z- £v&* (f\ Mr-J&aaU^~ s SEATS AND CAUSES **t&, « THE INVESTIGATED BY ANATOMY; CONTAINING * A GREAT VARIETY OF DISSECTIONS, atccomjmiricft fottft Remarks. 4/ BY JOHN BAPTIST MORGAGNf? ^^^ iniiniirii fcimBu 1 ■* J CHIEF PROFESSOR OF ANATOMY, AND PRESIDENT OF THE UNIVERSITY AT r.\DUA. ABRIDGED; AND ELUCIDATED WITH COPIOUS NOTESj By WILLIAM COOKE, MEMBER OF THE ROYAL COLLEGE OF SURGEONS, LONDON,—AND ONE OF THE SECRETARIES TO THE HUNTERIAN SOCIETV. ?*• "So^onn BOSTON WELLS AND LILLY:—AND H. C. CAREY AND I. LEA, PHILADELPHIA. 1824. .4T mi. v; ^ A/(?. 2i$3 f-» v* CONTENTS OF VOL. If. CHAPTER III. On Diseases of the Organs concerned in Digestion. page Section I. Diseases of the Mouth and (Esophagus 1 II. Diseases of the Stomach ... 7 III. Diseases of the Intestines 40 IV. Diseases of the Pancreas 144 V. Diseases of the Spleen .... 147 VI. Diseases of the Liver .... 160 VII. Ascites, Dropsy of the Peritoneum, and Hydatids.......202 VIII. On Tympany......251 IX Contusions and Wounds of the Abdomen . 257 CHAPTER IV. On Diseases of the Urinary and Genital Organs. Section I. Diseases of the Kidneys .... 265 II. Diseases of the Bladder, Prostate Gland, and Urethra......292 ill. Diseases in the Vesiculae Seminales and the Seminal Ducts ..... 368 IV. Diseases in the Testicle and Spermatic Chord 367 V. Diseases of the Uterus and its Appendages 386 VI. Utero-gestation, and Malformation and Dis- ease in the Foetus and Secundines 469 CHAPTER V. On Fever, Tumours, Diseases and Injuries of the Bones and Joints, Strangulation, and Poisoning. Section I. Fever.......511 II. Tumours .522 III. Diseases and Injuries of Bones and Joints 536 IV. On the Effects of Strangulation, with some Experiments on Nerves and Blood-Vessels 559 ^ Diseases induced by Poison"- 580 1 CHAPTER III. DISEASES OF THE ORGANS CONCERNED IN DIGESTION. SECTION I. Diseases op the Mouth and (Esophagus. Case 1. Ulceration of the soft palate, with suppuration of the lung. The man to whom this case refers experienced an inability to prevent partial regurgitation through the nostrils, whenever he attempted to swallow liquids. The bony palate was quite entire, but the palatum molle, and the uvula, had been destroyed by an old ulcer. As far as the eye could observe the ulcer had cicatrized, but it was evident from the sputum that ulceration was going on beyond the reach of vision. It was accompanied with a somewhat trou- blesome cough; and this circumstance, in conjunc- tion with other corresponding symptoms, (although indeed they were slight and ambiguous,) excited a suspicion that an ulcer extended downwards; and this suspicion was confirmed by the man dying sud- denly, as if he had been suffocated. Dissection. The upper lobe of the left lung was indurated, and when cut into was found to have sup- purated extensively. The ulcer of the mouth had extended to the upper part of the pharnyx* and to vol. n. I <-> the posterior foramina of the nostrils, where the ulcerative process was advancing at the time of the man's decease. The liver, some parts of the intestines, and the internal muscles of the abdomen, were livid, and exceedingly offensive. Morgagni, Epist. xxviii. Article 12 Case 2. Carcinomatous tumours of the larnyx and pharnyx. A man fifty years of age began to complain of some impediment to deglutition. This affection gradually increased, and was accompanied with loss of voice. The effort of swallowing became painful, a portion of food lodged in the fauces, and sometimes by degrees returned into the mouth, and appeared as if it had been putrid. The body became emaciated, and the left internal maxillary gland was perceived to be indurated. In this case also, the patient died suddenly, under circumstances indicative of suffo- cation. Dissection. The gland which it has been said was indurated, had matter on its inner side resem- bling albumen; and there were many carcinomatous tumours in the pharnyx and at the upper part of the larnyx.— Valsalva, xxviii. 9. Case 3. Carcinomatous tumours ; the epiglottis perforated. In a youth who died nearly in the same manner as the man whose case has just been related, similar tumours were discovered, especially at the upper part of the larnyx, and the adjacent sides of the pharnyx. The tumours were in some places ulcerated; and an ulcer had perforated the epi- glottis.—Valsalva, xxviii. 10. 3 Deficiency and disease of the epiglottis. Targioni met with an instance in which this car- tilage was entirely wanting, and yet the power of speech was unimpaired, and the act of deglutition was unattended with difficulty : nevertheless, the diseases of this part are worthy of consideration. In the case referred to, the arytenoid muscles were much thicker and stronger than usual, and might have closed the glottis, and thus have supplied the place of the epiglottis, as other parts have perform- ed the functions of the uvula, and sometimes even of the tongue, when they were originally deficient, or had been removed by disease. But we should regard those circumstances which generally happen, and not cherish the supposition that the epiglottis is almost useless in deglutition. Although I have frequently found the cartilages of the larnyx bony in old men, I never met with os- sification of the epiglottis. I do not doubt, however, that it may sometimes become less flexible and yielding—a lesion more prejudicial to the act of swallowing solid alimentary substances than fluids. Morgagni, xxviii. 13. 1 Paralysis of the cesophagus. It is needless to say much in reference to either spasm or paralysis of this tube, because examples of the former are so frequent in hysterical patients; and cases of the latter, although more rare, are not wanting. Like all other paralytic affections, it is a disease of much longer duration, and more obstinate than spasm. On this account patients have either been destroyed by hunger, or have been kept alive for twelve and fourteen months, and even for six- teen years, upon aliments conveyed into the stomach I by means of instruments. Ramazzini supported a female patient for sixty-six days by nutritive clysters; and as this is easily accomplished, it ought never to be neglected by physicians m any species of obstruct- ed deglutition. The case narrated by Heister in a dissertation by John Charles Spies, was, 1 think, an instance of slight paralysis. The patient was an aged nobleman, who, tor a long period, was unable to swallow his last morsel. It remained in the fauces from one meal till pushed down at the beginning of another, unless it had previously been thrown up by hawking or coughing. This undoubtedly arose from causes similar to those by which men advanced in years, after nearly evacuating the bladder, are disabled from expelling the last drops of urine, which the enfeebled muscles are unable to eject. Morgagni, xxviii. 14. Disease in the glands and coats of the oesophagus ; and compression of this tube. Sometimes there is deficiency of secretion from the mucous glands of the oesophagus, and at others they are occupied by an cedematous tumefaction. The coats of the oesophagus are liable to ulcera- tion, and although the ulcer may be in a healing state, or may actually have healed, it often leaves a caruncle, a callous thickening, a contraction, or even coalition of the parietes of the tube. Every callous thickening of the coat of the gullet must not indeed be ascribed to ulceration: and ad- hesion of its parietes may take place from other causes, as, for instance, from tumours formed in the coats of the oesophagus, of which examples are given in the Sepulchretum. The coats sometimes become cartilaginous, and 5 obliterate the canal of the oesophagus. Of this morbid state the»same work contains three instan- ces, and others might be added to them. If the cartilage should not project, the power of degluti- tion might remain unimpaired. Victorius Gornea communicated to me the particulars of a post mor- tem inspection of the body of a prince in Germany, in which he found the external coat of the oesopha- gus membraneous, whilst the inner was of a cartila- ginous texture; and towards fhe stomach it was os- sified to the extent of an inch: nevertheless, for the last two years of his life he daily vomited about two hours after dinner, and never complained of uneasi- ness, or of difficulty in swallowing. When, there- fore, the parietes of the gula are not contracted, and do not require dilatation, but are kept open by their own rigidity, the food seems to be urged for- wards by the muscles of the pharynx, in the same way that the blood is propelled through an ossifi- ed artery by the power of the heart, and the secon- dary action of the vessels which may intervene be- twixt the heart and the diseased vessel.- These lesions in the coats of the oesophagus have generally occurred at the lower part.—Morgagni, xxviii. 15. This tube has been constricted from tumefaction of its coats, and also from their being scirrhous, and filled with vomicae.—lxv. 2. An impediment to deglutition may arise from the oesophagus being'compressed by the contiguous parts. This has been effected by enlarged glands, as the thymus, the glandulae dorsales, glands near the termination of the gullet, and others. Dilated arteries, likewise, have often produced this effect. In a case of violent inflammation of the diaphragm, related by Heister, there had been an incapability of swallowing from the pressure of the muscular fibres upon the oesophagus ; and I perceived a simi- ulse small and weak. He also experienced general assitude, with pain and a sense of fulness in the stomach ; and so great was his disquietude and anxiety that he was perpetually changing his posi- tion in bed. All these symptoms continued without any abatement, till the temperature of the body be- came intense. He then took a draught of distilled water, and the symptoms underwent temporary mi- tigation ; but an exacerbation soon ensued, and con- tinued violent during the night. Early in the morn- ing he felt sick, but at first he was unable to excite vomiting even by irritating the fauces with his fingers : but he soon afterwards threw up four pints of fluid, similar to water in which chocolate had been dissolved. The odour of the fluid resembled that which usually exhales from the bodies of per- sons labouring under fever, and some portions of a membraniform substance floated in it, of the same colour as that of the fluid. Although the affection of the stomach appeared to be somewhat alleviated by this vomiting, yet the other symptoms not only continued, but even became more acute. In the morn- ing the physician ordered him to be bled. The blood received into the first cup exhibited a crassa- mentum softer than in the natural state, and having a thin crust on its surface; and the serum was milky. The blood in the second cup deviated less from the healthy appearance. When a few hours had elapsed, the vomiting recurred; and in the course of the day about sixteen pints of fluid were ejected. During the ensuing night the symptoms 14 which have been specified continued violent, accom- panied with delirium, and the left arm became af- fected with tremor. In the morning he had an attack resembling an epileptic paroxysm, in which not only the arm, but also the mouth, the eyes, and the left thigh, ^ere extremely convulsed; and hav- ing continued for some hours, the arm was observed to be paralytic. The epileptic attacks recurred so frequently, that upwards of twenty were counted within an hour. The retchings of a green matter, still containing fragments of substance like portions of membrane, became more frequent, and singultus was troublesome. The pulse languished, and the strength decreased through the following night, the patient being harassed with gentle vomiting at one time, with delirium and singultus at another, but most frequently with spasmodic paroxysms, which, though dreadful in degree, were of a shorter dura- tion than before. He died at twelve o'clock, and that day was the seventh after the disease com- menced. Dissection. The stomach and intestines were tinged of the same colour as the fluids which had been vomited; and the inner coat of the stomach was inflamed. All the minute vessels were ex- ceedingly turgid with blood. There was no bile in the gall-bladder, but this cyst was distended with air. The right lung adhered closely to the costal pleura, and both lungs were of a black colour and full of ichor.— Valsalva, xxx. 4. The colour imparted to the fluids evidently arose from morbid bile, united with other secretions in the stomach and intestines.*—Morgagni, 5. * I have sometimes found the contents of the stomach of an extremely dark colour, owing to blood which appeared to have 15 The following case was communicated to me by Manfredi. Case 3. Inflammation of the stomach, speedily fatal. A man, whose occupation was that of a smith, went from home in the morning, complaining of slight pain in the stomach. The pain afterwards became extremely violent, and he vomited a fluid which re- sembled ink, and died before the evening. Dissection. The stomach contained two pints of a fluid equally black, inodorous, and grumous. The inner coat of this viscus universally exhibited the same colour, and the greater part of the villous membrane of the duodenum presented the same appearance. The external coat of the stomach, facing the diaphragm, was occupied by a black spot four digits square ; but though the outer and inner coats had this appearance, the middle coat was no where of a deeper colour than that of tobacco—a circumstance which surprised those who witnessed it. Alorgagni, xxx. 16. This spot tprobably was of a gangrenous nature. The inner tunic of the stomach and of the duode- num might have been discoloured by the black fluid they contained, and that colour might have been de- rived from a mixture of bile, which was itself black, and of blood effused from the small vessels. Had it been mere extravasation of blood, death would not have occurred so speedily, even if the quantity had been much greater.—17. been extravasated from the minute and turgid vessels of the villi. In a case of death from poisoning by opium this tur- gescence was so great, that blood exuded upon the handle of the scalpel by the slightest touch; and the whole surface was almost livid. This happened also, although not so extensively, in a case in which claterium had been administered.—Ed. 16 Case 4. Inflammation in the mucous coat of the stomach, verg- ing to sphacelation; the glands enlarged; central contraction of the gall-bladder. A muscular man forty years of age, habituated to intense thought, had for some days been affected with headach, and ardor urinae, when, one evening in the middle of August 1707, after having eaten a moderate supper, he was seized with violent pain in the region of the stomach. The pain in the head eontinued, and that of the stomach increased. A large quantity of green matter was discharged per anum, and also ejected by the mouth, and under these symptoms he died at Venice on the third day. Dissection. When the stomach was opened, the right portion appeared in a healthy state, and nume- rous lenticular glands were developed. The left portion of this viscus was diversified at its fundus with vivid bloody spots; but some of them were coated with an appearance like rusty iron, indicating a tendency to gangrene. Even where there were no spots, and the internal coat appeared in a natural state, I could easily press out blood. At the dis- tance of two or three digits from its fundus the gall- bladder was contracted, but was again dilated before it terminated in the cystic duct. This bladder ap- peared as if it had been divided into two. The lungs adhered universally to the costal pleura and mediastinum. There was no suspicion that either improper food or medicine had occasioned this lesion of the stomach. Morgagni, xxix. 18 17 Case 5. Inflammation and central contraction of the\ stomach, with induration of the pancreas ; thickening of the coats of the gall-bladder ; disease in the heart and other organs. A lady of rank at Padua, the mother of several children, and in her thirty-fourth year, began, whilst lying-in, to be annoyed with frequent vomiting. At the expiration of two months she threw up a globu- lar body two inches in diameter, which was of a moderately soft consistence at first, but it acquired extreme hardness after being exposed to the air for three days. Although she was attended by several physicians the vomiting continued to the time of her death, which event did not happen till after the lapse of twenty-four years. Though a diversity of aliments was employed, the vomiting returned every morning, and two hours after dinner, and the matter thrown up was of a whitish colour, of a thick con- sistence, and glutinous. Whenever she attempted to repress the vomiting, she experienced great uneasi- ness in the region of the stomach till it returned, and the offending matter was thrown up. The vo- miting was not accomplished without very conside- rable straining, but afterwards she was free from pain. There was no evacuation from the intestines except by means of purgative medicine. Chocolate was not only retained upon the stomach, but appear- ed pleasant and serviceable to it. When the region of this viscus, and indeed the whole abdomen, was examined by the hand, nothing unnatural could be discovered. About two years before death the pulse became intermittent. Notwithstanding this complication of disease, the patient did not cease from her accustomed duties till VOL. II. 3 Tri o within the last month of her life, which she was constrained to pass chiefly in bed. At this time fe- brile symptoms arose, and increased every evening. The stomach was nauseated by every thing—even by the chocolate which previously had been so ac- ceptable. The pulse was full, and also intermittent, as it had usually been. After taking some of the opening pills which she had been accustomed to use, violent palpitation of the heart came on, and though it was almost immediately allayed by withdrawing a few ounces of blood from the arm, yet it soon re- turned with violence, and was then mitigated by bleeding from the foot: yet this relief was not so decisive as to allow of decumbence on the left side afterwards. The surface of the blood was not in- crusted. At the expiration of a few days, the bowels being again constipated, a gentle enema was inject- ed : but this also induced palpitation, and no means that could be devised at this period, either prevented the vomiting or subdued the palpitation. Five days antecedent to death, (palpitation continuing,) the pulse became extremely feeble, slender, and creep- ing; and diarrhoea also came' on—the dejections being frequent and in large quantity, though the fasces were indurated. When the hour of dissolu- tion approached, she gave direction for her body to be examined after death, hoping, that if the cause of her protracted illness should be apparent, the discovery of it might be rendered of advantage to her children, with respect to an hereditary disease. For her mother, who had been dead many years, ■ laboured under vomiting; and her daughter began to be affected Avith it. She died on the eighth of April 1744, and I was present at the dissection in the evening of the same day, in company with Peter de Marchettis, who, having attended this matron for twelve years, gave me the preceding narrative. 19 Dissection. The body was emaciated, although not to an extreme degree; and the limbs were free from oedema. The abdomen contained a considera- ble quantity of yellowish serum, and the omentum adhered to the peritoneum on the left side. The stomach was contracted, and near the antrum pylori the contraction was so much greater than in other parts, that the viscus appeared as if it had been di- vided into two cavities; and the mucous coat was of a red colour, as if from inflammation. This organ contained part of the water or broth which had been taken a short time before death, and likewise some portions of the viscid matter which she had been accustomed to vomit. The colour of the in- ner coat of the duodenum resembled that of the stomach. The pancreas was white and indurated, and exhibited no trace of succus pancreaticus. The whole of the spleen was of a pale colour, and also part of the surface of the liver. The parietes of the gall-bladder were thickened to a degree which exceeded any thing of the kind I had previously ob- served ; and the cyst was full of black bile. All the intestines were greatly contracted, but especially the small intestines; and indeed, the excessive eva- cuation which preceded death would have led us to expect this circumstance. Both cavities of the thorax contained a conside- rable quantity of bloody serum; and the pleurae were connected together by thick and rather long membraneous filaments. The pericardium adhered closely to the whole surface of the ventricles of the right auricle, and also to the surface of the large vessels pertaining to the heart: and the extrenie border of the aortic valves was greatly thickened, and was of a cartilaginous hardness. Morgagni, xxx. 7. 20 The nature of the organic lesion which had taken place in the heart has already been explained. The morbid state of the gall-bladder and of the pancreas probably "gave rise to the vomiting. I might have supposed that the contracted state of the stomach had some influence in producing this affection, had I not observed the same structure in other women, who had not been subject to vomiting. Similar con- tractions, too, have been discovered by other anato- mists in persons of both sexes; and sometimes the aperture of communication between the two por- tions of the stomach was exceedingly small. Doubt- less, in the preceding case the contraction was con- genital. The thickened condition of the gall-blad- der would render it less susceptible of being excited to action ; whilst it may easily be imagined, from the almost scirrhous state of the pancreas, how much less of the pancreatic juice would be secreted; and, it may be inferred, that the fluid which might be secreted would possess properties unfitting it for its usual purpose. Therefore from the deficiency of quantity, and from the morbid quality of the bile and of the pancreatic liquor, in conjunction with the diseased state of the duodenum, there would be a most imperfect elaboration of chyle. The coats of the duodenum also would be so irritated by the mor- bid secretions as to occasion inverted action ; and the unnatural conformation of the stomach, neither fa- vourable to digestion nor to the transmission of the chyme into the intestines, would probably conduce in some degree to the obstinate and protracted vomit- ing.*—8. * This of course will not be considered an instance of acute inflammation of the stomach; and although the central contrac- tion may have tended to derange the functions of this organ, I suspect that its morbid affections were not idiopathic. At first, perhaps, the functions only were perverted by sympathy; or they 21 Case 6. Scrofulous abscess in the parietes of the stomach, and in other parts ; tubercles in the liver, and on the mi- tral valves. A woman forty years of age, who had generally eaten salted provisions, and been accustomed to drink may have been disordered by a more immediate relationship to other diseased viscera. The most urgent case of gastritis which has recently fallen under my care, arose from sympathy with the uterus. A lady, who had borne several children, had advanced to the third month of pregnancy, when pains in the hypogastric region, and other symptoms, indicated uterine irritation, and ex- cited some fear of abortion. At the same time she became sick, but the vomiting was only occasional, and unattended with pain or .tenderness in the epigastric region, or any tension of pulse. The vomiting, however, increased in frequency and violence every day, till the most unequivocal signs of acute inflammation were established. The pulse was quick and hard, the region of the stomach was extremely painful and exquisitely tender, and a deep inspiration occasioned violent pain in the stomach and right hypochondrium. Nausea was incessant, and vomiting very frequent. Actively depletive measures were adopted, and the blood withdrawn exhibited a buff and. cupped surface. On the fourth day from the attack, the countenance was much distressed, there was extreme restlessness, and great prostration of strength ; but as the symptoms of active disease were undiminished, no mitigation of the treatment was considered warrantable. Again she was copiously bled, and the next day there was evident amendment—the sense of prostration of strength, the sickness, the tenderness on pressure, and the oppression of respiration, had decidedly abated; but, occasionally, the vomiting was dis- tressing. During the former period there had been an occasion- al recurrence of pains in the uterus, which now became more violent, and haemorrhage commenced. The discharge returned at intervals, till the middle of the next day, the tenth from the onset, when abortion took place. At the time this circumstance happened there was profuse haemorrhage ; the countenance was exsanguis, the body was covered with cold perspiration, and the pulse was quick and feeble. An alteration of treatment now being indicated, the patient took some of the diffusible stimuli, with an opiate; and she was cautiously nursed, both as to quietude, diet, 22 good wine, had been for many years subject to pain of the stomach, accompanied with impaired appetite and with nausea; and these symptoms were soon ac- companied with repeated vomiting of blood, continued fever, watchfulness, and thirst. When the abdomen was examined with the hand, no sensible hardness was discoverable ; yet the region of the stomach was not, at times, quite free from uneasiness even from a slight degree of pressure, although, at that period, the more violent pain was not experienced. Some- times a very protracted headach was united with the other symptoms. As often as the accession of gas- tric disease became most urgent, bleeding somewhat alleviated the symptoms; and drinking plentifully of water, in which nothing except a piece of bread had been boiled, was likewise of considerable benefit. She appeared more than once to have entirely recovered under the persevering employment of a milk diet; and every month her hopes were revived by men- struation, which continued regular to the termina- tion of life. Not long before her death, a hard tumour appeared on each side above the clavicles, where the external jugular vein proceeds down the neck. The tumours, which were painful, augmented daily, and rendered breathing difficult. She iiad continued fever, with an evening exacerbation, at- tended, sometimes, with chilliness. She still com- plained of her head; and the pain in the stomach was constant,-but at this time it was not accompanied and ventilation. She scarcely experienced any sickness after- wards ; and although her recovery was slow, she advanced pro- gressively to her wonted health. At first I apprehend that there was sympathetic derangement of function, and then inflammation resulting from it; and although the acute symptoms had been greatly subdued before abortion, it was satisfactory to observe how completely the stomach was exonerated from morbid action after that event.—Ed. 23 with vomiting of blood. She was still thirsty, and perceived an intensely bitter taste; and the odour from her mouth was very offensive. Under these circumstances she dragged on existence longer than might have been expected. Dissection. The emaciated body was brought into the anatomical theatre in February 1744. I found the omentum rolled up on the right side of the abdomen. The transverse arch of the colon lay a little below the navel, instead of immediately under the stomach, as it usually does. The whole external surface of the stomach was livid, but some parts were more deeply tinged than others; and the coats were greatly thickened and indurated, except in some places where they had become rotten, and might be lacerated with a touch. When they were ruptured, matter of a cineritious colour, of a soft pultaceous consistence, and very offensive odour, was effused. The posterior paries was^excessively thick- ened, and internally it was not only tumid and un- equal, but was in a foul and gangrenous state; and from this part, matter similar to that already describ- ed, had burst into the cavity of the stomach. The pylorus was, in a natural state, and all the intestines were contracted, as might have been foreseen from the long abstinence from nutriment. The right part of the liver exhibited some roundish scirrhous tuber- cles, of a white colour, and about the size of small grapes. They were at a little distance from each other, and partially imbedded in the substance of the viscus; and one of them I found entirely within the substance. The gall-bladder contained a large quan- tity of yellow bile. There was a tendinous line upon the posterior surface of the left kidney, which penetrated its substance and resembled a cicatrix, but there was no relick of any former lesion in the adjacent parts. 