax and tallow ; more commonly,
however, it presents the appearance of a piece of well-boiled
tripe, with some sections of it more transparent than others.
Nor is the hypertrophy always limited to the submucous cellu-
lar tissue. Cases are frequently met with in which it involves
the subserous substance, and even that between the muscular
fibres, rendering the latter pale and thin, or else, as we shall
presently see, hypertrophous.

Hypertrophy of the muscular coat has been particularly
described by Dr. Louis, and sometimes amounts to an enor-
mous degree, both as regards thickness and the extent of
surface which it occupies. Rarely does it pervade the whole
organ ; on the contrary, it usually occurs in considerable

SECT. IV.] ATROPHY. 241

sized patches, either alone, or in union with hypertrophy of
the cellular tissue. In this affection, the muscular fibres are
unnaturally large and distinct, harder, more dense and florid,
forming frequently thick, membranous intersections. In most
instances of this species of hypertrophy, the patient labors
under cancer, or some disease or other which forces the organ
habitually to reject its contents. It is also noticed sometimes
in great eaters.

Less frequent than the affection here noticed is the ex-
treme attenuation of the coats of the stomach, constituting
what is denominated atrophy. In making microscopic ex-
aminations, cases sometimes present themselves in which the
walls of the stornach are remarkably thin, pale, and ema-
ciated, being reduced to a soft, flabby substance. Under
such circumstances, the peritonseal covering seems as if it
had been bleached ; the muscular fibres are scattered, and
almost colorless ; and the mucous membrane is diminished in
thickness, pallid, deprived of its villosities, and scarcely capa-
ble of being separated from the subjacent textures. A degree
of atrophy like this, however, is extremely rare, and has
occurred to me only once. Partial attenuation is more com-
monly observed at the great cul-de-sac than in any other
portion of the stomach. In several instances, I have also seen
it immediately below the cardiac extremity. How far atro-
phy of this organ has any connection with chronic irritation,
it is diflicult to say ; but that there is some dependency of
this sort, most pathologists, I believe, are ready to admit.

The stomach is sometimes much reduced in size, from pro-
longed fasting ; from cancerous affections, or protracted pres-
sure : and cases occasionally happen, in which, from excessive
gluttony, or the effects of disease, it is enormously enlarged.
Some very interesting examples of this latter lesion are to be
found in different works on morbid anatomy ; but the most
instructive instance with which I am acquainted has been
recently published by Dr. Yvan, of Paris,* who exhibited
the specimen to the Royal Academy of Medicine of that city.
The subject of it was a soldier, who for some years had had
a large scrotal hernia, attended, during the last month of his
life, with the most intractable vomiting, although there was
no strangulation. On examination after death, the stomach,
situated parallel to the axis of the body, was found to be of

* Archives Generates, January, 1830.
VOL. II. 31

242 STOMACH. [chap. VII.

ail enormous volume, and to be divided by a circular depres-
sion into two portions, the one lying in the abdomen, the
other in the hernial sac. The length of the great curvature
was three feet, the circumference at the widest part twenty
inches, and the capacity nearly a gallon and a half. The
muscular fibres, as well longitudinal as circular, although
considerably attenuated, were yet quite distinct throughout
the greater part of the organ.

A part of the stomach is occasionally formed into a pouch.
Of this I have never seen an example ; but Dr. Baillie men-
tions one which came under his own observation, and which
had been produced by the swallowing and subsequent reten-
tion of five half-pennies. The walls of the pouch were con-
siderably attenuated, but not inflamed nor ulcerated.

Pieces of cartilage are sometimes, though 1 believe very
rarely, noticed in the stomach, when they grow either be-
tween the mucous and muscular tunics, or between the latter
and the peritonasal. Occasionally they appear in the form of
small, irregular tumors, projecting upon the inner surface of
the reservoir. They are most common towards the pyloric
extremity, and are frequently connected with cancerous for-
mations. De Haen has described a bony deposition in the
stomach, of what extent he does not inform us.*

Various kinds of twnors have been repeatedly observed in
this organ, Ruysch mentions that he saw a morbid growth,
from the stomach of a man, which contained hair, together
with several large grinders. Polypous tumors are very rare.
The only well-authenticated case of which I have any
knowledge, is to be found in Dr. Monro's Morbid Anatomy of
the Gullet, Stomach, and Intestines. The patient was a lady,
forty-five years old, who had complained of indigestion and
pain in the epigastric region, and died much emaciated. On
examining the body, a tumor, of an oval shape, and about the
size of an orange, was observed to adhere by a short neck to
the villous membrane of the stomach ; its surface being quite
smooth, and the internal texture so firm, solid, and tough as
to offer considerable resistance to the knife. This section of
it exhibited a uniform appearance.

Authors make mention of steatomatous tumors as of occa-
sional occurrence within the stomach. They are usually en-
cysted, and, when cut into, are found to contain a semi-con-

" Rat. Medend, t. iv. cap, i.

SECT. IV.] TUMORS. 243

Crete substance, resembling suet, tallow, or soft wax. This
morbid product is extremely rare, and has never been well
described. Perhaps the best account is that by Vic D'Azyr ;
but even this is so meagre as to offer us nothing satisfactory
upon the subject.

In making post mortem examinations, opportunities occa-
sionally present themselves of observing carciiiomatous tumors
in the stomach. Old age is the period of life in which this
frightful malady is most frequent ; and the parts most prone
to it are, first, the pylorus ; secondly, the cardiac extremity ;
and, thirdly, the body of the organ. Cases are sometimes ob-
served in which nearly the whole stomach is involved in this
affection, its coats being transformed into a dense, gristly sub-
stance, intersected by whitish membranous bands, without
any vestige scarcely of the normal structure.* Most general-
ly, however, the disease appears in the form of distinct tu-
mors, varying in size from a small nut to a foetal head. Their
surface is often remarkably rough, irregularly mammillated or
marked off into numerous lobules; and, on cutting into them,
they are found to exhibit a great diversity of texture, some
parts being fibrous, some cartilaginous, some osseous, some
mammary, some lardaceous, some fungoid, some medullary,
some gelatiniform, some hasmatoi'd. But it is not always
that these substances are thus combined. Cases not unfre-
quently occur in which they are observed separately, or in
which two or three alone are met with. In their primordial
condition, they are generally entirely fibro-cartilaginous ; and
afterwards, as their developeraent proceeds, other textures are
either superadded, or such as previously existed are modified
and transformed.

The mucous membrane, in carcinomatous diseases of the
stomach, is variously affected. In the generality of cases, it
is very much thickened, sometimes as much as a fourth of an
inch, indurated, elevated into irregular masses, and of a light
grayish color. • In others, again, it is of a dull yellowish,

* Of this variety of cancer died Napoleon Buonaparte. His body v/as inspected
on the 6lh of May, 1821, at Longwood, St. Helena. The internal surface of the
stomach, saj^s the report of the examiners, through nearly its v. hole extent, ^vas a
mass of cancerous disease, intermixed with poriions of scirrhus; the cardiac ex-
tremity, for a small space around the oesophagus, being the only part that was
healthy. The pyloric extreaiity adhered freely to the concave surface of the
liver, and about one inch from its orifice presented an ulcer,' which penetrated
the coats of the organ, and was sufficiently large to allow the passage cf the
little finger. Thus perished the conqueror of the world !

244 STOMACH. [chap. VII.

greenish, or light mahogany tinge, soft, pulpy, or almost
brain-like, vascular, ulcerated, or partly destroyed. Several
of these morbid alterations are generally met with in the
same specimen. The submucous tissue is also usually more
or less changed, the most common appearance being a dull
yellow lardaceous degeneration. The muscular fibres are
apt to be unnaturally distinct and florid ; and the peritonEeal
tunic, although it does not always participate in the disease,
is often much thickened, and almost of a gristly consistence.
In this affection the capacity of the organ is commonly much
diminished ; and there is almost always considerable swelling
of the neighboring lymphatic glands, with occasional extrava-
sations of blood into the submucous and subserous cellular
tissue. Such a diseased stomach usually contains a very of-
fensive gas, and also a quantity of dark-colored fluid, like
coffee-grounds.

I shall conclude this imperfect sketch of carcinoma with
the following case of diseased pylorus, which was communi-
cated to me, about eighteen months ago, by my friend Dr.
Asa Spalding, of Flushing, Long Island. The patient, a lit-
erary gentleman, was twenty-five years of age, during the
last four of which he had suffered under all the symptoms of
a chronic aff'ection of the stomach, such as dyspepsy, nau-
sea, and torpor of the bowels, with sallow and constricted
features. On inspection, the pylorous was found to be con-
verted into a thickened, scirrhous mass, partly cartilaginous
and partly bony, of a pale bluish color, with the orifice so
much contracted as scarcely to allow the passage of a com-
mon goose-quill. The coats of the stomach and duodenum,
in the immediate vicinity of the disease, were hypertrophied,
vascular, and almost of a gristly hardness. The pancreas,
indurated, and of a pale grayish hue, was enlarged to three
or four times its ordinary bulk ; and in the left lobe of the
liver was a big abscess, partially filled with thick, yellow
pus, which communicated, by means of an irregular, ragged
outlet, with the arch of the colon.

In the college museum is a specimen of scirrhous pylorus,
taken from a female, thirty-seven years old, in which the
opening is still smaller, if possible, than in the case of Dr.
Spalding. The disease was complicated with extensive le-
sion of the duodenum and gall-bladder, and, what was partic-
ularly remarkable, was the slight emaciation which had taken
place. The pylorus in this specimen is transformed into a

SECT, v.] DUODENUM. 245

thick, hard, gristly ring, above and below which there is ex-
tensive thickening of the mucous coat. Several cases, of near-
ly a similar character, are recorded in the valuable treatise
of Dr. Abercrombie, a work which should be in the hands of
every student of pathology. In some of these, the pylorus
was encircled by large masses of scirrhus, of a firm, cartila-
ginous hardness, and of the size of a big apple.

The symptoms of carcinomatous disease of the stomach
are often extremely obscure, and, what is singular, are never
so urgent when the lesion is seated near the cardiac extremity
as when it involves the pylorus. In most cases, the signs
are those of chronic irritation ; that is to say, the patient is
afiiicted with indigestion, lancinating pain, constant acidity
and flatulence, and occasional vomiting. There is considera-
ble emaciation, with gradual wasting of the muscular powers ;
the eye is sunk, the complexion sallow, and, towards the last,
the matter ejected from the stom^ach has a very off'ensive
smell, and is of a dark color, like coffee-grounds. These
symptoms, it is obvious, are not diagnostic ; nor should they
ever be so regarded, unless the scirrhous tumor be at the same
time perceptible by the hand placed upon the abdomen.

SECTION V.

Of the Lesions of the Duodenum.

The organic lesions of the duodenum, are in many respects
so peculiar, that they deserve to be considered separately.
Nor are they uninteresting on another account. From the
close proximity of the organ to the stomach, liver, gall-
bladder, and small intestine, with all of which it may be said
to be directly continuous through the intervention of its mu-
cous lining, disease can hardly ever exist in one of these
structures without implicating the other. Nowhere, indeed,
is there a more striking instance of the operation of what
Mr. John Hunter and his followers have denominated con-
tiguous sympathy, than in the viscera now under considera-
tion. What takes place in the conjunctiva of the eye, in
severe inflammation of the Schneiderian membrane of the
nose, may be supposed to occur precisely in the inner coat of

246 BUODENUM. [chap. VII.

the gall-bladder, common and hepatic ducts, in acute duode-
nitis. Here disease is directly propagated from one part to
another, because of the similarity of structure of the lining
membrane ; nor is it uncommon to find that the organ which
is secondarily involved, is obliged to bear the brunt of the
irritation. In this manner are produced, there is reason to
believe, many of the cases of the congestive fever, as it is
vaguely called, of the South ; the disease, in the first instance,
being probably merely an acute inflammation of the mucous
membrane of the duodenum or stomach, which, by propaga-
tion, involves the mucous membrane of the liver, gall-bladder,
and small bowel, and thus produces that universal obstruc-
tion in the portal circle so much spoken of by some writers.

True it is, the question has not yet been settled by post
mortem inspection ; but let any one reflect coolly and dis-
passionately upon the subject, and all the difliculties which
would seem at first sight to environ it will speedily vanish.
Who does not know that the whole liver is lined by a mu-
cous surface, the area of which, could it be properly esti-
mated, would, in all probability, be found to be quite as great
as that of the stomach ; at all events, certainly as great as
that of the duodenum, with Avhich it is directly continuous ?
Should any one say that this is impossible, let him but re-
flect for a moment upon the large size of this organ, and the
immense number of its granules, and then take into consid-
eration the fact that each of these bodies are provided with
an excretory tube, lined by a mucous membrane, and all
skepticism will at once fly from his mind. He will no longer
regard the liver simply in the light of a parenchymatous
structure, but as a viscus essentially composed of mucous
follicles, subject merely to the same diseases as the duodenum
which adjoins it, and which sends into its interior, one of its
own most important tissues. Thus may we perceive how
disease may be propagated from one of these organs to the
other ; how an irritation, seated in the mucous membrane of
the duodenum, may afl'ect that of the liver ; how the func-
tions of the latter may be impaired by the former ; and, con-
versely, how an inflammation of the liver may be transferred
to the duodenum, the stomach, and the mesenteric portion of
the small intestine, and do the most serious and extensive
mischief.

" The leading peculiarity of disease of the duodenum, as
far as we are at present acquainted with it," says Dr. Aber-

SECT, v.] ULCERATION. 247

crombie, "seems to be, that the food is taken with rehsh, and
the first stage of digestion is not impeded ; but that pain
begins about the time when the food is passing out of the
stomach, or from two to four hours after a meal. The pain
then continues, often with very great severity, sometimes for
several hours, and generally extends obliquely backwards, in
the direction of the right kidney. Tn some cases, it gradually
subsides after several hours, and, in others, is relieved by
vomiting." * This account has evidently reference to or-
ganic disease, not to such as is acute. In acute duodenitis,
whether simple or complicated, the most prominent symptoms
are, pain in the right hypochondriac region, spasmodic, deep-
seated, and augmented by pressure and full inspiration ; more
or less nausea and vomiting; and a yellow state of the skin
and eyes. Frequently the pain is of a dull, gnawing charac-
ter ; and in no case can the patient swallow solid food with-
out the utmost aggravation of all his sufferings. Duodenitis
is almost always present in yellow fever; and jaundice, as is
now well known, frequently depends upon the same affection,
either in its acute or chronic form. But let no one deceive
himself concerning the diagnosis of the diseases of this por-
tion of tile alimentary tube. Nowhere is it more difficult to
form an intelligent judgment. Nor will this appear strange,
if we remember the deep situation and the important organs
by which the duodenum is covered and surrounded.

Ulcers of the duodenum, whether originating in its mucous
membrane, or in its follicular structure, are extremely rare,
and run pretty much the same course as those of the stomach.
In ninety-two cases of ulcerated bowel, observed by Andral,
only one occurred in the duodenum ; and if this be taken as
an average estimate, it would appear that this portion of the
alimentary tube is peculiarly exempt from such lesions. That
they are infrequent, my own experience abundantly confirms.
Seldom is there more than one erosion ; nor is it very com-
mon to observe them below the insertion of the choledoch
duct. It is not improbable that the ulcers may heal ; never-
theless, owing to the irritating nature of the bile which lies
so constantly in contact with this portion of the small bowel,
they manifest a remarkable tendency to extend their ravages
from the mucous to the other tunics.

The peculiar characters of ulceration of the duodenum are

* Pathological and Practical Researches, p. 119.

248 DUODENUM. [chap. VII.

well illustrated by a case related by my friend Dr. W. F.
Irwin, of Pittsburgh.* The patient was sick for several
years, and during the last six months of his life was liable to
daily paroxysms of pain and vomiting. His bowels were
habitually constipated, and could never be moved without
the agency of purgative medicines. What was remarkable,
and what may be almost regarded as pathognomonic of duo-
denal disease, was, that the digestive process usually went on
well for two, three, or four hours after taking food. He was
then attacked with violent pain and vomiting, which regu-
larly continued until the stomach was thoroughly freed of its
contents. In this way he lingered on until he finally expired,
in a state of great emaciation. On inspection, the duodenum
was found to be in a hard, firm, cancerous condition, much
enlarged, and the whole internal surface covered with ragged
ulcerations. Numerous tubercles were also observed. They
varied from the size of a hazelnut to that of a hickorynut,
and the largest of them contained a white, friable matter,
resembling dried cream. The quantity of pus found about
the diseased part of the bowel was upwards of a gill. The
stomach, though enormously enlarged, was apparently quite
healthy, as were also the small and large bowels, the liver,
and spleen. The pancreas, reduced to one half its natural
bulk, was in a state of scirrhous induration.

When perforations take place, the contents of the tube
may, as in the case of the stomach, escape either into the peri-
tonseal cavity, or into some of the surrounding organs. In a
preparation in the college museum, the duodenum communi-
cates with the fundus of the gall-bladder ; and in another,
taken from a gentleman sixty-eight years old, with a large
pouch formed by the convex surface of the liver, and the
contiguous portion of the diaphragm. Without entering into
all the particulars of this remarkable and, so far as I know,
unique case of disease, it may be briefly stated that the outlet
of this extraordinary sac was a circular opening, about the
size of a half guinea, with thick, rounded, and well-defined
margins, which was situated one inch below the pylorus, on
the upper wall of the duodenum, which, as well as the arch
of the colon, adhered extensively to the anterior border of
the liver. Leading from this aperture, in a direction obliquely
upwards and outwards, was a narrow tortuous sinus, which,

* Philadelphia Journal of the Medical and Physical Sciences, vol. viii. p. 406.

SECT, v.] ULCERATION. 249

after a coarse of about one inch and a half, communicated
by means of a small, elliptical slit, with the pouch previously
adverted to. This artificial reservoir, formed in the manner
before mentioned, was flat, circular, a little more than six
inches in diameter, and capable of holding about ten ounces
of fluid, although perfectly empty at the time of the exami-
nation. It was lined throughout, however, by a thick, dense
layer of lymph, of a yellow-greenish color, from the inter-
mixture, probably, of fecal matter, which must have passed
into it at different times from the perforated duodenum. On
cutting into this substance, the hepatic texture was found to
be perfectly sound, excepting for about the fifth of an inch in
depth, where it was somewhat softened, and of a dark bluish
tint. The diaphragm, dark-colored and deeply injected, ad-
hered firmly all around the anterior surface of the liver, the
adhesion extending about an inch beyond the longitudinal
fissure, leaving the remainder of the left lobe perfectly free,
and healthy. The liver, it should be further stated, was of
the natural size, and, with the exception specified, quite sound.
The gall-bladder and other abdominal viscera presented noth-
ing worthy of special notice. The right lung was in a state
of purulent infiltration ; the cartilaginous rings of the trachea
and bronchiae ossified ; the heart softened ; the parotid glands
enlarged and suppurated.

The subject of this remarkable lesion had been liable,
throughout life, to attacks of rheumatism, but had otherwise
enjoyed good health. A few years before his death, he gradu-
ally lost flesh, his complexion assumed a dark sallow aspect,
the skin became dry and bloodless, the bowels were torpid,
and the pulse was weak and intermittent. In the month of
April, 1837, he was suddenly seized with excruciating pain in
the epigastric region, attended with reduction of temperature
and great prostration of strength. Large doses of stimulant
and narcotic medicines, with counter irritants, afforded some
relief, and produced a certain degree of reaction, with a
paroxysm of emesis. His bowels were opened with cathar-
tics, and he was bled at the arm, but the pulse sunk under
the operation. Much debility ensued, with occasional flushes
of fever, cough, and dyspnoea. After a few days, the parotid
glands became swollen and indurated. Finally, hiccup super-
vened, and continued to recur until he expired, which hap-
pened on the 13th of May, nineteen days after the attack of
epigastric pain. For an account of the symptoms of this

VOL. II. 32

250 duodenum/ [chap, vii.

case, and for the opportunity of making the post obit exam-
ination, I am indebted to my friend, Professor Drake, whose
zeal in the cause of pathological science is surpassed only by
his urbanity.

Cases are occasionally observ^ed in which the duodenum is
ruiJtured, apparently without any previous lesion. Of this a
highly interesting instance has been detailed by Professor
Drake, in his Medical and Physical Journal for April, 1839.
The patient was a cordwainer, thirty-eight years of age.
The symptoms were those, in the first place, of violent colic,
and afterwards of acute peritonitis, — death occurring in sixty
hours from the commencement of the attack. On inspection,
the duodenum, at the pylorus, was found to be ruptured
more than half way round, the fissure exhibiting the appear-
ance of a clean cut. Through this the contents of the tube,
as well as of the stomach, had escaped into the peritoneeal
sac, and excited fatal inflammation. No ulceration existed
any where, nor had any part suffered gangrene ; in short,
there was not the slightest organic change of any kind that
could account for the laceration.

Broussais mentions the singular case of a man, sixty-three
years of age, in whom an ulcer was discovered in the upper
portion of the duodenum, which had formed a communi-
cation with the hepatic artery. The intestinal canal was
found full of blood.* In a case described by Dr. Streeter, of
England, the duodenum opened externally, between the
seventh and eighth ribs, by means of a canal two inches and
a half in length, through which articles of food and drink
were frequently discharged. The tube was greatly con-
tracted beyond the seat of the communication, and the patient
lived about a month after it took place. f

Carcinomatous and other tumors are occasionally found in
the duodenum ; but I suspect they are extremely infrequent ;
and, thus far, no instance has fallen under my own observa-
tion. When seated in the neighborhood of the outlet of the
choledoch ducts, such tumors, by preventing the flow of bile,
may cause distention of the gall-bladder and congestion of
the biliary passages, with all the contingent phenomena of
jaundice. In the same manner may arise obstruction and
enlargement of the pancreas.

* Sur la Duodenite Chronique.

t Mitland Medical and Surgical Reporter. November, 1829.

SECT. VI.] SMALL BOWELS. , 251

The duodenum is sometimes enormously enlarged. Cases
have been recorded in which it equaled in volume the stom-
ach. Its tunics are also liable, though much more infre-
quently than those of the rest of the alimentary tube, to
thickening and attenuation.

SECTION VI.

Of the Diseases of the Small Boivels.

Amongst the most common organic affections of the small
intestines, properly so called, are ulcerations. Comparatively
infrequent in the upper portion of the tube, they always
increase as we approach the coBcum ; and, in the great ma-
jority of cases, it is not unusual to find them entirely con-
fined to the inferior half of the ileum. In their shape they
may be circular, elliptical, or linear, the frequency of their
occurrence being in the order here enumerated. Their di-
mensions vary from a line to several inches ; their margins,
which are ordinarily elevated and ragged, are grayish, pink,
or rose-colored, more rarely brownish or blackish ; their
cavity is generally formed by thickened and indurated cellu-
lar tissue, sometimes by muscular fibres, sometimes by peri-
tonaeum. Perforations are not infrequent, and the conse-
quences which they occasion, are of the same nature as in
the stomach, duodenum, or large intestine.*

When the ulcers are seated in the isolated follicles, their
number is sometimes immense, hundreds of them being scat-
tered in every direction. Under these circumstances, they
are generally of small size, rounded, and exhibit every variety
of disorganization, from incipient erosion to the complete
removal of the .gland.

In the glands of Peyer, the ulcers are not unfrequently
seen in thick clusters, resembling the confluent eruption of
the skin in small-pox. Their surface is often remarkably
uneven, granular, or honey-combed, — appearances which are
owing, as well to the partial destruction of these follicles as
to the hypertrophied condition of the intervening cellular tis-

* For specimens of ulceration of the isolated follicles and glands of Peyer, see
Plate I, Figs. 9 and 10.

253 SMALL, BOWELS. [CHAP. VII.

sue. Frequently I have seen them present an eroded, worm-
eaten aspect, with reddened, elevated, and indm^ated margin§. ^
The configuration which these ulcers assume generally re-
sembles that of the glands in which they are situated ; that
is, they are oblong, elliptical, or circular, and occasionally, as
in a case which fell under ray observation not long since,
they are T-shaped. When several of the patches run to-
gether, they are commonly very irregular, and their dimen-
sions are also much greater, the eroding process going on
until the mucous membrane is destroyed over a very consid-
erable extent of surface. Occasionally, all the glands of Peyer
are in a state of ulceration ; more commonly, however, not
more than five or six are involved, and sometimes only a
single one.

Follicular ulcers are exceedingly common in the small
intestines of phthisical subjects. Dr. Louis observed them
in different proportions, in nearly five sixths of all the cases
which he examined at the Charity Hospital in Paris. Andral
found the small bowel sound in only about one fifth of all
the consumptive patients who entered the wards of Lerminier
during a period of five years. This proportion difi"ers re-
markably from that of Bayle, who met with this lesion in
only two thirds of his cases ; but it may be satisfactorily
accounted for, by the greater care which Louis and Andral
employed in cleansing and thoroughly scrutinizing the whole
alimentary tract. Every one who is at all extensively en-
gaged in pathological researches, must fully admit the fre-
quency of this complication. So commonly have I met with
it, that I never examine a phthisical individual without
expecting to find ulceration of the small or large bov;^el, or
both.

Ulcers of the small bowel, whether originating in the
mucous or in the glandular texture, can often be recognized,
if they are deep, even before the tube is laid open, from the
translucent and discolored state of the peritonasal covering.
Often the free surface of the bowel is covered with globules,
shreds, or patches of lymph; and, in a few instances, I have
seen it studded with small granulations, which accurately
defined the seat of the disease. These remarks are equally
applicable to deep ulcers of the stomach, duodenum, and
large intestine.

I need scarcely say that these ulcers are susceptible of
healing. (PI. I, Fig. 28.) In the college museum are sev-

SECT. VI.] ULCERATIONS. 253

eral preparations which beautifully illustrate this subject. In
one of these, the ulcer, about the size of a half-penny, is of
a bluish color, and completely cicatrized, with a smooth,
slightly-depressed surface. In the same specimen are several
other erosions, some of them perfectly raw, others in a state
of partial reparation. Very recently, in examining a female
who died of phthisis, I found a small ulcer in the ileum, the
cavity of which was nearly filled up with hard, solid lymph,
of a yellow-greenish color, from the intermixture, doubtless,
of fecal matter. For the account of the process by which
this cicatrization is effected, the reader is referred to what
was said upon the subject, under the head of organic disease
of the stomach.

Another fact worthy of remark, relative to ulceration of
the small bowel, as well, I may say, as of the large, is, that
the influence of the disease is frequently propagated to the
mesenteric glands. The irritation seems to be spread, in this
case, from the mucous membrane along the lymphatic ves-
sels in the same manner as in chancre. This occurrence is
especially common in ulceration of the ileum, from the close
proximity of the glands under consideration. I need not now
particularly describe the appearances which these bodies
assume when thus affected ; suffice it to say, that they may
exhibit every grade of inflammation, from the slightest serous
infiltration to perfect suppuration. Large numbers, very much
increased in bulk, are sometimes involved ; and instances
occur in which they are all consolidated into one general
mass.

Not unfrequently the ulceration of the mucous membrane
seems to be consecutive, the suppuration commencing in the
subjacent cellular tissue, and elevating the mucous membrane
into little abscesses, about the size of a split pea. After a
while the covering breaks, and thus an ulcer is formed, which
runs the same course as in the preceding case. When sev-
eral of these purulent collections exist in close proximity,
they may communicate by means of fistulous tracts, in the
same manner as abscesses of the subcutaneous cellular tissue.

Ulcerations of the small bowel do not give rise to any
symptoms that can be considered as pathognomonic. In
most cases, there is intractable diarrhcea, with tenseness of the
abdomen, emaciation, and gradual failure of the strength.
The countenance has a withered, wo-begone look ; the appe-
tite is variable and capricious ; and the patient is harassed

254 SMALL BOWELS. [CHAP. VII.

with indigestion and great uneasiness after eating. There is
seldom any decided pain in tlie region of the affected bowel,
but often considerable tenderness on pressure, with griping
and tenesmus. Sometimes there is a peculiar rawness of the
mouth and fauces ; and. cases occur in which these parts are
covered with numerous aphthous incrustations. The alvine
evacuations are extremely variable. Generally they are thin,
watery, and highly offensive ; sometimes mixed with blood,
sometimes with pus. When the ulceration is combined with
thickening and induration of the coats of the intestine, there
may be the most obstinate constipation, from the loss of
power of the muscular fibres.

The stealthy and insidious manner in which ulceration of
the small bowel sometimes extends its ravages, and finally
leads to fatal perforation, is strikingly illustrated by the fol-
lowing case, for the particulars of which I am indebted to
my friend Dr. Dodge, of this city. It occurred in a young
merchant, twenty-four years of age, who was apparently in
perfect health until a short time before his death. Early one
evening, after having eaten a hearty supper, and spending a
part of the afternoon in horseback exercise in company with
a sister, he was suddenly seized with excruciating pain in the
region of the abdomen, followed by great irritability of the
stomach, and excessive prostration of the vital powers. Un-
der these symptoms, which continued with scarcely any
abatement, he sank in about thirty-six hours from the com-
mencement of the attack.

On examination of the body, thirty hours after death. Dr.
Dodge found the whole peritonaeum in a very red and in-
flamed condition, with all the viscera perfectly agglutinated
together by plastic lymph, which was effused in such quanti-
ties as to fill up every inter-intestinal groove. The abdominal
cavity contained about half a pint of thin, feculent matter,
which had escaped through a small oval ulcer, less than two
lines in diameter, which was situated in the ileum, eight
inches from its junction with the colon. Several other ero-
sions were discovered in the mucous membrane close by, but
the other tunics were perfectly sound, as were also the other
abdominal and the thoracic viscera.

The above case, of which we have given a brief outline,
is certainly one of great interest, and of real value to the
practitioner. The individual, as was before stated, was appa-
rently in the enjoyment of perfect health, yet the structural

SECT. VI.] LACERATION. 255

lesion which produced his death must have been going on
for a considerable period, gradually extending from the mu-
cous membrane, in which it doubtless began, to the cellulo-
fibrous, the muscular, and peritonaeal tunics. Notwithstand-
ing all this, however, there was not the slightest symptom
by which its presence could be suspected, either by the pa-
tient or his physician. Such cases are probably of much
more frequent occurrence than is generally imagined by the
profession.

I shall say a few words here respecting laceration of the
bowels from external violence, more especially as the subject
closely connects itself with ulcerative perforation, and is one,
moreover, of no little interest in a medico-legal point of view,
apart from any pathological consideration. All the mem-
branous viscera, properly so termed, appear to be liable to this
lesion, though not in an equal degree. Accidents of this
kind are usually produced by kicks or blows, and, as they
are always followed by an extravasation of the contents of
the affected organ, they speedily terminate the existence of
the patient. The few remarks Avhich will be offered on this
subject will be confined exclusively to laceration of the in-
testinal canal, as it is in this portion of the body that this
injury most frequently occurs.

It is a remarkable fact, and one for which it is not easy to
offer any satisfactory explanation, that most of the cases of
this accident of which we have any record, affected the
jejunum, or the superior portion of the ileum. Another cir-
cumstance worthy of notice is, that the bowel may be very
much lacerated by external violence without any discolora-
tion or bruises of the abdomen. The subject may be further
illustrated by examples, of which I select the following, as
having fallen under the immediate observation of two of my
medical friends. A coachman, twenty-two years of age, re-
ceived a kick from a horse upon the left side of the abdomen,
between the diaphragm and the crest of the ileum, of which
he died in thirty hours. There was no sign of contusion on
the skin ; but, on dissecting up the integuments, Professor
Drake found an extravasation of blood between the oblique
muscles, near the junction of their fleshy and aponeurotic
parts, which at once indicated the spot upon which the blow
had been inflicted. A large quantity of gas escaped from the
abdominal cavity, which, moreover, contained upwards of
two quarts of fluid feculent matter, of a turbid yellowish

256 SMALL BOWELS. [cHAP. VII.

color, without any admixture of blood. The peritonseura
was universally inflamed ; the bowels were closely aggluti-
nated to each other and to the surrounding parts ; and in the
upper portion of the jejunum, about eighteen inches from
the duodenum, were two rents with thickened, ragged, and
everted edges, one of which extended one third, the other
nearly entirely, across the tube. The mucous membrane was
but little inflamed. The cellular substance over the second
and third lumbar vertebrae was infiltrated with blood, and
the left psoas muscle had a swollen and lacerated appear-
ance.*

In the other case, that of a young man of twenty, the
injury was occasioned by the blow of a brick-bat, thrown
from a short distance. Death occurred in forty-two hours.
No mark of external violence was discoverable either on the
skin or in the abdominal muscles. On opening the peritonseal
cavity. Dr. Joshua Martin, of Zenia, to whom I am indebted
for a history of the case, as well as for the morbid specimen,
detected an oval aperture, about three quarters of an inch in.
diameter, in the superior division of the ileum, through which
had escaped a large quantity of fecal matter, giving rise to
violent inflammation of nearly the whole of the serous mem-
brane. The bowels were every where incrusted with coag-
ulating lymph, and the same substance thickly adhered to the
everted margins of the wound, as well as to the mucous
membrane immediately around.

In both these cases, as well as in every other of which I
have any knowledge, the symptoms which supervened upon
the injury were of the most urgent kind, and such, precisely,
as accompany perforation of the bowels from ulcerative ac-
tion ; that is to say, rapidly developed and speedily fatal
peritonitis.

Conjoined with ulcers of the small intestine, or occurring
without them, are occasionally to be observed small tuhercles,
seated either in the submucous cellular tissue, amongst the
muscular fibres, or between them and the peritonaBal covering.
Varying in size from a mustard-seed to a common pea, they
are often equally dispersed over the circumference of the
bowel, and are almost always most numerous in the lower
half of the ileum. What is remarkable, these small bodies
are extremely rare in the stomach, duodenum, and colon, — so

* Western Journal of the Medical and Physical Sciences, vol. i. p. 550.

SECT. VI.] TUBERCLES. 257

much so, that some writers have denied, though without
reason, their existence. Dr. Louis, who has given a very
able account of intestinal tubercles, has distributed them into
classes, founding his division upon their difference of density.
This, to say the least, is an unnecessary degree of refinement ;
for that all tubercles, no matter where occurring, are at one
period solid, is as fully established as that they have a ten-
dency ultimately to become soft. Thus, then, cases will
frequently present themselves in which some of those bodies
are semi-cartilaginous, whilst others are in a state of suppu-
ration.

These bodies are very common in phthisical subjects.
Louis observed them in thirty-six patients out of ninety-five,
or in upwards of one third of all his cases. I cannot think,
however, that they are so common in this country : in my
own dissections, I have met with them only twice ; nor can
I perceive that they have been often witnessed by the Phila-
delphia pathologists, whose reports of examinations are de-
cidedly superior, in point of accuracy and copiousness of
detail, to those of any other physicians in the United States.
In the human subject, these bodies, as has been already inti-
mated, seldom attain any considerable magnitude : in some
of the inferior animals, however, especially in the horse, they
may acquire the bulk of a small orange, their interior being
hollow, or, as is more generally the case, partially filled with
sebaceous matter, resembling that of the cutaneous follicles.*
When the covering of intestinal tubercles gives way, a cor-
responding number of ulcers is formed, with white, opaque,
and indurated edges. Such erosions are always peculiarly
loth to heal ; in which respect they afford a striking analogy
with those produced by the same cause in the lungs. There
are no symptoms which are peculiar to intestinal tubercles.

Tubercles of the intestines are not peculiar to the human
subject. I have noticed them in different classes of quadru-
peds, particularly in the horse, ox, and sheep, in the latter of
which they are exceedingly common, especially in the West-
ern States. The number of tubercles in this animal is some-
times immense : they occur throughout the whole length and
breadth of the intestinal tube, and, as in the human subject,
most of them are situated in the submucous cellular tissue.
Their volume varies between a millet-seed and a pea ; but, by

* Andral, Pathological Anatomy, vol, ii. p. 113.

VOL. II. 33

258 SMALL BOWELS. [cHAP. VIL

their agglomeration, they often form large nodules, which are
particularly conspicuous along the line of attachment of the
mesentery and meso-colon. In their color, these bodies are
usually of a greenish gray ; and, in their consistence, they
range between soft putty, fibro-cartilage, cartilage, and
bone.

In making post obit examinations, opportunities occasionally
occur for observing different morbid growths in the small in-
testine. Amongst these, the most important are polypous,
fungous, and carcinomatous tumors ; none of which, however,
as they do not differ materially from such as occur in the
stomach, need be here particularly described. They are all
extremely rare, and I have never met with them.

No mention has yet been made of the milt-like tumor of
the raucous membrane, so well described by Professor Monro,
of Edinburgh. I do not know whether it has ever been
found in the stomach ; but, as it has been repeatedly seen in
the bowels, especially in the small, the present seems to me
to be the proper place for making a few remarks upon it. In
color and consistence, this tumor bears a striking resemblance
to the milt of a fish, whence its name. It has an irregular
surface, adheres but shghtly to the part upon which it grows,
and is wrapped in a thin, delicate membrane, in which are
to be seen numerous vessels filled with blood. Its consist-
ence is such that it very readily falls to pieces ; and, on being
squeezed in water, it forms with it a turbid mixture.

This species of tumor generally attains a considerable vol-
ume, and, in some instances, almost fills the intestinal tube.
Its progress is usually very slow, and hence the individual
may live for years, the bowel gradually widening and accom-
modating itself to its pressure. Its attachment is effected by
a number of smalt, fibrous processes ; and, when these are
divided, it is not unusual to find the villous coat exhibiting
a honey-comb appearance. Such is a brief outline of what
Professor Monro has been pleased to denominate the milt-
like tumor, — a morbid product, which, although I have never
seen an example of it, is, in all probability, merely a variety
of medullary sarcoma.

Melanosis is occasionally observed in the alimentary tube.
The most common situation of this substance is in the small
bowel, but it may occur indiscriminately throughout the
whole intestinal tract. The quantity deposited is various ;
in general, however, it is very trifling. The black matter

SECT. VI.]

INTUSSUSCEPTION.

259

assumes different shapes, occurring either in thin, stratified
patches, or in the form of small, flat, rounded tumors, some
of which are occasionally encysted. Most usually this sub-
stance is accumulated in the cellular tissue between the peri-
tonseal and muscular tunics ; sometimes, however, it is found
upon the free surface of the bowel, and instances have been
known where it was seated in the submucous texture.

Small, brownish, mahogany, or slate-colored stains are
sometimes met with in the villous and follicular structures of
the intestines, produced either by a stagnation of the blood,
or by this fluid having been subjected to the action of some
acid. They are often seen in cases of chronic irritation, and
are apt to be particularly conspicuous in the glands of Brun-
ner and of Peyer, the former of which are occasionally
completely encircled by them. These stains are liable to
be confounded with those resulting from melanotic infiltration,
but may be easily enough distinguished from them by the
fact that they do not, like the latter, soil the finger when
washed in clear water.

Another affection which requires consideration in this place,
and which not unfrequently proves fatal, is intussusception.
(Fig. 55.) This consists

in the invagination of
one portion of bowel
within another, thereby
filling up its cavity, and
dragging along with it
usually a part of the
mesentery. Although,
generally speaking, there
is only one such invagi-
nation, yet sometimes
there are as many as six
or a dozen. The bowel
manifesting, if • the ex-
pression may be per-
mitted, a peculiar diath-
esis to this sort of dis-
placement. Much di-
versity obtains respect-
ing the length of the in-
vaginated portion. Most
commonly it does not

Fig. 55.

260 SMALL BOWELS. [cHAP. VJI.

exceed two or three inches ; in other cases, however, it may
be as much as one or two feet. Dr. Abercrorabie makes
mention of a case, in which the inverted intestine measured
thirty-eight inches ; and instances are to be found in which
nearly the whole of the large, together with a considerable
portion of the small bowel, was thus invaginated, the ileo-
GOBcal valve descending as low as the anus. Sometimes,
though very rarely, there is a double intussusception, one
inverted portion of intestine slipping within another.

The included portion of bowel may be variously affected,
and give rise to the most terrible results. In children, in
whom this lesion is much the most frequent, the invagina-
tion is occasionally disentangled, either by the natural energy
of the muscular fibres of the intestine, or by the influence
exerted upon them by purgative remedies. When the in-
carceration continues for any length of time, the part usually
manifests strong signs of inflammation, and either contracts
adhesions to the surrounding gut, or else it dies, and is evac-
uated. In this way may be discharged large pieces of the
alimentary tube, and the patient live for years afterwards, in
the enjoyment of perfect health. In the former case, that is,
when the bowel remains invaginated, its coats are very apt
to become thickened, and lay the foundation of permanent
stricture.

In thirty-five cases, collected from the writings of diff"erent
pathologists, by Dr. Thompson, of Europe,* the length of
the eliminated pieces varied from six inches to upwards of
three feet : they generally came away entire, and almost
every one had a portion of mesentery attached to it. In one
instance, there was a mesenteric ganglion ; in another, a frag-
ment of the omentum. The average duration of the disease
was between four and five weeks. In twenty-two of the
cases, the evacuated portion appertained to the small bowel,
in the other, to the large, or jointly to this and to the former.
The coecum was aff'ected alone only in a single instance, the
colon in two, the jejunum in three, the ileum in eleven.

Intussusception may take place in any part of the aliment-
ary canal, but is most common in the ileum, near its inser-
tion into the colon, owing doubtless to the vast difference of
size between these two portions. The greater frequency of
this lesion in this situation than in any other, was long since

* Edinburgh Medical and Surgical Journal, October, 1835.

SECT. VI.] INTUSSUSCEPTION ; SYMPTOMS. 261

insisted on by Dr. Baillie, and the same kind of testimony is
borne by almost every succeeding writer. Another fact
deserving of notice in this place is, that the invagination does
not always occur in the natural direction of the intestine,
but sometimes from below upv/ards ; which sufficiently dis-
proves the theory, at one time so much in vogue, that this
complaint is always caused by one part of the tube falling
within another, simply on account of its weight. Concern-
ing the proximate cause of this disease, very little indeed is
knov/n. Nevertheless, it may be conjectured that it is in
some way or other connected with inequilibrious action of
the muscular fibres, by which one portion of bowel, contract-
ing energetically, forces itself within another that is station-
ary, fixed, or passive. If this explanation be not satisfactory,
I confess my inability to offer a better one. The lesion, it
maybe here reiterated, is also much more common in infancy
than in manhood, — a circumstance affording additional proof
in favor of the supposition that has just been advanced, inas-
much as the muscular coat of the intestine, being much more
lax and irritable in the young than in the old, is liable to
greater irregularity of action.

The prominent symptoms of this complaint are, violent
pain in the bowels, generally increased by pressure, urgent
vomiting, tumidity and tenderness of the abdomen, and the
most obstinate constipation, every endeavor to evacuate the
alimentary tube proving unavailing. The pulse is from one
hundred and twenty to one hundred and fifty in the minute,
small and feeble, and the features have a singularly shrunken
and collapsed appearance. The pain in the abdomen, although
constant, is aggravated by paroxysms, and is sometimes almost
intolerable.

There is a species of intussusception very different from
the one just described, inasmuch as it is entirely unattended
by inflammation. I have repeatedly observed it in young
children, as \ve\\ as in adults ; and, so far as 1 can judge, it
appears to occur during the last struggles of life, from some
irregularity in the peristaltic movements of the muscular
fibres. The invagination in this variety of the lesion is al-
ways limited, according to my own experience, to the small
bowel.

The subject next in order to be discussed is that of hernia,
of which there are several distinct varieties, both as regards
the contents of the tumor and its situation. The most com-

262 SMALL BOWELS. [CHAP. VII.

mon place of rupture is at the inguinal and crural rings.
Cases, however, are often witnessed in which the bowel pro-
trudes at the -navel, or some other part of the abdominal wall ;
and, in a few rare instances, it has been known to pass into
the thorax, through an opening in the diaphragm. There is
also a species of rupture in which the intestine descends into
the scrotum, in consequence of imperfect closure of the in-
guinal canal. This constitutes what is termed congenital
herhia. The bowel in this case lies in the vaginal sac ; and
how it gets there may be easily accounted for by referring
for a moment to what takes place in the descent of the
testicle ; until the end of the seventh month of utero-gestation,
the testicle is situated in the pelvic cavity, immediately be-
neath the kidney. About this period it begins to advance
towards abdominal canal, along which it passes, until it finally
reaches the scrotum, carrying with it a tubular process of
peritonaeum. As the descent is being completed, the serous
sac here mentioned is gradually obliterated, and the commu-
nication between it and the abdomen closed. This usually
occurs a few weeks before the child attains to maturity. But
it is not always that things thus proceed. In many cases the
abdomino-scrotal sac remains open through life, and allows
the bowel to pass down in contact with the testicle, forming
the variety of hernia in question.

To enter into a minute detail of every thing relating to
these different varieties of hernial tumors, would be incon-
sistent with the scope of the present work; and I shall there-
fore restrict my remarks rigidly to the morbid appearances
which are usually to be witnessed in the protruded parts, re-
ferring those who may feel anxious for further information
upon this interesting topic to our treatises on surgical anat-
omy. In the congenital hernia, the mechanism of which has
just been described, the intestine generally retains its natural
characters, with the surrounding sac scarcely at all altered ;
and hence, when the patient assumes the recumbent posture,
it always has a tendency to glide back into the cavity of the
abdomen, descending again when he rises. In chronic cases,
however, although the protruded parts themselves may not be
particularly affected, the sac, in consequence of the constant
pressure that is exerted upon it, is apt to become indurated
and thickened, from the deposition of lymph. Shreds of the
same substance occasionally adhere to the enclosed bowel, and,
by gluing it fast, prevent its return into the abdomen. Simi-

SECT. VI.] HERNIA. 263

lar appearances are sometimes witnessed in the other varieties
of long-standing ruptures. In such cases, the sac is often as
much as the eighth of an inch in thickness, and evidently
consists of a number of well-organized layers. The shape of
the bag is either oval, rounded, or more usually pyriform, the
narrower part being above, the broader below. The neck is
sometimes quite long, and so narrow as to allow only a small
fold of intestine to pass out at a time. The outer surface of
the sac is rough and irregular ; the internal smooth, polished,
and slightly lubricated by serosity. Such are the ordinary
appearances to be observed in old and congenital ruptures.

In recent ruptures, the sac is generally thin and opaque,
differing very little from healthy peritonasum. When strangu-
lation occurs, a new state of things supervenes. For not
only does the sac evince signs of inflammation, but the pro-
truded part, whether it be the bowel or a portion of omentum,
is so excessively irritated that it frequently mortifies, whilst
the patient either dies, or is doomed to drag out a wretched
existence with an artificial anus. The morbid appearances
of strangulation of the bowel are well shown by the sub-
joined case, which I add so much the more willingly, as it
admirably illustrates the obscure character which sometimes
attends slight hernial protrusions. The patient was a married
woman, forty-five years old, who had labored for several
days under obstinate constipation, with slight vomiting, and
occasional pain in the epigastric region. Dr. Ridgely, who
now saw her, prescribed several doses of active cathartic
medicines, and in about twenty-four hours succeeded in pro-
curing a copious alvine evacuation. This, however, afforded
only transient relief. The vomiting became more urgent ;
the abdomen, although neither swollen nor hard, was some-
what tender on pressure ; no further discharge could be ob-
tained from the bowels ; and she died, gradually exhausted,
on the fourth day after sending for her physician. On ex-
amination, the. cause of these symptoms was found to be a
protrusion of a portion of the ileum, scarcely a third of an
inch in length, which had got into the internal ring, where it
seemed to have been strangulated by a fold of peritonasum,
stretched tightly across its upper border. That this was the
case, is abundantly proved by the fact, that the stricture still
remains in the preparation, although it consists solely of in-
testine and peritoneeum. The portion of bowel between the
ring and ileo-coecal valve was about four feet in length, quite

264 SMALL BOWELS. [cHAP. VII.

empty and contracted, and without any any sign of inflam-
mation. Above this point, the ileum was greatly distended
with gas and fecal matter, and bore all the marks of high
irritation, the redness, which was of a violet hue, occurring
in small patches in different parts of the circumference of the
tube. Externally, the bowel was covered with numerous
globules of lymph ; and the incarcerated part itself was in a
state of incipient gangrene, as was shown by its dark color,
and by its want of proper tenacity. No shreds of fibrin were
to be seen around the margins of the ring ; and the stricture
was so slight that the strangulated gut was easily withdrawn
from its unnatural situation. The colon was sound, but ex-
tremely contracted throughout the greater portion of its ex-
tent, being scarcely large enough to admit the little finger.
The rectum was in the same condition. All the other ab-
dominal organs, as well as those of the thorax, were in a
normal state. The peritonseum was natural, excepting im-
mediately around the seat of the stricture, where it was very
vascular and inflamed. No external tumor whatever, either
before or after death, could be perceived in the inguinal re-
gion.

Another occurrence of the intestinal coats is atrophy. Bo-
netus informs us that he has seen the bowels as thin as a cob-
web ; and Professor Chapman states that he has found the ile-
um so much wasted away that there was scarcely any thing
left excepting a most delicate peritonasal covering, expanded
over a few pallid and widely-separated muscular fibres. Such
an extreme attenuation of the coats of the bowels I have never
witnessed ; nor can it be supposed to be of frequent occur-
rence. A sort of general atrophy seems occasionally to per-
vade the alimentary tube. Tartra describes the case of an
individual who died three months after swallowing a consid-
erable quantity of nitric acid, in whom the bowels were re-
duced to a very small volume, their coats shriveled, and indu-
rated, and their caliber throughout not larger than a common
goose-quill. Large quantities of lymph eff"used from the
peritonasal surface, and agglutinating the bowels together, is
sometimes another source of atrophy of these organs.

Not less rare is hypertrophy of the coats of the small bowel.
The affection is generally the result of chronic irritation,
leading to an efl"usion of lymph into the connecting cellular
substance. Dr. Monro relates a case in which the intestinal
tunics were half an inch thick, and of almost fibro-cartilagi-

SECT. VI,] CONCRETIONS. 265

nous hardness. The part of the small bowel most subject to
hypertrophy is the lower end of the ileum, where it com-
monly occurs in particular spots. The affection is often at-
tended with stricture, carried to such a degree sometimes as
almost to close the natural passage. In these cases, tlie gut
above the seat of the contraction is often enlarged to three or
four times the ordinary capacity. One of the most extraordi-
nary examples of this dilatation perhaps on record was related
some years ago by Dr. M. H. Leon, of Columbia, South Car-
olina. It occurred in a young woman, aged twenty-five, who
had labored for a considerable period under scirrhus of the
rectum and uterus, and who had not had any alvine evacua-
tion for the last nine weeks preceding her dissolution. On
examination, the whole intestinal tube was found to be enor-
mously dilated, the colon measuring thirteen inches and a
half in circumference ; nor were the duodenum and ileum
any less. Every where marks of high inflammation were
discovered, and the valvular structure was completely effaced.
The quantity of feces amounted to nearly seven gallons, and
the long retention of it was no doubt the immediate cause of
this extraordinary enlargement. The stomach was much
contracted, and its coats highly inflamed and thickened.*

In another case, the particulars of which are given by Dr.
Mason L. Weems, an eminent physician of Washington city,
the dilatation was limited to a small portion of the ileum,
which was expanded into hollow, ovoi'dal sacs, from three
to five inches in diameter. The parietes of these pouches
were upwards of six lines in thickness, of a white pearly color,
and remarkably friable in their texture, exhibiting, when torn,
a fibrous, striated arrangement. The subject of this case was
a boy between six and seven years of age. No cause could
be assigned for the diseased state of the bowel.-|-

Concretions occasionally form in the alimentary tube, but
much less frequently in the human subject than in some of
the inferior animals. Their size is extremely various. Some-
times they do not exceed a garden pea ; at others, however,
they are as large as an orange ; and Professor Monro refers to
a case where a body of this kind, taken from the colon of a
woman, weighed four pounds. In the inferior animals, their
bulk is occasionally enormous. Thus, Dr. Voight, a German

* American Journal of the Medical Sciences, vol. ii. p. 334.
t American Journal of the Medical Sciences, vol. xvi. p. 246.

VOL. II. 34

266 SMALL BOWELS. [cHAP. VII.

writer, gives an instance of an alvine concretion in a horse
which weighed thirteen pounds.

Although there are seldom more than two of these con-
cretions, yet in some cases they are quite numerous, as many
as ten or fifteen being found in one person. They are gen-
erally of a globular shape ; and, when there are a good many
of them, they are apt to be a little flattened at the sides,
probably from the friction which they exert upon each other.
They are of a brownish color, feel soft, but are too hard to
be compressed, and have altogether a porous, spongy appear-
ance. On breaking a section of them, these concretions are
found to be composed of an immense number of small fibres,
which are intimately interwoven with each other, like the
felt of a beaver hat, the intervals between them being filled
up by earthy matter. In most cases, these fibres are ar-
ranged in distinct lamellae, the external of Avhich are about
two lines in thickness, and are generally of a lighter color
than the internal. Each concretion is commonly provided
with a central nucleus.

In their chemical constituents, these concretions present
considerable variety. Mr. Children gives an account of some
which were composed of albumen, common salt, phosphate of
lime, and phosphate of soda. Dr. Marcet describes them as
possessing the properties of soft cheese, and Mr. Brande as be-
ing made up entirely of the carbonate of magnesia. Thus,
then, their ingredients may be supposed to differ in different
cases, being scarcely ever precisely alike in any one instance.

These concretions are most frequent in Scotland, where
they owe their origin to the oats that are so much employed
by the lower orders as an article of food. But almost any
extraneous and indigestible substance may serve as a nucleus
to these bodies. Dr. James Murray, of Dublin, in an interest-
ing paper upon this subject, states that alvine concretions often
accumulate around fragments of almonds, nut-kernels, grape
and cherry-stones, pieces of radishes, and even tea-leaves.*
Occasionally they are caused by the long-continued use of
magnesia. Mr. Brande has published a case in which this
substance was impacted in the colon to the amount of three
pounds.

Other concretions are sometimes found in the intestinal
tube, very different from those just described. They are

* Medical Lancet, July, 1836.

SECT. VI.] FATTY DISCHARGES. 267

mostly observed in dyspeptic subjects, or in those who suffer
habitually from a torpid state of the bowels and derangement
of the assimilative functions. What their precise constitu-
tion is has not been ascertained, nor do we know any thing
satisfactorily respecting the nature of their origin or the
mode of their developement. These concretions are, in some
instances, of an irregular shape, of the consistence of inspis-
sated tallow, slightly translucent, and of a grayish drab color ;
in others, they are of a globular form, nearly or quite opaque,
of an adipocirous or waxy character, and of a pale yellowish,
whitish, or cineritious hue. In size, they vary between a
small pea and a large grape ; and they rarely if ever have
any proper nucleus, though they are often much harder at the
centre than at the circumference.

In the above account of calcareous and other concretions,
may be added a few remarks on fatty discharges from the
bowels. Although this subject was incidentally noticed by
some of the earlier physicians, as Tulpius and Fabricius Hil-
danus, it does not seem to have attracted the special attention
of the profession until within a comparatively recent period.
For our knowledge concerning it, we are principally indebted
to two distinguished English pathologists. Dr. Bright and Dr.
EUiotson, whose excellent papers on this disease, first pub-
lished, I beheve, in the Medico-Chirurgical Transactions of
London, comprise a great mass of highly interesting and val-
uable matter, of which I shall freely avail myself in this
brief notice.

The form in which this fatty matter presents itself is ex-
ceedingly various. Sometimes it has all the properties, appar-
ently, of oil, being perfectly liquid, specifically lighter than
water, and of an inflammable nature ; at other times, it is
semi-concrete, or of the consistence of tar, thick, treacle or
jelly, and of a pale straw color. Very frequently, it comes
away quite fluid, but acquires an immediate increase of con-
sistence on exposure to the atmosphere. The quantity evac-
uated is also liable to considerable diversity. In the interest-
ing case below, communicated to me by my friend Dr. J. B.
S.Jackson, Boston, it amounted, on an average, in the twenty-
four hours, to about eight ounces, during more than four
months. The quantity is often much less ; and, on the
other hand, it may be much greater. In a case recorded by
Dr, Johnson, in the Medico-Chirurgical Review, the patient
ejected, in a short time, the enormous amount of thirty

268 SMALL BOWELS. [CHAP. VII.

pounds : he had fasted for several days, when he eat vora-
ciously of indigestible food, which soon excited vomiting, at
first of blood, and subsequently of fatty matter. He recov-
ered in less than a month, but not without great loss of bulk.

I am not aware that any analysis has been made of this
fatty matter. In a specimen examined by Dr. Prout. it pos-
sessed all the properties of human fat ; and, in another case,
it is said to have formed good soap on being mixed with
alkali. In the generality of instances, it has a fetid odor ;
but occasionally it is perfectly pure, wholly devoid of smell,
and capable of protracted preservation.

Although these fatty discharges have been observed at
different periods of life, yet it would appear from an attentive
examination of the cases of it on record, that they are much
more frequent in the aged than in the young. What their
source is, or the particular condition of the system which
favors their occurrence, are points concerning which we are
in total ignorance. In nearly all the cases pubhshed by Dr.
Bright, there was a remarkable similarity in the pathological
phenomena. The most prominent symptoms were jaundice,
enlargement of the liver, and evacuations of fatty matter
from the bowels. On dissection, organic lesion was found in
the pancreas, liver, and duodenum, with obstruction of the
gall-duct. In a case mentioned by Mr. Lloyd, of England,
there was disease of the head of the pancreas, with closure
of the Wirsungian duct, by calculous concretions, and con-
traction of the duodenum. During life, the same symptoms
were noticed as in the examples reported by Dr. Bright.
Instances of a similar nature have been published by Scott,
EUiotson, Babington, and other writers. In a few cases, the
fatty substance coexisted with pulmonary phthisis, hysteria,
and diabetes, and proceeded simultaneously from the bowels
and urinary bladder.

To what source, then, are these singular discharges to be
ascribed ? Do they proceed from the pancreas, from the
liver, or from the gastro-enteric mucous membrane? Dr.
Bright, from his dissections and observations, is inclined to
believe that they are the result of a morbid secretion of the
pancreas, — an opinion which has since been adopted by sev-
eral highly respectable pathologists. Others, again, refer
them to the liver, alleging that they are merely an abnormal
increase of the fatty secretion which that organ performs in
the healthy state. Without entering at all into the merits of

SECT. VI.] FATTY DISCHARGES, 269

these questions — which my limited space does not admit of —
it will be sufficient to observe that there are numerous ex-
amples of this disease on record, which cannot possibly be
explained by a reference to either of these organs. We have
already alluded to the interesting case of Dr. Lloyd, in which
the pancreatic duct was completely obstructed by calcareous
matter, and we shall have occasion, presently, to mention
another of a similar description, by Dr. Jackson. That they
do not proceed from the liver, is abundantly shown by the
fact, that, in persons who labor under this affection, the
biliary channels are sometimes so- completely choked up as to
prevent any thing from passing along them to the duodenum.
Since, then, this fatty matter is not furnished by the pancreas
and the liver, whence does it emanate ? Is it poured out by
the mucous membrane of the stomach and bowels ? Here,
again, the pathologist is at a loss for proof. Nevertheless, it
appears highly probable, when we take into consideration the
circumstance that these evacuations are occasionally attended
by very great and rapid emaciation, that they are the result
of a sort of metastasis of the secretion of fat of other parts
of the body, in which it is naturally deposited, to the surface
of the alimentary canal. This opinion, which has been
ingeniously advocated by Professor Stokes,* of Dublin, al-
though not free from objection, affords, perhaps, the best
explanation that can be oflered in the present state of medical
science. My own idea about these fatty discharges is, that
they are a morbid secretion of the mucous membrane of the
stomach and bowels, which is often greatly modified and
influenced by organic disease of the liver, the pancreas, and
the duodenum.

I shall close this subject with the following case, already
several times alluded to, and which exhibits, in detail, the
symptoms and autopsic condition ordinarily observed in the
disease under consideration. I shall present it in the lan-
guage, nearly, of the intelligent physician. Dr. J. B. S. Jack-
son, who kindly communicated it to me, and whose zeal in
the pursuit of pathological science is well known to the pro-
fession. The patient, a laborer, forty years of age, died on
the 16lh of September, 1837. Thirteen years before, he had
an attack of hemorrhage from the bowels, by which he was
greatly reduced, and to which he always referred his disease.

* London Medical and Surgical Journal, March, 1834.

270 SMALL BOWELS. [CHAP. VII.

Little was known of him from that time till about three
years before death, when he had a second attack : the dis-
charges of blood, which were very large, continued more or
less for six or eight weeks, with diarrhosa, from which he
recovered so far as to resume his work. He had constantly,
however, great soreness and tenderness in the epigastric re-
gion, so that, at times, he could not bear the weight of the bed-
clothes, and he always had his dress made loose, that it should
not press on the stomach. He had also frequent returns of
diarrhosa and bloody discharges from' the bowels, which last,
he said, usually afforded him temporary relief: his appetite was
good, and the digestive function not particularly impaired.
Thus he continued till December, 1836, nine months before
death, when, after working all day in a damp cellar, with his
coat off, he was seized with symptoms of fever, pain, and
obstinate constipation, the latter of which, after persisting for
several days, was followed by severe diarrhoea. The evacua-
tions from the bowels were one half blood, and there was
great pain, with extreme tenderness in the epigastric region.
In about a fortnight, he began to have discharges of fatty
matter in a liquid state, resembling, when cold, yellowish
tallow, and estimated by himself to amount, on an average,
to eight ounces in the twenty- four hours. This substance
accompanied every dejection, but there was none in the
urine, and it continued until May, when it entirely ceased :
the feverish symptoms disappeared in two or three weeks, but
not so the pain and tenderness. He, however, went to work,
taking laudanum whenever there was a paroxysm of pain.
After eating, no matter how small the quantity, there was
always a sense of fulness and tightness in the stomach, fol-
lowed by the most excruciating pain, copious perspiration,
dyspnoea, nausea, and often vomiting. These attacks usually
lasted from four to five days, required large doses of lauda-
num for their relief, and always went off gradually; recur-
ring, at first, every eight or ten days, but afterwards, as the
disease progressed, at shorter intervals. The discharges from
the stomach and bowels, in whatever way produced, were
uniformly light-colored and clayey from Decemlier until he
died. The appetite, for the first five months was generally
good, — indeed, often craving ; after that, it became indifferent ;
five weeks before death, the skin assumed a yellowish cast.
A physician, who was called in about the last of August,
found the abdomen extremely tender, with a tumor in the

SECT. VI.] FATTY DISCHARGES. 271

epigastric and right hypochondriac regions, extending nearly
to the umbilicus ; the perspiration, urine, skin, and conjunc-
tiva, were of a yellow color, the latter deeply so ; the dejec-
tions were free from bile ; and the lungs presented signs of
advanced tubercular disease. From this time on, there was
little pain ; the cough was slight ; and the man sat up every
day till a short time before death. When in bed, he always
lay on the right side, with the body bent forward. On the
16th of September, he was comatose, but could still be
roused, and said he felt better. Early in the afternoon of that
day he expired.

On opening the cavity of the abdomen, a large fluctuating
tumor, of a regular oval form, was at once seen below the
right lobe of the liver, with which it was closely connected
by old adhesions : it was situated between the intestines and
the posterior parietes of the abdomen, and extended towards
the left side a short distance beyond the spine ; the duodenum
ran over, and almost around it. On making a free incision
into it, the tumor was found to contain, by estimate, from
ten to fourteen ounces of a red fluid, without coagula, not
viscid nor greenish, and without any appearance of fatty
matter. Branches of the coeliac artery were traced, and found
healthy. The tumor or cyst, after removal from the body,
measured four inches by three, — its walls being from one to
three lines thick, of a reddish color, membranous, and fleshy
to the feel. Nothing could be discovered like the structure
of the pancreas, yet the parietes of the cyst were evidently
formed by a dilatation of that organ, as they contained several
very minute calculi. The inner surface was for the most
part firm and smooth, but on the side towards the duodenum,
it was to a small extent irregular, soft, and apparently disor-
ganized : two calculi adhered to it near the opening of the
duct, which was entirely obliterated : they were several lines
in diameter, rough on the surface, and had the usual charac-
ters of pancreatic concretions. There was a third, also, but
much smaller. The remainder of the pancreas, forming the
left extremity of the organ, was about two inches in length
by two thirds of an inch in width, contracted, irregular, and
very hard, as if filled with small calculi. The duct itself
was considerably enlarged, and opened freely into the cavity
of the sac. There was no appearance of malignant disease
about the tumor, nor, indeed, in any part of the body. The
stomach was small and pushed high up in the abdomen ;

272 LARGE BOWELS. [cHAP. VII.

contained some thin liquid of a light but decidedly yellow-
ish color, (bile ?) About seven feet of the ileum were
opened, but there was no trace of bile. The liver was small,
dark-colored, and thrust high up by the tumor. The gall-
bladder was large and distended with moderately thick bile,
of a dark green hue. The biliary ducts were dilated and full
of bile, without any particular obstruction. The common
duct was traced freely into the duodenum : on slitting it
open, a portion of it, which formed a part of the parietes of
the cyst, was found in a very sloughy condition, similar to
the contiguous portion of the morbid mass. The gangrenous
part was about an inch long, without involving the whole
caliber of the tube, of a grayish-brown color, extremely
soft, ragged, and ready to give way.

SECTION VII.
Diseases of the Large Boioel and Anus.

Ulcers of the large bowel very much resemble those
of the small, except, perhaps, that they are more frequently
of a linear shape. This, at least, is the form in which I
have hitherto more particularly met with them. When be-
ginning in the mucous follicles, they are more apt to be
rounded : in this case, too, their edges are often remarkably
ragged, thin, and undermined, — a circumstance which gives
them the appearance of being much larger at the base than
at the top. In such instances, moreover, the glands are some-
times entirely removed, or portions of them are left in the
midst of the ulcerated surface, in a state of induration. Oc-
casionally nearly the whole of the large bowel is thus af-
fected ; but the sections most frequently diseased are the
coecum and ascending colon, together with the right half of
the transverse arch, whilst the rectum and the remainder of
the gut are comparatively seldom implicated. In ninety-two
cases of intestinal ulceration, reported by Andral, only one
occurred in the rectum.

The size of these ulcers is sometimes very considerable.
I have repeatedly seen them of the diameter of an American
dollar, and, on several occasions, between three and four inches

SECT. VII.] VERMIFOKM APPENDAGE. 273

in length by one and a half in breadth. When of these
dimensions, the abrasions are generally formed by the agglom-
eration of a number of smaller ones. In the linear variety,
I have, in a few instances, found the ulcers extending almost
completely around the circimiference of the bowel, constituting
narrow grooves, of variable depths, with rough, elevated, and
indurated edges. As in the rest of the alimentary tube, the
ulcerative process may successively invade the different tu-
nics, and finally lead to perforation ; in which case the con-
tents of the gut may be effused into the peritoneal sac, or
else find their way into the surrounding hollow viscera. A
fistulous opening sometimes forriis through the walls of the
abdomen, in the right iliac fossa, or in the groin just above
Poupart's ligament.

It is a singular fact, and one for which I cannot offer any
satisfactory explanation, that ulcers of the large bowel are
much less liable to cicatrize than those of the small. Never,
indeed, in a single instance, have 1 seen complete repara-
tion in this situation, though it has occurred to me on several
occasions to notice partial efforts of this sort. Thus, in the
ascending colon of a married woman, thirty-three years of
age, who died, gradually exhausted, after an illness of nine
weeks, I found the mucous membrane very much thickened,
and of a dark red color, with a deep linear ulcer two inches
and a half in length by three lines in width, the surface of
which was covered with small masses of plastic lymph, so
firmly adherent that it was difficult to scrape them away. In
this case, it is obvious, there was an attempt at cicatrization ;
and, had the patient lived long enough, it would, no doubt, have
gone on to completion. In another instance, that of a man
twenty-two years old, who died of chronic diarrhoea, a small
circular ulcer existed in the sigmoid flexure, the centre of
which was coated with a thick layer of lymph, which had
evidently been deposited only a short time previously to
death.

The vermiform appendage^ although in its structure closely
resembling the rest of the intestinal canal, may, nevertheless,
be considered as a distinct organ, possessing peculiar anatom-
ical relations, and executing functions different from those of
the rest of the alimentary canal. It is about three inches in
length by three lines in diameter, slightly convoluted, and
often considerably larger at some points than at othei's. Its
coats are as thick as those of the caecum, and composed pre-

voL. II. 35

274 LARGE BOWELS. [cHAP. VIL

cisely of the same anatomical elements. No little variety-
exists in relation to the size and situation of this tubular
diverticulum. Whilst occasionally it is very diminutive, I
have seen it, at other times, nearly half a foot long, and fully
as large as the little finger, without any apparent disease.
The appendage is occasionally deficient, even when the rest
of the bowel is perfectly normal ; and not unfrequently it
deviates remarkably from its accustomed position. In in-
flammation of the peritonasum it is often firmly glued to the
neighboring organs, as the uterus and urinary bladder ; and,
under such circumstances, it has been known to produce
strangulation of the small bowel. Of this, a very interesting
example fell under my notice, some years ago, in a young
married female, twenty-two years of age, whom I attended,
along with the late Dr. Herron, of this city. Up to the period
of her confinement, she had enjoyed excellent health ; but,
twelve days after this occurrence, she was seized with severe
peritonitis, attended with excessive irritabihty of the stomach,
and the most obstinate constipation of the bowels. These
symptoms persisted, without any decided abatement, until the
ninth day from the attack, when she died in a state of com-
plete exhaustion. On dissection, the serous membrane of the
abdomen was found to be extensively inflamed : there was a
copious deposit of lymph upon the pelvic viscera ; and the
vermiform appendage, the extremity of which was firmly
agglutinated to the side of the uterus, passed over a loop of
the ileum, and thus eflTectually intercepted its contents.