24 The uterus was small, and low in the pelvis ; and was greatly inclined to the right side, in consequence of the round ligament being shorter on that side than on the opposite. The ovaria were large in proportion to the woman's age, and to the size of the uterus, and externally they were of a winding form. The fimbriated extremity of the right Fallo- pian tube was pervious, but the opposite was closed: whilst, on the contrary, the left tube was only open at the uterine extremity. Although an emaciated woman, there was a considerable quantity of fat in the mesentery and in the omentum, as well as in the interstices of the muscles. Some of the mesenteric glands, though not very hard, were enlarged and sup- purated. The pancreas was somewhat thickened and indurated. When the thorax was opened we found the two lower jugular glands enlarged so as to measure two, digits in each direction. They constituted the tu- mour which had been perceived during life, and though of a hard texture they contained pus. The other jugular glands also were enlarged, and the bronchial glands were the size of grapes. They were of a blackish colour, and in a state of suppu- ration. The mitral valves of the heart were beset with numerous firm turbercles, of a roundish and de- pressed figure; and on one of the semilunar valves there existed a small scale, but it had not acquired a bony texture. The cerebrum was slightly indurated, the lateral ventricles contained some pellucid serum, and the pineal gland was somewhat larger, firmer, and whiter than is usual to this body.—Morgagni, xxix. 12. It seems probable that the commencement of this protracted disease was in some gland of the sto- mach, which gradually enlarged and became indurat- ed; and by obstructing the circulation, the adjacent 25 vessels became loaded, and occasionally, they pour- ed out blood. At length the gland suppurated and burst into the stomach; and it is easy to conceive what would have happened to the pancreas and liver, had the woman lived a little longer. Other instances of tumours and abscesses in the parietes of the stomach may be found in the eighth section of the Sepulchretum, and also amongst the Monuments of the Caesarean Academy, and in the works of Hoffman.—13. I am indebted to Mediavia for the particulars of the following history. Case 7. Enlarged glands in the stomach ; scirrhous duodenum; indurated pancreas. A monk who was a man of rank by inheritance, and equally noble in his manners, was cut off by a complication of diseases, but particularly by dropsy and vomiting. Dissection. There was general anasarca, and the abdomen contained about two pints of a serous fluid. The liver and spleen were larger than usual, and the former of these viscera was pale and indurated, and its lobes were conspicuous. In the stomach there was nothing worthy of observation except a crowd- ed plexus of glands, occupying a space four digits in length and two in breath. They were situated at the bottom of the stomach near the pylorus, and were not quite the size of lentils, but tneir orifices were evident. About a digit below the pylorus the duodenum was black, and a little lower it was scirr- hous. The pancreas was considerably indurated. In both cavities of the thorax there was a consi- derable quantity of serous fluid, and the lungs VOL. II. 4 26 were collapsed. One of the valves of the heart exhibited a portion of bone. On the inner surface of the aorta, from the upper branches to the emulgents, there appeared the rudiments of ossi- fication. Although he had been a man of tall stature, this artery was scarcely thicker than a finger of moderate size, and the other vessels were narrow in proportion.—Morgagni, xxx. 12. Probably this narrowness of the vessels had been the primary cause of the other diseases; and I have no doubt that the hardness of the pancreas, and especially that of the duodenum, had occasioned the vomiting.—13. Case 8. The parietes of the stomach scirrhous. A man sixty years of age, and of a bilious tem- perament, had complained for many years of weak- ness and pain in the stomach. In process of time, a degree of induration was perceptible about that re- gion, and below it one could feel some hard globular tubera, which were very moveable. The abdomen was tense, and when agitated it was evident that it contained fluid. There were frequent borborygmi and eructations. At the expiration of some hours after eating, vomiting sometimes occurred, although it had happened but seldom, during the first years of the disease. He voided but little urine, was thirsty, and complained of dryness of the tongue. His pulse was weak and small. At length, how- ever, he discharged a large quantity of serous fluid by the urinary organs, and the tumefaction of the abdomen subsided, but the other symptoms daily acquired an increase of violence. The fluid vomit- ed within the last month of the man's life presented the appearance of serum polluted with soot, and 27 exhaled an odour so offensive that he compared it with the smell of putrid flesh. His strength gradu- ally decreased, his speech faultered, and he died. Dissection. The abdomen contained one or two pints of bloody serum, and the omentum was con- tracted into tubera of various hues. The stomach was replete with a liquid similar to that which had been vomited. In a third portion of this viscus, towards the pylorus, the parietes were quite hard, and the pyloric orifice itself was so straitened that the chyme could scarcely be transmitted. Although the whole of this indurated part, when cut into, exhibited a white and solid texture, yet its inner surface, both in colour and fetor, resembled putrid flesh, diversified with some bloody points. Valsalva, xxix. 6. The tubera which had been felt beneath the epigastric region, were evidently connected with the state of the omentum; and the upper induration was formed by the scirrhus of the stomach. As long as this disease did not extend to the pylorus, and consequently did not compress and diminish its aperture, frequent vomiting was not occasioned. The pain in the commencement of this organic lesion was slight, but when the coats had become more exten- sively scirrhous, and had advanced to a state of cancerous ulceration, the pain, of course, became more severe. Under this disorganization, and the imperfect digestion which resulted from it, we can- not be surprised at the other circumstances of the history, namely, the flatulence, the vomiting, the ascites, the debility, and, ultimately, the decease.* Morgagni, xxix. 7. * Morbid appearances resembling those which have been described in the preceding case were discovered on examining the body of the late distinguished exile at St. Helena. It is i probable that in this extraordinary personage the disease origi- 28 Case 9. Carcinomatous tumour of the stomach. A man about fifty-four years of age had observed his body wasting for five or six months, when, in nated from mental causes. The vicissitudes of his eventful life, and especially the reverses attendant upon his later enterprises, must have enkindled passions uncongenial with the natural per- formance of the vital functions. To a man whose ambitious schemes were unbounded, nothing could be more deeply mor- tifying than banishment to a secluded spot. Here he could not but cherish the most poignant and humiliating reflection, and if the monotony of vexatious retrospection was interrupted, the variety would not unfrequently arise from depressing and irri- tating occurrences. Under these circumstances bodily health would inevitably suffer, and no organs are more dependent on mental influence than those which are subservient to digestion. The following is a copy of the official report, as it appeared in the daily journals. " Report of appearances on dissection of the body of Napo- leon Buonaparte. " Longwood, St. Helena, May 6, 1821. " On a superficial view the body appeared very fat, which state was confirmed by the first incision down its centre, where the fat was upwards of one inch and a half over the abdomen. On cutting through the cartilages of the ribs, and exposing the cavity of the thorax, a trifling adhesion of the left pleura was found to the pleura costalis; about three ounces of a reddish fluid were contained in the left cavity, and nearly eight ounces in the right. The lungs were quite sound; the pericardium was natural, and contained about an ounce of fluid. The heart was of its natural size, but thickly covered with fat; the auricles and ventricles exhibited nothing extraordinary except that the muscular parts appeared rather paler than natural. Upon open- ing the abdomen the omentum was found remarkably fat; and on exposing the stomach, that viscus was found the seat of ex- tensive disease : strong adhesion connected the whole superior surface, particularly about the pyloric extremity, in the con- cave surface of the left lobe of the liver, and in separating these, an ulcer, which penetrated the coats of the stomach° was discovered, about one inch from the pylorus, sufficient to allow the passage of the little finger. The internal surface ef 29 the beginning of August 1689, he became molested with vomiting, by which he threw up a fluid re- sembling sooty water ; and a similar liquid was some- times voided by stool. Scarcely any pain was per- ceived in the region of the stomach. At length the vomiting proved extremely urgent, with the excre- tion of the same matter as before. The pulse pro- gressively languished, and the patient died on the thirteenth of November. Dissection. All the limbs were flexible—a cir- cumstance not often witnessed in the dead body. Near the pyloric orifice of the stomach there exist- ed an ulcerated cancerous tumour, which appeared the stomach, to nearly its whole extent, was a mass of cance- rous disease, or scirrhous portions advancing to cancer; this was particularly noticed near the pylorus. The cardiac extremity, for a small space near the termination of the oesophagus, was the only part appearing in a healthy state. The stomach was found nearly filled with a large quantity of fluid resembling coffee grounds. The convex surface of the left lobe of the liver adhered to the diaphragm. With the exception of the adhesions occasioned by the disease in the stomach, no unheal- thy appearance presented itself in the liver. The remainder of the abdominal viscera were in a healthy state. A slight peculiarity in the formation of the left kidney was observed." The stomach is most frequently affected with scirrhous lesion towards its pyloric extremity, where the enlarged glands occa- sion an irregularly thickened and nodulated appearance. I pos- sess a specimen of cancerous stomach which I took from the body of an old woman, in which preparation the coats surround- ing the ulcer are nearly an inch in thickness. The ulcer was upwards of two inches in diameter. Its margin was irregular and callous, and where the ulcerative process shot beyond the boundary of the principal ulcer, destroying the villous coat, the border of this extended erosion also became thickened. At the bottom of the ulcer there were numerous sloughs, and in two places the coats of the stomach were totally destroyed to the extent of a finger's end. There had been no effusion, however, of the contents of the stomach ; for the colon and a mass of omentum were consolidated with this part by means of adhesive inflammation. The stomach was contracted, the villous coat throughout was thickened, and its vascularity increased.—Ed. 30 to be constituted of a congeries of glands ; and, on being pressed, it discharged matter like the semen virile. The stomach itself contained three pints of fluid, nearly the same as that which had been vo- mited. Betwixt the stomach and spleen there were two glandular bodies, the size of a bean; and, in their colour and texture, they were not very dissi- milar to the tumour which has been described. The right lung was somewhat inflamed on the posterior part, and serum issued from both lungs wherever they were cut into.— Valsalva, xxx. 2. Case 10. Ulceration of the stomach, and tumour of the right ovary. An old woman had been in this hospital for some months, on account of a tumour in the abdomen. About the umbilicus, and also below that part, the abdominal integuments were elevated; but the tu- mour inclined more to the right side than to the left, so that she was unable to lie upon the left side. The tumour was really large, but it appeared even larger than it was, from the circumstance that the hypochondria and most other parts of the abdomen had greatly subsided, from emaciation. It was very moveable when taken hold of by the hands, and gave but little pain. She constantly complained of an uneasy sensation in the stomach, with occasional nausea, but had no vomiting. Continued fever was united with the other symptoms, and there was no cessation of them to the close of life in October 1735. Dissection. When the abdomen was laid open, it was evident that the tumour was constituted of the right ovarium, the cells of which were enlarged, and full of a soft though not fluid substance, of a cineri- tious colour inclining to yellow, without any offensive 31 odour. Its bulk was increased by the Fallopian tube on that side being consolidated with it, and having become greatly enlarged and thickened; whilst the uterus and its other appendages were in a natural state. The tumour was united to the con- tiguous side of the pelvis, and had contracted some adhesion to the nearest intestines, so that by their movements it might be somewhat'moved also. The intestines were livid from inflammation, yet they exhaled no offensive odour. The cavity of the stomach was contracted, and some parts of its inner surface were inflamed; and in the middle of the upper part of the stomach there was a superficial ulcer nearly of a circular figure, about three fingers breadth in diameter. Within this ulcer numerous lenticular glands, of a moderate size, were so obvious, that into the orifice of one of them I inserted a bristle. The ulcer was surrounded by a thickened edge, and the substance of the coats of the stomach, corresponding externally with the ulcer, was thicker and harder than at any other part. In the centre of the ulcer the coats were entirely perforated, so as nearly to admit the little finger; and the circumstance of no effused matter being discovered in the abdominal cavity, may be explained by supposing that the stomach had not undergone this extent of lesion till the woman was moribund, during which period the stomach was contracted, corrugated, and empty. Morgagni, xxix. 14. It does not always happen, even though circum- stances seem favourable to it, that the contents of the stomach are effused when its coats are perforat- ed. In a case related by Mercklin there was no effusion, although the ulcer was sufficiently large to admit the end of a man's thumb. Death had been preceded by many years of pain in that part, but 32 perhaps the opening had not been completed till a short time before death. In the Commentaries of the Academy of Sciences at Petersburgh, a case of ulceration at the fundus of the stomach, from which there was no effusion, is recorded. The man appeared to have been consumptive, and died under constant vomiting. Tyson is said to have found the coats of the stomach perforated three times, and in one of these cases there was no escape of the con- tents. I do not here allude to those cases of per- foration in which there is adhesion to the colon, and perhaps an opening into it; or to those in which the orifice is closed by agglutination with the liver;.for under these circumstances no effusion into the abdo- men could possibly happen.—15. The cardinal Baronius was destroyed by irreme- diable nausea, which was found to have arisen from three ulcers in the mouth of the stomach. Other cases are on record of ulcerated tumours, of tuber- cles full of pus, of scirrhous affections, and of ab- scesses between the membranes, in which adhesion had been contracted with the colon, and a communi- cation was opened between these viscera by means of an ulcerated foramen. Whenever the contents of the stomach have been effused into the abdomen, death has either speedily ensued, or has not been de- layed beyond a few days.—16. * Case 11. Perforation of the stomach and of the abdominal parietes. Peter de Marchettis read to me, from the letter of a neighbpuring physician, the case of a woman who had a tumour in the region of the stomach, which her surgeon believed was advancing to sup- puration. However, the tumour disappeared, and 33 the skin contracted upon the spot so as to resemble a cicatrix, though no fluid had been discharged. The woman became pregnant, passed through the term of utero-gestation, and underwent parturition favour- ably. When three months had elapsed, she perceiv- ed that a little moisture oozed from the cicatrix, and on examination it proved , to be some wine she had drunk. She also discovered that she could force out some pudding which had been eaten. The ori- fice, however, perfectly closed, and she continued to enjoy good health.—Morgagni, xxxvi. 31. Wencker published an account of a woman in whose stomach an orifice remained open for twenty- seven years. Other cases may be found in the Se- pulchre turn.*—32. Case 12. Ulceration of the stomach and oesophagus ; the parietes of the left ventricle of the heart thickened; the aorta diseased, and the uterus inclined to one side. A poor country woman apparently about fifty years of age, had been subject, at intervals, to a dif- ficulty of breathing, united with a sense of constric- tion. The pulse was hard, and indeed the action of all the arteries was so powerful as to be observed by the eye, not only in the neck and temples but even in the hands. At a time when her respiration was extremely oppressed, she came to this hospi- tal ; and from the abstraction of a large quantity of blood, which was of a firm consistence, she was re- * In these cases, the effusion of the contents of the stomach into the abdominal cavity was prevented by adhesive inflamma- tion. Sometimes this process takes place between theulcerated stomach and some of the contiguous viscera ; at others, as in the preceding instances, between the stomach and abdominal parietes.—Ed. vol. ii. 5 34 lieved, and survived the attack four years. At the expiration of that period she was seized with pain in the stomach, and died in twenty-four hours. Her body was given me for the public lectures before the end of January 1737. Dissection. The stomach was large and half full, and on opening it, we were surprised that its con- tents had not been ejected by vomiting. Its mucous coat was ulcerated in several places, and the ulcers appeared recent, and exhibited a gangrenous black- ness. Near the pylorus they were minute and crowded, and in the fundus of the stomach they were larger and more dispersed; but at that part where the stomach begins to expand itself from the termination of the oesophagus, they were of a greater extent than at any other part. Nor was the oesophageal tube itself free from erosion. The disease seemed to have been occasioned by the in- gesta, but we could not ascertain what had been their nature. The spleen was somewhat enlarged and flabby. The uterus greatly inclined to the left side, conse- quently the round ligament was much shorter on that side than on the right. To one side of the cervix uteri a small and thick membrane of a pyra- midal form, and of a white colour, adhered, and which I supposed to be the remains of an hydatid. The blood-vessels of the internal coat of the blad- der, extending to the beginning of the urethra, were as turgid, and their inosculations as conspicuous, as if they had been injected. The mesentery abound- ed with fat, and the glands of this part were en- larged so that many of them equalled beans of a large si#e. The superior mesenteric artery ori- ginated in common with the cceliac; and the coro- nary artery of the stomach was much larger than usual. 35 Both cavities of the thorax contained a colourless fluid, and the pleurae adhered together at the back and sides. Tne parietes of the! left side of the heart were thicker than usual, whilst those of the right side were attenuated, yet there was no dila- tation. The aortic valves were somewhat hard, and some parts of the trunk of this artery, by the yellowness and protuberance of the inner coat, in- dicated a tendency to ossification. The diameter of the left carotid artery exceeded that of the right; and bifurcated at scarcely the distance of an inch and half from its origin, which is an extraordinary circumstance. It was somewhat dilated where it began to divide, as were both the subclavian ar- teries at their division into the larger branches. The brain presented a natural appearance.* Morgagni, xxix. 20. The agitation of the arteries during life, their dila- tations, and the rudiments of ossification in them, were partly ascribable to the thickened parietes of the left ventricle of the heart.—21. Excrescences of the stomach. In the observations of Hermannus and Basterus, either glandular or fungous excrescences of the pylorus were united with ulcers of that part, and appeared as if they had grown out of the ulcerated * The coats of the stomach are sometimes found extensively perforated by the succus gastricus, and the appearance is liable to be mistaken for ulceration, or it may be ascribed to corro- sive poisons. This occurrence was first noticed by John Hun- ter. It is not very likely to happen after a protracted illness, but a perfectly sudden death is by no means indispensable to its production. 1 found the fundus of the stomach very extensively destroyed from this cause, in a girl of a strumous diathesis, who died about eight and forty hours after being seized with con- vulsions.—Ed. 3C substance of the pylorus itself. All excrescences of the stomach, however, do not arise from an ul- cerated surface. Verruca?, as Paulinus termed them, and other fleshy tumours, have been found adhering to the coats of this viscus, where there has been no ulceration. Paulinus, in one case, found two of these tubera near the left orifice of the stomach, one of which was as large as a small apple, the other was the size of a large filbert. There was no appearance of ulceration, although the man had previously vomited a body equal to the size of an acorn, attended with considerable effusion of blood. Morgagni, xxix. 16. It cannot be denied, however, that these excres- cences, and other unnatural appearances, some of which seem to have arisen in the same manner as naevi materni, may ulcerate or be broken off from accidental injuries. In one or two persons, and especially in an old man who died from a blow upon the head, I found a kind of membraneous flap hanging from the ring of the pylorus, in so lacerated a state, that no doubt existed of its having been larger. At the same orifice I have also discovered protuberances like verrucee, not pendulous. In the bodies of two men there were two enlarged glands the size of a vetch, situated in the pylorus. In one of them they were of a somewhat livid colour, in the other they were red. Their glandu- lar structure was evinced in the latter case by a distinct development of their foramina; and the neighbouring glands of the antrum pylori were of a larger size than usual.*—17. *Dr. Monro has given an excellent representation of a gastric polypus, which adhered to the villous coat by a neck. The surface of the tumour was smooth, and the body of it so firm, solid, and tough, that it was cut through with some difficulty. It occurred in a lady forty-five years of age, and the symptoms 37 It will appear from the preceding cases, that the pyloric extremity of the stomach is more frequently the seat of organic lesion than any other parts of this viscus. The stomach was found ulcerated, and the pylo- rus contracted, on an occasion when unnatural ap- pearances were supposed to have been occasioned by imperfectly prepared mercurial remedies, which had been administered for a venereal affection.(—lxv. 3. The coats of the stomach have been found thick- ened, and almost converted into a cartilaginous struc- ture.—lxv. 2. Central contraction of the stomach. In one of the preceding cases the centre of the stomach was contracted. Indeed this constriction has been mentioned in former dissections, and will be distinguished in others. It has sometimes taken place to such a degree, that the aperture of com- munication between the two portions of the sto- mach was scarcely larger than the natural extent of the pylorus.* were, pain in the epigastric region, indigestion, flatulence, diarrhoea, and emaciation. Dr. Granville has described a similar occurrence in a female sixty-four years of age. She experienced chronic diarrhoea, marasmus, and complete adynamy. The tumour was attached near the cardiac orifice ; it was cylindrical, six inches in length, and about an inch in diameter; and it was covered by the mucous membrane of which it was a prolongation. Its texture was dense and solid, and distinctly vascular.—Med. Rep. Aug. 1817.—Ed. * Central contraction of the stomach is often met with; but, in general, it appears to be a temporary affection. In all the instances which have occurred to me it was instantly removed by inflation. Sometimes, however, it is permanent; and the aperture between the two portions has been found by others as small as Morgagni has represented it above. Sir E. Home and Dr. Monro have described this morbid appearance. In the Med. Chir. 38 Case 13. Prolapsus of the stomach. The subject of this affection was a slender woman about forty years of age, who was extremely liable to violent paroxysms of hysteria, which convulsively agitated the whole body, but especially the abdomi- nal viscera. At length, having undergone some ac- cessions of extraordinary severity, she observed a manifest depression in the epigastric region, and ful- ness in the hypogastrium. There was uniformity in the state of emptiness of the former part, whilst the degree of fulness in the latter varied frequently in the day. At one period the tumefaction would be of a considerable size, and very hard, yet this reple- tion often dispersed suddenly. The woman perceiv- ed that the ingesta descended to the hypogastrium, which became more elevated. The sense of weight too, which always existed there, was augmented; and four or five hours after food had been received into the stomach, severe pains, accompanied with tormina and syncope, were produced. The sensation she experienced conveyed to her the idea that her vis- cera had fallen from their natural situation. The digestive powers were evidently impaired, she was feverish, and became greatly emaciated; yet, under these circumstances, her life was protracted for three months. Dissection. According to my prediction the sto- Journal for January 1816, Dr. Palmer has related a case in which the contraction was as perfect as if a tight ligature had been applied, and great difficulty was found in passing the little finger through the narrow ring which separated the cardiac and pyloric portions. The inner coat seemed healthy, except at the strictured part where the coats were thickened ; and adjacent to it there were some spots resembling minute granulations.—Ed. 39 mach was found to have actually fallen into the hy- pogastric region, so that there was scarcely the space of four digits between it and the pubis. That part of the stomach corresponding with the oeso- phagus was elongated to such a degree, that even the whole fundus lay in the hypogastrium. Valsalva, xxxix. 