The usual contents of the vermiform appendage are of a
mucous nature, and of a soft, semi-fluid consistence. Fecal
matter rarely finds its way into it ; when it does, it is very
apt to become impacted, and to produce mischief Not a few
cases are recorded where the most violent inflammation was
thus induced, followed by gangrene of the tube and general
peritonitis. But the most common cause of disease, undoubt-
edly, is the ingress of some foreign body, such as a bean, a
cherry-stone, or biliary concretion, producing local irritation,
which rapidly spreads from the mucous to the other tunics.
Severe peritonitis is soon lighted up, lymph is poured out,
and the appendage speedily falls into a state of mortification.
In another series of cases, the disease assumes a milder char-
acter, the serous membrane is comparatively little affected,
there is scarcely any albuminous exudation, and the inflam-
mation finally passes into suppuration ; or adhesions are

SECT. VII.] VERMIFORM APPENDAGE ; INFLAMMATION. 275

formed between the coecal appendage and the adjacent parts,
and the extraneous body, exciting ulceration, at length es-
capes to some other situation.

Inflammation originating in the vermiform appendage is
ordinarily characterized by bold and well-marked symptoms.
"Very acute pain, tumefaction, and tenderness are complain-
ed of upon the invasion of this form of the disease ; first in
the right iliac region, and subsequently more or less over the
abdomen, with excruciating tormina, obstinate constipation
of the bowels, a very frequent, small, or contracted pulse,
heat of skin, dry tongue, great thirst, sometimes with numb-
ness of the right leg, or pain shooting down the thigh, and
retraction of the testicle." * Vomiting at length sets in, with
or without relaxation of the bowels, the patient manifests
great restlessness, the countenance assumes a sunken aspect,
and death generally takes place from the third to the sixth
day, preceded, observes Dr. Copland, by the symptoms ush-
ering in dissolution from intestinal peritonitis. In a letter
lately received from Dr. J. B. S. Jackson, of Boston, he in-
forms me that he has seen four dissections, besides two re-
cent specimens of gangrene and perforation of the vermiform
appendage, in which the symptoms corresponded sufficiently
well with the descriptions of the distinguished pathologist
just quoted.

The more insidious form of this disease is well illustrated
by the following case, communicated by my friend, Dr. Rich-
ards, of this city, who had the kindness to send me the dis-
eased bowel : the patient, a gentleman thirty-five years of age,
had enjoyed good health up to the 24th of August, 1837,
when he was attacked with bilious fever. His tongue at this
time was considerably coated ; there was headache, with pain
in the back and limbs ; the skin was hot and dry ; the pulse
ninety in a minute ; and there was, moreover, a slight hacking
cough, which, however, had been present, at intervals, for
the last ten months. Under an active course of treatment,
these symptoms gradually disappeared, and, by the fifth of
September, just a fortnight from the invasion of the disease,
the patient was to all appearance convalescent ; the pulse
being slow and soft, the tongue clean, and the appetite quite
good. On the evening of the same day, however, after par-
taking pretty freely of indigestible food, he was suddenly

* Copland's Dictionary of Medicines, article Ccecum.

276 LARGE BOWELS. [cHAP. VII.

seized with severe pain in the ahdomen, accompanied with
shght distention of the hypogastric region, and great ten-
derness on pressure : the pulse became feeble, beat one
hundred and forty strokes in a minute ; the surface was cold,
and bathed with profuse perspiration ; and there was consid-
erable embarrassment of breathing. These symptoms gradu-
ally increased in severity until the seventh of September,
about forty-two hours from their first manifestation, when the
man expired, in a state of complete collapse. On dissection,
the following appearances were noticed : the omentum, with
nearly the whole peritonaeum, was in a highly inflamed con-
dition ; the bowels were distended with gas, and extensively
agglutinated by coagulating lymph ; the pelvis was filled
with fecal matter ; and there was a large, ragged ulcer in the
vermiform appendage, which had perforated all the coats.
Through this ulcer the fecal matter had escaped, inducing
violent and fatal peritonitis. The mucous membrane of
the stomach was highly inflamed, incrusted with patches of
lymph, but that of the intestines was perfectly healthy, ex-
cept immediately aroun^ the seat of the disease.*

Hypertrophy of the coats of the colon is rare, but by no
means infrequent in those of the rectum, where it is occasion-
ally conjoined with permanent stricture. The gut, for some
distance above the narrowing, is usually considerably dilated,
either with or without attenuation of its tunics, or the re-
verse. The extent to which the hypertrophy occurs, varies
from a few inches to several feet ; and, in a few instances, I
have seen it involve the whole of the large bowel : the coats
which are more particularly affected are, the mucous and cell-
ulo-fibrous, the latter of which, especially, is frequently six
or eight times the normal thickness : the muscular fibres are
also apt to become very much altered, both as respects their
size and color ; but the serous texture rarely participates in
the morbid derangement. When the hypertrophy is of long
standing, the bowel almost always acquires an extraordinary
degree of density, oflfering as much resistance to the knife as
fibro-cartilage, and emitting the same creaking sound.

* Those who are anxious lo obtain further information on this subject, will do
well to eonsult Dr. Copland's Dictionary of Medicine — a work which should he
in the library of every intelligent physician — and Dr, John Bume'sjMemoir on
Tuphlo-Enteritis, or Inflammation and Perforative Ulceration of the Caecum
and Appendix Vermiformis, in volume xx. of the London Medico-Chirurgical
Transactions.

SECT.

VII.]

EXCRESCENCES.

277

Tubercular, melanotic, and cancerous affections are rarely
found in the large bowel. When carcinoma occurs, it usual-
ly has its seat in the ileo-coscal valve, or in some portion or
other of the rectum ; and, as it may be said to be almost pecu-
liar to the latter, we shall postpone, for the present, the con-
sideration of it.

Both the colon and the rectum are occasionally the seat of
wart-like excrescences^ similar, in many respects, to those
which we so often see on the female organs of generation.
Of this lesion I have seen several well-marked examples. In
a specimen (Fig. 56) preserved in the museum of morbid
anatomy, the mucous membrane of nearly the whole of the
large intestine is thickly studded with these vegetations, the
smallest of Avhich are scarcely as big as a pin-head, whilst
the largest are from three to eight lines in length, by two
lines and a half in diameter. The former, which are infin-
itely the most numerous, are, for the most part, of a spherical
shape : the latter, on the contrary, have an elongated, conical
appearance, not unlike the nipples of some of the inferior
animals. A few of

the larger ones are ^^§- ^^•

bifid, and several
adhere by a nar-
row peduncle, their
free extremity being
much broader than
the attached. These
singular excrescen-
ces are most abun-
dant in the rectum
and the sigmoid
flexure of the colon,
from which they
gradually decrease

in number, though not in volume, as they approach the coe-
cum, where they are entirely wanting. Their surface is
somewhat rough, as if covered with villi, and in the recent
state they were all of a dark mulberry hue. The parietes of
the bowel are very much thickened and indurated, especially
in the inferior three fourths of its extent ; and the caliber of
the tube is diminished to less than one half the normal size,
and of the rectum to less than one third. The subject of this
disease was a man about sixty years of age, during the last

278 LARGE BOWELS. [CHAP. VII.

four of which he was constantly harassed with diarrhoea,
and intestinal pains, which produced excessive emaciation
and gradual exhaustion.

In another specimen of a similar nature, which was kindly
presented to me by the late Dr. Herron, of this city — a gen-
tleman who died too soon for the cause of the science to
which he was so ardently attached, and of which he bid
fair to be one of the brightest ornaments — the walls of the
colon are also very much thickened, though not so much as
in the preceding case, and the inner surface, besides being
cellulated, like a honey-comb, is covered with an immense
number of soft, fungoid excrescences, some of which are
nearly half an inch in length. In their shape they exhibit
almost every variety, some being conical, some spherical,
and some angular. Many of them arise by a common base,
and, jutting out like little slender arches, unite at the top,
leaving thus a number of intervening spaces which readily
admit of the passage of a large-sized probe.

The structure of these vegetations seems to be very analo-
gous to, if not identical with, that of the natural mucous
membrane, upon which they grow, and of which they may,
therefore, be regarded merely as so many prolongations.
That this is the case, is sufficiently obvious when we make a
section of them. In both the specimens in my possession,
the inner surface of the colon and rectum presents thousands
of hypertrophied villi, and similar bodies are plainly visible,
even to the unassisted eye, on the warty excrescences. Thus,
then, it may be concluded, that these singular growths are
neither villosities in a state of preternatural enlargement, nor
new formations, but simply, as we have just intimated, so many
prolongations of the mucous corion, folded over a small quan-
tity of cellular substance. Their vascularity is sometimes
very great, and there is reason to believe that they are sus-
ceptible of a sort of erection.

How these vegetations originate is still a mooted question.
That chronic irritation has some agency in their production
cannot, I think, be denied, as we seldom if ever meet an
instance in which the bowels have not been seriously and
for a long time deranged ; but what the peculiar modification
is, and why these bodies should exist in some cases and not
in others, are problems which must, for the present, remain
undetermined. In the individual, a young courtesan twenty-
three years of age, from whom Dr, Herron obtained the

SECT. VII.] GENERAL DISEASE OF THE MUCOUS MEMBRANE. 279

interesting specimen which he presented to me, there had
been well-marked signs of chronic colonitis for several years,
with occasional intervals of perfect health. She finally died
of gangrenous inflammation of the vulva and vagina, having
for the last few months suffered severely from disease of the
bowels, the principal symptom of which was torturing pain
in the umbilical region, with frequent slimy and bloody
evacuations. So also in the other case that we have men-
tioned, chronic inflammation had invaded nearly the whole
of the large bowel, and had existed for nearly four years, hav-
ing been engrafted upon a severe attack of Asiatic cholera.

The following case, for which I am indebted to Dr. Aber-
crombie, conveys a very good idea of the symptoms and
modifications of disease of the mucous membrane of the
large bowel. A lady, thirty-five years of age, was suddenly
seized with vomiting and purging, Avhich continued, with
occasional intermissions, until the ninth day of the attack,
when she expired, in a state of perfect exhaustion. Some-
times there were not more than three or four alvine evacua-
tions in the twenty-four hours ; and she occasionally passed a
whole night without any disturbance ; yet, however this
might be, the countenance had always an expression of great
anxiety and feverishness. There was but little pain in the
bowels, and, after the first three days, scarcely any tenderness
on pressure of the abdomen. The evacuations are in general
copious, thin, and of a feculent appearance. Towai'ds the
last, they became extremely fetid, streaked with blood, dark-
colored and puriform.

On examination, the mucous membrane of the coecum wa&
found to be of a uniform deep red color, and covered by nu-
merous well-defined ulcers, some of them the size of a six-
pence. In the ascending colon, there was a more irregular
state of disease, consisting of slight wandering erosions, va-
riegated with dark fungoid elevations. In the arch of the
colon, the lesion assumed a still difl'erent character. Here the
ulcers, scarcely as large as a split pea, Avere quite distinct
from each other, with the intervening structures perfectly
sound. In the descending colon, the whole of the mucous
membrane exhibited one continued surface of disease. It
was of a dark brown color, fungoid and spongy, without any
defined erosion, and, throughout, very much thickened. The
other tunics along this portion were also considerably hyper-
trophied, and in some places almost of cartilaginous hard-

280 LARGE BOWELS. [cHAP. VII.

ness. This state of disease extended from near the com-
mencement of the descending colon to within two inches of
the extremity of the rectum, where it abruptly terminated.
The stomach and small intestines were quite healthy, except-
ing the inferior portion of the ileum, which was very vascu-
lar and inflamed. The peritonasal covering of the large bowel,
especially about the sigmoVd flexure and the upper part of
the rectum, was of a dark red color, and dotted with small
specks of lymph.

It deserves to be remarked here, that, about four years
before, this patient had an attack of disease very similar to
that of which she died, and that during the whole of this
interval she occasionally complained of uneasiness in her
bowels. Up to the day of the last attack, however, she was
apparently in perfect health, and able to take a great deal of
exercise, the body being full in flesh. The bowels were
habitually costive, and required the frequent use of gentle
laxatives.

In leaving this subject, there is one point upon which I
deem it necessary to make a few comments. I allude to the
singular contraction of the large bowel which is so frequently
met with in our post mortem examinations. Every physi-
cian who is in the habit of making researches of this kind
must have frequently observed this appearance. During the
early period of my professional life, before I had much ac-
quaintance with morbid structure, I was inclined to look upon
this contraction as the effect of disease ; and as such, there is
reason to believe, it is still regarded by many at the present
moment. That this, however, is not the fact, in the great
majority of instances, my own experience decidedly tells me ;
and, in order to avoid all mistake upon the subject, I would
suggest that, whenever this appearance is witnessed — as it
will, I feel confident, in nine cases out of every ten — the
bowel should be carefully opened with the scissors, and thor-
oughly scrutinized, with a view of ascertaining the color,
consistence, and thickness of its several tunics ; for by such
a procedure alone can the investigator expect to arrive at any
satisfactory conclusion.

The parts of the large bowel most subject to this contrac-
tion are the left half of the arch of the colon, the descend-
ing portion, the sigmoid flexure, and the upper half of the
rectum, — the frequency of its occurrence being in the order
here enumerated. All these parts are often narrowed at the

SECT. VII.] CARCINOMA. 281

same time, and occasionally to such a degree that the caliber
of the tube is nearly obliterated. What this condition is
owing to it is difficult to conjecture ; nor am I able to oifer
any opinion upon the subject, excepting that these parts of
the alimentary tube, being less liable, during the last stages of
our existence, to be distended by fecal matter, the muscular
fibres are enabled to contract with more energy than in the
rest of its extent.

There are some organic lesions which are either peculiar
to the rectum and the anus, or which occur so frequently in
these situations, as to render it proper that a short account
of them should be presented in this place. Of these affec-
tions, the most important, from the frequency with which
they demand surgical interference, are carcinoma, stricture,
ulceration, and vascular excrescences.

Carcinoma is generally seated several inches above the
anus, and presents itself in the form of a flattened, oval
tumor, from one to three inches in diameter. Its anatomical
characters are the same, pretty much, as in the stomach or
oesophagus ; that is, it is either of a hard, dense, gristly con-
sistence, with a rough, nodulated, and ulcerated surface, or it
is of a soft, spongy texture, like the medullary substance of
the brain. The mucous and muscular coats of the bowel are
usually very much thickened, and the former is often thrown
into large, irregular ridges, in the intervals of which, it is not
uncommon to find small erosions. When the disease is of
long standing, the hemorrhoidal vessels are apt to be enlarged,
and the surrounding cellular tissue matted into a condensed
mass, destitute, in great measure, of its primitive characters.

No perplexity can prevail in the recognition of cancer of
the rectum. The leaden and sallow complexion ; the deep-
seated, lancinating pains, darting through the hips and pelvis
into the groins, and down the thighs ; the difficulty of evac-
uating the bowels ; the frequent discharges of bloody, puru-
lent mucus ; and the presence of a tumor in some portion or
other of the tube ; are signs which unerringly stamp the na-
ture of this formidable malady.

There is a singular species of ulceration of the rectum,
which has attracted much attention in France, but which,
I believe, is extremely rare in the United States, and in many
districts of Europe. I refer to the lesion which was first
described by the late Professor Boyer, of Paris, under the

VOL. II. 36

283 LARGE BOWELS. [CHAP. VII.

name of fissure of the anus. The disease, as has been just
intimated, consists in an elongated, narrow ulceration, which
commonly arises immediately above the internal sphincter, on
the posterior surface of the gut, opposite the point of the
coccyx, in consequence, frequently, of some mechanical cause.
The bottom of the fissure, usually formed by the submucous
cellular tissue, has a soft, spongy feel, whereas the edges are
indurated and more or less prominent. The peculiar charac-
ter of this disease is, that it is invariably attended by spas-
modic contraction of the sphincter muscles of the anus ;
owing to which the patient generally experiences the most
horrible torture on every attempt at defecation. Occasionally
considerable hemorrhage takes place from an ulcer of this
kind.

There is a species of spreading ulcer of the mucous mem-
brane, which is said to be extremely prevalent amongst the
females of Great Britain.* The disease is characterized by
the complete removal of a considerable portion of the lining
membrane of the rectum, with a dense, indurated, and almost
gristly state of the muscular tunic. It usually commences
about half an inch within the anus, and terminates above by a
rather abrupt but very irregular line of demarcation. The
ulceration frequently extends around the whole bowel, and
sometimes high up into the sigmoid flexure of the colon. Un-
less taken in hand early, it is very apt to prove intractable.

The symptoms of this disease are, pain and soreness in the
rectum, difficulty in passing the feces, and a sense of weight
in the pelvis, with irritability of the bladder and bearing
down of the womb. The pain which is always much aggra-
vated by the action of the diseased bowel, frequently shoots
down the thighs, and the patient has no ease except in the
recumbent posture.

Orgmiic stricture of the rectum (Fig. 57)t consists in a
thickened, indurated condition of the mucous and cellular
textures, by which the caliber of the tube is more or less
contracted. A smooth gristly ring is thus formed, from a few
lines to half an inch in depth, above and below which the
bowel commonly retains its natural structure. The thicken-
ing does not, however, always embrace the entire circum-

* Mayo, Outlines of Pathology, p. 348.

t This and several of the succeeding figures are copied from the work of the
late distinguished Dr. Bushe, of New York, on the Diseases of the Rectum.

SECT. VII.]

SPASMODIC STRICTURE.

283

Fiff. 57.

ference of the rectum ; not unfrequently, indeed, it forms a
mere segment of a circle, and is so arranged as to give the
villous tunic in the immediate neighborhood a remarkably
puckered and drawn appearance. When the ring is complete,
it strongly resembles a scirrhous
pylorus. Hypertrophy of the
muscular tunic is also occasion-
ally observed, but the peritonaeal
is seldom implicated.

The common seat of organic
stricture is about three inches
above the anal orifice. Cases,
however, are frequently ob-
served, in which it is much
lower down or higher up. The
disease spares neither age nor
sex. Whilst it is not unusual
about the meridian of life, it has
been repeatedly witnessed in
children as early as the eighth
year, and in the old as late as the eightieth.

The nature of this lesion can only be satisfactorily deter-
mined by an examination with the finger, and by a careful
investigation of its history. The same difficulty is experienced
here in relieving the bowel as in carcinoma of the rectum,
and fissure of the anus ; but what perhaps serves, in some
degree, to distinguish this affection from any other, is the
peculiar shape of the feces, which, instead of being voided
in thick masses, come away in short, narrow pieces, often not
larger than a full-sized catheter. The bladder is sometimes
excessively irritable, from the pressure of the loaded gut ; and
occasionally one or more fistulee form in the nates or the
perinasum. In the female, a communication frequently takes
place between the rectum and the vagina ; and in the male
a similar passage may be established, though more rarely,
between the rectum and the bladder.

Authors have noticed a spasmodic stricture of the rectum,
caused by an irregular contraction of the muscular fibres. It
is supposed to be most common in the upper portion of the
tube, and to be dependent upon a vitiated state of the secre-
tions.*

Mayo, op. cit, p. 350.

284

LARGE BOWELS.

[chap. VII.

Hemorrhoids may be distinguished into two varieties, one
of them consisting essentially in a varicose enlargement of
the vessels, the other in the formation of a small sac filled
with blood. In the latter case, the disease appears in the
shape of one or more soft, florid, vascular tumors, (Fig. 58,)
seated either around the
verge of the anus, or just
above the internal sphinc-
ter muscle. In their
size, they vary between
a cherry and a walnut,
and their color is always
more pallid in proportion
to their age. When they
are old, they often ap-
pear like hard, indurated
knobs, destitute of that
erectility which forms so
distinguishing a feature
in them, when recent.
The hemorrhoidal sac
originates, as is supposed
by Richter, who has writ-
ten very learnedly upon
the subject, in an extrav-
asation of blood into the
cellular tissue, lifting up the mucous membrane, in the case
of internal piles, the skin, in the case of external ones. The
correctness of this explanation my own dissections have
fully verified. The blood being poured out, in the first in-
stance, in the liquid form, afterwards coagulates, and in pro-
cess of time undergoes pretty much the same changes as in
apoplectic and other effusions. Thus a satisfactory reason
is afforded for the difference of color and consistence between
a recent and an old hemorrhoidal tumor. When these bodies
are seated exactly at the margin of the anus, they are some-
times half covered by skin, half by mucous membrane.

Piles are largely supplied with blood, and hence they are
always more conspicuous during life than after death. As
soon, indeed, as the circulation ceases, they become pale and
flabby, their surface assuming a shriveled, corrugated aspect,
from the retrocession of the blood. These hemorrhoidal
tumors I have repeatedly injected ; and in several instances

SECT. VIL]

HEMORRHOIDS.

285

Fig. 59.*

I have found them converted into a semi-cartilaginous mass,
of a dirty yellowish color. (Fig. 59.)

Varicose enlargement of the hemorrhoidal vessels,
both arterial and venous, is particularly liable to
happen in females during utero-gestation, and in
males whose occupations oblige them to be con-
stantly in the erect position. The protrusions which
are thus formed are soft, spongy, erectile, and re-
markably prone to hemorrhage, the blood often spirt-
ing from them in a full stream. (Fig. 60.) In their
color, they vary from a light red to a deep purple ;
and they often acquire the magnitude of a common
almond. Their most usual situation is just within the verge
of the anus. In respect to number, there are seldom more
than two or three ; but, v o- rn

in a few rare instances, °

I have noticed as many
as five or eight.

Polypous growths are
sometimes found in the
lower part of the rectum ;
but, as their structure and
mode of origin are the
same as in the other parts
of the body, they need
not detain us in this
place. The same may
be said of the ulcers
and warty excrescences
which are occasionally
seen round the anus, and
of the partial protrusion
of the mucous mem-
brane, from relaxation of
the bowel.

Prolapsion of the anus is another disease which requires
brief notice in this place. Of this there are two forms. In
the first, (Fig. 61,) which may be termed the partial prolap-
sion, the mucous membrane of the lower bowel is alone
everted, so as to present the appearance of a ring : it is usu-
ally observed in the vigor of life, and very frequently de-

* Section of an old hemorrhoidal tumor, showing its internal structure.

286

LARGE BOWELS.

[chap. vn.

pends upon the presence of hemorrhoids. In the second

variety, (Fig. 62,) there
is a descent of all the
coats, the whole on the
greater portion of the
rectum falling through
the external sphincter
muscle. The extent to
which the protrusion
occurs varies from a
few lines to six or ten
inches. In cases of the
latter kind, it is proba-
ble that there is a real
invagination of the sig-
moid flexure of the co-
lon ; for it is difficult
to conceive, as has been
justly remarked by Pro-
fessor Syme,* of Edin-
burgh, how the rectum
could suffer the requi-
site displacement, even
supposing that it pos-
sessed the necessary
length. When the pro-
lapsion is complete, as
in the form of the lesion
we are contemplating,
the tumor is commonly
of an irregularly, glob-
ular figure, and varies
from the size of an egg
to that of the two fists,
the mucous membrane
is of a dark livid color,
from the constriction of
the capillary vessels, and
affords a thin, bloody
secretion, which has
been compared, not un-

* Principles of Surgery, p. 294. Edinburgh, 1837.

SECT. VII.] FISTULA MALFORMATIONS. 287

aptly, to red currant jelly. If the parts be allowed to remain
long in this situation, the effect is that they not only become
very much thickened, but they gradually assume a fibro-carti-
laginous consistence. Protrusion of all the tunics, it may be
stated in conclusion, occurs chiefly in children and aged per-
sons, particularly in females of relaxed frame.

A fistula is a small narrow passage, which has one of its
openings in the neighborhood of the anus, the other in the
rectum : in some instances, the upper extremity of the tube
terminates blindly as a cul-de-sac. Its length varies from a
fevT lines to several inches ; and its diameter generally equals
that of a common probe, and occasionally that of a goose-
quill. A channel of this kind may be either straight or
crooked ; and when there are several of them at the same time,
they not unfreqnently commimicate with each other. Inter-
nally, it is lined by a layer of adventitious membrane, the
surface of which, usually somewhat rugose, is constantly
bathed with purulent matter, either alone, or mixed with
feces. A fistula is always preceded by an abscess, and may
therefore be considered as a consequence of its imperfect
restoration.

Congenital malformations are sometimes witnessed in the
anus and lower extremity of the rectum, which are often
incompatible with the perpetuation of the life of the indi-
vidual. When the anus is absent, the large bowel is either
partly or entirely deficient, or else opens in a cul-de-sac, some
distance above the usual place. Occasionally the aperture is
closed simply by a thin fold of membrane, not unlike the female
hymen, which may be easily divided with the knife, and the
infant survive. Sometimes nearly the whole of the large in-
testine is wanting, as was the case with a foetus which I
dissected a few years ago, in which the ileum terminated in
a capacious cul-de-sac, two inches and a half in length, which
floated loosely in the pelvic cavity. At other times, again,
the anus and rectum are natural, whilst the colon is either
absent or so contracted as to render the continuance of life
impossible. Instances are also upon record, where the rectum
opened into the urinary bladder, the urethra, or the vagina ;
thus affording an approximation to the cloaca of birds, and of
some fishes.

288 INTESTINAL WORMS. [cHAP. VII.

SECTION VIII.

Of Intestinal Worms.

Five species of worms inhabit the intestinal tube of the
human subject, the lumbricoid, vermicular, tricho- ^.^ ^^ ^
cephaloid, the long tape, and the broad tape. These ^' ^ '
worms are not peculiar to man : they occur frequently
in the inferior animals, and, as might be supposed,
they all have a decided predilection for particular
parts of the alimentary canal, some selecting the
small, others the large bowel. How these parasitic
beings originate is still a mooted point with patholo-
gists : all are agreed, however, in the belief that they
must arise from one of two sources, — either that they
must be introduced into the body from without, or
else be generated within. It ^does not accord with
the plan of this work to enter into a detail of the
various arguments that have been adduced by the
advocates of these two questions : suffice it to say,
that the great majority of the best writers of the pres-
ent day are decidedly in favor of the doctrine which
ascribes their origin to internal generation. Inde-
pendently of the fact, that many of these animals
have been discovered in a great variety of organs and
tissues, both in man, in quadrupeds, birds, reptiles,
and fishes, the circumstance that they have been re-
peatedly seen in the foetus, seems to me to be amply
sufficient to settle the question as to their origin
within the body. Kerkringius mentions the case of
an immature foetus, in whose stomach he found sev-
eral lumbricoid worms ; and instances of tape-worms
having been discovered under like circumstances are
narrated by Pallas, Heine, and other authors. Rudol-
ph! and Bremser, two highly respectable German
writers, refer to numerous examples of worms existing
in the foetuses of various quadrupeds, and also in those
of birds which had just escaped from the shell.

The lumbricoid won?i, (ascaris lumbricoides, lum-
bricus teres,) as its name indicates, is of a cylindrical
shape, (Fig. 63,) gradually tapering towards each ex-

* Ascaris lumbricoTdes: a, the anterior extremity; h, the posterior; d, the
vulva ; e e, lonffitudinal lines.

SECT. VIII.]

LUMBRICOID WORM.

289

tremity. It is marked by numerous circular ridges, and by

four longitudinal

Fig. 64.* Fig. 65.t

^i

Fig. 67.§

^1

i

VOL. II.

^^' ■ lines,of which the

dorsal and ventral
are whitish, the
two lateral ones
dark and opaque.
The head is tri-
valvular, without
wings or process-
es; and the diges-
tive tube, which
runs in a straight
course, terminates
a short distance
from the tail in a
transverse fissure.
The length of
this worm is from
three to twelve
inches ; its thick-
ness about that
of a goose-quill ; and its color of a
reddish brown, bordering upon yel-
low. The male is much more slen-
der than the female, from which it
is readily distinguished by the singu-
lar curve of its caudal extremity,
and by its forked penis. This spe-
cies of worm (Figs. 64, 65, 66, 67)
exhibits a high degree of organiza-
tion, being furnished with integu-
ments, a muscular and digestive ap-
paratus, and well-developed sexual
organs, together, as is supposed by

* Organs of the female ascaris : a, the exter-
nal tunic; h 6, muscular fibres; d, mouth; e,
(Esophagus ; /, the alimentary tube ; Tilvi m, the
generative organs.

+ Organs of the male ascaris : d, the mouth ;
e, the oesophagus ; h h, generative organs ; /, the
intestine ; g, penis.

t Penis of the ascaris lumbrico'ides magnified :
a, the extremity : b, the base.

§ Head and mouth of the ascaris : a,bb, tu-
bercles ; c, oval aperture.

37

290

INTESTINAL WORMS.

[chap. VII.

Fig. 68.*

Cuvier and Cloquet, with a nervous and circulatory system.
Its natural residence is in the small intestines, where it often
occurs in considerable numbers. It has also been found in
the large bowel, in the stomach, biliary ducts, oesophagus,
fauces, and even in the larynx. In the latter situation, it
has been known as the cause of suffocation.

The vermicular species (ascaris vermicularis, oxyurus v.,
fusaria v.) is extremely small and delicate, (Fig.
68,) the male being not above the sixth of an inch
in length, with a very thin, tapering body, of a
whitish color. The mouth is of an orbicular
shape, with a bladder-like, transparent membrane
on each side : the tail is spiral and obtuse, and the
sexual organ is contained in a sheath. The fe-
male is considerably larger, being from four to six
lines long, and its tail is as fine as the most deli-
cate needle. The heads of these worms are in
constant motion : from this circumstance they are
often called leap-worms : from the uneasy, gnaw-
ing sensation which they are supposed sometimes
to occasion in the stomach, they have also re-
ceived the name of maw-worms ; and, from their
filliform configuration, they are vulgarly termed
thread-worms. They are found only in the
large intestines, especially in the rectum, where
they are often collected in vast multitudes, wrap-
ped up in thick, viscid mucus. In females, these
worms sometimes pass into the vagina, and give r^se to much
uneasiness.

The trichocephalo'id^ (trichocephalus dispar, trichuris, as-
caris trichnria,) hair-worm, or thread-worm, (Fig. 69,) as it
has been variously denominated, is principally found in the
coecum, and is said to be very common in the inhabitants of
England and Germany. It is also frequently met with in
the inferior quadrupeds, especially the monkey, dog, and fox.
This species is from one and a half to two inches in length,
with a white, cylindrical body, which is almost as thin as a
horse-hair anteriorly, the remaining third being considerably
stouter, and terminating in a rounded extremity. The mouth
is orbicular, the head extremely slender, and the capilliform
portion transversely striated : the alimentary tube runs in a

the head ; b, the tail ; *, natural size.

SECT.

VIII,]

T^NIA.

291

straight course from before backwards; and terminates in the
thick bulbous part, where it assumes
a flat, spiral form. The male is the
smallest, and is distinguishable from
the female by the sexual organs,
which are enclosed in a sheath, by
the greater brevity of the anterior
capilliform portion, and by the pecu-
liar circular whirl of the tail.

The long tape-worm (Fig. 70)
(taenia longa, tasnia solium, tasnia
cucurbitiva) naturally infests the
small intestines ; but it has also been
observed in the stomach, colon, and
rectum. This species is of frequent
occurrence in different sections of
the United States and Europe ; and,
according to Hasselquest, it is also
very common in many parts of the
East, especially amongst the Jews at
Cairo, large numbers of whom are
affected with it. The long tape-
worm is of a whitish color, from
three to six lines in width, and of
the average length of sixty feet.
Occasionally the length is enormous.
Bremser relates a case where it was
one hundred and fifty feet, and others
are given where it was above three
hundred. Towards the anterior part,
this worm suddenly tapers off into
a very fine thread-like extremity,
which is surmounted by a small
hemispherical head, provided with
four lateral suckers. The body is flat, rough, and composed
of numerous joints, on one edge of which there is a slight pro-
jection, pierced by a minute aperture. The configuration of
the articulations, their relative length and breadth, are much
influenced by the movements of the animal, and cannot be
specifically defined. The worm is rarely expelled entire :
most commonly it is voided in pieces several feet long, and

a, the head ; 6, the intestines ; c, sheath ; d, penis ; *, natural size.

292

INTESTINAL WORMS.

[CHA

P. Vll

not unfrequently it comes away in single joints, looking like
so many gourd seeds. p^o-. 70.*

In its organization
it seems to be great-
ly inferior to the
preceding species,
being a homogene-
O.US cellulo-gelatin-
ous mass, without
distinction of sexes,
or trace of a ner-
tous system. This
variety of tape-worm
seems to be at once
androgynous and
hermaphrodite, im-
pregnation occur-
ring indifferently by
means of the ap-
proximation of two
individuals, or, as is
probably more com-
monly the case, by
that of two joints of
the same animal.

The hroad tape-
worm (tasnia lata,
bothriocephalus latus, taenia membranacea) seldom exceeds
fifteen feet, though occasionally it attains a much greater
length. It is white, flat, from six to ten lines
in width at the broadest part, which is near the
middle, and consists of a series of concatenated
joints, the intervals between which grow suc-
cessively longer the nearer they approach the
tail. In its general features, it bears a pretty
close resemblance to the long variety ; but the
articulations are comparatively larger and strong-
er ; the flattened surface of each link is perforated
by a small hole, and the head of the animal,
(Fig. 71, a a,) when seen by means of a lens, is
found to be of an elongated, elliptical shape,
with a large fissure on each side of it. Both

a, the liead ; b b, the lateral orifices.

SECT. VIII.] SYMPTOMS. 293

extremities are remarkably attenuated, especially the anterior,
which is often perfectly thread-like for twelve or fifteen
inches. This worm inhabits the upper portion of the small
bowel, and is very common in France, Switzerland, Poland,
and Russia, — several of them often coexisting in the same
individual.

Of the hundred and one symptoms which have been enu-
merated by authors as indicative of the presence of worms in
the alimentary tube, there is only a single one that is of any
value, and that is the appearance of these bodies in the evacua-
tions. All the other phenomena are of negative importance, as
they may result from any irritation of the mucous membrane.
The functional symptoms of worms appear to vary according
to the particular species. Thus, the vermicular variety induces
the most distressing itching and titillation in the lower part
of the rectum and anus ; the tasnial, twisting and gnawing
in the vicinity of the stomach, with enormous appetite, and
irregular retraction of the abdomen ; the lumbricoi'd, pain and
itching about the navel. Worms are supposed by some to
be harmless inmates of the intestinal tube, — an opinion the
fallacy of which has been abundantly proved by the united
experience of the profession. If allowed to remain unmo-
lested, they not only create irritation in the mucous mem-
brane, but cause a variety of sympathetic disorders, which
eventuate either in the impairment of the general health, or
even in the destruction of life. Of this description are
chorea, paralysis, mania, epilepsy, hydrocephalus, with a
variety of other affections which it would be needless here to
specify.

CHAPTER VIII.

Of the PeritoncBum.

Is liable to different forms of Disease. — Acute Inflammation. — Deposition of
Lymph. — Effusion of Serum, Pus, and Blood. — Softening of the Subserous
Cellular Tissue. — Parts of the Membrane most apt to suifer. — Developement
of Vesicles. — Chronic Irritation. — Agglutination of the Bowels and forma-
tion of false Passages. — Tubercles. — Ascitic Effusions. — Generation of Gas.
— Heterologous Growths.

The lesions of the peritonseum may be referred to inflam-
mation, tubercles, melanosis, and cancerous growths. A very
brief description of these several pathological states is all that
will be attempted in this place.

The common characters of acute inflammation are increased
vascularity, opacity, exudation of lymph, and effusion of se-
rous fluid. The redness is generally of a florid tint, and is
either punctiform, arborescent, stellated, or patch-like, being
always most intense in those cases where there is least secre-
tion. Under opposite circumstances, indeed, the redness is
sometimes scarcely perceptible, and may even be entirely ab-
sent ; not so much, perhaps, from the reflux of blood from the
capillaries during the agonies of death, as from the manner in
which they are drained during the violence of the inflammato-
ry excitement. This conclusion, I am aware, is opposed to that
of Dr. Scoutetten,* a highly respectable French writer, who
asserts that there is always increased redness after death ; but
that this is not the case must be familiar to every pathologist,
however limited his observations.

Occasionally small ecchymoses are observed ; and, in al-
most all cases, the membrane loses a considerable share of its
transparency, assuming an opaque, turbid, or milky aspect.
Much has been said by writers concerning the thickening of
the peritonseum in this disease ; but if this condition ever oc-
curs, I have not been so fortunate as to witness it, and am
seriously inclined to doubt whether it ever takes place.

* Archives G6n6 rales, t. iii. p. 501.

CHAP. VIII.] inflammation; adhesions. 295

By the time the redness is fairly estabhshed, the affected
membrane throws out coagulating lymph and serum. Wheth-
er both these substances are separated simultaneously, or one
precedes the other, are points which do not seem to be fully
settled. The late Dr. Armstrong, of London, well known
as one of the ablest physicians of the age, was of opinion that
the lymph is deposited first ; whilst others maintain that the
priority, if any, is always determined by the intensity of the
inflammation. According to this theory, when the disease is
very mild, serum seems to be thrown out first ; but, if the ex-
citement is very acute, the earliest product is lymph.* After
all, this is a mere hair-splitting affair, in which the wisest
plan is to pursue a middle course, as the question cannot be
easily decided without numerous experiments upon the infe-
rior animals. To me it appears more than probable that
both substances are eliminated at one and the same time, as
we have reason to believe they are in the pleura and pericar-
dium.

At first, the lymph has a soft, unctuous feel ; but by degrees
it becomes dense, firm, and organized, vessels being either
developed in its substance, or else shooting into it from the
surrounding parts. The period at which it is vitalized va-
ries in different cases, from thirty hours to several days,
weeks, or even months. Of the numerous forms which this
matter assumes, the band-like is by far the most common.
Not unfrequently, however, we find it deposited in small
amorphous masses, filling up the intervals between the convo-
lutions of the intestines, and gluing them more or less closely
together. In many instances, from the presence of this sub-
stance, all the abdominal viscera present one uniform surface,
with extensive adhesions to the surrounding walls.

When partial, these peritoneal adhesions sometimes induce
fatal mischief, by strangling the bowel. Of this an interest-
ing case is mentioned by Dr. Abercrombie ; and another was
communicated, to me, a few years ago, by Dr. Paramore, of
Eaton, in the State of Ohio. It occurred in his own child, a
boy twenty-one months old, who was treated, at first, for
worms, and subsequently for intussusception. The case
lasted three days, and was marked chiefly by irritability of
the stomach, with obstinate constipation : there was consid-
erable pain in the abdomen, but no tenderness whatever on

* London Cyclopaedia of Practical Medicine, art. Peritonitis, p. 302.

296 PERITONEUM. [chap. VIII,

pressure. On examination, a band of false membrane, about
an inch and a half in width, was found passing over two
coils of the ileum, which were thus firmly constricted, and
deprived of their vitality. Both ends of the band were at-
tached to the mesentery, opposite the lumbar vertebrae.

The lymph is sometimes deposited in distinct layers, varying
in thickness. from the finest silk to the coarsest cassimere. Of a
light grayish tint, they are perfectly smooth and transparent',
and often contain long, slender vessels, filled with florid blood.
Such adventitious membranes, from the manner in which
they are attached to and spread over the surface of the bow-
els, may form small pouches, distended with serous fluid.

The serum poured out in this aff"ection varies in quantity
from a few ounces to several pounds, being always much less
than in chronic peritonitis. In its color, it differs in different
cases. Sometimes, especially when the inflammation is par-
tial, it is clear and limpid, like water ; at others, it is of a pale
reddish hue, whitish, or milky, and not unfrequently it is
mixed with flakes of lymph, or possesses all the sensible
properties of pus.

The effusion oi pus is a frequent termination in fatal cases,
and seems to take place occasionally at a very early period of
the disease ; but in general it is not considerable in quantity
until the affection has existed for some time. As there is no
breach of continuity in the membrane, the matter is probably
thrown out by a sort of exhalation, similar to that which is
concerned in the production of the serum and lymph. The
color and consistence of the pus are various, being white,
greenish, milky, or reddish, with shreds of membrane, flakes
of lymph, or dots of blood.

In very violent grades of this disease, it is not uncommon
to find clots of blood, sometimes of considerable size, in the
serous cavity. This appearance, which has been repeatedly
observed by Broussais and others, has been several times
witnessed in my own dissections. In a middle-aged man,
whom I examined a few years ago, along with the late
Dr. Herron, of this city, the peritonaeum exhibited all the
marks of high inflammatory action ; and, although there was
no breach of continuity or ruptured vessel, as, indeed, there
rarely is in such cases, yet there were nearly two pounds of
coagulated blood in the left iliac region.

There is another pathological state which is not unfre-
quently witnessed in connection with peritonitis, and which

CHAP. VIII.] INFLAMMATION. 297

is of too important a character to be passed wholly unnoticed
on this occasion, I allude to the softening of the subserous
cellular substance. This lesion, although principally observa-
ble in the acute form of the disease, is by no means peculiar to
it. It is generally associated with sero-purulent effusion, and
is particularly conspicuous in the pelvic portion of the perito-
ngeum, in the persons of lying-in females, and in those who
fall victims to injuries of the rectum and urinary bladder.
The softening, which sometimes involves a large extent of
surface, often amounts to such a degree as to permit the se-
rous membrane to be peeled off with the greatest facility from
the organs which it serves to envelope. This lesion, which
appears to have been known to De Haen, has been particu-
larly pointed out by Dr. Hodgkin, of England ; but I had met
with it several times before the excellent work of that distin-
guished anatomist fell into my hands. A similar pathologi-
cal condition is occasionally seen concurrently with the pre-
ceding, in the submucous cellular substance of the stomach
and bowels, produced, in all probability, by an extension of
the irritation from the serous envelope.

All parts of the peritoneeum are not equally liable to in-
flamm.ation : the portions most commonly affected are the
broad ligaments of the uterus, and the covering of the small
intestines, especially of the ileum, together with the tunic
of the spleen and liver. Rarely is the parietal part of the
membrane implicated ; and the same remark is applicable, in
a still higher degree, to the serous envelope of the stomach.
Indeed, serous gastritis must be regarded as an extremely
infrequent disease, infinitely more so than is generally im-
agined by the profession. In all my dissections, I cannot recall
a single instance in which this portion of the peritonasum
betrayed the least sign of acute inflammation. True it is,
the organ is occasionally found glued to the neighboring
structures, as the spleen, diaphragm, or arch of the colon ; but
even this circumstance is far from affording conclusive evi-
dence that it was the seat of the effusion which led to this
pathological condition.

Nor does the disease always remain confined to the origi-
nal seat of the attack. Thus it often happens that the
external coat of the bowel is inflamed in the first instance,
and that the irritation is afterwards propagated, either rapidly,
or step by step, as it were, to the other layers, or even to the
wall of the abdomen.

VOL. II. 38

298 PERITONEUM. [chap. VITI.

On some occasions, the peritonaeum is elevated into little
vesicles, produced by an evolution of air in the subjacent
cellular tissue. Dr. Gendrin tells us that he has several
times noticed this phenomenon in his experiments on inferior
animals ; and, he moreover adds, it is very often met with in
the violent inflammations which supervene upon intestinal
effusions. Another phenomenon, which is sometimes noticed,
is the developement of gas, either in the peritonasal sac, or in
the digestive canal, or in both these cavities simultaneously.*
How this fluid originates, it is not very easy to determine ;
perhaps, however, it would not be going too far to suppose
that, in some instances, it is the result of a true secretion,
whilst, in others, it is separated from the eflfused liquids and
alimentary substances.

Bold and well-marked symptoms often usher in this disease ;
nevertheless, its progress is frequently insidious, and the phe-
nomena, both local and general, such as not to afford any
satisfactory indications of the mischief that is going on in
this important membrane. Thus, there may be little or no
gastric irritability, little or no pain, little or no derangement
of the bowels. Towards the close of the disease, however,
there is usually vomiting, a tense and tympanitic condition
of the abdomen, an anxious and contracted state of the fea-
tures, great prostration of strength, and pain, on pressure,
over the region of the belly, with diarrhoea or constipation.
Often, the least pressure is insupportable, and even the weight
of the bed-clothes is distressing. The pain, though occa-
sionally wandering, is generally fixed, acute, and constant ;
and the patient rarely lies in m\f other position than on the
back. The formation of matter is indicated by irregular
chills, diminution of the abdominal pain, with a sense of
weight and oppression, pallor of the countenance, and cold-
ness of the extremities.

The presence of plastic lymph, with partial adhesions, is
indicated, at an early stage, by a remarkable symptom, which
was discovered, a few years ago, by that eminent pathologist,
Dr. Bright, of London. It consists in a peculiar crepitating
sensation, not unlike what is produced by bending a sheet of
new leather, which is recognized by the hand when applied
to the abdomen in a mode calculated to facilitate motion. It
has also been likened to the obscure creaking of pulmonary

* Gendrin, Histoire Analomique des Infl. t. i. p. 138.

CHAP, VIII.] GANGRENE. 299

emphysema, and to the sensation caused by passing a wetted
finger over a pane of glass. It is felt both during the ascent
and descent of the diaphragm, but more distinctly during the
latter, and appears to result from the friction of the roughened
surfaces of the peritoneeum. This symptom, it should be
added, is to be perceived only when the lymph, upon the
presence of which it depends, is of a plastic, organizable char-
acter, competent to form adhesions, and never lasts beyond a
few days.

The bowels, in this disease, as we have already seen, are
sometimes firmly agglutinated to each other, and to the
parietes of the abdomen. When this happens, the diagnosis,
as might be expected, must be extremely obscure and diffi-
cult. Indeed, there is no symptom or group of phenomena,
upon which we can place any special reliance. Dr. Armstrong
says that such adhesions may generally be suspected by an
irregularly lobulated state of the bowels, perceptible on pass-
ing the hand over the abdomen ; but this sign is by no means
constant, even in recent cases, whilst, in those of long stand-
ing, or in which the adventitious substance is in great
measure absorbed, or transformed into the cellular and serous
tissues, it is generally entirely wanting. Occasionally, though
rarely, the patient experiences a sensation, as if a ball were
rolling about the abdomen. The caliber of the bowels is
often very much diminished ; and these organs are either
habitually torpid, or very much relaxed.

Acute peritonitis generally ends favorably or fatally in from
five to ten days from its invasion. Occasionally it is disposed
to run into gangrene. This termination, which is more liable
to occur here than in any other serous texture, is anatomi-
cally characterized by the black, grayish color of the affected
part, by its soft, pulpy consistence, by its disagreeable, fetid
odor, and by the facility with which it can be scraped off
from the subjacent structures. If there be any adventitious
membrane, it usually participates in the disorganizing pro-
cess, assuming the same appearances as the natural texture.

In chronic peritonitis, the affected part is of a darker color,
the vessels are more dilated, and the subjacent cellular tissue
is more dense and thick. The serous texture itself is some-
times hypertrophied, not uniformly, but in patches ; but this
effect is by no means so well marked as is asserted by pathol-
ogists, and, in fact, is often entirely absent. Brownish, grayish,
bluish, or dark slate-colored spots, are frequently observable in
this affection, and might be mistaken by the young anatomist

300 PERITONAEUM. [cHAP. VIII.

for gangrenous eschars ; from which, however, they can be
easily distinguished by their firmness, want of odor, and
great extent. — the whole peritoneum being occasionally
marked with them. But we must not always expect to find
this membrane discolored ; for, in protracted cases, it is more
common to witness the opposite state, the affected parts being
unusually white and milky.

The false membranes are often very thick, forming large
masses of fibro-cellular substance, by which the abdominal
viscera are agglutinated into one general mass. When these
structures ulcerate, their ordinary color is a dirty green ; but
they may also present various shades of yellow, gray, and
brown, especially when, as sometimes happens, they are much
impregnated with blood. Occasionally these membranes do
not become organized, but have a friable, rotten aspect.
Masses of this description have been found from two to three
inches thick, overspreading the whole peritonasum like a
poultice of mashed carrots.*

The plastic lymph which is thus poured out not only
serves to agglutinate the abdominal viscera more or less
firmly to each other and to the enclosing parietes, but it
occasionally becomes the seat of fistulous tracks, having either
the arrangement of a blind sac, or communicating at each
extremity with the intestinal tube. In the only instance in
which I have observed this condition, and the only one, in-
deed, of which I have any knowledge, the canals were of an
irregularly cylindrical shape, from two to four lines in di-
ameter, and from two to nine inches in length. The course
of all, five in number, was remarkably tortuous. The prin-
cipal one extended in an oblique direction over the anterior
surface of the small bowel, from the sigmoid flexure of the
colon, towards the right side of the abdomen ; where, after
a distance of six inches, it terminated in two branches, each
three inches in length ; one of which opened into the upper
part of the jejunum, the other into the upper part of the
duodenum. The internal surface of these channels was some-
what rough and fleecy, as if lined by a mucous membrane :
their parietes were of a fibro -cartilaginous consistence, and
insensibly blended with the surrounding adventitious tex-
tures. At the time of making the examination, they all con-
tained a small quantity of fecal matter, of the same nature
as was found in the small and large intestines.

* Hojie, Principles of Morbid Anatomy, p. 224.

CHAP. VIII.] EFFUSION OF LYMPH. 301

The manner in which these new channels are found may
be explained in one of two ways. In the first place, we may
suppose that they are generated under the immediate influ-
ence of ulceration and perforation of the bowel. Under ordi-
nary circumstances, the consequence of such an event would
be an extravasation of fecal matter into the peritonseal sac,
rapidly followed by fatal inflammation. But, in a case like
that before us, no such occurrence, it is obvious, could possi-
bly take place, owing to the manner in which the intestinal
coils are tied together. Hence, when the bowel becomes
perforated, its contents, instead of escaping into the abdomi-
nal cavity, find their way into the connecting adventitious
substance, where they excite ulcerative absorption, and thus
gradually generate passages of communication between differ-
ent parts of the alimentary tube. What countenances this
view is the fact that, in the interesting case which fell under
my observation, there were numerous ulcers both in the small
and large bowel, and that the new channels all opened into
these reservoirs. The individual, a patient of Professor
Drake, was about twenty-eight years of age, during the four
last of which he had been harassed almost incessantly with
a griping diarrhoea, the relic apparently of a severe attack of
Asiatic cholera, complicated with acute peritonitis. Latterly,
whenever he took food, it would generally in a few minutes
pass by the bowels, in the state in which it was swallowed.
All the abdominal viscera were firmly and inseparably melted
together ; and the caliber of the whole intestinal tube was
contracted to nearly one half the original volume. In difier-
ent parts of its extent the new substance was studded with
hard, grayish, mihary tubercles, distinctly encysted, and many
of them as large as a common pea.

We may suppose, secondly, that these fistulous tracks are
formed under the influence of purulent matter, poured out
either simultaneously with the plastic lymph in which they
are situated, or subsequently to the establishment of adhe-
sions. The fluid which is thus accumulated, instead of
being absorbed, or extravasated into the peritonasal sac, works
its way into the neighboring intestinal coils, through which
it finds a ready outlet. In proportion as the contents of the
abscess are evacuated, fecal matter passes in and supplies
their place ; for the opening in the bowel, being prevented
from closing up, remains permanently patulous. According
to this theory, the ulceration of the intestinal tunic, it will

302 PERITONEUM. [chap. VIII.

be observed, is supposed to be consecutive to the formation
of the fistulous tracks.

Cases are occasionally observed in which these membranes,
both natural and adventitious, are of a fibro-cartilaginous
consistence ; and a very common occurrence is the develope-
ment of tubercles, either upon their surface, or in their sub-
stance. In their size these bodies vary between a mustard-
seed and a common pea ; and in several instances I have found
them so numerous as to cover nearly the whole peritonaeum,
thousands of them being visible in every direction, both on the
visceral and on parietal portions of the membrane. In a case
which I recently examined, the tubercles were seen in every
stage of developement, from the consistence of recent lymph
to that of fibro-cartilage. Many of them were confluent, like
the pustules of small-pox, and not a few appeared to have
vessels shooting into them from the surrounding parts, which
were highly vascular, as well as considerably thickened.

Although there is no part of the peritonaeum which is entire-
ly exempt from these heterologous bodies, yet they appear to
be much more liable to occur in some situations than in oth-
ers. In my own dissections, I have constantly found them
more abundant, larger, and more distinctly developed, in the
iliac and pelvic portions of the membrane than at any other
points. They are also frequently seen on the mesentery, the
omentum, and the serous coat of the spleen. In the early
stage of their formation, they are so soft as to be easily
wiped away ; but they gradually increase in density, and
finally assume, as was previously stated, a fibro-cartilaginous,
cartilaginous, or even bony hardness. In some instances they
have the consistence of putty, dry curds, or of semi-concrete
mortar. The older ones are generally distinctly encysted,
the enveloping membrane, which is very thin and delicate,
being evidently of new formation ; those, on the contrary,
which are more recent, are unprovided with such a covering,
and appear to consist merely of little masses of plastic lymph
in a state of incipient organization. No particular symptoms
are occasioned by the presence of these bodies ; and, in the
generality of cases, they occur in scrofulous subjects, in con-
nection with tubercles of the lungs, spleen, liver, or other
organs.

The effusion in chronic peritonitis is sometimes perfectly
clear and limpid ; but more commonly it is of a greenish
tint, white or milky, and blended with purulent matter, and

CHAP. VIII.] TUBERCLES ASCITES. 303

flakes of lymph. Occasionally we find it reddish, from the
exhalation of blood. The accumulation of watery fluid is
sometimes immense. Dr. Cordes, of Hirschberg, in Germany,
mentions a case, in which the patient, a female, forty years
old, was tapped in the short space of eighteen months, fifty-
nine times, and five hundred and sixty-nine quarts of water
drawn ofl".* A still more remarkable instance has been re-
cently detailed by Dr. Beall, of the State of Missouri. The
patient, a gentleman, whose age is not stated, was tapped
ninety-six times within a few years, and the whole amount
of fluid evacuated was two hundred and seventy-five gallons
and a half, the first fifteen operations yielding an average
quantity of twenty quarts ! f

The diagnosis of ascitic effusion is usually unattended with
much difficulty. The only state, indeed, with which it is
liable to be confounded is pregnancy. From this, however,
it may in general be easily distinguished, first, by the his-
tory of the case ; secondly, by the fluctuating nature of the
tumor ; thirdly, by the subsidence of the fluid to the more
dependent parts on varying the posture of the patient ;
fourthly, by the effects of hydrogogue medicines ; and, lastly,
by the absence of the ordinary symptoms of gestation. In
a few instances, I have been able, by applying the ear to
one side of the abdomen, and striking the other with the fore
and middle fingers, to recognize a peculiar plashing noise,
similar to what results from the agitation of a half empty
cask of water. Percussion produces a dull, flat sound, which
is always most distinctly marked in the hypogastric region,
as it is here that we usually find the greatest degree of ac-
cumulation. Higher up, the sound is commonly somewhat
sonorous or humoric, as it has been styled by M. Piorry, from
the presence of the intestines, which, on account of the
gaseous nature of their contents, generally follow the upper
level of the effused liquid.

There is a singular circumstance connected with the pres-
ent topic deserving of brief notice in this place. I allude to
the fact that the water in ascites occasionally exerts such a
degree of pressure upon the recto-vaginal portion of the
peritonaeal sac as to make the perinasum bulge out in the
form of a tumor. This singular lesion was first accurately
described, I believe, by the late Dr. Denman, of London, in

* Walther's and Grseffe's Journal der Chirurgie, &c. 11 ter. B.

+ Western Journal of the Medical and Physical Sciences, vol. x. p. 343.

304 PERITONEUM. [chap. VIII.

his excellent work on midwifery, though it had been inci-
dentally noticed by other writers. The swelling varies in
size between an orange and a fcetal head, and is generally of
an irregularly oval figure, like the urinary bladder : it dis-
tinctly fluctuates under the finger, and disappears temporarily
on pressure; When large it is usually more or less translu-
cent, and projects forward so as perfectly to occlude the mouth
of the vagina. The internal coat of the tumor is formed by
the peritonaeum, the external by the perinasum, which is
sometimes inverted.

Gas is also occasionally generated in this disease, and in
some instances it has been known to possess the odor of
sulphureted hydrogen. It generally occurs in connection
with sero-purulent effusions, and is most common in that
variety of peritonitis which is primitively chronic. Broussais
and Scoutetten also inform us that they have sometimes
seen minute, yellowish vesicles, filled with limpid serum, and
bearing a considerable resemblance to hydatids. None of these
appearances have ever been witnessed in my own dissections,
and I presume that they are very rare. The same may be
said of ulceration of this membrane, a lesion which has been
observed several times by Portal, Bonet, and Scoutetten.

In chronic peritonitis, when matter is formed in the ab-
dominal cavity, it sometimes works its way along the sper-
matic cord, and points externally. Dr. Gordon, of Edinburgh,
relates several cases in which it escaped at the umbilicus, and
another in which it found an outlet through the urethra. A
person thus circumstanced may live a considerable period,
with a fistulous opening, or fatal inflammation may arise from
the ingress of air.

This disease occasionally exists as an intra-uterine disorder.
Of this several interesting examples are detailed by Morgagni
and Billard. The children were pale and much emaciated,
and thick, old membranes were found in the abdomen, agglu-
tinating the viscera so firmly together that it was difficult to
separate them. Even tubercles, such as we have briefly
described them, have been detected in several instances in
children that have died within a few hours after birth.

Chronic peritonitis often lasts for a considerable length of
time, and is occasionally extremely obscure and insidious in
its nature. These characters are well shown in a case men-
tioned by Dr. Abercrombie. A young lady, aged sixteen,
had been observed for several weeks to lose flesh and
strength, with listlessness and impaired appetite. She be-

CHAP. VIII.] MELANOSIS. 305

came easily fatigued by exercise, had a hectic look, a foul
tongue, and a pulse of one hundred and twenty in a minute :
the abdomen was tumid and somewhat tender on pressure,
but otherwise she did not seem to suffer any inconvenience.

These symptoms continued from the fifth until about the
fifteenth of April, when she seemed to improve somewhat in
spirits, strength, and appetite; but the pulse remained fre-
quent, being generally from one hundred to one hundred and
twenty, and the abdomen retained a considerable degree of
tympanitic fulness. The bowels were regular in their action,
and, excepting some griping pain, there was no particular
uneasiness. In May she became worse, the emaciation and
debility gradually augmenting, but still there was no local
pain. At the end of the month she had some vomiting and
occasional diarrhoea, the former of which became more and
more frequent, until at length she was unable to retain any
thing on the stomach. She expired early in June, having
been confined to bed only a fev/ days.

On inspection, the contents of the abdomen presented one
solid mass of adhesion, in which it was impossible to distin-
guish one intestine from another. The mass likewise ad-
hered extensively to the walls of the abdomen ; and in various
parts of it were small cavities, containing purulent matter, and
exhibiting on their surface unhealthy scrofulous ulcerations.
The liver was considerably enlarged, as were also the mes-
enteric glands, and much pus was found in the pelvis.

Melanosis is sometimes found after chronic peritonitis, the
form in which it is poured out being liable to considerable
variety. Occasionally it occurs as an infiltration in the con-
necting cellular tissue; but more commonly it is deposited
upon the free surface of the serous membrane, and observes a
punctiform, stratiform, or nodulated arrangement. The parts
of the peritonasum most prone to this lesion are, the great
omentum and the epiploic appendages of the colon, from
the predilection, probably, which this substance has for the
adipons tissue. In the nodulated variety, the tumors, whether
isolated or agglomerated, generally adhere by small foot-
stalks, and are enveloped by cysts of fine cellular tissue, often
furnished with delicate vessels. When in layers, this sub-
stance is covered over by a thin film of membrane, and is
apt to be confounded with common hemorrhagic efiusions,
altered in their color by the chemical action of certain acids
and gases, developed either in the intestinal tube, or in the
peritonseal cavity.

VOL. II. 39

306 PERITONEUM. [chap. VIJI.

Scirrhous, steatomatons, and encephalo'id tumors sometimes
grow from the peritonasum, so large as to encroach very ma-
terially upon the abdominal viscera. Of the two first varie-
ties of disease I have never seen an example ; hut, of the
latter, an interesting specimen was transmitted to me, about
eighteen months ago, by Dr. George E. Conant, of Hunting-
ton, in the State of Ohio. It was taken from the body of a
little girl, five years of age, and weighed eleven pounds nine
ounces. It occupied the whole abdominal cavity, extending
from the ensiform cartilage low down into the pelvis, conceal-
ing the small bowels, and adhering to the great omentum —
from which it seemed to originate — the uterus, the urinary
bladder, and the parietal portion of the peritonseum. The
tumor is of a whitish yellow color, lobulated, soft and doughy,
with numerous vessels, of a large caliber, ramifying over its
outer surface. Internally, it has a distinctly fibrous arrange-
ment, and contains numerous little cells, some of which are
filled with pus, some with a thin, turbid sanies, some with
blood. This immense encephaloid mass- could be easily felt
through the abdomen during the life-time of the little patient ;
and its presence occasioned, especially towards the last, the
most frightful dyspncsa, together with great emaciation, and
gradual exhaustion of the powers of the system.

The most ordinary form in which the encephaloid matter
occurs is that of small tumors, from the size of a bean to
that of an egg. Their shape is either spherical or pear-like,
and their number is often quite great, from twenty to a hun-
dred being found in the same individual. They are generally
of a dull white color, mottled with dark modena spots, are
surrounded by a very delicate yet distinct membrane, and are
penetrated at different parts of their circumference by minute
florid vessels, which thus supply them with blood. The
contents of these tumors are subject to considerable variety ;
for, whilst some are composed almost wholly of cerebriform
matter, others are made up of a soft grumous substance, or of
a fluid closely resembling thin jelly or half-boiled arrow-root.
On some occasions they are exceedingly vascular, and pre-
sent an appearance very much like that of the spleen. These
heterologous growths are frequently observed on the visceral
portion of the peritonaeum, and they generally coexist with
similar formations in other parts of the body.

CHAPTER IX.
Of the Biliary Apparatus.

SECTION I.
Of the Liver.

I. The Liver. — Situation, Color, Dimensions, and minute Structure of the Liver.

— Has two Envelopes. — Lesions. — Inflammation. — Suppuration and Abscess.

— Gangrene. — Softening. — Induration. — Hypertrophy and Atrophy. — Tu-
bercles. — Carcinoma. — Melanosis. — Hydatids. — Adipous Transformation.

— The Liver Flake, and other Worms. — Cartilaginous Degeneration.— Os-
seous Concretions. — Sanguineous Effusions. — Restorative Powers of the Liver.
II. The Gall- Bladder. — Inflammation. — Ulceration and Rupture. — Atrophy
andT hickening of its Coats. — Diseases of the biliary Ducts. — Alterations of
the Bile.— Gall-Stones.

The liver, situated, as every body knows, in the right
hypochondriac region, also in part in the epigastric and
left hypochondriac, is a large glandular organ, from ten to
twelve inches in breadth, from six to seven in length, and
from two and three quarters to three and a half in thickness.
In loeight, it varies from two pounds and three quarters to
three pounds and a half; consequently, it may be said to
constitute about the thirty-fifth part of the entire weight of
the human frame. Its volume, however, it should be observed,
is much influenced by the state of its own circulation, — a
circumstance which might be anticipated from the immense
quantity of blood which is continually poured into it by the
hepatic artery and portal vein. Of the extent of this influ-
ence, a good i(3[ea may be formed by removing the liver from
the abdomen and washing out its fluids, when its bulk will
be found to be considerably diminished, as is shown by its
collapsed and wrinkled aspect. Nor is this all. Whatever has
a tendency to retard, interrupt, or prevent the return of the
blood from the hepatic veins to the right side of the heart,
must induce congestion, with all its necessary evils, in the
organ under consideration. Hence it is found that disease of

308 LIVEB. [chap. IX.

the liver is often directly dependent upon lesion of the heart
or large veins.

That the color of the liver, the next subject to be noticed,
should be modified, and, if I may so express myself, con-
trolled by the amount of blood which it receives, no one can
for a moment doubt. Accordingly, we find, that, in the foetus,
in which the liver is always remarkably vascular, the color
is much more florid than some time after birth, or in the sub-
sequent periods of life. In the adult, it is generally of a red-
dish-brown, with spots of blue, particularly along the anterior
margin and under surface. In persons who are hung, the
liver is usually of a deep pink color, — sometimes quite purple.
Such, in a few words, is the healthy complexion of this im-
portant organ. How it is altered by disease will appear in
the sequel.

In simple congestion, the hepatic tissue is generally of a
florid red ; the arteries and veins are preternaturally distend-
ed, and blood flows freely on making sections of it. By a
careless observer, this condition of the liver might be con-
founded with inflammation, but may be readily distinguished
from it, by the greater uniformity of its color, by its per-
vading the entire organ, and by the facility with which the
blood may be squeezed from its vessels. Dr. Kiernan, of
London, has recently shown, that, when the congestion results
from the portal veins, the granules are the parts which are
most vascular ; whilst, when it is caused by the hepatic
veins, it is most distinct in the intervening cellular tissue.
When both systems are filled with blood, the redness will be
equally conspicuous in both textures. This is an important
circumstance, and should not be lost sight of in our investiga-
tions.

The parenchymatous structure of the liver is very fragile
and lacerable, yet so compact that it cannot be much com-
pressed. When torn, it assumes the appearance of small
polyhedral granules, each of which may be considered as a
perfect gland, as it is furnished with an appropriate excretory
duct, together with nerves, blood-vessels, and absorbents.
Their size equals that of a millet-seed, and their number is
incalculably great. Lodged each in a distinct capsule of cell-
ulo-fibrous substance, they are of a lighter color usually than
the surface of the liver ; and, when a section is made of them,
they appear to be porous, — though whether this be really the
case or not is a point upon which anatomists are still unde-

SECT. I.] STRUCTURE. 309

cided. Around them may be observed, in a collapsed state,
the branches of the portal vein, accompanied by those of the
hepatic artery, and those of the hepatic duct, the latter being
frequently distinguishable by the exuding bile.

An important question here arises, not only in a physiologi-
cal but also in a pathological point of view, namely, — are
there two distinct sets of granules in the liver ? Ferrein,
Meckel, Andral, Hope, and other highly respectable anato-
mists, think that there are, and, in support of their opinion,
allege that, in certain diseases of the organ, they are distinctly
perceptible, one being yellow, the other red. Without enter-
ing into an elaborate discussion of the subject, which the
limits of this paper would render improper, I shall content
myself by observing, that, so far as my own researches go, I
see no reason for adopting the sentiments of these eminent au-
thorities. Nor am I singular in my want of orthodoxy upon
this point. Professor Cruveilhier, of Paris, who may be con-
sidered as decidedly the best anatomist, both descriptive and
morbid, of the present day, positively asserts, upon the evi-
dence of a series of the most carefully conducted observations,
that there is only one order of hepatic granules, lying in jux-
taposition, and having each a cellulo-fibrous envelope.* The
same sort of testimony is borne by Dr. Kiernan, in his admi-
rable monograph on the structure and functions of this organ,
published in 1833. He states that he has satisfied himself
by repeated injections, by examinations with the microscope,
and by experiments on living animals, that the two species
of granulations described by Andral and others are perfectly
identical, both in their texture and office ; and he attempts to
account for the error into which they have fallen, by refer-
ring the difference of appearance to a difference of congestion,
the color of these bodies being red when the portal capillaries
are engorged, but light yellow when there is distention of
the minute branches of the hepatic veins.

In the liver ©f the hog, in which these granules are unusu-
ally distinct, and of a polyhedral form, I have repeatedly
looked for these two orders of acini, but never, in a single
specimen, have I been able to make them out. For this rea-
son, therefore, as well as from the testimony of the French
and English anatomists whose names have been quoted, I am
warranted in the conclusion that they do not exist.

Anatomic Descriptive, t. ii. p. 567

310 LIVER. [chap. IX,

In the infant, the acini are much less distinct than in the
adult. When a section is made, the parenchymatous sub-
stance seems to be much more homogeneous ; and, if torn, it
does not exhibit such a well-marked granular aspect. Its
consistence, also, is more tenacious, and the organ is much
less liable to rupture from accident.

The liver is enveloped by two tunics, which, although they
are intimately connected, differ from each other widely in
their structure, and in the purposes which they are destined
to fulfil in the animal economy. Of .ttiese, the external, af-
ter covering the greater part of the surface of the organ, forms
a number of folds, improperly called ligaments, which unite
it to the diaphragm and wall of the abdomen. Derived from
the peritonasum, it is perfectly transparent, smooth, and lubri-
cated, for allowing the liver to move, without detriment,
upon the surrounding parts. No vessels can be discerned in
it in the healthy state ; and, when diseased, it often adheres
to the neighboring structures by bands of adventitious cellu-
lar tissue.

The other membrane, usually named the prope?- coat, is
much the more important of the two, inasmuch as it may be
considered as constituting the frame-work of the entire organ.
Not only does it enclose and sustain the liver, but sends thou-
sands of processes into its interior, which, intersecting each
other in every conceivable direction, form so many minute
capsules for the hepatic granules. Thus, each of these little
bodies may be viewed in the light of a representative of the
entire gland, as it is not only furnished, as already stated,
with appropriate vessels and nerves, but likewise with its
own proper covering.

In structure, this tunic assimilates itself to the fibrous mem-
branes. It is by no means so close and thick as the pericar-
dium, with which, however, it has many important charac-
ters in common. Thus, for example, it is composed of fibres
which interlace in different directions, and is in contact on one
side with a serous membrane, which, in both cases, answers
a similar purpose, — that, namely, of facilitating the move-
ments of the respective organs. Nor does the analogy cease
here. In inflammation of the fibrous coat of the liver, the
disease is generally propagated to the parenchymatous struc-
ture, in virtue of the processes which the membrane sends
into the interior of the organ, and also of its close connection
with its outer surface, in the same manner as an inflamma-

SECT. I.] SITUATION, 311

tion of the pericardium may be propagated to the muscular
substance of the heart along its serous investment.

Mnch difficulty is experienced, and much dexterity re-
quired, in dissecting this membrane from the part with which
it lies in contact. On the concave surface of the liver, it is
almost impossible to display it ; but, anteriorly, and especially
towards the upper margin, it is very easy to raise it in the
form of a strong, thick, dense, and consistent coat, inelastic,
and of a light grayish color. In a preparation in the museum
of the Cincinnati College, the membrane in question is nearly
the twelfth of an inch in thickness. Superiorly it runs into
the cellular tissue which is so abundantly found at the upper
border of the liver, and which serves the important purpose
of connecting the organ with the diaphragm. The mode of
this connection should never be lost sight of in our pathologi-
cal investigations. By bearing it in mind, we shall be enabled
to account for the manner in which disease may be propagated
from one of these structures to the other, and how the matter
of an abscess, that is originally formed in the liver, may find
its way into the lungs, and be finally expelled by coughing.