14. The stomach may occupy the hypogastric region under different circumstances. In December, 1717, when dissecting the body of a woman, I found the stomach so capacious, that, although empty, the distance of the fundus from the pubis did not exceed the space intervening between these parts in the preceding instance. When the stomach is exces- sively distended with flatus, or from other contents, it has been observed to descend so far as to excite the idea of the patient being in an advanced stage pf pregnancy, or labouring under ascites: but this rarely happens when the viscus is empty. Occasionally some part of the stomach has occu- pied the hypogastrium, as well as other regions of the abdomen, not from an increase of magnitude, but in consequence of the descent of one extremity ; or the whole may be forcibly drawn or pressed downwards. When the intestines have fallen into a hernial sac, the stomach has been dragged from its situation; and it has been forced into the lower part of the belly by a depression of the diaphragm, or by a greatly increased bulk of liver. Ruysch found the stomach and intestines in the hypogastric region of a woman who died asthmatic ; but he has neither assigned a cause nor stated the inconve- niences which resulted from this displacement. Molinelli has given the case of a woman in whom the commencement of the duodenum was closed by a large and firm tumour, and the magnitude of the stomach was so extraordinary that it descended to 40 the pubic region, and occupied nearly the whole hypogastrium. The patient had suffered the most difficult and protracted vomiting of food, and the body became emaciated and sallow. Although the pylorus was dragged lower than the other parts of the stomach by the weight of the tumour, there was an elongation of the oesophagus ; so that whilst the viscus was enlarged by the lodgement of ingesta, ' it was also prolapsed.—Morgagni, 15. If the case which fell under the observation of Valsalva is compared with these, its remarkable nature will be apparent. The stomach had been so drawn by the convulsive affection, and that part which is continued into the oesophagus had been so extenuated and elongated, that the fundus itself had descended into the hypogastrium. It is not unlikely that the oesophagus had also been somewhat length- ened. In the other instances alluded to, the dis- placement of the stomach was combined with lesion in some other organ; but in this, the prolapsus ven- tricuh was the only unnatural appearance.—16. SECTION III. Diseases of the Intestines. Case 1. Hemorrhage from the intestines, with inflammation. The subject of this case was a nobleman of Bolog- na, sixty-one years of age, who for many years had been afflicted with hemicrania, sometimes with erratic or fixed gout, and at others with renal calculi. He was invaded by an accession of podagra in the 41 right hand, but the part was not tumefied, nor se- verely painful; and as the sense of feeling became dull, the pain was scarcely perceived. The hand recovered, but the patient then suffered pain in the right kidney, accompanied with frequent but ineffec- tual retching. He obtained relief from this affection, but when the vomiting ceased, the gout attacked his right leg, in the calf and at the ankle joint of which, he experienced excruciating torture. After the lapse of one or two days the whole extremity of the foot was totally deprived of feeling and motion; but on the following day he had some consciousness of pain in the paralytic foot. After this he regained his wonted cheerfulness, and the pulse, which at other times was unequal and intermittent in the right arm, became natural. The day previous to death he vo- mited food mixed with a watery fluid, and felt slight pain with pulsation and heat, in the region of the stomach. Soon afterwards he twice vomited some yellow matter. He enjoyed but little rest that night, and the following morning complained exceedingly of thirst, of a disagreeable taste in the mouth, and of loss of appetite, all of which had considerably mo- lested him from the beginning. The pain and pul- sation in the region of the stomach continued, and he discharged blood per anum, with very cohesive and offensive matter like tar. He likewise perceived a sense of weight in the lower region of the abdomen, and some pain in the leg. Gradually he lost the power of moving the right arm, and the nails acquir- ed a livid hue. A few hours before death he per- ceived a tremulous sensation in the praecordia. He died thirty-six hours after being attacked with pain in the bowels. Dissection. The whole tract of intestines, from the stomach to the termination of the rectum, was horribly inflamed, so that not the least part was free vol. n. 6 42 from lesion. They contained bloody matter like that which had been discharged. The'stomach and kid- neys were in a healthy state. The posterior part of the lungs, especially on the right side, was slightly inflamed, and the pericardium contained a small quantity of fluid. Valsalva, xxix. 10. The pulsation remarked by Valsalva unquestiona- bly arose from the accumulation of blood in the pa- rietes of the intestines, whence it was effused into the canal; and to this case, perhaps, part of a pre- diction of Hippocrates may be applied: circa ventrem palpitationes—sanguinis eruptionem significant* Morgagni, 11. Case 2. Inflammation of the intestines, with extravasation of blood into the abdominal cavity. Laelius Lgelii, of Imola, a medical student, fond of solitude, and naturally of an irascible temper, was * This case of haematemesis exhibits much more extended plethora of vessels than is generally found after the evacuation of blood from the alimentary canal. 1 have examined bodies after most profuse haemorrhage, in which I have only found circum- scribed plethora. Occasionally the turgescence has presented a somewhat stellated appearance, having radii tending to a cen- tre, like the phenomena not unfrequenlly exhibited after the puncture of a leech. In such cases a species of haemorrhagic action, which should be distinguished from inflammation, is kept up. It would have been more satisfactory if Valsalva had men- tioned the condition of the liver in this gouty subject. In the case of a young lady, who died after profuse and repeated hae- morrhage from the alimentary canal, 1 found he liver of an un- natural solidity, of a yellow colour, and beset with minute tu- bercles. In the case of an old bacchanalian, who had vomited and purged bloody matter during some days before death, the whole liver was disorganized. In both cases the blood had been extravasated from the vessels of the stomach, without any appearance of ulceration.—Ed. 43 suddenly attacked in November 1705, about the fourth or fifth hour of the night, with pain in the umbilical region, but it was not uniformly violent in the same place. This seizure occurred at a time when he himself was enjoying good health, but was in hourly expectation of his father's decease. He soon began to vomit porracious bile, which, after a time, assumed an eruginous appearance; and, when dissolution approached, the bile became black. In the morning, about ten hours from the commence- ment of the attack, Valsalva visited him, and ob- served that the countenance was unpromising, the abdomen was tense, and likewise painful on pres- sure; the pulse was weak, and felt as if it were con- stricted; the urine was of a red colour, inclining to brown, and extremely turbid. Finding that such mischief had been so quickly effected, Valsalva pre- dicted that he would die within twenty-four hours. He was twice bled, by the advice of two senior physicians, but expired the ensuing night. Dissection. On opening the body about a pound and half of fluid blood was found extravasated into the abdominal cavity; and some blood was also effused into the bronchia. The abdominal viscera exhaled rather an offensive odour. A large portion of the intestines, especially at the upper part of the abdomen, was of a red colour, and the ileum began to assume a livid complexion. The peritoneum was marked, in several places, with black spots, especially where it invests the diaphragm; and the peritoneal coat of the sto- mach was unequal from what we should deno- minate black tubercles, rather than spots, which consisted of blood, or were the commencement of gangrene.— Valsalva, xxxv. 2. Inflammation of the intestines is accompanied with no inconsiderable degree of spasm, and this is grea- •11 ter in proportion as the pain is more severe, whether the pain excites the spasm or is occasioned by it; and usually it bears some proportion to the rapidity of the progress to a fatal termination. Boerhaaye having spoken of the exquisite sensibility of the in- testines, from the multitude of their nerves, imme- diately refers to it in explanation of the celerity with which persons are sometimes destroyed by in- flammation and ulceration af the intestines ; so that if there be excessive violence of pain, the strongest man may be despatched within an hour. In violent pains of the intestines manifest symptoms of spasm frequently discover themselves. In no part of the body, perhaps, does inflammation more speedily de- generate into gangrene than when it invades the intestines; and this often occurs when the physician is not at all apprehensive of such a result. Morgagni, 4, 5. The following case was communicated to me by my preceptor Jacob Sandri. Case 3. Inflammation of the intestines, preceded by pains re- sembling colic. M. Cupellini laboured under an affection which was considered to be colic. He was in the act of taking a dose of an emulsion, when he suddenly ex- pired. Dissection. The whole body was examined, but no disease was discovered except inflammation of the intestinum colon, which verged to a black co- lour.—Morgagni, xxxv. 8. Case 4. Inflammation of the intestines, speedily fatal. A footman, short in stature though corpulent, be- 46 coming disqualified for the duties of servitude, beg- ged his livelihood for some years, and drank plenti- fully of wine whenever he could obtain it. On the last day of his life he said he was unwell, and took nothing except bread and wine. Soon after taking this nourishment he complained of abdominal pain, and died about midnight. The body was brought into the anatomical theatre at the beginning of February 1736. Dissection. As soon as the abdomen was opened the viscera exhaled an offensive odour, and a con- siderable part of the small intestines lay in the pel- vis. Various parts of the small intestines were ex- ceedingly narrow, and of a brown colour; but in other places they were red. The smallest vessels were so turgid with -blood, that it appeared as if they had been injected. The same appearance was observable in several parts of the large intes- tines also, but especially at the caput coli. The edge of the liver was of a blackish colour. The spleen was enlarged, and the trunk of the abdominal aorta was not free from small ossifications. Morgagni, xx*xv. lCh Case 5. Inflammation of the intestines, with abscesses of the omentum and mesentery. A slender man, fifty years of age, after excessive fatigue in hunting, began to complain of extreme heat in the throat and chest. This sensation after- wards extended to the loins and abdomen, and the latter became so acutely painful that he could not bear its being touched. During the first days he was frequently seized with rigor; and five or six days ^before death volvulus came on, with the ejec- 46 tion of feces. He died about the thirteenth day af- ter decumbiture. Dissection. The abdominal cavity was full of pus. The omentum and intestines were inflamed, and agglutinated together; and inflammation also occupied the liver and spleen. Blood was extrava- sated beneath the inner coat of the left kidney. In the omentum and on the edge of the mesentery, especially where it was connected with the colon, numerous small abscesses and ulcers existed. Valsalva, xxxiv. 21. When the abscesses began to form, not only was uneasiness experienced in the abdomen, but also in the loins, to which the mesentery is attached. The suppurative process was indicated by the frequent rigors; and the rupture of some of the abscesses filled the abdominal cavity with pus, and left the part in a state of ulceration.*—Morgagni, 22. * Abscesses sometimes form among the abdominal viscera in a very insidious manner, of which the following case affords an example. Mr. T----m, about twenty-two years of age, and apparently of a scrofulous disposition, had laboured under dyspeptft symptoms for two months. The symptoms were, loss of appetite, pain and fulness in the abdomen after eating, de- bility, and a slight degree of fever. Being occupied in a small chemist's shop, and attempting to remove these affections by his own management, he, at length, took five grains of submu- rias hydrargyri, which, upon subsequent examination, was found not to have been finely levigated. This dose violently purged him, and from that period symptoms of acute abdominal dis- ease were developed. I was consulted on the eighth of March, when he had fever, sickness, and pain in the bowels. The right groin and the penis were also painful; and in those parts he had previously felt uneasiness. The abdomen was tense and tender. On the tenth he appeared to be convalescent, and cir- cumstances seemed auspicious till the twelfth, though he could not bear much pressure on the abdomen, especially in the right inguinal region. On the morning of the thirteenth, the pain in the groin and penis was extremely severe, and in the course of the day he experienced some difficulty of micturition, ap- 47 Case 6. Inflammation of the intestines, with effusion into the ventricles of the brain. A man of a pallid complexion, about the same age as the subject of the preceding case, was seized with acute fever, two years before the ill- ness of which I now more particularly speak. When the febrile symptoms subsided he experienced con- siderable thirst, with a sense of weakness in the head and stomach, and bodily languor. Under these circumstances he was attacked with oppression at the heart; and at night, when he began to fall asleep, the oppression was succeeded by tremor of the whole body. Some physicians supposed that parently from spasm in the urethra. The abdominal pain he described as " drawing the bowels to the back." He died at three o'clock the following morning. Dissection. The abdomen contained a considerable quantity of fluid, in which portions of coagulable lymph were suspended. The omentum was highly inflamed, especially at its lower bor- der, and was adherent to the circumjacent parts. In the right groin the convolutions of the jejunum and ileum were, by ad- hesive inflammation, firmly united with the coecum, and these parts included an abscess in which there were about five ounces of pus. The parts of the intestines forming the parie- tes of this abscess were abraded of their peritonaeal coat. Some parts of the intestines were in a state approaching sphace- lation. In other cases in which I have known matter form in the ab- domen, it has been the result of active inflammation. Here it apparently was the consequence of so slight a degree of increas- ed action as to have been scarcely regarded. The excessively augmented action induced by the irritating mercurial prepara- tion, seems to have brought on the acute symptoms. The affec- tion of the urethra, which had been occasionally troublesome, though only in a' slight degree before the accession of more active symptoms, was ascribable to irritation propagated thither in consequence of the right ureter being implicated in the in- flamed and suppurated mass.—Ed. 48 he laboured under phthisis; but Valsalva attributed these symptoms to effusion of serum within the cra- nium. After having drunk wine to excess, violent wandering pain came on in the abdomen, accom- panied with flatulence and bilious vomiting. On the following- day the pain became fixed, and the part it occupied was exceedingly tender. As inflam- mation evidently existed, blood was abstracted; nevertheless he died on the fourth day. Dissection. The greater part of the intestinum ileum was inflamed. There was alarge quantity of serum within the cranium, and the ventricles of the brain were filled with a similar fluid. The glandules of the choroid plexuses were much enlarged, and abounded with serum, and the compages of the cere- brum was relaxed.— Valsalva, xxxiv. 23. Case 7. Inflammation of the caput coli, with observations on volvulus. A woman who, a year before, had injured her back by a fall, became affected with most excruciat- ing and deep-seated pain in the abdomen, united with vomiting. After conflicting with these disor- ders for some days she was carried off. Dissection. The stomach was surprisingly con- tracted, but the caecum was so distended with yellow and semi-fluid excrement as, in capaciousness, to re- semble the stomach. Inflammation had existed in this part of the intestine, and began to diffuse itself through the neighbouring viscera. This case was communicated to me by M. An- thony Laurentio.—Morgagni, xxxiv. 27. If the accident had any influence in producing this disease, it may be conjectured that the woman fell upon her back, and at the same time injured the 49 right side of the abdomen and that part of the colon which is situated there, so that its power of propel- ling the feces upwards having progressively decreas- ed, the caecum was at length dilated by their deten- tion. If she had dragged on existence a little longer, probably she would have vomited excrement, or something which resembled it; for many persons, deceived by this similarity, have supposed that the matter which had passed into the large intestines was actually thrown up by vomiting in cases of vol- vulus. This circumstance, however, must happen much more rarely than is generally supposed, in con- sequence of the valvula Bauhini. It may be de- monstrated that this deception has occurred ; for in numerous cases, after death, the canal from the large to the small intestines was completely intercepted by the valve, though something like stercoraceous matter had been ejected. The ingesta which are conveyed downwards, with the succus intestinalis, the succus pancreaticus, and the bile, and are delay- ed in the small intestines, especially if the parietes of this canal are inflamed, acquire the peculiar odour of stercoraceous matter, and may be called excre- ment without impropriety.—28. Notwithstanding the observations I have just made, it is unquestionable, however, that feces may be carried back from the colon, and ejected by vomit- ing. In cases of ileus, suppositories and enemata have been vomited; but respecting the way in which this occurs, different opinions have been entertained. It has been supposed that there must exist a state of plenitude both in the large and small intestines, by which the valve would be prevented from perform- ing its office. Some have imagined that it must either be ruptured or paralytic, but this would scarcely be adequate to produce the effect. For though the valve may lose its power of contraction, VOL. n. 7 50 yet the frasnum which is placed transversely on each side within the colon, tends increasingly to contract the orifice in proportion as this intestine is dilated. This advantage, -I believe, often accrues from it, when, perhaps, there is a large quantity of matter accumulated in that part of the colon, and the abdo- minal muscles are in strong action to propel it. Ileus has appeared to arise from loss of the expulsive power, owing to an affection of the muscles of the abdomen and diaphragm: and it has also been ascrib- ed to a state of atony of the intestinal canal. There are several objections which may be urg- ed against the proposed explanations. It is not possible to conceive that the intestines are in a dis- tended state, or that they are even nearly filled, when enemata are vomited within an hour after they had been injected, without any great ejection of fecal matter. Another explanation must therefore be sought to explain how the clyster had been pro- pelled from the rectum to the stomach, and by what means the valve had been kept open. In reference to the former of these points I see no reason to reject the opinion of inverted action. In some living ani- mals, as the rabbit, a motion alternately anti-peristal- tic has been noticed. Haller has not only produced examples of peristaltic but also of anti-peristaltic ac- tion, in the human body ; and he quoted the authority of Wepfer, who observed both these actions in the human colon.—29, 31. Case 8. Inflammation of the intestines and liver ; adhesion be- tween the pericardium and heart; membraneous pro- duction in the uterus. A poor woman, who was old and blind, as well as diminutive and slender, having been ill for three Jl days, was brought into the hospital at Padua, being supposed to labour under thoracic inflammation. At that time she was so exhausted that no information could be obtained from her, and she died on the day of admission. Dissection. .The intestines and liver were in a state of inflammation. The inner surface of the uterus was not less red than if she had recently menstruated, and the redness was ascribed to the same cause as the intestinal affection. At the part where the fundus of this organ contracted into the cervix, and where the anterior and posterior inter- nal surfaces formed an angle at the right side, a pre- ternatural membrane originated. It was not very small in extent, and passed transversely to the pos- terior surface, with which the whole inferior border united, but in other parts it was loose. This de- scription shows that, contrary to the usual appear- ances of the valvula cervicis, it had its cavity turned upwards instead "bf downwards. . I suspected it to have been the consequence of difficult parturition, as she had borne children. The pericardium ad- hered to the heart, though not very firmly; but it was not united to the large vessels. Its inner sur- face, where it had been conjoined to the heart, ex- hibited a white spot.—Morgagni, xxxv. 12. Some of the preceding cases indicate how rapidly f>ain in the intestines may prove fatal, from the vio- ence of inflammatory action, and even from spasm; and they point out the circumspection demanded from the physician during the urgency of this dis- ease. He ought, however, to be still more cautious against being deceived into an unfounded hope of re- covery by a delusive remission of disease, and some- times an apparent cessation. The truth of this ob- servation will be confirmed by the following instan- ces.—13. :>2 Case 9. Inflammation of the intestines, terminating in mortifi- cation ; the spleen sphacelated. A youth addicted to the abuse of wine and spiritu- ous liquors, having laboured under intermittent fever not long before, was seized with pain in the abdo- men, which was removed by a discharge of flatus per anum. It returned, however, in a few days, and on the sixth day from this recurrence he was brought into the hospital of St. Mary de Vita. The pain was seated in the hypogastrium, and was constant, though slight in degree. Sometimes its severity in- creased, and during these accessions of augmented pain, that region of the abdomen often became tu- mid ; and on the hand being applied, inequalities re- sembling numerous hard balls were perceptible. The stomach also was painful, and he vomited both his aliment and medicine. Enemata of broths and decoctions of emollient herbs were injected, as well as linseed oil, and by this means alone, evacua- tions were obtained, but without any alleviation of the pain. When the patient sat up in bed he could endure the pain better than when decumbent, and he was most comfortable whilst the stomach was empty. On one occasion he vomited a lumbricus teres, but the absence of many symptoms of vermes forbade us to suppose that the pain arose from them. At length he began to retain some alimentary sub- stances, but he was thirsty, and the abdomen was universally distended. It was now about the fifth day since his admission into the hospital; and he re- presented himself as having slightly amended—an opinion which was corroborated by his countenance, the cheerfulness of his conversation, and the improv- ed strength of body. The pulse had never been un- 53 favourable, nor was it so at this period: at least there was no fever, nor had any been observed, un- less, perhaps once, since he came into the hospital. Who would have believed, from these circumstances, that a fatal termination was at hand? Yet scarcely two hours had elapsed from the time when, in com- pany with the students, I made these observations, before he suddenly began to cry out from the seve- rity of pain. Vomiting also came on. In the even- ing his pulse was imperceptible. The pain continu- ed till the ninth hour of the night, when he arose from bed for the purpose of a dejection; but he was attacked with syncope, and expired in half an hour. Dissection. During the time persons were wash- ing the body on the following day, a considerable quantity of a fetid liquid, the colour of tobacco, flow- ed from the mouth. It appeared to consist of pu- trescent blood, diluted with a stercoraceous fluid. In consequence of its escape, the hypogastric region of the abdomen became somewhat more flaccid; and though in the epigastric region, which was of a livid hue, and in other parts of the abdomen, there re- mained some distention, it was not so much so as during life. As soon as the scalpel penetrated the abdominal cavity, a large quantity of humour issued, which was similar to that which had escaped from the mouth. It appeared that the cavity had been filled with this fluid. All the small intestines were as black as charcoal; and part of the spleen was in the same state of sphacelation. The incredibly offensive odour compelled us to relinquish further investigation.—Morgagni, xxxv. 14. It appears from this dissection to how great an extent disease had advanced at a period when the young man seemed to be convalescent. If it is sup- posed that this injury had taken place before he 54 came into the hospital, then it must have been con- cealed during five days, without those symptoms which usually indicate mortification; and if it took place afterwards, then the previous inflammation was not accompanied with the ordinary symptoms, especially continued fever. It was not certain whether stercoraceous fluid had escaped from the intestines in consequence of their rupture before death, or from a puncture during the dissection.—15. I shall subjoin a lamentable case, in which there was not merely an abatement of pain, but its total cessation. Case 10. Inflammation of the intestines and spleen, terminating in mortification : numerous calculi in the gall-bladder ; disease in the uterus and ovaria. A slender woman, short in stature, of a bilious temperament, and about forty years of age, was lia- ble to occasional haemoptysis, which she attributed to a suppression of the menses for eight years. She came into the hospital Sancta Maria de Morte, at Bologna, about the beginning of March 1706, com- plaining of a cutting pain, which commenced under the left mamma, and extended to below the opposite, where, however, it was more slight. The pain was aggravated by pressure, and was accompanied with a difficulty of respiration. It commenced with rigor, of which there was a daily recurrence, though the fever was not of an intermitting type. Her face was florid, and her thirst troublesome; but she experienced more annoyance from cough, because it aggravated the pain. The sputum was often bloody, though at other times thick, white, and frothy. Occasionally she perceived a sensation as if something ascended to the throat: and had to endure what she described as 55 a gnawing pain in the umbilical region. The bowels were relaxed. In the treatment of the case blood was withdrawn, and other remedies were administered ; and in a few days there was such an abatement of all the symp- toms, that the physician pronounced her nearly well. She therefore arose from bed, but having become fatigued she returned to it, and was found there, drawing her limbs together from cold. The pulse was imperceptible ; but she reported herself to be exonerated from pain. On the same day she began to void dejections of fetid blood; she had subsultus tendinum, and afterwards became delirious and died. This event happened on the sixteenth day from the commencement of her illness. Dissection. As soon as the abdomen was opened, a fetid odour was exhaled like that usually emitted from sphacelated parts. Some lumbrici occupied the small intestines; and these intestines were 01 a livid complexion—indeed they were almost black. The same colour was exhibited by the flat inferior surface of the spleen, and penetrated somewhat into its sub- stance. The pancreas was thickened, and consisted of indurated globules. The liver also was a little firmer in structure than usual, and the gall-bladder was distended with calculi, and a little bile of a pale colour. The calculi amounted in number to a hun- dred and twenty. About twenty of the largest of them were, individually, the size of a filbert. The uterus was inclined to the right side, in consequence of the round ligament on this side being shorter than usual. At the point where the left Fallopian tube emerged from the uterus, there existed a pustule, the size of a lupine seed. The ovaries were con- tracted, and there were son\e vesicles in them. The coats cf one of them were nearly cartilaginous. The anterior surface of the lungs was. in a few 56 places, annexed to the costal pleura, by small fila- ments ; and a portion of the right lung was slightly indurated. The heart was somewhat flaccid. There was a redundance of fluid in the encepha- lon, and that which occupied the lateral ventricles was of a reddish colour. The choroid plexuses were rendered uneven by numerous hydatids, which were easily lacerated on being touched. The medullary substance exhibited numerous bloody points, and a large quantity of blood could be expressed from its sections.—Morgagni, xxxv. 16. On reading the preceding narrative it will readily be conceived, that when the extreme remission of pain took place, without any critical evacuation, mor- tification of the bowels commenced; and this opinion is sanctioned by the circumstance that, on the same day the patient began to evacuate fetid blood. In medical practice nothing is more suspicious than the sudden cessation of pain, contrary to rational expec- tation. I recollect that Peter Molinelli, a most sagacious and experienced physician, communicated to me a re- cent case of his own, which coincided with that of which I have just detailed the particulars. A young man, of a melancholic temperament, was seized with acute fever, accompanied with inflammation of the fauces and delirium. About the fourteenth day all the symptoms disappeared, except those of a febrile character ; but though he perspired, and had copious micturition, yet the fever continued, with only a sin- gle day's intermission, till the thirty-fifth day. In consequence of this continued pyrexia, notwithstand- ing the plentiful daily perspiration, and the free evacuation of urine, Molinelli suspected the exis- tence of some formidable though latent disease. At length, independently of any indiscretion, an eruginous diarrhoea suddenly came on, accompani- 57 ed with pain a little above the pubic region; and as these symptoms suddenly arose they vanished as abruptly. The whole abdomen became in- credibly tense, with a sensation of internal heat; and pain was occasioned by pressure. The pulse was imperceptible, the mind wandered, respiration was oppressed, and death occurred on the third day , from the time at which the abdominal tension was manifested. Permission to inspect the body could not be obtained, but no doubt was entertained re- specting its being a case of inflammation on which gangrene supervened.—-17. Case 11. Inflammation of the intestines and stomach, terminating in mortification ; a large biliary concretion. A princess fifty-four years of age, who was exceed- ingly corpulent in the abdomen, but not in the limbs, had a remarkable irregularity in the pulse ; for, after two natural pulsations an equal number followed which were weak and unequal. She had been at- tacked with violent pain in the intestines, accompani- ed with retention of urine, but she appeared so far convalescent that all pain had ceased. A few days afterwards, diarrhoea came on, and the evacuations were of a black colour. She died. Dissection. The stomach and part of the intes- tines were found in a gangrenous state. The gall- bladder was dry, but occupied by a calculus the magnitude of a small pear. In the kidneys there were granules of sand. The heart and pericardium were loaded with fat.—Morgagni, xxxv. 18. VOL. 11. o 58 Case 12. Inflammation and sphacelation of the intestines and liver ; psoas abscess. A man seventy-four years of age and addicted to wine, a month before I saw him began to walk in such a manner as to bear chiefly on hi$ left leg. This circumstance, however, was more observable to his domestics than to himself, and he complained of no pain. Eighteen days afterwards he was seized with a wandering pain in the abdomen, but it was easily removed. Twelve days subsequent to this time he suffered oppressive and gnawing pain in the upper part of the right iliac region, which was tumid, and when lightly touched, it felt soft, but on pressing the hand rather deeply, induration was perceptible. The pulse was quick and frequent, the eyes were sunk, and the tongue dry. On the following day the pulse was full and vibrating; and the pain and tumefaction extended to the middle of the abdomen, and, at length, to the left side. Seven ounces of blood were with- drawn, which evolved no serum, but exhibited a yel- low and thick crust. He experienced considerable nausea, but his dejections were easy. On the third day his pulse was depressed, and frequently he had eructations which were bitter and acid : his articula- tion was affected apparently from spasm, and occa- sionally he was delirious. On the fourth day his limbs were convulsed, and the whole body became rigid for a quarter of an hour. During the continu- ance of this convulsive affection and the rigidity, the pulse was imperceptible, but it afterwards regained the natural state, except being low and unresisting. Dyspnoea came on, with an increase of delirium ; and he vomited feces, and died under convulsions the evening of the same day. 59 Dissection. The left lobe of the liver was flabby and entirely sphacelated. The stomach and intes- tines, especially the small intestines, were in some places red, in some livid, and in others black. The caput coli, and the contiguous muscles in the hollow of the os iliiim, were affected with gangrene, and ad- hered together so firmly as to be inseparable without laceration. From this part matter, observed in the abdominal cavity, consisting of serum having a livid tinge, and pus, appeared to have been effused, as a similar fluid was contained in the intestines. Morgagni, xxxiv. 25. There is no great inconsistency in supposing that disease had first arisen in the muscles from which the neighbouring crural nerves were compressed, and hence the patient bore chiefly on the left leg in walk- ing ; and from the muscles it was propagated to the intestines.—26. Chronic inflammation. Instances are recorded in the Sepulchretum, and in other medical writings, in which the intestines had become sphacelated independent of preceding inflammation. This circumstance may occasionally happen, but it is worthy of inquiry whether the sphacelus might not have succeeded inflammation, the prominent and ordinary features of which did not discover themselves. Whilst discussing other subjects, it has occasionally been manifest that in- flammation of the intestines had existed when there had either been no pain, or painful sensations were experienced only in a very slight degree : and fever, so far as it is denoted by a quick pulse and an ele- vated temperature of skin, has either been totally absent, or exceedingly moderate.* Morgagni, xxxv. 20. * We must be aware that lividness of colour is not sufficient 60 The deceptive appearances to which I have ad- verted occurred more than once to Valsalva and Al- bertini. The latter strongly inculcated upon me the necessity of vigilance and caution in pains of the in- testines, because, after slight pain, without any mani- fest pyrexia, without spasm and vomiting, and while the powers of mind, and the strength of body, con- tinued vigorous, he had known persons suddenly fall into the utmost peril, and indeed be quickly carried off, in consequence of a latent inflammation of these viscera degenerating into sphacelus. I inquired of him the symptoms by which to distinguish the im- pending danger, that we might be able, at least, to anticipate it. He referred to the pulse, to the abdomen, and to the face. The pulse, he said, in such cases, is low and rather weak, and if closely at- tended to, slight irregularity will be detected. The abdomen is tense, hard, and somewhat painful ; and the face, though varying in different persons, has an unusual expression. Sometimes the eyes exhibit ter- ror, and at others the circumference of the lips is livid. These, he said, were the general indications, but, oc- casionally, the patient is thirsty, and the appearance of his tongue unnatural. The truth of these re- marks has often been verified by my own observa- tion.—21. Medical writers agree respecting the abdominal tension, but they add many other symptoms which clearly show the existence of enteritis. They al- lude, however, to that inflammation, the existence of which is easily ascertained, and not to the on- to determine tbat the intestines have actually sphacelated ; for they not unfrequently present this appearance from congestion or extravasation of blood. Therefore it should be ascertained whether the coats of these viscera have lost their natural cohe- giveness of texture, as well as their usual complexion, before they are pronounced in a state of mortification.—Ed. 61 scure affection of which I now speak, and of which very few entertain a suspicion. Van Swieten con- curred with Simpson, a celebrated man, who, after giving a salutary caution to those practitioners who suppose that inflammation cannot exist without fe- brile symptoms, said—Cum scepe flxos dolores intesti- norum et ventriculi inflammatio producat, licet nulla fc" bris observetur,pulsu explorato*—22. * Morgagni has here given an account of sub-acute or chronic inflammation—a form of disease to which much attention ought to be directed, because its symptoms are often obscure and anomalous; and though its termination may not often be so melancholy as has been represented above, yet its effects are, in various ways, grievous, and full of peril. My attention was strong- ly drawn to affections of this nature a few years ago by some cases which fell under my care. One of them 1 have related at page 45. In that young man there had been chronic inflammation, and even suppuration, without any symptoms which awakened suspicion, till the disease was rendered acute by an irritating drug. Another instance occurred in the person of an amiable young woman, who by faithful servitude had obtained the con- fidence and affection of a respectable family in the country, that regarded neither expense nor sacrifice in promoting her recovery. When I was consulted she had been indisposed for seven months, and under the management of a respectable medical practitioner of this metropolis, who, I learned, had fully tried what mercury, strengthening medicine, and nutritive diet would avail. As a part of his plan of treatment sb^ spent some time at Brighton, where the warm bath was of temporary ad- vantage. Her symptoms were, pain in the epigastric region, fur- red tongue, slightly elevated temperature of skin, anorexia, and amenorrhoea. There were occasional circumscribed swellings in the abdomen, which she attributed to wind. They were accom- panied with pain like cramp, and were most troublesome in the afternoon and evening. The bowels were irregular, although but seldom constipated ; and the evacuations were of a pale colour. Her sleep was interrupted by disturbing dreams. The urine was deeply coloured, and voided scantily, so as to be about half the quantity of the liquid drank. The pulse was natural, but the general bodily strength was greatly reduced. She complain- ed of the abdomen being rather distended with wind. At the first view of the case 1 considered it one of deranged function, and prescribed an alterative dose of the pilula hydrargyri, with 62 In dysentery a similar abrupt cessation of pain sometimes occurs previous to the supervention of gangrene^ the daily use of a light tonic. The general health was a little amended, but the abdominal disease was nearly stationary. Two powders, each containing three grains of hydr. subm. and one scruple of jalapium, were recommended to be taken three days apart: but the effect of them, as well as a previous observation that on pressing the abdomen firmly it was both tense and tender, led me to relinquish my first opinion of the case. She reported that the first powder acted freely on the bowels, the stools at first were yellow, but afterwards green and slimy, and she felt " lighter and more comfortable, and the lumps, though asr hard as before, were more scattered." But on the second day she had an increase of pain, especially in the rectum and in the loins. Two days after taking the second powder she wrote to inform me, that it did not act on the bowels, " but" to cite her own ex- pressions, u it made me so full and uncomfortable that I did not know what to do ; and I still feel very ill from fulness of the bow- els : the quantity of water has a little increased, but I feel a very unpleasant sensation after making it." Upon very close investigation I found, that after taking even the blue pill there had been a temporary increase of symptoms the next day. Ex- cept when under the excitement of the powders, or of some other stimulation, the pulse did not exceed eighty or eighty-five, and was moderately soft; and there was no continued abdominal pain. I now felt confident in steering another course ; and consequently directed the application of ten leeches to the abdomen, and a blister when the orifices had ceased bleeding. The only medicine administered was an oil of almond emulsion, with a few drops of tinctura opii, and an occasional dose of castor oil. I directed also that the diet should consist exclusively of milk, vegetables, and light puddings. Five days afterwards she reported herself much better; she was therefore directed to repeat the leeches and blister, and to continue the total abstinence from every prepara- tion of animal food. At the expiration of a fortnight she had some intimations of approaching menstruation, which I endea- voured to promote by the warm bath, and, at other times, by warm fomentations applied to the loins and abdomen. This plan was successful, and the menses flowed copiously, but accompanied, as usual in her, with slight fever. A few days afterwards I found that all abdominal tenderness and tension had vanished, but she had an occasional attack of cramp in the abdomen as before, though the intervals were now very distant. The dejections were still white, and only obtained after taking castor oil. I 63 We must be careful, however, not to adopt the opinion that cessation of pain is a universal pre- cursor of mortification of the intestines. The case now admitted a little broth to the diet list. The same medi- cines were continued, but the leeches and blistering were not repeated ; and at the termination of a week I found her in a state of advanced convalescence, with Scarcely any abdominal uneasiness, and the abdomen sunk to its proper size. The quantity of urinary secretion was fully equivalent to the fluids she drank; the alvine excretions were of a natural colour; the countenance was fully relieved of anxiety, and the strength was rapidly increasing. Five grains of blue pill every third night, with a little infusum calumbae twice a day, and a cautiously improved system of diet, completed the recovery. If I have been prolix on this case it is because I conceive it elucidates a principle of vast importance, namely, that there may exist inflammatory action when there are scarcely any other symptoms than those of dyspepsia ; though, indeed, this funda- mental truth has been distinctly asserted by Morgagni. Many such cases have occurred to me, and though, as in the preceding instance, the functions of the liver and of other organs were suspended, it was in vain to attempt their restoration till inflam- mation was subdued. The secretion of the liver, in such cir- cumstances, will not be restored by mercury, nor that of the kidneys by diuretics ; but when, by appropriate and persever- ing depletion, the inflammation is subdued, every organ either spontaneously returns to its natural duty, or is easily solicited. It was interesting to observe, that whilst even the mildest pre- parations of mercury were somewhat irritating, and larger doses decidedly injurious, as soon as inflammatory action was overcome the secretions of the liver became healthy, and the functions of the kidneys and uterus were at once recovered. There is a particular seat of erythema of the mucous coat of the intestines to which I shall ^ust advert, because it often modifies the symptoms of disease with which it may be asso- ciated. Upon various occasions when there existed some ab- dominal lesion, I had observed a bilious diarrhoea come on, though it did not appear to be connected with disease in the liver, nor was it ascribable to any of the ordinary causes of purging; and I had an opportunity of ascertaining, by a post mortem examination, that the inner coat of the duodenum, about the termination of the biliary duct, was highly inflamed, without the least evidence of hepatic disease. 1 have seen other cases, in which I had no doubt the liver was excited to 64 of the young man related in this section* is one amongst others which indicate the contrary. Dur- ing the last fifteen hours of his life he cried out in- a redundant secretion by irritation propagated thither, through the ductus choledochus, from an inflamed duodenum. There was no pain or tenderness in the region of the liver, but the epigastrium was tender, and the whole abdomen was a little tense. There was considerable rumbling in the bowels, a fre- quent dejection of almost pure bile, and occasional vomiting. The pulse was frequent, rather contracted, and soft. I found that nothing removed the diarrhoea promptly and effectually except bleeding. Affections ascribed to the liver probably arise more frequently from the duodenum than we are aware of. I shall only glance at a case of puerperal peritonitis, in which I believe the circumstances to which I have adverted tended to obscure the actual state of disease. On the first of March I was called upon to meet a medical gentleman in con- sultation upon what was termed a bilious affection after partu- rition. 1 found the lady had been confined a week, and during four or five days she had been distressed wiih excessive purg- ing, and occasional vomiting of bile, attended with violent pain in the epigastric region. The pulse was a hundred and forty, and feeble; the countenance was deeply distressed, and the lips and hands were livid. She complained of dyspnoea, and begged for air. The abdomen was tumid and tender, and the tongue white. I considered it an unequivocal case of peritoneal inflammation, and assured the friends that she could not survive the day. To the medical gentleman I ventured to predict, that the mucous coat of the duodenum was inflamed as well as the peritoneum. Dissection. The abdomen was tumid. The peritoneum in- vesting the muscles, as well as covering the intestines, was highly inflamed, especially throughout the ileum. Coagulable lymph had been effused, and adhesions formed in consequence; and certainly in this case there was slight inflammation of the peritoneal coat of the liver. The mucous coat at the pyloric extremity of the stomach, and for some inches within the duo- denum, was considerably inflamed, as 1 had anticipated; and from attentive investigation, I believe that in this case, as well as in the others to w hich an allusion has been made, the ap- pearance in the duodenum was the cause of hepatic excitation. Ed. * Vide page 52, 65 cessantly from excruciating pain; nevertheless the greater part of his intestines was as black as possi- ble. Acute inflammation may affect the parts not implicated in the process of mortification, or there may exist some other cause of pain, as spasm or worms. In some of these patients, which others as well as myself have examined, calculi were found in the gall-bladder ; but whether the coin- cidence was accidental or not I leave others to de- termine. When discharges of black matter by stool are united with a cessation of pain, the occurrence must be associated with the most alarming symp- toms, and those which intimate the approach of death. With this observation I must unite the circumstances mentioned concerning a nobleman;* not, indeed, as being conjoined with pain in the intestines, for in consequence of their paralysis they had not become painful; but as being con- nected with violent inflammation in the whole of these viscera.—23. Case 13. A tumour formed by adhesion of the small intestines, from chronic inflammation of the peritoneal coat; the coats of the stomach thickened and tuberculated ; the omentum consolidated. Fortunato Maurocini, a bishop of sedentary and studious habits, gradually became the subject of hy- pochondriacal affections, and of haemorrhage from the haemorrhoidal vessels. Whilst the loss of blood continued to be in a moderate proportion he enjoyed good health, although there was considerable obesity of the whole body, and especially of the abdomen. * Vide page 40. vol II. 9 , 66 As he advanced in years the discharge of blood di- minished, and he began to be annoyed with pains in the abdomen, which he attributed to flatus. Fre- quently they were sudden and momentary, but some- times they were of a rather more protracted dura- tion. When he had completed his sixtieth year the hemorrhoidal bleeding ceased, and the pains became more troublesome, especially in the autumn of 1726, at which time he frequently experienced febrile affections. He was relieved from the latter by peruvian bark, and the pain was alleviated by the seasonable return of a discharge of blood. The fever, as well as the pains, having arisen again the following winter, they were mitigated by the same means, but never perfectly removed; and it was in this winter that he first perceived some hardness and a tumour in the abdomen. His bowels were constipated, vomiting became exceedingly trouble- some, and if he did retain any food for a conside- rable time, it at length came up unaltered. This was actually the case with a boiled apple, which had remained in the stomach for eight and forty hours. Besides food, the stomach ejected a consi- derable quantity of a colourless and insipid watery fluid; indeed its quantity exceeded that of the liquids which he drank. In this stage of the disease I was consulted, with two other physicians. We found that he had been confined to bed for some days, his face and limbs were emaciated, his pulse was fre- quent, but the temperature of the body was natural. We were informed that the frequency of the pulse increased towards evening and in the night. The tumour which has been mentioned was per- ceptible to the eye. Its form was nearly circular, and its diameter eight digits. The abdomen being extremely prominent, the tumour was situated mid- way between the cartilago ensiformis and the umbili- 67 cus. On examination with the hand, it was perceiv- ed to be unequally tuberose, and on being compress- ed, or on the viscera becoming distended with flatus, a painful sensation was excited, though not in a vio- lent degree; but, at other times, slight uneasiness was experienced. By taking hold of the tumour with both hands I could easily move it to either side. No pain arose from pressing the circumjacent parts. Morgagni, xxxix. 21. There was great diversity of sentiment as to the precise situation of the tumour, but we united in opinion that it was incurable, and that our efforts should only be directed to the palliation of symptoms and the prolongation of life. Consequently we ad- vised that all irritating and unpleasant medicines should be avoided, and also those articles of diet to which the patient felt a repugnance. Purgatives in general, except rhubarb, produced considerable un- easiness: we therefore recommended him to keep the bowels open with that medicine, to lose a little blood occasionally from the haemorrhoidal vessels, and to select such food as remained longest on the stomach.—22, 23. The symptoms gradually became worse, and, in June following he was seized with subsultus tendi- num, and occasionally betrayed a wandering of intel- lect. Vomiting continued, and the matter ejected had a bitter taste, and exhaled an offensive odour. Its colour, too, was so black, that some persons sup- posed it to be blood, but a piece of paper dipped m it and dried exhibited a pale yellow colour, verging to green. On the twenty-fourth of this month he was assaulted with so violent a paroxysm that his decease was apprehended; and about the same hour of the ensuing day he had a similar attack, under which he placidly expired.—25. In the evening of the same day trie body was opened for the purpose of being embalmed. 68 Dissection. The fat upon the abdomen was two digits in thickness; and about three pints of bloody serum were contained in the abdominal cavity. The figure of the large tumour, about which there had been so much controversy, was between that of a globe and a hemisphere, and it resembled a foul car- cinomatous mass in its colour, and in the odour it ex- haled, as well as in the inequality of its surface. The whole space below the umbilicus was destitute of viscera except the inferior part of the descending colon and the rectum, from which circumstance we immediately understood what the nature of the tu- mour really was. The whole intestinum ileum, and some part of the neighbouring jejunum, having been drawn upwards, and the convolutions having con- tracted very close adhesions, constituted this promi- nent tumour, without any addition of scrofulous, scirrhous, or cancerous substance. The unevenness of the surface was occasioned by the numerous flex- ures of the intestines, and their alternate constriction and protuberance. With the exception of some por- tions which were still red, the general complexion of the tumour was black; which circumstance, with the fetor rising from it, indicated that inflammation had degenerated in sphacelus. The intestines of which the mass was composed were nearly filled with a substance which resembled the stercoraceous matter usually occupying the large intestines, and not very soft in its consistence. It was therefore evi- dent that the matter which naturally descends very speedily into the large intestines, combined with gas, being obstructed, the tumour might afford that resis- tance to the touch which had been perceived in the living body. The adhesions between the convolu- tions in the centre, and at the upper part of this congeries of intestines, was not so firm as in the cir- cumference. The mesentery was in a perfectly 69 healthy state, and filled with fat, which, as usual, was of a pale yellow colour. The omentum was folded up and lay totally con- cealed between the stomach and tumour. It form- ed a hard and thick roll, closely attached to the fundus of the stomach and to the transverse arch of the colon, passing transversely from one hypochon- dnum to the other, and depressing the viscera to which it adhered by its ponderousness. In diffe- rent places it was from one to three digits in thick- ness, and the thickest portion was contiguous to the spleen, where it was of such inflexible solidity, that on being cut into, it grated under the knife. Al- though there was uniformity in the appearance of its texture, yet whilst some parts were of a ligamentous firmness, others were nearly as hard as cartilage. The contents of the stomach resembled the fluid which had been vomited—they were blackish, and exceedingly offensive in smell. The inner surface of this organ appeared of a brownish-red colour, which, perhaps, it had derived from the humour contained in the stomach, or it might have been the result of inflammation. Within the antrum pylori we discovered some spots which at first sight appeared to be coagula of blood, but on more attentive examination they proved to be small and depressed tubercles. Their internal texture was white and firm, but the surface of them was gan- grenous. Some were of an oval figure, but most of them were constituted of many smaller tubercles, so as to give them a radiated appearance. The largest was scarcely equal to the magnitude of a bean. As they approached the pyloric orifice from the antrum, their size and number decreased, so that at length there was but a solitary tubercle. Within the pylorus itself there were neither tubercles nor excrescences ; nor was the orifice so contracted as to 70 prevent the introduction of my finger, though the coats in this aperture, as well as through the whole pylorus, and at the commencement of the duodenum, were equal in thickness to the apex of the little fin- ger, and resembled the omentum in appearance and hardness. Out of this compact texture the tubercles which I have described arose. The liver was pale and somewhat indurated, and the gall-bladder contained bile resembling a blackish scum. The pancreas was somewhat diseased, but the rest of the viscera in the abdomen, and all the viscera of the thorax, were healthy.