The discovery of this important tunic has been claimed by
some of the German anatomists for Professor Soemmering ;
by the French, for the celebrated Laennec ; but the truth is,
it was described more than a hundred years ago by Dr. Grieve,
an English physician.*

Nor can all the good be done by paying attention simply
to the healthy and morbid appearances of the liver. To the
practising physician, with a view of determining the diag-
nosis of some of the structural lesions of the organ, a knowl-
edge of its situation, in respect to the neighboring parts, is
of tantamount importance. Such information will be in the
highest degree useful, also, as enabling him to comprehend
how an enlarged liver may compress the stomach and interrupt
its functions ; how it may produce jaundice, by impeding the
flow of bile ; dropsy of the abdomen, by obstructing the re-
turn of the blood to the heart ; how abscesses, originally
formed in the hepatic tissue, may burst into the surrounding
organs.

The position of the liver is sometimes singularly altered,
even although it may not have undergone any change in bulk.
Thus, in hydro-thorax, it may be prominently felt, not only

* De Secretione Bills, Edinburgh, 1731.

312 LIVER. [chap. IX.

in the epigastric, where a part of it is naturally situated, but
also in the umbilical, and left hypochondriac regions. On the
other hand, in copious ascitic effusions it may be forced so
high up into the chest as to encroach seriously upon the
right lung, producing atrophy in that viscus, and terrible
dyspnoea. Sometimes, again, the liver is pushed over into the
left hypochondriac region, by an encysted tumor, or by en-
largement of the right kidney. Now all these facts should
be borne in mind by the physician, as they have an important
relation to the diagnosis of abdominal diseases.

The lesions, which will be treated of in the present chapter,
are, inflammation, suppuration, gangrene, softening, indura-
tion, hypertrophy and atrophy, tubercles, cancer, melanosis,
hydatids, adipous degeneration, worms, cartilaginous and
osseous concretions, apoplexy, and laceration.

hifiammation of the liver may involve either its proper
substance or its investing membranes, and, like the same dis-
ease in other organs of the body, it may be either acute or
chronic. The acute form of the complaint is of rare occur-
rence in this country, but is sufficiently common in hot
climates. In warm latitudes, there is always, as is well
known, a high degree of nervous excitability of the chylo-
poietic viscera, and hence nothing is more usual than to see
a large proportion of the maladies of those regions charac-
terized by a predominance of inflammation of the stomach,
liver, bowels, or spleen. In our Southern States, almost all
diseases assume a bilious type ; but whether the liver labors
under much inflammatory irritation, or is merely sympathet-
ically affected, are points which still remain undetermined.
The term congestive, which is so much in vogue with the
physicians of those regions, seems to me to be often used
unmeaningly, certainly without a proper regard to the funda-
mental principles of pathology. It is with them a sort of
talisman, — a mantle which covers a multitude of sins in the
way of unsuccessful practice. That the internal organs, and
especially the liver and spleen, are often inundated with
blood in the intermittent and bilious fevers of those districts,
may be readily supposed ; but that this condition can last
long without inflammation, is what very few will be willing
to concede.

Inflammation of the liver appears occasionally to assume
an epidemic type, affecting a considerable number of persons
at the same time. An instance of this tendency occurred in

SECT. I.] INFLAMMATION. 313

1828, in the city of Dublin, where, as we are informed by
Professor Stokes, prior to this period, acute hepatitis was
looked upon as a very rare disease, — a case- being seldom met
with more than once in a year or tAVo, in their largest hospi-
tals. At the date here specified, however, every institution
of the kind in the Irish metropolis had a considerable number
of individuals afflicted with it, and of these not a few died.

The anatomical characters of acute hepatitis vary, as might
be expected, according to the intensity of the irritative ac-
tion, and the length of time it has been in operation. In
genera], the first perceptible effect is an increase of the vas-
cularity of the parenchymatous structure, which becomes
engorged in circumscribed spots, of a light red color. The
part affected is somewhat tumid, abnormally dense, and
bleeds freely on being incised : the hepatic canals are dis-
tended with a viscid, yellow, brownish fluid ; and the acini
are increased in size, and of a florid tint, though sometimes
the reverse is the case, these bodies being much less distinct
than natural.

In a more advanced stage, in addition to the vascularity,
the hepatic structure becomes singularly softened, so that it
may be reduced, by the slightest pressure of the finger, to a
mere pultaceous mass. This state is analogous to the second
stage of acute pneumonitis, and, like it, may be accompanied
by the formation of pus, or a deposition of lymph upon the
serous surface. In this respect, however, there is a wide
difi'erence between the liver and the lung, as we seldom meet
with inflammation of the substance of the latter without
pleuritis, while the reverse often obtains in acute hepatitis.

In its transition from the first to the second stage, the in-
flammation gives rise often to various shades of color. Thus,
the parenchyma may be of a deep red, disposed in arborescent
lines ; or the vessels may encircle the acini in the form of
wreaths, which freely anastomose with each other. When
the disease is very intense, it is not unusual to see a number
of small ecchymoses, produced by a rupture of some of the
capillary arteries or veins ; and instances frequently occur in
which the afi"ected part assumes a deep brownish, violet, or
mottled aspect, the latter appearance being particularly liable
to happen when the inflammation occurs in circumscribed
spots. In such cases, the whole portal circle is gorged with
black blood, the biliary ducts are deeply injected, and their
contents, being of a sero-sanguinolent nature, have no longer

VOL. II. 40

314 LIVER. [chap. IX.

that bitter taste and ropy feel which characterize healthy
bile. The mucous coat of the duodenum, also, is more or less
phlogosed, and the minute branches of the hepatic artery and
portal vein no longer admit injecting matter.

It is not often that the whole of the liver is involved in
acute inflammation : most commonly it is limited to its sur-
faces, to its borders, or some of its deep-seated parts. In the
latter case, the disease sometimes escapes the attention of
the examiner, owing to the normal aspect of the exterior of
the organ. Hence the necessity, in all our investigations,
after having tied the large vessels, of removing the liver from
the abdomen, and cutting it into thin slices. In some cases,
especially such as follow surgical operations, the hepatic and
portal veins are inflamed ; and cases occasionally occur in
which these tubes are filled with purulent matter.

When the inflammation is seated in the investing mem-
branes, they exhibit the same appearances pretty much as the
fibro-serous textures generally. Numerous vessels pervade
them, passing up from the parenchymatous texture, and they
are thicker and more opaque than in the healthy state. Lymph
is also commonly deposited upon their outer surface, either in
narrow bands, in small patches, or in considerable masses.
The organ being thus glued to the neighboring parts, is often
compressed, and much restrained in its movements. In some
instances it is literally buried in lymph, and so strong are its
adhesions, that much dissection is required before it can be
removed from its situation. The disease, however, is seldom
thus extensive : in the generality of cases, it is limited ; and,
if I may judge from my own observations, it has a peculiar
predilection for the anterior segment of the membranes.

Does disease of the substance of the liver ever exist with-
out involving its coverings, and, conversely, of its coverings
without involving its substance ? Upon this point, different
opinions have been expressed by different writers ; some
answering affirmatively, others negatively. M. Bonnet, a recent
French writer, evidently a disciple of the Broussais school,
maintains that inflammation of the hepatic parenchyma is
almost always accompanied with inflammation of its perito-
nseal investment. The arguments, however, upon which he
endeavors to sustain his proposition have but a very slender
foundation ; and, as they are directly at variance with the
testimony of some of the best authorities of the present day,
no further notice need be taken of them here. The dissec-

SECT. I.] INFLAMMATION SYMPTOMS, 315

tions of Annesley, of Ahdral, and of Louis, are sufficient to
negative a thousand speculative notions ; and, if any reliance
is to be placed upon them, it must be clear enough to every
candid mind, that the very reverse of the position as-
sumed by M. Bonnet is the true one. Not only do these
pathologists assert that hepatic peritonitis is of extreme rarity,
but they declare, upon the evidence of repeated personal ob-
servations, that the substance of the organ may be greatly
altered, nay, even seriously disorganized, and yet its tunics
be perfectly sound. " Even abscesses of the liver," says Mr.
Annesley, " may proceed to the utmost extent, and ultimately
break into the abdominal cavity, without having induced
inflammation of the serous surface, where they point, and
consequently without forming adhesions to the parts with
which they are in immediate and close contact."

Not much need be said here of the symptoms of acute
hepatitis, as all the information that the student may desire
upon this point can be obtained in the common treatises on
the practice of medicine. The local phenomena, to which
my remarks will be limited, may be referred principally to
the pain, tenderness, and swelling in the region of the
affected organ. When the disease is seated in the parenchy-
matous structure, the pain is of a dull, heavy, aching char-
acter; if in the investing membranes, it is sharp, lancinating,
and often extremely severe. In either case, but especially in
the latter, it is constantly increased by pressure, by inspiration,
and by coughing. In some instances, the pain is felt in the
right shoulder, along the spinal column, under the short ribs,
in the loins, or in the epigastric region ; but, as these symp-
toms may arise from other affections, as, for example, inflam-
mation of the top of the right lung, incipient phthisis, pleu-
ritis, aneurism of the right subclavian, gastritis, colonitis, or
disorder of the kidney, they are perfectly worthless as diag-
nostics. The patient lies commonly on the affected side,
seldom on the back or on the left side ; in which respect,
there is a striking difference between this disease and acute
pleuritis, in which the person always lies on the sound side.

The tumefaction of the liver, which, next to the pain and
tenderness, may be regarded as the most important symptom,
is seldom considerable. When it is, the right hypochondriac
region appears unnaturally full, and the margin of the organ
can be felt beneath the edges of the false ribs. In some
instances, the costal cartilages seem to be tilted out ; but, in

316 LIVER. [chap. IX.

such cases, the intercostal spaces retain, ahnost invariably,
their depressed appearance, — affording thus a striking contrast
between hepatic and pulmonic disease, in the latter of which,
when the cavity is distended, the intercostal spaces are either
flat, or pushed beyond the level of the ribs.

Such, then, are the three signs upon which our principal
reliance is to be placed, when endeavoring to make up our
diagnosis of acute hepatitis, pain, tenderness on pressure, and
swelling. Add to these, the position which the patient as-
sumes in bed, the derangement of the digestive organs, and
the inflammatory state of the system, and little or no difficulty
can occur in coming to a correct decision.

Acute inflammation sometimes terminates by resolution,
but much oftener by the formation of matter, gangrene, or
softening of the hepatic texture. Not unfrequently it passes
into the chronic form, when it is liable to give rise to indura-
tion and other structural lesions. There is reason to believe
that chronic hepatitis sometimes exists as a primitive aff"ec-
tion, its invasion being very gradual, and unaccompanied by
any severe symptoms. It is a much more frequent complaint,
in this country, than the acute form ; yet it is not quite so
common, perhaps, as the term " liver disease," so generally
used by the profession, v/ould lead us to suppose. The ana-
tomical characters of the disease, together with its diagnostic
symptoms, so far as they are understood, may be collected
from what we shall say concerning induration, hypertrophy,
atrophy, and fatty degeneration of this organ.

Although suppuration of the liver occasionally follows
chronic inflammation, yet this effect is much more frequently
witnessed as the result of the acute variety of the disease.
The pus may be diffused, occur in small points, or be col-
lected into one or more abscesses. The number of these
purulent deposits is often quite great, the liver being literally
burrowed by them ; sometimes they communicate together
by narrow fistulous passages, but in most cases they are sepa-
rated by considerable intervals, or by thin partitions of hepatic
substance. Occasionally the abscess is of extraordinary size,
occupying nearly the whole of one lobe, or the greater part
of the organ. In this way quarts of matter are sometimes
accumulated, and the hepatic textures almost entirely wasted.
When the quantity of fluid is great, or if it be long detained,
even when small, it is apt to become encysted, the membrane
by which it is enclosed, and which is susceptible of organi-

SECT. I.] SUPPURATION. 317

zation, varying in thickness from the fourth of a hne to half
an inch, and in consistence from the softness of lymph to the
firmness of fibro-cartilage. Jn other cases, especially in snch
as run a very rapid course, the matter lies in immediate con-
tact with the hepatic tissue, which is itself usually in a state
of purulent infiltration, or very much softened and altered in
color.

The matter of a hepatic abscess usually partakes a good
deal of the nature of true pus, being of a thick, white, cream-
like appearance. Sometimes it is thin and sanious, some-
times thick and curdy, sometimes thin and brownish, like
chocolate, and sometimes of the color and consistence of a
decoction of unburnt coffee. In the generality of cases, it is
destitute of smell ; but occasionally it is highly oflensive and
irritating. Now and then the fluid contains flakes of blood
of a dark gray color ; and instances occur in which it looks
like the washings of flesh.

Suppuration of .the liver does not always prove fatal. In
many instances the matter has a tendency to discharge exter-
nally, or to force its way into some one of the adjacent organs.
The principal circumstances which appear to influence the
point of communication are the seat of the abscess and the
general volume of the hepatic tumor. In the abdomen, the
opening usually takes place in the peritonseal sac, the colon,
duodenum, the stomach or gall-bladder : when the abscess
points externally, the matter may find its way out at the
epigastric region, the right loin, or between the false ribs;
and in either case it generally pursues a narrow, fistulous
route. It is not improbable that the pus, formed in the sub-
stance of the liver, may sometimes pass into the bowels
through the biliary ducts ; and authors mention instances in
which it found an outlet through the right kidney. When
the abscess is seated at the upper border or on the convex
surface of the liver, it not unfrequently breaks into the right
side of the ch.est, where it either excites fatal inflammation,
or erodes the pulmonary tissue, and is finally discharged
through the bronchial tubes between the ribs, or even through
the axilla. But the most extraordinary circumstance con-
nected with this subject is, that the fluid sometimes works its
way into the pericardium. Of this an interesting case has
been reported by Dr. Smith. The liver adhered closely to
the upper part of the diaphragm, and was occupied by an
enormous quantity of pus, about a quart of which had escaped

318 LIVER. [chap. IX.

into the pericardium. When the matter is discharged, the
abscess sometimes heals, the process being analogous to that
which is observed under like circumstances in the lungs and
other organs.

Hepatic abscesses, on the whole, I have reason to believe,
are very rare in this country, having never, in all my dissec-
tions, seen more than two cases. In Europe, they are also
extremely infrequent ; * but they are sufficiently common in
hot climates, and nowhere, perhaps, more so than in the East
Indies.

In acute hepatitis, pus usually begins to be deposited in
the course of six or eight days from the commencement of
the attack ; whereas, in chronic cases, months often elapse
before the occurrence of this event. When suppuration is
about to take place, there is a sudden aggravation of all the
symptoms ; the patient experiences frequent rigors, followed
by profuse sweats ; the pain in the side is of a throbbing,
lancinating nature ; and there is a peculiar sense of sinking,
with anxiety and precordial oppression ; the organ is com-
monly somewhat enlarged ; and although there is no distinct
fluctuation, especially if the matter be deep-seated, there is
almost always a boggy, yielding sensation imparted to the
finger when passed over the region of the tumor. This sen-
sation, as might be anticipated, will be more distinct in pro-
portion as the purulent fluid approaches the surface ,* and in
this case, too, the diagnosis will be much aided by percussion.
In the natural state, the hepatic tissue is so dense as to afford
a very dull sound when we strike the hypochondriac region ;
but in superficial abscesses, especially in such as do not con-
tain too thick and consistent a pus, there is usually a consid-
able degree of resonance, which serves to define the limits
between the healthy and diseased parts. After all, however,
the nature of the lesion is often extremely obscure, and it
may be truly said that there are few occasions for finer diag-
nosis than in the affection in question.

Abscesses of the liver are liable to be produced by irritation
of the lungs ; and in many instances they supervene upon
injuries of the head, large wounds, and surgical operations.
The matter in these cases is supposed by some to be trans-
mitted with the blood through the veins, from remote and
diseased parts ; but the more philosophical opinion, and that

* Andral's Pathological Anatomy, vol. ii. p. 373.

SECT. I.] GANGRENE. 319

which meets my own decided approbation, ascribes its origin
to inflammatory irritation of the substance of the liver,
brought on by some inscrutable sympathetic action. That
matter may be thus conveyed, no one will deny ; but that it
should create irritation in one organ in preference to another,
is a point in pathology which cannot be very easily compre-
hended. If it has any truth at all, it forms merely an excep-
tion to the general rule. To admit that abscesses may be
thus produced in any organ, is to admit that such an organ
has an elective attraction for the purulent fluid that shall be
flowing in the circulating mass ; or, on the other hand, that
its tissues are so close and peculiar, its capillaries so exceed-
ingly fine, as to entangle the matter, and retain it, vi et armis,
as it were, in its interior. To me the hypothesis appears not
only objectionable, but too absurd almost for serious consider-
ation.

The termination of acute hepatitis by gangrene is so rare,
that many writers have denied the possibility of its occur-
rence. Baillie never witnessed an instance of it,* and An-
nesley, although for many years an inter-tropical practitioner,
and constantly in the habit of making examinations, declares
that he has not been more successful. f In several thousand
dissections made by Andral.J this lesion occurred only in a
single case. From all these facts, then, it maybe justly con-
cluded that gangrene of the liver is of great rarity. Portal
describes the mortified part as being extremely offensive, of a
dark color, pervaded with sanious fluid, very soft and lacera-
ble. In a case recently detailed by Dr. Stokes, of Dublin,
the organ bore numerous marks of chronic disease, and in
the left lobe was a cavity which was distinctly gangrenous,
having in its centre a large mass of slough. The patient, an
old drunkard, complained, during the last few days of his life,
of great pain and tenderness of the abdomen ; and, a short
time before he expired, he was seized with vomiting, and
threw up a large quantity of fetid matter.

Softening of the liver is said to be a very common and
destructive affection in warm latitudes ; but it is very rare, I
presume, in the more temperate regions of America and
Europe. That this is the case I am disposed to believe from
my own experience, and from the few cases that are reported

* Morbid Anatomy, p. 136.

t Diseases of India, vol. i. p. 435.^

* Pathological Anatomy, vol. ii.

320 LIVER. [chap. IX.

of this disease in our periodicals. Softening of the Hver
presents itself under two distinct forms, differing from each
other both in their color and consistence, but resulting proba-
bly from the same cause, namely, inflammatory irritation. In
the more common variety, which I shall denominate brownish
softenings the substance of the organ usually retains its nor-
mal color, but is broken down and friable, oY has so fa:r lost
its cohesive properties that it readily yields to the force of
the finger. In some instances, the affected part is infiltrated
with thin, bloody, sanious, or puriform matter, and is con-
verted into a soft, brittle mass, not unlike a rotten pear.
When put in water, an immense number of small granules
appear, resembling the seeds of a bunch of dried grapes :
they are of a yellowish, brownish, or cinnamon color, and are
attached to the large vessels by delicate vascular pedicles.
In other cases, maceration produces an appearance like the
washings of half-putrid flesh, the water becoming discolored,
and the part exhibiting multitudes of shreds, the remains,
probably, of vessels and fibrous filaments. This variety of
mollescence is generally most remarkable on the convex sur-
face of the liver, and occurs almost always in combination
with diseases of the other viscera, especially of the stomach,
spleen, and lungs. According to Mr. Annesley, it is frequently
met with in India, in persons who are rapidly carried off by
cholera, dysentery, and malignant fevers.

The second species of softening has received the name of
blacky and, from its close resemblance to gangrene, is proba-
bly the result of a higher grade of inflammatory action, dis-
organizing the parenchymatous texture of the liver. It com-
monly invades a large extent of surface, sometimes, indeed,
almost the whole organ, which it reduces to a dark pultaceous
mass, having the consistence and aspect of grumous blood,
or of a black, softened spleen. In some instances, the affected
part emits a remarkably fetid odor, — a circumstance which,
together with its color, has given rise to the belief that the
disease is analogous to if not identical with gangrene. The
size of the liver is commonly altered : in most of the cases
of which we have any account, it was reduced to one half or
less of its normal volume : it is occasionally, I presume, en-
larged ; but this does not occur often.

Very often there are no symptoms which denote the exist-
ence of this fatal lesion during life. In a case recently com-
municated by Dr. C. A. Lee, of New York, in which the

SECT, I.] ., INDUKATION. 331

liver was completely disorganized, and converted into a black
mass, like grumous blood, the patient, a colored man, of in-
temperate habits, forty years old, suffered no other incon-
venience than diarrhoea and slight debility : he was not con-
fined to his house, and suddenly expired while walking the
street * ' In another case, mentioned by Dr. Abercrombie,!
the symptoms were jaundice, want of appetite, and nausea,
followed, towards the last, by vomiting of black matter : there
was no pain, no tenderness, no fulness in the region of the
liver. From these and various other facts of a like character,
it may be inferred that the disease, commencing in the pa-
renchymatous structure of the organ, progresses in a stealthy
and insidious manner in its work of disorganization, without
always particularly impairing the general health.

Neither Morgagni, nor Haller, nor Baillie seem to have ever
met with this disease ; and, although numerous examples
have been narrated by more recent writers, a good description
of its anatomical characters is still a desideratum. The causes
of this singular lesion are not well understood ; but that it
depends upon inflammation, either acute or chronic, is an
opinion which seems to be borne out by an attentive exami-
nation of the various cases of it which are to be found upon
record.

There is a state of the liver, not at all unusual, the very
reverse of that which has been now described. I need
scarcely say that I refer to induratioti. In this disease, the
substance of the organ is unnaturally hard, firm, and dense,
exhibiting, when torn, a singularly granulated surface. The
volume of the gland is sometimes unaltered, but in most
cases it is much reduced, occasionally nearly one half. The
color varies in different instances, being either a pale red,
purple, nutmeg, brown, or lilac. Cruveilhier informs us that
he has often seen induration of the liver accompanied with a
green olive hue ; but of this I have never witnessed an in-
stance, nor am I aware that the same observation has been
made by other pathologists. This change, which T am
inclined to believe commonly results from chronic inflamma-
tion, is often characterized by great thickening of the fibrous
structure, and by a remarkable atrophy of the hepatic gran-
ules. In some cases, indeed, the granules seem to be entirely

* American Journal of the Medical Sciences, vol. xvii. p. 60.
t Pathological and Practical Researches, p. 357.

VOL. II. 41

323 LIVER. [chap. IX.

removed, their place being occupied by a cellular tissue, very
hard, and of a dull grayish color. The tunics of the liver
usually participate in the condensation ; the cellular substance
accompanying the ramifications of the hepatic artery and
portal vein is frequently indurated ; and many of the excre-
tory ducts are permanently obliterated, whilst others are
thickened, and of almost gristly consistence.

The induration is not always partial : I have frequently
seen it pervade the entire organ, though in the majority of
cases it occurs in patches, or is limited to particular parts.
The right lobe and lobule of Spigelius are perhaps more
generally implicated than any other portions. The disease
is often attended with pain in the hypochondriac region ; the
countenance is wan and sallow ; the conjunctiva is more or
less yellow ; and the patient is liable to be affected with
ascites. The secretion of bile is frequently very sparingly
performed, and the properties of this fluid are singularly
altered. These symptoms, however, are far from being con-
stant ; nor can they be considered, when present, as diagnos-
tic of hepatic induration.

Hypertrophy of the liver is a frequent affection. This
state is said occasionally to exist simply, but the assertion, I
think, may well be doubted. In by far the greater number
of cases, if indeed not always, it is combined with one or
other of the states which we have just described, — induration
and softening. The color, size, and form of the liver in this
affection vary infinitely, according to the period of its exist-
ence and the nature of the primary lesion. The most com-
mon tints are pale red, gray, brownish, dark green, mahoga-
ny, and nutmeg. Frequently these colors are more or less
blended, so as to impart a variegated appearance to the paren-
chymatous structure.

The bulk of the organ is sometimes enormous. Cases
have been recorded in which the human liver weighed from
twenty to thirty pounds ; and in animals, as the horse and
ox, the weight not unfrequently exceeds one hundred pounds.
In a case mentioned by Dr. Ruyer, in the Encyclographie
des Sciences Medicales for 1835, the organ weighed twenty-
four pounds.* It was taken from a woman thirty-three years

* " Mr. Gooch gives a case in whicb, during dropsy, the liver acquired the
monstrous weight of twenty-eight pounds. Baldinger reports another instance,
in which it reached twenty pounds ; and Bonetus a third, in which it weighed
only two pounds less."

SECT. I.] ATROPHY. 323

of age, was of a brownish slate color, soft and friable, and
filled the whole abdominal cavity, forcing the diaphragm
high up into the thorax, and pressing the bowels and other
viscera firmly against the spinal column. In its substance
were contained numerous whitish tumors, varying in size
from that of a mustard-seed to that of a hen's egg, some of
which were occupied by purulent fluid.

The hypertrophy may be limited to a single lobe, or it
may occur in all of them at the same time ; most commonly,
however, it attacks the right side. The shape of the liver,
as has been already hinted, may be variously affected ; and
the surface of the organ is remarkably rough, granulated, fur-
rowed, notched, or mammillated.

Hypertrophy is most common in young strumous subjects,
or in such whose constitution has been tainted by syphilis,
and is usually connected with a low and protracted inflam-
matory state of the parenchymatous structure. The affection
is rarely attended with much inconvenience, save what arises
from the increased bulk of the organ. In the generality of
instances, there are jaundice, dropsy of the abdomen, irritable
stomach, and constipation of the bowels, with enlargement of
the spleen, and a sense of weight in the right hypochondriac
region.

Atrophy of the liver is much less frequent than hypertro-
phy, and, like it, usually occurs in combination with indura-
tion or mollescence. I have seen it repeatedly affect the
whole organ ; but it is much more common to find it limited
to one of its lobes ; and, what is rather paradoxical, the liver
may not only be of its natural dimensions, but even enlarged.
In speaking of induration, mention was made of the fact that
the granular structure is sometimes entirely absorbed, and re-
placed by dense cellular substance. In this case, although
there may be no diminution of bulk, there is yet an actual
wasting of the hepatic tissue, the part affected being reduced,
as it were, to its primordial frame-work. The color of an at-
rophied liver presents every variety of shade, from grayish
white to almost entire black.

This state of the liver is often observed in persons who are
in the constant habit of using ardent spirits. It is rarely seen
before the middle term of life, and is most common in old
age. The hepatic vessels are always much diminished in
size, and the functions of the organ more or less impaired.
Its cause is manifestly chronic inflammation, producing an ef-

324

LIVER.

[chap. IX.

fusion of lymph and a partial absorption of the granular tissue.
This atrophy of the liver is frequently connected with ascites,
either as cause or effect, as was pointed out several years
ago by Dr. Andral, and more recently by Dr. Seymour, in
his valuable work on the nature and treatment of dropsy.

As intimately connected with the two changes last de-
scribed, it will be proper here to notice that peculiar state of
the liver to which some of the French and British pathologists
have applied the epithets granulated, onammillated, and tuber-
culated. The affection seems to have first attracted the at-
tention of Laennec, who has described it under the name of
cirrhosis, in reference to the tawny yellow color which it
occasionally presents. (Fig. 73.) It was soon after noticed
by Dr. Baillie, of London :

and, since his time, it has ^' '

been particularly investi-
gated by Andral, Bouil-
laud, Cruveilhier, Hope,
Carswell, and other anat-
omists. The lesion seems
to consist essentially in a
hypertrophy of the hepat-
ic granules, brought about
by chronic irritation, act-
ing in a slow and insidi-
ous manner. Their tex-
ture is dense and compact,
and exhibits a great varie-
ty of tints, being sometimes of a deep brownish red, some-
times of a tawny yellow, like bees-wax, and not unfrequent-
ly of a pale cinnamon, pink, or lilac hue. When cut, they
present a perfectly fiat surface ; and, if further examined, are
found to be invested by a dense cellulo-fibrous capsule, of a
light grayish color, from which they can be easily removed
by dissection, their principal bond of connection being a small
peduncle, through which they receive their supply of blood-
vessels, nerves, and absorbents. The size and shape of the
granulations are variable. I have seen them of the magni-
tude of a common cherry ; but usually they do not exceed a
garden pea, and often they are not larger than a mustard-
seed or a currant. Although mostly spherical, they are some-
times irregularly round, and even angular.

When these granules are very numerous, large, and of a

SECT. I.] TUBERCLES. 325

variegated brownish color, they give the liver a peculiar nut-
meg-like appearance. (Fig. 73. ) This state of the organ is
said by Dr. Hope to be most p-^^ ^3_

prevalent in old dram-drinkers ;
but it may also result from re-
peated attacks of chronic irrita-
tion, or from long-continued
congestion.* Hence obstruction
of the vena cava or hepatic veins
seldom exists long without pro-
ducing enlargement of this kind.

In whatever form this species of hypertrophy occurs, the
surface of the liver generally presents a singular mammillated
aspect, as if it were raised into a multitude of spherical emi-
nences ; the peritonasal coat is thickened, opaque, and wrin-
kled ; and the volume of the organ is either diminished or aug-
mented, seldom natural. In the former case, the hepatic
texture is generally very dense, and almost destitute of moist-
ure ; in the latter, it is usually somewhat soft, more or less
vascular, and impregnated with thin, bloody matter, which
can be easily squeezed out with the fingers. In both varie-
ties, but more especially in the first, the hepatic tissue is often
of a yellow tinge ; and the bile being retained in the rootlets
of the hepatic duct, exudes pretty freely on making sections
of it. If, in this state, a portion of liver be macerated for ten
or twelve days in water, the little granules will assume the
appearance of adipocire, and may be easily washed out of
their cellulo-fibrous capsules, leaving them in a soft, flocculent
condition.

Tubercles are of very common occurrence in the liver, be-
ing either seated in its substance, or scattered over its surface,
giving it, in the latter case, a very rough appearance. Lying
in close contact with each other, or separated, as the case may
be, by large intervals, these bodies are generally of a rounded
shape, and con.sist of an opaque yellowish substance, in vari-
ous degrees of maturation. Their size, although sometimes
not exceeding that of a mustard-seed, is usually considerable,
many of them being as big as a cherry or even a hazelnut.
When the liver is thus tuberculated, it feels much harder
than natural, and its vessels are compressed and sometimes
greatly reduced in volume, though the organ itself rarely de-

* Principles of Morbid Anatomy, p. 103.

326 LIVER. [chap. IX.

viates much from the ordinary standard. In some cases, the
tubercles bear a strong resemblance to those of the lungs :
they have the same size, the same form, the same consistence,
and, in all probability, the same origin, but are a little
browner in their color. They are obviously connected, in
most instances, with a scrofulous diathesis of the system, as
is manifested by their frequent coexistence with pulmonary
phthisis, and by their contents being usually of a curdy na-
ture.

Besides this variety of tubercles, Baillie has described an-
other, which he has designated by the phrase, large white
tubercles of the liver. His division, however, has not been
generally adopted by succeeding writers, and may justly be
rejected on pathological grounds, it being now pretty well as-
certained that the bodies in question are merely a species of
carcinoma, presently to be described.

Tubercles of the liver produce marked symptoms only
when they are numerous, or when they are associated with
hypertrophy or structural lesion. Under opposite circum-
stances they seldom cause much local inconvenience, or im-
pairment of the general health. They are seen occasionally in
old subjects, but are most frequent by far in children. Cru-
veilhier asserts that he has never met with them in adults
who died of pulmonary phthisis, although he has made nu-
merous examinations.* Louis, however, has been more suc-
cessful ; for, in one hundred and twenty-three cases of con-
sumption, he met with these tubercles twice in the liver.f

I have also, in a few cases, found them in association with
tubercular phthisis, though more commonly without it. On
the whole, I am induced to believe that this lesion of the liv-
er is of rare occurrence in this country. In some of the in-
ferior animals they are sufficiently common, and in none more
so than in the sheep, in which they are observable at a very
early age.

The liver is extremely liable to be affected with cancer ;
more so, according to some writers, than any other organ in
the whole body. That this may be the case in some coun-
tries is probable, but that it is not in the United States I am
convinced, both from my own observations, and from those
of the profession at large. Be this as it may, cancer is always

* Diet, de Medicine ct de Chirurg. t. viii. p. 329.
\ Palliological Researches on Phthisis.

SECT. I.] SCIRRHOS. 327

a most formidable disease, perfectly uncontrollable by medi-
cine, and consequently invariably fatal. Two varieties of
cancer are usually recognized by authors, namely, the scir-
rhous, and the encephaloid,

Scirrhus always occurs in distinct masses, the size, form,
and consistence of which exhibit numerous diversities. The
smallest are frequently not larger than a mustard-seed, but in
most cases their volume equals that of a chestnut, a walnut,
or an orange. In a specimen in the museimi of the Cincin-
nati College, the tumors, two in number, are about the size
of a common apple : they are of a spherical form, hard, dense,
and gristly, and situated in the very centre of the organ.
The masses sometimes lie close together, and, by their agglom-
eration, form a tumor equal in size to a foetal head ; but
such cases are rare, and I have never met with them. These
heterologous structures seldom occur singly. In the majority
of cases, there are not less than six or eight ; and instances
have been known where there were as many as two or three
hundred at the same time.

In their form, these tumors are generally spherical ; and
those which project beyond the surface of the liver, for which
they have a great predilection, have often a white grayish
dimple in their centre, produced, it is supposed, by a conden-
sation of the subserous cellular substance. The smallest, and
those that are of recent formation, are of an opaque white ap-
pearance, and intimately connected with the surrounding
tissues ; whilst such as are old, and of great magnitude, are
often of a brownish color, with various shades of gray and
black, and can be easily lifted from their situation. Vessels
frequently shoot into them, sometimes so large that they can
be filled with injecting matter : nerves and absorbents they
also no doubt receive, but their existence has not yet been
demonstrated by actual observation. To the touch they are
hard and firm : and to the scalpel they offer the resistance of
fibro-cartilage,.the largest and densest yielding a slight creak-
ing sound. The section generally displays a fibrous struc-
ture, the fibres radiating irregularly from the centre towards
the circumference, like those of a tulip. In other cases, the
tumor is lobulated and internally areolar, filaments of a gray-
ish, brownish, or yellowish hue intersecting it in every pos-
sible direction. A juice may be obtained from them by
pressure, and, in the cellular variety, a substance of the con-
sistence and color of thin putty, paste, or concrete lard. Small

328 LIVER. [chap. IX.

masses of blood are sometimes diffused through them ; but
this occurrence is seldom witnessed, except in such as are
old, or in a declining state.

The hepatic substance in the immediate neighborhood of
these bodies is in most cases perfectly sound. In others it
is indurated, softened, infiltrated with different kinds of mat-
ter, or partially absorbed. Hypertrophy of the liver is some-
times observed ; but a much more common occurrence is an
extreme reduction of its weight and bulk. When the tumors
are numerous, the larger vessels are apt to be compressed ;
and, as a consequence, the organ is often exsanguine. From
the same cause may result obstructions in the hepatic duct,
with retention of the bile, and yellowish discoloration of the
parenchymatous texture.

Encephalo'id disease of the liver is occasionally observed,
though not so often as carcinoma, with which it probably has
a similar origin. Like the preceding variety, this species of
cancer occurs in various sized masses, of a grayish white
color, soft, compressible, and elastic, with trifling vascularity.
They offer very little resistance to the knife, and are com-
posed of an areolar mesh-work, occupied by a soft, pulpy,
brain-like substance, intermixed with fibrinous concretions,
and dark-colored clots. The intersections are commonly of
a lighter tissue, and, instead of being dense and thick, are
eminently lax and delicate. Occasionally, though, very rarely,
the contents of these tumors are of the nature of hard jelly,
constituting the gelatiniform sarcoma of Portal, Cruveilhier,
and other pathological anatomists. The liver is sometimes
much enlarged, and presents a mixed mass of disease, carci-
nomatous, encephaloid, melanotic, and tubercular, in various
stages of maturation. The encephaloid matter is sometimes
deposited in the portal and hepatic veins, as has been so ably
represented by Carswell, in his Illustrations of Morbid
Anatomy.

The symptoms of cancer of the liver are often exceedingly
obscure, and frequently a long time elapses before the patient
experiences much constitutional disturbance or local suffer-
ing. The disease in some instances appears to be latent, or
manifests itself only a short time before death. The appetite
is generally more or less impaired, the skin is sallow, the
strength gradually declines, the body becomes emaciated, and
there are frequent attacks of pain in the right hypochondriac
region, with occasional nausea and vomiting. When the

SECT. I.] HYDATIDS, 329

liver is much enlarged, and the cancerous tumors have at-
tained considerable magnitude, the surface of the organ may
impart a hard, nodulated, or lumpy feel to the hand applied
over the abdomen, and this constitutes the only pathogno-
monic sign of which we have at present any knowledge.

It is seldom that the liver is affected with melanosis. When
it occurs here, it exhibits the same characters as in the other
organs, and need not therefore be particularly described. I
have never seen this disease in the human liver, but several
times in that of the ox, in which it is by no means uncom-
mon, especially in such as are raised in Ohio. In one speci-
men, the organ contained a great number of melanotic masses,
arranged in the form of encysted tumors, varying in size from
a small pea to a walnut. In man, the matter either assumes
the tuberiform arrangement, or is diffused throughout the
parenchymatous structure as an infiltration.

Hydatids are of frequent occurrence in the liver, either
occupying its substance, or studding its surfaces. Like tuber-
cles, they may occur at any period of life, although they are
witnessed most usually in adults, and persons who have been
addicted to intemperance in eating and drinking. Commonly
of a globular shape, they are often closely clustered together,
and are almost always contained in a cyst, formed of a dense,
fibrous texture, of a white, opaque appearance. In an ex-
amination which I made about eighteen months ago, the
hydatids looked like spherical bags, the largest of which was
about the size of an onion, whilst the smallest was scarcely
as large as a rifle-ball : their external tunic was dense, opaque,
marked with numerous yellowish dots, and liberally supplied
with vessels : their number did not exceed fifteen. The
liver was much reduced in size, pale in its color, and its tex-
ture in many places so soft as to be unable to withstand the
slightest pressure of the finger.

These parasitic beings are not peculiar to the human liver :
they occur also -in that of animals, especially in oxen, hogs,
and sheep. In these quadrupeds, the organ is sometimes
completely crowded with them, immense numbers being
every where scattered through its substance. In the liver of
a cow, Mr. Youatt found nearly three hundred of these sin-
gular animals, varying from the size of a sparrow's egg to
that of a swan. Some of the cysts were filled with blood,
some with lymph, and many of them were intersected by
fibrous bands. The liver in which they occurred weighed

VOL. II. 42

330 LIVER. [chap. IX.

one hundred and thirty-seven pounds, and measured, from one
lobe to the other, more than a yard and a quarter : its centre
was perfectly fibro-cartilaginous, without any trace of its
original structure.* This case is an exceedingly interesting
one, and I mention it here not only with a view of showing
the great number of hydatids that are sometimes congregated
together, but also for the purpose of pointing out the fact,
that the liver may be sometimes almost totally disorganized,
and still the animal not evince any serious indisposition.
The disease in this instance had no doubt existed for a long
period, yet the cow's health was but little impaired, — enlarge-
ment of the belly, yellowness of the skin, and slight emacia-
tion, being the only symptoms which she exhibited previously
to being killed by the butchers. In the human subject, there
are no manifestations which mark the presence of these
bodies, distinct from those of chronic hepatitis. The disease
may simulate ascites ; and not a few cases are recorded in
which the patient was actually tapped for this complaint.f

Less distinctly organized are those serous cysts which are
sometimes observed on the surface of the liver, constituting
the disease which some writers have described under the
name of encysted dropsy. The walls of these vesicles are
generally transparent, smooth and polished, and supplied
with numerous vessels, of the finest texture and most beauti-
ful arrangement. Their contents, which are thin and limpid,
like the v/ater of ascites, are coagulable by heat, alcohol and
acids. In the only case in which I have observed these
tumors, they hung pendulous from the convex surface of the
liver, were somewhat globular in their shape, and about the
size of a walnut. Their most common size is that of a grape ;
but they may increase to a magnitude capable of holding
many pints. Thus, in a man aged thirty-two, Dr. Aber-
crombie found a cyst which contained eighteen pounds of
fluid, and the walls of which were firm and dense, like
thickened peritonaeum. At the bottom of the sac were two
coiled up cylindrical bodies, of a soft gelatinous consistence,
which, when unrolled, had the appearance of false mem-
branes, being about ten inches in diameter, and the eighth of
an inch in thickness. The liver was not altered in struc-
ture, and all the other abdominal viscera were in a normal

* The Management and Diseases of British Cattle, p. 460. Phila. 1836.
t See Medico-Chirurgical Review for March, 1824, p. 930.

SECT, I.] FATTY LIVER. 331

State. The patient had experienced much suffering, caused
mainly, perhaps, by the encroachment of the immense tumor
upon the diaphragm and surrounding organs.

The Kver has occasionally a peculiar adipous appearance,
the fatty matter being either diffused through its parenchy-
matous structure, or confined to particular spots. The affected
part is of a pale yellowish color, not unlike that of a pale
autumnal leaf; its consistence is more or less diminished ; it
perceptibly greases the scalpel, is unctuous to the touch, and
yields an oily principle by boiling. This, according to the
recent experiments of Mr. Bird, of London, is a soft, brownish
substance, very fusible, and possessing a peculiar and un-
pleasant odor. The quantity yielded by a pound of hepatic
tissue is about five drachms and a half.

Frequently the surface of the organ presents small brown-
ish spots, which, from the manner in which they are ar-
ranged, give it a very singularly mottled appearance, resem-
bling very much the liver of the shark, cod, and other oily
fishes. When a section is made, the interior is found to be
of a much more uniform color, being of a pale yellow, deep
orange, or light ochre. The hepatic tissue is generally di-
minished in specific gravity, though this occurrence is by no
means constant. In two specimens examined by Mr. Bird,
the weight was only 1,027, whereas in the same amount of
healthy liver it was 1,062.

This fatty degeneration occurs almost exclusively in phthis-
ical subjects. Louis found it in forty-four persons out of
the one hundred and twenty-three who died of this disease
under his care, in the Charity Hospital at Paris. This writer
even goes so far as to contend that this state of the liver is
never seen, except in connection with tubercles of the lungs,
or of some other organs. That this, however, is not neces-
sarily, although it may be generally, the case, is abundantly
disproved by the observations of other pathologists.

Various hypotheses have been offered with a view of ac-
counting for this curious state of the liver ; but the only ex-
planation which seems to me to be at all tenable, is that
which ascribes it to chronic inflammation, with venous en-
gorgement, giving rise to an augmentation of the secretion of
fatty matter, which, according to the well-known experiments
of Braconnet and Yauquelin, is naturally contained in the
organ. This opinion derives support and illustration from
what is observed in the inferior animals. In the goose and

332 LIVER. [chap. IX.

duck, an almost complete adipous transformation of the liver
may be induced in the course of a few weeks, by subjecting
them to inactivity, withholding the light, and cramming
their stomachs with a paste made of barley-meal, mutton-suet,
and coarse sugar, mixed with milk. This mode of fattening
fowls has been pursued for many years in the neighborhood
of London, and it has been found that if the repletion be
kept up longer than a fortnight, so much structural lesion
will be induced as to kill them, or render the meat unfit for
the table, the liver being converted in]to a soft, red, oily
mass. In the human subject, this change seems to take
place very rapidly in some instances, as in the course of five
or six weeks ; and the organ is not unfrequently double the
usual weight and bulk. Louis has ascertained that it is more
common in young than in old persons, and in females than in
men, in the ratio nearly of four to one.

The bile seems to be considerably altered in this afiection,
both in its chemical and physical properties. Dr. Addison,
of London, who has published an able essay upon the subject
in a late number of Guy's Hospital Reports, states that this
fluid is frequently of a dirty-brown color, and contains an
infinite number of carbonaceous grainiles. After the addition
of almost any of the acids, a most intolerable odor is evolved.
The urine, too, is usually a good deal altered, being of very
low specific gravity, quite neutral, and holding in suspension
numerous flakes of mucus.

There are no signs, either general or local, which charac-
terize this singular state of the liver. How far the symptom,
recently pointed out by Dr. Addison, forms an exception to
this remark, is a question, which, for the present, must remain
undecided. The symptom to which I allude consists in a
peculiar alteration of the color and texture of the integu-
ments, most conspicuous on the face and back of the hands.
These parts exhibit a singularly bloodless, almost semi-trans-
parent, and waxy appearance, which by degrees becomes
observable over the whole body. Sometimes the skin has a
fine, polished, ivory look. To the touch, it is remarkably
smooth, loose, flabby, and almost as soft as satin, apparently
from the natural asperities being obliterated. In several in-
stances, in which this peculiar condition of the integuments
was present, has Dr. Addison confidently and correctly pre-
dicted the existence of the fatty defeneration of the liver.
The subject is certainly of great interest, and will no doubt
receive the serious attention of the profession.

SECT.

I]

PARA.SITES.

333

74,) of hel-

Fig. 74 *

The liver-fluke^ the distoma hcpaticum, (Fig.
minthologists, although said to have been several
times found in the human subject, is much more
common in the inferior animals, as the sheep,
horse, stag, and ox. It is also found in the gall-
bladder ; and Pallas mentions that he once de-
tected it in the hepatic duct of a young female.
Somewhat lanceolated in shape, it is of a yellow-
ish color, obtuse at either extremity, and scarcely
a fourth of an inch long, by one line in breadth.
It has two openings, one in front, which is
directed obliquely inwards, and another behind
and inferiorly, which is slightly prominent, and
answers to the anus ; the neck is rounded, and
of a light brownish hue ; and the belly is marked
by spots of an opaque dingy white. The insect
is thought to have a distinct genital apparatus,
with a vascular, and probably also a nervous system. In
animals, it is often an inch long, by nearly half an inch broad.

Worms sometimes crawl from the duodenum into the liver,
where they have been known to create profuse suppuration,
followed by fatal irritation. Of this I have never seen an
example in the human subject, but several highly interesting
cases of it are recorded by writers. The late Dr. Thomas
Bond, of Philadelphia, has detailed the particulars of an ex-
traordinary instance of hepatic disease occasioned by a worm
nearly two feet long by one inch in diameter. On dissection,
a large abscess was discovered in the substance of the liver,
containing nearly two quarts of bloody matter.f Many other
cases of a similar kind are related by authors ; and it is
worthy of remark that in nearly all of which I have read an
account, the parasites belonged to the lumbricoid species. In
the liver of the hog I have frequently seen the vessels and
excretory ducts of the liver filled with small worms of this
kind. In this animal they generally coexist with hydatids.

In examining, not long ago, the liver of a rat, I discovered
a serous cyst, about the size of a marble, on the under sur-
face of the organ, which contained a toenia one foot in
length by two lines in breadth. The parasite was completely
coiled up, and lived for upwards of an hour after its removal.

* a, the mouth; b, suctorious disc ; c, generative orifice,
t London Medical Observations and Inquiries, vol. i. p.

334 LIVER. [chap. IX,

The liver itself was perfectly sound. The specimen is pre-
served in my museum of pathological anatomy.

Cartilaginous depositions are sufficiently rare in this or-
gan ; most frequently they are confined to the investing
membranes, occurring in small patches, of a soft texture and
grayish color. Dr. Roberts, of Paris, relates a case in which
the whole of both tunics was converted into one mass of
cartilage, in some places half an inch thick. In the midst
of this substance were several scales of bone, one of them
of the size of a half-crown piece.

The depositions are sometimes entirely osseous. Dr. Vena-
bles met with a case in which the concretion, consisting
almost entirely of phosphoric acid and lime, was about the
size of the patella, with very much the same shape. It was
embedded in the parenchymatous structure, and resembled
common bone.* In other cases the earthy matter is soft,
gristly, of a brownish white color, and enclosed in a dense,
firm, fibro-cartilaginous cyst.

Very recently I have met with very small osseous concre-
tions in several livers which were otherwise perfectly healthy.
In one of the cases there were altogether about fifteen, vary-
ing in volume from a mustard seed to a currant. They were
hard, somewhat gritty, of a yellowish hue, and most of them
distinctly encysted, the capsule, which was of a grayish
color, and fibro-cartilaginous firmness, being from the sixth
to the fourth of a line in thickness, and closely adherent to
the surrounding tissues. In another case, the concretions
were only five or six in number, the largest of which was
about the magnitude of a common pea. They were also
encysted, but of a light brownish color, and of great hard-
ness. How these little bodies originate, cannot be very
easily determined. In one of the cases now referred to, it
seemed to me that they were nothing but tubercles in a
state of osseous degeneration, — a supposition which derives
strength from the fact that several of them, evidently less
advanced than the rest, contained a minute quantity of curdy,
friable matter. The individual, moreover, was of a decidedly
scrofulous habit, and numerous tubercles were detected in
different organs.

Blood sometimes escapes into the substance of the liver,
constituting the disease to which some of the French writers

* London Cyclopedia of Practical Medicine, vol. iv. p. 611.

SECT, 1.] OSSEOUS DEPOSIT ; RUPTURE. 335

have applied the name of hepatic apoplexy. It generally
proceeds from one or more ruptured vessels distributed through
the parenchymatous texture, and occurs in small spots, vary-
ing in density and color according to the length of time they
have existed, being always softer and darker the more recent
they are. The disease, I presume, is extremely rare, as very
few pathologists make mention of it. In my own dissections
I have never met with an instance of it ; nor am I aware
that any of my friends have been more successful. No
symptoms have yet been pointed out as indicative of hepatic
apoplexy ; nor is it reasonable to suppose that the organ
would suffer much inconvenience, unless the effusion should
be copious.

The liver is very easily ruptured, in consequence of exter-
nal violence ; and when this happens, large quantities of
blood are liable to escape into the abdominal cavity. The
accident is always fatal, the patient seldom surviving more
than a few hours. To this statement, however, a remarka-
ble exception is to be found in a case, the particulars of which
have been recently given by Dr. Fazely, of the island of
Trinidad. The individual, a man fifty years of age, sur-
vived the effects of the injury eight years, and finally died
from a complication of disease. On examination, it Avas
found that the right lobe of the liver had been ruptured
throughout its whole length and substance, from the anterior
to the posterior part, and that the lacerated edges had per-
fectly reunited through the medium of a broad, thick cica-
trix, of a hard cartilaginous texture. In the interior of this
cicatrix, at the depth of half an inch, a considerable cavity
was seen, which communicated with the hepatic substance,
and contained about fifty biliary concretions. The surface
of the liver, it should be remarked, adhered extensively to
the walls of the abdomen. The gall-bladder was empty and
flaccid, and the alimentary tube perfectly sound.

That such accidents are not so fatal as has been generally
imagined by the profession, may be inferred from some ex-
periments performed by Professor Monro, of Edinburgh. He
opened the abdomen of a living rabbit, and cut off one of the
lobes of the liver. The divided vessels bled very profusely ;
but, by pressure, the hemorrhage entirely ceased in the course
of three or four minutes. After the wound was sewed up,
the animal appeared uneasy, but only for a short time, when
it gradually recovered its spirits, and took food as before.

336 GALL-BLADDER. [CHAP. IX.

During the five weeks that it was kept and closely watched
by the experimenter, it was in perfect health, the digestion
going on well, and the alvine evacuations being of the usual
color, quantity, and consistence.

In another experiment, also performed upon a rabbit, the
results were precisely similar. The animal lived upwards of
twelve weeks, when it was killed. On examination, the cut
surface of the liver was found firmly glued to the walls of
the abdomen, by means of lymph.* The results of these
experiments are extremely interesting, as showing how large
a portion of an organ, so important to life, may be ablated or
destroyed, and yet the animal perfectly recover.

SECTION II.
Of the Gall-Bladder.

I. Inflammation of the gall-bladder, characterized by the
usual anatomical appearances, may be caused by irritating
bile, by the presence of biliary concretions, or by external
violence. Very frequently it coexists with duodenitis, or
with inflammation of the substance of the liver, or of one or
other of its envelopes. The disease commonly assumes the
chronic type, though occasionally it enters into suppuration,
the quantity of matter being sometimes very considerable.
In a case recently reported by Dr. James Johnson, of London,
the gall-bladder, dilated into an enormous sac, contained a
pint of thick purulent fluid, mixed with a large number of
calculi. The cystic duct was entirely obliterated, and the
walls of the tumor, which had contracted extensive adhesions
to the adjacent organs, were much thickened, and in some
places ulcerated.-f In many instances, the pus is of a pecu-
liar greenish aspect, owing to the admixture of bile ; more
rarely it is thin, sanious, and extremely ofi"ensive.

Ulceration of the gall-bladder generally begins in the in-
ternal coat, being usually caused by the irritation of biliary
calculi. In this manner extensive abrasions are sometimes

* Elements of Anatomy, vol. i. p. 5G7. Edinburgh, 1831.
t Meclico-Chirurgical Review, July, 183G.

SECT. II.] INFLAMMATION. 337

produced, with hard, elevated edges; and when there is
obstruction of the cystic duct the disorganizing process is
very apt to impHcate the other tunics, leading finally to per-
foration and escape of the bile. The immediate effect of
this accident is violent peritonitis, rapidly terminating in
death. In a case of rupture of the gall-bladder, reported in
the Western Journal of the Medical and Physical Sciences,
by Dr. Rogers, the patient survived the escape of the fluid
sixty hours ; and in another, the particulars of which are
given by Professor Drake, death took place at the end of the
third day. In the former case, the gall-bladder contained a
large, rough calculus, and the rent, which was about half
an inch in diameter, occupied the side of the organ ; in the
latter, the viscus was contracted, and the opening, which was
evidently caused by ulceration, was near the cystic duct, its
dimensions being much smaller than in the preceding case.
Professor Drake's patient was thirty-four years of age, and the
rupture occurred soon after eating an ordinary supper, being
announced by violent pain in the region of the liver, which
continued, with slight intermission, until a short time before
he expired. The abdomen was swollen, tense, and painful
on pressure ; countenance pale and haggard ; stomach ex-
ceedingly irritable; bowels constipated; secretion of urine
suspended ; pulse weak, small, and one hundred and twenty-
four in the minute ; drowsiness ; dyspnoea ; and inability to
lie on either side.*

The gall-bladder may be affected with atrophy, accom-
panied with partial or total obliteration of its cavity. In
three or four instances I have seen it reduced to a mere
fibrous mass, without any trace whatever of its normal con-
figuration. In a specimen in the museum of the Cincinnati
College, the cystic duct is annihilated, and the coats of the
gall-bladder, considerably thickened, are rigidly contracted
over five or six small calculi. When thus wasted, the
reservoir may be easily overlooked, and induce the belief that
it is entirely absent. The most common cause of atrophy of
this organ is an obstacle in the cystic duct preventing the
influx of bile ; but in many cases it exists without any
assignable reason.

The coats of the gall-bladder are occasionally in a state of

* Western Journal of the Medical and Physical Sciences for 1834, p. 521.

VOL. II. 43

338 GALL-BLADDER. [cHAP. IX.

hypertrophy ; and cases have been recorded where they were
partially converted into cartilaginous, calcareous, or even
osseous matter. Dr. Baillie mentions an instance where they
were above a quarter of an inch thick, and studded with
large tubercles, of a remarkably firm texture. Hydatids and
worms are also sometimes found in the gall-bladder ; but all
these affections are extremely rare.

II. The biliary ducts are liable to the same lesions as the
gall-bladder, in whose structure they participate. Thus they
may be affected with inflammation, acute or chronic, soften-
ing, induration, ulceration, and even perforation. In the
latter case the bile escapes into the peritonseal sac, and induces
disastrous results. In more than half a dozen instances have
I found the cystic duct obliterated and transformed into a
dense, fibrous cord ; and similar lesions have occasionally
been observed in the hepatic and choledoch ducts. The
affection, however, I have reason to believe, is much more
common in the former than in either of the latter of these
tubes. Most generally the obliteration arises from the irrita-
tion of a gall-stone, or from the pressure of some tumor, as
the head of an enlarged pancreas or a scirrhous lymphatic
ganglion.

Dilatation of these tubes, caused by some obstacle to the
egress of the bile, is a common occurrence. Baillie saw the
hepatic and choledoch ducts nearly an inch in diameter ; and
Cruveilhier details the particulars of a case where the latter
of these passages was of the size of the duodenum. The
same writer also relates an instance in which indurated
absorbent glands, compressing the common duct, had caused
enlargement of the gall-bladder to the size of the urinary
reservoir. An equally astonishing example, in which it con-
tained eight pounds of inspissated bile, is reported by Mr.
Gibson, in the Edinburgh Medical Essays. When thus en-
larged, the gall-bladder forms a pear-shaped tumor, which
projects beyond the ribs, and sensibly fluctuates under the
finger. There is no sign by which it can be discriminated
from other lesions. Indeed, the diagnosis is not only obscure,
but sometimes very deceptive. A distended gall-bladder has
been mistaken for a hepatic abscess ; an opening has been
made into it under this belief; bile has escaped instead of
pus, and this, getting into the peritonseal sac, has speedily
destroyed life by inducing inflammation. A remarkable case

SECT. II.] BILE DUCTS BILE. 339

of this kind, which fell under the observation of the late Mr.
Todd, of Ireland, is related in one of the early numbers
of the Dublin Hospital Reports.*

HI. Healthy bile is a greenish-yellow colored fluid, of a
viscid, ropy consistence, readily miscible with water, of a
peculiar sickening odor, and of a taste at first sweet and then
bitter. Respecting the precise amount of bile secreted in the
twenty-four hours, our means of judging are too inaccurate to
enable us to arrive at any definite conclusions ; probably,
however, it does not exceed two or three ounces. From
these normal states of the fluid, there may be numerous
deviations, depending upon the condition of the liver, or the
period of its retention in the gall-bladder. Thus it may be
unnatural in its color, augmented or diminished, in quantity,
unusually acrid or bland, uncommonly thin or viscid. In
some diseases of the liver, the bile is of a deep black, and in
several instances I have found it of the color and consistence
of a warm solution of arrow-root. In addition to these tints,
there are often numerous intermediate shades of green, red-
dish, brown, orange, and yellow. In warm weather, the
quantity of bile poured out is generally much greater than in
cold seasons, and the fluid, also, is more acrid and stimulating,
frequently inducing diarrhoea, cholera-morbus, and spasmodic
colic. Its consistence may be as thin as pure water, or as
thick as molasses, tar, mucilage, or half-dissolved glue. In
the diseases of tropical climates the bile is sometimes so hard
and viscid that it can scarcely be forced along the excretory
ducts. In organic affections of the liver, it is occasionally of
the color and consistence of coffee-grounds ; and in chronic
hepatitis I have several times seen the gall-bladder distended
with a thin reddish bile, not unlike the juice of the poke-
berry. In some cases, if tasted, the fluid produces no particu-
lar inconvenience ; but, in others, it is so poisonous in its
qualities as to cause the most violent irritation, and even
death. In most of these abnormal states of the biliary fluid,
there are important alterations in its different chemical
elements, consisting either in their modification, or in the
abstraction of some, or the substitution of new ones. Simply
changing the food, or, in other words, modifying the

* See Stokes's Lectures on the Theory and Practice of Medicine, Dunglison's
Library, vol. i. p. 137.

340 GALL-BLADDER. [cHAP. IX.

blood, enables us to alter at pleasure the composition of the
bile.

TV. Gall-stones are sometimes formed in the ducts of the
liver, but most generally they are found in the gall-bladder,
where they are often accumulated in great numbers. J. Hun-
ter examined a case in which there were above a thousand ;
and Morgagni refers to one in which there were three thou-
sand six hundred and forty-six. When thus numerous, they
are commonly very minute, frequently not exceeding a small
shot ; under opposite circumstances, however, they often at-
tain a considerable magnitude. The largest 1 have ever seen
was about the size of a walnut. Hildanus mentions one
which weighed eighteen drachms ; and Dr. Baillie saw an-
other which was fully the size of a hen's egg.

Much diversity prevails in relation to the form and color
of these concretions. When numerous, they are often per-
fectly smooth, and marked off into regular sides and angles,
evidently occasioned by their mutual friction. In this man-
ner they may assume various mathematical figures, as the
tetrahedral and the hexagonal. In the gall-bladder of a man
fifty years old, whom I examined in 1828, there were seven-
ty-one of these six-sided concretions, none of which exceeded
the dimensions of an ordinary pea : they were of a deep
brown color, and emitted a peculiar fragrant odor, not unlike
frankincense, on exposure to heat. When there is only one
gall-stone, it is usually of an oval shape, with a rough, grooved,
tuberculated, or mulberry surface. The principal colors of
these concretions are brown, cinnamon, and black ; but
there are many minor shades, which it is very difficult to in-
dicate, but which will readily suggest themselves to the
reader. Sometimes they are semi-transparent, and of a white
pearly lustre ; and, when they are formed in the substance of
the liver, it is not unusual to find them of a dingy black, not
unlike grumous blood.

Gall-stones often possess a considerable degree of solidity,
and, when cut, are commonly found to consist of a number of
concentric laminae, placed around a radiating nucleus. This
central structure is frequently much softer than the exterior,
and is sometimes made up entirely of inspissated bile. The
nature of these concretions has been investigated by numer-
ous chemists ; but the most satisfactory analysis yet made is
that by Chevreul, of France. According to this distinguished

SECT. II.] GALL-STONES ; SYMPTOMS. 341

philosopher, gall-stones are composed of the yellow coloring
matter of the bile and cholesterine ; the latter generally pre-
dominating, and, in many instances, forming the entire con-
cretion.

Professor Thomson, of the University of Glasgow, supposes
that all biliary concretions may be referred to three species, —
the cholesteric, the mellitic, and the inspissated. The first
variety, composed nearly entirely of cholesterine, is of a white
pearly lustre, with a slight shade of brown, of a spherical
shape, and of a crystallized, laminated structure. It is of low
specific gravity, without taste or smell, without acid or alka-
line properties, insoluble in water, partially soluble in boiling
alcohol, and fuses at a temperature of about 279°. The mel-
litic concretion, by far the most common variety of biliary
calculi, has been thus named by Professor Thomson, from
its dark, honey-like color. It is soft, smooth, and always of
a polygonal shape, being generally composed of two tetrahe-
drons, applied base to base, with their edges and angles
rounded off. Externally it consists of thin, concentric layers
of cholesterine, spread over a nucleus of indurated bile,
strongly resembhng granulated honey. The third variety,
as its name indicates, is composed wholly of inspissated bile :
it is of a yellowish cinnamon hue, semi-concrete in its con-
sistence, and much more uncommon than either of the other
species just described.*

Biliary calculi induce symptoms only when they are in the
act of passing towards the bowel. As long as they remain in
the gall-bladder, they are productive of little annoyance, even
though they be large and numerous. In the former case,
that is, when they are about making their egress, they fre-
quently create the most intense suffering that it is possible
for a human being to endure. The pain is of a spasmodic
kind, and usually comes on in sudden paroxysms, though
occasionally it continues for hours together ; the stomach is
oppressed with nausea and vomiting ; and the surface is
bathed with a cold, clammy sweat, preceded and accompanied
frequently by rigor. The bowels are constipated, the feces
pale, the urine scanty and high-colored, the eyes sallow, and
the skin of a deep yellowish tint. When all or most of these
phenomena are present, there can, in general, be no doubt re-

** London CyclopEedia of Practical Medicine, vol. i. p. 337.

343 GALL-BLADDER. [CHAP. IX.

specting the true nature of the complaint ; yet it is important
to remember, as has been justly remarked by Dr. Marshall
Hall, that precisely similar symptoms may originate from a
diseased and crowded state of the colon.

Gall-stones are more common between the ages of forty
and fifty than at any other period of life. They are most
frequently observed in persons of sedentary habits, and hence
women are more subject to them than men. It is stated that
in England five sixths of all the cases of this affection occur
in the female sex. Whether the proportion is equally great
in this country, I am unable to say, as this is a subject which
has not been particularly investigated.

CHAPTER X.

Of the, Spleen,

Normal characters of the Spleen. — Its Color, Weight, Dimensions, and Intimate
Organization. — Acute Splenitis. — Anatomical Characters. — May pass into
Suppuration or into Gangrene. — Softening. — Induration and Hepatization. —
Hypertrophy and Atrophy. — Tubercles. — Calcareous Concretions. — Fibro-
cartilaginous and Osseous Matter. — Hydatids and Serous Cysts. — Sanguine-
ous Deposits.

The spleen, situated deeply in the left hypochondriac
region, lies beneath the diaphragm, behind the descending
colon, and immediately over the left kidney. Externally, it
is convex, and corresponds to the ninth, tenth, and eleventh
ribs ; internally, where it is slightly concave, it is perforated
by six or eight foramina for the passage of vessels, and in
contact with the stomach and pancreas. Thus the spleen is
in relation with a number of highly important organs, upon
all of which it must encroach, to a greater or less extent,
when in a state of hypertrophy. In case of excessive en-
largement, it might sensibly interfere with the motions of the
diaphragm, and thus cause difficulty of respiration ; with the
stomach, and thus occasion indigestion ; or with the colon
and small bowels, producing displacement, together with
difficulty of voiding the feces. The great vessels would
also be apt to be compressed, and in this manner might result
an unequal distribution of the blood, some of the viscera
being surcharged, others sparingly supplied with it. Moreover,
by interfering -with the ready return of this fluid from the
abdomen and pelvis to the heart, as must necessarily happen
whenever there is an obstruction in the ascending hollow
vein, ascites will be induced, generally of the most intracta-
ble kind. Naturally, the spleen is attached in a loose man-
ner by vessels and peritonseal folds ; but in certain states of
disease, it is more or less firmly agglutinated to the circumja-
cent viscera.

In shape, the spleen resembles the longitudinal section of

344 SPLEEN. [chap. X.

an ellipse, being convex, as before stated, on one side, and
nearly flat on the other. Its margins are of unequal thick-
ness, and not unfrequently, though not always, intersected
by notches. The color varies from a pale gray to a dark
brown, being considerably influenced by the age of the indi-
vidual, the nature of the disease, and the kind of death. In
the recent subject it is generally of a light bluish cast, which,
in a few hours, changes into a deep purple, so as to resemble
a mass of clotted blood. This alteration always takes place
very rapidly when the spleen is exposed to the atmosphere.
With respect to its texture, it is soft, somewhat spongy to the
touch, easily torn, and, next to the brain, decidedly the most
friable organ in the body.

The size of this organ is subject to so much variety, even
within the bounds of health, as to render it impossible to lay
down any definite rule concerning it. In the generality of
cases, it is about five inches in length by three in width, and
one and a half in thickness ; but from these dimensions, there
are frequent deviations. Thus I have often seen perfectly
healthy spleens that were not more than three inches in
length by two in breadth ; and, on the other hand, some that
were from seven to nine inches long, and from four to five
inches wide. Not less variable is its weight. In the average
number of cases, it does not exceed eight ounces ; but in one
instance, that of an adult male subject, I found it range as
high as fourteen ounces ; and in another, that of a full-grown
female, as low as three and a half. The mean specific gravity
of the organ, according to Krause, is 1060 ; according to
Cloquet and Cruveilhier, 1160.

An additional spleen is occasionally found. This is more
commonly the case, I believe, when the main organ is rather
small. The greatest number of supernumerary spleens that
I have ever seen was seven. Other writers have observed as
many as ten, twelve, or even twenty. Of a rounded shape,
they are about the volume of a nutmeg, and are usually situ-
ated in the gastro-splenic omentum, along the principal vas-
cular trunks. *

The spleen, like the liver, has two distinct tunics, which
are so closely connected as to render is extremely difficult,
nay almost impossible, to separate them. The external one
is derived from the peritonasum, and consequently of a serous
character, being thin, transparent, smooth and polished. The
other is of a fibrous nature, grayish in its color, compact, ex-

CHAP. X.] STRUCTURE. 345

tensible, and elastic. Like the corresponding covering of the
liver, it detaches an immense number of processes, which
extend into the interior of the organ, so as to convert it into
a spongy structure, not unlike the cavernous body of the
penis. These processes support the ramifications of the
splenic vessels and nerves, and the cavities which they form
communicate freely with each other; such at least is the
conclusion I have arrived at from my own examinations. In
the spleen of the horse and ox, the cells are remarkably
large, and, by macerating the organ for a few days in water,
their pulpy contents may be easily washed out, leaving noth-
ing but the fibrous frame- work, together with the vascular
and nervous ramifications.

The precise nature of the pulpy substance of the spleen is
not well understood. It bears a very close resemblance to
the blood, whence some have supposed that it is merely that
fluid in a modified condition. In all probability, however, it
is a peculiar structure upon which are spent the ultimate
ramifications of the splenic vessels, nerves, and absorbents,
though the manner in which these terminate is a point that
remains to be settled. It is of a dark brownish color, similar
to that of wine-lees, extremely soft, and so strongly impreg-
nated with albumen as to form a dense coagulum on being
steeped in alcohol. Interspersed through this pulpy substance
are a great number of rounded corpuscles, varying in size
from that of the smallest pin-head to that of a millet-seed.
Occurring either separately, or in groups, they are of a gray-
ish color, semi-transparent, and of a soft gelatinous consist-
ence. Their nature is quite unknown. Ruysch considers
them as being composed of convoluted vessels, whilst Mal-
pighi regards them as small glands.

The spleen, in proportion to its size, receives a larger
amount of blood than almost any other organ in the body.
Its principal artery is derived from the cceliac axis, being the
most capacious branch of the three which are detached from
that vessel : it courses along the superior margin of the pan-
creas ; and, as it approaches the fissure of the spleen, it divides
into several trunks, which enter the parenchymatous sub-
stance at different points, having previously sent ofii" five or
six branches to the great tuberosity of the stomach. The
accompanying vein is still more capacious : it is destitute of
valves, and is one of the principal trunks which form the
portal vein. The precise mode of termination of these ves-

voL. II. 44

346 SPLEEN. [chap. X.

sels is unknown. It would appear, however, from the dis-
sections of Assolant and others, that the communications
between them are not so free, by any means, as in other parts
of the body. It may be observed here, that the volume of
the spleen varies much in proportion to the amount of blood
it contains. If a ligature be thrown around the principal
vein, the organ augments considerably in size, whilst the
pressure exerted upon it by a distended stomach diminishes
it. Lieutaud asserts that the spleen always enlarges during
chymification ; but this has been denied by others. The
absorbent vessels of this viscus are extremely numerous. Its
nerves are small, and are derived from the solar plexus : as
they proceed towards their destination, they creep along the
coats of the splenic artery, upon the surface of which they
form a beautiful and inextricable plexus.

Until recently, the diseases of the spleen seem to have
received but little attention from the pathologist ; and hence,
as might be expected, our information concerning them is
still, in many respects, vague and unsatisfactory. Independ-
ently of the imperfect manner in which morbid anatomy was
cultivated in former times, various other circumstances have
concurred to retard our knowledge of the different lesions of
this singular organ. Amongst these not the least important
are, the obscurity which still envelopes the functions of the
spleen ; the depth of its situation in the left hypochondriac
region ; the mode of its connection with other viscera ; and,
finally, the tardy and insidious way in which it becomes de-
ranged, years sometimes elapsing before the organ suffers
much inconvenience or before the rest of the body takes cog-
nizance of the particular disorder with which it is affected.
Another source of deception has arisen from a supposition, at
one time very prevalent amongst physicians, that the lesions
of the spleen are rare ; but that this is not the case is a fact
which must be familiar to every one who has been at all
extensively engaged in the practice of medicine, where few
examples occur of abdominal or thoracic malady, in which
the organ in question is not more or less involved. In some
countries, as Holland, South America, and certain districts of
India, the diseases of the spleen are occasionally endemic •
and they are very common, indeed, wherever marsh miasm
has an opportunity of exerting its malign influence. Hence
intermittent fevers are rarely present without them, especially
when violent or of long standing.

CHAP. X.] INFLAMMATION. 347

The lesions of the spleen, so far as they have hitherto been
observed, may be comprised under the following heads : 1.
inflammation; 2. suppuration; 3. gangrene; 4. softening; 5.
induration ; 6. hypertrophy ; 7. atrophy; 8. tubercles ; 9. mel-
anosis ; 10. calcareous deposits ; 11. hydatids; 12. apoplexy.

Inflammation of the spleen may be seated in its parenchy-
matous structure, or it may be limited to its envelopes. In
many cases the serous coat remains perfectly sound, but
there are probably few in which the fibrous is not more or
less implicated, either primarily or consecutively. Acute
splenitis seems to be a very rare disease, both in this country
and in Europe ; but it is very common in the East Indies,
and often runs its course in a very short time. In the milder
grades of the disease, or in the early stages of its attack, the
substance of the organ is of a red brownish color, verging
towards livid, gorged with grumous blood, and somewhat
indurated : it tears with more facility than in the healthy
state, is considerably swelled, and the congestion frequently
extends to the great omentum, the stomach, and the liver,
the latter of which, according to Gendrin, is ordinarily aug-
mented in volume. At a more advanced degree of intensity,
the spleen is reduced to a soft blackish mass, not unlike half-
dissolved blood : it exhibits a homogeneous aspect, and readily
breaks under the pressure of the finger. In very violent
cases, lasting several days, globules of pus are not unfre-
quently disseminated through the disorganized structure, or
collected into one or more depots, which are either enclosed
by a distinct sac, or surrounded by softened splenic sub-
stance. The peritonasal and fibrous coats, also, are more or
less inflamed ; and in many instances the organ is glued to
the adjacent viscera, such as the stomach, colon, or diaphragm,
by masses of lymph. The splenic artery no longer admits
injecting matter, and the splenic vein usually contains black
grumous blood, mixed with pus. This phenomenon, how-
ever, is far from being constant.

In acute splenitis, the patient commonly complains of a
peculiar fulness and sense of pain in the left hypochondriac
region, increased by coughing and external pressure. Often-
times the pain extends to the left shoulder, and is of a sharp
lancinating nature, like that of pleurisy ; at other times, it is
perceived over different parts of the abdomen, and leads to
the inference that the individual is laboring imder peritonitis
or gastro-enteritis. Much difficulty is experienced in lying

348 SPLEEN. [chap. X.

on the affected side ; there is a burning and oppressive sensa-
tion in the epigastric region ; and, in violent cases of the
disorder, those which rapidly terminate in a general dissolu-
tion of the structure of the spleen, incessant vomiting is a
frequent and distressing symptom, which is often attended
hy a discharge of grumous blood, both from the stomach and
the bowels. The same phenomena are present, only in a
more aggravated degree, when the inflammation attacks the
coats of the organ. Of chronic splenitis, we shall speak
when we come to consider the subject of hypertrophy.

Suppuration of the spleen is a very rare occurrence, though
perhaps not so much so as the few cases of it which are to
be found on record would lead us to suppose. The pus,
although frequently of the creamy kind, is sometimes hard and
fl.aky, or thin and dark-colored, like coffee-grounds. In most
cases, it is collected in a distinct sac, round which the paren-
chymatous structure is more or less softened, broken down, or
even altogether destroyed. Occasionally the pus is infiltrated
into the substance of the organ, or it occurs in minute yellowish
clots, intermixed with sanious matter. In quantity, it varies
from a few ounces to several quarts. In a case mentioned by
L'Hermite, a French author, not less than fifteen pounds
were found, the sac in which it was contained measuring
eighteen inches in length by twelve in breadth ; and in the
Memoirs of the Royal Academy of Sciences a still more
remarkable instance is recorded, the quantity of matter
amounting to the enormous weight of thirty pounds. The
coats of the spleen are almost always sooner or later affected,
and, together with the neighboring viscera, are covered with
false membranes, which are sometimes perfectly organized.
Cases occur in which the whole organ is converted into one
great abscess, the sac being either fibrous, cartilaginous, or
even bony.

The matter may find its way into the peritonseal cavity,
the stomach, colon, or small intestines ; or it may burst
through the intercostal spaces, the loins, or the walls of
the abdomen. Occasionally the spleen contracts adhesions
to the diaphragm, and the matter is discharged into the left
side of the chest. In this way it may get into the lung, and
be finally expelled by coughing.

The symptoms of suppuration of the spleen are frequently
very obscure. When the investing membranes remain sound,
the pain in the part is sometimes very trifling ; but there is

CHAP. X.] SUPPURATION. 349

always uneasiness in the hypochondriac region, with pro-
gressive emaciation and debihty. When the suppuration su-
pervenes upon acute splenitis, the suffering is generally of the
most poignant kind ; and, in such cases, the formation of mat-
ter often takes place very rapidly. In a young, robust farm-
er, for whom I prescribed several years ago, the pain, which
was of a sharp, lancinating character, similar to that which
accompanies acute pleuritis, continued almost uninterrupt-
edly for nearly two weeks. The spleen gradually augmented
in volume, and, at the expiration of the period here specified,
it projected over towards the umbilicus, forming a large,
rounded tumor, between the linea alba and the margin of the
ribs. In a short time, fluctuation was perceived, and, on in-
troducing a trocar, about three pints of fetid, dark-colored
matter issued from the incision. The wound was kept open
for several days, by means of a tent ; but in a short period it
closed, and from thence on, the patient's health began grad-
ually to improve. This case, decidedly one of the most in-
teresting and instructive on record, supervened upon repeated
attacks of intermittent fever, and was characterized by ex-
cessive irritability of the stomach, great pain and tenderness,
and an impending sense of suffocation, caused, no doubt, by
the pressure of the enlarged organ upon the diaphragm.

The termination of splenitis by gangrene is a very rare
occurrence, notwithstanding the assertion of Portal, that the
reverse is the case.* Morgagni records only two examples of
it, in both of which there was a similar lesion of the intes-
tines. Modern authors, also, say very little upon the subject,
and we have good reason to complain of the neglect with
which it has hitherto been treated. The spleen, in this dis-
ease, is converted into a soft, diffluent mass, of a brownish,
livid, or blackish color, and extremely offensive to the smell.

A much more common effect by far of inflammatory irri-
tation of the spleen, is a softening of its substance, or a conver-
sion of it into a dark-colored, bloody colluvies. The disease
is a very frequent attendant on intermittent and typhoid fe-
vers, chronic diarrhoja and dysentery, and aff"ections of the
brain and liver. In some countries it is occasionally sporadic,
but more ordinarily it is epidemic. The regions most re-
markable in this respect are the marshy districts of Italy,

* Anatomie Medicale, t. v. p. 336, — " La Gangrene de la rate s'observe assez
souvent."

350 , SPLEEN. [chap. X.

Bengal, Denmark, La Vendee, the island of Walcheren, and
East Friesland.* Animals are often affected with it ; and it
is asserted, though I do not know upon what ground, that it
is much more common in women than in men. In softening,
the spleen may be enlarged or diminished, or it may retain
its normal dimensions ; its whole parenchymatous struc-
ture is broken down into a soft, blackish mass, not unlike
grumous blood, thin tar, or currant jelly, surrounded by thick-
ened and indurated coats. In the more aggravated forms of
the complaint, the organ sometimes bursts spontaneously,
without any violence on the part of the patient, and the mat-
ter escaping into the peritonaeal cavity induces fatal inflam-
mation. Occasionally, however, the shell which encloses it
is so strong as to prevent this. This was evidently the case
with a spleen in the museum of the Cincinnati College, in
which the parenchymatous structure, although perfectly soft-
ened, is surrounded by a layer of lymph at least one fourth
of an inch thick.

Of the mode in which this change of structure is effected,
nothing more is known than of mollescence in general. Most
pathologists, however, concur in the opinion that it results
from inflammatory irritation, breaking down the vascular and
parenchymatous textures of the viscus by a kind of gangrene.
This doctrine derives support from several circumstances, a
brief examination of which will not be without interest in
connection with this topic. In the first place, it may be al-
leged that the changes here spoken of do not occur all at
once, but attain their perfection by degrees. In the incipient
stage of the disease, the spleen is merely injected with dark,
dirty-looking blood, and its reticulated structure is as yet not
very materially altered. Indeed, it is not until the disorder
has existed for some time that the organ assumes that black,
tar-like aspect which characterizes the softening when it has
reached its full developement. The disease, secondly, is often
accompanied by inflammation of some of the other viscera,
and by severe pain in the left hypochondriac region, corre-
sponding to the seat of the spleen. Crendal and Abercrombie
relate cases in which it coexisted with pneumonitis ,• and oth-
ers refer to examples where it was complicated with lesion of
the stomach, liver, pancreas, kidneys, and intestines. In ma-
ny of the subjects who died of the celebrated Walcheren

* Hackmann, on Softening of the Spleen, Medico-Chir. Rev. July, 1832.

CHAP. X.] SOFTENING ; LACERATION ; INDURATION. 351

fever, examined by Wardrop, Vetch, and other physicians,
the spleen was greatly enlarged, often weighing from three
to five pounds, and reduced to a mere bag, filled with a semi-
fluid pulp, not unlike black currant jelly. In the malignant
fevers of Italy, Sardinia, Bengal, and Hungary moUescence
of this organ is a very common affection ; and the same
change is often witnessed in those who die of typhus in
France, England, and America. In forty-six dissections of
typhus, Louis found the spleen softened in three fourths, and
in a fifth part of these to such an extent as to be reduced to
a pulpy mass with the greatest ease. In the Egyptian plague,
this viscus is generally softened, and double its natural vol-
ume.* From all these facts, then, it may, I think, be justly
concluded that mollescence of the spleen is uniformly depend-
ent upon inflammatory irritation, generally of a high grade,
though occasionally of a slow, chronic character.

Softening of the spleen is hardly ever to be observed at a
very early period of life, but it is very common in middle
and advanced age. Its progress is often very rapid, reaching
its height in the course of four or five days. Occasionally,
though rarely, it assumes a chronic form, as in the cases men-
tioned by Bonetus, Portal, and Hackmann, The symptoms
resemble for the most part those of acute splenitis. The pre-
cordial distress is often exceedingly great, and is said never
to be entirely absent in any attack of this disease. Towards
the last, the patient is harassed with debilitating diarrhoea,
vomiting of blood, and hectic fever, dissolution being not un-
frequently preceded by a state of coma resembling apoplexy.

The spleen is sometimes indurated. This change is gen-
erally associated with hypertrophy, and is probably occasioned
by chronic irritation, giving rise to congestion of the capillary
vessels, and to effusion of lymph into the reticulated tex-
ture. The spleen seldom retains its natural color ; most com-
monly it is of a light brownish hue, tears with a granulated
surface, and i.mparts to the finger the same solid feel as the
substance of the liver. When these characters are present,
the organ is said to be hepatized, — a phenomenon which is
frequently witnessed in this country, in persons who die from
the effects of intermittent fever. Induration of the coats of
the spleen will be spoken of in another paragraph.

* Clot-Bey, on the Plague in Egypt: British and Foreign Medical Review,
vol. i. p. 248.

352 SPLEEN. [chap. X.

One of the most common affections of the spleen is hyper-
trophij^ a state which I have observed in nearly three fifths
of all the examinations that I have ever made. It gener-
ally occurs in connection with intermittent, remittent and
typhous fevers,* and seems to depend chiefly upon mechan-
ical congestion, exciting ultimately, perhaps, irritative ac-
tion. That this is probable, is proved by the fact that the
spleen is usually more or less indurated, and otherwise
changed in its structure. The enlargement is sometimes truly
enormous. In many cases the organ is ten or fifteen times
the natural size ; and, in an example recorded by Lieutaud,
it weighed not less than thirty-three pounds. The patient
was an aged female, and the hypertrophy had been gradually
progressing for seventeen years. The hypertrophy is some-
times partial, occurring in the form of a tumor, about the
size of a walnut or an orange. Of this I have seen several
well-marked examples. Some writers, and amongst others
Dr. Abercrombie, speak of what they call simple enlargement
of the spleen, unaccompanied with derangement of structure :
if such a state exists, I have never met with it, and am much
disposed to doubt the possibility of its occurrence. This re-
mark applies of course exclusively to cases of permanent
hypertrophy, and has nothing to do with that tumid and
erected condition of the spleen which results from the tem-
porary congestion that occurs during the cold stage of inter-
mittent fever, or from violent emotions of the mind.

The hypertrophy is sometimes of a mixed character, some
parts of the spleen exhibiting a healthy aspect, whilst others
are indurated, scirrhous, broken down in texture, or in a state
of suppuration. The coats of the organ are usually hardened,
opaque, and thickened, either by interstitial effusion, or by
depositions of lymph upon their surface.

The symptoms of this disease are often remarkably ob-
scure. In many cases they are such as would lead us to
believe that the patient is laboring under chronic splenitis ;
but, oftentimes, no other inconvenience is experienced than
what results from the increased size and weight of the
affected organ. More rarely the symptoms are of an acute

* Enlargement of the spleen is observed in a very large proportion of those
who die of typhus. Louis and Chomel found the organ prelernaturally volu-
minous in nearly all their cases. In the majority of the patients, it was double the
natural dimensions ; in others, it was three, four, or even five times the usual

CHAP. X.] ATROPHY— TUBERCLES. 353

character. As the hypertrophy advances, a firm, solid tumor
is formed, which projects below the false ribs of the left side,
occasionally as far down as the umbilicus, and imparts either
a smooth, or notched sensation to the hand applied to the
abdomen. In protracted cases, there is sometimes hemateme-
sis, hemorrhages from various parts of the body, and at last
general dropsy.

Atrophy of the spleen is by no means so frequent as hyper-
trophy. Various writers, especially amongst the ancients,
relate cases of it ; but their statements are so contradictory
that it is impossible to draw any useful information from
them. Andral had seen the spleen no larger than a walnut ,•
and, in a case which came under my notice a few years ago,
it was scarcely as big as a billiard-ball. It was of a grayish
color, rounded in figure, indurated, almost bloodless, and
weighed only one ounce. Both coats were thickened, and
the internal one was partially converted into cartilage. The
patient, an old man of seventy-two, had died of tubercular
phthisis.* Hitherto, this wasting of the spleen has been ob-
served chiefly in connection with chronic aifections of the
alimentary tube, the liver, and kidneys, with ascites, and pro-
fuse discharges of blood from different parts of the body.
The lesion is sometimes partial, and consists apparently in a
removal of the parenchymatous texture of the organ, leaving
merely the original fibrous frame-work.

Tubercles are not uncommon in the spleen. I have seen
them repeatedly in this organ in children, but only once in
the adult, and never in the very aged. In one instance, I
met with them in an infant only a few months old : they
were very small, solid, and so numerous, that the organ was
literally crowded with them. Tubercles of the spleen seldom
occur in clusters, and, excepting in adults, they do not often
acquire a great size. Occasionally, though rarely, they soften,
and form numerous small abscesses, filled with thick, curdy
matter. These little bodies are not peculiar to the human
spleen ; Andral has repeatedly found them in the horse, and
Ileynaud in the monkey. They seldom lead to fatal results,
either in man or in animals ; and, in the present state of our
knowledge, we know of no symptoms which are indicative

* Thonerus saw a case in which the spleen weighed only one ounce, and
Portal refers to another in which it was not bigger than a nutmeg. Cruveil-
hier states that he has seen this organ redttced to the weight of a drachm.

VOL. II. 45

354 SPLEEN. [chap. X.

of their presence. In most cases they exist at the same time
in the lungs. When large and numerous, they are apt to
excite inflammation in the neighboring portions of the peri-
tonaBum, leading to ascitic accumulations.

In some instances, the spleen is afiected with tnelanosis ;
but of this I have never seen an example. Authors also
mention a deposition of fatty substance, as an occasional
phenomenon ; and encephaloid matter is likewise, I presume,
sometimes found. All these lesions are extremely rare, and
there are no symptoms, so far as we know, by which they
can be discriminated during life.

Calcareous deposits are rarely observed in the spleen. They
are of a whitish color, soft and friable, generally small, and
few in number. Bonetus, however, mentions a case in which
the organ was literally filled with them ; and Morgagni states
that he saw a concretion of this kind, which weighed twenty-
one drachms, and which was arranged in concentric layers.
Similar cases have been witnessed by Valsalva, Baader, and
Bartholin.

A very frequent affection of the spleen is a conversion of
its tunics into a substance resembling fibro-cartilage. The
change generally begins on the convex surface, to which it
either remains confined, or gradually spreads over the rest of
the organ. The cartilage commonly occurs in small, soft,
thin patches, separated by considerable intervals ; but, in a
few instances, I have seen it quite thick, hard, and occupying
a very large extent of surface. This transformation, which
may affect one or both tunics, is no doubt, slow in its pro-
gress, and is never marked by any special symptoms.

In some rare instances, these coats are transformed into
bony matter, either in part or entirely. Lithe saw a spleen
which was completely ossified : it was taken from an old
man, who died suddenly in apparent good health, and weighed
only one ounce and a half. A somewhat similar case was
seen by Andral. The organ was converted into a mere
osseous shell, intersected by numerous bony septa, and filled
with a small quantity of thin, reddish fluid, like dirty wine.

Hydatids are occasionally found in the spleen, but I have
never seen an instance. Their origin is probably the same
here as in the liver, and hitherto they have been met with
chiefly in persons of a cachectic constitution. The substance
of the spleen immediately around these bodies is variously
affected ; in most cases, it remains unaltered, but occasionally

CHAP. X.] SEROUS CYSTS APOPLEXY. 355

it is indurated, softened, or even quite pulpy. The hydatids
may be simply attached to the surface of the organ, grow
between its tunics, or be developed in its parenchymatous
structure. Andral states that he has occasionally seen them
in the splenic veins, where they either floated about, or ad-
hered by delicate foot-stalks.

Serous cysts are sometimes met with in the spleen ; they
are generally of a globular shape, adhere to the surface of
the organ, by short, delicate pedancles, and contain a clear,
limpid fluid, like spring-water. Such vesicles I have seen in
quite a number of instances. They rarely attain much mag-
nitude ; and in some cases they are occupied by a sort of
milliceric, atheromatous or steatomatous substance. No symp-
toms accompany these lesions, that can te considered as in the
slightest degree pathognomonic. Their mode of origin is
extremely obscure, and they admit of but little medical in-
terference.

The spleen is occasionally affected with internal hemor-
rhage, so nearly resembling that of the brain that M. Cru-
veilhier, by whom this lesion was first accurately described,
has been induced to designate it by the term apoplexy*
The blood is deposited in one or more points, commonly of
a rounded shape, and of variable size, and is evidently the
result of a laceration of some of the branches of the splenic
vessels. When the hemorrhage is connected with softening
of the organ, the fluid sometimes accumulates in large clots,
or it bursts the coverings of the spleen, and rushes into the
peritonasal sac. The changes which the apoplectic deposits
exhibit are of the same nature as under similar circumstances
in the brain and other organs. This malad}?- is not uncommon
in some of the inferior animals. In the horse and cow it
often proves fatal in the course of a few hours, the quantity
of blood poured out sometimes amounting to several gallons.
It is now well ascertained that ossification of the splenic
artery is a very frequent lesion in old age ; and it is not im-
probable, I think, that this state of the vessel is the principal
cause of the internal hemorrhage of the organ. This opinion
has nothing in it that is at all absurd. Similar results, we
know, often follow ossification of the cerebral arteries; and
if this lesion exists in the spleen, we have only to suppose

* Diet, cle Med. et Chir. Pratiques, t, i. p. 29G.

356 SPLEEN. [chap. X.

that the individual would have to expose himself to great
exertion to bring about the same phenomenon.

The spleen, owing to its soft, brittle texture, is liable to
be lacerated by external violence, such as a blow or kick,
or by a fall from some height. In such cases, of which a
great many are referred to by Portal and other authors, the
individual usually expires in a short time, of hemorrhage, or
from the shock of the nervous system.

CHAPTER XI.

Of the Pancreas.

Where situated, and how organized. — Weight and Dimensions. — Color. —
Has no special Envelope. — Is liable to pretty much the same Diseases as the
Salivary Glands. — Rarely the Seat of Acute Iniammation. — Is sometimes
affected with Scirrhus. — Fatiy Transformation. — Serous Cysts. — Tubercu-
lar Deposits.

The pancreas, situated deeply in the abdominal cavity, is
stretched horizontally across the vertebral column, the aorta,
and great hollow vein being concealed by the stomach and
the arch of the colon, and extending from the spleen to the
second portion of the duodenum, the latter of which it closely
embraces. In its structure it bears the strongest resemblance
to the salivary glands, being, like them, composed of numerous
lobules and granules, which are of a faint pink color, firm in
their consistence, and connected together by dense cellular
substance. It is of an irregularly elongated form, slightly
convex in front, and nearly flat behind ; the inferior margin
is rounded, and the superior is grooved for the lodgement of
the splenic vessels. Its dimensions, for about two thirds of
its extent, are nearly uniform ; after which it becomes remarka-
bly contracted, but soon expands again, so as to constitute
what is called the head of the pancreas, or that part which
adheres to the small bowel.

The following are the mean weight and dimensions of the
healthy adult pancreas, as they were revealed to me in six
examinations :

Weight, - • - - - - - - - §2|

Length, 7 inches.

Breadth at the body and splenic extremity, - - 16| lines.

" at the neck, ----- 12 lines.

" at the head, - - - - 2 inches 3 lines.

Thickness at the body, neck, and splenic extremity, 4 lines.

" at the head, 8 lines.

The color of this organ varies somewhat in the different
periods of life. In children it is of a rosaceous tint, in the

358 PANCREAS. [chap. XI.

adult it is a shade or two lighter, and in old age it commonly
exibits a pale yellowish appearance. Its consistence, con-
sidered in reference to the different stages of our existence,
does not appear to be liable to much diversity.

The pancreas has no distinct envelope, unless we consider
as such the delicate film of cellular substance which is
spread over its exterior. Its excretory duct, which extends
the whole length of the gland, is about the size of a crow-
quill, and opens at an acute angle into the duodenum, either
alone, or, as is more commonly the case, conjointly with the
choledoch duct. The canal is almost always single ; some-
times, however, there are two, or even three. In one in-
stance I found it enlarged to the size of a goose-quill, and
filled with thick, whitish mucus, from a partial closure of its
orifice. The nerves of the pancreas are derived from the solar
plexus. Its vessels are numerous, but small.

There is much variety in the different organs of the body,
with regard to their susceptibility of being excited to disease.
Amongst these, there is none, except, perhaps, the thymus
gland, which is less frequently affected than the pancreas.
This exemption from derangement may probably be owing,
certainly in part, to the singular structure of this viscus, to
its concealed situation, and to the absence of every thing like
a proper envelope. Occasionally it is attacked with inflam-
mation, originating either in its substance, or propagated to
it from the surrounding organs, especially the duodenum, the
lining membrane of which, as before stated, is reflected into
its interior along the rootlets of its excretory duct. In the
acute form of this disease, the pancreas is of a light reddish
color, and the interlobular tissue is infiltrated with serosity,
by which the glandular texture is rendered unusually distinct.
When the inflammation is violent, the color becomes more
deep, not unfrequently of a brownish mahogany tint, and the
proper substance of the organ undergoes such a degree of
softening that it may be readily torn asunder.

Although acute pancreatitis generally terminates by reso-
lution, yet cases occasionally occur where it passes into the
chronic form, or leads to suppuration. The matter, as in the
other viscera, may be diffused through the interlobular cellu-
lar tissue, or be collected into an abscess. In the former case,
the pancreas is generally very soft, and its glandular structure
of a reddish gray color ; in the latter, a portion of the organ
is usually broken down, and the matter ultimately bursts

CHAP. XI.] DISEASES. 359

into the adjacent reservoirs, as the stomach, arch of the colon,
or duodenum. In some instances, it escapes into the celhilar
tissue of the meso-colon, where it is either absorbed, or it
erodes those of the lamina of this fold, and makes its way
into the abdominal cavity. In a case mentioned by Gendrin,
the abscess opened, into the jejunum, and the gland was con-
verted into a hard, reddish friable mass, the interior of which
was filled with drab-colored, fetid pus. I am not aware of
any instance being on record where the matter that was thus
collected, discharged itself into the aorta and vena cava ; but
I can readily conceive of the possibility of such an occurrence.
The fluid is sometimes contained in a strong pouch, formed
by the condensation of the cellular tissue which naturally
surrounds the organ, aided by a deposition of fibrin.

There is considerable diversity observable in relation to
the nature and consistence of the purulent matter. Most
commonly it is thick, yellowish, and inodorous, as it occurs
in healthy suppuration of other parts. In other cases, how-
ever, it has been known to be very thin, sanious, greenish,
curdy, and highly off"ensive. The quantity of pus seldom
exceeds a few ounces. In an example recorded by Portal,
the abscess contained upwards of two pounds.

It is a remarkable fact, that, in most of the examples that
have hitherto been reported of acute inflammation and suppu-
ration of this organ, there was disease in some of the other
viscera. In a case related by Portal, the patient had labored
for some time under violent paroxysms of gout in the feet,
and suddenly expired during an attack of vomiting. In other
instances we find it to have been connected with continued
and intermittent fevers, chronic diarrhoea, dropsy, epilepsy,
and disease of the liver and spleen. In several cases record-
ed by Anthony Petit, the suppuration would seem to have
supervened upon the extirpation of the testicle, with ligature
of the spermatic cord, — a circumstance which induced that
celebrated surgeon to write a memoir against the propriety of
using the ligature in such operations. In a gentleman, who
was attended by Dr. Percival, of England, and whose
pancreas was much enlarged, and contained a considerable
abscess, there was a distinct tumor in the epigastric region,
with jaundice and bihous vomiting, a gradual failure of
strength, and frequent discharges of bloody and fetid pus from
the bowels. On the whole, we are unable to point out any
particular symptoms or series of phenomena that indicate the
existence of this disease during life.

360 PANCREAS. [chap. XI.

In regard to the softening of the pancreas, our knowledge
is still extremely limited and imperfect. The disease, which
is marked by the usual anatomical characters, has hitherto
been observed chiefly in persons that have died of scurvy,
small-pox, scrofula, and measles. In two children who suc-
cumbed under the latter malady, Portal found the pancreas
remarkably softened, without any alteration of color or in-
crease of volume.

Acute pancreatitis, especially when it supervenes on a chron-
ic attack, sometimes ends in gangrene. Of this termination,
instances are related by Greisel, Portal, and other respectable
authorities. In the case mentioned by the first of these
writers, the whole organ seems to have been sphacelated, as
well as the parts immediately around it. Indeed, violent in-
flammation of the surrounding viscera is one of the most
common complications of gangrene of the pancreas. When
this event has taken place, the substance of the pancreas is of
a dark livid color, greatly softened, and exudes a blackish,
fetid fluid on pressure, like mortified structures in other situ-
ations.

Chronic inflammation is no doubt much more frequent than
the form of the disease which we have just been considering.
Under the influence of this disorder, the pancreas becomes
hard, firm, crisp, and of a dull reddish color, at the same time
that it augments considerably in volume, from the interstitial
deposition of lymph. This increase of size, however, is far
from being a constant phenomenon. Indeed, I am inclined
to believe that, in very many cases, the organ experiences a
real diminution, its lobules and granules becoming more close-
ly aggregated than they are in the normal state. When the
irritation is protracted, the pancreas often assumes a pale
grayish aspect, and a hard gristly consistence, giving rise to
a real scirrhous induration.

The scirrhous induration may pervade the entire gland, or
occur in small patches, separated by portions which retain
their normal structure and appearance. In a case mentioned
by Dr. Abercrombie, the pancreas was more than seven
inches in length, five in breadth, by three inches in thickness,
and presented a singularly mixed state of disease. Some
parts being almost as hard as cartilage, others quite soft, and
composed of alternate strata of white and yellowish matter.
The patient, a youth of sixteen, had complained for several
months of pain in the back and stomach, and died, gradually

CHAP. XI. 1 CHRONIC INFLAMMATION; CYSTS. 361

exhausted by vomiting and diarrhoea, a large, irregular tumor
having been latterly observable in the epigastric region. Ma-
lignant disease rarely attacks the pancreas alone, but, in com-
mon with it, almost always involves the stomach, liver, duo-
denum, or spleen. Dr. Southwood Smith states that this
organ is very constantly diseased in fever. It is generally
more firm, he avers, than natural, and sometimes nearly car-
tilaginous. This, if true, is certainly an interesting circum-
stance, and one which should engage further attention.

There are no symptoms, unfortunately, which can be re-
garded as pathognomonic of these chronic affections of the pan-
creas. In most cases, the phenomena are such as indicate a
deranged state of the digestive apparatus. The pain, which
is occasionally quite acute, is commonly of a dull, aching
character, shooting along the spine, and augmented by pres-
sure ; often there is great irritability of the stomach, so that
the individual retains his food with difiicLilty ; and, in some
instances, there is deep jaundice, arising probably from the
enlarged and indurated mass choking up the biliary ducts.
When the tumor is considerable, it can be readily felt in the
epigastric region, and, by compressing the nerves of the ab-
domen, frequently gives rise to pain in the hips, and numb-
ness of the lower extremities. The outline of the swelling
will be most distinct when the stomach is empty, and the
examination, in order to be satisfactory, should always be
made during this state.

The pancreas is sometimes transformed into a substance
resembling fat. Examples of this disease have been reported
by Dupuytren, Becourt, and Lobstein, the latter of whom has
delineated a specimen of it in his plates of morbid anatomy.
When the pancreas is thus affected, it is of a pale yellowish
color, more or less soft, indistinctly lobulated, and readily
greases the scalpel. Its size is usually augmented, and the
vessels preternaturally small and brittle. This degeneration
is extremely rare, and the causes which give rise to it are still
involved in obscurity.

Of serous cysts, as occurring in the substance of this gland,
very little is known. Indeed, there are only two cases of this
disease on record of which I have any knowledge. One of
these has been recently published by Dr. Becourt, a French
physician. The tumor, which is contained in the medical
museum of Strasburgh, is fully as large as the head of a child
four years old, and is composed of very strong, fibrous walls,

VOL. II. 46

362 PANCREAS. [chap. XI.

the twelfth of an inch in thickness. The other case came
under the observation of Dr. Duponchel, in the raiUtary hos-
pital at Cadiz. The cyst, in this instance, was somewhat
smaller, and had entirely supplanted the pancreas, not a ves-
tige of which remained. It had thick, dense parietes, and
was occupied with a brownish, bloody-looking matter, not
unlike the gray substance of the brain.*

The same remark may be made in reference to tubercular
disease of the pancreas. In one hundred children who died
of scrofula, Dr. Lombard met with this affection only five
times in the present organ ; and Professor Carswell declares
that he has never seen an example of it in the human subject,
and but one in an inferior animal, — the monkey. Dr. Louis
does not seem to have paid any attention to the pancreas in
the dissections which he made of persons who died of pul-
monary phthisis under his care in Paris. Had it been found
diseased, however, he would no doubt have mentioned the
circumstance ; his not having done so is a sufficient proof, it
seems to me, that it was always healthy. In an interesting
case recorded by Mr. Mayo, the pancreas was partially infil-
trated with tubercular matter, which was converted, in some
places, into thick pus. Similar depositions were observed in
one or two of the mesenteric ganglions, in the kidneys, and
in the thymus gland. In another instance, which came under
my own notice, the head of the pancreas contained nearly a
dozen tubercles, of a spherical shape, whitish in their appear-
ance, and of a firm, solid consistence. The subject was a
negro boy, between eight and nine years of age, who died of
pulmonary phthisis. Suety, atheromatous, and meliceric
substances have been observed in the pancreas ; but this is
extremely rare ; I have never met with an instance.

The pancreas may be in a state of atrophy. This is some-
times congenital, but most commonly it is induced by com-
pression of the neighboring viscera, as an enlarged spleen,
a scirrhous duodenum, or a hypertrophied liver. In a case of
this kind which I had an opportunity of observing, not long
ago, in a young female who died of chronic hepatitis, at-
tended with peritongeal efi"usion, the pancreas was scarcely
four inches in length, by eight lines in width, and did not
weigh more than an ounce and a half: its substance was of
a pale grayish color, remarkably soft, and the excretory duct

* Bull de la Soc. Med. d'Eraul, Mars;.1824.

CHAP. XI.] TUBERCLES ; ATROPHY ; CALCULI, 363

nearly obliterated. Similar examples are recorded by Mor-
gagni, Guerin, Lobstein, and other authors. Berjaud saw a
case in which the wasting was produced by the pressure of a
large aneurism of the abdominal aorta. It might also be
caused, I should suppose, by contraction of the splenic arte-
ry, interrupting the nutritive function of the organ.

The duct of the pancreas, like that of the liver and gall-
bladder, is liable to be obliterated, and choked up with tuber-
cular matter, or earthy concretions. Of these morbid states,
I have never witnessed an example. The calculi vary in
size between a small pea and a nutmeg, are of a whitish
color, hard, friable, and of a spherical shape, with a rough,
irregular surface. They are easily dissolved by muriatic
acid, and are composed chiefly of carbonate of lime, in com-
bination with a minute quantity of animal matter. The
number of these concretions is sometimes considerable, as
many as a dozen having been found in a single subject. We
are not acquainted with any symptoms which may be con-
sidered as indicating the presence of these bodies. It may
be imagined that, when they are large, rough, or numerous,
they v/ould probably occasion a good deal of pain and irrita-
tion, together with gastric distress. But these symptoms, as
just stated, would not be characteristic, as they could not be
distinguished from those which attend disease of the neigh-
boring organs.

CHAPTER XII.

Oj the Urinary Apparatus.

SECTION I.

Of the Supra-renal Capsules.

I. Supra- renal Capsules. — Their Structure and Diseases enveloped in obscuritJ^

— II. The Kidneys. — Observations on their Normal Characters and Congenital
Vices. — Lesions of their Fibrous Covering. — JNephrilis, Acute and Chronic.

— Abscesses. — Softening. — Induration. — Gangrene seldom or never ob-
served.-— Bright's Disease. — Scirrhus and Encephaloid. — Tubercles. — Se-
rous Cysts. — Hydatids. — Fibro-Cartilaginous, Osseous, and Fatty Degenera-
tions.— Enlargement and Atrophy. — Renal Calculi. — The Strongylus. —
III. The Ureter. — Liable to Deposits of Tubercular Matter. — Effusion of
Lymph, Thickening and Attenuation of its Parietes, with Contraction or En-
largement of its Cavity. — IV. The Urinary Bladder. — Is rarely affected with
acute Inflammation, Suppuration or Gangrene. — Hypertrophy of the Mucous
and Muscular Tunics. — Developement of Cysts. — Ulceration. — Encepha-
loid Disease. — Neuralgia. — Calculous Concretions. — Healthy and Morbid
Urine. — V. The Prostate Gland. — Situation, Weight, and Volume. — Is liable
to various forms of Disease, especially to Enlargement.

The supra-renal capsule, situated at the upper extremity of
the kidney, is seldom found diseased. In the adult it is
always much smaller, relatively speaking, than in the infant,
in whom it probably performs a very important function,
though what that function is we are still ignorant of. As
life advances, this body gradually diminishes in size, becomes
indurated, brittle, and assumes a peculiar dark color. These
changes, which I have frequently noticed in young persons,
are generally very conspicuous in old age. The atrophy is
sometimes very great, the organ scarcely retaining a vestige
of its original shape and structure.

In a few instances, I have seen the supra-renal capsule very
red, injected, and softened, without, however, being able to
satisfy myself that it was inflamed. This disease, I suppose,
rarely exists independently ; in most cases, it is no doubt
propagated to it from the kidney or some other organ. Ab-

SECT. II.] KIDNEYS. 365

scesses have been known to form in this viscus. Such an
appearance has never come under my own observation, and I
am persuaded is extremely rare.

Earthy concretions have occasionally occurred in the supra-
renal capsule, and in a few rare instances it has been observed
to be changed into a substance like cartilage. Baillie once
saw tubercles in this organ, and two cases of a similar kind
have come under my own notice. In one of these, a young
man twenty-seven years of age, the right supra-renal capsule
was remarkably hard, dense, of a grayish mottled aspect, and
filled with concrete tubercles, many of which were quite
large. The left capsule was of a light slate color, and like-
wise contained several scrofulus deposits.* In the other
instance, that of a child of fifteen months, the disease was
connected with pulmonary phthisis, and consisted of a large
yellowish mass, of the consistence of soft putty. In both
these cases, the affected organs appeared to be of the natural
size.

SECTION II.

Of the Kidneys.

The kidneys are two glandular organs, whose office it is
to secrete the urine, and assist in depurating the blood. Sit-
uated deeply in the lumbar regions, a little exterior to the
spinal column, they are five inches in length, three in breadth,
and one and a third in thickness, their weight being usually
about five ounces. These statements comprise the average
results of twelve examinations, made with a view of deter-
mining the standard bulk of the kidney. But, it should be
observed, that there is no organ, excepting the spleen, which is
so liable to variation. Hence the weight of a healthy kidney
may range from four to eight ounces, its length from four to
six inches, its breadth from two and a half to three, and its
thickness from one to one and three quarters.

The color of these organs is of a reddish brown, not un-
like that of the muscles, and their parenchymatous structure
is harder and denser than that of any other glandular viscus

* See Western Journal of the Medical and Physical Sciences, vol. xi. p. 21.

366 KIDNEYS, [chap. XII.

in the body. Such, indeed, is their fragility, that they are
very easily ruptured by external violence, applied either
directly to the lumbar region, or communicated to them in
the form of a general shock. The kidneys are sometimes
remarkably pale, in consequence of extreme emaciation of
the system, from protracted and painful maladies of the other
viscera ; and not unfrequently they are of a dark purple
color, and greatly loaded with blood, from congestive stagna-
tion of this fluid in the capillary vessels. These phenomena
should not be mistaken for those of disease of the renal
tissues.

The kidney is enveloped by a thin fibrous capsule, which
is loosely connected to its exterior by short cellular substance.
On making a section of the organ, it will be found to be
composed of two substances, differing from each other in
color, situation, structure, and function. Of these, the exte-
rior is essentially vascular, being made up of the ultimate
ramifications of the renal artery and vein ; and it is in this
portion of the kidney that is secreted the urine. It is of a soft
glandular consistence, of a red dusky color, and about two
lines in thickness. Occupying the exterior of the viscus. it
is in contact, on the one hand, with the fibrous capsule, and
sends off prolongations on the other, which extend between
the cones of the tubercular texture, and thus insulate them
from each other. Thickly scattered through this substance
are small granulations, not larger than a pin-head, which are
supposed by Malpighi to be hollow, but the precise nature of
which is still undetermined.

The other substance is of a rose tint, inclining to grayish,
its color being usually a few shades lighter than that of the
vascular structure by which it is surrounded. It is arranged
in the form of cones, of which there are, on an average,
about ten in each kidney. The substance of these bodies is
essentially tubular, being composed of an immense number
of the most delicate canals, which give the part, when torn,
a striated fibrous arrangement. The office of these canals is
to convey the urine into the calyces of the kidney as fast as
it is secreted by the vascular texture ; and they are all lined
by a prolongation of the mucous membrane of the ureter.

The kidney receives an immense supply of blood through
the renal artery, more so, in proportion to its size, than any
other organ in the body. Its nerves, which are derived from
the solar plexus and from the small splanchnic, are also ex-

SECT. II.] STRUCTURE. 367

tremely numerouSj and establish important sympathetic rela-
tions with all the other viscera,- especially with the stomach,
brain, urinary bladder, testicles, and penis. A little attention,
to the distribution and relation of these nerves will enable us
to comprehend the sympathetic irritations which so frequently
accompany the diseases of the renal tissues.

Considerable variety is observed in regard to the original
conformation and situation of the kidney. No well authenti-
cated case has yet been recorded, I believe, of the complete
absence of both these organs in the adult. Dr. Klein, a
German physician, has, it is true, reported an example of this
kind ; but his account is too loose and unsatisfactory to be
entitled to the imphcit confidence of the pathological anato-
mist. Nor is it at all common to find one of the kidneys
wanting. In all my dissections, I have never met with an
instance, and Andral seems to have noticed only two. When
this anomaly exists, the other kidney is generally unnaturally
large, to compensate for the deficiency.

It is not rare to see one of these viscera in front of the
spinal column, or in the cavity of the pelvis, the other occu-
pying its usual situation. Cruveilhier states that he has sev-
eral times observed the right kidney very low down in the
corresponding iliac fossa, in women who had been in the
habit of wearing tight corsets. The renal organs are some-
times joined together by a narrow isthmus. When this is
the case, they lie close to the vertebrge, forming a kind of
arch, with the concavity directed towards the diaphragm.
They are more compressed than usual, the fissure is absent,
and the vessels enter lower down, generally at the anterior
surface. The situation of the ureter is likewise different.

Instances have been recorded of individuals who had three
kidneys. In these cases, either two of the organs were on
the same side, or they occupied their usual place, whilst the
supernumerary one was situated in front of the spine, or
within the pelvi'c cavity.

The fibrous capsule of the kidney is seldom implicated in
disease. Dr. Baillie remarks that he has never seen it under
acute inflammation, and the same is the result of my own
dissections of several hundred subjects. The reason why
this affection so seldom occurs in this structure, probably is,
that it has no connection with the peritonaeum, as is the case,
for example, with the spleen and liver, the envelopes of
which, as is well known, are very prone to inflammation.

368 KIDNEYS, [chap. XII,

Another reason, no doubt, is the fact that this membrane
sends no processes into the glandular structure of the organ,
the attachment between it and the outer surface of the kid-
ney being effected by very short cellular tissue, which, we
may suppose, rather prevents than admits of the propagation
of diseased action from the one to the other. When in-
flamed, this membrane will exhibit the same anatomical char-
acters that are found under similar circumstances, in the
other viscera.

In tubercular and scirrhous disease of the kidney, I have
found the jfibrous capsule, in several instances, very much
thickened, opaque, preternaturally strong, and covered with
patches of organized lymph. In the fatty degeneration, it is
sometimes remarkably attenuated, and hangs almost loose
around the organ, from the destruction of the connecting
cellular tissue. Portal states that he has seen the capsule of
the kidney partly ossified ; and cases are recorded by Bone-
tus, Morgagni, and Yoigtel, where it was converted into a
substance like cartilage. Not unfrequently it is glued to the
surrounding organs by thick masses of lymph.

The kidney itself is little liable to disease, which seems
surprising when we consider the great activity of its func-
tions, and the facility with which its secretions are modified
by the most trifling deviations from health. The principal
affections of this gland may be referred to inflammation,
suppuration, softening, induration, scirrhus, encephaloi'd, tu-
bercles, serous cysts, hydatids, hypertrophy, atrophy, and
earthy concretions.

Acute inflammation of the kidney is a very rare disease in
this country, and, as might be supposed, is much more fre-
quently observed in the vascular than in the tubular sub-
stance. It seldom involves the entire organ, and the redness
which accompanies it varies from a slight increase of the
natural color to a deep chocolate. This change is ordinarily
combined with softening of the structure of the kidney,
slight intumescence, and sero-purulent infiltration. The in-
jection on which the redness depends differs as it occurs in
the tubular or vascular substance. In the former, it is striated ;
in the latter, capilliform, the vessels forming beautiful wreaths
around the granulations. When the inflammation is seated
superficially, the affected parts can be readily distinguished
by their deep color, the arborescent arrangement of the capil-
laries, and the effusion of serous fluid beneath the fibrous
envelope.

SECT. II.] NEPHRITIS. 369

Nephritis — for so this disease is termed — is commonly at-
tended with great constitutional excitement, irritability of the
stomach, and a discharge of bloody urine, or urine mixed
with pus. It is a singular fact, in connection with this lesion,
that there is sometimes scarcely any pain experienced by the
patient ; or it is so obtuse as almost to escape attention.
Nevertheless, in the majority of cases the pain is extremely
severe, and is not only felt in the region of the kidney, but
darts along the ureter into the pelvis, and up towards the
chest and spine. With these symptoms there is more or less
numbness of the thighs, the testicle is retracted and tender
on pressure, and there is a frequent desire to void the urine,
which, when the disease is severe, is either limpid and scanty,
very high-colored and bloody, or entirely absent. When this
happens, we observe the same phenomena as in animals from
which both kidneys are removed ; that is to say, the con-
stitutional excitement becomes extremely violent, the skin
exhales a strong urinous odor, deep coma sets in, and the
patient expires in great misery.

Nephritis may terminate by resolution, or it may relieve
itself by softening, by passing into the chronic state, or by
the formation of purulent matter. In the latter case, the
pus, on inspection, will be found infiltrated into the glandular
substance, or collected into an abscess. When infiltrated, the
fluid oozes out muddy and blood-tinged on pressure ; and,
when there is much softening, it sometimes gives the organ a
dark pultaceous appearance, like the lees of wine.

When abscesses occur, they are sometimes seated upon the
outer surface of the organ, beneath the fibrous capsule, some-
times in its interior. Occasionally they are very small,
scarcely exceeding the diameter of an ordinary pea ; now and
then, however, they are of the size of a large walnut, and
so numerous as to destroy effectually the parenchymatous
structure. These collections generally open into the pelvis
of the kidney, and are thence discharged with the urine. In
a few instances, they have been known to burst into the
colon, the rectum, and small bowel ; and they have also been
found, though very rarely, to open into the loins, an inch or
two from the spine. Most commonly the pus is of the curdy,
scrofulous kind. Calculi are sometimes contained in these
abscesses, and are abundantly discharged along the ureter, or
through a fistulous aperture in the region of the kidney.

The whole kidney is occasionally converted into one im-
voL. II. 47

370 KIDNEYS. [chap. XII.

mense purulent cyst. Of this description was the case of a
gentleman, forty years of age, whose body I examined in
Philadelphia, in 1828. He had long suffered under symptoms
of chronic nephritis ; and, on inspection, the left kidney was
found reduced to a mere membranous shell, containing three
pints of a thin chocolate-looking fluid. All the other viscera
were healthy, excepting the stomach, which exhibited marks
of former inflammation. Very often the sac is thick, lami-
nated, and multilocular ; the intersecting bands, of a hard,
fibro-cartilaginous consistence, grating under the knife.

Abscess of the kidney seems in some instances to be con-
nected with disease of the spinal marrow, and the nerves
which are detached from it. Four highly interesting cases
of this kind have been recently published by Mr. Stanley, an
English physician, in the eighteenth volume of the London
Medico-Chirurgical Transactions. Most of the patients had
been affected with paralysis of the lower half of the body,
with tenderness of the spine, pain in the loins, and irritabil-
ity of the bladder. The kidneys, in nearly all, were gorged
with blood, of a dark color, remarkably flaccid, and infiltrated
with purulent matter. From the apparent absence of disease
of the spinal marrow in several of the cases recorded by Mr.
Stanley, he seems disposed to conclude, very erroneously as
I think, that the paralytic symptoms were caused by the
renal lesion. The relations between these affections are cer-
tainly interesting, and will, I doubt not, receive the serious
attention of the pathologist.

Although inflammation sometimes terminates in softening,
yet this is unquestionably a very rare occurrence. Of this
affection there are two varieties. In one, the substance of
the kidney is of a pale grayish tint, with small dot-like
points, and the patient lives a long while without being sen-
sible of any disease of the urinary apparatus ; in the other,
which is generally attended with serious derangement of the
health, and which occasionally proceeds to a fatal termina-
tion, the renal tissues are converted into a soft, spongy mass,
resembling, when shook in water, the shaggy vessels of the
placenta. The color in this species of softening may be red,
gray, brown, or even purple. The symptoms in both varie-
ties are obscure, and consequently uncharacteristic. Like
acute nephritis, of which this disease is commonly the result,
it seldom implicates the entire viscus.

The kidney is seldom affected with gangrene ; indeed, I

SECT.

II.]

GANGRENE : GRANULAR DISEASE.

371

am not certain that it is susceptible of this disease. At all
events, very little is known respecting it. Portal asserts that
it is frequently observed as a consequence of inflammation,
and that it is always preceded by severe pains in the lumbar
region, acute fever, vomiting, and retraction of the testicles,
with scanty secretion of urine, or even entire suppression of
this fluid. In persons who die of this disease, the kidney is
generally tumid, softened, and pervaded by a foul, oflTensive
serosity. Some parts occasionally lose their consistence to a
much greater extent than others, being of a black, livid color,
and converted into a shreddy, putrilaginous substance.

In chronic nephritis, the redness is of a duller hue, and the
affected parts frequently exhibit a marbled aspect. The
structure of the kidney becomes hard and granulated, and
the patient is gradually worn out by slow, hectic fever.
Diabetes is a frequent attendant on this disease. In a few
cases, I have seen the kidney converted into a yellowish
homogeneous mass, without being able to discern the least
trace of the original textures. Its size is also sometimes very
much diminished, as I have repeatedly had occasion to re-
mark in my dissections. This is especially the case in the
granular disease of this organ, so ably described by Dr.
Bright, of London. (Fig. 75.)
On tearing a kidney that is
thus affected, the surface will
be found studded with hard,
whitish, spherical bodies, from
the size of a clover-seed to
that of a gooseberry : they
are occasionally extremely
numerous : and, in some in-
stances, they project beyond
the surface of the organ, so
as to be discernible through
its fibrous envelope. What
the nature of these bodies is,
is still a litigated point. The
most plausible opinion, I think,
is that which refers them to
a hypertrophied condition of
the granulations which are
supposed, by Malpighi and
others, naturally to exist in

372 KIBNEYS. [chap. XII.

the vascular substance. The affection may thus be said to
be analogous to the mammillated slate of the liver. Like it,
it is frequently connected with dropsy of the abdomen, and
with the secretion of albuminous urine. Andral remarks
that he has seen the granulations, in one instance, in the
tubular structure ; but this is probably a mistake. Accord-
ing to the theory we have advanced above, they should al-
ways be confined to the vascular substance ; and this, as we
are informed by Bright, is uniformly the case.

Induration of the kidney, like mollescence, may be divided
into two species, one of them being attended with increased
vascularity, the other with remarkable pallor. In the former,
the organ is generally enlarged ; in the latter, diminished.
In the pale induration, the kidney occasionally retains its
natural structure, excepting that it is unusually firm ; some-
times, indeed, as will be shown hereafter, it may even be of
a fibro-cartilaginous consistence. When both organs are
thus affected, very little urine will be secreted, and the
patient will complain of the various symptoms which charac-
terize chronic disease of the other viscera.

iScirrhus of the kidney is a very rare disease, and hither-
to I have met with it only once in the human subject,
though I have often seen it in the hog. The organ, in the
case to which I refer, was at least six times the usual bulk.
It adhered to the liver, colon, and wall of the abdomen, and
formed a big tumor which could be prominently felt in the
right lumbar region, between the lower rib and the crest of the
iliac bone. In the interior of the kidney were eight large
scirrhous masses, some of which were of a white bluish tint,
hard, gristly, and intersected with yellowish-looking filaments ;
others were broken down, and converted into a thin chocolate-
colored fluid. All traces of parenchymatous structure were
lost, except towards the upper extremity of the viscus, where
it still retained some of its normal features. Both the pelvis
and ureter were closed up by the heterologous substance.
The opposite kidney was of the usual size, but extremely
pale, and the cortical and tubular textures were so blended
that it was impossible to distinguish them from each other.

This disease occurred in a child, two years and a half old,
whom I saw in consultation with Dr. Marshall, of this city,
in 1836. The body was excessively emaciated, the abdomen
hard and distended, and the right lumbar region unusually
prominent. All the intestines were firmly agglutinated to-

SECT. II.] SCIRRHUS J ENCEPHALOID. 373

gether, and the mesenteric ganglions, of a white rose color,
and gristly hardness, presented one agglomerated mass of
disease. Individually they varied in size between a cherry
and an orange. The entire mass nearly equaled a musk-
melon, and embraced loops of intestine, the aorta, vena cava,
and choledoch duct. The thoracic viscera, the stomach,
small bowel, spleen, and urinary bladder, were perfectly
healthy ; the anterior margin of the liver had a few tumors
similar to those of the kidney ; and the mucous membrane
of the colon exhibited patches of inflammation, with here and
there a small ulcer.

There are no symptoms, which, so far as we know at
present, can be considered as diagnostic of this disease. In
the case just detailed, the little patient frequently suffered
under severe pain in the region of the right kidney, but at no
time was there, I believe, any particular disturbance of the
urinary function. The disease is most common in persons
after the middle period of life.

Much more common than scirrhus is encephalo'id^ a disease
which may make its appearance at any period of life, though
it is by far most frequent in young children. The heterolo-
gous matter may be deposited into the renal vein and the ex-
cretory tube ; and in some instances the whole organ is trans-
formed into a soft pulpy mass, of the color and consistence of
the brain. Andral alludes to a case of encephaloid, where
one of the kidneys had attained the dimensions of the right
lobe of the liver ; and Mr. Langstaff, of London, has described
another, in which the diseased mass weighed nearly twelve
pounds. Externally, the tumor was irregularly lobulated,
and on cutting through it, a large clot of blood was found,
composed of loose, concentric layers, as in a rapidly formed
aneurism.

When this disease is present in the kidney it usually exists
also in some other part of the body. In general it is attended
with severe suffering, though the symptoms are often vague
and unsatisfactory. In the majority of cases there is pain in
the region of the affected kidney, difficulty of voiding the
urine, which is often tinged with blood, and great irritability
of the bladder, the uneasiness extending along the rectum
and urethra, and in the female along the uterus. In the
lumbar region, there is gradual enlargement, with more or
less pain on pressure, and inability of lying on the affected
side.

374 KIDNEYS. [chap. XII.

In the sixteenth volume of the American Journal of the
Medical Science.s is related a case of encephaloid disease of
the kidney, in a female thirty-five years old, which, as has
been justly observed by the reporter, Dr. Weems, of Wash-
ington city, was remarkable for the total absence of every
symptom, direct or indirect, that could have caused a sus-
picion of the existence of renal disorder. The left kidney,
increased to the weight of seven pounds, was completely dis-
organized, and converted into a soft, bloody, cerebral mass,
in which it was impossible to discern any thing of the normal
structure. The disease had existed for about four years, and
been treated for an enlarged spleen. An instance of a some-
what similar character is mentioned in the London Medical
Gazette for May, 1831 : it occurred in a child only four years
old: the symptoms of renal affection here were so trifling
that the medical attendant never suspected that it was the
cause of the patient's distress. Thus, then, whilst encepha-
loid of the kidney is sometimes accompanied with sufferings
the most excruciating, at others its features are so masked as
to render it utterly impossible to distinguish its true character.
Tubercles are likewise of rare occurrence, and are seldom
seen except in connection with this disease in other organs.
Their number is sometimes immense. Thus, in the right
kidney of a young man, of twenty-seven, who died last sum-
mer of psoas abscess, in the Cincinnati Hospital, there were
upwards of five hundred in the cortical substance, of all sizes
between that of a mustard-seed and a cherry-stone. In some
parts they were agglomerated, in others isolated. They were
of a white opaque appearance, semi-cartilaginous in their
consistence, and evidently organized, since, in cutting through
some of them, I could distinctly trace the existence of vessels,
the blood standing upon the incised surface in minute dots.
Externally the organ had a dark mottled aspect, and in its
interior were two tubercular excavations ; one, situated in
the superior extremity of the gland, was scarcely larger than
a hazelnut ; the other, which occupied the lower half of the
viscus, was about the size of a turkey's egg, and filled with
thin, ropy, whitish pus, destitute of smell. The abscess was
lined throughout by a thick layer of lymph, and intersecting
it in different directions were four rounded cords, the remains,
probably, of the tubular texture, which resembled a good
deal the fleshy columns of the heart, or the bands which we
so often see in tubercular excavations of the lungs. The

SECT. II.] TUBERCLE ] SEROUS CYSTS. 375

kidney was very little enlarged, and some tubercular matter
was also found in the excretory passages, the cavity of the
ureter having been nearly obliterated by it.

In this case not a tubercle could be detected in the lungs.
They were, indeed, perfectly sound, as were also the heart and
brain, together with most of the abdominal viscera. Strumous
matter was abundantly contained in the lymphatic ganglions
of the pelvis, and the seminal vesicles were completely dis-
tended with it.

In the human kidney, serous cysts are occasionally found,
but not so frequently, I am inclined to think, as is supposed
by Cruveilhier, Andral, and Hope. They are very common
in the hog, and it is here that the best opportunity is afforded
for examining them in the different stages of their develope-
ment. In reference to their origin, these cysts may be
arranged into three classes. In the first class are comprised
the little bags which are developed upon the exterior of the
kidney, immediately beneath the fibrous covering. These
are generally small, not exceeding a hazelnut, of a spherical
shape, and filled with a thin, pellucid fluid, which possesses
all the properties of the serum of the blood. This variety of
cysts sometimes attains an enormous magnitude, giving rise
to much pain, great constitutional disturbance, and excessive
enlargement of the lumbar region. In the case of a child,
six years old, detailed by Mr. Hawkins, of London, the
tumor, which displaced the ribs and liver, and protruded
slightly below Poupart's ligament, through the femoral ring,
contained five pints of fluid, partly clear and limpid, partly
opaque and semi-purulent.

The second class consists of cysts which are developed in
the midst of the cortical structure. The granulations which
exist in this substance, it will be remembered, are hollow,
at least such was the opinion of Malpighi, which has been
adopted by some highly respectable anatomists of our own
times. When from any cause the cavities of these bodies
become irritated, they pour out serous fluid; and, as the secre-
tion advances, a bag is thus formed, varying in size from a
pea to that of a walnut, the walls of which consist, for the
most part, of a thin fibrous membrane. By degrees the pres-
sure exerted by the effused matter produces absorption of the
cortical substance, until finally the cyst approaches the sur-
face of the organ, presents a globular shape, and receives an
adventitious covering from the proper capsule of the organ.

376 . KIDNEYS.. [chap. XII.

The contained fluid is not always of a serous character, but
frequently possesses all the properties of urine, only that it is
more limpid, and less strongly impregnated with saline in-
gredients.

In the third class are included the serous bags that are
formed in the tubular structure, by some obstruction in the
excretory passages. This is a very common variety, and
the tumor is sometimes of considerable size, fully as large
as the fist. The manner in which it is formed is of very
easy explanation. Let us suppose that one of the funnel-
shaped tubes of the kidney becomes closed through in-
flammation, and that the renal structure above remains per-
fectly sound. Under these circumstances, the cortical sub-
stance would continue to secrete its usual amount of urine,
which would be as readily conveyed by the tubular texture
into the proper excretory duct. Here, however, its passage
would be resisted by the obstruction, and the consequence
would be, that, as the accumulation increased, it would en-
croach upon the corresponding pyramid, and finally upon the
cortical substance, destroying them by absorption. In this
variety, the cyst maybe supposed — for this cannot be satis-
factorily demonstrated — to consist of two coverings, similar to
those of the funnel-shaped process of the pelvis of the kidney.

The three species of serous cysts now described I have
had frequent opportunities of studying, both in the human
subject and in the lower animals. The views that have
been advanced will be found not to difi'er materially from
those of Bouillaud, Cruveilhier, and other anatomists, on the
same subjects.

The serous cysts of which I have just given an account,
differ remarkably from true hydatids, which are always
thicker, much firmer, and composed of two lamellse, as
hydatids are in other parts of the body. Very often they
possess the hardness of a fibrous membrane, and have clusters
of smaller ones attached to their inner surface, or floating
about in their serous contents. Hydatids may be developed,
first, on the external surface of the kidney, beneath its proper
capsule ; secondly, in its parenchymatous substance ; and,
thirdly, in its excretory passages. Sometimes there are only
a few ; at others, several hundred. In their size, they vary
between a hemp-seed and an orange. Occasionally they are
discharged along with the urine ; and this affords the only
distinct evidence of their existence during life, — all the other

SECT. II.] FATTY DEGENERATION. 377

phenomena, such as pain in the back, symptomatic fever, and
gastric irritability, belonging equally to other renal affections.

In a few instances I have seen the kidney transformed into
a substance resembling fihro-cartilage. In one of the cases
to which I refer, the organ was less than one third the natural
volume, remarkably white, dense, fibrous, and creaked sensi-
bly under the scalpel on being cut. The fibrous capsule
was inseparably adherent to the outer surface of the kidney,
the ureter and funnel-shaped processes were obliterated, and
scarcely a trace remained of the tubular structure. The
renal vessels, both artery and vein, were much diminished in
size, and many of their larger branches, with nearly all the
smaller ones, had disappeared. This transformation some-
times occurs in small patches, which are generally of a light
bluish tint, and distinctly fibrous in their texture.

The kidney has been found partially ossified. The earthy
matter is mostly confined to the miniferous tubes, where I
have seen it form narrow, slender pencils, running the whole
length of the pyramids. The number of these lines, which
are commonly of a pale yellow color, is sometimes very con-
siderable, hundreds of them occurring in a single specimen,
perhaps in a single cone. In several cases in which I care-
fully examined, this lesion, it appeared to me that the earthy
substance was deposited into the walls of the uriniferous
tubes. Occasionally it is not improbable that the appearance
is caused by small arterial branches, in a state of ossification.

Morbid anatomists have alluded to what they call th.Q fatty
degeneration of the kidney. Such an appearance I have never
witnessed in the human subject, but have repeatedly met with
it in the hog. It seems to be analogous to the adipous transfor-
mation of the liver, and is seldom attended with any serious
symptoms. Indeed, in many cases it would appear to be com-
patible with the most perfect health. When this state is pres-
ent, the kidney is of a light yellowish complexion, has a soft
fatty feel, and greases the scalpel that is employed in cutting
it. The fibrous capsule can be peeled off much more easily
than in health, and in most of the cases that have fallen
under my observation, the transformation was confined to the
cortical substance, the pale color of which strikingly con-
trasted with the fleshy red of the uriniferous cones. The
fatty kidney rapidly putrefies, and yields a peculiar oily prin-
ciple by boiling. The cause of this degeneration is entirely
unknown.

VOL. II. 48

378 KIDNEYS. [chap. XII.

Andral has seen the kidney converted into a semi-fluid,
glass-Uke substance, resembhng a thick solution of starch.
Such a lesion has never come under my observation, and I
presume that it is very rare. In the case mentioned by the
French anatomist, the transformation was confined to the
cortical substance, and the individual showed no symptoms
of urinary disease during life.

Hypertrophy generally exists only in one kidney, the other
being either reduced in volume, or else absent. It is recognized
by the following characters r the kidney is one fourth, one
third, or one half larger than in the normal state ; and its sub-
stance is of a deeper color, more firm and compact. A devel-
opement of this kind, under whatever circumstances it may
occur, may be supposed always to depend upon an increased
determination of blood to the sound organ. Hence we
frequently find that the enlarged kidney is furnished either
with two arteries, or with a single one of unusual size. In
other cases, chronic irritation gives rise to this preternatural
bulk of the organ, by keeping up an habitual congestion.
This state of the kidney, combined with augmented vascu-
larity, is a common appearance in diabetes.

Not unfrequently the state of the kidney is diametrically
opposite to the one just described, its size b^ing much less
than natural, and its parenchymatous structure pale, indu-
rated, and shriveled. As hypertrophy is the result of an
unnatural supply of blood, so atrophy of the kidney may be
regarded as the consequence of a deficiency of this fluid. In
some instances, this appearance is strictly congenital ; but
most commonly it is caused by an obstruction in the circula-
tion of the blood, arising from the pressure of a tumor in its
vicinity, an enlarged liver or spleen, or a collection of pus
around its exterior. I have a specimen of atrophy of the
kidney in which the parenchymatous texture was nearly
entirely destroyed by a number of serous cysts that were
developed in its interior.

The concretions which are so often found in the kidney,
may be developed either in its parenchymatous substance,
the calices, funnel-shaped processes, or the pelvis of the
ureter. In most cases, it would seem that they are the result
of a peculiar diathesis of the system, and they generally
consist of the same chemical elements as those of the blad-
der. The commonest variety is the uric calculus, which is
usually of a light brownish color, and of a spherical shape,

SECT. II.] CONCRETIONS ; STRONG\LI. 379

with a perfectly smooth surface. Next in point of frequency
is the oxalic concretion, of a dark complexion, and of an
irregular, oval figure, with a rough mulberry exterior. A
third variety of renal calculus is the ammoniaco-magnesian.
This generally occurs in connection with one or the other of
the preceding species, forming an external layer around them,
varying in thickness from a line to half an inch or more.
The phosphatie concretion is seldom met with in the kidney,
and seems not to proceed from the urine, but from other
secretions of the affected organ.

Kenal calculi may exist for a long time unsuspected.
Most generally, however, they produce hemorrhage, inflam-
mation, abscess, or ulceration, with pain in the loins, obstruc-
tion to the flow of urine, uneasiness in the ureter and blad-
der, and constitutional disturbance. Should the concretion
become immovably fixed in the excretory duct, the urine,
v/hich is still secreted, will accumulate in the passages above •
and, by the pressure which it exerts upon the parenchyma-
tous structure, it will gradually eflect its absorption, until
the organ is wasted to a mere remnant. At other times, the
ureter bursts, as the urethra sometimes does behind a stric-
ture ; or suppression of urine ensues, and the patient dies.
Of these occurrences, interesting cases are recorded by Mor-
gagni, Brodie, Travers, and other pathologists. The symp-
toms which denote the passage of a renal calculus are, vio-
lent pain in the lumbar region, excessive irritability of the
bladder, discharge of bloody urine, numbness of the thighs,
and retraction of the testicles, with sickness at the stomach
and severe constitutional disturbance.

The large sti^oiigylus, a species of lumbricoi'd worm, has
been observed in a few rare instances in the human kidney.
It is oftener met with in the inferior animals, as the horse,
ox, wolf, dog, otter, and racoon, and is exceedingly common
in the hogs which are brought to the slaughter-houses in the
environs of Cin,cinnati. The situations in which it is ordi-
narily found are the pelvis and infundibular prolongations of
the ureter, in which it is frequently coiled up in considerable
numbers. Occasionally it makes its way into the parenchy-
matous structure, where it produces suppuration, atrophy, or
other mischief. Mr. Owen supposes that the parasite is origi-
nally developed here, but this is probably a mistake.

The strongylus is a very slender cylindrical worm, from
two to three inches long, of a light grayish color, interspersed

380 URETER. [chap. XII.

with dark spots: in some instances it has been known to
attain the length of three feet, with a diameter of from four
to six lines. The male is smaller than the female, and tapers
slightly towards each extremity. The head is obtuse, and
furnished with an orbicular mouth, encircled by six hemi-
spherical papillce : the body is transversely striated, and marked
by two longitudinal impressions ; and the tail, which is incur-
vated, ends in a dilated pouch, from the base of which pro-
jects a single penis. In the female, the caudal extremity is
less pointed than in the male, with the anus just below the
apex : the vulva is situated at a short distance from the head,
and communicates with a slender cylindrical vagina : the
uterus, in the larger individuals, is about three inches long,
and leads to a simple ovary, which is nearly four times the
length of the body. A nervous system can be distinctly
demonstrated in this parasite. It consists, according to the
statement of Mr. Curling, of London,* of two delicate rings,
one encircling the oesophagus, the other the anus, connected
by a single cord running in a straight line along the middle
of the ventral aspect.

SECTION III.
Of the Ureter.

The principal lesions of the ureter are, deposits of tuber-
cular matter, effusion of lymph, thickening and attenuation
of its walls, with contraction or enlargement of its cavity.
Dilatation is generally produced by the retention of a renal
calculus, or by some tumor seated along the course of the
tube, and interfering with the egress of the urine. In the
male, it is sometimes caused by stricture of the urethra ; in
the female, by the pressure of a carcinomatous uterus. In a
case of this description, which fell under my notice several
years ago, the left ureter was fully as large as the thumb,
with remarkably thin, transparent walls. Sir B. Brodie men-
tions an instance where, in consequence of obstruction, both
tubes were dilated to the size of the small intestine.

* See his Lectures on the Entozoa, in the London Medical Gazette, part v-
vol. i. p. 712.

SECT. IV.] URINARY BLADDER. 381

Occasionally the duct presents a singularly sacculated ar-
rangement, some portions of it being greatly expanded, others
very much constricted. Sandifort mentions * an instance
where the dilatation, alternating with slight contractions,
was more than two inches in circumference ; and a still
more extraordinary example has been recently recorded by
Dr. Thurnam, of England. In both cases, there was con-
genital malformation of the urinary organs.

The ureters may be absent, and in some instances they
have been known to terminate in a cul-de-sac. When the
bladder is wanting, they open either into the urethra, the
vagina, or the rectum. Occasionally, again, they are reduced
to small, narrow, almost impervious cords ; and when this
happens, the pelves of the kidneys are generally dilated into
large pouches, capable of holding many ounces of fluid. I
have never seen valves in the interior of these tubes ; but
examples of this have been recorded by Coschwitz, Mor-
gagni, Desgranges, and other writers, and are perhaps more
frequent than is generally supposed. These folds, it may be
remarked, are usually connected with a dilated and tortuous
state of the ureters.

SECTION IV.

Of the Urinary Bladder.