—26. It is a circumstance worthy of remembrance, that in this case a tumour constituted of the intestines so greatly resembled scirrhus in its tuberose and resist- ing surface, that five intelligent and experienced phy- sicians were deceived. In the Transactions of the Cesarean Academy, and in the Sepulchretum, I have read of the convo- lutions of the intestines being agglutinated to one an- other, and also adherent to the mesentery, so as to form conglobate masses ; but in none of those instan- ces did the cohering parts present externally a distinct and circumscribed tumefaction. In two of them, indeed, this could not have happened, because the morbid adhesions were coexistent with ascites. In a dropsical woman Thomas Bartholin found all the in- testines forced into the right hypochondrium; and Laubius discovered them collected into a globular heap in the umbilical region. In Cardinal Campe- gio, Columbus found that all the intestines, except ,part of the colon and the rectum, had been removed from their natural situation into the hypochondria, so that, with the exception just named, the inferior part of the abdomen was destitute of intestines, and, as in the bishop whose case I have just described, the spine was uncovered. 71 I afterwards met with a more extraordinary oc- currence of this nature in the body of a female foetus ; for on opening the belly and wiping away the blood which had been extravasated there, no intestine could be perceived besides part of the colon and the rectum. The remainder, with nearly the whole of the mesentery, were concealed and confined under the concave surface of the liver. Nobody would have suspected the real state of these viscera, be- cause, in consequence of the extravasated blood, the abdomen did not subside below the umbilicus ; and if it had done so, the circumstance would have been as- cribed to the prominence of the liver, which is al- ways large in the foetus; and in such a case as this, probably it would have been considered enlarged. In the bishop I did not examine that part of the abdomen which is below the navel, during life, be- cause the attending physicians assured me that every thing was perfectly natural in that part; and proba- bly the excessive quantity of fat would have prevent- ed the discovery of the exact state of things. But when there is not so great an accumulation of fatty substance in the abdominal integuments, the facility of feeling the vertebrae, and the pulsations of the aorta when there is no suspicion of its being dilated, are circumstances which in the diagnosis may not be without advantage, especially if we find the abdomen unnaturally depressed below the umbilicus, and pro- portionately more tumid above it. In attempting to distinguish tumours formed by adhesions of the intes- tines from those which are carcinomatous or strumous, the signs to which I have adverted will be strength- ened by an inquiry into other symptoms. If the patient has frequently suffered pains in the small intestines, and the bowels have become costive—if there has been repeated haemorrhage from the haemorrhoidal vessels—if the tumour is particularly affected with 72 pain when the intestines are distended with gas—- and if it varies in its size and firmness, like intestinal herniae, we may infer that the tumefaction is occa- sioned by these viscera.—28. Although in the following case the disease was complicated, yet it has some relation to tumours formed as those were on which I have more particu- larly dwelt. I did not see the patient myself, how- ever, and therefore I cannot answer for its being accurately described. Case 14. A monk of the monastery of St. Francisco, in my native place, having indications of slight ascites, ap- peared to have suddenly evacuated the abdomen by copious vomiting. In the hypogastric region, how- ever, a tumour was perceptible, which was so hard as to induce those who attended the patient to con- sider it scirrhous. When it was compressed with the hands, flatus was expelled downwards. The vomit- ing continued, and was conjoined with constant and excessive nausea, and insuperable costiveness. At length, feces, or, at least, matter resembling the al- vine excretion, was thrown up; and although no pain had been felt in the abdomen, nor had any signs of inflammatory action come on, yet the patient was carried off by the disease on the fifth of November 1709. The physician who had attended the patient, and who communicated the preceding information, re- quested me to preside at the dissection; but at that time I was unwell, and therefore desired him to su- perintend the examination, and to favour me with the particulars. He complied with my request, and brought the report on the following day. Dissection. The intestines were extremely livid, 73 but not rotten. The convolutions of a part of the small intestines were surprisingly entangled, and were connected together by a firm and dense substance, which resembled tendon—indeed it was almost of a cartilaginous texture : and these adhering parts con- stituted the tumour. The hardness which it had acquired was not only derived from the connecting substance, but also from balls of indurated feces. Globular masses of the stercoraceous matter also ex- isted in the continuous colon; and for some extent, near the termination in the rectum, this intestine was rendered impervious. The stomach was filled with a dark-coloured fluid, and its inner coat was of a slightly livid hue—Morgagni, xxxix. 29. Adhesion of the intestines to each other, and to the peritoneum, without being drawn from their natural situation, is not an unfrequent consequence of inflammation; and is a morbid appearance often ob- served in cases of ascites.—30. Persons who are subject to pain in the intestines, t especially if it is united with spasmodic affections, are peculiarly liable to a displacement of these viscera. —31. The union of the intestines by a kind of cartilagi- nous substance does not surprise me, because Valsalva and myself have observed this medium of attach- ment after ascites. Indeed the peritoneum itself, a production of which constitutes the external coat of the intestines, may, in dropsical subjects, become very thick, and, in process oi time, acquire a cartila- ginous hardness. Paul Barbette reminds us that it is | v*0 necessary to bear this circumstance in mind in per-1, ^\ forming paracentesis abdominis. Occasionally too, the intestines adhere together by firm bands of this nature, independent of any ascitic effusion ; and their coats sometimes become so thickened that the cali- ber is nearly obliterated.—32, VOL. II. 10 \ 74 Case 15. Ulceration of the intestines, unth flaccidity of the heart. The young man to whom the following particulars refer had always been subject to relaxed bowels, even when in the enjoyment of perfect health. Hav- ing attained his twentieth year he was seized with tormina, accompanied with frequent dejections of blood, so that, in fact, he laboured under dysentery. When about twelve or fifteen days had elapsed, the disease assumed the form of simple diarrhoea, with yellow evacuations; and it was unattended with pain. The purging appeared to be somewhat checked by the remedies employed, when an attack of tertian fever manifested itself, which, however, was remov- ed within a month. Some diarrhoea continuing, he was suddenly affected with acute fever, which had distinct accessions; and his pulse was frequent and quick, as well as small and feeble. To these symp- toms dulness of intellect and considerable deafness were added ; and a remarkable swelling was noticed on the anterior part of the left side of the thorax. He died about the fourteenth day from the com- mencement of acute symptoms. Dissection. Although there had existed no tume- faction of the abdomen, yet this cavity contained a considerable quantity of sanious ichor which had escaped from the perforated intestines. The parts in which ulceration had taken place were the ex- tremity of the ileum, and the contiguous portion of the colon, to the extent of two spans; and the inner surface of this tract was gangrenous, and consequent- ly might easily be perforated. Some of the adjacent mesenteric glands were enlarged, and formed a tu- mour which contained a purulent fluid similar to that which had been effused into the abdomen. The 75 substance of the tumour was soft and flaccid. The spleen was enlarged to three times its natural bulk. The swelling upon the chest consisted of an accu- mulation of serum in the cellular substance about the pectoral and subclavian muscles; and when that substance was divided, the fluid issued in several small streams. The lungs were healthy. - The peri- cardium contained some bloody serum, and the heart was so flaccid that on being handled it felt rather of a membraneous texture than muscular. The ven- tricles contained fluid blood; and this was so frothy that, when agitated, it resembled the lixivium used by barbers. The veins contained but little blood, but all of them were exceedingly turgid with gas; and one which belonged to the spleen, though hav- ing scarcely any blood in it, was dilated to the utmost degree. A small quantity of serous fluid had been effused into the brain.— Valsalva, xxxi. 2. The gas had been extricated during the process of putrefaction. The flabbiness of the heart account- ed for the arterial pulsation being small and feeble. The spleen 1 have frequently observed to be enlarg- ed after fevers which have been protracted in dura- tion, and which have varied in their type. But the chief object of the preceding narrative was the state of the bowels, in which there had been a natural tendency to redundant and vitiated secretion, and upon that state ulceration supervened. Morbid matter being absorbed by the lacteals, and convey- ed into the neighbouring glands, disease was excited in them, and they became obstructed and enlarged. Morgagni, 13. When this had taken place a new source of increas- ed intestinal flux was established, because less of the alimentary matter traversing the intestines could be absorbed. When obstructions of this nature exist, they not only tend to increase diarrhoaa if it previously 76 existed, but they may produce it. The chyle itself blended with recrementitious matter is discharged, and the dejections are nearly of a cineritious colour.* —14. ♦Ulceration usually commencesin the villous coat of the large intestines; and when this coat of the small intestines is the seat of ulceration, I believe that it most frequently occurs in the ileum, near its. termination in the caput coli, where I have repeatedly found it. Dr. Baillie states that he had not met with an instance in which the ulcer began on the outer surface and spread in- wardly. Not unfrequently, however, it extends from the inner coat, and perforates the peritoneal. When this takes place it does not necessarily follow that the contents of the intestines are effused into the abdomen, for most frequently the ulcerated part is united with some contiguous viscus or with the peritoneum, by adhesive inflammation. In a case of annular contraction of the descending colon, combined with extensive ulceration, by which all the coats, in one place, were destroyed, I found that the escape of fecal matter was prevented by consolidation with one of the fatty appendages. Sometimes there has been com- munication between different portions, of intestine, in conse- quence of this adhesion and ulceration. The symptoms of inflammation and ulceration in the mucous coat of the intestines are sometimes exceedingly obscure. At the onset, in the following case, they rather indicated a pulmo- nary affection. On the first of September 1813 1 was requested to see a gen- tleman about forty-five years of age—a remarkable strong and healthy man. A few days before, having experienced consi- derable giddiness, he was cupped, and by that means obtained re- lief. I found his respiration very quick, and he articulated with unusual haste, though he was unconscious of any difliculty of speaking. He had neither pain in the thorax, nor inability to make a deep inspiration, yet he was sensible of some oppression at the chest. His tongue was a little white, his pulse was a hundred, and rather full; and he had slight anorexia. His bowels were relaxed, and he micturated freely. The blood which was repeatedly withdrawn, presented a firm and cupped surface. The breathing had become more natural, but on the sixth the dyspnoea increased, and every morning he had an ac- cession of diarrhoea accompanied with tormina. He had consi- derable flatulence, and slight tumefaction of the abdonien. The stools were liquid and of a deep yellow colour, and the difliculty of respiration was most urgent at the time of the purg- il Celsus entertained the opinion that in dysentery the villous coat of the intestines was in a state of ulceration. Sometimes he noticed a kind of mucous secretion voided with the blood, and at others, por- ing. A most intelligent and experienced physician attended the patient with me, and hitherto we believed that the primary seat of disease was the lungs, and that the affection of the bowels was subordinate ; but about this period the symptoms of disease in the mucous coat of the intestines became more striking. On the seventh he complained of a sense of constriction across the abdomen, but on the tenth he considered himself better. From this time, however, he gradually sunk, his respiration was quick and laborious, but he could make a deep inspiration without in- convenience, and pressure on the abdomen did not occasion pain. He died on the thirteenth, and during the last two days he voided a liquid bilious dejection about every six hours. Dissection. The transverse arch of the colon was inflated to an enormous extent. The omentum and peritoneal coat of the intestines were inflamed, and the intestines were generally dis- tended with gas, and with a large quantity of yellow feces. The mucous membrane of the stomach was slightly erythematous, and that of the duodenum, for an extent of several inches, evinced a high degree of erythema. The ileum, near its termination, was inflamed and ulcerated in patches, and nearly the whole in- ner membrane of the caecum was destroyed. There was scarcely any apparent deviation from healthy structure in the lungs, though 1 thought them a little denser than usual. Dr. Duchateau has published a fatal case of disorganization of the colon, the symptoms attendant upon which were regarded, even by Corvisart, as clearly indicative of aneurism of the heart: however, after death, all the thoracic viscera were found healthy. The relation between the symptoms and morbid appearances has sometimes been the reverse of what occurred in these cases. There have been symptoms of abdominal inflammation, and then of thoracic effusion; yet after death the abdominal viscera were found healthy. In the same month in which the preceding case occurred, I attended a girl in whom the ulcerative process must have been extremely latent, and its progress to a fatal issue was remarkably quick after symptoms of enteritis became manifest. She appeared to have contracted a modification of typhus by exposure to some relatives who laboured under that form of pyrexia ; and on the twenty-seventh of September, when in an advanced stage of convalescence, pain in the bowels supervened, which was-ac- companied with obstruction and inflammatory symptoms. The 78 tions of substance which resembled flesh. The in- testines certainly are often ulcerated in these cases, but not always. In a dysenteric woman, Brunnerus saw the orifices of the glands of the duodenum erod- ed ; and in others who had laboured under protract- ed diarrhoea he discovered ulcers of a cancerous na- ture. In one patient who had been annoyed with a purging for a long time, he counted upwards of sixty small ulcers in the tract of the intestinal canal, and in another the colon betrayed signs of ulceration. When this lesion has taken place, those parts of the intestines which are the seat of ulceration being ir- ritated by the contents of the ingesta, their expul- sion is accelerated without sufficient delay for the absorption of chyle, or, indeed, for its complete for- mation.—13. Many cases may be adduced which show that blood may be poured into the intestines from the orifices of the small vessels without any ulceration having taken place. Wagner observed this circum- stance in a case of scirrhous enlargement of the me- senteric glands. The large and small intestines were devoid of that mucous secretion with which they symptoms continued without abatement during the twenty-eighth, and on the following day she expired. Dissection. The abdomen contained about two pints of a thick yellow fluid, exceedingly offensive ; and flakes of lymph were suspended in it. The convolutions were united together, and the whole surface of the large and small intestines was highly inflamed, and covered with a coat of lymph. The villous coat of the intestines was inflamed and thickened ; and that of the large intestines was ulcerated in several places, especially in the caecum. In the ascending colon an aperture was formed by ulceration, capable of admitting a large quill, and through it feces haJ escaped into the abdominal cavity. I presume that inflammation and ulceration commenced in the villous coat, and insidiously proceeded till the intestine was perforated, when the acute symptoms were developed by effu- sion into the abdomen, and the consequent peritoneal inflamma- tion.—/W. 79 are generally covered, and the rectum was in a gangrenous state. In consequence of the obstruc- tion to the return of blood which arose from the in- durated condition of the mesenteric glands, the small vessels exuded a kind of blue liquor. Glisson, in his Treatise on the Diseases of the Stomach and Intestines, relates, on the authority of Wharton, an instance of excessive vomiting of blood consequent on taking poison. After death, however, though the stomach contained a small quantity of blood, there appeared neither the rupture nor the ulcera- tion of any vessel, but when the inner coat was wiped, with the handle of the scalpel, innumerable bloody points presented themselves on the surface. When Boernaave had been speaking of retention of the menses, and of the consequent effusion of blood by some other channel, he says, Vidi hujus- modi hcemoptoen, quae in consuetudinem abierat, ut san- guis floridus singulis mensibus, absque detrimento sani- tatis, cum levi tussicula excrearetur. Vidi ubi evome- batur sanguis : vidi per alvum deponi, et per sudorem. Haller has added a considerable number of exam- ples in which it happened not only without detri- ment to health, but may be supposed to have oc-i curred without ulceration. The circumstances which transpire upon the skin and on the surface of the stomach may take place in the intestines, so that, without doubt, in dysenteric affections there may be an effusion of blood independently of any destruc- tion of parts by ulceration.—23. It does not take place, however, without a con- currence of circumstances favourable to its produc- tion. If there is obstruction to the circulation through the vena portae, there must also exist a dila- tation of the secerning extremities of the vessels. Ortlobius placed a ligature on this vein in living dogs, but although the whole coat of the intestines wn- 80 imbued with a red colour, no blood issued from the intestines, because no dilatation of the orifices had taken place. The same author, however, speaks of a case of sphacelated intestines, in which the orifices of the mesenteric veins were enlarged and filled with coagulated blood. In dysentery there is sometimes genuine inflammation, and, from that state, a fatal degeneracy into gangrene takes place.—24. Case 16.. Dysentery from inflammation ; solitary kidney. A woman died of dysentery. Dissection. The intestines were found to be in- inflamed. The left kidney was altogether wanting, but the deficiency was supplied by the right, which was twice as large as that organ usually is, and was furnished with a double pelvis and double ureter. Valsalva, xxxi. 25. In a soldier who had been carried off by violent convulsions, whilst labouring under diarrhoea, Brun- nerus found the whole intestinal canal, but especially the small intestines, considerably inflamed, and the stomach was not wholly free from marks of erythe- ma. There were coagula of blood in the stomach, and a red mucus pervaded the intestines—circum- stances which indicated that the diarrhoea was about to degenerate into dysentery. There was no ap- pearance of gangrene, but it has already been shown that inflamed intestines readily pass into that state ; and probably to this circumstance is attributable the fallacious disappearance of fever which not unfre- quently happens a few days before death in cases of dysentery. The membraniform substances which are dis- charged from the intestines during dysentery, with blood ■ VOL. II. 30 306 The result of enlargement of the prostate gland is not always a retention of urine, for often it occa- sions a stillicidium. As the disposition of circumstan- ces varies, a diversity of inconvenience is induced. More or less impediment to the egress of urine, how- ever, generally arises from these prostatic produc- tions.—11. The following instance shows, that even in the female there may be an appearance of incontinence of urine, when the bladder is actually distended. Case 8. Retention of urine ; thickening of the coats of the blad- der ; dilated ureters ; cancerous uterus and vagina. A woman who appeared to be nearly forty years of age, had been affected with uterine haemorrhage, which was succeeded by a discharge of white matter from the uterus, accompanied with severe pain in the hypogastric region and in the subjacent parts, es- pecially in the night. She also perceived a degree of tumefaction in this part, and said that some smal- ler tubera, which formerly were scattered in the middle of the hypogastrium, had coalesced. Twelve months had elapsed from the commencement of this affection, when the tumour was found in the state which has been mentioned; but it ascended so high as scarcely to be two digits from the umbilicus. It was of a proportionate width, and was so prominent externally as to be visible. Its figure was roundish, its surface was uniform, and it offered resistance to the fingers. A constant dripping of urine came on, accompanied with spasmodic pain in the throat, nau- sea, occasional vomiting, emaciation, and fever. She was so debilitated and broken down by these affec- tions about the beginning of 1741, when she came into the hospital at Padua, that she died within six 307 or seven days : and none entertained a doubt that there existed a cancerous tumour of the uterus. This organ was, indeed, partially destroyed by cancerous ulceration, but the protuberance did not arise from that cause. Dissection. The abdomen being opened, it in- stantly appeared that the bladder, distended with urine, constituted the large tumour—a circumstance which nobody would have supposed, because urine had continually been running from her. The anteri- or part of the bladder had become adherent to the parietes of the abdomen high above the pubes; and, with the exception of this surface, and a portion of the fundus, the coats were so thickened as to equal the thickness of a finger. The inner membrane of the bladder was healthy, though, in some places, small vessels were turgid. On each side of the orifice of the bladder a white body was prominent internally, of an irregular figure, and equal in size to the apex of a man's thumb. They were produced from the substance that surrounded the urethra, and this sub- stance was universally thickened and indurated, and of a white colour. The ureters were greatly dilat- ed, and that part of each which passes between the coats of the bladder was unnaturally prominent, and terminated in an orifice wider than usual. One of the ureters was full of urine, and the other appeared to be filled with air. Even the tubuli and pelvis of each kidney had undergone dilatation. The ovaria were closely connected with the pa- rietes of the pelvis, and of a white colour. The left was about the size of a large chestnut, and the right was equal to a small nut. The latter contained a little serous fluid, probably within some kind of vesi- cle ; but there was nothing beneath the coat of the former except a soft and white matter like suet. The parietes at the fundus of the uterus were softer 308 than they usually are, but the cervix and nearly the whole of the vagina were made up of very thick, white, and hard parietes. The internal surface of the cervix uteri, and the orifice, and more espe- cially the vagina, were eroded by deep ulcers, which in some places were white, in some of a black and bloody colour, and in others cineritious. From these parts a putrid secretion, tinged with their respective colours, could be scraped off with the handle of the knife; and all the adipose and membraneous sub- stance, which is usually found at the sides of the va- gina, was converted into the same hard and white substance of which the vagina itself consisted. Morgagni, xxxix. 33. In many respects this case may be useful by tend- ing to excite caution. Under all the circumstances which have been related, who would not have sup- posed that the tumefaction in the hypogastric region, was a tumour of the uterus? The detached tubera, perceived at an early stage of the disease, were pro- bably the intestines forced upwards and compressed by the distending bladder. Who, being informed that the urine was dripping away, would have sus- pected that the bladder was distended with urine and which by an adroit introduction of the catheter might have been removed, to the great relief of the miserable patient? In a parturient woman who be- lieved that there was no urine in her bladder on ac- count of a similar stillicidium, Ruysch, at length, de- tected its fulness; and a large quantity was found to be retained. Therefore, whenever there is a tumour in the hy- pogastric region of women, although symptoms of a diseased uterus may not be wanting, we ought not to be unmindful of the bladder, which is situated an- terior to the uterus. Even should Ave be inform- ed that the urine issues from them involuntarily, we 309 must not take it for granted that none remains. And in those cases in which it is certain that the vagina is ulcerated, as well as the uterus, we are not always to infer, that should there be a stillicidium urinae, it is attributable to the ulceration of the annexed urethra and bladder. In the preceding case neither of these parts was ulcerated, but, what is an extraordinary ex- ample of cause and effect, a scirrhous induration of both of them produced an incontinence of urine and a re- tention at the same time. The hard parietes of the urethra did not admit of such constriction as pro- perly to close the orifice of the bladder; and the in- durated coats of the bladder, or, at least, of the greater part of them, could not so contract as to ex- pel its contents, and the remaining portion of these coats had coalesced with the anterior parietes of the abdomen.—34. Retention of urine often arises from affections of the urethra, some of which will be spoken of here after.