The urinary bladder, situated in the pelvic cavity, and
composed of the same anatomical elements as the stomach, is
seldom affected with disease. Acute inflammation, which is
so common in the alimentary tube, is extremely rare in the
organ now under consideration, and in my own dissections I
do not remember to have met with it more than twice.
Such also is the result of the more extensive observations of
Louis, Andral, and Hope. In five hundred individuals ex-
amined by the former of these distinguished pathologists, the
mucous membrane of the bladder was found preternaturally
red, and injected only in six cases, and ulcerated only in one.

* Observ. Anatomico-Patholog. t. iii.

382 URINARY BLADDER. [CHAP. XII,

The disease usually occurs in small irregular patches, which
present the arborescent, dot-like, or capilliform injection ; but,
in some instances, it affects the greater part of the organ, and
is attended with effusion of lymph, or even extravasation of
blood. Acute cystitis may terminate in several ways, — in
resolution, suppuration, and even in gangrene.

The termination by suppuration is by no means infrequent.
The matter, in most cases, is poured upon the inner surface
of the bladder, where, mixing with the urine, it imparts to
this fluid a peculiar lactescent aspect, and sometimes a very
offensive odor. In other cases, the pus collects in the sub-
mucous cellular tissue, or between the muscular and serous
tunics, and finally escapes into the pelvic cavity. Occasion-
ally the bladder contracts adhesions with the rectum of the
male or the vagina of the female, and the matter finds an
outlet in this way. The quantity of pus seldom exceeds
two or three ounces. The mucous membrane of the bladder
is sometimes greatly softened, without any attendant vas-
cularity. The lesion occasionally extends to the other tunics,
and so leads to spontaneous perforation.

Gangrene of the bladder I have never noticed, and I pre-
sume that this termination is extremely rare. The disease is
most frequently seated at the neck of the viscus, and has
hitherto been remarked chiefly as the result of the protracted
retention of urine. The eschars are of a dark, livid color,
soft, easily torn, and bathed with a thin sanious fluid, of an
exceedingly fetid odor.

Chronic inflammation is much more frequent than acute,
of which it is sometimes the result, and gives rise to various
alterations, among which the more important are, hypertro-
phy, the formation of cysts, and fungous excrescences, not
unlike those that have been described as occurring in the
large bowel. Hypertrophy, although it may be seated in
either of the tunics, is most common by far in the muscular,
which sometimes acquires the thickness of an inch or more.
Oftentimes the lesion is partial, that is to say, it is limited to
a small number of fleshy fibres, Avhich are of a deep florid
color, very strong, and collected into large bundles. When
this happens, the inner surface of the organ becomes fascicu-
lated, like the interior of the ventricles of the heart, and thus
constitutes what the French term the cohimniform bladder.
Hypertrophy of the muscular tunic, whether partial or gener-
al, is usually referrible to obstruction at the mouth of the

SECT. IV,] INFLAMMATION. 383

urethra, to overcome which it is obliged to make increased
exertion ; a larger flow of blood is invited, and excess of nu-
trition, with diminished capacity of the reservoir, is the con-
sequence. This condition frequently coexists with vesical
calculi, enlargement of the prostate gland, and stricture of the
urethra.

When the hypertrophy is seated in the lining membrane, or
in the subjacent cellular substance, there is generally a great
developement of the mucous follicles, which, instead of being
small and scarcely perceptible as they are in the normal state,
are rendered extremely prominent, and pour out an unusual
amount of thick, ropy fluid. In some instances we meet
with well-developed villosities ; and, more frequently still,
with pretty large, fungous-looking excrescences. These veg-
etations, as they may be termed, are commonly of a light
slate color, firm, in their consistence, and of a pyriform shape,
with a short, slender peduncle. Around their base are occa-
sionally to be observed beautiful vascular wreaths, showing
that they originate in inflammation.

A frequent consequence of hypertrophy of this viscus is the
developement of small cysts, caused by the outward protru-
sion of the mucous membrane, or by the interlacement of
the muscular fibres. In the latter case, considerable cavities
are sometimes intercepted, which become lined with a sheet-
ing of lymph, and filled with difl'erent fluids, such as serum,
urine, or pus. When the lining membrane is forced between
the enlarged fascicules, it occasionally dilates into a large
pouch, perhaps half as large as the bladder itself, with which
it communicates by a narrow aperture. This appearance is
generally observed near the fundus of the organ, and is much
more common in the male than in the female, as in the lat-
ter, from the peculiar construction of the urinary passages,
there are fewer causes to produce it. The walls of these
cysts are often much thickened by new deposits, and not un-
frequently they .contain calculous concretions. The bladder,
in this state, is almost always irritable, and admits of very
little distention. The number of sacs varies from one to six
or ten.

We sometimes find the bladder ulcerated. Of this, I have
seen only one well-marked example, in a young man of thir-
ty. The ulcers, which were five in number, and situated
around the mouth of the urethra, were of a circular shape,
with reddened, elevated, and slightly undermined edges, re-

384 ^ URINARY BLADDER. [CHAP. XII.

posing upon the submucous cellular tissue. The largest was
an inch in length, by half an inch in width ; the smallest
about the size of a. split pea. In several of these erosions
there was an evident effort at reparation, as was indicated by
the strongly adherent lymph which was stretched across their
surface, and which gave them a rough, uneven appearance.
The bladder itself was very much contracted, being scarcely
larger than that of an infant, and contained about two ounces
of thick, purulent fluid, resembling that which was found in
the right kidney. Sometimes the ulcerative process extends
through the muscular tunic, and the individual perishes from
the extravasation of urine. In a few cases, the inner mem-
brane of the bladder has been found entirely destroyed,
the fleshy fibres being as bare as if they had been neatly dis-
sected.

Encephalo'id seldom occurs in the bladder as an original
disease ; most commonly it is propagated to it from the sur-
rounding organs, as the rectum and the uterus. On the
whole, however, it is a very rare disease, and is seldom wit-
nessed except in old people. It appears to have its origin
in the submucous cellular tissue ; and, as it advances, it forms
a large tumor, which projects into the cavity of the organ,
and greatly diminishes its capacity. In some instances, as
observed by Sir B. Brodie, it makes its way in other direc-
tions, passing outwards, and contracting adhesions with the
sides of the pelvis, the uterus, or the bowels. Such tumors
are sometimes of a mixed character, scirrhous, cartilaginous,
and fungous ; and, occasionally, they have been found
studding the inner surface of the bladder in great numbers,
not larger than a common pea, and of a soft medullary tex-
ture.

This disease is sometimes protracted for eight or ten
years ; but in the majority of cases it runs its course with
great rapidity, destroying life in six or eight months. Fre-
quent desire to void the urine, pain at the neck of the
bladder, extending to the perinseum, and along the track of
the urethra, and constant discharge of clotted blood, are the
most prominent symptoms of the complaint. In the advanced
stage of the disease, the urine is of a dingy brown color,
extremely offensive, and often contains fragments of medul-
lary substance. The hemorrhage is occasionally quite abun-
dant, and at length leads to fatal exhaustion.

In old persons, of nervous, irritable temperament, the blad-

SECT. IV.] CALCULOUS CONCRETIONS. 385

der is sometimes the seat of severe pain, slanting through the
pelvis in different directions, and recurring in regular parox-
ysms. In its nature, it is evidently neuralgic, and it is often
associated with similar uneasiness in other parts of the body,
especially the face and scalp. In some cases, it seems to be
produced by sympathy with the kidney, or by an altered state
of the urinary fluid.

The bladder, lastly, is subject to atrophy, a lesion which
is sometimes congenital, sometimes the result of disease. It
is most commonly seated in the muscular tunic, the fibres of
which are extremely thin and pale ; and it is apt to be at-
tended with outward protrusion of the mucous membrane.
Cases sometimes occur in which the bladder is totally ab-
sent, or where there is a deficiency of its anterior v/all. This
malformation almost always coexists with an imperfect de-
velopement of the straight and pyramidal muscles, which,
instead of passing down to the pubes, leave an aperture
there, of greater or less extent, through which there is a
constant trickling of urine. Ectropia is the term by which
this state of the bladder is designated. Strong partitions are
sometimes thrown across the interior of this organ, so as to
divide it into several distinct chambers. They are frequently
situated along the middle line, but now and then transversely ;
and when this happens, the bladder has a singular hour-glass
contraction. These compartments, whether the result of
disease, or of original malformation, generally communicate
with each other ; in some instances, however, they receive
each a ureter, and open directly into the urethra.

Having thus briefly considered the several lesions of the
bladder, I shall bring this section to a close by making a few
remarks on the morbid states of the urine, and on the nature
of vesical calculi.

Calculous concretions are much more common in the
urinary bladder than in any other organ of the body. Much
diversity obtains in regard to their prevalence amongst indi-
viduals of difi^erent ages, and the inhabitants of different dis-
tricts. Children are particularly prone to them, as are also
persons who are far advanced in life ; and men are infinitely
more frequently afl'ected than women, owing, no doubt, to
the more complicated construction of the urethra and to their
more intemperate mode of hving. In some instances the
disorder seems to be of a hereditary nature, like the kindred
diseases of gout and rheumatism, — the calculous diathesis

VOL. IT. 49

386 URINARY BLADDER. [cHAP. XII.

being transmitted from parent to child through several genera-
tions. Dr. Prout contends that hard, impure waters are favor-
able to the production of vesical concretions, from the changes
which they are supposed to induce in the renal secretion.
The explanation, however, is not very satisfactory, and the
subject demands further investigation. Paral ysis of the bladder,
stricture of the urethra, enlargement of the prostate gland,
injuries of the back in the region of the kidneys, and impair-
ment of the digestive apparatus, especially of the stomach,
may be enumerated as so many exciting causes of this
disease.

The number of urinary calculi is extremely variable.
Yery frequently there is only a single one, whilst at other
times there are a great many. Sir Astley Cooper met with
one hundred and forty-two ; Dessault with two hundred ;
Boerhaave with three hundred ; Murat with six hundred and
seventy-eight ; and Physick with upwards of one thousand.
This case occurred, in the person of the late Chief Justice
Marshall, and is perhaps the most remarkable of the kind on
record. The concretions were all of an oval shape, and
varied from the volume of a partridge-shot to that of a bean.
When numerous, they are always more or less polished from
continued friction against each other ; and, although they
generally lie perfectly loose in the bladder, it sometimes hap-
pens that they are encysted, impacted in the urethra, or lodged
in the ducts of the prostate. These concretions are of all-
sizes, from a hemp-seed to that of the fist ; and, in their
weight, they vary from a few grains to a pound or more,
their average being from three drachms to an ounce.

Urinary concretions are generally arranged under different
heads, according to their color, consistence, and intimate
characters. Their chemical composition has attracted much
attention during the last forty years in Europe, and the indi-
viduals who have particularly distinguished themselves for
their researches in this respect are Scheele, Bergmann, Wollas-
ton, Marcet, Fourcroy, and Prout. Much, however, as they
have done, the subject is far from being exhausted ; and an
interesting field is still open, which, if properly cultivated,
cannot fail to be of the greatest benefit to the human race.
The subjoined arrangement includes the most important
species of urinary concretions that have hitherto been de-
scribed.

The uric calculus, the most common species of all, was

SECT. IV.] URO-AMMONIAC CALCULUS. 387

first noticed by Scheele, in 1776. Jn its color, it is brownish,
inclining to that of mahogany, of a flattened, oval shape,
occasionally finely tuberculated on the surface ; but most
generally smooth, though not polished, unless there are seve-
ral concretions at the same time, and from the size of a
currant to that of a hen's egg. If the uric calculus be divided
with the saw, it will be found to consist of several layers
arranged concentrically around a common nucleus, the laminEe
being frequently distinguishable from each other by a slight
difiierence in color, and sometimes by the interposition of
other ingredients. Water has but little action upon it ; it is
perfectly dissolved by caustic potash ; disappears with efl"er-
vescence in hot nitric acid, the solution affording, on evapora-
tion to dryness, a bright carmine-colored residue ; and, before
the blow-pipe, it becomes black, emits a peculiar animal
odor, and is gradually consumed, leaving a minute quantity
of white, alkaline ashes.

As a variety of the preceding, the uro-ammotiiac calculus
may be here mentioned. It is principally observed in children,
and is so extremely rare that several distinguished chemists
have been induced to deny its existence. It is generally of
small size, with a smooth surface, of a clay color, and con-
sists of concentric rings, which present a very fine earthy
appearance when fractured. Much more soluble in water
than the uric calculus, it gives out a strong ammoniacal smell
when heated with caustic potash, and deflagrates remarkably
before the blow-pipe. This variety of calculous concretion
was first described by Fourcroy.

Next to the uric calculus, in point of frequency, is the
oxalic, which is generally of a dark brown color, rough and
tuberculated on the surface, very hard, compact, and imper-
fectly laminated, seldom larger than a walnut ; spherical, and.
always single. Under the blow-pipe, it expands and efflo-
resces into a white powder ; and it dissolves slowly in mm'iatic
and nitric acidj provided it be previously well broken up.
In the alkalies, it is perfectly insoluble. This species of
urinary concretion, called by many the mulberry calculus,
from its resemblance to the fruit of the mulberry, was first
correctly analyzed, in 1797, by Dr. Wollaston, who proved
it to consist essentially of oxalate of lime.

A variety of this species of calculus has been described
by the terra hemp-seed, from' some resemblance which it bears
in color and lustre to that substance. It is always of small

388 URINARY BLADDER. [CHAP. XII.

\

size, remarkably smooth, and generally exists in considerable
numbers, being rarely if ever found alone.

The phosphatic calculus, described by Wollaston in 1797,
is of a pale brownish color, and of a loosely laminated struc-
ture, with a smooth, polished surface, like porcelain. The
shape is mostly oval, and the size, though generally small, is
sometimes very considerable. It whitens when exposed to
the blow-pipe, but does not fuse ; and readily dissolves in
muriatic acid, without effervescence. This calculus, com-
posed essentially of phosphate of lime, is extremely rare, as
forming entire concretions, but frequently constitutes alternate
layers with other matters. It is sometimes called the hone-
earth calculus, and occasionally contains small quantities of
carbonate of lime.

The next species is the ammoniaco-magnesian, so called
fi'om its being composed of the phosphate of ammonia and
magnesia. This mixed calculus is of a white color, friable,
crystallized on the surface, and looks a good deal like a mass
of chalk : its texture being never laminated, it easily dis-
solves in dilute acids, but is insoluble in caustic potash :
before the blow-pipe, it exhales an ammoniacal odor, and at
length melts into a vitreous substance. This species of con-
cretion, first noticed by Wollaston in 1797, sometimes attains
an immense size. In a case mentioned by Dr. Thomson,
the circumference was fourteen inches, and the weight nearly
two pounds.

The fusible calculus, the nature of which was first deter-
mined by Wollaston, consists of a combination of the two
last. It is of a white color, extremely brittle, leaves a soft
dust on the fingers, and is easily separated into layers : when
broken, it presents a ragged, uneven surface. It is insoluble
in caustic potash, but gives off ammonia ; and, under the
blov/-pipe, it is readily converted into a transparent, pearly-
looking glass. This concretion is very common, and some-
times attains a very large size. It is frequently met with as
an incrustation of foreign bodies.

A very rare species of urinary concretion is the cystic, so
called from an erroneous supposition that it was peculiar to
the bladder. It consists of a confused, crystallized mass, of a
white, yellowish color, with a smooth surface. The structure
is compact, and the fracture exhibits a peculiar glistening
lustre, like that of a body having a high refractive density.
It exhales a strong characteristic odor under the blow-pipe, and

SECT. IV.] CALCULI. 389

is very abundantly dissolved in acids and alkalies, with both
of which it crystallizes. This species is commonly of an
irregular, spherical shape, and seldom attains a large volume.
Wollaston termed it an oxide, and gave it the name of cystic,
from a belief that it occurred exclusively in the urinary
bladder. Tt has since been detected, however, in the kidney.

The xanthic calculus was first pointed out by Dr. Marcet,
whose account of it is the best that is extant. It is extremely
rare, having hitherto been met with only several times. Its
texture is compact, hard, and laminated ; its color is of a
cinnamon brown, its surface smooth, and its volume small.
It dissolves very readily in acids and alkalies, and is gradu-
ally consumed before the blow-pipe, leaving a minute quan-
tity of white ashes.

There is, lastly, what is called the fibrinous calculus. Like
the preceding species, this is also extremely rare, and appears
to be composed principally of the fibrin of the blood, — a prop-
erty to which it owes its name, and by which it is charac-
terized. Sir Benjamin Brodie has described a concretion of
this kind, which was about the size of a horse-bean, of an
oval shape, and of a yellow transparent appearance, not unlike
amber, but less hard. When dried, it shrunk to a small size,
and became considerably shriveled.*

Such is a succinct account of the relative frequency of the
different species of urinary concretions, their physical proper-
ties and chemical composition. In many cases they are formed
in the kidneys, whence they descend into the bladder, where
they gradually acquire the characters that have just been
ascribed to them ; but at other times they take their origin en-
tirely in the urinary reservoir, and not unfrequently they grow
around a foreign body as their central nucleus. A substance
like mortar is occasionally contained in the bladder, filling
up a large portion of its cavity. It is of a pale yellowish
color ; is composed principally of phosphate and carbonate of
lime ; and is usually connected with chronic inflammation of
the lining membrane, leading to effusion of lymph. Hair is
sometimes found in the softer varieties of urinary calculi, but
this, I presume, is very rare. The immediate cause of the
formation of vesical calculi consists in the inordinate deposi-
tion of the earthy salts of the urine, which, instead of being
discharged with that fluid, sink to the bottom of the bladder,

"* Lectures on the Urinary Organs, p. 214, second edition. London, 1835.

390 URINARY BLADDER. [CHAP. XII.

and so become the nuclei around which the accretion gradu-
ally takes place.

The symptoms of stone vary in diiferent cases, according
to the size of the concretion, the roughness of its surface, and
the accompanying state of the bladder. When the disease
is fully developed, there is a frequent desire to make water,
the calls to which are often sudden, irresistible, and liable to
be induced by the slightest change of posture. A small
aching pain is usually felt at the neck of the bladder, which,
extending along the urethra, is always most severe imme-
diately after micturition, or during the flow of the last drops
of urine. Itching of the head of the penis is a very common
and distressing symptom, and is usually more distinctly
marked in children than in adults. The urine is frequently
tinged with blood, especially after exercise ; and, as it flows
from the bladder, it is liable to be stopped by the stone fall-
ing against the inner orifice of the urethra. With these phe-
nomena are often observed uneasy sensations in the perinaeum,
groin, testicle, and lumbar region, a peculiar expression of
suffering and anxiety in the patient's countenance. Tenes-
mus is sometimes experienced from the propagation of the
irritation to the rectum ; and the urine, upon settling, gener-
ally deposits a considerable quantity of mucus. The only
diagnostic sign, however, is the recognition of the stone by
the sound.

There is no fluid which, even within the limits of health,
js liable to so many variations in its physical and chemical
properties as the urine. Its quantity, also, is extremely un-
certain, as it is influenced by numerous causes, especially by
the state of the skin and the amount of liquids received into
the stomach. On an average, however, a healthy person
voids about forty ounces in the twenty-four hours. When
perfectly normal, the urine is of a pale amber color, transpa-
rent, saline in its taste, and slightly aromatic in its odor. It
is of the .average specific gravity of about 1.025; is supposed,
from its giving a red tint to litmus paper, to contain a free
acid ; and deposits, on standing, an insoluble substance, con-
sisting of mucus and the super-urate of ammonia. The quan-
tity of solid matter that passes oft" by this excretion dailj'' is
about sixteen drachms, and does not seem to be subject to
much variation.

The most elaborate analysis of this fluid is by Berzelius.

SECT. IV.]

URINE ; ANALYSIS.

391

According to this distinguished chemist, 1000 parts of urine
are composed of

Water, .....

. 933.00

Urea, . . . . . .

30.10

Uric acid,

. 1.00

Sulphate of potash.

Sulphate of soda,

Phosphate of soda.

Phosphate of ammonia.

Muriate of soda, ....

3.71
. 3.16

2.94
. 1.65

4.45

Muriate of ammonia, .

. 1.50

Phosphate of lime and magnesia.
Siliceous earth, ....

1.00
.03

Vesical mucus, ....

.32

Free lactic acid, lactate of ammonia,

and animal

matter not separable from them.

. 17.14

Besides these ingredients, the urine hkewise contains a
small amount of sulphur, phosphorus, and a pecuHar yellow
coloring matter, which has not yet been obtained in a sepa-
rate state. In the urine of infants there is also generally
some benzoic acid.

Such, then, in a few words, are the characters of this
excretion in the normal state of the system. But, as might
be expected, this fluid undergoes great changes in various
disorders of the body, which may be conveniently reduced, as
has been suggested by Andral, to three classes. Under the first
category are comprised those cases in which there is merely
deficiency or excess of the natural constituents of the urine ;
in the second, there is an addition of new principles, analo-
gous to those that are contained in the blood ; and under
the third head are embraced such substances as are deposited
with the urine, but are not found in the circulating fluid,
either in the healthy or diseased state. Each of these classes
affords interesting topics of inquiry, which demand brief con-
sideration in thi<5 place, referring for more ample details to
the excellent treatises of Berzelius* and Prout.f

1. Water and urea, being naturally present in greatest
abundance, are more liable to variation than any of the other
constituents of the urine. In nervous diseases, especially

* Traite de Chimie, t. vii. Paris, 1833.

t Inquiry into the Nature and Treatment of Gravel, &c.

392 URINARY BLADDER. [cHAP. XII.

such as are of a hysterical nature, this secretion is generally
copious, remarkably limpid, and of an aqueous character. In
diabetes insipidus, the urine, which is discharged in immense
quantities, is almost wholly composed of water ; the urea is
entirely absent ; and the fluid, on evaporation, leaves a yel-
low-brownish sirup, in which there is no appearance of crys-
tals, and which possesses a very feeble acid reaction. Urea
is fin-nished sparingly in chronic inflammation of the liver, in
the granular disease of the kidney, in dyspepsy, pulmonary
phthisis, gout, and intermittent fevers. This substance has
been supposed, but erroneously, to be wanting in diabetes
mellitus. Both Barruel and Henry have shown that it is
generally present, and they suppose that the error into which
other chemists have fallen in respect to this matter, has arisen
from the tendency which the sugar has to prevent the nitrate
of urea from crystallizing. Urea sometimes exists in excess.
This state is usually combined with preternatural activity of
the renal function, and can be easily recognized by mixing
with the urine an equal quantity of nitric acid.

The lactic acid, which, according to Berzelius, naturally ex-
ists in the urine, is seldom or never altered either in quantity
or quality. Bat this is not the case with the uric and phos-
phoric. The former of these, supposed by Dr. Prout never to
be present in healthy urine, generally greatly predominates in
arthritic affections, as is shown by the formation of the earthy
concretions, which are so frequently seen in the joints of the
extremities, and which seem to be composed principally of
the urate of soda, with a small quantity of the urate of lime.
Gravel commonly consists of uric acid, and it is well known
that this substance forms the basis of one of the worst kinds
of urinary calculi. In diabetes mellitus this acid is entirely
absent, no trace of it whatever being discoverable by the
most delicate tests.

In some instances this acid occurs in a free state ; but most
generally it appears in combination with an alkali ; and, so
long as this is the case, it does not yield a crystalline deposit.
The undue secretion of this substance is usually produced
by errors in diet, and by whatever has a tendency to impair
the digestive powers. Hence it is most commonly met with
in dyspeptic persons, of a gouty, irritable habit, in whom it
sometimes prevails to a most unhappy extent, constituting a
sort of uric acid diathesis.

A deficiency of phosphoric acid is not less injurious than

SECT. IV.] URINE ; EXCESSIVE SECRETION. 393

an excess of uric. Prout supposes that, when this acid is not
secreted in due proportion, the earthy materials of which it is
the base are converted into neutral salts, and then precipi-
tated, so as to afford an opportunity for the formation of a
stone.

The alkalies which enter into the composition of this fluid
are sometimes secreted in excess, and, by combining with the
acid ingredients, may form salts, which, on being deposited
in the bladder, give rise to calculous concretions. This is
especially the case with the lime and ammonia, the soda and
potash producing little or no inconvenience.

2. The process of secretion, which is constantly going for-
ward in the kidney, sometimes proceeds to a morbid extent,
in consequence of which substances are generated which do
not naturally occur in the urine. The most important of
these, in reference to the pathology and treatment of diseases,
are albumen, fibrin, and the coloring matter of the blood.
Other substances are occasionally observed, which get into
the urine accidentally, and impart to it their peculiar prop-
erties. Of this description are the yellow matter of the
bile, asparagus, oil of turpentine, and most of the balsamic
preparations. Cantu detected mercury in the urine of per-
sons who had been subjected to frictions with that substance,
in the form of ointment ; and the ferro-cyanate of potash,
tartaric acid, iodine, and a hundred other articles have been
observed by different chemists in this fluid, after they had
been used as medicines.

In severe cases of jaundice, whether resulting from duo-
denitis, inflammation of the liver, or obstruction of the natu-
ral outlets of this organ, the bile passes from the blood into the
kidneys, and communicates a yellow tint to the urine, at the
same time that it renders it more acid. The most delicate
test of its presence is muriatic acid, which causes either a
green or brownish hue, according to the peculiar modification
of the coloring, principle of the foreign ingredient. Linen
and paper will receive a very distinct yellow stain, which re-
mains when dried. The muriate of iron and the acetate of
lead produce a yellow precipitate, the sulphate of copper, a
dirty green one.

Albumen is said by some to be always contained in very
minute quantity in healthy urine ; but, however this may be,
this substance is frequently present in certain diseases, in
large proportion. In the granular affection of the kidney, so

VOL. II. 50

394 URINARY BLADDER. [cHAP. XII,

ably elucidated by Dr. Bright, albumen generally exists in
considerable quantities, though it cannot be regarded as pa-
thognomonic of that singular lesion, as it has been repeatedly
observed in pneumonitis, dropsy of the abdomen, tubercles of
the lungs, prurigo, and typhoid fevers. Both Bouillaud and
Piorry declare that they have frequently noticed this sub-
stance in diseases which had no connection whatever with
the urinary organs. According to Dr. Blackall, it is charac-
teristic of certain kinds of dropsy, especiahy such as are ac-
companied with a phlogistic diathesis, — an opinion which
has been amply confirmed by the researches of other patholo-
gists.

Albuminous urine is generally of low specific gravity, from
deficient quantity of urea and salts, of a pale, opaline color,
and readily coagulates on exposure to heat. The ferro-cy-
annate of potassium, alum, and nitric acid will also curdle it.

The urine may also contain fibrin ; but this, I presume, is
very rare ; at all events, the subject is seldom alluded to by
writers. Dr. Prout saw a remarkable instance of this deposit,
in a middle-aged woman, who had a most voracious appetite,
but was otherwise perfectly healthy. Her urine, which was
of a pale yellow tint, was extremely thick, and contained a
large quantity of matter, which bore the greatest resemblance
to the fibrin of the blood. The appearance of this substance
is occasionally associated with certain forms of dropsy ; but
how it is produced it is impossible, in the present state of our
knowledge, to determine, as nothing is yet certainly known
respecting it. Perhaps it may depend upon some structural
lesion of the kidney, that has hitherto escaped the attention
of the anatomist, or it may be that it is connected with a sort
of inflammatory diathesis, either of the renal tissues, or of the
system at large.

The coloring matter of the blood is sometimes found in the
urine. It may get into it either in consequence of external
violence, giving rise to the laceration of some of the vessels
of the urinary organs ; or it may be a product of exhalation
of the mucous membranes ; or, finally, a secretion from the
kidney.

3. In the third place, the urine may be altered by the in-
gress of principles which, so far as we know, are not natu-
rally contained in the blood. Amongst these, the most com-
mon are the cystic and xanthic oxides, oxalic acid, and a
peculiar saccharine substance, like the sugar of grapes. The

SECT. IV.] URINE J DIABETES. 395

cystic and xanthic oxides are never observed in healthy
urine : they form the base of several varieties of vesical con-
cretions, and the causes which predispose to their develope-
ment are still unknown. Oxalic acid is more frequently seen,
and is often traceable to articles of diet, which naturally pos-
sess a large quantity of this substance.

An abundant secretion of sugar is a circumstance by no
means uncommon. In diabetes mellitus, where it is gener-
ally present in large proportion, it forms the characteristic
feature of the disease. The urine in this complaint is com-
monly of a pale straw color, of a faint, whey-like odor, and
of a decidedly saccharine taste : it has a greater specific
gravity than in health, yields a sirup by evaporation, has
little tendency to putrefy, and is susceptible of undergoing
the vinous fermentation. Diabetic urine almost always con-
tains the usual proportions of saline matters ; but, in the
majority of cases, there is a great deficiency of urea and
lithic acid. In a specimen of this fluid, examined by Mr.
Kane, of England, 1000 parts were found to be composed of
913 of water, 60 of sugar, 7 of urea, and 20 of salts.

The quantity of urine discharged in diabetes is sometimes
surprising. Cases are on record, in which from two to four
gallons have been voided every twenty-four hours for a num-
ber of weeks, and even months. The amount of saccharine
matter is also very great. From some observations of Dr.
Henry, of England, it appears that ten pints of diabetic
urine, of the specific gravity of 1.040, contain upwards of a
pound and a quarter of solid extract. The proximate cause
of this disease is still unknown. From the facility with
which the saccharine matter is furnished by -the kidneys, it
has been supposed to exist in the blood. No chemist, how-
ever, has hitherto succeeded in detecting it in this fluid ; and,
until this be done, it would be idle to indulge in specula-
tions. The kidneys are generally large and flabby, and there
is almost always great disorder of the digestive apparatus.

Though oil is not contained in healthy urine, it is found
in certain diseases. In one instance, Mr. Prout observed a
substance like butter ; and, in some cases, the fluid has the
aspect of milk. Of oily urine, Raciborski has pointed out
three varieties. In the first, the fluid is of a reddish yellow
color, and of a viscid, ropy consistence ; in the second, it is
of a mahogany brown. When this appearance is witnessed
in acute diseases, it is always indicative, according to Landre-

396 URINARY BLADDER. [CHAP. XII.

Beauvais, of great danger ; in the third, the fatty matter
floats on the surface of the urine, forming a thin pelhcle, not
unHke a spider's web.

The urine is occasionally of a bluish tint, owing to the
presence of a peculiar coloring matter, which it holds in sus-
pension. This substance, whatever may be its nature, is
slightly soluble in boiling water and alcohol, has neither
taste nor smell, and is entirely destroyed by nitric acid. Ex-
posed to heat, it yields carbonate of ammonia, and an em-
pyreumatic oil.

The urine may likewise be of a Mack color, from the
presence of melanic acid. When this substance is very abun-
dant, the fluid has sometimes the appearance of black ink,
or may be made such by the addition of ah alkali. More
frequently, a pink color is observed, which is supposed by
Dr. Prout, to be owing to the presence of purpuric acid.
Raciborski has often noticed this tint in rheumatic affections
of the joints, of which, however, it is far from being diag-
nostic ; and he has also witnessed it, though much less fre-
quently, in catarrhal complaints of the chest.

The urine, under certain circumstances, deposits amorphous
sediments, which Dr. Prout has divided into several classes,
the difference of color forming the basis of the division.
They all consist essentially of the lithate of ammonia, tinged
with the coloring principle of the urine, or the purpurates of
ammonia and soda. The yellow sediment is characteristic
of health ; the pink, of hectic ,• the lateritious, of inflamma-
tory fever. To this statement, however, there are numerous
exceptions.

Lastly, the urine may contain hairs. Of this singular oc-
currence, highly interesting cases have been published by
Magendie, Brodie, and some other writers. The hairs, which
are occasionally quite numerous, are seldom more than five
or six lines in length, and they generally appear in combina-
tion with an excessive secretion of earthy matters. Whence
these hairs are derived, we have no means of ascertaining.
The subjects of most of the cases that have been reported,
were old men of intemperate habits.

SECT, v.] PROSTATE GLAND. 397

SECTION V.

Of the Prostate Gla7id.

The prostate gland, situated at the inferior part of the
neck of the urinary bladder, is a small conical body, of a
firm consistence, yet easily compressed, and of a grayish
color, bordering upon red. Its weight, in the adult human
subject, although liable to considerable variation, is generally
found, according to my own examinations, not to exceed five
drachms. In length it is ordinarily about twenty-one lines,
by eighteen in breadth, and nine in thickness. Larger behind
than in front, it consists of two lateral halves, which are
separated posteriorly by a deep notch, in the upper part of
which, at the origin of the urethra, lies the small pyramidal
tubercle, which Sir Everard Home has described as the third
lobe of the prostate, but which, in the generality of cases,
seems to be merely a portion of the body of the gland, in a
state of hypertrophy. Enveloped by a strong capsule, the
organ is composed of a dense, fibrous substance, of a white
grayish tint ; in the interior of which, are a large number of
mucous follicles, which pour their contents, by means of ten
or a dozen ducts, upon the inner surface of the prostatic
portion of the urethra, at each side of the caput galli-
naginis.

The prostate is liable to be affected with inflammation,
suppuration, ulceration, hypertrophy, enlargement of its ducts,
tubercular depositions, and earthy concretions.

Acute injiainjnation of the prostate is rather a rare disease,
especially in the young. Its anatomical characters are in-
creased vascularity, and, as a natural consequence, deep red-
ness, with tumefaction, serous infiltration, and preternatural
lacerability. The disease is generally induced by an exten-
sion of irritation from the neighboring parts, as the urethra,
perinasum, or rectum, and is always marked by great dis-
tress in the neck of the bladder, difficult micturition, dull,
aching pain in the pelvic cavity, and numbness in the groin
and thighs. The urine is hot and scanty, and sometimes,
especially when there is much swelling of the prostate, there
is complete obstruction to its evacuation.

Suppuration is commonly the result of acute inflammation.

398 PROSTATE GLAND. [cHAP. XII.

though occasionally it supervenes on the chronic form of the
disease. The matter, which is ordinarily of a thick creamy
consistence, and of a pale straw color, is sometimes diffused
through the substance of the gland ; but more frequently it
is collected into little abscesses, which have a natural ten-
dency to burst into the urethra, the bladder, or the rectum.
In some instances, the fluid finds an outlet through the peri-
nasum. Occasionally the abscesses attain a very considerable
size, containing from one to three ounces of pus. Suppura-
tion of the prostate is seldom seen before the age of twenty ;
but, from this period on, it is by no means infrequent. Its
existence may be suspected by a variety of symptoms ; but
the only certain sign is the sudden discharge of pus with the
urine.

When the inflammation becomes chronic, it sometimes ter-
minates in ulceration. The erosions generally exist on the
vesical surface of the gland ; and as they are constantly in
contact with the urine, they often give rise to the most in-
tense suffering. Their edges are usually hard and irregular,
and their depth is frequently such as to render it difficult to
pass the catheter. When these ulcers are extensive, they
are liable to bleed, the hemorrhage being generally small, but
sometimes copious and alarming.

Chronic inflammation is much more common than the
acute, of which it is occasionally the result. The affection
is very frequent in the decline of life, and in persons who
are suffering from calculous disorders, or disease of the rec-
tum. The most ordinary effect of this species of irritation,
in relation to the proper structure of the gland, is hypertrophy.
The enlargement is sometimes very great, exceeding many
times the natural size ; and it is commonly much more con-
spicuous on one side of the organ than on the other. Often it
seems to be entirely confined to the third lobe, which projects
upwards into the cavity of the bladder, like a big nipple. The
enlargement is sometimes unattended with alteration of tex-
ture; in most cases, however, it is remarkably hard and firm,
presenting, when cut into, a dense, gristly substance, of
a whitish-brown color, with membranous bands extending
through it in different directions. This constitutes the scir-
rhous prostate of authors. The vessels in the neighborhood
of the gland are often very much enlarged, and even quite
varicose.

This hypertrophous state of the prostate is always attended

SECT, v.] TUBERCLES. 399

with difficult micturition, resulting from the mechanical
obstruction which it produces at the mouth of the urethra.
The urine has to be drawn off with the catheter, and even
this often fails in entirely emptying the bladder, the fluid
which lies behind the enlarged gland, in the bas-fond of the
organ, escaping the instrument. When the disease is obsti-
nate, as, in fact, it usually is, the patient is not only tortured
with retention of urine, but he suffers from disease of the
rectum, which, in consequence of the frequent straining
efforts which he is obliged to make, is everted at the anus ;
the penis is often in a state of partial priapism ; at night,
there are involuntary seminal emissions ; severe pains dart
along the groin and urethra ; there is a dull, aching sensa-
tion in the peringeum ; and, in obstinate cases, oedema of the
scrotum and inferior extremities. The bladder, in most in-
stances of this kind, is excessively irritable : it becomes small
and contracted, and, from the great exertion which it is con-
stantly obliged to make to expel its contents, its middle
tunic is often very much thickened, the muscular fibres being
rendered as distinct as the fleshy columns of the heart. The
mucous secretion is thick and viscid, and not ^infrequently
mixed with blood, or even purulent matter. The kidneys
are also liable to become affected, and the patient sometimes
falls a victim to the disease which is thus lighted up in them.

A very rare affection of this gland is sometimes met with,
which, until recently, seems to have entirely escaped the at-
tention of the pathological anatomist. I allude to the dilata-
tion of the excretory ducts of the prostate, forming small
pouches which may arrest the beak of the catheter, or become
depots of earthy concretions, or urinary calculi. The sacs
are seldom numerous, and they vary in size between a cherry
and a marble : sometimes they attain a magnitude capable of
holding several ounces ; and cases occur, in which the whole
of one lobe, or even the entire organ, is converted into a thin,
fi.brous capsule, the proper substance of the gland being al-
most wasted. This lesion most commonly occurs in old per-
sons, in connection with urinary calculi and chronic enlarge-
ment of the prostate.

The prostate is occasionally the seat of tubercles. Of this
disease, I have never seen but one example, in a young man
who died in the Cincinnati Hospital, of psoas abscess. There
were six or eight small masses, of a pale yellowish color, and
of a soft, curdy consistence, scattered through different

400 PROSTATE GLAND. [CHAP. XII.

parts of the gland, which was at the same time considerably
reduced in size. The deposition of tubercular matter here
is commonly associated with pulmonary phthisis : it seldom
occurs under the age of forty-five or fifty, and appears to
have a decided predilection, so to speak, for the follicular
structure of the gland.

I have never met with earthy concretions in the prostate ;
but cases of this description have been frequently noticed
by others. Their composition is invariably phosphate of
lime, with a little animal matter. In their size, they vary
between a mustard-seed and a hazelnut ; they are of a
rounded figure ; their surface is smooth and polished ; and
their color of a yellowish-brown. These bodies often exist
in considerable numbers, being either embedded in the sub-
stance of the gland, or situated in the dilated ducts. They
rarely cause much uneasiness, and thence their presence is
not always suspected during life. Occasionally they create
retention of urine ; and, in some instances, their existence
has been detected by the sound, or by the finger introduced
into the rectum.

CHAPTER XIII.

Of the Male Organs of Generation,

SECTION I.
Of the Testicle.

I. T/te Testicle. — Observations respecting its Coverings, Weight, and Volume .
— Diseases of its Vaginal Tunic. — Inflammation. — Hydrocele. — Hema-
tocele.— Earthy Concretions, — Orchitis. — Malignant Affections of the Tes-
ticle. — Tubercles and Hydatids. — H3rpertrophy and Atrophy. — II. The
Spermatic Cord. — Encysted Dropsy. — Varicocele. — Neuralgia. — III. The
Seminal Vesicles. — Their Lesions, few in number and still involved in ob-
scurity. — IV. Tlie Scrotum. — Carcinoina. — Excessive Enlargement. — Is
sometimes affected with a peculiar sloughing Ulcer. — They contain foreign
substances, such as Teeth, Hair, and pieces of Bone. — Earthy Concretions. —
V. The Penis. — Gonorrhoea. — Gleet. — Chordee. — Organic Stricture. —
Abscess along the Course of the Urethra. — Malformations of this tube. —
Morbid Erection of the Penis. — Degeneration of the Pectiniform Septum and
Fibrous Sheath. — Carcinoma. — Syphilitic Ulceration. — Experiments of
Ricord. — Herpetic Affections. — Warty Excrescences. — Phymosis and Para-
phymosis.

The testicle, suspended in the scrotum by the spermatic
cord, is of an ovoi'dal figure, and surrounded by two en-
velopes ; the one of a fibrous, the other of a serous struc-
ture ; the former giving it firmness, the latter, usually termed
the vaginal tunic, enabling it to execute its various move-
ments. In the adult, it is generally, according to my own
measurements, about twenty-two lines in length, by eighteen
in breadth, and seven in thickness. Its medium weight, I
have found, in a considerable number of subjects, to be about
five drachms, — the minimum being three and a half, and the
maximum six and a half. The weight of the epididymis gen-
erally ranges from two to three scruples. In its consistence,
it bears a strong resemblance to the ball of the eye ; exter-
nally, it is of a white grayish color, owing to its fibrous cov-
ering ; and, when cut into, it is found to consist of a soft,
yellowish, pulpy substance, arranged into small pyramidal

VOL. II. 51

403 TESTICLE. [chap. XIII.

masses, composed each of a coiled string of seminiferous
tubes.

The diseases of the testicle are numerous and important,
and they may be conveniently considered with reference to
its serous investment, and its proper parenchymatous texture.

I. The principal lesions of this membrane are, acute and
chronic inflammation, suppuration, hydrocele, induration,
heematocele, fungous growths, cartilaginous and osseous trans-
formations.

Acute inflammation of the vaginal tunic exhibits the same
phenomena precisely as the serous textures in other situations.
There is more or less redness, with effusion of serum, fibrin,
pus, or blood ; and not unfrequently the contiguous surfaces
of the membrane coalesce by the adhesive process. The
water that is poured out by the vessels is either absorbed or
remains until it is drawn off by a surgical operation.

Suppuration of this membrane is very rare, except as a
consequence of hydrocele and its treatment. The matter is
generally of a yellowish straw color, and, when allowed to
stand, separates into two parts, one of them thin and watery,
the other thick and purulent.

Chronic inflammation of the vaginal tunic is of frequent
occurrence in the inhabitants of warm climates, and in per-
sons who are subject to diseases of the urethra and prostate
gland. It is characterized by opadty and thickening of the
inner surface of the membrane, and by. the effnsion of differ-
ent kinds of fluids, especially such as are of a serous nature.

Naturally, the vaginal tunic is lubricated by a thin vapor.
In inflammation this vapor becomes condensed, and thus leads
to the formation of what is named hydrocele. The quantity
of fluid poured out in this affection does not usually exceed
six or eight ounces ; but, in some instances, it amounts to
several quarts. In the case of the celebrated Gibbon, Mr.
Cline drew ofl' not less than a gallon and a half. The water
is generally quite limpid, especially in young subjects, and
somewhat saline to the taste : sometimes it is of a deep yel-
low tint, and contains white, flaky particles, soft and greasy,
like adipocire, and composed of cholesterine ; * more rarely
it is of a red color, from the admixture of red globules. It

* " Dr. Bostuck has suggested, with apparent probability, that these small,
flaky particles are not the direct result of secretion, but the product of a chem-
ical change taking place in the cHused fluid, similar to that by which adipocire is
formed from flesh when subjected to long maceration in water."

SECT. I.] HYDROCELE. 403

is coagulable by heat, alcohol, corrosive sublimate, and dilute
acid, — facts which show that it closely resembles the serum
of the blood. When the disease is of long standing, and
dependent on organic lesion of the testicle, the accumulated '
fluid is often purulent. In a case in which I operated several
years ago, I drew off nearly two quarts of pus and serum, of
a very fetid smell.

In recent hydroceles, the vaginal tunic is commonly unal-
tered ; in old ones, it is apt to become opaque, hard, and
thickened. Occasionally the inner surface has a rough, pitted
aspect, caused by the effusion of coagulating lymph ; and
instances sometimes occur, though rarely, where it is partially
ossified, or studded with small cartilaginous growths, similar
to what take place in the movable joints. Infants sometimes
labor under this complaint, from the vaginal tunic continuing
to communicate with the cavity of the abdomen, and allow-
ing the water effused there to descend into it. This, I need
scarcely say, is called congenital hydrocele.

Most hydroceles have a pyriform, conical, or globular
shape ; sometimes they exhibit a sort of hour-glass contrac-
tion, and in a few instances the water has been found in dis-
tinct sacs. This species of the disease is commonly of slow
growth, and often remains stationary for years.

Hydrocele occurs at all periods of life, in infancy, in ado-
lescence, and in old age. The disease is generally unattended
by pain, except where the accumulation is large, when it is
apt to incommode by its weight. The tumor is hard but
compressible, and, when examined by candle-light in a dark
room, is usually quite translucent. What is remarkable, and
worthy of particular notice, is, that the testicle lies almost
always at the posterior part of the tumor, opposite the inferior
third of the swelling.

Hematocele ^ as its name imports, is a collection of blood
in the vaginal sac, caused by mechanical violence, or inflam-
matory irritation; in the latter case it is ordinarily connected
with hydrocele. The tumor is pyriform, dark, compressible,
and filled with thick, grumous blood, often of the color of cof-
fee-grounds. The vaginal tunic is somteimes preternatural ly
hardened, and its inner surface roughened with lymph. This
affection, which is seldom painful or attended with constitu-
tional disturbance, may be distinguished from hydrocele by
its dark color, its obscure fluctuation, its weight, and by the
fact that it is usually the result of external injury. Some-

404 TESTICLE. [chap. XIII.

times the clots that are thus formed become organized, the
vessels which they contain being susceptible of artificial
injection.

Encephaloid, though occasionally found in the vaginal sac,
is extremely rare. I have never met with it, and Sir Astley
Cooper has seen it only once. The morbid mass has a white
brain-like aspect, and possesses all the characters of fungus
hasmatodes. It is commonly connected with hydrocele and
thickening of the serous tunic. No particular pain seems to
attend the developement of this disease.

Sometimes the vaginal tunic acquires a cartilaginous hard-
ness ; and portions of it, as before stated, have been found in
an ossified state. These transformations, which are not in-
frequent attendants on old hydroceles, ordinarily occur in
small patches, of no determined shape ; but sometimes they
grow from the free surface of the membrane in the form of
little spicules, the attachment of which is affected by very
slender footstalks.

In dissecting persons that have labored for a long time
under hydrocele, or other chronic affections of the serous
covering of the testicle, we occasionally find small earthy
concretions, either contained in distinct sacs, or floating about
in the serum. Their number, though sometimes considera-
ble, seldom exceeds two or three ; their size varies from that
of a shot to that of a pea ; and not unfrequently they have a
peculiar pearly lustre. Sometimes such bodies are partly
osseous and partly cartilaginous ; and now and then they are
remarkably hard and gritty, like grains of sand. Their com-
position is carbonate and phosphate of lime, with about thirty-
eight parts of animal matter in the hundred. The celebrated
John Wesley, who was afflicted with hydrocele in his old
age, is said to have had a small concretion of this drawn off
by his physician.

II. The testicle is liable to inflammation, purulent deposits,
scirrhus, encephaloid, tubercles, hydatids, and osseous degen-
eration.

The anatomical characters of acute orchitis are, increased
vascularity, and thickening of the tubular structure, followed,
when the disease runs high, by deep redness and softening.
The organ swells, becoming hard and rounded, and the vagi-
nal sac is either distended with watery fluid, or lymph is
poured out, by which the two contiguous surfaces of the
membrane are permanently glued together. The epididymis

SECT. I.] ACUTE INFLAMMATION. 405

is usually involved in the affection, and in many cases the
irritation extends along the spermatic cord, rendering it tumid
and painful.

This disease, although it generally terminates by resolu-
tion, sometimes proceeds to suppuration, or it leaves the organ
in a state of chronic enlargement, or, finally, it may give
rise to hydrocele. The most common causes of acute orchi-
tis are, local violence, suppression of the gonorrhceal discharge,
mumps, stimulating injections, and vicissitudes of tempera-
ture. Great tenderness and swelling of the part, inflamma-
tory fever, nausea, and vomiting, with irritability of the
bladder, and dull, aching pain along the course of the sper-
matic cord, constitute the characteristic symptoms of the dis-
ease.

When suppuration is about to set in, all the symptoms be-
come suddenly aggravated ; rigors now come on, attended
often with slight delirium ; and the part is so painful that the
patient can scarcely tolerate the weight of the bed-clothes.
The pus, being generally mixed with seminal fluid, is seldom
of a healthy character ; and, as it is confined by the albugi-
nous coat, it is always a long while in working its way to the
surface. The abscess often breaks at several places, thus
leaving unhealthy sores which it is difficult to heal, and which
not uncommonly lead to a total disorganization of the tubu-
lar structure. Suppuration of the testicle is most common
in scrofulous subjects.

Chronic inflammation of the testicle seems to be of rather
frequent occurrence, especially in warm latitudes. It usually
begins in a hardness and swelling of the epididymis, from
whence it gradually extends to the body of the gland, the
seminiferous "ducts of which are dilated, indurated, and of a
dark grayish color. At first, the organ enlarged perhaps many
times beyond its ordinary bulk, retains its natural smoothness,
but by and by it becomes knobby and irregular. This form of
the disease is often accompanied with efl'usion of serum into
the vaginal sac, by the deposition of purulent matter in the
parenchymatous structure, and by enlargement and thicken-
ing of the spermatic cord. In obstinate cases, the gland is
sometimes of a hard, compact consistence, grates under the
knife when cut, and is of a dark, reddish color, not unlike
half-boiled flesh. Cells are often found in its interior, con-
taining different kinds of fluids. The disease occasionally
aflfects both testicles. There is seldom much constitutional

406 TESTICLE. [chap. XIII.

derangement, and the organ is usually free from pain, mani-
festing little or no tenderness on pressure.

When the testicle is scirrhous, the disease may be recog-
nized by the great hardness of the gland, by the tardiness of
its progress, by tenderness on pressure, and by pain darting
along the spermatic cord to the loins. It seldom appears be-
fore the age of thirty-five or forty, though in a few instances
I have noticed it at a much earlier period. In many cases it
can be traced directly to the effects of injury, syphilis, or
gonorrhcea.

Encephaldid is a malignant growth of the testicle, com-
mencing with sweUing and induration of the body of the
organ, generally slow in its progress, but sometimes so rapid
as quickly to attain a very great size. When thus rapid, the
disease soon reaches the epididymis, and the gland, instead
of being globular, as it was in the first instance, is rendered
pyriform, and so much resembles hydrocele as to be readily
mistaken for it. The deception is increased frequently by
the elastic nature of the tumor, by the effusion of water into
the vaginal sac, and by the absence of pain and tenderness
on pressure. As the disease advances, the testicle loses its
smoothness and regularity, its surface becoming rough and
knobby ; the swelling is soft, doughy, and irritable ; the
spermatic cord enlarges, its vessels being often hard and vari-
cose ; the inguinal ganglions of the affected side are tumid
and tender ; the patient complains of occasional pain in the
tumor, darting into the groin and lumbar region ; the counte-
nance is wan and sallow ; and all the phenomena, both local
and general, indicate the destructive nature of the malady.
Ulceration sometimes occurs, attended by a discharge of
bloody, serous fluid, and by the formation of fungous granu-
lations, remarkably sensitive, and so tender as to bleed on the
slightest touch.

If, in the first stage of the disease, the tumor be ampu-
tated, and carefully inspected, it will be found to consist of a
soft, grayish, pulpy mass, looking very much like the cerebral
tissue. Frequently the tumor contains serous cysts, coagu-
lated blood, chocolate-colored matter, or a dark creamy sub-
stance, more or less offensive to the smell. The tubular
structure of the gland is generally entirely destroyed ; the
albuginous coat is very much thickened and indurated, or
broken up, and confounded with the diseased structure ; and
a considerable quantity of watery fluid, usually mixed with

SECT. I.] TUBERCLES ; HYDATIDS. 407

blood, is almost always found in the vaginal sac. This hor-
rible malady commonly occurs in connection with tubercles
of the lungs, liver, or spleen, and always manifests a disposi-
tion to reappear, after the removal of the testicle, in the lym-
phatic ganglions of the groin, pelvis, or lumbar region.

Excepting the bones, eye, and mammary gland, the testi-
cle seems to be more liable to this disease than any structure
in the body. It is generally met with before the middle pe-
riod of life, and may often be referred directly to blows,
bruises, and other external injuries.

Tubercles are sometimes seen in the testicle, occurring
either in its interior, on its surface, or in the epididymis : they
are commonly of a pale yellowish color, spherical, and about
the size of a pea. Occasionally the scrofulous matter is infil-
trated into the tubercular structure ; and cases are observed
in which the whole gland is converted into a curdy, friable,
cheese-like substance. The disease begins without local un-
easiness ; but, as it sometimes ends in ulceration, a very un-
pleasant sore may be thus created, which is of a pink color,
fungous, irregular on the surface, and often highly sensitive.
The deposition seldom takes place in both glands at the same
time : it generally begins at the epididymis of one of them,
and extends from thence to the body of the organ, which, as
just stated, it sometimes entirely occupies. The matter is
usually poured into the cellular element of the organ ; but, in
some cases, there is reason to believe that it is deposited di-
rectly into the excretory tubes.

It is very rarely that the testicle contains hydatids. When
present, they are commonly small, and their tendency is grad-
ually to destroy the tubular structure, in which they are lo-
cated. These remarks are equally applicable to the serous
cysts, which are occasionally found in this gland. Both these
affections are unattended by pain, and they are seldom wit-
nessed before the age of twenty-five or thirty. The cysts
vary in size from, the head of a large pin to that of a small
grape ; they are extremely delicate, highly vascular, gregari-
ous, and contain a thin, transparent, straw-colored fluid, anal-
ogous to the serum of the blood. Occasionally their coats
are much indurated, and their contents thick and glairy, like
the white of an egg. With these growths is usually asso-
ciated enlargement of the testicle, sometimes of great extent.

Nodules of cartilage are not of uncommon occurrence in
the testicle, existing either alone, or, as is more commonly

408 TESTICLE. [chap. XIII.

the case, with other lesions. Of this disease I have never
seen an instance ; nor have I met with the osseous degenera-
tion, spoken of by BailKe, Cooper, and other writers. Such
deposits, whether seated in the substance of the gland, or in
its envelopes, are probably always the effects of protracted or-
chitis : they do not seem to be accompanied by any particu-
lar symptoms, and they never admit of relief from treatment.
Hypertrophy of the testicle, without any appreciable change
of structure, is a very uncommon circumstance. Baron Lar-
rey has witnessed some cases of it, and several have been re-
cently reported by other writers. The gland may attain the
magnitude of a large fist. The general health is usually
good ; but the penis is incapable of erection, and the tumor
incommodes by its weight. More commonly the hypertro-
phy is connected with induration, and various other devia-
tions from the normal state.

Atrophy of this organ seems to arise from chronic irritation,
leading to absorption of the tubular structure. It may re-
sult, however, from a great variety of causes, such as an
abuse of venery, indulgence in masturbation, mechanical in-
jury, obliteration of the spermatic arteries, and immoderate
and long-continued use of iodine, opium, and other narcotics.
In some instances it has been known to supervene upon in-
jury or organic disease of the cerebellum ; and, in the French
soldiers, in Buonaparte's first campaign in Egypt, it was often
produced, as was supposed by Larrey, by the employment of
a species of brandy, manufactured from the date and laurel-
berry. The wasting was generally very gradual, commenc-
ing with a loss of sensibihty of the organ, which became
softened, and at length reduced to the size of a small bean.
Contemporaneously with this structural lesion was an altered
state of the voice, with cessation of the growth of the beard,
and complete loss of sexual powers.

Another very frequent cause of this lesion is mechanical
pressure exerted upon the testicle by varicose tumors of the
spermatic veins. Of this, several cases have come under my
own observation, and others have been communicated to me
by my medical friends. The absorption which is thus in-
duced often proceeds with great rapidity, until the gland is
reduced to a soft, pulpy mass, scarcely equal in volume to a
Lima bean.

Atrophy of the testicles occasionally exists as a congenital
defect. I am acquainted with two young men, natives of the

SECT. II.] SPERMATIC COKD. 409

State of Ohio, in whom these organs are scarcely as large as
a hazelnut. One of them has never experienced the slightest
sexual desire ; the other has been married upwards of eight
years, but no offspring has followed the connection. Com-
plete inaction, such as is observed in monks, is often attended
with atrophy and impotence.

SECTION II.

Of the Spermatic Cord.

The spermatic cord, composed of the deferential duct, of
blood-vessels, nerves, and absorbents, all invested by a thin,
fibrous sheath, is liable to encysted hydrocele, varicocele, and
neuralgia.

Encysted hydrocele may be seated in the free portion of
the cord, or it may occupy the part which lies in the ingui-
nal canal. In the former situation, the nature of the swelling
may be readily distinguished by its globular figure, by its
firmness, transparency, and diminutive size ; in the latter,
the diagnosis is often obscure, and the surgeon is liable to
confound the disease with inguinal hernia. The fluid of a
hydrocele of this kind is generally very thin and limpid, and
the cyst consists of two layere, the external being formed by
the spermatic fascia, the internal, which is almost always
thickened, by the remains of the peritonseum. Let us be un-
derstood on this subject. In the descent of the testicle, the
cord is loosely invested by a prolongation of the serous mem-
brane of the abdomen ; this, after a time, contracts close ad-
hesions around the cord, and in this way the communication
between the peritonasum and the testicle is gradually de-
stroyed. Occasionally, however, it happens that the union is
in some places incomplete, and, a space being thus left, a
slight secretion goes on, and an encysted hydrocele, as such
an accumulation is called, is the consequence. The tumor
is commonly small, rarely exceeding the volume of a pullet's
egg-

Varicocele consists in an enlargement of the spermatic
veins, as they stretch from the testicle, where they originate,
to the groin. The vessels have a singularly knotty and tor-

VOL. II. 52

410 SPERMATIC CORD. * [CHAP. XIII.

tuous arrangement ; their coats are much thickened, and not
unfrequently they feel like a cluster of worms. The tumor,
which is irregular, compressible, and of a conical or globular
shape, occm's much oftener on the left side than on the right,
and is seldom attended with much uneasiness. In a few
cases, there is pain in the loins and in the course of the cord;
but in the generality of instances the enlargement, however
great, causes little suffering, save what results from its weight.
Pathologists have endeavored to assign a reason for the great-
er frequency of this affection on the left side than on the
right, by supposing that it is connected with the more de-
pendent situation of the left testicle, and the greater length
of the left spermatic vein, which, instead of ending in the in-
ferior cava, like the right, terminates in the left renal, nearly
at a right angle with the stream of blood from the kidney.
This explanation, suggested originally, I believe, by Morgag-
ni, is certainly plausible, and perhaps sufficiently near the
truth. Be the cause, however, what it may, the fact is un-
deniable that the disease is generally found on the left side.
In upwards of one hundred cases examined by M. Breschet,
of Paris, only one occurred on the right side.

Although vericocele may show itself at any period of
life, yet it is undoubtedly most common in young subjects,
within the first ten years from the time of puberty. In twen-
ty-seven cases of this affection, recorded by M. Landouzy, a
recent French writer,*" seven occurred between the ages of
nine and fifteen ; seventeen between fifteen and twenty-five ;
and three between twenty-five and thirty-five.

Neuralgia sometimes occurs in the spermatic cord, extend-
ing to the epididymis and body of the testicle. The affec-
tion, seated probably in the nervous plexus, around the
spermatic vessels, is of the nature of tic douloureux, being
characterized by unnatural sensibility of the affected parts,
with excessive tenderness on pressure, and pain in the groins,
sometimes darting into the back and thighs. The testicle is
but little swelled ; the cord is not perceptibly altered ; and, if
the parts composing it be removed from the body, and care-
fully inspected, no lesion whatever is to be observed in them,
excepting, in some rare cases, a slight thickening of the
nerves.

* Essai sur la Varicocele, Journal des Connaissances Medico-chirureficale,
Jan. et Mars, 1838.

SECT. III.] SEMINAL VESICLES. 411

SECTION III.

Of the Seminal Vesicles.

Little is known respecting the lesions of the seminal
vesicles. That they are liable to derangement, is sufficiently
obvious ; but that their diseases are few and of rare occurrence,
is equally certain. Hitherto, these reservoirs have been almost
entirely overlooked in our examinations ; and to, this omission,
perhaps, more than to any thing else, is to be ascribed the
meagreness of our information. Their average length is about
two inches and a half, their breadth six lines, and their thick-
ness four lines.

Inflammation of the seminal vesicles rarely exists as a pri-
mary disease ; most generally it is propagated to them from
the urethra, bladder, prostate gland, or testicles. In a few
instances, pus has been detected in them ; and, on one occa-
sion, I found the left in a fetid, gangrenous condition. The
individual was fifty-eight years of age, and died of inflam-
mation of the prostate, accompanied with complete retention
of urine for nearly a week. The right vesicle was of a dark
color, from the loaded state of its vessels ; and its cavity was
filled with a thick, muco-purulent fluid, mixed with a small
quantity of semen.

Tubercular matter is much more rarely deposited in the
seminal vesicles than in the testicles, uterus, or Fallopian
tubes. Baillie saw one of thiese reservoirs entirely distended
with this substance ; and a case occurred to me, not long ago,
in which both were filled with it. The individual was a
young man, twenty-seven years of age, in whom similar
deposits existed in some of the other organs. The vesicles
were remarkably pale, and reduced to less than one half their
ordinary volume. Small earthy concretions, of the same
nature as those of the prostate, have occasionally been found
in these bodies ; and, in several instances, they have been
observed to be very hard and scirrhous.

None of the changes here described seem to have any par-
ticular signs that mark their existence during life. In the
case above mentioned, in which one of these organs was
gangrenous, there was violent pain in the region of the pros-
tate gland, with retention of urine, and, towards the close of

412 SCROTUM. [chap. XIII.

the illness, the most furious delirium ; but no symptom
whatever that could be referred to the seminal vesicle.

The seminal vesicles are sometimes remarkably small, and
occasionally one of them is absent. In some instances, their
ducts are wanting, and in others, they are obliterated by in-
flammation, lymph, or tubercular matter, of which I have
seen several examples. Professor Blandin mentions * a case,
which he observed in the body of a mendicant, where both
the excretory tubes terminated in a sort of flexuous cul-de-sac,
which supplied the place of the seminal vesicle.

SECTION IV.

Of the Scrotimi.

The scrotum is liable to be affected with inflammation,
cancer, and other diseases. Of these, it is only necessary to
notice a few of the more important.

Cancer of the scrotum seldom occurs before the period of
puberty- It is most common in scrofulous persons, and
chimney-sweepers ; and hence it has by some been named
the chimney-sweeper's ca.ncer. The affection generally be-
gins at the base of the scrotum, in the form of a small, wart-
like excrescence, covered by a thin, scaly crust. After this
has continued for a time, the hardened cuticle sloughs off",
leaving a superficial, painful, ill-looking ulcer, with indurated
and everted edges. The surface of the sore has a red, ex-
coriated aspect, and discharges a thin, sanguinolent fluid,
often highly irritating and offensive. In this way, the ul-
cerative process gradually extends, until at length a large
surface of the scrotum, together with the vaginal tunic, and
the exterior of the testicle, is involved in the disease. In
this advanced stage, the cellular tissue around the sore is gen-
erally white and scirrhous ; and the inguinal glands on one
or both sides are enlarged, injected, and, in some instances,
filled with scrofulous matter. At the commencement of the
disease, the part is merely affected with troublesome itching j

* See his " Nouveaux Elemens d'Anatomie Descriptive," t. ii. p. 264. Paris,

1838.

SECT. IV,] SARCOMATOUS ENLARGEMENT. 413

but, after a while, the patient complains of darting pains,
which often extend along the spermatic cord, and the scrotum
is hot and tender on pressure.

The scrotum is sometimes transformed into a hard, fleshy
mass, constituting what is termed sarcomatous enlargement.
The enormous magnitude which this disease may attain is
almost incredible. A surgeon of the West Indies, removed
a tumor of this kind, from the scrotum of a negro, which
weighed seventy pounds ; and Baron Larrey has detailed the
particulars of another, which was supposed to weigh one
hundred and twenty pounds. In the medical museum, at
Montpelier, there is a diseased mass of this character, which
was amputated by the learned Delpech, the weight of which,
I am told, is one hundred and sixty pounds.

This disease is seldom observed in this country or in Eu-
rope ] but in some parts of Asia and Africa it is not of infre-
quent occurrence, especially in persons that are afflicted with
elephantiasis. Externally, the morbid growth is rough and
fissured, and its surface, particularly in old cases, is covered
with yellowish, scaly crusts, the detachment of which leaves
so many small, herpetic sores, emitting a thin, ichorous dis-
charge. The skin is very thick and indurated ; the cell-
ular tissue is firm and scirrhous, from the distention of its
cavities with semi-concrete, albuminous matter ; and the
blood-vessels of the part, instead of being large and varicose,
as we find them in most other tumors, are remarkably small
and contracted. The swelling is commonly indolent, and
incommodes rather by its weight and bulk than by its pain.
In its shape it is mostly pyriform, but sometimes ovoi'dal, or
globular. The testicle is not necessarily implicated in this
disease, nor is the spermatic cord so much indurated and en-
larged, as in some of the other disorders of the genital ap-
paratus.

A peculiar sloughing disease occasionally occurs in the
scrotum of young children. In a case which I recently saw
with Dr. Woodward, in an infant two weeks old, a slough,
about an inch in diameter, suddenly formed over the right
testicle, leaving the vaginal tunic perfectly denuded, and pro-
ducing an angry-looking sore, with hard, glossy edges, re-
posing upon black-colored cellular tissue. The spermatic
cord was indurated, tumid, and remarkably tender on pres-
sure. The constitution did not seem to suffer much. In
the course of twenty-four hours after these symptoms were

414 SCROTUM. [chap. XIII.

discovered, the vaginal sac became distended ; and, on punc-
turing it, a considerable quantity of sero-purulent fluid, of a
yellowish color, followed the lancet. A small portion of the
membrane now sloughed, leaving the gland quite bare ; but,
by touching the part with lunar caustic, and applying the
yeast poultice, granulations gradually sprouted up, and the
infant got well.

We sometimes find cysts in the scrotum filled with fatty
matter, teeth, hair, or osseous fragments, or all these sub-
stances in a state of combination. In a case of this description,
observed by St. Donat, a French surgeon, the tumor con-
tained, amongst other pieces, two distinct frontal bones, the
orbits of which were regularly hollowed out for the recep-
tion of two small, rudimentary eyes. In another example,
the particulars of which have been published by Dr. Die-
trich, professor of midwifery in the University of Glogau,
the debris which was found in the testicle was composed
of a pelvis and a lower extremity. A still more extraordinary
instance was observed by Dr. Ekl.* In this case, the scrotal
tumor was formed by the ribs, the spinal column, the orbits,
and thigh-bones of a fostus. We have already alluded, in
another section, to the singular case reported by Dr. Andre,
of Petronne, in which he discovered hair and teeth in the
testicle of a boy, seven years of age. These formations,
which, on the whole, are extremely rare, bear the closest
analogy to those of the ovary ; and they can only be ac-
counted for on the theory of monstrosity by inclusion.

There is another affection of the scrotum, which, although
of very infrequent occurrence, may be briefly noticed in con-
cluding this article. I allude to the deposition of earthy
matter. This may take place in the form, either of sand-like
granules, or in that of calculous masses, from the volume of
a pea up to that of an almond. Their number, although
generally small, sometimes amounts to several dozens ; they
are of a dull whitish color, and of a cretaceous consistence,
or even of the density and solidity of bone. Their chemical
composition has not been ascertained ; but, judging from what
we know in reference to these bodies in other situations, it
is not improbable that they consist mainly of phosphate and

* See the interesting treatise of Dr. OUivier, of Angers, entitled " Memoire
sur la Monstrositie par Inclusion," in which this and other cases are de-
tailed.

SECT. V,] PENIS. 41d

carbonate of lime, cemented together by a small quantity of
animal matter.

Hitherto these concretions have been fomid exclusively in
subjects past the middle period of life, in association with hy-
pertrophy. Their formation is generally very tardy, and the
irritation which they produce sometimes leads to ulceration.
In the interesting case observed by my friend, Professor Mott,
of New York, the scrotum was, nearly fifteen times the nor-
mal bulk, the patient was very far advanced in life, and the
disease, which was removed by a surgical operation, had
existed for upwards of twenty years.*

SECTION V.

Of the Penis.

The penis consists of several parts, differing from each
other in their structure and functions, and liable, therefore, to
dissimilar lesions. The cavernous bodies, as they are termed,
are rarely affected, whereas the urethra and the spongy tex-
ture around it are extremely liable to disease. Of the lesions
of these different component elements, I shall notice only the
more important, and I shall commence with those of the
excretory duct.

Acute inflammation of the urethra, generally the result
of impure connection, is marked by the same anatomical
characters as acute inflammation of the mucous textures
generally ; that is to say, there is more or less redness, with
opacity, and thickening of the lining membrane. In three
or four days after the infection, sometimes not under a week
or even a fortnight, there is an increased discharge of mucus,
followed in a short time by purulent matter, of a thick, ropy
consistence, and of a pale straw color. The quantity evacu-
ated in the twenty-four hours varies from one to several
drachms, and, in violent cases, it is not unfrequently ex-
tremely acrimonious, of a greenish cast, or tinged with blood.
The morbid action is usually Hmited to the extremity of the

* Philadelphia Journal of the Medical and Physical Sciences, vol. v. p. 335,
new series, 1827.

416 PENIS. [chap, XIII.

urethra, occupying the first two or three inches, — probably
from this portion being most abundantly supplied with mu-
cous follicles, and from the poison expending its virulence
principally in this situation. Now and then, however, the
disease pervades the entire tube, from one end to the other.

The symptoms of acute urethritis consist in a peculiar
scalding sensation in voiding the urine, the calls to which are
much more frequent than usual, and in a general turgescence
of the virile organ, with redness and swelling of the external
orifice, the edges of which are often tender and excoriated
from neglect of ablution. The pain is always increased
during erection, and the discharges of urine, which com-
monly flows in a small narrow stream, from the diminished
caliber of the tube, caused by the turgid state of the lining
membrane and the infiltration of the surrounding structures,
especially the submucous. When the inflammation is violent
it is apt to extend to the neck of the bladder, the testicle,
and spongy body of the penis, giving rise to eff'usion of
lymph and the formation of abscesses. In ordinary cases,
however, there is seldom if ever any breach of continuity.

When the disease assumes the chronic form, the discharge
becomes more thin and limpid, bearing a greater resemblance
to the white of egg than to real purulent matter. The
quantity, also, is much less than in acute urethritis, and there
is seldom much pain, scalding, or itching during micturition.
The passage, however, usually remains somewhat contracted,
from relaxation of the mucous lining, and the urine, in conse-
quence, is always discharged in a narrow, tortuous stream.
When the disease, now called gleet, is protracted, it often
gives rise to stricture, by which the canal is permanently
obstructed.

A very frequent efl"ect of gonorrhcea is the extension of the
inflammation to the spongy structure of the penis, and the
consequent eff'usion of lymph into its cells. This complaint,
constituting what surgeons are in the habit of calling chordee,
is characterized by abnormal erections, which are always
most distressing during night, when the patient becomes
warm in bed. The organ is curved downwards, from the
spongy structure not admitting of so complete distention as
the cavernous; and sometimes the cells are permanently ob-
literated, causing deformity of the penis, and imperfect erec-
tions. The effusion generally takes place about the middle
of the organ, occupying occasionally a large extent of surface.

SECT, v.]

STRICTURE.

417

In some cases, the deposition is affected at several points,
though this is unusual.

the urethra (Fig. 76) is the re-

Fig. 76;

Fi£

-7.t

Organic stricture of
suit of inflamma-
tory action, caus-
ing an effusion of
lymph into the sub-
mucous cellular tis-
sue and upon the
free surface of the
lining membrane.
After some time,
varying from a few
days to several
weeks, the effused
fluid becomes or-
ganized, and thus
forms a permanent
obstruction, in front
of which the pas-
sage is generally
contracted, whilst
behind it is dilated.

The urethra is sometimes narrowed
by a circular ring, not thicker than a
thread, but more commonly the stric-
ture occupies a considerable extent of
surface, from a line or two to an inch
or more. (Fig. 77.) Nor does it always
surround the whole tube; in many
cases, perhaps in most, it forms merely a segment of a circle.
The bridle stricture, (Fig. 78,) as it is called, consists of a
dense band of organized lymph, stretched from one side of the
urethra to the other. In old cases, the contracted part is some-
times very elastic, firm, almost of the consistence of carti-
lage, from repeated attacks of inflammation. The most
common seat of the disease is at the membranous portion,
about seven inches from the external orifice ; the one next in
point of frequency is at the junction of the posterior with the

* aa, corpus spongiosum; b c, urethra; d, stricture; e, indurated ring beneath
the mucous membrane.
i a d, urethra ; b c, stricture.
VOL. II. 53

418

PENIS.

[chap. XIII.

1)—

anterior two thirds of the Fig- '^^■*

tube ; and, lastly, at the
part immediately behind
the neck of the penis.

Organic stricture is gen-
erally attended with pain
in the loins, chronic
swelling of the testicle,
irritability of the bladder,
itching about the anus
and perinseum, and dis-
charge of thin, gleety mat-
ter from the urethra. The
stream of urine is small,
forked, spiral, or dribbling,
the bladder is emptied
with difficulty, and mic-
turition is usually accom-
panied with pain.

Besides the lesion now
described, some writers believe in the existence of a tempo-
rary stricture, caused by spas?nodic action of the urethra.
The circumstances which are supposed to afford evidence
of spasmodic stricture, are, according to Mr. Syme, the
sudden invasion and disappearance of the complaint, its con-
nection with mental agitation, and the difficulty which the
surgeon experiences in introducing the catheter. Some
anatomists have imagined that this disease is caused by
the contraction of the muscular fibres, which enter, as they
allege, into the composition of the urethra ; but as no such
fibres have ever been satisfactorily demonstrated, the most
plausible idea, it seems to me, is that which ascribes it to
the turgescence of the lining membrane, or to the erectile
texture which immediately invests its outer surface ; and this
opinion is strongly corroborated by the fact that the disorder
in question is almost entirely confined to persons of an irri-
table, nervous temperament.

A very distressing consequence of stricture is abscess, fol-
lowed by fistula in the perinseum, the rectum, or along the
course of the urethra. The canal, as was before stated, is

* a a, urclhra :
duels.

6 c, mucous membrane; d, stricture; c, orifices of seminal

SECT, v.] MALFORMATIONS. 419

generally very much dilated behind the constricted part,
forming a sort of pouch for the lodgement of the urine. Oc-
casionally calculi are retained here, and give rise to very
disagreeable symptoms. The suppuration is often very slow-
in its progress, and as the matter accumulates in the submu-
cous texture, the lining membrane of the canal yields at one
or more points, followed by the escape of the contents of the
bladder into the surrounding cellular substance, where they
always produce considerable sloughing. Extensive infiltra-
tion is sometimes prevented by the cellular tissue immediately
around the abscess, being so much condensed by the deposi-
tion of fibrin, as to present an effectual barrier to the difi'usion
of the fluid. The fistulous openings that are thus formed
gradually diminish in size, and become incrusted by a layer
of lymph, which, in cases of long standing, sometimes degen-
erates into fibro-cartilage. The passage in front of the per-
foration being no longer needed for conveying urine, now
contracts, and, unless there be means used to dilate it, it is
finally entirely obliterated. The number of these apertures
is often considerable, the perineeum being literally burrowed
by them.

Malforinatio7is of the urethra are far from being un-
common, and as the subject is one of much interest in refer-
ence to surgery and legal medicine, it requires brief consider-
ation in this place. For practical purposes, they may be
arranged under the following heads : first, where the canal
opens on the upper or lower surface of the penis ; secondly,
where it terminates in the perinasum ; and, thirdly, where it
opens in front of the abdomen, just above the pubes. In
epispadius, as the first of these malformations is styled, the
preternatural orifice usually exists about an inch and a half
behind the extremity of the penis ; whilst, in hypospadias, it
may be situated at any point between the gland and the
scrotum, though its ordinary seat is opposite the neck of
the organ, or just behind it. When the opening is in the
perinaeum, the under surface of the penis is sometimes deeply
grooved, the fissure extending down over the scrotum, and
giving rise to an appearance of hermaphrodism, especially if,
as occasionally happens, the testicles are retained in the
abdomen, and the penis is very diminutive.

When the opening is placed far back, the individual who
is the subject of the malformation is generally impotent.
To this rule, however, striking exceptions sometimes occur.

420 PENIS. [chap. XIII.

I am acquainted with a colored man, a patient of mine, who,
ahhough the urethra terminates at the scrotum, at least four
inches from the ordinary point, is yet the father of five chil-
dren ; and similar examples are to be found in every work on
forensic medicine.

Morbid erection of the penis is sometimes produced by
inflammation, followed by an effusion of lymph into the cells
of cavernous bodies. I have never inspected a case of this
kind after death, but observed one several years ago in a
young mechanic, which lasted for nearly four weeks, in spite
of the most rigid antiphlogistic measures. It came on soon
after ordinary intercourse, and was attended with excessive
pain, together with much constitutional disturbance. For
several months after the violence of the disease had abated,
the organ remained small, flaccid, and incapable of complete
erection. Sometimes the priapism is caused by an effusion
of pure blood ; as in the interesting case related by Mr. Cal-
laway, of London, and in which the individual continued
permanently impotent.

The 'pectiniform septum of the penis is liable to be trans-
formed into cartilage. I have never seen an example of this
disease, but an instance once occurred to Dr. George McClel-
lan, of Philadelphia, in which he was obliged, on account of
the existing deformity, to perform a surgical operation. The
individual was between fifty and sixty years of age ; the dis-
ease had been coming on gradually ; and the organ was
curved towards the peringeum to such a degree as to interfere
materially with sexual intercourse. The operation was en-
tirely successful. Such a lesion, as the ■ reader may readily
conceive, might be a cause of impotence.

The fibrous sheath of the cavernous body of the penis is
sometimes similarly affected. Boyer, Grainger, and Sir Ast-
ley Cooper have noticed examples of this kind.* The lesion
usually occurs in persons who have freely indulged in sexual
intercourse.

The penis is liable to be affected with carcinoma. The
disease usually begins in one of the mucous follicles on the
head of the organ, in the form of a little wart, from which
it gradually spreads to the other parts, until the greater por-
tion of it is destroyed. The ulcer, though deeply seated, is
at first quite narrow ; but by and by it becomes broader and

* London Cyclopcedia of Anatomy and Physiology, p. 266.

SECT, v.] CHANCRES. 421

broader, and at last throws out a cauliflower-like fungus.
There is now a profuse discharge of thin, sanious, and offen-
sive matter, the inguinal glands rapidly enlarge from the
sympathetic irritation, and the patient is harassed with severe
lancinating pains darting up towards the abdomen, his con-
stitution being at the same time completely undermined by
the local disease. Cancer of the penis is most common in
old men that have frequently suffered from syphilis ; but it
may also occur in young persons, as the consequence of ex-
ternal injury.

It will scarcely be necessary, in a work of this kind, to
say any thing concerning the different ulcers that are found
on the penis, excepting such as are of a specific character.
Amongst these, the most common are herpetic, psoriasic, and
syphilitic, — each of which is worthy of brief notice.

Syphilitic ulcers^ generally known by the name of chancres,
although they may occur on any part of the body, invade the
mucous texture always in preference to the cutaneous. In-
deed, before the latter can be involved, it must be deprived
of epidermis ; for, so long as this preserves its integrity, it is
impossible for the venereal virus to produce its specific effect.
Their most usual seat is the inner surface of the prepuce,
together with the neck of the penis, the *^ orifice of the
urethra, and the sides of the frsenum. These ulcers vary
extremely, both in size and number, being sometimes quite
small, and at other times forming large sores. In the plu-
rality of cases, there are not more than two or three ; but
occasionally there are as many as six or eight, appearing
either simultaneously, or following each other in pretty rapid
succession.

It is now well ascertained that all chancres of the mucous
membrane of the genital organs, both in the male and female,
are originally of a pustular form. The only exception to
this law is where the virus is applied to an abraded surface,
which modifies .the appearance of the sore, converting it at
once into a running ulcer. It is highly probable, I think,
that the matter is deposited, in the first instance, into the
mucous follicles, where it excites a , specific inflammation,
eventuating in the secretion of a fluid, which is capable, in
its turn, of creating a similar disease. What corroborates this
opinion is the fact, just adverted to, that the chancre always
begins in the form of a pustule, and that it is most apt to

423 PENIS. [chap. XIII.

be developed in those situations which abound in muciparous
glands.

The initial step of the disease is a small, reddish, indurated
speck, the summit of which is speedily converted into a
spherical vesicle, filled with a thin, colorless serosity. Its
size scarcely equals that of a mustard-seed ; and its parietes,
being formed by the mucous epithelium, are so excessively
delicate as to break upon the slightest touch. Hence it is
frequently ruptured before an opportunity is afforded of in-
specting it, which is the reason, doubtless, why it so long
escaped the notice of pathologists. On bursting, the vesicle
leaves a small circular ulcer, with hard, jagged, and abrupt
edges, as if they had been cut vertically. The surface of
the sore is gray, yellowish, or ash-colored, and the parts
immediately around it are indurated, thickened, and of a
deep, florid hue, being formed into a distinct, circumscribed
tumor. The discharge is at first of a foul, sanious, irritating
character ; but, by degrees, it assumes all the properties of
laudable pus. The induration commences about the fifth day ;
and, as was first remarked by John de Vigo, and afterwards
by John Hunter, forms one of the most constant characters of
chancre. It is about this period that the system begins to
be in danger of contamination from the absorption of the
virus.

A chancre appearing on the cutaneous surface, generally
begins in the form of a pimple, which is surrounded by a
red areola, and contains a thin, serous fluid, which, on the
fifth or six day, becomes purulent. The part about this pe-
riod presents the aspect of a pustule, not unlike that of small-
pox ; and the structures on which it rests are somewhat
indurated and oedematous, from the eff"usion of coagulating
lymph. In a few days more, the matter becomes thick, the
pustule shrinks, and scabs begin to form, which, on falling
off", expose deep, rounded ulcers, encircled each by a promi-
nent, violet-colored ring. The scabs, which are thick, and
often of a truncated, conical shape, are soon succeeded by
others ; and thus the disease proceeds until the part either
gets well, or yields to the devastating influence.

Syphihtic ulcers are very apt to spread, and even to ter-
minate in gangrene. The slough is small, circumscribed,
and black at first, but afterwards, more or less extensive and
ragged. The entire chancre is sometimes thus lifted from its

SECT, v.] CHANCRES. 423

place, leaving the surrounding tissues in an inflamed and
infiltrated condition, with a sore that can be easily healed.
More generally, however, the ulcers assume a phagendenic
character, and throw off fresh sloughs until the whole penis
is involved in the ruinous mischief.

Many chancres, after having persisted for a variable time,
gradually exhaust themselves, and finally cease spontaneously,
the event being announced by the secretion of laudable pus,
and the developement of healthy granulations. In whatever
manner the reparation be efiected, whether by art or the
efforts of nature, there almost always remains a hard, gristly
tumor, which is more or less tender on pressure, very slow
in disappearing, and extremely prone to new attacks of ulcera-
tion. Indeed, so common is this, that chancre may be con-
sidered, in the language of an ingenious writer, as a genuine
phoenix, which springs from its own ashes, and furnishes the
food for its own nourishment. So long as the disease is con-
fined to the penis, it is strictly a local affection ; but it has
a tendency, sooner or later, to work its way into the system ;
the first evidence of which, is generally a swelling of one
of the lymphatic ganglions of the groin, known by the name
of bubo.

Chancre can alone produce chancre. That this is the fact,
appears to be conclusively established by the recent researches
of Dr. Ricord,* of Paris. This distinguished physician re-
peatedly inoculated persons with the muco-purulent matter
of simple gonorrhosa, without succeeding in a single instance
in producing chancre. He has also ascertained that it is
during the ulcerative stage that the sore yields its specific
secretion : after this has passed, it loses its character, its na-
ture changes, and its poisonous property is destroyed. Dilu-
tion with other substances renders its operation not only
uncertain, but at times completely inert. The part to which
it is applied must likewise be free from acute inflammation,
from purulent fluid, and from unctuous matter.

The time intervening between the application of the virus
and the developement of the chancre is very uncertain. Oc-
casionally the disease follows in the course of twenty hours ;
at other times — and this is most generally the case — several
days elapse ; and, in some instances, it does not make its

* Edinburgh Medical and Surgical Journal, vol. x. L. ix. p. 479.

424 PENIS. [chap. XIII.

appearance under a few months. The nature of the part
affected seems to exert some influence upon the production
of chancre. Thus, the prepuce is more easily diseased than
the gland, and the latter than the skin of the penis and of the
scrotum.

Herpetic ulcers are only observed in adults, generally on
the inner surface of the prepuce, though also sometimes on
the skin. They manifest themselves by inflamed spots, of a
bright red color, varying in size from that of a millet-seed to
that of a split pea. Small x'esicles soon succeed, of a glob-
ular shape, remarkably transparent, agglomerated, and con-
taining at first a serous, and subsequently a puriform fluid.
On the internal surface, these vesicles lead to the develope-
ment of thin, flat scales, which fall off" about the fifth day,
leaving a corresponding number of round, yellowish excoria-
tions : on the external surface, rough, irregular scabs form.
This disease is very apt to recur. It is usually attended
with some itching, rarely with real pain. Friction and want
of cleanliness are the principal exciting causes. By running
together, these ulcers occasionally form one unbroken sore,
occupying nearly the whole of the prepuce. From experi-
ments made by Mr. Evans, of England, it appears that the
matter secreted by these ulcers is not contagious.

The psoriasic ulcer is most frequently met with in persons
who have the fore-skin unnaturally long, moist, and tender.
It is an obstinate and painful disease, characterized by deep
cracks, or fissures, on the edges of the prepuce, which be-
comes gradually thickened, hardened, and so corrugated as
to occasion phymosis. The number of ulcers is sometimes
quite considerable : they are very tender and unseemly ; apt
to bleed when injured ; extremely difiicult to heal ; and, if
large, attended with a very copious, puriform discharge.
Small, brownish-looking scales occasionally form on these
sores.

A not uncommon consequence of gonorrhoea and syphilis
is the developement of warty excrescences, principally around
the neck of the gland, and by the side of the fra3num. The
number of these growths is usually inconsiderable, though
occasionally there are as many as six or a dozen. Their
volume varies extremely, being sometimes quite small, and at
other times constituting large tumors. They have generally
narrow necks, with thick, rough bodies ; are of a firm, fibrous

SECT, v.] PHYMOSIS PARAPHYMOSIS. 425

consistence, and, of a pale grayish color, with various shades
of red. When injured, they are very painful, and apt to
bleed. On being extirpated, they often reappear.

It is unnecessary here to say any thing, particularly in
reference to phymosis and paraphymosis, two congenital mal-
formations, consisting, the one in an inability to retract the
prepuce, the other in an inability to pull it forward. Both
these states may be the result of accident, and are often met
with in association with gonorrhoea and syphilis.

VOL. II. 54

CHAPTER XIV.

Of the Female Organs of Getieration.

SECTION I.
Of the Uterus.

I. The uterus. — Situation and Shape. — Observations on its Weight and Vol-
ume. — Is composed of a peculiar Substance. — Liable to Malformations. —
Retroversion. — Prolapsion and Inversion.' — Is apt to suffer from Inflamma-
tion, both of its Lining Membrane, its serous Covering, and its proper Tissue.

— Remarks on Uterine Phlebitis. — Softening. — Induration. — Fibrous Tu-
mors.— Different Species of Polypes. — Calcareous Concretions. — Trans-
formation of the Uterine Tissue into Cartilage and Bone. — Malignant Dis-
eases.— EncephaloTd and Scirrhus. — The Corroding Ulcer and Cauliflower
Excrescence of Clarke. — Tubercular Deposits. — Hemorrhage. — Accumu-
lation of Air. — Obstructions of the Mouth of the Womb. — Hydatids. — Ute-
rine Moles. II. The Omrics. —Normal Characters. — Their Disorders are
numerous and important. — Serous Cysts and Hydatids. — Scirrhus. — Occa-
sionally contain Teeth, Hair, and Fragments of Bone. —Hemorrhage. — Re-
marks on the Corpora Lutea. III. The Fallofian Tiibes. — How organized.

— Are seldom affected with Disease. IV. The Vagina and Vulva. — Liable
to the same sort of Maladies as the other Mucous Structures. — Polypes of the
Vagina. — Enlargement of its Mucous Follicles. — Vices of Formation. —
The Great Labia. — Clitoris. — Nymphas, and Orifice of the Urethra. V.
The Mammary Gland.— Structure, Volume, and Color. — Is often the seat of
Acute and Chronic Inflammation. — Its Diseases, in many respects, resemble
those of the Testicle and Ovary, VI. Placenta. — Structure. — Inflammation.

— Suppuration. — Softening. — Cartilaginous Degeneration. — Ossification. —
Hypertrophy. — Sanguineous Effusions. — Umbilical Cord.

The sexual system of the female consists of the uterus,
Fallopian tubes, ovaries, the vagina, vulva, and mammary-
glands. Previously to the age of puberty, the uterine organs
are extremely small, and as they do not exert any particular
influence on the constitution, they are not at all prone to dis-
ease. When they have attained their full developement,
however, their importance is deeply felt by the system at
large, and they then become subject to a great variety of
morbid alterations, both of a functional and organic character,
which either impair the general health of the female, or ter-
minate in destructive mischief.

In women who have borne children, the womb is always
larger, and its substance more firm and dense ; its lips, also,
are more ragged and irregular, and sometimes, though rarely.

SECT. I.] UTERUS J DESCRIPTION. 427

the orifice of the organ is obliterated. Morgagni refers to a
case where the closure was effected by the growth of an ad-
ventitious membrane, and similar examples have since been
recorded by other writers. Occasionally, though rarely, the
uterus and the vagina have been known to form one solid
mass, without any cavity or opening in either.

Situated obliquely within the pelvic cavity, the uterus is
in contact, above, with the folds of the small intestines, in
front, with the urinary bladder, and behind, with the rectu.m.
Inferiorly, it is intimately connected with the vagina, forming
an angle with it of about forty-five degrees. In/its shape, it
is pyriform, the broader part being above, and the narrower,
which is called the neck, below. It is closely invested by
two folds of the peritonseura, and is kept in its position prin-
cipally through the agency of the round ligaments, which are
attached, on the one hand, to its upper and lateral aspect, and,
on the other, to the cellular substance of the groin and pubes.

The weight and dimensions of the uterus vary very much
in different individuals, as well as at the different periods of
life. In six specimens, taken from young virgins, soon after
the establishment of the menstrual function, I found the ave-
rage weight to be one ounce and a half, the minimum one
ounce, and the maximum one ounce and three quarters : the
medium length was two inches seven lines ; the breadth, from
one Fallopian tube to the other, eighteen lines ; and the thick-
ness ten lines and a half. Of the neck, the length was fourteen
lines, the breadth eleven, and the thickness eight. The lips,
which varied in thickness from three to four lines, were per-
fectly smooth and rounded, and enclosed a circular orifice
scarcely a quarter of an inch in diameter. In two of the
specimens the aperture presented the appearance of a trans-
verse slit. The horizontal diameter of the inferior extremity
was eight, the antero-posterior, seven lines. The medium
thickness of the parietes was five lines at the body, and four
at the neck. The length of what is termed the fundus of
the organ rarely exceeds the fourth of an inch.

The cavity of the uterus, very small in proportion to the
thickness of the parietes of the organ, is marked off, though
very faintly, into two lateral halves by two slightly-raised
longitudinal lines, running along its anterior and posterior
surfaces. In shape it is somewhat triangular, being much
wider above than below, where it gradually assumes a cylin-
drical appearance, conforming thus to the external configura-

428 UTERUS. [chap. XIV.

tion of the neck. A very smooth, dehcate, mucous mem-
brane, evidently a prolongation of that of the vagina, but
considerably modified in its structure, is reflected into this
cavity, and furnishes it with a complete lining. It is of a
light pink color, except during menstruation, when it is gen-
erally of a florid complexion, and is so intimately adherent to
the proper substance of the viscus, that Morgagni, Azzogindi,
Chaussier, and many others, have been induced to deny its
existence, — an opinion, however, which is not only opposed
by analogy, but by numerous pathological facts. In the neck
of the womb the membrane is thrown into very delicate, ob-
lique folds, which are more conspicuous in virgins than in
females who have borne children, and which are arranged
into beautiful arborescent lines. Throughout its entire ex-
tent, but more particularly at the mouth and neck of the or-
gan, it is studded with mucous follicles, which are so minute,
in the healthy state, as to render it diflicult to demonstrate
them, but which are always rendered prominent during ges-
tation and in certain diseases.

The proper substance of the uterus seems to be peculiar.
In appearance it is not unlike a half-tanned hide, and in con-
sistence it is so dense and firm that it is not easily cut with
the knife. Varying in thickness from four to six lines, it is
composed of strong, elastic fibres, of a yellowish buff color,
which intersect each other in every conceivable direction.
With respect to the proximate nature of this texture, writers
are still much divided in opinion ; for, whilst some assert that
it is essentially muscular, others are disposed to look upon it
as being altogether peculiar, and consequently unlike any
other substance in the body. Vesalius, the great restorer of
anatomy in the seventeenth century, describes these layers of
fleshy fibres, one of them as being arranged transversely, the
second perpendicularly, and the third obliquely. Malpighi
speaks of them as constituting a sort of net- work ; and
Ruysch maintains that they appear in particular parts of the
organ, especially at the base, in the form of orbicular mus-
cles. In the admirable plates of Dr. William Hunter, they
are represented as being transverse in the body of the uterus,
and concentric at the base. This subject has been investi-
gated, more recently, by Mr., noAv Sir Charles Bell, an ac-
count of which observations may be found in the fourth vol-
ume of the London Medical and Surgical Society. This
distinguished anatomist asserts that the muscular fibres of

SECT. I.] STRUCTURE. 429

the womb can be as easily demonstrated as those of any oth-
er organ ; and he snpposes that their presence is absolutely
necessary to enable us to explain the powerful contractions
which take place during labor. It would seem, from his dis-
sections, that the circular fibres prevail at the base, and the
longitudinal in the body and neck. According to Madame
Boivin, again, an eminent Parisian midwife, the substance of
the womb consists of two fleshy cones, of which the outer
is composed of longitudinal, the inner of circular fibres, a
disposition similar to that which obtains in the intestinal
canal.

In opposition to this view, concerning the muscularity of
the uterus, might be arrayed the names of many of the most
distinguished anatomists of the last and present centuries ;
but to do this would far exceed the limits of the present trea-
tise, and I shall therefore content myself with observing that,
so far as a careful examination of this substance, both in the
healthy, impregnated, and diseased state of the organ enables
me to judge, I am compelled to believe that it is of a peculiar
nature, altogether unlike any other texture in the body. Not
only is this conclusion sanctioned by the results of numerous
and well-conducted dissections, but, if analogy be allowed to
have any weight in the argument, it is wholly on that side of
the question which I have just taken. Indeed, it may be as-
sumed as an established anatomical fact, that the structure un-
der consideration does not possess a single characteristic attri-
bute of the muscular tissue, with the exception of its contrac-
tile power ; and this, it is well known, is much greater, in pro-
portion to the volume of the organ, than that of any other mus-
cle in the whole body. Instead of being red and soft, it is pale
and firm ; and, as it is a doctrine in physiology that the
strength of a muscle is always in direct ratio to the depth of
its color, it might justly be expected that the fibres of the
uterus would be of a transcendently florid hue, which, how-
ever, is not the case. Additionally to all this, it may be re-
marked that no chemist, at least so far as I am acquainted
with their writings, has hitherto succeeded in obtaining fibrin,
the proximate element of muscular substance.

Nor do these fibres, as they are termed, observe any partic-
ular arrangement. With the exception of the neck of the
uterus, where they are apparently circular, they run in all di-
rections, crossing each other at various points, and thus form-
ing a strong, dense, and resisting web.

430 UTERUS. [chap. XTV.

This organ is very plentifully supplied with blood-vessels,
absorbents, and nerves. The arteries are derived from the
spermatic and hypogastric, the former being distributed chiefly
to the base of the womb, the latter to the body and neck.
Anastomosing freely with each other, they are remarkably
tortuous, and thus accommodate themselves readily to the
great changes which the organ experiences during pregnancy.
The veins are exceedingly numerous, and still more serpen-
tine than the arteries. During gestation they greatly aug-
ment in volume, and thus constitute what Haller has termed
the uterine sinuses, some of which are sufficiently large to
admit the point of the little finger. The absorbents are like-
wise extremely numerous, and, as in the other viscera, are
arranged into two sets, — a superficial and deep-seated.

The nerves are furnished by the sacral and hypogastric
plexuses. It is through the filaments of the latter that the
uterus is connected with the great trisplanchnic system, and
that so many of the other viscera, especially the stomach, so
completely sympathize with it, both in its impregnated and
diseased state. So fully were some of the ancient physicians
and philosophers impressed with the peculiar properties of
this organ, that, without being probably aware of this ner-
vous connection, they regarded the womb as " an animal
within an animal."

Before we proceed to speak of the diseases of this organ,
it will not be amiss to make a few remarks concerning some
of its more important malformations, — a subject which is
not only interesting to the pathological anatomist, but like-
wise to the medical jurist, to the latter of whom, especially,
a knowledge of them is indispensable. Various attempts
have been made to classify these vices, but I am not cer-
tain that they have resulted in much good. A plain state-
ment of facts is all that I shall aim at on the present occasion.
The subjects that will be treated of are, first, entire absence
of the uterus ; secondly, deficient evolution ; and, thirdly,
increase of developement.

1, Authors have sometimes noticed an entire absence of
the uterus. Examples of this description have been recorded
by Columbus, Meyer, Klintosch, Bousquet, Engel, Boyer,
Walther, Macfarlane, Dupuytren, and other writers. In
Voigtet's Manual of Pathological Anatomy,* a work which

* Band iii. s. 452,

SECT.

I]

BIALFORMATTONS.

431

abounds in profound erudition, and which should be in the
Ubrary of every intelhgent physician, may be found a copious
hst of references to cases of this variety of malformation.
In some of these examples, indeed in nearly all, this congenital
vice was connected with absence of the ovaries and the Fal-
lopian tubes. The vagina was also frequently wanting ; and
the external parts of generation were either completely defi-
cient, or represented as it were in miniature. When the
ovaries were present, the vulvo-vaginal structures were more
perfect, the mammary glands more expanded, the females
possessed more of the characteristic attributes of their sex.

2. There also, secondly, occur cases in which the womb is
remarkably small, or in which it exists only in a rudimentary
state. Professor Jules Cloquet, the distinguished anatomist,
exhibited, some years ago, to the Medical Faculty of Paris
the sexual organs of a young woman, twenty-two years of
age, where the uterus was not larger than that of a child of
twelve months. The vagina was also very small ; but the
ovaries and Fallopian tubes were, on the contrary, quite well
developed.* Cases not unlike this are to be found in various
periodicals, but, on the whole, they are rare.

3. There are other deviations from the normal standard
deserving of brief notice in this place. Among these the
most common are, where the uterus presents the appearance
of being bilobed, or where it is prolonged superiorly into two
shoulders or horns. In the first variety, (Fig. 79,) the organ
is of an elon-
gated cylindrical
shape, and is di-
vided, by a lon-
gitudinal sep-
tum, into two
parallel canals,
precisely alike in
size and figure,,
and opening sep-
arately into a
common vagina.
In a few cases,
however, the ca-
nals have each

Fia;. 79.

Journal Generale de lyiedicine, t. Ixx. p. 274.

433

UTERUS.

[chap. XIV.

an appropriate vagina. In the bicorned uterus, (Fig. SO,) the
base and body of the organ are extended upwards into two
conical horns, from six to fifteen lines in length, and from

Fiff. 80.

eight to twelve in breadth, the neck and mouth retaining
their natural conformation. This variety, which is not un-
common in grown-up females, is of frequent occurrence in
monsters. Finally, there is a third form of congenital vice,
the bipartite, (Fig. 81,) as it may be termed, which presents
a much greater departure from the natural condition than
either of the others : here the organ is really double, or it
consists of two distinct and separate portions, generally con-
nected by a thin, narrow isthmus of matter, and both open-
ing into the vagina, which may be either single or double, or
one into the vagina, and the other into the rectum. Of this
mode of communication, an interesting example has been
recorded by Vallisnieri. Occasionally the cavity of one of
the uteri is impervious.

All these deviations from the normal formation are per-
fectly compatible with impregnation. In some cases they

SECT. I.]

MALFORMATIONS.

433

are associated with absence or deficient developement of the
ovaries and Fallopian tubes ; but, generally speaking, these

Fk. 81.

Structures are present, as in the natural state. In no instance,
so far at least as my knowledge extends, were there two
ovaries and two Fallopian tubes on each side, not even in the
bipartite variety, the nearest approach.

In women who have borne children, the womb is always
larger than in virgins, or than in those who are barren : its sub-
stance is also more dense and firm, its lips are more jagged
and irregular, and sometimes, though rarely, the orifice of the
organ is completely obliterated. Morgagni refers to a case
where the closure was effected by the growths of an adven-
titious membrane ; and similar examples have since been
recorded by others. The occlusion may also be produced by
inflammation, attended with an efi'usion of plastic lymph.
The orifices of the Fallopian tubes are also sometimes closed,
either congenitally or as the effect of disease. In a few rare
instances the uterus and the vagina have been known to
constitute one solid mass, without any cavity or opening in
either ; and occasionally, again, though this is also very infre-
quent, the cavity of the former is divided, by a transverse
septum, into two chambers, one corresponding with its base,
the other with its neck. This lesion is most common in
very old females, and is generally, if not invariably, the result
of inflammatory irritation, leading to adhesion of the isthmus
of the organ.
. Of the various malpositio7is to which the uterus is liable,

VOL. IL 55

434 , UTERUS„ [chap. XIV,

not much need be said in a treatise on pathological anatomy.
Those which we shall briefly notice on this occasion may
be comprised under the heads of retroversion, anteversion, pro-
lapsion, and inversion.

In retroversion, the orifice of the uterus is tilted up against
the pubic symphysis, and the fundus is thrown downwards
and backwards, so as to form a tumor between the vagina and
the rectum. Thus the axis of the organ is totally reversed
relatively to its natural situation within the pelvis. This
species of displacement is most apt to occur between the
third and fourth months of pregnancy ; it may, however, take
place at a much later period ; and, in some instances, it has
been noticed soon after delivery. Its progress, though occa-
sionally gradual, is generally rapid.

Anteversion is a displacement precisely the reverse of
the preceding, that is to say, the fundus of the womb is car-
ried forwards on the urinary bladder, and the mouth back-
wards towards the rectum and the hollow of the sacrum. It
rarely occurs during pregnancy, and is almost always asso-
ciated with hypertrophy of the uterus. The anteversion is
sometimes produced by morbid adhesions between this organ
and the peritonseum, which have the effect of forcing it out
of its normal position.

Notwithstanding the uterus has four ligaments which serve
to maintain it in its natural position within the pelvis, it not
unfrequently happens, both in its empty and gravid state,
that it loses its hold, and falls down into the vagina, or even
through the vulva. In the latter case, the organ forms a
tumor between the thighs, with a small central aperture cor-
responding to the mouth of the womb, and the vagina is
completely inverted, or pulled inside out. This prolapsion is
always attended, especially when complete, with severe drag-
ging pains, and a thick muco-purulent discharge.

Inversion of the uterus is that displacement where the
viscus is turned inside out. It is generally attended with
more or less prolapsion of the body of the organ, and seldom
happens except during delivery of the after-birth, or the for-
cible removal of some tumor from its interior. Of this lesion
there may be several degrees. In the first, the fundus falls
down to the mouth of the womb, where, from some obstacle
or other, it is arrested ; in the second, it passes beyond this
point for half or more of its length ; and, in the third, the
whole organ escapes at the inferior orifice. In the second

SECT. I.] INFLAMMATION. 435

case, it is obvious that the body and fundus may be com-
pressed, or strangulated, by the contraction of the neck.

The uterus is hable to infiammation, both in the married
and in the single female, but much more frequently in the
former than in the latter. The disease may attack any por-
tion of the organ, the lining membrane, the parenchymatous
substance, or, finally, the peritonasal covering ; and, in some
instances, though this is rare, all these structures may be
involved simultaneously, together with the venous and ab-
sorbent trunks.

When the disease affects the lining membrane^ all the phe-
nomena will be present that are observed in inflammation of
the mucous textures in other parts of the body. The red-
ness, which is of a deep shade, is often spread over a large
extent of surface, and in violent cases it is not uncommon to
meet with small ecchymoses, followed by an escape of blood
on pressure. The mucous follicles, especially those about
the mouth of the uterus, are in a state of enlargement, and
there is usually, in the course of a few days, a great increase
of the natural secretion. In some instances, pus is deposited,
and continues to be discharged for a considerable period, as
in inflammation of the mucous membrane of the vagina.

Occasionally the lining membrane is aftected with a sort of
specific inflammation, eventuating in the eflTusion of coagu-
lating lymph. It is very often seen in young females of a
robust, irritable temperament, in whom it constitutes a fre-
quent cause of dysmenorrhoea. The membranous concre-
tion, which is seldom thick or firm, generally moulds itself
to the inner surface of the uterus, and is sometimes expelled
entire, though much more commonly in small pieces ; in
some cases it is probably absorbed. The period required for
the extrusion, varies from a few hours to one or two weeks,
and is almost always attended with considerable suff"ering.
When the lymph extends into the Fallopian tubes, it leads to
sterility, as it prevents any thing from passing along them.

The immediate cause of the production of this membrane
has been a source of considerable dispute with pathologists.
By Dr. Dewees it is supposed to depend upon debility of the
uterus, giving rise to derangement of its secretory functions.
That this is true does not admit of doubt, but it will be at
once perceived that this theory does not account for the
cause, but only for one of the symptoms of the complaint.
Whoever has investigated the subject of dysmenorrhoea, must

436 UTERUS. [chap. XIV.

acknowledge that it is an inflammatory affection, not of the
proper structure of the uterus, but of its mucous hning.
That this is the case, is sufficiently proved by the great suf-
fering which is so often present. What do the severe pelvic
pains, the sense of fulness in the region of the womb, the
hot and feverish skin, the tense and accelerated pulse, indi-
cate, but a congested and irritated state of this organ, amount-
ing to inflammation ? Analogy, also, affords us good grounds
for this opinion. Lymph is never thrown out by parts, unless
they are in a state of inflammation. The adventitious mem-
brane of pleuritis, of croup, and of enteritis, is always de-
pendent upon this cause, and upon none other. If, then, this
be true here, why should it not be true also in regard to the
uterus ?

Inflammation of the body and serous covering of the ute-
rus is most common in females during the first eight or ten
days after parturition. It sometimes betrays an epidemic
tendency, and rapidly passes into suppuration, softening, or
even gangrene. The pus that is poured out in such cases
may be situated in the parenchymatous structure, in the
uterine cavity, the subserous cellular substance, between the
folds of the broad ligaments, or, finally, in the venous or
absorbent trunks. In most of the localities here referred to,
it occurs in the form of small yellowish-looking globules ;
but cases are occasionally observed in which the fluid is col-
lected into one or more abscesses, which are never very large,
and which manifest a disposition, sooner or later, to burst
into the vagina, the rectum, pelvis, or urinary bladder. The
pus is generally blended with a good deal of lymph, and is
sometimes highly offensive.

Inflammation of the uterine veins, although of very fre-
quent ocurrence, does not seem to have attracted much notice
until a very recent period. For our knowledge concerning
it we are mainly indebted to Professor Meckel, of Germany,
Dr. Lee, of England, and to Dance, Tonelle, and Cruveilhier,
of France. From the researches of these and other anato-
mists, it appears that uterine phlebitis is an extremely com-
mon disease, and that it is a frequent cause of the fatal ter-
mination of what is vaguely termed puerperal fever. The
lesion may originate in and be limited to the veins ; but, in
the great majority of cases, the parenchymatous structure
participates in the inflammation, and assumes a dark livid
aspect, at the same time that it loses its natural consistence.

SECT. I.] SOFTENING, 437

Serum and pus may also be found in the subserous cellular
tissue ; and the peritonseal investment is sometimes covered
with thick patches of lymph. The veins themselves are
always much enlarged, and their cavities are filled with pus,
clots of blood, or plugs of adventitious membrane. The
disease often extends along the venous trunks of the pelvis
to those of the abdomen, or even to those of the inferior ex-
tremities ; and very frequently the absorbent vessels are simi-
larly circumstanced, being greatly augmented in volume, and
infiltrated with enormous quantities of purulent matter. The
causes of uterine phlebitis are not always very evident. In
some cases, it appears to result from violence done in the
extraction of the placenta, and, in others, it may be traced to
the effects of cold and moisture, irregularities of diet, or to
some peculiar noxious condition of the atmosphere. As to
the symptoms, we are equally in the dark, none having yet
been pointed out that can be considered as pathognomonic.
The lesion is said to be more frequent on the right side than
on the left, and to be sometimes entirely limited to the veins
in that situation.

Softening of the uterus is probably a very rare affection,
at least I should think so from my own experience. The
disease has hitherto been found chiefly in the persons of
lying-in females. Amongst two hundred and twenty-two
fatal cases of puerperal fever, observed by Dr. Tonelle, in
the Maternity Hospital, at Paris, in 1829, there were forty-
nine in which the parenchymatous structure of the uterus
was more or less softened, and of a dark livid color. In
most cases, it is confined to the neck or inner surface of the
viscus, seldom penetrating to or commencing in its exterior.
Here, as elsewhere, the mollescence presents several stages,
running insensibly into each other. In the first stage, the
uterine substance is preternaturally flaccid, lacerable, and in-
filtrated with serosity ; in the second, it readily yields under
pressure, and may be broken up into a soft, stringy tex-
ture, like that of the spleen ; in the third, when the disor-
ganization is at its maximum, it is of a semi-fluid consistence,
and scarcely retains any trace of its former character. The
softened organ sometimes preserves its natural color, but more
commonly it is remarkably pale, grayish, or even brownish.
Occasionally, where the attending inflammation is violent,
and runs its course very rapidly, the color is purple, slate, or

438 UTERUS. [chap. XIV.

black, and occurs in patches, varying in diameter from a
split pea to a twenty-five cent piece.

Frequently this disease continues for a considerable period,
and yet the woman does not seem to be aware of its pres-
ence. That it is the result of inflammatory irritation, gen-
erally of an acute kind, appears sufficiently obvious, both
from its anatomical characters, which have just been enu-
merated, the rapidity of its progress, and the symptoms which
indicate its existence during life. Commonly these phenomena
are extremely vague, and hence the diagnosis is always diffi-
cult. A sense of weight in the pelvis, a dull, aching pain in
the hypogastric region, augmented by pressure, uterine
hemorrhage, and febrile exacerbations, together with a re-
markable prostration of the mental and physical energies,
are the usual accompaniments of this singular lesion. This
state of the uterus sometimes terminates fatally, either by
rupturing the organ, or by bringing on gradual exhaustion ;
and, what is remarkable, we not unfrequently find it asso-
ciated with mollescence of the other viscera, especially of the
stomach and the heart.

It sometimes happens, though not often, that the substance
of the womb is preternaturally hard. This change, which
may exist with or without mollescence, is very different from
scirrhus. It is characterized by unnatural paleness, and by a
dense, firm, and almost incompressible state of the uterine
tissue. There are no symptoms by which induration of the
womb can be recognized during life. It seems to be the re-
sult of chronic irritation, going on, there is reason to believe,
often for a long period, and is most commonly found in con-
nection with scirrhus, encephaloid, and polypes, in females
who have ceased to menstruate.

Chronic inflammation of the uterus is often attended with
an extraordinary developement of its mucous glands. The
enlargement is most conspicuous about the mouth and lip of
the womb, where the follicles are sometimes as big as a
hemp-seed, a currant, or even a pea, dense, almost gristly,
and of a white grayish color. The parts between them are
generally tumid, red, morbidly sensitive, and disposed to
bleed. In several cases, I have seen the enlarged glands
transformed into considerable cysts, filled with a pale, tremu-
lous substance, which could be easily removed by pressure.
It is in this manner, perhaps, that the greater number of

SECT, I.]

FIBROUS TUMORS.

439

Fie;. 83.

diseases of the mouth of the uterus, whether benign
malignant, originate.

One of the most common appearances observed in
uterus is the developement oi fibrous tuinot^s, (Fig. 82,)
curring either in its
substance, in its cav-
ity, or on its outer
surface beneath the se-
rous covering. Their
shape is usually spher-
ical ; their diameter
from the size of a
hickorynut to that
of a melon ; their
structure firm, dense,
opaque, (Fig. 83,) and
of a light grayish
color, tearing into
strong, concentric fi-
bres. Such excres-
cences have some-
times a rough, gran-
ulated texture, and
not unfrequently they
contain small cavi-
ties, filled with earthy
matter, or various
kinds of fluids, such
as serum, jelly, blood,
or pus. The calcare-
ous matter, which in
some instances almost
encases these morbid
growths, in the form
of a thin, brittle, shell,
not unlike that of an
egg, has been shown,
by Dr. Bostock, to
consist chiefly of the
phosphate and carbo-
nate of lime, together
with a minute quan-
tity of animal sub-

or

the
oc-

Fie. 83.

440 UTERUS. [chap. XIV.

stance. It is generally of a pale grayish complexion, very
soft, and porous, like pumice-stone ; but examples are record-
ed where it had the hardness of ivory, and admitted of a
fine polish.

Only one such tumor sometimes exists in the uterus ;
whilst, at other times there are as many as six, eight, ten, or a
dozen. When large, they are usually irregularly lobulated, or
divided by deep fissures ; and blood-vessels, often of con-
siderable magnitude, can be traced into their substance.
They have no disposition to ulcerate, to become soft, or
to degenerate into malignant disease ; and, although they
occur both in the married and the unmarried female, they
seldom if ever make their appearance before the age of
puberty.

When seated under the serous covering of the uterus, these
tumors often hang by a very slender neck, and they then as-
sume a pyriform shape. They possess very little sensibility ;
and, so long as they remain small, they produce no change
in the form of the uterus, or local inconvenience ; but, when
they attain a large bulk, they often incommode, by their
weight, and, by the pressure which they exert upon the
bladder and the rectum, may seriously interfere with the ex-
pulsion of the urine and feces. When these bodies are em-
bedded in the walls of the womb, or spring from its inner
surface, the subjects of them are apt to be barren ; or, if they
conceive, the uterine tissue is unable to undergo the necessary
expansion, and abortion is sooner or later the result. Some-
times these tumors are attached to the base of the womb,
and, by rising into the abdomen, may be felt movable in that
cavity, and thus simulate pregnancy. When situated in the
uterine cavity, they are occasionally expelled during labor,
and the woman either recovers, or dies of the profuse hemor-
rhage that ensues.

In the fourth volume of the American Medical Recorder
are detailed two highly-interesting cases, by my learned and
distinguished friend. Professor Francis, of New York, of
fibrous tumors growing from the external surface of the ute-
rus, of which I shall here give a brief abstract. In the first,
the woman was thirty-two years of age ; during the last six
of which she was married, but never proved pregnant. The
womb was of the natural size, and every where healthy,
except at its base, where it gave attachment, by means of a

SECT.

!•]

FIBROUS TUMORS,

441

narrow foot-stalk, to an immense tumor, (Fig. 84,) which
weighed more than one hundred pounds, and filled the whole
of the abdom- ^. „,

inal cavity, put- ^'

ting the integu-
ments and mus-
cles greatly on
the stretch. It
was of a pale red-
dish color, and of
a fibro-vascular
structure, look-
ing a good deal
like a mass of
flesh. The sur-
face of this mor-
bid growth was
covered with se-
veral excrescen-
ces, the largest
of which weigh-
ed nearly two
pounds ; and in
its interior was
contained a large sac, which discharged three quarts of puru-
lent and highly offensive matter. The disease had existed
for five years. The annexed engraving will convey a better
idea of the nature and extent of these tumors than any
description, however elaborate.

In the other case, which occurred in a female, aged forty,
the uterus had attained the size it usually has at the sixth
month of pregnancy : its walls were one inch and a fourth in
thickness, and the substance itself was in many parts ossified.
Internally, at the fundus, was attached, by a short pedicle, a
round, bony tumor, about the size of a small orange ; and a
similar body occupied the uterine extremity of the Fallopian
tube : the corresponding ovary was hypertrophied, but other-
wise sound. There were other appearances still more extra-
ordinary. Near the neck of the womb were six large oblong
tubercles, adhering by small narrow foot-stalks, and branching
out in different directions, so as to fill the abdomen as high
up as the umbilicus : they were of a vascular texture, of a
pale reddish color, very firm, dense, resisting, and bore evi-

voL. II. 56

442 UTERUS. [chap. XIV.

dent marks, in many places, of ossification. The weight of
the diseased nterns was upwards of thirty-two pounds. The
patient died apoplectic. Her principal ailments were, an
acrid discharge from the uterus, a sense of fulness and op-
pression in the pelvic region, cessation of the menses, and oc-
casional irritation of the stomach and bowels.

These fibrous growths, which are most common in old
women, are seldom met with before the age of thirty. Bayle
estimated that they existed in one case out of every five after
the middle period of life. This may be true of the French,
but certainly not in regard to the females of this country,
in whom these tumors, so far at least as my own observation
goes, are far from being frequent. Old maids ax'e said to be
particularly liable to them.

As intimately connected with the lesion first described, I
may advert here briefly to what are termed polypous tumors
of the uterus. This is a subject which, notwithstanding the
great attention that has been bestowed upon it by the profes-
sion; is still involved in great obscurity, scarcely any two
writers agreeing upon the real nature of these morbid growths.
Without entering at all into the discussion of the matter,
which my limits will not permit, it appears to me that all
such tumors might be conveniently arranged into three
classes, according to their anatomical characters. Adopting
this arrangement, I shall divide uterine polypes into fibrous,
vascular, and gelatinoid ; and to each of these I shall devote
a few remarks.

The first variety bears a strong resemblance to the fibrous
tumor of the uterus, and is perhaps the most common of the
three. Growths of this kind are of a fleshy consistence, firm,
yet compressible, smooth, elastic, of a pale grayish color, and
composed of dense filaments, which are so intimately inter-
woven with each other as to render it impossible to unravel
them. In their shape, they are commonly globular ; some-
times pyriform ; and, in one instance, I found one that was
of the figure of a mushroom, the rounded foot-stalk being at-
tached to the neck of the uterus, the base projecting into the
vagina. The fibrous polype has few vessels and nerves ; and
it is therefore little liable to bleed or to be attended with pain.
Tumors of this kind have often a very rough surface, and
they sometimes contain considerable cavities, filled with se-
rum, jelly, pus, or earthy matter.

The vascular polype is composed essentially of vessels and

SECT.

I]

POLYPES.

443

cellular tissue, the fibrous element being either entirely want-
ing, or existing only in a very limited degree. This species is
extremely rare, and seldom attains a large size ; it is of a
red, florid color, of a soft spongy consistence, sensitive on
pressure, erectile, and exceedingly prone to hemorrhage. In
respect to shape, it presents the same diversities as the other
species.

The gelatino'id polype holds a sort of intermediate rank
between the other two, being softer than the fibrous and
harder than the vascular. This species is readily distinguished
by the following characters : It is semi-transparent, of a pe-
culiar grayish complexion, compressible, glistening on the
surface, and attached by a delicate pedicle, which renders it
pendulous. If it be carefully examined, after it is removed
from the body, it will be found to exhibit a shreddy, tremu-
lous structure, interspersed with a few vessels, which are
generally too small to emit much blood. The gelatinoid
polype is sometimes quite large, but on the whole may be
considered as infrequent. It seems to be much under the in-
fluence of atmospheric pressure, increasing in size when the
weather is moist, and diminishing when it is dry.

Such are the distinc-
tive characters of the
three species of uterine
polypes now described.
To these it will be ne-
cessary to add a few re-
marks respecting certain
features which they pos-
sess in common with
each other.

Uterine polypes (Figs.
85, 86) are found of all
sizes, from that of a bean
up to that of a gourd.
Their weight, in some
cases, is immense. Du-
puytren mentions that he
saw one which weighed
twenty-five pounds ; and
another, described by
Dr. De Clanby, weighed
thirty-nine pounds, and

Fi.?. 85.

444

UTERUS.

[chap. XIV.

C^'C-

')r>)

was nearly three feet in Fig. 86.

its vertical circumference.
They occasionally extend far
down into the vagina, and
cases have been witnessed
in which they reached more
than ten inches below the
vulva. The shape of these
morbid growths is mostly
pear-like; and, although they
may originate in any portion
of the cavity of the uterus,
they are most frequently at-
tached to its neck. Many
of them have a narrow, slen-
der peduncle ; and, in such
as are of great size, it is not
uncommon to see deep fis-
sures, which give them
a lobulated arrangement.
Each of the three species
that we have described is invested by a thin mucous mem-
brane, which is more or less vascular, and merely a prolonga-
tion of that of the womb, immediately beneath which the
morbid growth is developed.

Uterine polypes often contain large cavities, filled with
substances that are not natural to them. Earthy concretions
have been found in their interior, and some have pretended
that they have detected tubercular matter. These tumors are
most common in aged females. A notion, but a very erro-
neous one, was formerly entertained that they occurred most
frequently in old maids. On this subject the observations of
Dupuytren are not only instructive, but decisive. Of fifty-eight
women atfected with polypes, all were married except four,
who were single, and supposed not to have had sexual inter-
course. Nearly all of them had borne children.* Their
presence often occasions alarming hemorrhage ; and, when
they become ulcerated, they may give rise to a copious dis-
charge of irritating and offensive matter.

Calculous concretions sometimes occur in the uterus. Of
these formations many cases are described by the older

Lemons Orales, t. iii. p. 485. Paris, 1833.

SECT. I.] CALCULOUS CONCRETIONS. 445

writers, and not a few by those of a more modern date.
One of the most interesting examples, perhaps, on record,
is that related by the celebrated Louis, in the Memoirs of
the Royal Academy of Surgery of Paris.* It was observed
in an old female, who was affected for a long time with diffi-
culty in voiding her urine, and severe pain in the loins and
perineum. The uterus, which was in a state of scirrhosity,
and of extraordinary size, contained a hard, compact, and
irregularly-shaped concretion of a bony structure, which
weighed jfive ounces and a half. Generally, however, these
heterologous formations are much smaller, not exceeding the
volume of a grape, a pigeon's egg, or of a walnut. Most of
them are of a light grayish color, of an osteo-cretaceous
character, and somewhat lamellated, with a rough unequal
surface. It would seem, from the researches of the late Pro-
fessor Turner, of London, that these bodies essentially consist
of carbonate of lime, in union with a little animal matter.

Concretions of this sort are sometimes surrounded by a
delicate membrane provided with minute vessels, and not un-
frequently they contain small nodules of cartilage. Although
their most usual situation is the cavity of the organ, yet they
are occasionally developed in its substance, beneath its serous
investment, or even in the uterine veins. Violent pain in the
pelvic region, more or less uneasiness in the back and
perinasum, and bearing down efforts similar to those of labor,
are the principal symptoms marking the presence of these ab-
normal formations. When seated in the proper cavity of the
womb, nature sometimes makes an attempt to expel them,
which is almost always attended with considerable hemor-
rhage. At other times, though very rarely, their presence
excites ulcerative absorption, leading to great local suffering
and the formation of fistulous tracks between the uterus and
the adjacent viscera. Calculous concretions are most com-
monly observed in advanced life ; but in a few instances they
have been witnessed in young females, married as well as
single, soon after the establishment of the menstrual function.
Indeed, there is a case recorded in one of the early volumes
of the German Ephemerides, in which a body of this kind is
stated to have been developed in the uterus of a girl five
years of age : it was of a pale yellowish color, and a little
larger than a pigeon's egg.

* T. ii. 4to. edit. 1769.

446 UTERUS. [chap. XIV.

How these concretions are developed is still a litigated
question. I have already described, the formation of similar
bodies in the plastic lymph of the serous membranes of the
joints of the visceral cavities ; and it is not improbable. I
think, that those under consideration have an analogous
origin. It is well known that the uterus is liable, at all
periods of life, but especially in old females, to the effusion
of fibrin, either into its cavity, into its substance, or into the
submucous cellular tissue. In either case, the fluid, if it be
permitted to remain, becomes organized, and converted ulti-
mately into an adventitious structure of a fibrous, fibro-carti-
laginous, cartilaginous, or osseous character. It is possible that
they may also be produced by the presence of coagula, formed
during uterine hemorrhage : and it is probable, likewise, that
in some rare instances the earthy matter is poured out with-
out being preceded by any new growth, whether of an analo-
gous or heterologous nature. This hypothesis derives sup-
port from the fact that these concretions are occasionally
found entirely disconnected from the substance of the womb,
lying perfectly loose in its cavity, or upon its outer surface.

The uterine tissue is sometimes partially transformed into
cartilage, bone, or earthy matter. The foreign substance is
generally seated in the proper texture of the organ, but occa-
sionally it is lodged in the submucous cellular tissue, and ap-
pears to be encysted. Examples of this description are
recorded by Baillie, Littson, Meckel, Bouvet, and other
authors. Louis, in his excellent Essay on Calculous Concre-
tions previously alluded to, quotes an instance in which the
parietes of the uterus were so completely ossified as to
require to be broken with a hammer : the organ was of
enormous size, and contained a considerable quantity of thick
purulent matter. In another case, referred to by the same
distinguished writer, the internal surface of the womb was
studded with numerous projections, of a yellowish color, and
a firm rock-like consistence, bearing a striking resemblance
to stalactites. " I have seen a uterus," says Dr. Hooper,* " the
size of an adult head, irregular on its surface, and formed
wholly of hard bony matter, surrounded by the expanded
fibres of the organ, and in many parts covered only by the
peritoneum." Such transformations are, however, extremely
rare, and I have never seen a specimen. They occur almost

Morbid Anatomy of the Human Uterus, p. M. London, 1832.

SECT. I,] MALIGNANT DISEASE. 447

exclusively in females past the age of forty-five, and they
appear to be produced by a perverted action of the uterine
vessels, caused probably by chronic irritation. It would be
interesting to ascertain, if this could be done, how far these
deposits are connected with similar lesions of the arterial
system.

The womb is often the subject of malignant disease^ de-
scribed by authors under the several denominations of scir-
rhus, fungus hsematodes, cauliflower excrescence, corroding
ulcer, and carcinoma. Scarcely any one of these appellations
seems to me to be well chosen, as they have reference rather
to certain states or appearances of the parts than to their true
nature and constant anatomical characters. Not unfrequently
all the conditions expressed by these terms are blended
together, or even when they exist separately, they have inva-
riably the same tendency, namely that of destroying the
different textures of the uterus and the adjacent viscera.

Malignant disease, be its nature what it may, generally
begins at the neck and lips of the organ, from which it grad-
ually ascends to the other parts. So common is this mode
of attack that it was once supposed to be invariable in its
occurrence. Recent observations, however, made by some
of the most able pathologists of Europe, prove that there are
numerous exceptions to this rule, and that in many cases the
disease, instead of showing itself first in the parts just men-
tioned, commences at the base or body of the organ, thence
spreading downwards so as to manifest itself last in its infe-
rior extremity.

The mouth of the womb in this affection usually becomes
hard, thick, and irregular, and the lips are everted, and painful
on pressure, bleeding not unfrequently on the slightest touch.
One of the earliest symptoms is hemorrhage, not slight, but
severe, and long-continued. Of twenty-one eases collected
by M. Louis at the Charity Hospital in Paris, sixteen com-
menced in this manner ; and of six observed in the ward of
the same institution by the late lamented Dr. James Jackson,
Jr. of Boston, five began in a similar manner. Both these
writers lay great stress upon this phenomenon, considering
it of more diagnostic value in the inceptive stage of the
complaint than any other hitherto pointed out.* The pain
accompanying this disease is variable, being at one time

* Memoir of James Jackson, Jr. M. D. p. 116. Boston, 1835.

448 UTERUS. [chap. XIV.

severe, at another so slight as almost to escape notice.* After
this state has continued for some time, ulceration takes place,
a thin, sanious fluid, abundant in quantity and highly irrita-
ting in quality, oozes from the vagina, and all the textures of
the aff'ected part are completely destroyed. The base and
body of the uterus, which are often much enlarged, also
change their appearance ; they become hard and firm, like
fibro-cartilage, and are intersected by dense, grayish filaments
running in a radiating direction. In some instances, the
organ, when cut, has a raw flesh-colored aspect, like a slice
of fresh pork ; this is called the lardaceous degeneration of
the uterus. In other cases, it has a gelatinous structure ;
and, in a third variety, as the softening and ulceration pro-
ceed, it assumes the color and consistence of encephaldid.

The brain-like variety of the disease generally occurs in
the form of soft, lobulated masses, the interior of which
contains clots of fibrin, varying in color and consistence,
according to the length of time they have been deposited.
Their size seldom exceeds that of an orange, but sometimes
they are as large as a foetal head, of an irregularly globular
figure, and of a dark brownish complexion, caused by the
secretion of melanotic matter. In other cases, again, though
these are rare, the internal structure is of a deep red color,
and composed essentially of anastomosing vessels.

As the disease progresses, various morbid growths spring
from the ulcerated surface, and fill up the vagina. These at
length fall off" by sloughing, and are either speedily succeeded
by others, or they leave a deep excavated sore, with hard,
irregular edges. In this stage of the complaint, there are
generally copious discharges from the vagina, consisting of a
thin, corroding sanies, serum, pus, or sero-purulent matter.
In many individuals such discharges are exceedingly fetid,
and at once serve to point out the true nature of the lesion.

Carcinoma of the uterus is most common about the decline
of the menses, in married females that have borne children.
Of twenty-two cases of this disease recently reported by Dr.
Ashwell, of London,! eight occurred between thirty and

* " Authors generally describe this disease as attended with excessively severe
pains, &c. This is sometimes tnie, but by no means so generally as has been
thought. Of tlic six cases now in on r wards — Charity Hospital — in three there
was no pain until a very advanced period ; and then it was inconsiderable ; and
in one, although the disease is quite advanced, there has as yet been no suffering."
Op. cit. p. Ml.

•t Guy's Hospital Reports, No. 4. April, 1837.

SECT. I.]

CORRODING ULCER.

449

Fig. 87.*

forty ; six between forty and fifty ; six between fifty and
sixty ,' and two between sixty and seventy. All the women
were married, and, except two, had been mothers ; seven
were of light complexion and fifteen dark.

" There is a variety of malignant disease of the uterus,
which some have considered as essentially different from the
preceding, but which is a mere modification of the varieties
already described. It has been called the phagedcenic or
corroding ulcer (Fig. 87) of the womb. Sometimes the
ulcer, which is of a deep
violet color, is quite su-
perficial, without much
thickening, induration,
or enlargement of the
part. The ulcer begins,
like any other malig-
nant ulcer, on the surface
of the body, and gradu-
ally proceeds until the
greater portion of the
neck of the uterus has
been destroyed, or re-
moved by ulcerative ab-
sorption, and openings
are formed into the blad-
der and rectum. The
portion of uterus which
remains after death is

sometimes not much altered in appearance ; more frequently,
however, it becomes softened in texture, and assumes a yel-
low or reddish brown color." f This affection, so destructive
in its consequences, rarely if ever occurs before the age of
forty, and commonly not until that of fifty or sixty.

Soft fungous excrescences, (Figs. 88, 89,-) of a cauliflower
shape, also sometimes grow from the mouth of the uterus,
and undergo changes similar to those observed in other varie-
ties of malignant disease. These morbid structures, first
accurately described, I believe, by the late Dr. John Clarke, of
London, have a rough, granulated surface, and in most cases
are of a bright flesh color : they are of a soft erectile texture,

* a, corroding nicer ; b, vagina ; c, vUerus.

t Cyclopeedia of Practical Medicine, article Uterus, p. 344.

VOL. II. 57

450

UTERUS.

[chap. XIV.

extremely vascular, Fig. 88.*

and very liable to
bleed when injured.
In their size, they
vary from that of a
hen's egg to that of
a large fist ; their
growth is often quite
rapid, and, when the
vagina is very dilata-
ble, as in women
who have borne many
children, they some-
times protrude be-
yond the lips of the
vulva. Excrescences
of this sort do not
appear to be endowed

with much sensibility, and hence the patient seldom com-
plains when pressure is made on them. They invariably
spring from the
mouth of the ute-
rus, never from any
other part ; and it
is pretty generally
admitted now by
all pathological an-
atomists that they
have always a ma-
lignant tendency,
destroying life ei-
ther by constitu-
tional irritation, or
by the exhaustion
produced by the profuse sero-sanguinolent discharges. Dr.
Dewees f states that he has never met with this disease, and
I therefore conclude that it is extremely rare in this country.
I have seen only one specimen of it, which is preserved in
our college museum.

TuhercMlar matter, such as we find in the lungs, seldom
occurs in the uterus, and perhaps never before the age of pu-

* a, excrescence ; Z>, os uteri ; c c, ovaries ; d, body of the uterus.
\ Treatise on the Diseases of Females, p. 296. Philadelphia, 1837.

SECT. I.] HEMORRHAGE. 451

berty. It is usually deposited upon the inner surface of the
organ, which is sometimes entirely incrusted with it, forming
a layer of half an inch or more in thickness. Bayle and
Laennec make no mention of this disease ; Andral, though
he indicates its existence, offers no cases of it ; Louis met
with it only once ; and Regnaud saw only three examples of
it during a residence of six years in one of the largest Paris-
ian hospitals. In one of his cases the malady was asso-
ciated with tubercles of the lungs. The females had men-
struated, and borne children. In some instances, though this,
I believe, is very rare, the matter is deposited into the sub-
stance of the womb, or into the cellular texture between it
and the peritonaeum. In my own dissections I have never
met with this disease.

Of hemorrhage from the uterus we shall speak only as it
affects the organ in the unimpregnated state. Contemplating
it under this restriction, the occurrence, it may be remarked,
is most common in married females, about the cessa-
tion of the menstrual function, and is observed in every state
of constitution, in the strong and plethoric, as well as in the
feeble and relaxed. A great variety of causes have been
enumerated as giving rise to uterine hemorrhage ; but the
most frequent by far is that peculiar state of the system
which accompanies the disparition of the menses, together
with ulceration of the mouth of the womb, or the presence
of some adventitious growth. Disease of the ovary also
powerfully predisposes to this lesion ; and there are some
females who are naturally, or from habit, so prone to it, that
the most trifling exertion is sufficient to bring on an attack.
The duration of the hemorrhage varies from a few days to
several weeks. When dependent upon structural disease, or
the presence of a polypous tumor, the blood often comes
away suddenly, in a gush, which continues for a few hours,
and then ceases.

The effused blood is generally of a dark red color, and
comes away in coagulated masses, though occasionall}'',
especially when the hemorrhage is sudden and profuse, it is
of a fluid consistence, as well as of a lighter tint. With re-
gard to the quantity of blood lost, it may vary from a iew
ounces to several quarts; and, although it is generally greatest
when it proceeds from a ruptured vessel, it is often not less
abundant when it has its source in exhalation of the mucous

452 UTERUS. [chap, XIV,

membrane. On dissection, we find the surface of the womb
either of a uniform red color, or mottled with blackish spots,
soft and corrugated, with here and there a submucous ecchy-
mosis. The whole organ is commonly somewhat relaxed,
and, on cutting through its substance, small clots of blood
are occasionally observed, resembling apoplectic effusions of
the brain.

Large quantities of water have been known to accumulate
in the cavity of the womb, — ten, fifteen, and even twenty
quarts. The affection, however, is extremely rare, and is
always connected with a closure of the mouth of the organ,
caused by previous inflammation, malignant disease, or some
morbid growth. The fluid is generally clear and limpid like
the serum of the blood, which it also resembles in its chem-
ical properties. In some cases, it is thick and turbid ; and
it has also been found of the color and consistence of coffee-
grounds, from the admixture, probably, of sanguineous matter.
The tumors thus formed often simulate pregnancy, are pain-
ful on pressure, and slightly fluctuate under the fingers. The
disease, which, it may now be observed, is technically called
hygrometra^ is occasionally connected with utero-gestation, of
which it forms one of the most distressing complications. Its
true pathology is still involved in great obscurity. In all
probability, it is dependent upon chronic inflammation of the
lining membrane of the womb, — a conjecture deriving con-
siderable plausibility from the facts already adverted to, that
the disease is generally attended with obliteration of the
orifice of the organ, and with more or less tenderness on
pressure of the hypogastric region.

Air now and then collects within this viscus, constituting
the disease which has been described by pathologists
under the name of emphysema, physometra, and tym-
panites. How this is formed is still a litigated point. In
many cases, it can be traced to the decomposition of effused
fluids, such as blood, serum, or pus ; and, in others, it is not
unlikely that it is the product of a true secretion from the
uterine vessels, brought about by some morbid condition, the
precise nature of which is unknown. These accumulations
may take place at any period of life, in the married and the
single, in the young and the old. When considerable, they
cause the womb to expand and rise up in the abdomen, as in
pregnancy, with which it may be easily confounded. After

SECT. I.] HYDATIDS. 453

the flatus has existed for several months, the uterus com-
monly makes an effort to dislodge it, expelling it with a
noise somewhat similar to what is occasioned in eructa-
tion.

The mouth of the uterus is sometimes preternaturally small,
or so much contracted as scarcely to admit a small silver
probe, or even a hog's bristle. This lesion is often congenital,
but in other cases it is brought about by inflammatory irrita-
tion, in the same manner as stricture of the urethra. The
late Dr. Mackintosh, of Edinburgh, thought that this condi-
tion of the uterine orifice was a frequent cause of dysmenor-
rhoea ; and the cases which he has adduced, in illustration of
the subject, tend very much, it must be confessed, to favor
his conclusion. As yet no opportunity has presented itself
to me for verifying the results of the Scotch pathologist, nor
am I aware that this has been done by others.

We sometimes find hydatids in the uterus, though not so
frequently, perhaps, as has been generally imagined by the
profession. This subject, notwithstanding the great number
of physicians who have written upon it, was first fully noticed
by Madame Boivin, of Paris. In her celebrated Memoire '' Sur
I'Origine, la Nature et le Traitment de la Mole Vesiculaire
ou Grossesse Hydatique," published in 1827, she developed
the leading facts, and has left scarcely any thing else to
future observers, than to verify and strengthen her inferences.

The number of uterine hydatids is often immense. In a
specimen in my collection, notwithstanding a great many
were lost during the delivery, there are at least ten thousand,
of all sizes between an almond and a mustard-seed.* (Fig.
90.) In their shape, these bodies are either globular, pear-
like, or conoi'dal ; and they are usually strung together by an
intricate plexus of pedicles, which ramify in every direction,
and are frequently not thicker than a common sewing-thread.
The length of these stems varies from a few lines or less to
several inches ; "ihey are of an irregularly, cylindrical figure,
and from two to six are occasionally attached to the same
vesicle ; their strength is always very slight, so that they
break with great ease ; and many of them, though not all,

* I am indebted for highly interesting specimens of these parasites, to my
friends, Dr. Joshua Martin, of Xenia ; Dr. M. Dunlap, of Greenfield ; and Dr.
Thompson, of Columbus, in the State of Ohio.

454

UTERUS,

[chap. XIV.

are distinctly tubulated, being inflatible, from the hydatids
with which they are associated. The canal, however, does
not generally extend through the whole length of the foot-
stalk, but only
a comparatively
short distance,
seldom more, in-
deed, than six
lines or an inch.
The larger hy-
datids have gen-
erally smaller
ones attached to
different parts of
their surface, —
an arrangement
not unlike what
is observed in
some tuberous
roots. From five
to ten, not bigger
than a grain of
barley, are often
seen sprouting
out in this way,
their connection
with the parent
parasite being ef-
fected by means
of a narrow,
delicate stem,
scarcely half a
line in length.
But, whatever
may be their
size or form,

they all adhere, immediately or indirectly, to one common
stalk, exactly like a bunch of grapes, and which con-
sists either of a portion of degenerated placenta, a fibrinous
concretion, somewhat similar to an ordinary mole, a blighted
ovum, or the remnants of the foetal envelopes. These are, I
conceive, highly important circumstances in the history of

SECT. I.] HYDATIDS ] STRUCTURE. 455

these singular productions, inasmuch as they fully confirm
the opinion, so warmly advocated by many writers, but so
strenuously denied by others, that hydatids are never found
except as the result of impregnation.