* * Morgagni has very justly intimated that suppression of urine is a much more rare occurrence than retention; but as it some- times occurs, it is of considerable importance, for practical pur- poses, to distinguish the two conditions. The renal ischuria, as well as the vesical, may be total or partial, and it has been sup- posed to arise from inflammation and other morbid states of the blood-vessels, from obstruction in the secreting tissue, from spasm, local paralysis, certain passions of the mind, and as a symptom attendant upon some general diseases, as nervous fever. Retention of urine may arise from a great diversity of causes, and some of them I shall briefly enumerate. Although no urine should descend into the bladder, there may not exist any deficiency of the renal functions. For after the urine has been secreted, it may be retained in the pelvis of the kidney, or in the ureters. If detained in the ureters, Morgagni has shown that they may become greatly dilated, and their pa- rietes thickened. Urine may be arrested in its progress through these tubes, 1st, from calculi, hydatids, coagula, worms, pus, or mucus of a dense consistence ; 2d, from affections of the parietes, 310 Coats of the bladder thickened. The coats of the bladder are often found thick- ened after urgent and protracted dysury, not only when it arises from calculus, but also when it as inflammation, swelling, spasm, and some other lesions to which membraneous canals are liable; .»lly, from affections of the adjacent parts, as encysted dropsies, distended bowels, tu- mours, or scirrhous affections of the rectum, womb, ovarium, or bladder; and it has been attributed to inflammation of the blad- der. When the urine is retained in the bladder, it has been shown not only that the capacity of this organ has been so extended as to form a distinct elevation above the pubes, but, the valve of the ureters being obliterated, these canals, and the pelvis of the kidneys, may likewise participate in the dilatation. The bladder has been so enlarged under these circumstances as to contain eighteen pints of urine. The causes of ischuria vesicalis may be seated in the bladder itself, in the urethra, or the adjacent parts. At an advanced period of life, the contractile power is sometimes lost from paralysis; but this impediment may arise at any age, especially from injuries of the spinal marrow. In old age, too, the whole of the coats have been found cartilaginous, or this degeneracy has taken place only in the inner coat. The bladder is sometimes rendered unable to contract from inattention to the calls of nature, and this is particularly liable to occur after the person has drunk copiously, or has taken diuretics. Retention may be occasioned by tumours and hernia of the bladder; by extraneous bodies, as calculi, hydatids, worms, or coagula; and it has been said to arise from inflammation. Mechanical impe- diments pressing upon the cervix vesicae, or obstructing the orifice, may also render the patient unable to expel his urine. The most frequent of these causes is an enlargement of the prostate gland, and generally from a projection of its middle lobule; but it may be occasioned by the pressure of the gravid uterus, or a displacement of this organ; by tumours, or by the pressure of the child's head during protracted labour. In addition to the causes mentioned by Morgagni as obstructing the canal of the urethra, we might name inflammation and laceration of the inner membrane, spasmodic and permanent strictures, tubercles in the parietes of the canal, and tumours in the perineum. The bladder seems not only capable of sustaining a great de- gree of dilatation, but also of recovering from other important lesions. Patients have been restored after it has partially 311 originates from an excrescence of the prostate gland. In a case of this description which will be related when treating on the subject of calculi in the urinary bladder, the fibres of the bladder were so enlarged as to resemble the strong fasciculi of fibres in the heart. Ruysch mentions cases in which they were thickened to the extent of a digit, and the cavity was nearly obliterated. Riverius has described simi- lar occurrences, and amongst other cases mentions one calculous patient in whom the bladder had be- come externally fleshy. It is related in the Sepul- chretum,concerninga girl who had also been the sub- ject of febrile disease, that the inner coat of the bladder had been destroyed by ulceration, and the fleshy fibres of the outer coat were so affected with inflammation that the whole of it appeared to be fleshy. With this case we might join that of Camerarius, in which he found the bladder like a fleshy mass, the parietes being two inches in thickness, and the cavity scarcely larger than a nutmeg. We are the less surprised at this circumstance from recollecting the particulars of a case detailed in the Acta Helve- tica. The coats of the bladder were of such im- mense thickness, that although the bladder itself was almost equal in size to the head of an infant, the cavity was scarcely capablevof admitting a nut. I have just described the fibres of these coats as resembling the lacerti or fasciculi of the heart, and this comparison has been employed by other anato- mists. Indeed, no other can appropriately be em- ployed by those who meet with the bladder in the sloughed, from long continued pressure during labour. Mr. Hennen has mentioned a case in which the bladder was pene- trated by a ball, yet the patient recovered. Two pieces of cloth carried in with the bullet were voided, but the ball was not found.—Ed. 312 state which Trew has described and delineated. The inner coat was destroyed, and of the muscular he says, pro fibris tunicce muscularis ostenderet varios mirumque in modum collectos lacertos, magnis interce- dentibus lacunis distinctos. The bladder, whose parie- tes were in this state, contained large and rough cal- culi. Thickening of these parietes has occasionally been conjoined with ulceration; and sometimes it has appeared to arise from acrimonious urine. I have already shown that the parietes of this viscus may become thickened, and its fibres enlarg- ed, when it does not contain a calculus. In persons addicted to excessive drinking, the urine solicits the bladder to frequent contraction, and consequently may induce this state of the bladder: and any other cause which acts as a stimulus to it, excites an in- creased determination of blood to its vessels, and occasions thickening of the coats. Therefore, al- though this augmented thickness usually arises from an impediment in making water, it sometimes origi- nates from other causes; and when it has taken place it may tend to increase the difficulty if it pre- viously existed ; or it might produce it. This I shall briefly demonstrate after having related the follow- ing case.—Morgagni, xliL 33. Case 9. Thickening of the coats of the bladder; enlargement of the heart, and disease in the aorta ; the pharynx thickened. A sailor, fifty-five years of age, rather fat, addict- ed to drinking, ruptured, and accustomed to void his urine with difficulty, came into this hospital. He was not admitted, indeed, in consequence of the affec- tions alluded to, but on account of pain in the fauces. In the morning, he walked through the hospital, but 313 soon retired to bed again, where, not long after, he was found dead. When first discovered his face was black, but it speedily became pallid. This cir- cumstance happened about the end of January 1733, when I had commenced the anatomical lectures, and the body, still warm, was brought into the college the day after the fatal event. Dissection. The omentum was drawn above the stomach; the liver was elegantly marbled with red- dish and whitish streaks, and was rather large ; but the spleen was larger in proportion, although this organ was not of an extraordinary size. The kid- neys and ureters were in a healthy state, but the bladder was enlarged, and its coats were exceeding. ly thickened. The urethra was free from lesion- There was a hernial sac in the scrotum, but it was empty. The trunk of the aorta was somewhat tortuous where it lay upon the lumbar vertebrae, and its coats exhibited some white spots. There was some tor- tuosity also in the iliac branches, which were not only beset with opaque spots but were partially ossified. The heart was enlarged; in some places the semilunar valves were indurated, and the sides of the anterior mitral valve were ossified. Near the heart, the aorta exhibited more numerous spots than in other parts, and these would soon have been converted into bone. Between the heart and the curvature, the aorta was somewhat expanded, and was rugged internally from thick and rather tor- tuous rugae ; nor was it entirely free from slight - appearances of erosion. There were no spots in the carotid arteries; and I had not an opportunity of inquiring after the cause of the sudden death by ex- amining the head. The sides of the pharynx, of which this man had vol. ii. 40 314 complained, were thicker than usual, and by cutting into them, I found that the thickness was in the sub- stance of the pharynx itself, which, being unusually distended, resembled structure having an interme- diate nature between glandular and viscid sub- stances.—Morgagni, xlii. 34. There was nothing in this case to which the difficulty of making water could be imputed, except the extreme thickness of the coats of the bladder. I do not suppose, however, that a dysury would result from every species of thickening. It would not be likely to arise from that state in which the fleshy fibres are naturally enlarged, and which would render them still more capable of contrac- tion ; but from that in which not only the fleshy fibres are enfeebled by the deposition of extra- neous juices in their interstices, but the remaining coats, also, are in such a state of infarction as to render them less flexible, and on that account they obstruct the contractions of the bladder. In some of the preceding cases the coats of this viscus were not only thickened but also hard and callous,, so that although they were not all universally adherent to the pelvis, as happened in a case which occurred to Hottinger, yet they contracted with difficulty, and the expulsion of urine required vio- lent straining and exertion. These symptoms we may frequently observe from the same cause in cal- culous patients, unless the urine flows involuntarily from debility of the sphincter. In a nobleman of Pistoia, Targioni saw the coats of the bladder not only a digit in thickness, but also callous and full of steatoma; so that not admitting of extension they were capable only of containing a very small quanti- ty of urine between themselves, and a large calcu- lus which occupied the^avity. 315 Narrowness and coarctation of the bladder are usually conjoined with thickening of the coats, and the efforts employed to remove the disease often subject the patient to increased uneasiness and dan- ger. If the catheter is introduced, it is difficult to give it the necessary motion to "ascertain whether a calculus exists or not; and if violence is used, the pain becomes intolerable. When the bladder is cut into, under these circumstances, its coats being thick, and constricted about the calculus, considerable im- pediment may arise in its extraction. These remarks relative to the diminution of the Vesical cavity, in conjunction with thickness of the coats, and difficulty of extension, are not only im- portant to the lithotomist, but also extremely mo- mentous to the physician. For if a person subject to dysury is seized with ischuria vesicalis, the prac- titioner, duly impressed with these facts, will not suffer himself to be deluded, and suppose it prema- ture to draw off the water should there be but little tension in the hypogastrium. From a slight but very painful tension in that part, he will infer that as much urine has already accumulated as the nar- row and little extensible bladder can contain ; espe- cially if the patient is far advanced in years, and if, before the retention, he had been habituated to make water very often, and to void but little at a time. Under considerations of this kind, it has been my custom opportunely to accelerate the re- moval in cases of retention of urine, and I have never had occasion to repent this practice.—35. I must briefly advert to some impediments to the discharge of urine which are found in the urethra. Already I have spoken of induration and enlarge- ment of the prostate gland, which comprises the commencement of this canal. Sometimes an abscess forms in this gland, and it may not only swell and 316 ulcerate, but become callous. If the pus is effused, there may be an unnatural freedom for the transmis- sion of urine, and the same effect may arise from ulceration, in consequence of the action of the sphincter being destroyed; so that a stillicidium urinae might be produced. When the circumstances, at one period, are precisely such as now described, and, at another, the gland becomes tumid from re- turning suppuration, there will, at one time, be in- continence of urine, and, at another, dysury. The latter may degenerate into a very dangerous reten- tion, and the danger will be increased if the inflam- mation, or the hardness and tumefaction of the gland, forbid the employment of the catheter. These circumstances have occurred to others as well as myself; and in 1714, Valsalva was consulted in behalf of a knight, in whom retention took place under these circumstances; on which occasion he suggested that if an instrument could not be passed through the natural channel, the bladder should be punctured.—36. Prostatic calculi, and other lesions in the urethra. Calculi have sometimes been found in the pros- tate gland. In one of the cases which occurred to me, there could be no emission of semen, because the calculi were situated so as to prevent its escape; and this instance brought similar ones to my recol- lection. Marcellus Donatus, speaking of a man in whose prostate he found a calculus, says, JVon po- tuisse semen, nisi paucum admodum, aquosumque valde in coitu excernere. Lossius ascribes impotence to this cause ; and Nicolaus de Blegny relates that se- minal ejaculation had been prevented in consequence of the vasa ejaculatoria being full of hard concre- tions, most of which, in their shape and size, re- 317 sembled a pea. Rhodius found a calculus in this part by which the orifice of the bladder was com- pressed, and the expulsion of urine prevented. Ter- raneus found small and unequal calculi lodged in the ducts of the prostate, and at the orifices of the vasa deferentia, from which circumstance the patient suf- fered uneasiness, and both the discharge of urine and the emission of semen were obstructed. James Douglas found some small hard bodies, similar to white peas, in the substance of the prostate gland, and others adhered by small roots to the membrane which covered the gland. Additional instances might be adduced, but they do not afford any peculiar symptoms by which the existence of prostatic calcu- li can be ascertained. For though, in most cases, the ejaculation of semen is prevented, this is not a uniform result; and other causes might produce the effect alluded to.*—37. I shall now briefly advert to some of the lesions which are common to other parts of the urethra. On a future occasion I shall allude to a case in which calculi were found beneath the internal membrane of the female urethral*, and shall not anticipate it, but will rather describe the appearances which pre- sented themselves, at any part, through the ure- thra. A difficulty in expelling urine, as well as ob- struction to the catheter, may be ascribed to various causes within the urethra. Amongst others, these impediments may be particularly attributable to ci- catrices, to turgid and varicose blood-vessels, by * Prostatic calculi have been found by Dr. William Hyde Wollaston to consist of phosphorated lime in a state of neutrali- zation. According to Dr. Marcet they are composed of phos- phate of lime, not distinctly stratified, and tinged by the secre- tion of the prestate gland.—Ed. + Vide Calculi in the uterus. 318 which a coarctation of some part of the urethra takes place. The corpus spongiosum urethrae itself is said to protuberate within the canal at those parts where gonorrhoea might have considerably relaxed the inner coat. Goulard entertained the opinion that this was the most frequent cause of obstruction in the urethra, but that it was not observable after death, as the cause which dilated the cells ceased with the circulation of the blood, at the time of death; so that, by degrees, the protruded parts sub- sided, and left no trace perceptible to the anatomical inquirer. However, I believe that when they have existed in the living body, they will become visible after death, if the spongy part of the urethra is in- flated, in the same degree as it had been distended with blood during life; and if the urethra is dried in this state, and cut into, undoubtedly the place within this canal where the obstacle had existed will be discovered. This author has not, indeed, denied that there are other causes of obstruction, such as contraction, corrugation, cicatrices, and some- times even a fleshy excrescence. In the great num- ber of urethras which I have attentively examined, I have only once distinctly observed a fleshy excres- cence, but many times have witnessed strictures and cicatrices ; and the excrescence to which I have al- luded was associated with these other morbid ap- pearances.—38. Case 10. Excrescence in the urethra. A young man died in this hospital of a wound in the head, about the middle of December 1717. Dissection. The stomach was enlarged, and ex- hibited scarcely any rugae. The liver exceeded its usual bulk, and the hepatic artery was dilated. 319 There were many cicatrices on the kidneys; but they were more numerous on the glans penis, which had become very small, and exceedingly misshapen, owing to the large scars. From this extremity the urethra was very distinctly straitened through a third part of its whole length, and none of the larger canals which I have described in a former work were visible ; but their place was occupied by an interrupted line, composed of a thin excres- cence of luxuriant flesh. The epiglottis was not perfectly healthy, and in the aorta there were incipient marks of ossification, and obscure traces of ulceration. Besides these ap- pearances, the aorta, a little above the heart, was considerably dilated.—Morgagni, xlii. 39. Case 11. Stricture of the urethra; diseased bladder and kid- neys ; ureter dilated. About the same time I dissected the body of an old man who was a foreigner. That he had been affected with the venereal disease, as well as- the young man of whom I have just spoken, the follow- ing appearances will sufficiently demonstrate. Dissection. One of the kidneys was very large, but the other was contracted, and the ureter be- longing to this organ was almost universally dilated to such a degree as to admit the point of my little finger. The bladder was large, and its parietes were thickened and purulent. The glans penis was hollowed out by numerous deep cicatrices, and the urethra was extremely contracted, so that I was scarcely able to demonstrate one of the small ducts. The epiglottis was not perfectly healthy, and the 320 contiguous part of the tongue, which is covered with glands, in some places exhibited small ulcers. Morgagni, xlii. 40. In former articles I have mentioned other changes which had taken place in the urethra, as promi- nent fibres, oblong whitish lines, oblique and almost fleshy fibrillse ; and I shall specify other appear- ances when treating on the subject of gonorrhoea. —41. Excrescence, and other diseases, in the female urethra. I have frequently dissected female urethras, and attentively examined them, but hitherto, with a solitary exception, I have neither met with cica- trices nor excrescences ; and this circumstance should not occasion surprise, because the canal is short, and not very narrow. However it is not wholly exempt from ulceration or excrescence. As- true, more than once, has seen the substance which surrounds the female urethra suppurated and fistu- lous, and discharging pus by an opening in the ure- thra. At other times he found the urethra exces- sively straitened, from the same substance being tumid and callous. Alghisi mentions a maiden in whom a thin medicated candle had been left in the urethra to destroy a carnosity. Mullerus, too, has described a fleshy excrescence found in the urethra of a widow. Examining the body of an old woman about the beginning of 1751,1 met with a small triangular ex- crescence within the external orifice of the urethra, but it was not prominent: and very often, particu- larly after acute fevers, I have observed nearly parallel blood-vessels creeping through the internal coat of the urethra, so turgid and crowded that nearly the whole of the canal was black. In a 321 young maiden, and also in a woman advanced in years, I saw a portion of this coat prolapsed exterior to the orifice of the meatus ; but although it was easy to conjecture what inconvenience in the expul- sion of urine must have resulted, I was not informed on that point. I was unwilling to entertain the sus- picion that the protrusion had arisen from the mea- tus's being frequently irritated by a needle or bodkin, especially as it might arise from strangury. That this membrane might be urged downwards by violent strainings to expel the urine, is not only accordant with reason, but has been confirmed by the observa- tion of Mullerus. For the red and fungous excres- cence, which was of the size of a bean, and proceeded from the orifice of the urethra, so as to close it, having been in a great degree removed, the remain- ing internal part was rendered conspicuous only by that kind of straining which is employed in empty- ing the bladder. Corn: Solingen relates an instance of inversion of the meatus urinarius, which hung downwards the length of a finger; but a suspicion has been enter- tained that Solingen was deceived as to the nature of the pendulous part. The female urethra being shorter, and having more laxity of structure than the male, small calculi frequently fall out; and occasionally, stones which are by no means of a small size, are extruded spon- taneously. Various authors have described such instances, but I know of none in which the calculi were so large as in an instance mentioned by Senner- tus, and that recorded by Tulpius. The for- mer says that the stone expelled was nearly as large as a hen's egg; and in the case spoken of by the latter, it weighed three ounces and two drams. I do not recollect to have read of any other calculus being expelled, which was so large as this, and, in- VOL. II. 41 322 deed, I believe it to have been of the greatest mag- nitude which a calculus has attained in the female bladder; but in the male bladder, I know that they have acquired an immense size. In the Sepulchre- tum human calculi are mentioned of thirty-two and thirty-four ounces; and Targioni asserts that there is one at Florence which weighs thirty-nine ounces; and it is more remarkable because it was found in a man, who, after a happy and vigorous old age, was carried off by a disease which excited little suspicion of urinary calculus. Another of the same weight is noticed by Verdu- cius ; one met with by Launayus weighed fifty-one ounces; and Kesselringius asserts that he saw one in the possession of Morand equal to six pounds and three ounces. But we read of no such large calculi in the female bladder; and, undoubtedly, this is ascribable to the urethra being shorter and wider, so that the greater part of the viscid and calculous mat- ter passes off. This matter being retained in the male bladder, enlarges the calculi by accretion. Adolphus published a case in which an oblong cal- culus formed in the urethra of an old woman, and firmly adhered to it; and the circumstances just ad- verted to, contribute to render this occurrence the more extraordinary.—42. Morbid appearances in the urine. Urine is sometimes voided which is white and tur- bid like milk. About forty years ago, a controversy was agitated whether this appearance was occasioned by chyle or pus, but after a careful investigation of the conflicting opinions I expressed my belief that it arose from the latter. I was not ignorant, indeed, that chyle might be discharged from the kidneys if the secretory structure was greatly relaxed; but in 323 the patient whose disease led to this controversy, long before the urine had the qualities which have been mentioned, symptoms of lesion in one kidney had existed; and the same symptoms accompanied the discharge. After death the kidney of the af- fected side was found half putrid, and reduced to a very small bulk. A purulent sediment in the urine is not always viscid, and that deposite which is most glutinous has been attributed by the most experienced physicians to the bladder: and, from his dissections, Valsalva was accustomed to ascribe this morbid secretion much less frequently to the kidneys than to the parts below them.—44. The controversy alluded to was carried on at Pa- dua; and at Venice there was another dispute, to de- termine whether or not blood was combined with the urine of a certain abbot, for none subsided, even when it had long been kept. On being consulted, I persuaded the disputants to institute the experiment of applying fire, assured, that if blood should be con- tained in the urine, by this means it would coagulate. This experiment at once terminated the discussion.* * Invalids very properly attach great importance to the state of the urinary excretion ; but although uniformly inquired into by practitioners, few possess any precise knowledge respecting its morbid qualities. I gladly, therefore, avail myself of an inte- resting abstract of these phenomena from Dr. Ure's Dictionary of Chemistry. " The changes produced in urine by disease are considerable, and of importance to be known. It is of a red colour, small in quantity, and peculiarly acrid in inflammatory diseases, but de- posites no sediment on standing. Corrosive muriate of mercury throws down from it a copious precipitate. Towards the ter- mination of such diseases it becomes more abundant, and depo- sites a copious milk-coloured sediment, consisting of rosacic acid, with a little phosphate of lime and uric acid. " In jaundice it contains a deep yellow colouring matter, ca- pable of staining linen. Muriatic acid renders it green, and this 324 I have already intimated that concretions of blood which form in the ureters, or urethra, have been mistaken for worms.*—45. indicates the presence of bile. Sometimes, too, according to Fourcroy and Vanquelin, it contains a substance analogous to the yellow acid, which they formed by the action of nitric acid on muscular fibre. " In hysterical affections it is copious, limpid, and colourless, containing much salt, but scarcely any urea or gelatin. " In dropsy the urine is generally loaded with albumen, so as to become milky, or even to coagulate by heat, or on the addi- tion of acids. In dropsy from diseased liver, however, no albu- men is present, but the urine is scanty, high-coloured, and depo- sites the pink-coloured sediment. " In dyspepsy, or indigestion, the urine abounds in gelatin, and putrefies rapidly. " !n rickets the urine contains a great deal of a calcareous salt, which has been supposed to be phosphate of lime; but, ac- cording to Bonhomme, it is the oxalate. " Some instances are mentioned, in which females have voided urine of a milky appearance, and containing a certain portion of the caseous part of milk. " But among the most remarkable alterations of urine is that in diabetes, when the urine is sometimes so loaded with sugar as to be capable of being fermented into a vinous liquor. Upwards of one twelfth of its weight of sugar was extracted from some di- abetic urine by Cruickshank, which was at the rate of twenty- nine ounces troy a-day, from one patient. In this disease, how- ever, the urine, though always in very large quantity, is some- times not sweet but insipid."—Ed. * The caution here given by Morgagni is a very necessary one, because concretions from extravasated blood, formed in the ureters or urethra, are liable to be mistaken for the animals they resemble. However, worms have unquestionably been voided from the urinary organs. In a case related in the Medico-Chi- rurgical Journal, (Sept. 1816,) a description is given of a worm said to have been expelled from the urethra. It was four inches long, as large as a lumbricus, had a flattened head like a leech, and was very lively. When examined by the microscope, rings could be distinguished on the thickest part of the body. A very interesting case, too, is related by Mr. Lawrence, in the second volume of the Medico-Chirurgical Transactions. Medical men, however, need excessive caution, because, from motives inac- cessible to them, artifices are often employed which they are called in to sanction. I am acquainted with one instance in 325 Preternatural communication between the bladder and i adjacent parts. It has occasionally happened, that in consequence of inflammation, adhesion and ulceration have taken place between the bladder and nearest intestine, and a communication has been established between them, so that some of the contents of the latter, such as feculent matter, portions of leaves, roots, small grapes, and other undigested substances, have been voided with the urine.—45. When there is a communication between the blad- der and rectum, urine is expelled through this chan- nel. The most ancient example of this fact is de- rived from Praxagoras, who relates that he had seen a man who had then excreted urine per anum for twelve years, but he was uninformed how long it continued afterwards. In the Sepulchretum there is the example of a man who, from childhood till his fiftieth year, had uniformly discharged urine through the anus; for a lithotomist having extracted a calcu- lus from him when a boy, had so far injured the bladder, that after death an aperture, a digit wide, was found between the bladder and rectum. Ab- scesses sometimes form and occasion this preternatu- ral channel for the discharge of urine; and some- times it is the result of accidental injury. The blad- der and rectum have also been ulcerated from cal- culi. In a nobleman who had discharged blood and urine from the intestines, Moraschius found a calcu- which a deception of this kind was attempted with worms af- firmed to have been voided from the bladder, but on minute in- spection they were found to be small earth worms. Hydatids have been discharged from the urethra, but I do not know that they have ever been found attached to the blad- der.— Ed. 326 lus of the bladder adhering to fungous flesh, and the stone, at length, had perforated the bladder and in- testinum rectum. However, in some instances, there have been dis- charges of urine from the intestine, which appeared to be entirely unconnected with ulceration of the bladder. The case of a boy is mentioned in the Sepulchre- tum, who, for ten years, had suppression of urine, but a few drops of turbid urine escaped from the anus. After death his kidneys and ureters were found in a state which must have totally unfitted them for their natural functions, and the bladder was not perforated. In other cases «of ischuria renalis, as well as in re- tention of urine, I have already shown that this fluid has been excreted by the anus. Reusnerus relates, that on the seventh day of complete suppression, a child voided urine from the intestines, which, in co- lour, smell, and quantity, resembled that which is naturally excreted. It was not combined with any feculent matter, or attended with pain; and it pass- ed off" about three or four times daily. At the ex- piration of some days the urine was again suddenly emitted through the urethra, without the least pain, or troublesome symptom; and it continued to be evacuated naturally during the succeeding years. Therefore we must not attempt to explain every excretion of urine per anum, by supposing the exis- tence of an unnatural communication; but where, in consequence of renal or vesical ischuria, the blood is overloaded with urinous particles, and there is no symptom of any preternatural canal between the kidneys or bladder and intestine, the case may be explained in the same way as I have accounted for a vomiting of urine, namely, from its being secreted by the intestinal glands.—46. 327 Abscess of the bladder. That abscesses may form between the coats of the bladder, is shown by a case in which, from the tumefaction of the abdomen, and other symptoms, the woman Was supposed to be pregnant; when, in fact, the prominence arose from a large abscess form- ed between the anterior coats of the bladder. xxxix. 34. Case 10. Ulceration of the bladder and vagina. An old woman for seven months was afflicted with pain in the lower part of the- abdomen, especially at the time of micturition; and, at length, the pain be- came exceedingly excruciating. She died in 1757. Dissection. 1 he ovaria were white and scirrhous, and of a small size. The whole inner surface of the vagina and of the bladder was ulcerated, and cover- ed with fetid pus, with which the bladder was half filled. It appeared that these organs were the seat of carcinoma.—Morgagni, lxvi. 2. Calculi in the urinary bladder. I have found but two cases of this affection in the papers of Valsalva, and one of them has been already described on account of its relation to apoplexy. Case 1. A boy, nine years of age, had for six years suffer- ed from a calculus, which at intervals exceedingly annoyed him. His urine often contained filamentous substances, but it was of a natural colour, except when bloody from over-exertion: and frequently it escaped involuntarily. Sometimes by introducing the 328 finger within the rectum the calculus could be felt, but at other times it was imperceptible. A lithotomist undertook to extract this calculus, and after having teased the boy for a long time, he with great force drew away a small stone; and per- ceiving that there existed another, he again tortured the little patient to such a degree that the pain al- most suffocated him. The stone was broken, and, at length, he extracted a fragment. Scarcely had half an hour elapsed when the boy began to vomit, and he constantly complained of vio- lent pain at the lower part of the abdomen. Slight tumefaction of the abdomen was added to these symptoms, and was accompanied with fever, difficulty of breathing, and disquietude. He died in twenty- four hours after the operation. Dissection. The bladder and surrounding mem- branes were inflamed; and at the anterior part, near the cervix, the bladder was lacerated. One half of the second calculus remained in the cavity. Valsalva, xlii. 8. The temerity or unskilfulness of the lithotomist in this case is inexcusable, and the fault consisted in not having made a sufficient opening.—Morgagni, 9. It has happened in other cases besides this, that at one time a calculus could be distinguished by the in- troduction of a finger into the rectum, and, at ano- ther season, it was imperceptible; nor is even the introduction of a catheter at all periods satisfactory. Even Cheselden himself, as well as other surgeons, has sometimes not been able to detect a calculus though the catheter was introduced three times, and yet it was unquestionable that one existed. Calculi have sometimes been latent in the blad- der for many months, indeed, for several years. In the Sepulchretum a case is mentioned in which, dur- ing five successive years, scarcely any of the trouble- 329 some symptoms of stone remained ; and, in another case, this comparative immunity was experienced from childhood to the age of thirty-five ; yet in both cases the patients had previously been afflicted with those symptoms, and large calculi even then occu- pied the bladder. In the bodies of some persons who died of de- crepit old age, either a large calculus, or a number of calculi, were found in the bladder, and the cir- cumstance excited surprise, because no complaint had been made of this disease. In relation to this fact I could multiply examples. In the year 1752, when teaching anatomy in the college, an eminent apothecary showed me a perforated calculus which had been voided by a female. It resembled that delineated by Alghisi, except in the greater narrow- ness of the foramen ; and I suppose it had formed at the orifice of the urethra. When sabulous and viscid matter abounds, particles of them remaining after the last drops of urine have been expelled, may sometimes concrete at the part where a hollow is occasioned by the projection of the prostate gland in the male, and of the corpus glandosum in the female, and here it may acquire an annular form, as if it had been cast in a mould. It may remain there till dislodged, and urged into the urethra, which in females is rather wide and dilatable. In this woman its passage was proportionately more easy in con- sequence of approaching an elliptical figure, one ex- tremity of which was a little narrower than the other. She was a maiden, eighty-two years of age, and had not been warned of its existence by pain or even by an uneasy sensation; she had only no- ticed that the urine was sometimes voided in a more slender or thread-like stream than usual. However, when the calculus fell into the urethra, it suddenly excited pain, and produced efforts for its vol. ii. 42 330 expulsion; so that within half an hour it became prominent, and was removed by the fingers. No un- pleasant consequences resulted. Although the foramen allows the transmission of urine, however, it does not always prevent the su- pervention of uneasiness. Several cases on record demonstrate this circumstance, and Vallisneri inform- ed me that an intimate acquaintance of his at Pa- dua, had been violently affected with most of the symptoms of urinary calculus, and they were so pro- tracted that had there been an obstruction of urine, every physician would have pronounced that a stone occupied the bladder. However, many were of a different opinion because he always voided urine without any difficulty, even when in an erect posi- tion. On examining his bladder after death three smooth calculi were discovered; they were of a roundish figtire, and when placed near together, a triangular foramen was left between them. In these cases the calculus might be perceived by the introduction of the catheter, but when cal- culi are contained in a diverticulum, formed at the side of the bladder, they are imperceptible. Of the origin of these diverticula I shall have a better op- portunity of speaking hereafter; an allusion to them now is sufficient to show how much patients them- selves, as well as hthotomists, may be deceived, if calculi which before were in the bladder, should re- cede into a sacculus, from which, according to the position and motion of the patient, they may return into the bladder. It will sometimes happen that out of many hthotomists only one may perceive the stone, and to the same individual it may at one time be perceptible, but not at another. The pa- tient might previously have complained of tenes- mus, from the weight of the stone pressing against the subjacent rectum like a quantity of hardened 331 excrement; when the bladder was contracted to ex- pel its contents, he might have experienced violent pain from the stone irritating the coats of the blad- der ; and he might have suffered occasional obstruc- tion to the discharge of urine from the interposi- tion of the foreign body ; but when the stone has been diverted into a lateral sacculus of the bladder, he is exonerated from all these symptoms, and ap- pears totally relieved from the disease.—10. Case 2. Calculi in the kidneys and bladder; and calcareous matter in the prostate gland. Andrew Cortini, the subject of the present case, was rather fat, and sedentary, and when he had passed his sixtieth year, his urine became white and viscid. A surgeon, on introducing a catheter, dis- covered a stone in the bladder. After the intro- duction of this instrument he voided urine more easily, and did not complain so much of the incon- venience attendant on this evacuation, as of a pain at the scrobiculus cordis, which compelled him to stop if he attempted to walk a little quicker than usual. This was accompanied with turgid and vi- brating pulsations of the arteries, such as frequent- ly happen from aneurism; nor did these affections cease when, after a long interval, the difficulty of making water returned, with a sense of ardor about the pubis. Indeed, he complained of almost con- stant pain at the scrobiculus cordis. Three or four years had elapsed from the com- mencement of the dysury, and twenty-two months from the beginning of the other unpleasant symp- toms, when in February 1711, I was called to the patient, to console him, rather than to cure him, as I immediately said to his domestics. 332 The quantity of urine he voided greatly exceeded that of the fluids drank. It was of a whitish yellow colour and turbid; and was discharged with difficulty and pain. The pain at the pit of the stomach, at in- tervals, was extremely violent and gnawing; and at these periods the sternum and adjacent parts were painful also. The left arm became benumbed and insensible, and the heart palpitated to a troublesome degree, especially during decumbence on the left side. Every day these symptoms increased in se- verity, and the face, instead of being florid during the exacerbations of pain, as it had generally been, became cold. His hands and feet also were cold, and the bowels, which hitherto had required the daily excitement of an enema, became so lax that he passed a bilious dejection after each exacerba- tion. In proportion as the severity of these pa- roxysms increased, every symptom of irritation about the bladder was mitigated, and the urine was ex- pelled with greater freedom. There was no hard- ness or tension of the abdomen. His sleep was in- terrupted by the painful affections I have described, his appetite was impaired, and he was annoyed with thirst; consequently, his strength failed, his mind became torpid, his pulse sunk, and frequently was unequal, and the feebleness and inequality of pulsa- tion were greatest on the left side. On the eighth of March he died. Dissection. The body was still rather fat, and the thoracic viscera were healthy. The liver was not of a natural colour, the gall-bladder was con- tracted and flaccid, and the fundus of the stomach exhibited a slight appearance of blackness. The interior substance of the left kidney was al- most entirely removed, and the remainder was ex- ceedingly flabby, and contained an irregular calcu- lus, with some urine similar to that which had been 333 voided. Urine having the same appearance was contained in the right kidney, the upper surface of which was divided into a considerable number of prominences like globules of an unequal magni- tude. The bladder contained three calculi which were neither rough nor large. The inner surface of this cavity appeared to be constituted of a fine tomen- tum; and, at the side of the cervix, a hard tubercle arose, not larger than a bean, and of the same co- lour throughout as the bladder. There was a sinus in the prostate gland which contained matter re- sembling tartar, and nearly calculous. Morgagni, xlii. 13. The causes of dysury, in this patient, were seated in the prostate gland, the bladder, and kidneys ; and the violent pains by which he was so excessively tormented, likewise arose from the kidneys. No practitioner can be ignorant how intimately the stomach sympathizes with those organs ; and to this sympathetic influence the vomitings usually atten- dant upon disorders of the kidneys are ascribable. It is also well known that pain in the stomach is frequently united with renal diseases, but it is not pain which leads to fatal consequences, nor is it usually disjoined from pain in the loins, which gene- rally accompanies the lesions of these viscera. How- ever, in the preceding instance, there was no pain in the loins, no severe pain in the bladder or hypo- chondria, nor any vomiting; but the intolerable pains in the scrobiculus cordis were the only symptoms of disease in the kidneys.—14. Case 3. Culculus in the bladder ; suppuratiofi in the kidneys ; ureters dilated. A young man, who had passed his twentieth year. 334 had for a long time been afflicted with such pains of the bladder, especially when he made water, that he could not expel his urine without crying out, and the urine itself presented a purulent appearance. Emaciation, fever, and the other affections which usually accompany stone in the bladder, had come on; and, before the close of 1742, he died in this hospital. Dissection. The bladder contained a calculus which was somewhat rough externally, three digits in length, and two and a half broad ; and in some places a large quantity of tough and bloody mucus adhered to it. The coats of this viscus were thick- ened and ulcerated, and were partially scirrhous. The kidneys and ureters were full of pus and urine; and the ureters were dilated to such a degree as to equal the intestinum ileum in diameter. Morgagni, xlii. 15. Mucus, which we saw adhering to the calculus in this instance, sometimes accumulates so abun- dantly upon these concretions, that, from this cause, they may not be distinguishable even upon introduc- ing the catheter. This circumstance, which has happened to the most experienced men, occurred to Fallopius ; and the pain, also, which arises from cal- culus, becomes mitigated, especially if the adhering mucus is of a thick consistence. On this account, diuretic medicines tend to augment pain. The other symptoms attendant upon stone are not alleviated in consequence of this mucous investment; indeed some of them are increased.—16. My dissections of persons afflicted with stone certainly have been but few, because it is not a disease of frequent occurrence in this country. The disease is not peculiar to the human subject, for cal- culi have been found in the bladder of oxen, pigs, dogs, and other animals. In a dog that had been 335 affected with incontinence of urine for a long time, some thousands of small calculi were found in the distended bladder; and this viscus, in another dog, contained a calculus which weighed a pound and a half. When there have been asperities on the sur- face of these concretions in dogs, the discharge of urine has been accompanied with violent howlings. Calculi have also been found in the liver, gall-blad- der, stomach, and intestines of animals.—17. Calculi are said to have been voided by one in- fant two days old, and by another eight days; and in both instances concretions were found in them after death. Whether an incipient calculus, or the matter of which it is formed, descends from the kidneys into the bladder, or is generated in the bladder itself, undoubtedly the calculus derives its increase from the same matter; and I apprehend that those who maintain that the accretion of these granules will be firm in proportion as the increase is slow, are cor- rect in their opinion. Besides calculi originating in the kidneys and blad- der, the same earthy deposite may adhere to any extraneous body introduced into the bladder. Many examples of this description have been collected by authors, but I shall chiefly describe those observed by myself or by my friends.—18. The first case that offered itself to me was pub- lished in the Ephemerides Ccesarece JY. C. Academicce, forty-three years ago. The incrustation had taken place around a needle. The calculous matter was friable; its texture was spongy; and there were some lamina? towards the surface. In the Sepulchretum calculi are spoken of which had a flinty hardness, and even struck fire with steel; and, on the autho- rity of Heers, one is said to have been harder than flint. However, no calculus has ever been exhibited 336 to me, to which this description was applicable, ex- cept when some fraud had been practised. These deceptions have been carried so far, that on one oc- casion a river pebble smeared with blood, was ob- truded upon the incautious for a calculus of the bladder. A physician at Venice, in other respects a well-informed man, transmitted to me the particulars of a woman who he said almost daily voided a con- siderable number of calculi, and not very small; and with the letter he forwarded a considerable number of the stones in question. I was astonished that an individual existed, who did not discover them to be large and rugged fragments of common flint. However, calculi generated in the bladder are sometimes extremely hard; and undoubtedly we must believe the celebrated Morand, when he as- serts that those which he denominates murales take the same polish as marble. In consequence of observing that when calculi were thrown into a mixture of acids and alkalies, they were either totally or partially dissolved, ex- periments were made, by injecting effervescing fluids into the bladder of a dog, to ascertain how far the bladder could bear them. But although borne by this viscus when in a healthy state, certainly they would be intolerable to it when irritable and ulce- rated from calculi.—19. Case 4. Calculus from deposition on a bodkin. A country girl, about the same age as the indivi- dual alluded to above, had committed similar indis- cretion, and the consequences were equally fatal. She died in her fourteenth vear, and sixteen months before that event happened, she introduced a brass hair-bodkin, bent in the middle, very high into the 337 urethra. At that moment she perceived that it was suddenly snatched out of her fingers, and became entirely concealed within the bladder. She expe- rienced much pain, especially at the time of making water, but a consciousness of guilt restrained her from acknowledging the real cause of her sufferings till her decease approached. Swelling arose and occupied the hypogastrium, and the adjacent part of the ileum; and pus escaped by two foramina which had spontaneously formed. The larger open- ing was in the left iliac region, and the smaller on the right side, in that part designated by Laurentius, the fines hypogastrii. In this state she was received into the hospital a month or two before her death ; and it was observed that urine issued from the fora- mina as well as pus, and that there was a space be- neath the left, with which the right also communi- cated. Within this cavity the probe came into con- tact with something hard, and I immediately recol- lected what had resisted a similar instrument when introduced through a fistulous opening, discharging urine, in the former girl. Combining this circum- stance with the pain in the bladder, I inquired if she had introduced a bodkin, or any extraneous body into the urethra. She denied having done this, till the left foramen was enlarged by a slight division of the common integuments, when the greater part of the bodkin was distinctly visible. Unable any longer to conceal the truth, she confessed what she had done when it was too late. The bodkin could not be extracted on account of a calculus having gather- ed around it; and though it was easy to perceive the calculus by introducing a probe through the ure- thra, or through the cavity which has been mention- ed, yet it was impossible to move it in the slightest degree without exciting most violent pain. The concretion blocked up the urethra so that nothing vol. n. 43 338 could be injected into the bladder to allay the pain. She became emaciated, the quantity of purulent discharge increased, the fever became extremely violent, and the putrescent odour exceedingly strong. These symptoms were accompanied with a loathing of food, vomiting, and bilious diarrhoea; and the debility was progressive till death terminated the patient's miseries. It is worthy of remark, that she had not been heard to complain of pain in the loins. Dissection. In the examination of the body I first directed a probe to be passed through the right foramen into the cavity of the ulcer, and the whole sinus to be laid open. It was situated between the abdominal muscles and integuments, and was three digits in length and breadth. It extended from the left ileum towards the linea alba; the posterior pa- rietes were thin, and were constituted of the re- mainder of the muscles, and of the peritoneum ; but through the same parietes, which were open on the right side, it communicated with the fundus of the bladder; and at that point a large extent of the bod- kin projected into the cavity of the ulcer. When the abdomen was opened, it was observed that the bladder adhered to the abdominal parietes pretty high above the pubes, so that there had been no effusion of urine into the abdominal cavity ; and the lower border of the omentum, which scarcely con- tained any fat, was closely united with the peritoneal coat of the bladder. The coats of the bladder were thickened, and so contracted that the cavity would scarcely contain any thing except the stone. In many places the inner coat was rough and ulcerated, and in some parts it adhered to the concretion. Like the cavity of the ulcer, too, at several points the inner coats had become gangrenous. The calculus was a little more than two digits in 339 length, and somewhat thicker than a man's thumb. It was of an oval figure, and its vertex, with the point of the needle, was turned upwards. It weigh- ed about seven drams. Some of the intestines were slightly livid, and somewhat turgid with yellowish matter. The liver was white; the spleen was of a rather deep livid colour, and a little enlarged. The ureters were dilated, and full of a purulent fluid mixed with urine, which resembled matter found in consider- able quantity in the ulcer. The kidneys were en- larged, especially the right, which also was hard, and excavated into small cells. The cells, as well as the pelvis of this organ, were excessively distended with the same kind of fluid as that con- tained in the ureters. The capsule and proper coats of the left kidney were united together, were thick- ened and indurated; and matter resembling that which has been mentioned, pervaded both the inte- rior of this kidney, and also the surface, which was ulcerated in several places. A most offensive odour exhaled from the kidneys and bladder. Morgagni, xlii. 20. Occasionally, bodkins said to have passed into the bladder have afterwards fallen out. Two cases are mentioned by Vallisneri, in one of which the bodkin escaped during sleep, and in another it was expelled at the time of making water. Although I suspect that in these instances the bodkins had only partial- ly entered the bladder, I do not intend to deny the possibility of their being discharged when they have been completely admitted into that viscus. Extra- neous bodies have remained* in the bladder fifteen days, yea, for a month, without being incrusted. The urine in all persons is not equally impregnated with particles suitable for the generation of calculi; some persons retain their urine longer than others; and 340 there is a diversity also in the composition and sur- faces of bodkins. Deposition seems more likely to take place upon a somewhat rough surface, than on one that is polished ; and hence, perhaps, we are to account for the circumstance that generally one part of a bodkin is covered with calculous matter, whilst another remains naked. When a bodkin had been thrust into the bladder, and it had remained there for a long time, and a cal- culus of a considerable size had formed upon it, 1 do not recollect to have read of more than a solitary in- stance of its being successfully extracted. The sub- ject of this favourable issue was a Venetian woman, and the circumstances were published by Molinetti, under whose management the cure was effected in 1649.—21. The unhappy consequences which result from the retention of these extraneous bodies may be averted, if the fact is disclosed before a deposition of calcu- lous matter has taken place; and sometimes the re- moval is effected without injuring the bladder. 1 was present when Vulpius accomplished the extraction of a brass pin, by means of a very smooth iron wire, one extremity of which he had curved nearly into a ring; so. that while no injury could be inflicted on the bladder, it was capable of holding the pin, with- out suffering the head to slip through. Should the real state of things be unknown till a much later period, when deposition shall have actu- ally taken place, before the woman is subjected to the tortures of a difficult extraction it is necessary to inquire, not only whether the bladder is diseased, which is naturally suspected, but whether the ure- ters, and especially the kidneys, have already con- tracted so much disease, that although the needle and calculus should be removed, death is still inevi- table.—22. 341 The dilatation of the ureters and kidneys in cases of retention of urine, and of the detention of pus, is a fact which has been demonstrated on numerous oc- casions; and sometimes the same result happens when the bladder is excessively contracted, or when its cavity is filled by some foreign body. Although, in the natural state, nothing can pass from the bladder into the ureters, yet when they become greatly dilat- ed, no part remains to pass obliquely between the coats of the bladder. Therefore, not only may a portion of urine then regurgitate, but even after the retention begins to yield, or is effectually remedied, whenever the bladder contracts to expel urine it will urge more of that secretion upwards, through the ex- panded orifices, in proportion as its exit through the urethra is impeded. If pus exists in the bladder un- der these circumstances, that fluid, also, might be urged up the ureters quite to the kidneys; especially if the patient attempt to make water whilst in the horizontal posture.—23. These occurrences are equally common to males and females. Besides the young man whose case is described,* I might subjoin other instances in addition to those recorded in the Sepulchretum. In his trea- tise de Abscessu Mesenterii, Henricus Henrici speaks of a girl five years of age, who was affected with, calculus, and in whom one ureter resembled an intes- tine, and the corresponding kidney was three times the size of the opposite. In an old man afflicted from the same cause, Mauchartus found these canals dilated so as to equal the size of the intestinum ile- um, and distended with urine resembling buttermilk. The kidneys, at the same time, were very large and unequal, and their pelves were expanded to the ex- tent of an egg. Laubius not only saw the ureters and * Vide p. 333. 