When carefully examined, each vesicle is found to have
three distinct coverings, which may generally be separated
without much difficulty with the knife, care being taken to
hold the morbid growth under water : the external tunic is
extremely delicate, almost like a film, and of a pale cineri-
tious color, which becomes more perceptible when it is de-
tached from the subjacent layer ; it is easily lacerated, semi-
transparent, and may be considered as a sort of deciduous
membrane. The second lamella, on the contrary, is compara-
tively thick, firm, dense, and resisting ; it has a whitish ap-
pearance, possesses the property, in some respects, of a fibrous
texture, and serves at once to give shape and consistence to
the vesicle which it assists in forming. Within the two cov-
erings now described lies the hydatid, properly so called,
which is generally so weak as to break under the pressure of
the atmosphere, and which appears to consist merely of a
thin, lymph-like sac, filled with serous fluid. In the recent
state, this lamella is perfectly smooth and transparent ; but,
by immersion in alcohol, it speedily becomes opaque and cor-
rugated. In most cases the parasite lies loosely within its
envelopes, but occasionally, especially when the vesicles are
old or of large size, there is a pretty strong adhesion, by means
of thread-like filaments, between them. Its contents are clear
and limpid, like the purest spring-water ; slightly saline to
the taste, and partially coagulable by heat, proof-spirit, and
dilute acid.

We have already seen that the number of these bodies is
sometimes extremely great. By their agglomeration large
masses are formed, the weight of which has been known to
exceed ten pounds, though ordinarily it is considerably less.
These masses are generally expelled piecemeal, and they are
rarely if ever enveloped by distinct foetal membranes, unless
there are at the same time remnants of a blighted ovum.

The period of hydatid gestation, as might be supposed, is
extremely variable. The following table, compiled from
Madame Boivin, and other writers, gives an accurate view of
the duration of this disease in forty-four cases, including five
that have been communicated to me by medical friends.

456

UTERUS.

[chap. XIV

Duration

of the Disease.

Number of Cases.

3

months,

• > • V

4

4

*• , ,

• • • •

. 3

5

• • •

3

6

• ,

• • • •

. 5

7

• • • •

6

8

" , ,

• . •

. 7

9

. 10

10

" «

. • • •

. 3

11

.

1

13

" . ,

•' • • •

. 1

14

1

44

From this table it appears that the number of hydatic
births, if so they may be styled, is, within a fraction, twice
as great after the sixth month as anterior to that period.
Never, so far as my knowledge extends, does delivery occur
before the expiration of the third month. The mean dura-
tion of this species of pregnancy, calculated from the above
cases, is a little more than seven months, provided we receive
as correct — which I am disposed to think we should not —
the examples of Baudelocque, Vernois, and others, where the
female is said to have carried the morbid product more than a
year.

It has been supposed that hydatids of the uterus are most
common in women about the decline of the menses ; but this
opinion is evidently grounded upon superficial observation.
Of thirty-one cases, in which the age is satisfactorily stated,
I find that twelve occurred between the twentieth and thir-
tieth year ; eight between the thirtieth and fortieth ; and
eleven between the fortieth and fiftieth, or rather between
the fortieth and forty-sixth, for beyond this period I am not
acquainted with a single well-authenticated instance in which
this degeneration was observed.

The developement of these parasites is generally, if not
invariably, preceded by one or more normal gestations. In a
case, the particulars of which were recently communicated to
me by my friend. Dr. Dunlap, of Greenfield, in the State of
Ohio, the woman, who was forty-six years old, and had
always been in the enjoyment of excellent health, had given
birth to eleven children. Occasionally these bodies form in
several successive pregnancies ; and, in a few rare instances,
they have been observed in several members of the same
family.

SECT. I.] HYDATIDS. 457

The expulsion of the hydatids is almost constantly attended
with more or less hemorrhage. To this statement, indeed,
there are few exceptions. A discharge of blood frequently
takes place at a very early period of gestation, and recurs at
variable but generally short intervals, until the time of par-
turition. The quantity of blood lost is often very great, so
much so as seriously to undermine the vital powers, or even
destroy the patient. Of this unhappy termination, instances
are recorded by several writers, amongst others by Pechlin,
Home, and Moth. The expulsion of these bodies, it may be
observed, is always accompanied by labor pains.

The symptoms produced by the presence of uterine hydat-
ids are such as are observed in ordinary pregnacy, — that is
to say, with suppression of the menses there is morning
sickness, faintness, and capricious appetite, with gradual in-
crease of the abdomen. If the morbid mass be retained
until the eighth or ninth month, the breasts occasionally en-
large and secrete milk, as in normal gestation. The only
sure sign of the existence of these bodies is a discharge of
sero-sanguinolent fluid from the vagina, which may set in at
a very early period, and is particularly abundant in the morn-
ing when the patient rises from her bed, or whenever she
subjects herself to any severe bodily exertion. The abdom-
inal tumor is also more soft and flaccid than in ordinary preg-
nancy, it falls more easily from one side to the other, and no
placental sound is heard on the application of the ste hoscope.

As to the causes of these morbid growths, they are still
enveloped in complete mystery^. It has been conjectured by
many that they are occasionally an original production of the
uterus ; but there is no case on record, so far as I remember,
which warrants such a conclusion. Indeed, when we re-
flect upon the fact already adverted to, that they always
occur in association with mole-like concretions, the mem-
branes of a blighted ovum or some remains of the fostus itself,
or, finally, with portions of the placenta in a state of degen-
eration, it must be conceded that they are invariably the re-
sult of impregnation. If this view be adopted, it follows, as
a natural deduction, that the developement of the new being,
after having sojourned for some time in the uterus, is arrested,
and another action set up, under the influence of which the
bodies in question are created. What the nature of this ac-
tion is, we cannot of course determine any more than that
which presides over ordinary generation.

Many anatomists have imagined that these parasitic forma-
voL. II. 58

458

UTERUS.

CHAP. XIV.

Fis- 91.*

tions are mere watery vesicles, not genuine acephalocj'^sts, as
is the case with hydatids in other organs. That this is occa-
sionally true is not improbable ; but that they are really living
animals, in the generality of instances, the concurrent testi-
mony of the best writers on the subject abundantly proves.
M. Hippolitus Cloquet has given them the name of racemose
acephalocysts ; and various naturalists -regard them as hyda-
toid worms. Schroeger, a German author, considers them as
varicosities of the lymphatic vessels of the placenta ; Ruysch,
as dilatations of the extremities of the arteries. The latter
opinion has recently been revived, and warmly advocated by
Professor Cruveilhier. Such views, however, notwithstand-
ing they possess some plausibility, are certainly altogether
idle and unprofitable, as they have not a single fact to recom-
mend them to our judgment.

The last subject which we proposed to discuss was that of
uterine moles. Under this term authors have described dif-
ferent, and often verj'' dissimilar products, which, after con-
tinuing for a variable pe-
riod in the womb, are
finally expelled with all
the phenomena of ordi-
nary labor. For the sake
of perspicuity, so essen-
tial in all pathological in-
quiries, I shall at once
proceed to divide uterine
moles into two species,
the fibrinous and the vas-
cular. This arrangement,
it will be perceived, alto-
gether excludes uterine
hydatids, which have
been referred to this
head by Madame Boivin^
in the work before quoted,
and which, from the many
peculiarities they display,
are worthy, I conceive, of
separate consideration.

The fibrinous mole
(Figs. 91, 92, 93) is a

* Exterior of a fibrinous mole.

SECT.

!•]

FIBRINOUS MOLE.

4.59

Fig. 92.*

much more interesting
and intricate structure
than we might be led to
infer from the imperfect
descriptions of it, which
are to be found in authors.
In its shape it is always,
so far at least as reiter-
ated inspection has ena-
bled me to judge, more
or less conical, pyriform,
or gourd-like, — never, I
believe, perfectly globu-
lar. Occasionally, though
this is rare, it is some-
what lobulated or angu-
lar, either externally or
upon the inner surface,
or in 'both these situa-
tions at the same time.
Its size and weight vary
very much in individual
cases. In five specimens of this
species of mole which I exam-
ined with great care along with
Professor Parker, the mean
weight was found to be a little
more than one ounce, the maxi-
mum two ounces, the minimum
six drachms. The length in
the same cases varied from two
inches and a half to three inches
and a quarter ; the width, from
one inch and a half to two inches
and a quarter ; and the thick-
ness, from one inch and a half
to two inches. We are told by
some writers, amongst others
by Unezwolf, a German physi-
cian, of fibrinous moles that weighed nine pounds, and were

Fig. 93.t

* Mole cut open, showing its structure : «, chorion : b, amnion-
t Mole with the cavity communicating externally.

460 UTERUS. [chap. XIV.

as large nearly as an adult head ; but such examples must be
exceedingly rare, and I have never met with them.

The fibrinous mole, in the recent state, has very much the
appearance of a mass of blood, being of a modena color, not
uniformly, but darker in some places than in others. It is
of a firm, solid consistence, requires a good deal of force to
cut it, and emits a dull, creaking sound under the knife, like
fibro-cartilage. The degree of induration, however, is not
the same in all cases, or even in all parts of the same speci-
men. When retained long, this species of mole sometimes
partially degenerates into a hard, gristly substance, similar to
certain transformations of the placenta.

Externally, the adventitious product is invested by a gray-
ish, fragile lamella, generally not more than the fourth of a
line in thickness. It evidently serves to connect the mole to
the inner surface of the uterus, and possesses all the charac-
ters of the deciduous membrane. Not only does this lamella
cover the exterior of this body, but it usually passes into the
internal canal, which it thus lines throughout its whole ex-
tent. Hankoph * has recorded an instance where the mole
was surrounded by an osseous covering, which was formed,
doubtless, by a degeneration of the structure we have here
described.

On making a longitudinal section of this morbid growth,
an internal cavity is found, which is always remarkably small
in proportion to the enclosing parietes. In most instances, it
extends nearly from one extremity to the other, at the larger
of which, much more frequently than at the smaller, it has
an external opening. To this law, which may be regarded
as a very important one, I have met with only a single ex-
ception in a considerable number of specimens. To attempt
to describe the shape of the internal canal would be idle, so
much does it vary in different cases. Irregularity is its dis-
tinguishing characteristic. Very frequently it presents itself
in the form of a fissure ; sometimes it is cylindrical, and at
other times it is angular. Equally irregular is the outlet of
this canal ; whilst in some instances it is small and tolerably
well-defined, in others — and these are by far the most com-
mon — it is large, grooved, or slit-like. Occasionally it closely
resembles the mouth of the unimpregnated uterus.

But wherever may be the form and dimensions of the in-
ternal canal, or of its outlet, it is always lined with two short

* In Haller, Disp. Med. t. iv. p. 715,

SECT. 1.] FIBRINOUS MOLE. 461

sacs, which, though intimately united, are perfectly sepa-
rable by dissection, and which appear to correspond exactly
to the natural envelopes of the foetus. The outer layer is
rough, flocculent, and loosely connected with the deciduous
membrane, which, as was before stated, is always reflected
into the mole when there is an open cavity ; the inner, on
the contrary, is perfectly smooth and glossy, like the serous
tissue in other parts of the body, and generally, though not
always, contains a small quantity of transparent fluid, similar
in every respect to, the amniotic liquor.

The parietes of the cavity which we have just described
are also exceedingly irregular, and they vary in difl'erent parts
of their extent from the twelfth of an inch to six or eight
lines in thickness. Examined in reference to their structure,
they are found to be composed principally, if not wholly, of
the fibrin and coloring matter of the blood, cemented together
by plastic lymph. On making a section of the mole in the
direction of its long axis, the outer portion is observed to
have an imperfectly lamellated arrangement, and also to be
somewhat more compact than the internal parts, which are
of a much darker complexion, homogeneous, much more
friable, and almost entirely made up of coagulated blood.
In some instances, the walls are essentially fibrous, the fibres
extending longitudinally from one extremity, or nearly so, to
the other ; they lie in close, parallel lines, are very coarse,
easily torn and separated from each other, and of a reddish-
gray color, darker at some points than at others. These three
varieties of structure are not unfrequently met with in the
same tumor, the linear arrangement being seen at the apex,
the lamellated at the external part of the body, and the
uniform, homogeneous, or hematoid towards the centre.

The cellular tissue entering into the composition of this
variety of mole is usually very small in quantity, and is often
so intimately incorporated with the morbid mass, as to be
perceptible only after protracted maceration. Its vessels,
which are generally quite large, may be seen ramifying over
its outer surface, running, for the most part, in the direction
of its long axis. They enter the new product at various
points, but none can be traced beyond the depth of a few
lines :■ they are sometimes quite varicose, their parietes are
remarkably brittle, and they have altogether much more of a
venous than of an arterial character. The anastomoses which
exist between these vascular trunks are commonly very im-

462

UTERUS.

[chap. XIV.

perfect, — a circumstance which, with the dehcacy of their
structure, renders them exceedingly Hable to congestion, rup-
ture, and hemorrhage.

The second species of mole may be called the vascular,
(Fig. 94,) in consideration of its structure, which, as the
term imports, is essentially
of that nature. It is much
more rare than the preced-
ing, but in what proportion
it occurs we have no means
to determine. In its shape,
the vascular mole is generally
globular, and, in its diameter,
it varies from one to four
inches. Its weight, after the
discharge of its contents,
ranges from three drachms to
one ounce, according to its
dimensions, or the thickness
of its parietes.

In regard to its structure, this variety of mole may be said
to bear a striking resemblance to the placenta. Like it, it
appears to be essentially composed of blood-vessels, which
freely anastomose with each other, and are bound together by
delicate, cellular tissue, the whole forming a soft, spongy
substance, the thickness of which rarely exceeds the sixth of
an inch. In some instances, numerous intersecting filaments
may be observed, which are either of a fibrous nature, or
obliterated arterial and venous ramifications. Externally,
the mole is incrusted with a thin, coriaceous lamella, which
is much more delicate than in the fibrinous form : internally,
it is furnished with two distinct membranes ; the one answer-
ing to the chorion, the other to the amnion. They are much
more perfectly developed than in the preceding variety, as
well as more easily separable from each other ; and the latter
always encloses a considerable quantity, occasionally as much
as three or four ounces, of watery fluid.

Such is a brief account of the two species of uterine moles.
The period during which they are retained in the womb is
of course liable to some variation, but in the generality of
cases it does not exceed three months. In a few instances I
have known them to come away as early as the end of the
tenth week, and on one occasion as late as the middle term

SECT. 1.] VASCULAR MOLE. 463

of normal gestation. Their expulsion is invariably accom-
panied, as far as my experience goes, with more or less
hemorrhage. The parturient efforts are usually very feeble,
and often occupy from two to three days. The flow of blood
may be so profuse as to endanger life. De Lamotte has
recorded a case where it proved fatal.

The fibrinous mole has occasionally been observed in com-
pany with a healthy or diseased fostus ; and I have a speci-
men of the vascular variety, in the interior of which there is
evidently the remains of an umbilical cord. Like hydatids,
these products may occur in several successive pregnancies ,•
and- they have been noticed at all periods, from the age of
puberty to the decline of the menses. Their developement
is commonly attended with the phenomena of ordinary ges-
tation.

It is supposed by many that these bodies are never formed
except as the consequence of conception, — an opinion which
is in perfect accordance with the result of my own obser-
vations. I speak now, of course, of what I consider to be
the true genuine mole ; that is to say, an organized body of a
certain or determinate form and structure, having an internal
cavity, either closed or open, and lined by two distinct memr
branes of the character already ascribed to them. Such a
product, no matter whether it be fibrinous or vascular, I do
not hesitate to say, on the authority of considerable experi-
ence, is never developed in the virgin uterus. I have never
seen an example of what some have called a spurious mole —
a dense, compact, and amorphous mass, composed essentially
of clotted blood — but such a substance might form, there is
reason to believe, in females during the period Avhich inter-
venes between the establishment and the decline of the
menses, without intercourse or the stimulus of conception,
simply from the effusion and retention of a small quantity of
sanguineous fluid.

Of the causes' under the influence of which the true mole
is developed, nothing is known with any degree of certainty.
We may suppose, however, in the absence of positive facts,
that the uterus, instead of providing for the growth and
nourishment of the new being, as nature has designed it
should, takes on inflammatory irritation, which is followed
by the destruction of the germ, the effusion of blood, and the
formation of an abnormal structure, which, as we have
already seen, is sooner or later detached and expelled.

464 OVARIES. [chap. XIV.

SECTION II.

Of the Ovaries.

The ovaries are two small oblong bodies, lying in the
upper part of the broad ligaments, behind and somewhat
beneath the Fallopian tubes. Their color is of a light gray-
ish, and their volume nearly equals that of a common almond.
With regard to the weight of these organs, much diversity
obtains in the different periods of life, as well in the single
as in the married state. In eight young females, who died
between the ages of seventeen and twenty-three, and in
whom, from their previous health and moral habits, there
was every reason to believe that the ovaries were perfectly
natural, I found the mean weight to be one drachm and a
quarter, the maximum one drachm two scruples and a half,
and the minimum fifty-six grains. With regard to their dimen-
sions, the mean length of the organs, measured in the same
subjects, was seventeen lines, the breadth nine lines, and the
thickness four lines and a half. In women who have borne
children, the ovaries are generally about half a drachm
heavier, and they are also broader and thicker, but seldom
any larger. They are remarkably large in children : from
the eighth to the twelfth year, they undergo little change in
respect to their volume ; but, from this period on, they gradu-
ally augment in size, and at puberty they present the weight
and dimensions here assigned to them.

Connected to the uterus by means of a thin, rounded, fibrous
cord, scarcely an inch and a half in length, each ovary is
invested by two tunics, which, although intimately united,
differ from each other materially in their structure. Of these
the outer is derived from the peritonaeum, and is consequently
of a serous nature ; the other is a dense grayish membrane, of
a fibrous texture, perfectly similar to the corresponding sub-
stance in the male, and denominated the alhugineous coat.
This coat, which gives shape and consistence to the ovaries,
sends numerous processes, finer than the most delicate threads,
though their proper parenchymatous structure, which they
thus intersect in every j)ossible direction.

Concerning the precise nature of the parenchymatous struc-
ture of the ovaries, the present state of our knowledge is such

SECT. II.] OVARIAN VESICLES. 465

as not to enable us to communicate any positive information.
All that is known, with any degree of certainty, is, that it is
of a soft spongy consistence, highly vascular, succulent, and
of a light rosaceous color. Their properties are particularly
well-marked in females from the age of puberty until thirty-
five, but they are much less conspicuous before and after
these periods. Situated in this substance are the ovarian
vesicles, or, as they are often termed, from the anatomist who
first accurately described them, the ovules of De Graaf.
Their number is from five to fifteen ; they are usually of a
spherical shape, and in a specimen which I recently examined
along with my friend Professor Parker, they varied in size
from three quarters of a line to two lines and a half. The
largest are almost always seated superficially, just beneath
the coverings of the organ, which they often elevate, like
so many little pearls. The structure of these vesicles is
much more intricate, I apprehend, than is generally imag-
ined by anatomists. From a considerable number of dissec-
tions, some of which were witnessed by the gentleman just
named, I am convinced that each consists of two membranes
lying in close juxtaposition but perfectly distinct from each
other. What their precise nature is, 1 am unable to specify,
but am disposed to believe that the outer is fibrous, the inner
serous. The first is of a pale grayish color, much thinner
than the other, and pretty firmly adherent to the surrounding
parenchyma; the latter, on the contrary, is strong, thick,
dense, and quite transparent in the normal state, but is ren-
dered opaque on being immersed in alcohol and boiling water.
This internal layer is sometimes arranged in the form of a
double sac, by a sort of midriff or partition. Its ofiice evi-
dently is to secrete the humor which distends the Graafian
vesicles, and which, as is shown by its ready coagulability on
exposure to heat, proof-spirits, or any of the mineral acids, is
of an albuminous nature, slightly viscid to the touch, per-
fectly pellucid, but inclining to yellow in the larger ovules.

The ovaries are supplied with blood by branches from the
spermatic arteries, and their nerves are offsets from the renal
plexus. Their absorbents, which are scanty and extremely
delicate, empty into those of the kidney.

The ovaries are subject to inflammation, suppuration, soft-
ening, tubercles, melanosis, scirrhus, encephaloid, fibrous
growths, and serous cysts. Almost all these affections occur

VOL. II. 59

466 OVARIES. [chap. XIV.

after puberty, seldom before ; and they are much more com-
mon, as a general rule, in the married than in the single.

The anatomical characters of acute ovaritis are increased
vascularity, softening, and sero-purulent effusion. In violent
attacks, the organ is of a deep red color, much swelled and
gorged with blood. On cutting into the parenchymatous
structure, it will be found succulent, and to contain small
globules of pus, or to be converted into a pulpy, disorganized
mass. When the disease affects the albugineous and serous
coverings, lymph is very apt to be poured out, sometimes in
great quantities, by which the ovary is embedded, and firmly
attached to the adjoining viscera. In such cases, I have
known the gland to be permanently fixed to the sigmoid
flexure of the colon, the bladder, or body of the womb ; and,
in five or six instances, I have seen the fimbriated extremity
of the Fallopian tubes firmly glued to the ovary, either on
one or both sides. Under the latter circumstance, the indi-
vidual must of course be sterile.

Ovaritis, especially the puerperal variety, sometimes passes
into suppuration. The matter is commonly of a thick cream-
like consistence, such as occurs in phlegmonous abscess, and
it may be either infiltrated into the parenchymatous structure
of the organ, or collected at one or more points. The quan-
tity of fluid, though usually small, is sometimes almost in-
credible. In a woman, aged thirty-five, whose case is re-
corded by Dr. Taylor, of Philadelphia, it amounted to sixteen
quarts. The right ovary occupied the whole of the abdomi-
nal cavity, and was converted into a large vascular sac,
weighing seventeen pounds after the removal of its contents.
The disease, which was of about four years' standing, was
imagined to be an encysted dropsy, and its real nature was
only discovered after death. During the latter part of her
life, the woman suffered under dyspnoea, severe cough, diffi-
culty of lying, and oedema of the lower extremities. The
abdomen was unusually large, and fluctuated feebly on pres-
sure. The uterus was sound.* The matter thus formed
may escape into the pelvic cavity, the rectum, vagina, or
urinary bladder. In some cases it finds its way into the
bowels ; and occasionally it has been known to travel along
the course of the round ligament of the uterus, and work its
way out at the inguinal ring.

* North American Medical and Surgical Journal, vol. i. p. 443, 1836.

SECT. II.] TUBERCLES MELANOSIS SCIRRHUS. 467

Softening of the ovary is a very iincommon affection. It
generally results from active inflammation, and occasionally
coexists with puerperal peritonitis. Under the influence of
this disease, the organ becomes tumid, infiltrated with sero-
purulent matter, extremely soft, and lacerable. In some
instances, the entire structure of the ovary is reduced to a
dark-colored vascular pulp, in which it is impossible to per-
ceive the slightest trace of its natural organization. In other
cases, again, the organ is of a dark complexion, hard and
friable, like a half-rotten pear.

Tubercles of the ovary are rarely met with, being still
more uncommon here than in the testicle. Thus far they
have been observed chiefly in females of a scrofulous diathe-
sis, after the decline of the menses. These bodies existed
in one twentieth of the persons who died of pulmonary
phthisis under the care of Dr. Louis. They do not give
rise to any particular symptoms ; and, as they present the
same characters as in the other organs, it is unnecessary to
say any thing further concerning them in this place.

The ovaries are sometimes, although very rarely, affected
with melanosis. A case reported by Professor Alison, of
Edinburgh, admirably illustrates this disease. The ovaries,
several times larger than their natural size, lay in front of the
uterus, in the lateral iliac regions. Their outer surface had a
dark, shining, lobulated appearance ; and, when cut into,
their substance was found to be uniformly black, as if they
had been steeped in China ink.

Scirrhus of the ovary is often found in connection with
serous cysts, encephaloid disease, and fibrous growths, but is
rarely met with alone. The viscus is enlarged, often many
times beyond the natural bulk, hardened in texture, and of a
light yellowish color, with membranous filaments, of a dense,
fibrous nature, intersecting it in different directions. This
change of structure is similar to what takes place in the tes-
ticle ; it seldorfi evinces any disposition to ulcerate, and fre-
quently continues a long period without affecting the general
health.* The disease is most apt to come on some time after
the cessation of the menses ; and, in its progress, the enlarged

* In the case of a woman, forty-five years old, related by M. Vetter, a French
■writer, the right ovary was transformed into a tumor weighing fifty-six pounds.
Its substance was homogeneous, grayish, and of a cartilaginous consistence, ex-
cepting at a few points, where it was softened, and of the character of the cere-
bral tissue. The disease Avas brought on by a blow, seventeen years before.
(Bulletin des Sciences Medicales, Oct. 1825.) "

468 OVARIES. [chap. xtv.

and indurated viscus sometimes degenerates into a lardaceous,
hydatic, cartilaginous, or bony state. Sharp, lancinating
pains, referrible to the region of the ovary, with dysmenor-
rhoea, often attend this affection, and serve to distinguish it
from other lesions.

More common perhaps than scirrhus is encephalo'id, which
usually runs its course with frightful rapidity. It may occur
at any period of life, soon after the appearance of the menses,
and it seems, in some instances, to be called into activity by
the process of impregnation. Generally the brain-like matter,
which distinguishes this disease, is found in small, irregular
masses, enclosed in a distinct cyst, of a fibrous, cartilaginous,
or bony texture. These masses sometimes attain a very
great magnitude. In the case of a young woman, narrated
by Dr. Carswell, the ovary was as large as the gravid uterus
at the full term. They are usually of different shades of
color, being of a pale olive, brownish, or mahogany, in some
places ; white, cream-like, or grayish in others. Branches of
vessels may often be traced, in great numbers, into their
structure ; and not unfrequently they contain large cysts,
filled with serum, pus, or sanious fluid. In some cases, though
this is rare, the ovary is transformed into a large lumpy sac,
the interior of which presents an areolar arrangement, and is
occupied by a glistening, serai-concrete, jelly-like substance,
constituting the gelatiniforon cancer of Cruveilhier.

Dr. Seymour, of London, has pointed out the connection
which so often exists between this disease, scirrhus, and fun-
gus hasmatodes in other parts of the body, especially the py-
lorus and the lymphatic glands.* Its existence, during life,
may be suspected by the deteriorated health of the patient ;
the wan and sallow countenance ; the progressive emaciation
and debility ; by the unevenness and rapid growth of the tu-
mor ; and by the occasional occurrence of sharp, lancinating
pains in the pelvic region.

Fibrous tumors, similar in their texture to those of the ute-
rus, occasionally grow from the substance of the ovary.
They are said to be of common occurrence in European
women, but are seldom seen in the females of this country.
Varying in size between a hazelnut and an orange, they
are of grayish color, firm consistence, and attached usu-
ally by a long, narrow foot-stalk. Occasionally these tumors

* Diseases of the Ovaries, p. 61. See his work for plates.

SECT. II.] SEROUS GYSTS, 469

coexist with scirrhus, encephaloid, or serous cysts ; and it is
not uncommon to find in them small, irregular cavities, filled
with a thick, dirty-looking fluid. Sometimes they are inter-
spersed with cartilaginous, osseous, or earthy concretions.

There are probably no organs in the human body in which
serous cysts are more frequently developed than in the ovaries.
Assuming every variety of shape, they are most generally
globular, ovoidal, or pyriform, varying in size from the small-
est nut to the magnitude of a large melon. Sometimes the
whole ovary is converted into one enormous sac ; at other
times the cysts seem to be gregarious, or united into clusters,
having no communication with each other. Occasionally the
sac is multilocular, or divided into small compartments. The
contents of these cysts vary in color and consistence in differ-
ent cases. In some, the fluid is thin, pale, and ropy ; in oth-
ers, thick, and dark-colored, like coffee-grounds ; in others,
purulent, sero-purulent, sanious, meliceric, saponaceous, tar-
like, greasy, or suety. The quantity of fluid is occasionally
truly surprising. In the case of a woman, aged forty, recently
reported by Dr. Hintze, of Baltimore, the cyst contained up-
wards of twenty-three gallons. It communicated with the in-
ferior portion of the colon of the urinary bladder, was nearly
spherical in shape, and of a thick, compact, fibrous structure.
Thus an ovary which, in the normal state, scarcely weighs
two drachms, will expand, under disease, to a magnitude ca-
pable of holding an immense amount of fluid. Externally, the
sac is commonly smooth and polished ; internally, it is rough
and irregular, sending off frequently little septiform processes.
In some instances it has a dense, cartilaginous feel ; and oc-
casionally it has been found partially ossified.* These sacs,
it may now be observed, constitute what is termed encysted

* A case of extraordinary enlargement and ossific transformation of the right
ovary of a colored woman, sixty years of age, has been recently reported by Dr.
Geddings, the able .professor of pathological anatomy in the University of the
State of South Carolina. The tumor, the weight of which was fifteen pounds,
was nine inches in length by seven inches and a half in breadth. On being cut
into, about eight ounces of curdy matter escaped. The rest of the mass was so
hard and resisting that it could only be divided Avith a saw. From three to four
fifths of its substance was composed of bony matter, part of which existed in the
form of homogeneous, solid nodules, part in that of plates and spicules, cemented
together by lough, fibrous tissue. The ossific transformation was not confined to
the external envelope of the organ, but extended through its entire substance, and_
had supplanted every vestige of the natural structure. (Southern Medical and'
Surgical Journal, May, 1838.) Similar examples are related by Henning, (Med-
ical Fragments, p. 345 ;) by Stork, (Ann. Med. ii. p. 245 ;) by Schlenker, (De
Singulare Ovarii Sinistri Morbo, § 8 ;) and by Walter, (Observ. Anat. p. 44.)

4ro

OVARIES.

[chap. XIV.

Fie:. 95.

dropsij of the ovary, and there is reason to believe that they
often arise from a diseased state of the Graafian vesicles.

Hydatids are occasionally found in these cysts. My friend,
Dr. McDonald, of Alabama, described to me a case not long
ago, in which there were upwards of two hundred of these
parasitic growths, of all sizes between a small pea and a large
fist. Some of them adhered to the inner surface of the sac,
by narrow, slender necks ; others were loose, and floated
about in the effused fluid, the quantity of which was very
great. The hydatids, which are generally, if not invariably,
of the acephalocystic kind,
sometimes amount to several
thousands.

Teeth, bones, (Fig. 95,) car-
tilages, and hairs (Fig. 96)
are sometimes discovered in
ovarian cysts, wrapped up in
a peculiar saponaceous, fatty,
or suety matter. One of the
most extraordinary examples
of this kind perhaps on record
is to be found in the " Breslau
Collections " for 1722. The
woman had been afiiicted
from her earliest youth, and
died when she was thirty-
eight years old : on inspection,
the right ovary was found
converted into a large sac,
weighing fifty-four pounds.
The tumor was of a soft, mel-
iceric consistence, and scat-
tered through its substance
were several fragments of
bone, together with a consid-
erable quantity of hair, some
of which was rolled up in
tufts two feet long. Of the
osseous pieces, which were
eight in number, the largest
was eight inches in length by
two inches in thickness ; and
several of them evidently ap-

SECT. II,] MALFORMATIONS. 471

pertained to the jaws, as they were surroimded by incisor,
canine, and molar teeth. Cleghorn discovered in an ovarian
tumor irregular pieces of bone, hairs, and twenty-seven teeth ;
and similar cases are described by Bicker, Murray, Soemmer-
ing, Baillie, Cruveilhier, and other writers. The hairs are
said by Meckel to be furnished with distinct bulbs ; and, in
their color, they present every variety, like those of the head,
to which they bear a great resemblance. These singular
productions do not seem to be confined to any particular pe-
riod of life ; hitherto they have been observed with almost
equal frequency in the married and in the virgin female, and,
what is remarkable, instances are not wanting in which they
have been found in different parts of the male, especially in
the stomach and intestines.

Ruysch discovered teeth and hair in the stomach of a man ;
Mr. Brodie, a jaw, with full-grown teeth, in the urinary blad-
der ; Gordon, hair, with a piece of bone, in the thorax. In a
case, the particulars of which are detailed in the third vol-
ume of the " Berlin Collections," the tumor, which was of
an adipous nature, adhered to the diaphragm, and contained
twenty-one fragments of bone, four teeth, and a tuft of hair ;
and in another, recently reported to the Royal Academy of
Medicine at Paris, by Dr. Andre, of Peronne, teeth and hair
were found in the testicles of a boy, aged seven years.*

Concerning the mode of origin of these singular products,
various opinions have been expressed by writers. In the
majority of cases, it is highly probable that they are the re-
sult of conception, the embryo being developed in the ova-
ry instead of the uterus ; but this explanation cannot apply,
certainly, to those instances in which these substances are
found in the male sex, and in the young, immature female.

Their presence here can only be accounted for, as has
been justly observed by Andral, on the theory of monstrosity
by inclusion, so well described by Dr. Olivier, of France.

Tumors of the ovary, from whatever cause arising, are
liable to be confounded with ascites, from which, however,
they are easily distinguished by the following signs : 1. they
are generally more tense, circumscribed, and protuberant ; 2.
they are situated more to one side of the abdomen, especially
in the early stage of their existence ; 3. they always lie in
front of the intestines, never posterior to them ; 4. they are

* Memoires de I'Academie Royale de Medicine, t. iii. p. 480.

472 OVARIES. [chap. XIV.

less influenced by change of posture, and they do not fluctu-
ate so distinctly under the finger. In ascites the fluid gravi-
tates to the lowest part of the abdomen in the erect and to
the posterior part in the recumbent position ; 5. ovarian tu-
mors always grow slowly, and are seldom attended with
much constitutional derangement ; ascites, on the contrary,
often comes on rapidly, and the general health is invariably
impaired, Additional evidence is to be obtained from insti-
tuting a vaginal examination. In peritoneeal efl'usions, the
neck of the uterus always occupies its accustomed place,
whereas in ovarian enlargements it is usually drawn up, so
as to be beyond the reach, in great measure, of the finger.
The organ is also, in some instances, dragged to one side. It
may be further stated, that, when the cyst is multilocular,
the surface of the tumor is commonly irregular, and yields a
sensation, on being percussed, as if it contained liquids of dif-
ferent degrees of consistence.

One of the ovaries is sometimes wanting, in which case it
almost, always happens that the other is considerably enlarged,
full twice the natural size. I have met with several instances
of this kind, and others are referred to by Duges, Meckel,
and Hooper. Occasionally both organs remain in a sort of
rudimentary state, being scarcely as large as a bean, and of a
dense fibro-cartilaginous consistence. In such cases, of which
a number of examples have fallen under my observation,
there is frequently an entire absence of the vesicles of De
Graaf.

Atrophy of the ovary is frequently observed in old females,
after the cessation of the menses. The period for the exer-
cise of the reproductive function being passed, the organ is
no longer needed, and it accordingly, in many cases, greatly
decreases in volume, the interior structure is dry, dense, and
almost crisp, and the serous and fibrous envelopes are remark-
ably rough and puckered. Similar phenomena are sometimes
witnessed in women who are habitually barren.

The ovary is sometimes, though rarely, the seat of hemor-
rhage. This may occur in three distinct situations: 1. in
the parenchymatous structure ; 2. in the ovules of De Graaf;
3. immediately beneath the fibrous envelope. The blood is
generally collected into irregularly rounded masses, varying
from the size of a currant to that of a garden pea. It is
either of a dark red color or almost black ; coagulated, or
partly fluid and partly solid. Ovarian hemorrhage is most

SECT. II.] LUTEAL BODY. 473

common in young plethoric females, and usually occurs in
combination with a highly congested state of the uterus, the
Fallopian tubes, and broad ligaments.

As a very curious and interesting question connected with
the morbid anatomy of the ovaries, it will be proper here to
allude briefly to what is called the luteal body, more espe-
cially as the subject is one of considerable interest in a
medico-legal point of view. In the ovaries of a woman who
has recently been pregnant, we may observe, in addition to
the ovules of De Graaf, a tender, friable, vascular structure,
generally of a circular or oval shape, the dimensions of which
vary according to the period which has elapsed between the
conception and the examination. The first account of this body
was given by Fallopius towards the latter part of the seven-
teenth century : it was afterwards more particularly described
by Haller and his disciples ; and, in our own times, it has been
particularly investigated by J. F. Meckel, Blundell, and Sir
Everard Home. For the latest and most accurate additions,
however, to our stock of knowledge relative to this topic, "we
are indebted to Professor Montgomery, of Dublin, the results
of whose observations are comprised in a short article, replete
with valuable information, in the London Cyclopaedia of
Practical Medicine.*

In reading the various accounts which have been published
on this subject, one cannot help being forcibly struck with
the contradictory statements presented by different authors.
This confusion has been produced, in great measure, if I
mistake not, by applying the term "luteal body" at one
time to a separate structure, and at another to the cicatrice
caused by the rupture of the ovarian membranes. The
truth is, these are not, as many have supposed, identical parts,
but parts that are perfectly distinct from each other, — a cir-
cumstance which must be constantly borne in mind if we
wish to avoid error. With this remark, intended to obviate
future perplexity, we may proceed one step further, and in-
quire into the nature of the luteal body, and into the charac-
ter of the resulting cicatrice.

The color of the luteal body varies according to the period
at which it is examined. In the early stage of its existence,
it is always more or less red ; by degrees, however, it assumes,
as its name indicates, a dull yellow complexion, not unlike

* See article Signs of Pregnancy, vol. iii. p. 496.

VOL. II. 60

474 OVARIES. [chap. XIV.

that of the biifty coat of the blood ; after parturition, again,
and generally several months even before that event, it becomes
gradually more and more pale, and at length loses its charac-
teristic tinge altogether. In some instances, indeed, the
yellow color, from which this body derives its name, is en-
tirely absent.

The structure of this body is strikingly glandular, resem-
bling a section of the human kidney.* In the early stage of
its developement, it is quite vascular, being surrounded by a
large plexus of arteries and veins, branches of which pene-
trate it in every direction, and can be easily filled with inject-
ing matter. Its surfaces are somewhat convex, like those of
the crystalline lens, and the superficial one not unfrequently
projects beyond the natural level of the ovary, resting upon
it like the segment of a smaller globe. As it grows older its
vascularity decreases, but its density sensibly augments.

In its form, the luteal body is almost always oval, in nine
cases probably out of ten ; but, in some instances, I have found
it circular, or rather presenting the appearance of a disk, slightly
convex at the sides. Its size, like its color, is liable to con-
siderable variety, according to the period at which it is in-
spected. In the early months of utero-gestation, the longer
axis is stated by Professor Montgomery to be from four to
five eighths of an inch, and the shorter from three to four
eighths. Its thickness, according to the same authority, is
generally less than its breadth. These measurements nearly
coincide with those of the celebrated Rcederer, who says the
luteal body is four lines long, three lines broad, and two lines
thick. Surprised at the statements of these distinguished wri-
ters, and confidently believing that they were greatly exagger-
ated, Professor Parker and myself determined to put this matter
to the test of observation. Unfortunately, however, the speci-
mens which we could command were all taken from females
who died either during labor or immediately after delivery, and
offered us no opportunity for examining these bodies in the
earlier stages of their formation. Yet, notwithstanding this,
our investigations have fully convinced us that the assertions
of Montgomery and Roederer, as to the dimensions of the
corpora lutea, are perfectly correct, and therefore in every
respect entitled to our confidence and regard. That this
conclusion is well grounded, the following facts will, I con-
ceive, fully warrant.

* Montgomery, op. cit, p. 497.

SECT. II.] LUTEAL BODY. 475

The first examination was made upon a female who died
within a few hom's after the dehvery of her third child, at
the full term of utero-gestation. On the anterior surface of
the right ovary was a distinct luteal body, of an oblong shape,
opaque, two lines in length, one line and three quarters in
breadth, and scarcely half a line in thickness. It was of a pale
yellowish color, opaque, homogeneous in its appearance, and
of a fibro-cartilaginous consistence. Another luteal body was
observed on the opposite organ, apparently more recent than
the first, of a spherical form, two lines and a half in diameter,
and encircled by a depressed, puckered cicatrice, four lines
in length by three lines in breadth.

In the second case, that of a female who died soon after
parturition, the luteal body, situated in the right ovary, was
of a circular shape, two lines and a half in diameter, about
the twelfth of an inch in thickness, and of a pale yellowish
color, similar to the buffy coat of the blood. It was sur-
rounded by a cicatrice nearly five lines across, which was
evidently formed at the expense of the serous and fibrous
envelopes, and the margins of which had a rough, tattered
appearance. In other respects the surface both of this and
of the left ovary was perfectly natural.

In the third examination, the luteal body was found to oc-
cupy the posterior surface of the left ovary. It was likewise
of a circular shape, two lines in diameter, and of a pale gray-
ish color, surrounded by a yellow areola about the fortieth
part of an inch in width. To the knife it offered a good
deal of resistance, and it was evidently of a fibro-cartilaginous
nature. The right ovary exhibited nothing unusual, except-
ing that both surfaces were rough and puckered, from the
presence, apparently, of several ancient cicatrices, the largest
of which was nearly half an inch in diameter. In this case,
also, death took place within the first twenty-four hours after
delivery, at the full term of utero-gestation.

In the fourth case, the woman who was about thirty-five
years of age, and the mother of two children, died from an
attack of cholera, at the end of the seventh month of her
pregnancy. The left ovary was of the usual size, and per-
fectly natural in regard to its exterior. On cutting into it, a
soft, spongy structure was discovered, of an irregularly oval
shape, five lines and a half in length by four in breadth, and
of a reddish color. No cicatrice could be detected over or
around this substance, of the precise nature of which it was

476 OVARIES. [chap. XIV.

impossible to form, any accurate idea. The right ovary con-
tained what was thought to be three distinct luteal bodies.
They were of a pale yellowish color, slightly rnammillated
on the surface, or studded with numerous little prominences,
resembling the eggs of certain insects, and of a dense fibro-
cartilaginous consistence. The largest was three lines and a
half in length, one line and a fourth in thickness, and two
lines and three quarters in breadth. The other two were
somewhat smaller, but had the same color and consistence ;
and one of them, the most superficial of all, was surrounded
by a distinct cicatrice, and projected some distance beyond
the natural level of the organ. On looking at these bodies
with a magnifying-glass they exhibited a singularly convo-
luted appearance, like that of the human brain, and which is
so well described by Sir Everard Home, in a paper in the
London Philosophical Transactions.

If we couple the results of the preceding examinations with
the fact that the luteal body gradually diminishes in size as
utero-gestation advances towards completion, and at length
partially or wholly disappears, it will be perceived, as was be-
fore intimated, that they strikingly corroborate the measure-
ments of Montgomery and R.oederer ; in other words, they
clearly show that the structure in question is much larger
than is generally imagined, and very difi"erent also from the
cicatrice which accompanies and surrounds it.

The manner in which this body is formed admits of easy
explanation. The larger Graafian vesicles, it will be recol-
lected are always seated superficially, and are frequently from
two to four lines in diameter. Now let us suppose that un-
der the influence of its appropriate stimulus one of these little
sacs bursts, and we can readily imagine what will be the re-
sult. In the first place, there will undoubtedly be an escape
of its contents, whereby a cavity will be formed for the re-
ception of the yellow body. Not only, it will be perceived,
are the coats of the vesicle itself ruptured, but there is also a
laceration, or, perhaps, more properly speaking, an absorption
of the corresponding portion of the serous and fibrous en-
velopes of the ovary, caused by the pressure of the subjacent
ovule, distended as it must be to the very utmost under the grasp
of the fimbriated extremity of the Fallopian tube. The ovule
having passed from its original bed, the cavity which is thus
left is gradually if not immediately closed up with plastic
lymph, poured out by the irritated and inflamed membranes

SECT. II.] LUTEAL BODY. 477

of the ruptured vesicle, the inner of which, as was shown in
a previous section, is of a serous nature, and therefore well
qualified to yield the substance alluded to. Generally the
lymph is not perfectly pure, but blended with it there is more
or less blood ; and hence the reason why a recent luteal body
is always of a redder color than one that is older. In a short
time this new matter acquires solidity, its opacity diminishes,
vessels shoot into it from the surrounding parts, and in this
manner it becomes an organized structure, capable of with-
standing, for a limited period, the action of the absorbent
vessels of the ovary, but finally yielding to their influence.
Such, in a few words, I conceive, is the mode of formation of
the luteal body.

In regard to the accompanying cicatrice, which, as I have
already endeavored to show, differs essentially from the
yellow body itself, it is altogether dependent for its formation
upon the general envelopes of the ovary. The serous and
fibrous tunics of this organ being ruptured, the ulcerative
absorption induced by the subjacent vesicle, a sort of ring is
left, of an oval or circular shape, with ragged tattered edges
of a grayish or whitish appearance, which surround the luteal
body, and frequently project considerably beyond the level of
its surface. By and by the ring contracts adhesions with the
newly-deposited substance, the intervening opening dimin-
ishes in size, and the tattered edges finally approximate,
leaving merely a radiated, linear, or stellated cicatrice, or re-
building, if I may use the expression, the part so effectually
as to render it impossible to determine where the rupture
occurred.

Having thus pointed out, with as much fidelity as my
reading and observation enable me, the difference between
the luteal body and its accompanying cicatrice, let us proceed,
finally, to inquire at what period, if at all, these structures
disappear, and how far they may be regarded as affording
evidence of previous conception. It has been thought by
many that the luteal body is a permanent ineffaceable texture,
and therefore always indicative of the number of pregnancies ;
but this is unquestionably a mistake, both as respects the prem-
ises and the conclusion thence deduced. At what period
after delivery its disparition is affected, is a circumstance
which is not satisfactorily settled. Professor Montgomery,
in the able paper already adverted to, distinctly states that he

478 OVARIES. [chap. XIV.

has never been able to detect the existence of the luteal body
beyond the fifth month. In the case of a young woman who
died at this period after giving birth to her first child, the
structure in question was scarcely any larger than a mustard-
seed, but the external cicatrice was still perfectly obvious,
and served to point out the escape of the ovule. Judging
from my own observations, I should be inclined to look upon
the final disparition of this body as liable to much diversity,
depending upon the state of the ovary, the age of the female,
and a variety of other circumstances which. must readily sug-
gest themselves to the mind of the reader. In a case already
referred to, the fourth that was examined by Professor Parker
and myself, three distinct corpora lutea were observed, cor-
responding exactly with the number of offspring. Only one
of these had a characteristic cicatrice ; it was of yellow buff
color, remarkably prominent, several lines in diameter, and
comparatively soft and friable. The most ancient was quite
small, and would no doubt have shortly disappeared had the
woman lived. This examination cannot be regarded, it is
true, as conclusive ; but, as far as it goes, it certainly cor-
roborates the view we have taken, that the luteal body occa-
sionally continues much longer than is imagined by Dr.
Montgomery, the cicatrice in the mean time becoming entirely
effaced.

The next topic to which I proposed to advert was, how far
the luteal body can be regarded as proof of previous impregna-
tion ? Concerning this question different opinions have been
expressed by different writers ; some contending that this sub-
stance is always a certain indication of this condition ; others,
that it affords, at best, very equivocal evidence. Those who
espouse the latter side of the question allege that it can be of
no value in this respect, inasmuch as it is frequently produced,
both in the human subject and in animals, in consequence
merely of strong sexual excitement, without any incercourse
whatsoever. Upon this subject, the researches of Montgom-
ery are, I conceive, perfectly conclusive. " In addition to
the authorities here cited, we may be allowed," says this
distinguished writer, " to add the result of our own observa-
tions, which have been now continued through a period of
more than six years, during which time we never omitted a
single opportunity within our reach, for examining the bodies
of women of all ages, and under all the varying circumstances

SECT. II.] LUTEAL BODY. 479

of virginity, after intercourse, during gestation, and subse-
quent to delivery, at different periods from conception, — these
opportunities having been afforded by more than one large
hospital, as well as in private practice. We have also dis-
sected hundreds of the inferior animals with reference to this
point, and have in our museum preparations of ovaries ex-
hibiting the corpus luteum in different conditions in the
human female, and also in cows, mares, sheep, sows, goats,
bitches, cats, hares, and rabbits ; and our firm conviction is
of the truth of both of Haller's propositions, namely, that con-
ception never happens without the production of a corpus
luteum," and " that the corpus luteum is never found in
virgin animals, but is the effect of impregnation." In re-
gard to the virgin corpus luteum, or that which results simply
from lascivious excitement, it can be readily distinguished,
according to Montgomery, from the genuine luteal body, by
the following particulars : 1. There is no prominence of the
ovary over it. 2. The external cicatrice is wanting. 3. There
are often several of them in both organs, especially in females
who die of tubercular phthisis. 4, It is not vascular, and
cannot be injected. 5. Its texture, instead of being tender,
friable, and. regularly glandular, is inferior, consists merely
of the remains of a coagulam, or of a fibro-cellular substance.
6. It has neither the central cavity, nor the radiated cicatrice
which results from its closure.*

Finally, it should be observed that the accompanying cica-
trice, like the yellow body itself, is gradually effaced, gener-
ally within the first year after delivery, sometimes, indeed,
several months sooner, but at other times, not until consid-
erably later. Taken by itself, it affords no evidence of pre-
vious conception, inasmuch as it is impossible to distinguish
it from a cicatrice produced by the discharge of an abscess,
a tubercular excavation, or a sanguineous effusion. The
opinion, therefore, that the scars remain for life, and exactly
indicate the number of births, is absurd and erroneous.

* London CyclopEedia of Practical Medicine, vol. iii. p. 502.

480 FALLOPIAN TUBES. [cHAP. XIV.

SECTION III.
Of the Fallopian Tales.

The Fallopian tubes are two slender, tortuons canals, about
four inches and a half in length, which extend between the
ovaries and the superior angles of the uterus, with both of
which they are connected. Their caliber is extremely nar-
row in the inner half of their extent, being scarcely large
enough to admit a common-sized bristle ; but, as they proceed
to their destination, they gradually augment in diameter, and
finally terminate in a wide, trumpet-shaped mouth. They
serve as excretory ducts to the ovaries, and consist each of
three tpnics, — an external one, which is serous, an internal,
which is mucous, and an intermediate, which seems to be
similar in its structure to the spongy body of the urethra, and,
like it, capable of temporary erection. The vessels of the
Fallopian tubes are branches of the spermatic arteries, —
the nerves of the hypogastric plexus.

Thus organized, the Fallopian tubes are liable to attacks
of acute and chronic inflammation, both in the virgin and
in the gravid state. These diseases may be propagated to
them from the uterus, or they may have an independent
origin : they may be limited to one tube, or even to a part of
that tube, or they may involve both ducts simultaneously.
Inflammation is most apt to be present in dysmenorrhosa and
puerperal peritonitis, when the tubes are extremely vascular,
and of a deep red color ; and, in severe cases, they are closed
up either partially or entirely with coagulating lymph, or dis-
tended with purulent matter. In a case mentioned by Pro-
fessor Harrison, of the Cincinnati College, the left tube con-
tained at least an ounce of thick, laudable pus, the right about
three drachms : the mouth of the uterus was red and tumid,
and the whole of its inner surface bathed with purulent
matter. Occasionally, when the accumulation is very great,
the tube bursts, and the matter escapes into the pelvic cavity ;
at other times, it discharges its contents through the rectum,
the small intestines, the urinary bladder, or the uterus.

In some instances, these tubes terminate in a cul-de-sac ;
and cases are occasionally witnessed in which their fringes
are destroyed by ulceration, or by adhesion to the ovaries or

SECT. III.] WATERY FLUIDS, 481

adjacent organs. Their canals are also sometimes obstructed
by inspissated mucus, lymph, and scrofulous matter. In a
young girl of ill fame, examined by Professor Harrison, the
Fallopian tubes, very greatly dilated, contained a thick,
cheese-like deposit ; and to the outer surface of each were
appended two small tumors, filled with a similar substance.
All these lesions are so many causes of sterility.

Fibrous tumors sometimes grow from the Fallopian tubes ;
sometimes in their interior. They are usually of a rounded
shape, very hard, and exhibit the same appearances, when cut
into, as fibrous tumors of the womb. Malignant disease
occasionally invades these passages, commencing in them
either as an original afl:ection, or extending to them from the
uterus or the ovaries. The true hydatid, I believe, has never
been found here ; but very often small cysts, filled with a
thin, limpid fluid, are seen hanging from the fimbriated ex-
tremities of these tubes, and this sometimes in women who
have never borne children. Their size varies from that of a
currant to that of a walnut, an orange, or even a small
gourd.

Accumulations of watery fiuids are sometimes seen in the
Fallopian tubes. (Fig. 97.) The most usual quantity is from
one to two ounces ; but occasionally it amounts to many
pints. In such cases, the duct commonly assumes a pyriform
shape, and greatly augments in thickness, — a condition which
is absolutely necessary to prevent its rupture. De Haen re-
lates an instance in which the tube weighed seven pounds,
and the cavity contained nearly four gallons of fluid ; and a
still more extraordinary one has been detailed by Madame
Boivin.

When the ovum is retained in the Fallopian tube, as has
been known to happen in some rare cases, it generally grows
until the third, fourth, or fifth month of gestation, and then
makes its escape. In some instances, the escape is preceded
by ulceration ; but more commonly there is a rupture of the
tube, its attenuated walls being incapable of further disten-
tion. Fatal hemorrhage almost always follows this accident.
A very instructive case of this species of pregnancy is men-
tioned by the late Dr. Clarke, in the second volume of the
London Medical and Chirurgical Transactions ; a second is
detailed in a late number of the American Journal of the
Medical Sciences ; and a third was recently communicated to
me by my friend, Dr. Kennedy, of Easton, Pennsylvania.

VOL. II, 61

482

FALLOPIAN TUBES.

[chap. XIV.

In this case, the tube was ruptured in consequence of a blow
on the abdomen, and the woman gradually sunk under the
hemorrhagOj having been pregnant about seven months.

Fis-. 97.

Of the symptoms of these various affections, it will not be
necessary to speak ; I need only remark, concerning them,
that they are generally very obscure, and that they do not
afford any indications by which the lesions of the Fallopian
tubes can be distinguished from those of the rest of the
uterine system.

SECT. IV.] VAGINA AND VULVA. 483

SECTION IV.
Of the Vagina and Vulva.

The vagina is liable to ordinary and specific inflammation.
The disease is marked by the usual anatomical characters,
and is often attended with profuse discharges of purulent
matter, of a very acrid nature, and mixed at times with
blood. In bad cases, abscesses are formed in the submucous
cellular texture ; and instances have been witnessed where
the parts were rapidly destroyed by gangrene. A coating of
adventitious membrane is sometimes observed, especially
when the inflammation is connected with disease of the
mouth and neck of the uterus. Ulcers of the vagina are
generally referable to the syphilitic, cancerous, or scrofulous
poison, and do not differ from the same class of sores in other
regions of the body.

Polypes are occasionally developed in the walls of the
vagina ; but this is very rare, and hitherto I have not seen
one instance. Tumors of this description may attain a very
considerable magnitude, so as not only to distend the whole
tube, but project eight or ten inches down the thighs. Bau-
dier has published an account of a polypous growth of the
vagina, the weight of which was ten pounds and a half; and
similar cases are narrated by Dupuytren and other authors.

A singular tumor is sometimes observed in this tube, which
seems to consist in a morbid enlargement of the mucous fol-
licles that are so abundantly found in this division of the
mucous system. I once saw a swelling of this kind imme-
diately beneath the orifice of the urethra of a young lady,
the mother of four children. It Vv^as of a spherical shape,
about the size of "a walnut, and of a white, glossy appearance,
with a rough, corrugated surface. She told me that it was
at times painful, and that she had first perceived it eight
years ago, soon after her marriage. I opened the tumor with
a lancet, and let out a considerable quantity of a viscid,
glairy fluid, like the white of eggs. The fluid never reaccu-
mulated.

Obstruction of the vagina is liable to occur from inflamma-
tion, and the consequent eff'usion of fibrin into the submucous
cellular tissue. In this way, not only the orifice, but the

484 VAGINA AND VULVA. [cHAP. XIV.

greater part of the tube, may be much diminished in size,
either uniformly, or, as more frequently happens, at particular
points. The stricture, though generally partial, occasionally
completely encircles the vagina, presenting the appearance as
if it had been bound by a ligature. The affected part feels
firm, thick, and rigid, not unlike the mouth of the uterus, for
which it has sometimes been mistaken during labor. The
obstruction may be seated at any part of the length of the
tube, but in most cases it is found within the first two inches
of the lower outlet. The outlet of the vagina, again, may
be closed up by an imperforate hymen, or by a dense, pale,
gristly substance.

The vagina is sometimes very short. Baillie states that he
has seen it not more than half its natural length ; and still
more remarkable examples are mentioned by Dr. Dewees.
In one of these the whole distance to which the finger could
be passed did not exceed an inch and a half; and in the
other, which seemed to be connected with an absence of the
uterus, the tube terminated in a cul-de-sac. At other times
the vagina is entirely wanting, greatly contracted, or con-
verted into a solid, gristly mass ; and cases have occasionally
been noticed where, through accident or congenital defi-
ciency, it communicated with the bladder and the rectum,
at various distances from the anus. In a female mentioned
by Sue, the rectum opened into the vagina, and the vagina
into the bladder.

The vagina may be double. Of this I have never seen, an
instance, but cases of it are recorded by Haller, Eisenmann,
Bartholin, Callisen, Meckel, and other writers. The septum
sometimes extends the whole length of the tube, dividing it
into two cylindrical canals, each of which may terminate
inferiorly by a separate aperture. Callisen refers to two cases
where the canals thus formed were closed each by a perfect hy-
men. In some instances, which, however, must be extremely
rare, the froenum is situated transversely, constituting a sort
of diaphragm, which prevents the flow of the menstrual
fluid.

We have already intimated that the great lips are subject
to bloody infilti'ation. This lesion, which results from a rup-
ture of some of the neighboring vessels, during or imme-
diately after delivery, usually involves only one of these
organs, seldom both at the same time. The tumor which is
thus formed is generally of an irregularly oblong shape, with
a dark livid surface, more or less compressible, and about the

SECT. IV.] WARTY EXCRESCENCES. 485

size of a hen's egg. Occasionally, however, it is much
larger, equaling or surpassing the volume of a foetal head,
and containing from ten to twenty ounces of blood. The
effusion commonly takes place suddenly, or in a very short
time, and, when copious, it almost always makes its escape
spontaneously, by lacerating the superincumbent textures, or
it remains, and speedily induces gangrene in them. In the
latter case, the blood is generally of a very black color, partly
fluid and partly coagulated, and emits a highly offensive odor.
The infiltrated tissues are sometimes frightfully lacerated,
and converted into a dark, shreddy substance, without any
trace whatever of their original characters.

The external lip may be the seat of different kinds of
ulcers ; and they are likewise liable to gangrene, malignant
disease, and bloody infiltration. An eminent English physi-
cian, Mr. Kinderwood, many years ago described a fatal dis-
ease of the vulva of young children, which, commencing at
one or more points of the mucous surface, rapidly spreads
over the nymphse, clitoris, and hymen. Gangrenous spots
appear in a very short time, and continue to enlarge until the
parts are converted into dark-colored, fetid sloughs. Great
prostration of strength, accompanied by fever and severe
pain, is the most prominent symptom of the complaint.

Dr. Parker and I recently removed a tumor of this sort
from the entrance of the urethra of a young lady of eighteen.
It was of a conical shape, nearly an inch and a half in length
by three quarters of an inch in diameter, very sensitive, of a
bright florid color, elastic, and compressible. On maceration
for a few days in water, it became perfectly white, and
seemed to be composed essentially of blood-vessels, supported
by soft cellulo-fibrous substance.

Warty excrescences are often seen within the vulva. In
some instances they extend into the vagina, and down the
perinseum as far as the margin of the anus. Their number
may be very great. In one case, that of a young girl of
eighteen, I counted as many as sixty-five, of all sizes, from
that of a mustard-seed to that of a raspberry. Usually they
are of a pale florid color, of a fibro-cartilaginous consistence,
rough on the surface, pediculated, and somewhat painful on
pressure. Their origin in most cases is referable to gonor-
rhoea and syphilis.

The clitoris and nymphse are sometimes hypertrophied to
such a degree as to require excision. In some countries these
structures are naturally much larger than in America and

486 MAMMARY GLAND. [CHAP. XIV.

Europe. In Persia and Turkey their developement is often
very great.

The female urethra is rarely diseased. The principal
lesions to which it is liable are, stricture, dilatation, and vas-
cular excrescences. The stricture is usually situated at the
extremity of the tube, and may be so great as to produce
much difhculty in making water. Sir Benjamin Brodie has
described a case where the urethra was so much contracted
that it scarcely admitted the finest probe : the stricture com-
menced at the extremity of the canal, and extended about
half an inch back. In some congenital malformations, the
orifice of the urethra opens into the vagina at some distance
from the external aperture. Occasionally, where the mouth
of the vagina was closed up by a dense membrane, the ure-
thra has been known to be dilated to such an extent as to
admit the male organ.

Vascular excrescences sometimes spring from the female
urethra, or are seated around its orifice. They are of a
bright scarlet color, exquisitely sensitive under pressure, and
of a soft, spongy, erectile structure, with a smooth, fissured,
or granulated surface. The shape is generally pear-like, and
the size varies from a small pea to that of a horse-bean.
This disease has been observed in young girls under seven-
teen, but is most common in adults. The causes which lead
to its production are unknown.

In the female, the parts most commonly attacked with
chancre are, the edges of the pudendal lips, the nymphs,
and the orifice of the vagina. In some instances the disease
affects the perinasum, the interior of the vagina, and even
the mouth of the uterus. The ulcers exhibit the same char-
acters as when seated on the penis ; generally, however, their
number is greater, and they are apt to produce more extensive
devastation.

SECTION V.

Of the Mammary Gland.

The mammary gland is situated in front, of the great pec-
toral muscle, nearly equi-distant between the breast-bone and
the arm-pit, in the midst of a considerable quantity of adipous
substance. In its size it varies very much in different indi-

SECT, v.] STRUCTURE. 487

viduals, as well as in the different periods of life. Until the
age of puberty it is always remarkably small, and exists only,
so to speak, in a rudimentary state ; but, from this time on, it
rapidly augments in volume, and attains its maximum devel-
opement during pregnancy and lactation. When the period
of child-bearing is past, the gland gradually diminishes in
size, and is ultimately transformed into a soft, drab-colored
substance, in which it is impossible frequently to distinguish
any of the primitive tissues.

Divested of the fatty matter by which it is surrounded,
the adult mammary gland is found to be of a circular shape,
convex in front, but flattened posteriorly, from three to five
inches in diameter, and from ten to fifteen lines in thickness.
It is of a light pink color, and of a remarkably tough con-
sistence, being cut with more difficulty than fibro-cartilage.
Like the pancreas, which in many of its features it closely
resembles, it is composed of an assemblage of lobes of differ-
ent sizes, which are connected together by dense cellular
substance, and which impart to the surface of the organ its
rough and knotty aspect. These lobes are more abundant,
as well as more intimately cemented together, at the centre
than at the periphery of the gland, and they are always ren-
dered very conspicuous when affected with inflammation.
By dissection, each can be shown to consist of a series of
smaller masses, which are themselves resolvable into gran-
ules not bigger than a poppy-seed. These little bodies, the
number of which is very great, are very distinct during lac-
tation, and are made up of oblong vesicles, which can only be
seen by the aid of the microscope.

From the minute granules that compose the mammary
gland, fine excretory tubes arise, which unite together and
form the lactiferous ducts. Of these there are commonly
from fifteen to twenty : they are tortuous, extensible, semi-
transparent, and composed each of two distinct tunics, the
external of which is fibrous like that of the ureter ; the inter-
nal, mucous : they proceed in a radiated manner from the cir-
cumference towards the centre of the organ, and, as they
approach the base of the nipple, they all become sensibly
expanded, forming so many little sinuses, of a conical shape,
the largest of which are more than the sixth of an inch in
diameter. All these ducts are destitute of valves, which
accounts for the facility with which they can be injected in
the backward direction. It was formerly thought, by many

488 MAMMARY GLAND. [cHAP. XIV.

respectable anatomists, that these canals freely communicated
with each other ; but more recent investigation has disproved
the opinion, it being clearly ascertained that each tube is con-
nected with its proper branches only.

The part in which the lactiferous ducts terminate is called
the nipple. This projects from the central portion of the
anterior surface of the gland, in the form of a conical emi-
nence, the volume of which is liable to great variation,
being scarcely alike in any two subjects. Of a light rosy
tint, it is firm, elastic, and susceptible of temporary erection,
like the penis and the clitoris ; externally it is rough, some-
what reticulated, and furnished with numerous papillsB ; and,
on making a section of it, it is found to be composed mainly
of the extremities of the lactiferous ducts supported by blood-
vessels and cellular substance. The skin, for a short distance
around the base of the nipple, is extremely soft and delicate,
of a rosy color in virgins, but of a dark brown in those who
have borne children, and provided with several zones of seba-
ceous follicles.

The mammary gland receives a large supply of vessels,
which are always very capacious during lactation. Its nerves
are branches of the intercostals and of the brachial plexus.
The lymphatics, which are numerous and arranged into two
sets, are superficial and deep, terminate in the axillary gan-
glions,— a circumstance which explains the great facility
with which these bodies become enlarged whenever there is
any serious lesion in the mammary gland.

This body exists in the male, but only in a rudimentary
state. Nevertheless, there have been instances in which it
was quite large, and even secreted considerable quantities of
milk. It has also been known in a few rare cases to be
affected with carcinoma in the same sex.

Sometimes a supernumerary mamma is observed. Dr.
Roberts, of Marseilles, recently reported a case where, in
addition to the ordinary glands, a third one occupied the left
groin, and served to suckle several children. Supernumerary
nipples, capable of furnishing milk, are by no means uncom-
mon, and must have been noticed by almost every practi-
tioner.

The lesions of the breast may be arranged under the fol-
lowing heads : inflammation, scirrhus, encephaloid, encysted
tumors, tubercular deposition, hypertrophy, atrophy, earthy
concretions, neuralgia, and apoplexy.

SECT, v.] INFLAMMATION. 489

Acute injiaratnation of the mamma most commoDly occurs
dm'ing lactation, being rarely observed at any other period.
It usually sets in within the first week or two after parturi-
tion, from the effects of cold, or from an obstruction in some
of the lactiferous tubes. The gland is tumid, hard, and en-
gorged with blood, all its vessels being deeply injected. At
first there is merely tenderness on pressure ; but, in the pro-
gress of the disease, the patient complains of severe pain,
generally of a sharp, pricking kind, which shoots along the
corresponding axilla, and sometimes even along the whole
of the upper extremity.

After this state of things has continued for a week or ten
days, the disease either stops, passes into the chronic form, or
leads to suppuration. When the latter event is about to hap-
pen, all the symptoms become suddenly aggravated ; there-
are deep-seated, throbbing pains, with excessive tenderness
on pressure ; the skin becomes red and injected ; and the pa-
tient suffers under great constitutional irritation, accompanied
by alternate chills and flashes of heat. The matter usually
collects in one or more abscesses, and is of a thick, cream-
like aspect, with a slight mixture occasionally of milk, serum,
or blood. The quantity of pus seldom exceeds five or six
ounces ; in some cases, however, I have known it to amount
to several quarts. The time required for the matter to work
its way to the surface, varies from ten to twenty days, accord-
ing to the depth at which it is situated, and the irritabihty of
the constitution. When several abscesses exist, they some-
times communicate together by fistulous tracts.

Chronic inflammation of the breast, although it may occur
at any period of life, is most common between the ages of
seventeen and thirty. Invading usually only one or two lob-
ules, it sometimes attacks the whole gland, the substance of
which has a peculiar doughy feel, like that of a fatty swell-
ing, and appears to consist of a number of nodules, from the
size of a currant, to that of a filbert ; its color is generally a
pale yellow, sometimes pink ; and its consistence firm and
dense, almost fibro-cartilaginous. This disease often contin-
ues for years ; but, what is remarkable, it rarely manifests a
malignant tendency, or disposition to suppurate. On pressure,
the part is hard and painful, and there is commonly a gnaw-
ing uneasiness in it, which is almost always aggravated about
the catamenial period. The breast sometimes becomes great-
ly enlarged in this disease, and causes so much inconvenience

VOL. II. 62

490 MAMMARY GLAND. [cHAP. XIV.

as to require removal. Hey mentions a case of this kind,
where the organ weighed upwards of eleven pounds, and
yet exhibited no structual lesion. I once saw the gland am-
putated, under the supposition that it was carcinomatous.

iScirrhus of the breast rarely appears under the age of thir-
ty-five. It is most frequent about the period of the decline
of the menses, and is witnessed quite as often in old maids as
in women who have borne children. When inspected after
death, the mamma is found to be inelastic, firm, dense, and
crisp, like cartilage, which it also resembles in color : some-
times it is of a dry, fibrous texture, like the interior of an un-
ripe pear, and of a light grayish tint, interspersed with yel-
lowish lines, probably the remains of lactiferous ducts: more
rarely the organ is soft and succulent, presenting a considera-
ble number of small vessels, and yielding, upon pressure, a thin,
opaque, serous fluid, occasionally blended with milk. These
appearances frequently occur together, forming so many
zones, gradually and insensibly running into each other. In
some instances, again, the tumor contains one or more cavi-
ties, filled with purulent matter, or with a viscid, ropy fluid,
not unlike the synovia of the joints.

The malady usually commences in a few lobules; but, as
it progresses, the whole organ becomes converted into a firm,
solid mass, with a rough, tuberculated surface. In a scirrhus
breast in the museum of the Cincinnati College, removed by
Professor Parker, from a widow, thirty years old, there are
four or five tumors, the largest of which, hard and crisp, like
cartilage, and of an oblong, spherical shape, scarcely equals
the size of a pullet's egg. Before the gland was extirpated,
it had an irregular, knobby feel, and could be freely moved
in difi'erent directions. When the whole of the breast is not
involved, the excepted part is generally somewhat changed
in its color and consistence, being yellowish, firm, and coarse-
ly granulated, so as to resemble the substance of the pancreas.

Beginning usually with slight swelling, the disease is soon
follov/ed by sharp, darting pains, accompanied by a peculiar
tension and fulness of the mamma. After some time, a cir-
cumscribed lump is perceived, hard and irregular to the
touch, and somewhat tender on pressure. The induration
gradually augments ; and, as the turgescence spreads, the
whole gland becomes firm, and knobby : in this stage, the
organ is still movable, but by degrees it contracts adhesions
to the pectoral muscle, so that it can no longer be pushed

SECT, v.] ENCEPHALOID HYDATIDS. 491

about with the hand. In the mean time the nipple is painful
and retracted ; the skin is puckered and discolored ; the su-
perficial veins enlarge, and assume a deep bluish tinge, from
the obstacle to the return of the blood ; the patient loses her
flesh ; the appetite diminishes ; and the strength rapidly de-
clines. Ulceration now sets in, leaving one or more circular
sores, with hard, depressed, angry-looking edges, and a foul,
sloughy base. The discharge is thin, ichorous, offensive, and
often so acrid as to corrode the healthy skin. With this state
of the disease, the constitution always deeply sympathizes •
the woman is harassed with sharp, lancinating pains, darting
into the axilla of the aflected side, and down the arm ; and the
irritation now rapidly extends to the neighboring lymphatic
ganglions, which either become white, firm, and tumid, or
they are rendered preternaturally soft and vascular, having
often a bloodshot appearance.

Scirrhus of the breast frequently remains indolent for a
considerable length of time, when it rapidly assumes the
characters that have just been described. When removed,
after an interval of several years, the disease is almost always
sure to return, either in the cicatrix or in the contiguous
lymphatic ganglions.

Encephalo'id, when occurring in the breast, exhibits the
same anatomical characters as in other structures of the body.
Although it occasionally exists as a primary lesion, it most
commonly supervenes upon scirrhus, — the tumor in this case
being partly fibro-cartilaginous and partly brain-like in its tex-
ture. The swelling has a pulpy, doughy feel, is very apt to
ulcerate, and usually coexists with encephalo'id in some one
or other of the internal organs.

Cruveilhier has noticed a peculiar species of mammary can-
cer, to which he has applied the term gelatiniform. External-
ly, it is of a light grayish color, dense, firm, and glistening ;
internally, it is more soft and succulent, yields some moisture
on pressure, and- tears into hard, jelly-like strings. Of this
disease I have never seen an instance, and am inclined to re-
gard it merely as a variety of encephaloid.

Hydatids are sometimes found in the breast, constituting
what surgeons call encysted tumors. Varying in size be-
tween a currant and an orange, they generally invade the
entire gland, the proper substance of which they often com-
pletely destroy. As in other parts of the body, they occasion-
ally occur in clusters, but more generally they are perfectly

492 MAMMARY GLAND. [cHAP. XIV.

distinct from each other, and of a globular figure. When
these bags are of considerable size, it is not uncommon to find
within them smaller hydatids, hanging by narrow foot-stalks,
and having precisely the same configuration and structure.
The contained fluid is either thin and limpid, like spring-
water, or thick and glairy, like the white of egg. Sometimes
there is an admixture of blood, pus, curdy matter, or particles
of inspissated lymph. Hydatids usually occur in connection
with carcinoma, and they occasionally attain the volume of a
foetal head, though generally, as before stated, they are
much smaller. When they are large and numerous, the breast
will sometimes weigh eight or ten pounds. Tumors of this
kind have not always a malignant tendency ; oftentimes they
cause little or no sufl'ering, and if, after their contents are
discharged, their sides be brought into contact, they will fre-
quently unite by adhesive inflammation.

Tubercles are of rare occurrence in the breast. When ex-
isting in this organ, it is presumable that they would present
the same appearances as in other parts of the body. They
are seldom numerous, and they are most commonly found in
connection with tubercles of the lungs, and the lymphatic
ganglions.

Hypertrophy of the mamma is by no means uncommon,
nor is it, as might be supposed, confined entirely to the female
sex. In several instances I have seen both breasts of the
male enlarged many times beyond their usual bulk ; and not
a few cases are recorded where they have freely, and for a
long time, secreted milk. In women, the swelling is com-
monly associated with amenorrhoea, but sometimes it occurs
during pregnancy, and disappears soon after delivery. One
of the most extraordinary examples of hypertrophy of the
mamma, perhaps, to be found on record, has been recently
reported by Dr. S. C. Houston, in the fourteenth volume of
the American Journal of the Medical Sciences. The sub-
ject was a colored girl, aged sixteen, who died in the Phila-
delphia Almshouse, in April, 1834. The left breast, which
began to enlarge much earlier than the right, weighed
twenty pounds, and measured forty-two inches around the
base, forming an oviform mass, which extended from the
lower part of the neck to some distance beneath the umbili-
cus. The other breast, which was of the same shape as the
left, was also enormously enlarged ; yet, notwithstanding this,
it was perfectly sound, presenting not the slightest structural

SECT, v.] CALCAREOUS CONCRETIONS. 493

lesion. Around both glands, the cellulo-adipous tissue was
in a state of hypertrophy, and in neither could there be de-
tected any trace of the nipple. The girl had menstruated,
and enjoyed good health, until a few weeks before her
death, which was occasioned by a contusion of the left mam-
ma, terminating in gangrene. A laced jacket was worn, to
sustain the weight of the enlarged organ.

Hey, in his Practical Observations on Surgery, alludes to
several cases of a similar nature, in all of which the hyper-
trophy was connected with suppression of the menses ; in
one of these, the breast weighed fifteen pounds, and so great-
ly incommoded by its bulk that it was obliged to be ampu-
tated. Dorsten, a German physician, attended a young lady
in whom the enlargement was associated with retention of
the milk. Both breasts were pendulous and painful, and the
left was found to weigh sixty-four pounds. No decided struc-
tural change could be detected in the gland, except the mere
hypertrophy of the integrant cellular texture.

Atrophy of the mamma is the natural effect of old age.
When the menstrual function ceases, the gland begins to
diminish in volume, and the wasting gradually progresses
until at length the whole organ is reduced to a soft, flabby
mass, of a dirty grayish tint, in which it is often difficult to
detect any of the natural structure, except the lactiferous
ducts, which are seldom completely effaced. Sometimes the
gland shrinks early in life, particularly in married females
who do not nurse their offspring. Temporary atrophy of
this viscus results occasionally from the effects of neuralgia,
either of the nerves of the face, the trunk, or of the extrem-
ities ; and, from the observations of Professor D'Outrepont, of
Wijrtzburgh, the same change, it would appear, is often in-
duced by the extract of hemlock, exhibited during lactation.

Calcareous concretions are occasionally met with in the
breast, either in its substance or the lactiferous ducts : they
are commonly small, not exceeding an ordinary pea, and
hitherto they have been observed chiefly in connection with
encephaloi'd and scirrhus. Sir Astley Cooper supposes that
these concretions are the result of a process similar to what
takes place in the formation of natural bone ; that this is occa-
sionally the case, seems to me not improbable, but I am far
from believing that it is of uniform occurrence. I have seen
these bodies only in two instances, in females far advanced in
life. They were of a whitish color, irregularly spherical
in shape, and of a hard, solid consistence, like dry mortar.

494 MAMMARY GLAND. [CHAP. XIV.

A still nearer affection than this is melanosis, which may
occur either as an infiltration amongst the granules of the
gland, or, as is more frequently the case, in the form of small
spherical nodules, of a black, sooty color. Of this disease,
I saw an interesting specimen, some years ago, in an old
female who died of pulmonary phthisis, accompanied by
scirrhus of the left mamma. The little tumors, which were
five in number, were distinctly encysted, and contained a
thin, ropy fluid, of the color -and consistence of China ink.

Neuralgia of the breast may occur at any period after
puberty, but is most common in young females from the age
of fifteen to thirty. It is characterized by exquisite pain,
darting through the part like electricity, and extending gen-
erally to the corresponding shoulder and axilla, sometimes
down the elbow to the fingers. The sufi'ering resembles that
of tic-douloureux, observes often a regular periodicity, is
very much increased prior to menstruation, and is sometimes
so severe that the patient is unable to lie upon the affected
side, or bear the weight of the bed-clothes. The disease,
although it may last for years, has no malignant tendency :
it is met with mostly in persons of a nervous, irritable tem-
perament, and is frequently produced by external injury, such
as a blow or contusion. The menstrual secretion is gener-
ally very deficient, and there is almost constantly leucor-
rhoea.*

The complaint, although it sometimes affects the whole
gland, is most commonly confined to several of its lobules,
which either retain their natural bulk and appearance, or they
are converted into small, solid tumors, distinctly circum-
scribed, movable, and highly sensitive to the touch, the pain
that is induced by handling them continuing in some cases
for several hours. Occasionally these swellings seem to be
seated in the connecting cellular tissue, rather than in the
glandular structure ; and they seldom exceed the size of a
marble, an almond, or a walnut ; they never suppurate, and
sometimes spontaneously disappear. The nature of this
disease is still involved in considerable obscurity, — a cir-
cumstance which is not at all surprising, when we reflect
how little we know concerning neuralgia in general.

Closely allied to the lesion just described, is a morbid
change which occasionally occurs in the breast of young

* Sir A, Cooper, on Diseases of the Breast, p. 76. London, 1829.

SECT, v.] LACTIFEROUS DUCTS. 495

girls soon after the period of puberty. It may be considered
as a species of apoplexy, as it consists in an effusion of blood
into the cellular tissue of the organ, resembling an ecchy-
mosis produced by a blow or leech-bite. Generally there is
only one such spot, but now and then there is as many as
five or six : they come on a few days before the menstrual
period, and disappear within the first ~week or two after ;
though, in some instances, they have been known to con-
tinue for more than a mouth. This disease, first pointed out,
I believe, by Sir Astley Cooper, seems to depend upon some
sympathetic action between the uterus and the breast, causing
a great determination of blood to the latter, eventuating in
the rupture of some of the smaller vessels. The affected
parts, which are always of a dark, livid hue, are exquisitely
tender on pressure, the pain sometimes shooting down to the
ends of the fingers.

Erectile tumors are sometimes found about the mamma,
and attaining occasionally a very large size. They are soft,
exceedingly vascular, of a dark florid color, and liable to bleed
on the slightest touch. Composed essentially of an inter-
lacement of arterial and venous branches, they are most
common in adult females, though in a few instances they
have been noticed in the male.

The lactiferous ducts, like other excretory canals, are liable
to be permanently closed by causes which interrupt the pas-
sage of the milk, such as external tumors, or accidental pro-
ducts contained in their interior. Of these the most common
by far is the efl"usion of plastic lymph produced by inflamma-
tory irritation. The extent to which the tube is obliterated
varies in different cases, from a few lines to an inch or more.
The lesion generally arises within the first month after de-
livery ; and, as the breast is then engaged in secreting milk,
the portion of the tube behind the constricted or obliterated
part is apt to become dilated, forming a globular, ovoidal, or
pear-shaped tumor, the volume of which occasionally exceeds
that of an orange. A swelling of this kind is almost always
attended with a peculiar sense of distention, and distinctly
fluctuates under the finger. On cutting into it, the contents
are found to be of a whitish color, and of a thick, cream-like
consistence, or of the nature of curdy whey, — the quantity
ranging from a few drachms to several ounces.

496 PLACENTA. [chap. XIV.

SECTION VI.

Diseases of the Placenta.

The placenta is a soft, spongy, vascular organ, serving as
a bond of connection between the mother and the foetus.
When fully developed, its weight is about twelve ounces. It
is nearly circular in itsform, from six to eight inches in diam-
. eter, and about eighteen lines thick at the centre, from which
it gradually decreases towards the circumference. When
divided, it is found to be essentially composed of the ramifi-
cations of the umbilical vessels, which are distributed in all
directions, connected together by cellular substance, and in-
tersected by fibrous filaments, giving the whole the aspect of
a parenchymatous structure. Of the two surfaces of the
placenta, the foetal is perfectly smooth and polished, being
invested by a reflection of the chorion and amnios ; the ute-
rine presents a considerable number of lobules, technically
named cotyledons, and is covered by a soft, cellulo-fibrous
lamella, known under the name of the deciduous membrane.
In their shape, the lobules are irregularly rounded, and they
each receive an arterial and venous branch, which ramify
through its substance, but do not anastomose with the vessels
of the adjoining masses. Neither nerves nor absorbents have
been satisfactorily traced into the placenta, though the proba-
bility is that both exist there.

When we consider that the placenta is a species of organ-
ized pseudo-membrane, it is not surprising that, notwithstand-
ing its temporary existence, it should be liable to various mor-
bid alterations. Until recently this subject appears to have
attracted very little attention ; Morgagni and some of the
older anatomists have, it is true, transmitted to us some in-
teresting cases of diseases of the placenta ; but they are, for
the most part, so loosely drawn up as to render it extremely
difficult to deduce from them any thing like general princi-
ples. The most important facts of which we are at present
in possession have been furnished by Professor Cruveilhier,
of Paris, Monsieur Brachet, of Lyons, and Dr. Simpson, of
Edinburgh. The researches of these pathologists are of the
greatest vahie, not only to morbid anatomy, but to medical
jurisprudence, — a branch of science upon which they have

SECT. VI,] INFLAMMATION SUPPURATION SOFTENING. 497

the closest bearing. The most common diseases of the pla-
centa, and those which will be briefly noticed on this occa-
sion, are inflammation, atrophy, cartilaginous degeneration,
ossification, and sanguineous efl'usions.

Acute inflmnmation of the placenta is extremely rare ; at
any rate, such must be our conclusion when we reflect upon
the few cases of it that are to be found on record. The
disease is generally limited in its extent, and appears to ter-
minate in one of three ways, — either in the eff"usion of lymph,
in suppuration, or, finally, in passing into the chronic form.
In the first case, the afllected part presents all the characters
of a hepatized lung ; that is to say, it is dense, solid, easily
crushed, and of a dark reddish color. When the lymph is
poured out between the inner surface of the organ and the
corresponding portion of the uterus, the two structures be-
come so intimately incorporated, as to render it frequently
impracticable, when the period arrives for their separation, to
detach them from each other. In this way, there is reason
to believe, usually arises what is called morbid adhesion of
the placenta.

Suppuration of the placenta is extremely rare, and I have
never met with an instance of it. The matter is commonly
confined to one or more cotyledons, and is either diifused
through their substance, or collected into one or more ab-
scesses. In a case recorded by Brachet, not less than fourteen
depots were found, varying in volume between that of a pea
and a nut. The pus was of a thick consistence, without
any particular odor, and looked a good deal like softened
tubercular matter.*

Another lesion which is sometimes observed is softening.
How far this is dependent upon inflammatory irritation is a
point which has not been determined. I have noticed this
condition in quite a number of cases, in several of which it
was associated with the fibro-cartilaginous and osseous de-
generations presently to be described. Occasionally the soft-
ening appears to affect the entire organ ; but, in the majority
of instances, it is confined to particular sections of it, occu-
pying one fourth, one third, or one half of its extent. The
volume of the placenta is seldom altered in this lesion.

The most common disease of the after-birth is the carti-
laginous degeneration. This generally occurs in small, cir-

* Jouraal Generale de Medicine, 1828.

VOL. II. 63

498 PLACENTA. [chap. XIV.

cnmscribed masses, from two to four lines in thickness, of a
whitish milk-like color, and of an irregularly oval shape.
In their consistence, they vary from the softness of fibrous
texture to the density of articular cartilage. In some in-
stances, they are of a pale yellowish color, and partially trans-
formed into osseous matter. In other cases, though this is
not common, the masses are intersected by fibrous bands,
constituting that form of the disease to which the older anat-
omists have applied the term scirrhus. In a third series of
cases, the affected part has a remarkably granular appearance,
being composed of an infinity of small, spherical bodies, of
a reddish buff color, dense and firm in their consistence, and
scarcely exceeding the volume of a millet-seed. This degen-
eration is generally associated with atrophy, and, as might be
supposed, interferes more or less with the nutrition of the
foBtus.

Another rather frequent lesion of the placenta is ossifica-
tion. Of this I have observed several well-marked exam-
ples. The degeneration may occur under two varieties of
form. In one, the more frequent of the two, the ossifica-
tion is confined exclusively to the smaller arterial branches,
which assume an acicular arrangement, hundreds of them
sometimes existing in a space not exceeding half a square
inch. They are of a yellowish color, fragile, and particularly
conspicuous at the uterine surface of the organ. In this way
whole cotyledons are occasionally transformed. This species
of degeneration, which sometimes pervades the entire pla-
centa, is analogous to senile ossification of the arteries. The
larger arterial branches usually remain sound, and the bulk
of the organ is seldom materially diminished.

In the second variety, the foreign matter occurs in the
form of a layer, varying in thickness from the fourth of a
line to a quarter of an inch. In its diameter, it rarely ex-
ceeds a cotyledon, to the inner surface of which it closely
adheres, the deposition commencing apparently in its cellulo-
fibrous envelope. In some instances, these plates are partly
osseous, partly cartilaginous, and partly fibrous, according to
the length of time they have been in progress of forming ;
their number is occasionally considerable ; and, in a few rare
cases, they have been known to constitute a complete shell,
which was accurately moulded to the uterine surface of the
organ. A radiated arrangement is sometimes observable in
these plates, not unlike that of the parietal bone of the foetus,

SECT. VI.] HYPERTROPHY SANGUINEOUS EFFUSIONS. 499

the osseous fibres extending from the centre to the circum-
ference.

Like other organs of the body, whose existence is of a less
temporary nature, the placenta is liable to hyperti^ophy. When
this happens, the weight and bulk of the viscus are consid-
erably augmented, sometimes enormously ; its color is ab-
normally pale ; the parenchymatous structure is infiltrated
with serosity, pits on pressure, and is often uncommonly
firm. This lesion, I presume, is rare ; and further observa-
tions are necessary before we shall be able to furnish a com-
plete history of it.

The placenta, finally, is sometimes the seat of sanguineous
effusions. Several snch cases have occurred in my own prac-
tice, and not a few are recorded by authors. The blood
is poured into the parenchymatous substance of the organ,
near its uterine surface, in the form of irregular masses, vary-
ing in volume between a pea and a walnut. The number of
depots is usually small, though in a ie^ rare instances, every
cotyledon has been affected. The fluid, at first of a dense
modena color, and of a soft consistence, becomes gradually
lighter and more dense, until finally it presents all the proper-
ties of an old apoplectic effusion of the brain. The surround-
ing textures are generally more or less altered, and many of
the vessels are plugged up with fibrin. This lesion is occa-
sionally connected with the fibro-cartilaginous degeneration.

Nearly all the lesions above described are either directly
hostile to the persistence of the placenta, or they interfere, to
a greater or less extent, with the nourishment of the foetus.
In the cartilaginous and osseous transformations, many of the
vessels are either entirely obliterated, or their caliber is so
much diminished as to admit of a very imperfect circulation.
Hence, atrophy of the placenta, and emaciation of the new
being. When the lesions are extensive, abortion is the con-
sequence. Ossification of the placenta occurs occasionally in
several successive pregnancies.

The placenta may adhere to any part of the uterus, but
is usually found at the base. In twin cases, it is either
double, bilobulated, or furnished with two cords. Occasion-
ally it is attached to the head of the infant.*

The umbilical cord presents some anomalies worthy of
brief notice. It is occasionally double, and cases are recorded

* Nouv. Bibliotheque, Med. 1830.

600 PLACENTA. [chap. XIV.

where it was inserted into the head, chest, and extremities.
The length of the cord at birth is generally about twenty
inches ; but it may be much longer. In one instance I
found it four feet and a half, and in another, mentioned to me
by Dr. Catlin, of Massachusetts, it was nearly six feet. Its
veins are sometimes varicose ; it is occasionally twisted,
knotted, or tuberculated ; and, in a few rare instances, it has
presented black nodosities, or been partially filled with hydat-
ids. Blandin, Velpeau, and others, narrate cases .where there
was but one artery and two veins, instead of two arteries and
one vein.

INDEX.

A.

Abernethy on nature of tubercle, i. 181.

Abscess, i. 71 ; of brain, 446; of liver,
ii. 316; of gums, 181.

Absorption, how influenced by inflam-
mation, i. 37.

Acephalocyst, i. 135; mode of repro-
duction, 136 ; solitary and social, 137;
of the brain, 467.

Acne, i. 381.

Adipous diathesis, i. 243.

Adipous transformations ; causes, i. 128;
artificial ; in old people, 129 ; effect of
inflammation, 130.

Adipous tissue, i. 239; composition, 241
■wounds, and inflammation of, 242
hypertrophy, 243; adipous tumors
cases, 244 ; adipous tumor of brain,
467.

Adenoid tumor, i. 468.

Albinism, i. 407.

Amaurosis, i. 560.

Ammoniaco-magnesian calculus, ii. 388.

Analogous tissues, i. 65.

Anasarca, i. 54.

Andral on nature of tubercle, i. 162;
on diseases of the blood, 221.

Aneurism, i. 282 ; sacculated, 283 ; cyl-
indroid, 284 ; varicose, 285 ; anasto-
motic, 285 ; arterio-venous, 286 ; con-
tents of aneurisms, 288 ; diagnosis,289.

Anteversion of uterus, ii. 434.

Anthracion, i. 371.

Anus, prolapsion of, il. 285.

Aponeurosis, inflammation of, i. 267.

Apoplexy in hydatid, i. 142 ; of mus-
cles, 262; cerebral, 457 ; meningeal,
460; hereditary, 462.

Aqueous humor, i. 501.

Aquo-capsulitis, i. 501.

Arachnitis, symptoms and course of, i.
433 ; tubercular, 437 ; stages, 438.

Arteries, structure of, i. 271 ; valves
and nerves, 273 ; wounds of, 274 ; ar-
teritis; suppuration, ulceration, 278 ;
tubercles, 279 ; atheromatous deposit ;

cartilage, 280 ; calcareous matter, 281 ;
hypertrophy; contraction, 289.

Areolar tissue of bones, i. 344.

Ascites, ii. 304.

Atrophy, general or partial, i. 116;
causes; senile atrophy, 117; of mus-
cles, 260 ; tendons, 266 ; bones, 344 ;
hair, 415 ; brain, 469 ; spinal cord,
472; nerves, 482; thyroKd body, ii.
18 ; lungs, 69 ; heart. 142 ; salivary
glands, 169 ; stomach, '241 ; liver, 323 ;
spleen, 353 ; kidney, 378 ; testis, 408 ;
mamma, 493.

Auditory nerve, i. 518.

B.

Barron on the nature of tubercles, i. 160.

Beard of females, i. 416.

Bile-ducts, lesions of, ii. 338.

Bile, ii. 339 ; gaU-stones, 340.

Biliary apparatus, ii. 307.

Blood, quantity and quality, how altered,
i. 19; physical characters; quantity of,
197 : specific gravity ; analysis, 198 ;
component parts, 199 ; importance,
201 ; lesions, 202 ; want of coagula-
bility from effects of lightning, dis-
ease, &c. 209 ; hemorrhagic diathesis,
210; causes; influence of nerves, 211;
buffy coat, quantity of fibrin, 212;
effects of ligature on the par vagum,
212 and 215 ; hematosine, 213 ; its
relative quantity in males and fe-
males, 214; in cholera, typhus, and
plague, 214 ; serum, 216 ; milky se-
rum, 217 ; general diseases of blood,
221 ; contaminated blood, effects of,
221; increased circulation, effects of;
blood in cholera, fever, 224 ; yellow
fever, chlorosis, jaundice, 225 ; scur-
vy, 226.

Bones, organization of, i. 324 ; compo-
sition, 326 ; forms, 327; texture, 328;
restorative process in, 330 ; fractures,
331 ; false joints ; osteitis, 332 ; suppu-
ration, 333; caries, 334; necrosis, 335 ;

/

502

INDEX.

exfoliation, 336 ; sequestrum, 337 ; re-
generation, 338; softening, 339; fra-
gility, 340 ; hypertrophy, 341 ; exos-
tosis, 342 ; atrophy, 344 ; osteo-san-
guineous disease, 345 ; cartilaginous
tumors, 346; osteo-sarcoma, encepha-
loi'd, 347 ; melanosis, tubercles, 348.

Bowel, large and small, see large and
small bowel.

Brain, envelopes of, i. 419 ; cephalo-
spinal fluid, 421 ; white substance,
422; granular substance, 423; con-
sistence, 424; color, 425; sensibility,
vessels, 426 ; no absorbents, compres-
sibility, opinions of Kellie, Abercrora-

■ bie, and others, 427 ; weight and form,
430; wounds of, 441; inflammation,
442; yellow and red softening, 443 ;
stages and progress, 444 ; abscess, 446 ;

• gangrene, 448 ; softening, its progress
and termination, 449 ; chronic inflam-
mation, 454 ; ulceration, 456 ; apo-
plexy, 457; hereditary, 462; tuber-
cles, 463 ; melanosis, encephaloTd,
464; cartilaginous and calcareous
deposit, 465 ; cysts, 466 ; acephalo-
cyst, adipons tumor, 467; adenoid
tumor, hypertrophy, 468 ; atrophy, 469.

Breast, female, structure of, ii. 486;
nipple, 488 ; inflammation, acute and
chronic, 489 ; scirrhus, 490 ; enceph-
alol'd and hydatids, 491 ; tubercles,
hypertrophy, 492; atrophy, calcare-
ous concretions, 493 ; melanosis, neu-
ralgia, 494; apoplexy, lactiferous
ducts, 495.

Bronchiae, dilatation of, ii. 29 ; obliter-
ation, 31.

Bronchitis, ii. 27.

Bronchocele, ii. 15.

Bronchophony, ii. 49.

Bullar diseases, i. 392.

Burses, synovial ; inflammation, i. 268 ;
hydatids, hypertrophy, 269.

C.

Calcareous matter in arteries, i. 281;
in brain, 465.

Calculi, urinary, ii. 385 ; pancreatic, 363.

Canaliculated texture of bones, i. 329.

Capillaries, structure, i. 38 ; two kinds ;
not equally abundant in all parts, 40 ;
condition in inflammation, 43.

Carcinoma of the uterus, ii. 447; of
nerves, 481 ; stomach, 243.

Carditis, acute, ii. 133.

Cartilaginous transformations, i. 124.

Cartilages, articular, i. 312 ; loose car-
tilages of joints, 320.

Caries of bones, i. 334; of teeth, ii. 174.

Cataract, i. 505.

Caverns, tubercular, i. 168.

Cellular texture, i. 228 ; ossification , 127
organization, 229 ; sensibility, 230
lesions, 231 ; acute inflammation, 232
gangrene, chronic inflammation, 233
induration, 234; infiltration, hemor-
rhage in, 236.

Cellular transformations, i. 122.

Cephalo-spinal fluid, i. 421.

Chalk-stones, i. 321.

Charbon, i. 371.

Chaussier, case of tubercles in foetus,
i. 153.

Chlorosis, blood in, i. 225.

Cholera, saline injections in, i. 215.

Choroid coat, i. 498.

Chordee, ii. 416.

Cicatrice, i. 104.

Cicatrization, stages of, i. 103.

Cirrhosis, ii. 324.

Congestion, causes of, i. 45.

Coagulability of blood, want of, i. 209.

Conjunctiva, i. 489; suppuration, 490;
pustules, granulations, 491.

Conjunctivitis, i. 489.

Contaminated blood, effects of, i. 221.

Contractility of muscles, i. 252.

Contraction of arteries, i. 289.

Cornea, i. 492 ; corneitis, 493 ; suppu-
ration, 494; ulceration, cicatrization,
opacity, ossification, 495; fleshy ex-
crescences, 496.

Cooper, Sir Astley, estimate of the
amount of blood in arteries and veins,
i. 198; experiments on the pneumo-
gastric nerve, i. 211 and 215.

Corpora lutea, ii. 473.

Crassamentum of the blood, i. 200.

Crude tubercle, i. 158.

Crusta lactea, i. 385.

Cruveilhier, experiments on hydatids,
i. 140.

Crystalline lens, capsule of, i. 504 ; situ-
ation and structure, 506; cataract, 507.

Cupped blood, i. 208.'

Cutaneous and mucous tissue, their
mutual transformations, i. 123.

Cutaneous system, i. 355 ; (see skin.)

Cuticle, i. 356.

CylindroTd aneurism, i. 284.

Cysts, simple, i. 144 ; multilocular, 145;
included, 146 ; inflammation of, 147 ;
of brain, 446.

Cysticercus, organization and situations
of, i. 132; five species of ; cellular,
vesicular, dycystic, speckled, 133;
Fischerian, 134.

D.

Diabetes insipidus, ii. 392 ; mellitus, 395.
Demours, membrane of, i. 500.

INDEX,

503

Dermis, i. 359.

Diceras, i. 134.

Diffuse inflammation, i. 232.

Discoloration after death, i. 47.

Disease, wlrat ; functional or organic,
i. 23; result of inflammation, 24;
modified by age, sex, climate, 25.

Dot-like melanosis, i. 172.

Dropsy, i. 54.

Du Hamel, case of malignant pustule,
i. 222.

Dupuy on nature of tubercles, i. 161 ;
experiments on the pneumogastric
nerve, 212 ; on transfusion, 222.

Duodenum, inflammation and ulcera-
tion of, ii. 346 ; perforations, 248 ;
rupture, carcinoma, 250.

Dura mater, inflammation of, i. 431 ;
suppuration, fibrous tumors, ossifica-
tion, 432; Pacchioni's glands,. 433.

E.

Ear, L 512; polypes, 513; tympanum,
514 ; Eustachian tube, labyrinth, 517 ;
vestibule, auditory nerve, 518.

Echinococcus, i. 134.

Ecthyma, i. 383.

Eczema, i. 394.

Edson, Calvin, living skeleton, i. 245.

Eilol'des, i. 365.

Elephantiasis, i. 398.

Emphysema, of cellular texture, i. 237 ;
lungs, ii. 58 ; vesicular, 59 ; interlob-
ular, 60.

Emetics, causes of gangrene, i. 93.

Encephalo'id, i. 185 ; seat and forms,
186 ; color and consistence, 188 ; or-
ganization, 189 ; origin ; a disease of
early life, 190 ; progress and termina-
tion, 191 ; in the muscles, 259 ; lym-
phatic glands, 308 ; brain, 464 ; bones
347 ; skin, 364 ; nerves, 475 ; eye, 509
lungs, ii. 64 ; pleura, 109 ; heart, 141
peritonssura, 306; liver, 328; kidney,
373; bladder, 384; testicle, 406; ute-
rus, 448; mamma, 491.

Encysted tubercle, i. 156-

Encephalitis, i. 442.

Endocardium, ii. 128.-

Endocarditis, symptoms and characters,
ii. 150; effects, 151; diagnosis, 154.

Ephelis, i. 407.

Epidermis, i. 356.

Epispadias, ii. 419.

Epulis, i. 170.

Ergot a cause of gangrene, i. 91.

Erysipelas, i. 380.

Erythema, i. 378.

Exanthems, i. 377.

Excavations, tubercular, i, 167.

Exfoliation, i. 336.

Exostosis, i. 342.

Eye, i. 485; ball of, 488; conjunctiva,
ocular fascia, conjunctivitis, 489
suppuration of conjunctiva, 490; pus
tules. granulations, 491; cornea, 492^
corneitis, 493; sclerotica, 497; cho-
roid, 498; retina, 499; optic nerve,

500 ; aquo-capsulitis, aqueous humor

501 ; filaria papillosa, iiis, 502 ; iritis
503 ; capsular cataract, 505 ; lens
506; lenticular cataract, 507; vitre-
ous humor, 508; encephalo'id, 509
melanosis, 510.

Fallopian tubes ; inflammation, ii. 480;
watery fluids in, 481.

Fatty discharges from bowels, ii. 267.

Fibrinous calculus, ii. 389.

Fibrin, chemical composition, disposi-
tion to become organized, i. 61 ; mode
of organization, 62; tissues resulting
from it, 65; its importance in pro-
ducing union, 66; want of coagula-
bility, 209 ; quantity of in health and
disease, 212.

Fibrous transformations, i. 124.

Fibrous variety of scirrhus, i. 178.

Filaria Mediiiensis, i. 237; papillosa,
502.

Fistula in anus, ii. 287.

Fluids and solids, i. 19, 20.

Fluke in liver, ii. 333.

Follicular enteritis, ii. 219.

Foy, analysis of melanosis, i. 170.

Fractures, mode of union, i. 331.

Fragility of bones, i. 340.

FrambcEsia, i. 398.

Frontal sinus, ii. 162.

Fusible calculus, ii, 388.

G.

Gall-bladder, inflammation of,- ii. 336;
atrophy, 337; ducts, lesions of, 338;
bile, 339.

Gall-stones, ii. 340 ; symptoms, 341.

Ganglia, nervous, i. 476 ; lesions, 482.

Ganglions, lymphatic, i. 305.

Ganglion of tendons, i. 266.

Gangrene, i. 87 ; characters and seat,
89 ; causes, 90 ; senile gangrene, 95 ;
cellular tissue, 233 ; bones, 335; skin,
370 ; brain, 448 ; nerves, 481 ; lungs,
ii. 53 ; heart, 136 ; teeth, 174 ; gastro-
enteric mucous membrane, 221 ; liv-
er, 319 ; spleen, 349 ; rare in the kid-
ne3^s, 370 ; also in bladder, 382.

Gastro-enteric mucous membrane, its
organization, ii. 191; glands, crypts
and follicles, 195; glands of Brun

504

INDEX.

ner, 195 ; glands of Peyer, 197 ; vil-
losities, 198 ; color, 199 ; color in fe-
tus, and during digestion, 20O; color
influenced by the kind of death, 201 ;
acute inflammation, 203 ; redness,
205 ; arborescent and capilliform in-
jection, 206; speckled appearance,
207 ; vascularity, 209 ; transparency,
210; dryness, thickness, softening,
211 ; vesicular eruption, 212; lymphy
exudations, 213 ; suppuration and
eifusion 'of blood, 215 ; rice-water se-
cretion, 216; absorbing power of,
217 ; follicular enteritis, 219 ; gan-
grene, 221 ; chronic inflammation,
223; its characters, 22^1; softening,
stages of, 227 ; color of, do. 228 ; symp-
toms, 229 ; softening after death, 230.

Gelatinoid scirrhus, i. 178.

Gendrin, experiments on transfusion, i.
221.

Generation, organs of in male, ii. 401 ;
in female, 426.

Gibson, Dr. remarkable case of fragili-
ty of bones, i. 341.

Glands, lymphatic, i. 305 ; of Brunner,
ii. 196; of Peyer, 197.

Gleet, ii. 416.

Globules of blood, i. 200.

Glossitis, ii. 164.

Goitre, ii. 15.

Goose skin, i. 360.

Granulations, i. 100 ; structure and sen-
sibility; absorb and secrete; their
importance, 102.

Granulated kidney, ii. 371.

Granulated liver, ii. 324.

Gubernaculum testis, transformation of,
i. 122.

Guinea worm, i. 237.

Gums ; epulis, ii. 179 ; abscess, 181.

H.

Hair, organization of, i. 412; Polish
plait, 414 ; atrophy, 415; hypertrophy,
416 ; other lesions, 417.

Heat of inflammation, experiments on,
by Hunter, Home, and Huber. i. 31.

Heart, situation, shape, and structure,
ii. 122; dimensions, 124; capacity,
126; endocardium, 128; malforma-
tions, 130 ; carditis, 133 ; suppuration
and ulceration, 135; gangrene, 136;
softening, 138; induration, 139; osse-
ous transformations, 140; scirrhus,
encephalo'fd, 141; fatty transforma-
tion, atrophy, 142; passive aneurism,
143; rupture, 145; tubercles, mela-
nosis, hypertrophy, 146.

Hecht on the composition of tubercles,
i. 154.

Hematosine, relative quantity in males
and females, i. 213 ; is slowly repro-
duced when removed, 214 ; its condi-
tion in cholera, typhus, and plague,
214 ; effects of dividing the pneumo-
gastric nerve on, 215.

Hemorrhage, causes of, i. 76; most
frequent seat, 79 ; different kinds of,
82; quantity, 83; remarkable case of,
following extraction of a tooth, 210;
hereditary cases, 210; how arrested
by nature, 275; from the skin, 375.

Hemorrhagic diathesis, i. 210; causes,
211.

Hgemophthalmus, i. 502.

Hemorrhoids, two varieties of, ii. 284.

Hemoptysis, ii. 97.

Henry, Dr. on the composition of me-
lanosis, i. 170.

Hepatitis, ii. 312.

Hernia, varieties of, ii. 26L

Herpes, i. 397.

Heterologous formations; classification,
i. 148; duration and origin, 149.

Hodgkin, Dr. on tubercle, i. 181.

Horny excrescences, i. 368.

Hughes, Dr. cases of hereditary predis-
position to hemorrhage, i. 210.

Hunter, John, experiments on heat, i.
31 ; on softening of the stomach after
death, ii. 230.

Hydatids, seat of; met with in nearly
all animals, i. 131 ; organization and
classification, 132; origin, 138; how
nourished, 140; mode of termination,
141; apoplexy of, 142; in muscles,
261; bursse, 269; bones,, 345; brain,
467; lungs, ii. 66; liver, 329; spleen,
354; kidne}^, 376; testicle, 407 ; ute-
rus, 453.

Hypertrophy, causes, i. 110; general or
local, 112'; color, weight, and volume,
114; its nature, 115; h}^pertrophy of
the adipous tissue, 243; muscles, 260;
arteries, 289 ; Ivmphatics, 307 ; bones,
341; skin, 366; nails, 410; hairs,
416; brain, 468; spinal cord, 471;
nerves, 481 ; thymus gland, ii. 11 ;
thyroid gland, 15; lungs, 68; heart,
146; tongue, 165; salivary glands,
169; tonsils, 183; stomach, 239;
small bowels, 264; liver, 322; spleen*
352; kidney, 378; bladder, 382; pros-
tate, 398; testis, 408; clitoris and
nympha3, 485 ; mamma, 492.

Hypospadias, ii. 419.

I.

Ichthyosis, i. 401.

Impetigo, i. 383.

Induration, i. 106; color and degrees of

INDEX,

505

induration, 107; period necessary for
its production, 108; causes, 109; termi-
nation and results, 110; of cellular tis«
sue, 234 ; muscles, 256 ; brain, 455 ; spi-
nal cord, 471 ; heart, ii. 139 ; liver, 321;
spleen, 351 ; kidney, 372 ; uterus, 438.

Infiltration, tubercular, i. 157.

Inflammation, originally local ; modi-
iied by age, sex, climate, i. 24 • acute
and chronic; its frequency in differ-
ent organs variable, 26 ; common and
specific, 27; its nature and symptoms,
28—37 ; its seat, 38 ; agency of the
vascular and nervous systems, 41 ;
condition of the capillaries 43 • ex-
periments of Kaltenbrunner, 44 ; the-
ories of Boerhaave, CuUen, and
others,. 50 :• terminations of inflamma-
tion, 51; buffy coat of blood in, 209 ;
cellular texture, 232 ; adipous tissue,
242; muscles, 254; tendons, 265;
aponeuroses, 267; bursse, 26S; arte-
ries, 276; veins, 293; lymphatics,
303 ; lymphatic glands, 305 ; joints,
314; synovial membrane, 318; liga-
ments, 323; bones, 332; periosteum,
350 ; dura mater, 431 ; arachnoid,
433; pia mater, 439; brain, 442;
nerves, 479 ; lacrymal gland, 486 ;
conjunctiva, 489 ; cornea, 493 ; scle-
rotica, 497; choroid, 499; retina,
500 ; iris, 503 ; tympanum, 515 ; thy-
roid gland, ii. 14 ; larynx, 20 ; trachea,
26 ; bronchiee, 27 ; lungs, 45 ; pleura,
102; pericardium, 115; heart, 133 ; en-
docardium, 150; nasal cavity, 157;
maxillary sinus, 160; frontal sinus,
162; tongue, 165; salivary glands,
168; teeth, 175; tonsils, 182; pharynx,
185 ; oesophagus, 186 ; gastro-enteric
mucous membrane, 203 ; duodenum,
245; vermiform appendage, 275 ; per-
itonaeum, 295 ; liver, 123 ; gall-blad-
der, 336; spleen, 347; pancreas, 358;
kidney, 369; bladder, 381; prostate,
397 ; testicle, 404 ; seminal vesicles,
411; penis, 415; uterus, 435; ovary,
466 ; Fallopian tubes, 480 ; vagina
and vulva, 483 ; mamma, 489 ; pla-
centa, 497.

Intestinal worms ; lumbricus, ii. 288 ;
trichocephaloid, 290 ; tape-worm, 291;
symptoms, 293.

Intussusception, ii. 259.

Inversion of uterus, ii. 434.

Iris, i. 502 ; inflammation of, .503 ; pro-
lapsion of; pupil, alterations of, 504.

Itch; itch insect, i. 397.

Jackson, James, Jr. Dr. on expiration
as an early sign of phthisis, ii. 94.

VOL. II. 64

Jackson, J. B. S. Dr. case of fatty dis-
charges from the bowels, ii. 267 ; on
ulceration of vermiform appendage,
275.

Jaundice, state of blood in, i. 225.

Joints, structure of, i. 311 ; inflamma-
tion, softening, suppuration of syno-
vial meinbrane, 314 ; ulceration, 315 ;
ossification, 316.

K.

Keloides, i. 363.

Kentucky giant, i. 243.

Kidneys, structure and organization,
ii. 365 ; acute inflammation of, 369 ;
chronic inflammation of, 371 ; indu-
ration, scirrhus, 372; encephaloid,
.373; tubercles, 374; serous cysts,
375; hydatids, 376; ossification "and
fatty degeneration, 377 ; hypertrophy,
concretions, 378 ; sirongyli, 379.

Labyrinth of the ear,, i. 517.

Lacrymal apparatus, i. 485; gland, in-
flammation of, 486; scirrhus, serous
cysts of, 487 ; excretory ducts, dila-
tion of, 487; inflammation of, 488;
lacrymal sac, 488.

Lamellated transformation, i. 126 ; tuber-
cular deposit, 157 ; melanosis, 172.

Lambert, Daniel; h3rpertrophy of adi-
pous tissue, i. 243.

Lardaceous tissue, i. 176.

Large bowel, ulceration of, ii. 272; cic-
atrization; vermiform appendage, dis-
eases of, 273 ; hypertrophy of coats of
the colon, 276; excrescences, 277;
general disease of mucous membrane,
279; carcinoma, 2^1; organic stric-
ture of the rectum, 282; spasmodic
stricture, 283; hemorrhoids, 284; pro-
lapsion of anus, 285 ; fistula, malfor-
mations, 287.

Larynx, inflammation, ii, 20; oedema of
glottis, 21 ; ulceration of lar3mx, 23;
osseous transformations, 24 ; polypes,
25.

Lecanu, analysis of the blood, i. 198.

Lens, crystalline, i. 504.

Lenticular cataract, i. 507.

Lentigo, i. 407.

Lepoides, i. 365.

Lepra, i. 400.

Lichen, i. 371.

Ligaments, organization, mode of repa-
ration, i. 322; inflammation, 323;
atrophy, 323 ; calcareous concretions,
323.

Lips, encysted tumor of; hare lip, ii.
163.

506

INDEX.

Liver, structure, and organization of, ii.
307; situation, 311; inflammation,
312 ; anatomical characters of, 313 ;
s3anptonis of, 315 ; suppuration, 316;
gangrene, softening, 319 ; induration,
331 ; hypertrophy, 322 ; atrophy, 323 ;
granulated, 324; nutmeg liver; tuber-
cles, 325 ; scirrhus, 327 ; encephaloid,
gelatiniform sarcoma, 323; melano-
sis, hydatids, 329 ; serous cysts, 330 ;
fatty liver, 331 ; parasites, 333 ; osse-
ous and cartilaginous deposits, 334;
rupture, 335.

Lombard, Dr. on relative frequency of
tubercles in different organs of young
subjects, i. 152.

Louis on site of tubercle in adults, i.
152.

Lumbricoid worm, ii. 288.

Lungs, structure and organization, ii.
34 ; lymphatics of, 40 ; nerves, 41 ;
respiratory sounds, 43 ; bronchial
respiration, 44 ; acute inflamntiation,
stages of, 45 ; symptoms of inflamma-
tion, 48 ; terminations, 51 ; chronic
inflammation, 56 ; emphysema, 58 ;
apoplexy, 62 ; encephaloid, 64 ; me-
lanosis, 65 ; serous cysts, 6G ; calca-
reous concretions, 67 ; atrophy, 69 ;
tubercles, 70 ; varieties of tubercular
deposit, 71 ; cicatrization of tubercu-
lar cavities, 77 ; hemoptysis, 97.

Lupus, i. 399.

Luteal bodies of the ovaries, ii. 473.

Lymph uniformly the result of inflam-
mation, i. 59 j forms of, 60 ; chemical
composition, 61 ; organization of, 62 ;
tissues resulting from it ; analogous
tissues, 65 ; importance in the union
of divided parts, 66.

Lymphization, i. 59.

Lymphatics, structure of, i. 301 ; in-
flammation, 302 ; suppuration, tuber-
cles, ossification, dilatation, 303 ;
aneurism, 304; obliteration of tho-
racic duct, 305.

Lymphatic glands, i. 305 ; inflamma-
tion, suppuration, 306 ; gangrene,
hypertrophy, scirrhus, 307 ; encepha-
loid, 308 ; tubercles, 309 ; ossification,
310; melanosis, 311.

M.

Male organs of generation, ii. 401.

Malignant pustule, i. 371.

Mammary gland, structure of, ii. 486 ;
nipple, 488 ; inflammation, suppura-
tion, 489 ; .'^cirrhus, 490 ; encepha-
lo(d, hydatid, 491 ; tubercles, hyper-
trophy, 492 ; atrophy, calcareous con-
cretions, 493; melanosis, neuralgia,

494 ; apoplexy, obstruction of ducts,
495.

Mammary sarcoma, i. 178.

Maxillary sinus, ii. 160; carcinoma,
exostosis, 161.

Medullary membrane of bones, i. 353 ;
inflammation of, 354.

Melanosis, i. 168; found in man and
lower animals ; chemical analysis of,
170; color and forms, 171; most
common seal, 173; causes, 174; mus-
cles, 259 ; lymphatics, 310 ; perios-
teum, 352; skin, 364; brain, 464;
eye, 560 ; lungs, ii. 65 ; heart, 146 ;
small bowels, 258 ; peritonseum, 304 ;
liver, 329.

Meningeal apoplexy, i. 457.

Meyer, experimenis on the pneumo-
gastric nerve, i. 211.

Miliaria, i. 395.

Miliary tubercle, i. 155.

Milky serum, case of, i. 216 ; characters,
217.

Moles, ii. 458.

Mucous membrane gastro-enteric, see
gastro-enteric mucous membrane.

Mucous transformations, i. 124.

Mucific apparatus of skin, i. 357.

Mucous web of skin, i. 358.

Multilocular cyst; most frequent in
the brain ; is found in the ovaries, i.
145.

Mumps, ii. 168.

Muscular system ; muscles of volition,
i. 247 ; involuntary and respiratory
do. ; structure of muscles, 248 ; mus-
cular fibres, 249 ; vessels and nerves,
250 ; color, 251 ; chemical composi-
tion, contractility, 252; sensibility,
mode of union, 253 ; acute inflamma-
tion, 254 ; suppuration, gangrene,
chronic inflammation, ulceration,
255 ; induration, 256 ; ossification,
257 ; fatty degeneration, 258 ; tuber-
cles, melanosis, scirrhus, encephaloTd,
259.

N.

Nsevus, i. 285.

Nails, i. 409 ; hypertrophy, 410 ; onyxi-
tis, 411.

Nasal sinus, ii. 156 ; inflammation, 157 ;
ozoena, epistaxis, polypes, 158.

Necrosis, i. 335.

Nephritis, ii. 369.

Nerves, two kinds of, i. 474 ; eneepha-
lo-spinal nerves, 475; ganglia and
plexus, 476 ; structure of nerves, 477 ;
neuritis, 479 ; suppuration, 480 ; ul-
ceration, gangrene, carcinoma, hy-
pertrophy, 481 ; atrophy, tumors, 482 ;
enlargement of ganglia, 483.

INDEX.

507

Nervous system, i. 419, influence of, on
the blood, 211.

Neuritis, i. 479.

Nigritism, i. 408.

Noack, ideas of melanosis, i. 174.

Nutrition, how affected by inflamma-
tion, i. 37.

O.

Obesity, i. 245.

Ocular fascia, i. 489.

(Edema, i. 54 ; of cellular texture, 236.

CEsophagus, inflammation of, ii. 186;
ulceration, 187; abscess, softening,
stricture of, 188 ; malformations, 189.

Oil, in serum, i. 217.

Onyxitis, i. 411.

Optic nerves, diseases of, i. 500.

Organs of generation in male, ii. 401 ;
female, 426.

Osseous transformations, i. 125 ; three
varieties of; of the dura mater, 126;
most common seat and mode of for-
mation, 127.

Osseous system, i. 324 ; (Fee bones .)

Ossification, is it always preceded by
cartilage"? i. 128; of muscles, 257;
tendons, 266 ; hnnphatics, 303 ; lym-
phatic glands, 3l0; cartilages of joints,
315; dura mater, 432; of the laryn-
geal cartilages, ii. 24 ; tracheal rings,
27; pleura, 107; heart, 140; endocar-
dium, 153; gall-bladder, 338 ; spleen,
354; kidney, 377; uterus, 446; pla-
centa, 498.

Osteitis, i. 332.

Osteo-sanguineous disease, i. 345.

Osteo-sarcoma, i. 347.

Ovaries, situation and structure, ii.464 ;
ovarian vesicles, 465; inflammation
and suppuration, 466 ; softening, tu-
bercles, melanosis scirrhus, 467 ; en-
cephalol'd, fibrous tumor, 468; serous
cysts, 469 ; hydatids, malformations,
470; atrophy and hemorrhage, 472;
luteal bodies, 473 ; their structure and
mode of formation, 474.

Owen, Prof, experiments on hydatids, i.
140.

Oxalic acid calculus, ii. 387.

Palate, soft ; polypes, split palate, uvula,
hypertrophy of uvula, ii. 184.

Pancreatic sarcoma, i. 174.

Pancreas organization, weight and
dimensions, ii. 357 ; diseases of, 359 ;
softening, gangrene, chronic inflam-
mation, scirrhus, 360; fatty degenera-
tion ; serous cysts, 361 ; tubercles,
atrophy, 362; calculi, 363.

Papillae of skin, i. 3G0 ; of tongue, their
diseases, ii. 167.

Papular diseases of skin, i. 391.

Paraphymosis, ii. 425.

Parotid, inflammation of, ii. 168.

Pellagra, i. 403.

Pemphigus, i. 392.

Penis, acute inflammation of urethra,
ii. 415; chronic do. 416; gleet, chor-
dee, 416; stricture of urethra, 417;
malformations of urethra, 419 ; pec-
tiniform septurn; carcinoma, 420;
chancres, 421 ; herpetic and psoriasic
ulcers, 424 ; phymosis and paraphy-
mosis, 425.

Pericarditis, ii. 115; hydro-pericardium,,
symptoms of, 119; air in; serous
cysts in, 121.

Pericardium, ii. 115.

Periosteum, organization of, i. 349 ; in-
flammation of, 351 ; ossilication me-
lanosis, 352.

Periostitis, i. 351.

Peritonseum, acute inflammation of, ii.
294; adhesions, 295; pus in cavity
of, 296; symptoms of inflammation,
298; gangrene, chronic inflammation,
299; false membranes; fistulous
openings, 300 ; tubercles, 302; ascites,
304; melanosis, 305; scirrhus and
encephaloid, 306.

Peyer's glands, ii. 197.

Phagedenic ulcer of uterus, ii. 449.

Pharynx, inflammation of, ii. 185 ;
sacculated, 186.

Phlebolites, i. 297.

Phlegmonous inflammation, i. 232;
erysipelas, 381.

Phosphatic calculus, ii. 388.

Phthisis, ii. 70 ; miliary tubercle, 71 ;
gray granulations, 72 ; stra,tiform, 73 ;
caverns and excavations, 74 ; cicatri-
zation, 77 ; sex, influence of, 80; age,
81 ; duration of phthisis, 82 ; occupa-
tion and dress as exciting causes, is it
contagious 1 83 ; disease of pleura in
phthisis, 85 ; of air-passages, 86 ;
spleen and liver, 87; 'stomach and
intestines, 89; anal fistula a frequent
attendant on phthisis, 90 ; disease of
lymphatics, brain, 91 ; nature of
phthisis, 92 ; hemoptysis, pain, 97 ;
latent phthisis, 98.

Phymosis, ii. 425.

Pituitary gland, lesions of, i. 445.

Pityriasis, i. 401.

Pia mater, inflammation of, tubercles,
ossification, 439; cysts in, 440.

Piles, two varieties of, ii. 284.

Placenta, structure and diseases of, ii.
496 ; inflammation, softening, suppu-
ration, cartilaginous degeneration,

508

INDEX.

497; ossification, 498; hypertrophy
and sanguineous efTusions, 499.

Pleura, ii. 99 ; organization, 100 ; acute
inflammation of, 102 ; gangrene, 105 ;
concretions, 107; formation of gas ;
ulceration ; ossification, 108 ; tuber-
cles, 109; chronic inflammation, 111;
physical signs of pleurisy, 112.

Pleurisy, ii. 102; (see pleura.)

Plica polonica, i. 414.

Poisons, acrid, effects of on the gastro-
enteric raucous membrane, ii. 207.

Plexus, nervous, i. 476.

Pneumonia, acute, ii. 45 ; stages of, 46;
symptoms, 48 ; terminations, 51 .; gan-
grene, resulting from, 55; chronic
pneumonia, 56.

Polycephalus, characters and situation
of, i. 134.

Polypes of the ear, i. 513 ; larynx, ii.
25; nasal cavity, 158; maxillary
sinus, 161 ; pharynx, 186; uterus, 443;
vagina, 483.

Porrigo, i. 384.

Prolapsion of anus, ii. 285 ; uterus, 434.

Prostate gland, acute inflammation of,
ii. 397 ; ulcerations chronic inflam-
mation, scirrhus, 398; dilatation, tu-
bercles, 399 ; calculi of, 400.

Prurigo, i. 391.

Psoriasis, i. 402.

Pterygium, i. 492.

Pupil, lesions of, i. 504.

Pulmonary apoplexy, ii. 62.

Pus, healthy, scrofulous, sanious, i. 72 ;
characters and mode of production,
73.

Pustular diseases of skin, i. 381 ; (see
skin.)

Pustule, malignant, i. 371.

R.

Redness as a symptom of inflammation,

i. 30.
Regeneration of bones, 330.
Rectum, organic stricture of, ii. 282;

spasmodic stricture, 283.
Red particles of blood, theirphysical and

physiological characters, i. 200 — 206.
Respiratory apparatus, ii. 20.
Retina, i. 499.

Retroversion of the uterus, ii. 434.
Rives, tubercles in an infant, case of, i.

153.
Roseola, i. 377.
Rubeola, i. 379.
Rupia, i. 393.

S.

Saline injections in cholera, i. 215.
Salivary glands, inflammation of, ii.

168 ; suppuration, gangrene, atrophy,
hypertrophy, 169 ; scirrhus, fatty de-
gen eration, salivary calculi, 170.

Salts of blood, abstraction of, i. 215.

Sanguineous liquor, i. 203.

Scabies, i. 396,

Scaly diseases of skin, i. 400.

Scarlatina, i. 379.

Scirrhus, i. 175; varieties of; tuberoid,
stratiform, 176; mammary pancre-
atic, lardaceous, gelatinoid, fibrous;
chemical composition, 178; influence
of age and sex, 179 ; most common
situation, 179; causes, 180; charac-
ters, 184 ; muscles, 259 ; lacrymal
gland, 485; thymus gland, ii. 12;
thyroid gland, 19 ; heart, 141 ; paro-
tid, 170; oesophagus, 189; pylorus,
244; peritonaeum, 306; liver, 327;
kidney, 372; prostate gland, 398;
testicle, 406 ; womb, 447; ovary, 467;
breast, 490.

Sclerotica, diseases of, i. 497.

Scrotum; cancer of, ii. 412; sarcoma-
tous enlargement, sloughing, 413 ;
concretions in, 414.

Scudamore on hlood in inflammation,
i. 212.

Scurvy, i. 226.

Sebaceous follicles, i. 361 ; diseases of,
373.

Seminal vesicles, diseases of, ii. 411.

Sequestrum, i. 337.

Serosine, i. 200.

Serous cysts, i. 142 ; seat and structure,
143 ; multilocular, 145 ; included
cysts, 146 ; in brain, 466 ; lacrymal
gland, 487; lungs, ii. 66; pericardi-
um, 121 ; spleen, 355 ; pancreas, 361.
kidney, 376 ; ovary, 469.

Serum effusion, i. 52; color, consistence,
and chemical composition, 54 ; causes,
56 ; serum of the blood, 199 ; milky
serum, 216 ; causes of, 217 ; serum in
inflammation and other diseases, 218.

Sheaths of tendons, i. 264.

Sims, Dr. on cure of cerebral .moUes-
cence, i. 454.

Skin, i. 355; cuticle, 356; mucific ap-
paratus, 357 ; mucous web, 358 ; der-
mis, 359; papillae, 360; sudorific
glands, sebaceous follicles, 361 ; re-
production of; unclassifiable lesions
of, 363 ; melanosis, 364 ; encephaloTd;
cartilaginous tumors, 364 ; eilo'ides,
lepoTdes, 365 ; hypertrophy, 366 ;
corns, 367 ; verruca, horns, 368 ;
gangrene, 370 ; malignant pustule,
371 ; white gangrene ; sebaceous folli-
cles, diseases of, 373 ; hemorrhage,
374 ; classifiable lesions, exanthems ;
roseola, 377; urticaria, erythema,

INDEX.

509

378 ; rubeola scarlatina, 379 ; erysip-
elas, 380; pustular diseases ; acne,
381 ; sycosis, 382 ; ecthyma, impetigo,
383 ; porrigo, 384 ; crusta lactea, 385,
vaccinia, 386; variola, 388 ; varicella,
390 ; papular diseases ; lichen, prurigo,
391;Bullar diseases; pemphigus, 392;
rnpia, 393 ; eczema, 394 ; miliaria ;
vesicular diseases, 395 ; scabies, 396;
herpes, 397 ; tubercular diseases ; ele-
phantiasis, framboesia, 398; lupus,
399 ; scaly diseases ; lepra, 400 ; pii}^-
riasis, icthyosis, 401 ; psoriasis, 402 ;
pellagra, 403; syphilitic diseases; ex-
anthematous, vesicular, pustular, 404;
tubercular, 405; papular and scaly,
406; stains ; lentigo, ephelis, albinism,
407 ; nigritism, 408.

Small bowel, ulceration, ii. 251 ; lacer-
ation, 255; tubercles, 256; tumors,
melanosis, 258 ; intussusception, 259;
symptoms of do. 261 ; hernia, 262 ;
atrophy, hypertrophy, 264 ; concre-
tions, 265 ; fatty discharges, 267.

Softening, i. 84 ; causes, 85 ; of tuber-
cles, 166 ; bones, 339 ; brain, 443 and
449 ; spinal cord, 471 ; gastro-enteric
mucous membrane, ii. 226 ; do. after
death, 230.

Solids and fluids, i. 20.

Spermatic cord, encysted hydrocele,
varicocele, ii. 409 ; neuralgia, 410.

Spicular transformation, i. 126.

Spinal cord, suppuration, 470; soften-
ing, induration, hypertrophy, 471 ;
atrophy, hydrorachitis, 472.

Spina bifida, i. 472; analysis of fluid
contents, 473.

Spleen, situation and structure, ii. 343 ;
inflammation, 347; suppuration, 348;
gangrene, softening, 349 ; laceration,
induration, and hepatization, 351;
hypertrophy, 352 ; atrophy, tubercles,
353 ; melanosis, calcareous matter,
ossification, and hydatids, 354 ; se-
rous cysts, apoplexy, 355 ; laceration,
356.

Stratiform tubercular deposit, i. 157 ;
encephaloid, 186 ; scirrhus, 176.

Stomach and bowels, 'li. 190.

Stomach, ulceration of, ii. 235 ; symp-
toms of ulceration, 238; hypertrophy,
239; hypertrophy of fiisro-cellular
tissue, of muscular coat, 240 ; atrophy,
241 ; tumors, 242 ; carcinoma, 243.

Stricture of urethra, ii. 417.

Strongylus, ii. 379.

Sudorific glands, i. 361.

Suggillations, i. 236.

Suppuration, a result of inflammation,
i. 69 ; does not occur with equal fa-
cility in all organs, 80 ; muscles, 255;

veins, 294 ; lymphatics, [303 ; joints,
314; synovial membrane, 319; bones,
334 ; tympanum, 515 ; spinal cord,
470 ; nerves, 480 ; thyroid gland, ii.
15; lungs, 47; pleura, 104; heart,
135 ; gums, 181 ; oesophagus, 188 ;
peritoneeum, 296; liver, 316 ; spleen,
348 ; kidneys, 369 ; tesiicle, 405.

Supra-renal capsules, ii. 364.

Sycosis, i. 382.

Sylvius de la Boe on tubercle, i. 159.

Syphilitic diseases of skin, i. 404.

Synovial membrane, i. 317; inflamma-
tion of, 318 ; suppuration, 319; ul-
ceration, 320 ; chalk-stones, 321.

T.

Taenia solium, ii. 291 ; lata, 292.

Tape-worm, ii. 291.

Teeth, organization and structure, ii.
171 ; chemical composition, 173 ; gan-
grene, 174 ; inflammation, 175 ; ex-
ostosis, 176; calcareous concretions,
177; elfects of age on, 178; in ova-
ries, ii. 470.

Tendons, organization, i. 263 ; sheaths
of; mode of union when divided, 264;
regeneration, inflammation, 265 ; os-
sification, atrophy, ganglions, 266.

Tetter, i. 402.

Testicle, organization, weight, and vol-
ume, ii. 401 ; vaginal sac ; hydrocele,
402; haematocele, 403 ; concretions;
acute inflammation of testicle, 404;
encephalold, 406; tubercles, hydatids,
and cartilage, 407 ; hypertrophy and
atrophy, 408.

Thackrah on blood, i. 212.

Thoracic duct, aneurism of, i. 304 ; ob-
literation, 305.

Thymus gland, ii. 9 ; diseases, 11.

Thyroid gland, ii. 13 ; diseases, 14.

Tissues, formation and combination of,
i. 20 ; cellular tissue, 228 ; adipous,
239 ; muscular, 247.

Tongue, inflammation of, ii. 164 ; ul-
ceration, aphthae, hypertrophy, 165 ;
of mucous membrane, 166 ; papillae,
atrophy, cancer, 167; malformation,
16a

Tonsils, inflammation, suppuration,
gangrene, ii. 182 ; ulceration, hyper-
trophy, scirrhus, encysted tumor, 183 ;
calcareous concretions, 184.

Trachea, trachitis, ii. 26.

Transformations, i. 120; cellular, 122;
mucous, fibrous, cartilaginous, 124;
osseous, 125 ; adipous, 128 ; of the
umbilical vessels of foetus, 124.

Transfusion, experiments on, i. 221.

Trichina spiralis, i. 261.

510

INDEX.

Tricocephalo'rd worm, ii. 290.

Tubercle, i. 150 ; seat of; how influenced
by age, 151 ; comparative frequency
in different organs, 152; most fre-
quent between 20th and 24th years ;
occurs at all periods of life, 153 ; met
with in lower animals ; composition,
154; miliary tubercle, 155; encysted,
156 ; tuberculous infiltration, strati-
form do. 157; crude and semi-con-
crete, 158 ; origin and nature, 159 ;
organization, 163 ; softening of, 166 ;
tubercles in arteries, 279 ; muscles,
259; lymphatics, 309; bones, 348;
of brain, 467; thyroid gland, ii. 18;
lungs, 70 ; (see phthisis ;) small bow-
els, 256 ; peritonaeum, 302 ; liver,
325; spleen, 353; pancreas, 362;
kidney, 374; testicle, 407; seminal
vesicle, 411 ; uterus, 450.

Tubercular diseases of skin, i. 398.

Tuberoid transformation, i. 126 ; mela-
nosis, 171; scirrhus, 176; encepha-
loid, 186.

Tyloses, i. 367.

Tympanum, i. 514 ; inflammation, sup-
puration, 515.

U,

Ulceration, i. ^&; causes, 97; nature,
98. (For ulceration, see the different
organs.)

Ungueal matrix, i. 411.

Union by first intention, i. 66.

Ureter, ii. 380.

Urethra, male, inflammation of, ii. 415 ;
stricture, 417 ; malformations, 419 ;
urethra of female, 486.

Uric acid, ii. 386.

Urinary apparatus, ii. 364.

Urinary bladder, ii. 381; gangrene,
382 ; cysts, ulceration, 383 ; encepha-
lo'fd, 384; neuralgia, ectropia, 385;
calculi ; uric acid, 386 ; uro-ammoni-
ac, oxalic, 387; phosphatic, ammoni-
aco-magnesian phosphate, fusible cal-
culus, 388 ; xanthic oxide, fibrinous,
289.

Urine, analysis of, ii. 390 ; diseases, 391 ;
diabetes insipidus, 392 ; excessive se-
cretion, 393; diabetes mellitus ; oil in
urine, 395 ; bluish and black, 396.

Urticaria, i. 378.

Uro- ammoniac calculus, ii. 387.

Uterus, situation and shape, ii. 426;

weight and volume, 427; malforma-
tions, 430; malposition, 433; retro-
version, anteversion, inversion, 434;
inflammation, 435; softening 437 ; in-
duration, 438; fibrous tumors, 439;
polypes, 442; transformations, 446 j
malignant disease of uterus, 447; tu-
bercles, 450 ; hemorrhage, 451 ; water,
air, 452; contraction of mouth, hydat-
ids, 453 ; moles, 458.

Uvula, fissure of, ii. 184.

V.

Vaccinia, i. 386.

Vagina, inflammation, polypes, obstruc-
tion of, ii. 483; short, double ; bloody
infiltration, 484; ulcers, excrescences,
485.

Varicella, i. 390.

Varicose aneurism, i. 285; veins, 295.

Variola, i. 388.

Veins, amount of blood in, i. 198; struc-
ture of, 291 ; inflammation, 293 ; sup-
puration, ulceration, dilatation, hy-
pertrophy, 295; calcareous deposits,
296; phlebolites, 297; admission of
air into veins, 298.

Vermiform appendage, inflammation
and ulceration of, ii. 273.

Verruca, i. 368.

Vesicular diseases, i. 395.

Vestibule, i. 518.

Vitreous humor, i. 508.

W.

Wardrop on want of coagulability of
blood, i. 209 ; hereditary case of, 210.
Warren, Dr. J. C. on eiloides, i. 365.
Warts, i. 368.
Worms, intestinal, ii. 288.

X.

Xanthic calculus, ii. 389.

Yellow fever, blood in, i. 225.
Yaws, i. 398.

EXPLANATION OF PLATE.

Fig. 1 •, color of the mucous membrane of the stomach during digestion. The
rugee are seen of a lighter tint than the surrounding parts, which are of a bright
red, bordering on vermilion. Page 200.

Fig. 2 ; color of the mucous membrane of the jejunum during chylification. The
redness is somewhat less than in Fig. 1, and is most conspicuous in the intervals
between the winking valves. In both figures the color is considerable higher
than when these reservoirs are in a state of vacuity. Page 200.

Fig. 3 ; a portion of mucous membrane in a state of inflammation. The red-
ness is greater at some points than at others, and the vessels are spread out in a
beautiful arborescent manner. Page 206.

Fig. 4. This drawing represents a higher degree of inflammatory irritation ;
the redness is more diffused and uniform, and the capillary vessels are arranged
so as to form a delicate net-work. Page 206.

Fig. 5 ; section of the stomach. The mucous membrane is thrown into folds'
and the free surface presents an immense number of small points, produced by
a slight extravasation of blood into the submucous cellular substance, or the mu-
cous corion. Page 207.

Fig. 6 illustrates the diffiise discoloration produced by high inflammatory
action. The redness, which is of a darker color than in the arborescent, dot-like,
and capilliform injection, is uniformly diffused, and the small vessels seem to
have disappeared. Page 207,

Fig. 7; a portion of bowel, tlie mucous membrane of which is incrusted with
a thin layer of lymph, of a soft consistence, and a light greenish color. Page 213.

Fig. 8 shows the effects of the acid and gaseous contents of the stomach upon
the blood. Page 216.

Fig. 9', a a, acute inflammation of the isolated follicles ; b b, ulceration of the
mucous corion, which probably commenced in the glandular texture. Page 219.

Fig. 10 ; inflammation and ulceration of one of the glands of Peyer. The
part IS very red, from the injection of the capillary vessels, and presents a full,
tumid appearance. The edges of the ulcer are straight and not very high, and
the bottom is formed by the muscular fibres of the ileum. Page 220.

Fig. 11 ; mucous membrane in a state of gangrene. Some parts are of a red
scarlet color, others black, and there is also a spot which is incrusted with lymph.
Page 222.

Fig. 12. In this figure, the gangrene is at its height; the mucous membrane is
of an almost uniform black color, and there is no appearance of any vessels.
Page 222.

Figs. 13, 14. These figures illustrate the effects of chronic inflammation,
particularly as they occur in the large bowel. Page 225.

Fig. 15; hypertrophy of the isolated follicles, and discoloration of the mucous
membrane, the results of chronic irritation. Page 225.

Fig. 16 ; softening of the mucous membrane of the stomach from inflamma-
tion. The vessels are seen ramifying through the submucous cellular tissue, and
present the appearance as if they had been flattened. Page 228.

Fig. 17 ; softening from the effects of the gastric juice. The mucous membrane
is of a paler color than in the preceding figure, and in one part there is a large
perforation, followed by an escape of the contents of the organ. Page 230.

Fig. 18 ; ulcer of the mucous tunic of the stomach in a state of cicatrization.
The pari has a bluish, corrugated appearance, and the reproduction of the origi-
nal textures is only partial. Page 237.