342 pelves greatly dilated from the same disease, but there was lesion of the kidneys also. One of these organs was affected with atrophy, and the other was large and ulcerated. Lospichlerus found the ureters in a merchant so exceedingly distended with urine as easily to admit a pretty large thumb. However, it must be acknowledged that not un- frequently the kidneys become diseased, and the ureters dilated, from a calculus, before it arrives at the bladder; but if these lesions have taken place before the calculus falls into the bladder, they will be proportionately augmented by the reflux of puru- lent urine. A prudent lithotomist, therefore, wilj act with great caution, and should he be induced to operate from the solicitude of the patient, he will feel that it is incumbent upon him to give a candid prediction in relation to the organic lesion and the danger which may remain, notwithstanding the successful extraction of the stone. I am aware, however, that some per- sons have recovered from this operation although the previous symptoms had been extremely unfavoura- ble ; and I am not unmindful that after symptoms of disease in the kidney, and the discharge of pus, that part which appeared to have been the seat of an abscess in this organ, has been found completely cica- trized. Cicatrices, too, have been found in the blad- der after ulceration produced by a calculus; but certainly, to be guided by circumstances which rarely occur, is very different from being governed by those which happen most frequently.—24. I am indebted to Mariani for the following case. 343 Case 5. Calculus from deposition on a bodkin ; kidneys suppu- rated ; bladder sphacelated. A young country girl had a bone bodkin drawn into the bladder in the same way that a similar accident happened to the individuals already men- tioned. Although it excited much pain and uneasi- ness, yet she made no disclosure till a calculus had formed around the bodkin, when her agonies be- came intolerable. On examination, the point of the bodkin was found to have perforated the urethra, and to project within the vagina. Mariani conceiv- ed that if the urethra were a little slit in the longi- tudinal direction, the point might be drawn into the urethra, and by scaling away the probably fragile concretion, it might be possible so to reduce its bulk as to extract the bodkin; but this opinion was over- ruled by other practitioners, so that nothing was at- tempted, and the girl was abandoned to her misera- ble destiny. The calculus enlarged, the pain increas- ed, the orifice of the bladder became almost obstruct- ed, so that little urine was discharged, and that was extremely offensive. Fever also came on, and a painful life was terminated. Dissection. As soon as the abdomen was opened pus was observed in the pelvis, and it was supposed to have escaped from the kidneys, in which sup- puration had taken place. The bladder was in a state of sphacelation, and contained a pyriform cal- culus. In one part it was connected to the bladder, and on being removed some squamulge remained ad- hering to the inner coat. Nevertheless it weighed eighteen drams. Afterwards, however, when the account was transmitted to me, its weight did not exceed fourteen.—Morgagni, xlii. 25. 344 Case 6. A bodkin introduced into the bladder and removed. Not long after the fatal termination of one of the preceding cases, a surgeon, who had been a pupil of mine, informed me that he had been called to a girl, who, when in a sitting posture, had thrust the head of a bodkin, which was almost as large as the urethra itself, very far into that canal. Being alarm- ed by the sudden appearance of her mother, she let go the bodkin, and at the same instant it was drawn upwards. For nearly four days she bore the uneasi- ness in silence, and then confessed to her mother what had happened. When the surgeon was consulted, he supposed, from the seat of a pricking sensation, that the lower part of the bodkin was fixed about the middle of the urethra; and fearing that if an instrument were introduced to extract the body it might be pushed into the bladder, he successively introduced two fingers into the vagina, and moved the needle so far downwards, that its point appear- ed at the orifice of the urethra, and could be seized by the forceps. The bodkin was four digits long, had a very sharp point, and appeared to be made of tin. A little calculous matter had been deposited upon it. Morgagni, xlii. 26. I have no doubt that these occurrences would be found more common if a sense of shame did not induce most women to conceal the true cause of their disease. With a view to deceive the physician, some young females pretend to have swallowed the extraneous body; but credulity is more circumscrib- ed than formerly, at least among the better inform- ed Italians ; but of the credulousness of some other 345 countries I discern pretty evident traces even in ex- cellent books.*—27. Case 7. Calculus, whose nucleus was a bodkin, contained in a diverticulum of the bladder; coats of the bladder ulcerated and thickened. A countryman, forty years of age, had, for a long time, laboured under great difficulty of making water. He came into the hospital a month before his death, not exclusively because of the dysury, but, in part, on account of ulceration in the scrotum, and fever. Diarrhoea, at first, was combined with the febrile affection, and afterwards constipation. The maras- mus daily increased, and ultimately he became ema- ciated to the utmost extent; his face was cachectic, and, in process of time, he died from the pain in the bladder. When the period of dissolution drew near, he ex- pressed a desire that the cause of his protracted and troublesome dysury might be investigated by dissection. He therefore acquainted the surgeon, that, two years before, he had introduced a brass hair-bodkin into the urethra, but whether it had fallen out or still remained there he scarcely knew. Having been informed of this circumstance, I ordered the body to be brought for examination. Dissection. The scrotum was ulcerated froafc the dripping of urine, and the coats of the testicles were * Dr. Molyneux appears to have been aware of this species of misrepresentation. Upon a girl who reported that she had swallowed a bodkin nine weeks before, he performed lithotomy, by the high operation, and removed the extraneous body from the bladder. According to the patient's acknowledgement she felt it in the bladder the day after she had swallowed it, but he suspected that it had been introduced by a more direct channel. Phil. Trans, abridged, vol. 4.—Ed. vol. ii. 44 346 thickened. The urethra was laid open longitudi- nally, but the inner surface was not in a state of ulceration, nor did any cicatrices or redness appear. It was whitish and smooth, though considerably thickened. The bladder was empty, contracted, and of an irregular figure. For at the upper and right side it protruded into a kind of small pouch, of a square figure; and this process had acquired a black- ish hue. The seminal caruncle was shrivelled, but it was furnished with its natural sinus. Immediately above the caruncle, the whole inner surface of the prostate gland, and also that of the bladder, was ulcerated, and covered with a kind of whitish eschar. The coats of the bladder were thickened and almost scirrhous. In some places they were livid and black, and in others white. The sacculus did not present a different appearance, for it not only communicated with the bladder, by an orifice equal in diameter to its whole extent, but the cyst itself consisted of an extension of all the coats of this reservoir. Within this sacculus a calculus was contained the size of a rather small walnut, and it was smeared over with a secretion resembling the white of an egg. From the side of this calculus, near one ex- tremity, the bodkin projected to the extent of two digits; and the remaining part, which appertained to the head, being firmly buried within the calculus, was about equal to the breadth of one finger, or perlf^ps exceeded it. The point was fixed in the inferior and left side of the contracted bladder. The orifices of the ureters were much larger than ' they generally are, and these ducts themselves were so much dilated, and distended with pus, as in some places to equal the thickness of a man's thumb. The kidneys were turgid and greatly enlarged; they were pale externally, but internally they were half putrid, and abounded with pus. Morgagni, xlii. 28. 347 The circumstance most extraordinary in this case was, that so long a bodkin should have reached the bladder through the male urethra. There are cases on record of the needles commonly used by semstresses, and other foreign bodies being found in calculi of the male bladder, but they do not seem to have entered by the urethra. In some instances they are known to have been swallowed, and must have penetrated the bladder from the intestines.* —29. * Animal chemistry was not very successfully cultivated till within a very few years, and little, comparatively, was known respecting the composition of urinary concretions, till Dr. Wol- laston's extremely interesting and important discoveries—dis- coveries which have been confirmed and amplified by other chemical philosophers. Dr. Marcet, in his valuable Treatise on the Chemical His- tory and Medical Treatment of Calculous Disorders, divides calculi into the following nine species; of which I shall sub- join an abstract, chiefly derived from Dr. Ure's Dictionary of Chemistry. Species 1. Uric acid calculi. Dr. Henry says, in his instruc tive paper on urinary and other morbid concretions, read be- fore the Medical Society of London, March 2d, 1819, that it has never yet occurred to him to examine a calculus composed of this acid in a state of absolute purity. They contain about 9-10ths of the pure acid along with urea, and an animal matter which is not gelatine, but of an albuminous nature. This must not, howev«r, be regarded as a cement; the calculus is aggre- gated by the cohesive attraction of the lithic acid itself. The colour of lithic acid calculi is yellowish or reddish brown, re- sembling the appearance of wood. They have commonly a smooth polished surface, a lamellar or radiated structure, and consist of fine particles well compacted. The relative fre- quency of lithic acid calculi will be seen from the following statement. Of 150 examined by Mr. Brande, 16 were compos- ed wholly of this acid, and almost all contained more or less of it. Fourcroy and Vauquelin found it in the greater number of 500, which they analyzed. All those examined by Scheele consisted of it alone; and 300 analyzed by Dr. Pearson con- tained it in greater or smaller proportion. According to Dr. Henry's experience, it constitutes 10 urinary concretions out of 348 Sacculi and supernumerary chambers in the bladder. Some anatomists have attempted to explain the origin of sacculi of the bladder by referring to na- 26, exclusive of the alternating calculi; and Mr. Brande has lately stated, that out of 58 cases of kidney calculi, 51 were lithic acid, 6 oxalic, and' 1 cystic. Species 2. Ammonia-magnesian phosphate. This calculus is white like chalk, is friable between the fingers, is often covered with dog-tooth crystals, and contains semi-crystalline layers. It is insoluble in alkalis, but soluble in nitric, muriatic, and acetic acids. According to Dr. Henry, the earthy phosphates, com- prehending the second and third species, were, to the whole number of concretions, in the ratio of 10 to 85. Mr. Brande justly observes, in the sixteenth number of his Journal, that the urine has at all times a tendency to deposite the triple phosphate upon any body over which it passes. Hence, drains by which urine is carried off, are often incrusted with its regular crystals ; and in cases where extraneous bodies had got into the bladder, they have often, in a very short time, be- come considerably enlarged by deposition of the same sub- stance. Calculi composed entirely of the ammonia-magnesian phosphate are very rare. Mr. Brande has seen only two. They were crystallized upon the surface, and their fracture was some what .foliated. In its pure state it is even rare as an in- crustation. The powder of the ammonia-phosphate calculus has a brilliant white colour, a faint sweetish taste, and is some- what soluble in water. Fourcroy and Vauquelin suppose the above depdsites to result from incipient putrefaction of urine in the bladder. It is certain that the triple phosphate is co- piously precipitated from urine in such circumstances out of the body. Species 3. The bone-earth calculus. Its surface, according to Dr. Wollaston, is generally pale brown, smooth, and when saw- ed through, it appears of a laminated texture, easily separable into concentric crusts; sometimes, also, each lamina is striated in a direction perpendicular to the surface, as from an assem- blage of crystalline needles. Dr. Henry says he has never been able to recognise a calculus of pure phosphate of lime, in any of the collections which he has examined, nor did he ever find the preceding species in a pure state, though a calculus in Mr. White's possession contained more than 90 per cent, of ammo- nia-magnesian phosphate. i 349 tural conformation; and others attribute them to calculi generated between the coats of the bladder, and gradually enlarging till they form for them- selves a cyst; and the inner coats, at length, Species 4. The fusible calculus. This is a very friable con- cretion of a white colour, resembling chalk in appearance and texture. It often breaks into layers, and exhibits a glittering appearance internally, from intermixture of the crystals of triple phosphate, sp. gravity from 1.14 to 1.47; soluble in dilute, muriatic, and nitric acids, but not in alkaline lixivia; the nu- cleus is generally lithic acid. In four instances only, out of 187, did Dr. Henry find the calculus composed, throughout, of the earthy phosphates. Species 5. The mulberry calculus. Its surface is rough and tuberculated, and colour deep reddish brown. Sometimes it is pale brown, of a crystalline texture, and covered with flat oc- tohedral crystals. This calculus has commonly the density and hardness of ivory; a sp. gravity from 1.4 to 1.98; and when sawed exhales the odour of semen. A moderate red heat con- verts it into carbonate of lime ; it does not dissolve in alkaline lixivia; but slowly, and with difficulty, in acids. When the oxalate of lime is voided directly after leaving the kidneys, it is of a greyish brown colour, composed of small cohering spherules, sometimes with a polished surface resembling hemp- seed. They are easily recognised by their insolubility in mu- riatic acid, and their swelling up and passing into pure lime before the blowpipe. Mulberry calculi contain always an ad- mixture of other substances besides oxalate of lime. These are, uric acid, phosphate of lime, and animal matter in dark flocculi. The colouring matterkof these calculi is probably ef- fused blood. Dr. Henry rates the frequency of this species at 1 in 17 of the whole which he has compared; and out of 127 calculi he found that 17 were formed round nuclei of oxalate of lime. Persons who have voided this species of concretion are supposed to be less liable to a return of the complaint than those who are subject to lithic calculus. Species 6. The cystic oxide calculus. It resembles a little the triple phosphate, or, more exactly, magnesian limestone. It is somewhat tough when cut, and has "2. Obliquity of the uterus from distortion of the spine; hydatid in the ovary. About the end of January 1748, an elderly wo- man, who was gibbous, was brought into the hospital when disease was so far advanced that I was unable vol. n. 56 442 to ascertain who she was ; and she died immediately after being admitted. Dissection. The surface of the kidneys was not quite healthy, and the cervix of the bladder was unusually vascular. The right ovarium was some- what turgid, precisely resembling the ovary of a young woman; but this turgescence arose from an hydatid, of considerable size, enclosed within its substance. The spine was distorted to such a de- gree, that the uterus inclined to the right side; and the left iliac vein was twice as long as the right. Morgagni, xlviii. 34. Case 3. Obliquity of the uterus from shortness of the ligamen- tum rotundum, and distortion of the spine. Another aged woman, who also was deformed, died in the hospital from an old ulcer of the leg, two years before the subject of the preceding case. The kidneys and generative organs only were brought into the college. Dissection. The right kidney was of a natural form and size, but the left, though of the same length as the opposite, was considerably narrower. The lumbar vertebrae were so inflected to the right side, that the uterus hung towards that side, and this was evident from the corresponding round liga- ment being much shorter than the left. Morgagni, xlviii. 35. In cases already detailed 1 have seen the uterus drawn aside, in consequence of one of the round ligaments being very short; and the same effect has been supposed to arise from defective length of one of the ligamenta lata. I apprehend that it sometimes happens from the shortness of both liga- ments on one side, or from their laxity on the oppo- 443 site; and, at other times, the obliquity appears to arise from a diminution of length in either of them, if its fellow appears to be relaxed. I attribute the retroversion of the uterus, as well as its turning for- wards, to a state of relaxation of both the broad ligaments.—36. Case 4. In the lungs of a woman thirty-five years of age an abscess had ruptured at the time of lactation. At length, expectoration ceased for two days, and she died in the hospital in December 1740. Dissection. The stomach was very long, and be- fore reaching the antrum pylori it contracted to the extent of some digits, and then expanded into that an- trum. The commencement of the colon was, also, so contracted as scarcely to exceed the thickness of a man's thumb. The small intestines appeared to be inflamed in some places on the left side. The liver was large, and extended into the left hypo- chondrium. The uterus was greatly inclined to the right side, consequently the tube and ovary were forced into a narrow compass on that side.—Morgagni, xlviii. 37. Case 5. An elderly woman was bit in the leg by a dog, and diarrhoea with febrile symptoms ensued. After the expiration of some days the former ceased, but she was seized with vomiting, and ejected worms. She had occasional intermission of pulse, and slight cough. She gradually sunk, and died in the hospital early in March 1741. Dissection. Air-bubbles were observed in the ves- sels of the pia mater; and a serous fluid had been deposited beneath this membrane and also in the ventricles. Some of the bronchial glands were 444 greatly enlarged and contained calcareous matter. The lower part of the valvulae mitrales was con- verted into a compact and white substance internally; especially at that part which is nearest to the aorta. None of the valves of this artery were totally ex- empt from the rudiments of ossification, and one of them, on the surface facing the parietes of the arte- ry, was almost universally covered with bony gra- nules. On the other surface, the corpuscle exhibited a fleshy excrescence somewhat larger than itself. The stomach was inflated, and descended so low in the abdomen that the subjacent colon was below the umbilicus; and the whole of this intestine, ex- cept at its commencement, was so contracted as to resemble one of the small intestines. The duode- num was much larger than usual, and passed down- wards, on the right side, over a long tract of verte- brae. The liver was large, and on the convex surface there were two parallel furrows which appeared as if made by a strong impression of the fingers, The spleen was somewhat thickened, and had whitish granules on its surface; and its structure internally was pale. The uterus was inclined to the left side, and the whole of its inner surface was uneven, but not ulce- rated. The fundus was covered over with dark- coloured blood, and the corona of the osculum was thickened.—Morgagni, xlviii. 38. The number of these observations might be mul- tiplied by adducing cases in which the uterus was urged to one side in consequence of a tumour in the opposite ; but these are sufficient to corroborate my statement, that obliquity of the uterus is not an un- frequent occurrence. Ruysch supposed that violent pain in the hypogastrium, and continual excitement to make water, would necessarily ensue from the la- teral inclination of the uterus; but these evils were not observed in the preceding instances. 445 In the excellent dissertation of Camerarius on the subject of generation, a curious instance of contortion as well as obliquity is related. The uterus was so inclined to the left side that the anterior part of the fundus appeared to be twisted towards that side. He conceived that the contortion, by contracting the orifice of the uterus, had probably impeded the birth of the foetus.—39. The obliquity of the os uteri, under these circum- stances, may be an impediment to procreation by resisting the entrance of semen.—xlvi. 19. » Uterus of a small size. Case 1. Uterus extremely small, no ovary, abscess in the mesen- tery. The subject of this case was a little woman, sixty- six years of age, who had been married for many years, but had borne no children. She came into the hospital in December 1749, in a very weak state, complaining of nothing, however, except hun- ger, and the effects of an inclement season. Whilst remaining in the hospital to recruit, she was suddenly seized with deliquium animi, and died within an hour. Dissection. The immediate cause of sudden death was found to be the rupture of an abscess in the mesentery, by which a large quantity of stinking matter was effused into the abdominal cavity. The kidneys exhibited turgid vesicles, some of which were prominent on the surface, and others half imbedded in the substance. The outer coat of the bladder was extremely flaccid, and was so easily separable from the others as to follow the hand when lightly drawn over it. In some places upon 446 the inner surface of the urethra, very minute vesi- cles were distinguishable. The pudendum was very small, and only the rudiments of the nymphae could be perceived. The glans and praeputium clitoridis were not discoverable, but instead of these parts there was a round tubercle slightly prominent. Upon cutting into this body I found a quantity of matter similar to that which collects under the praeputium of the cli- toris and of the penis, and beneath that matter I disco- vered the glans and its prepuce extremely small. The greater bulk of the tubercle was constituted of the matter. Although there remained but a slight trace of the hymen, vagine tamen orificium ea erat angustia, ut virum nunquam admisisse videretur, certe crassiorem de quatuor minoribus mee manus digitis non transmisisset. The vagina, when laid open longitudinally, did not exceed two digits in breadth, and was not quite four in length. There were no caruncles or rugae in the vagina, with the exception of a very short and nar- row corrugation behind the orifice of the vagina. The os uteri was not surrounded by any protuberat- ing corona; it was almost circular, and so small as not to admit the head of a little probe. The inter- space from this aperture to the outer part of the fundus uteri, did not equal the largest breadth of my thumb; nor did the diameter of the upper and wider part of the uterus exceed the length I have men- tioned. The other part did not equal even the width of the point of my little finger. On cutting into it, I found the thickness of the parietes, both of the fundus and cervix, considerably less than the figure by which De Graaf represents the uterus of an in- fant which died on the twenty-third day after birth, and where they are described as extremely thin. Therefore it is probable that in this woman the ute- rus had not increased from the time of her birth, 447 and certainly had never discharged any menstrual fluid. The cavity of the cervix was double the length of the fundus uteri, and this fact is represented in the delineation alluded to. The inner surface of the cervix was of a white colour; and in it there were only some obscure fibres running longitudinally: the fundus was of a brownish red colour. The Fallopian tubes were longer than might have been expected from the diminutive size of the ute- rus, and the orifice between the fimbriae was open: but there were asperities on the external part of one of the fimbriae, owing to white and roundish bodies, which were of an osseous texture, or, at least, were extremely hard. There was no plexus in the broad ligaments, but many nerves traversed them in a longitudinal direc- tion. The round ligaments were very slender; but the ligamenta lata were extremely large, in conse- quence of the narrowness of the uterus. Upon the upper edge of these appendages I looked for the ovaria but found that there w,ere none, nor was there even a rudiment of them. Tracing the sper- matic vessels I found that they were scarcely smaller in this subject than in other persons, especially where they proceeded to the broad ligaments, and the neighbouring portion of the peritoneum, whence these ligaments originate.—Morgagni, xlvi. 20. From these appearances it was evidently the same with this woman, virtually, as if she had been en- tirely without a uterus. Such instances are uncom- mon, but it is believed that when they do occur, the mammae are small and contracted. I have known some barren women who had scarcely any appearance of mammae—indeed, none, except the nipple and areola. Other instances of the uterus being unusually small are extant.—21. 448 In the preceding observation it was an additional extraordinary circumstance that the ovaria were wanting.—22. Case 1. Uterus wanting. I was requested to examine the organs of genera- tion of a country woman \vhose pudendum was in a natural state, but the vagina terminated at about a third of its usual length. No circumstance had hap- pened from which there was reason to suspect that adhesion of the parietes had taken place. The va- gina was smooth, shining, and equal; and every part appeared in its original state. The roof consisted of the same texture as the parietes. Nee vero id lacu- nar urgenti explorantium digito, aut mariti jam per triennium peni, membrane instar que in transversum ducta esset, quidquam cedebat; sea ut solidior crassi- orque paries, renitebatur. She was in the prime of life, and enjoyed perfect health. She never men- struated, nor did siie feel any periodical uneasiness. Morgagni, xlvi. 11. Case 2. Uterus wanting ; the urethra mistaken for a vagina. I was consulted by another woman, who informed me, that although the vagina was not imperforate, yet it had been so narrow that, even in early life, its "dilatation had been recommended by an eminent physician, and the measures resorted to had some- what dilated the aperture, but she was unable to bear any farther dilatation.— Virum quoque, cui a tri- ennio collocata esset, crebris conatibus idem orificium paulo magis amplificasse; subire autcm nunquam po- tuisse. I examined the parts with an intention that should 449 the obstacle consist of a pretty thick hymen, to ad- vise her to undergo its division; but, on seeing the foramen, I immediately perceived that it was the orifice of the urethra, out of its situation, and it was a happy circumstance for the woman that she was unable to tolerate any farther dilatation of that ca- nal. If she had, undoubtedly an inability to retain the urine would have resulted. How much detriment might have been sustained from the physician's advice!—advice which arose from an insufficiency of anatomical knowledge to dis- tinguish the orifice of the urethra; or from an over- hasty examination; or a prejudged opinion, founded upon what had been incorrectly related to him con- cerning the narrow foramen. Directing my attention to the place where the orifice of the vagina is usually found, not the smallest foramen or perforation appeared, but the part was closed with firm and solid integuments, and consequently it was not a case of adhesion. Like the former woman, she had never menstruated, nor had she experienced any periodical uneasiness about the pubes. As she was in perfect health, I began to suspect that there might be no uterus, so that if the obstacle could be removed by the knife, there would be some danger lest the bladder, or some of the intestines, lying in contact with the integuments in consequence of the absence of the uterus, might be pierced at the same time. Itaque earum utrique auctor fui, ut equo animo ferrent, conju- gium male initum potius dissolvi, quam se temere se- candas preberent. These cases are totally different from those in which there is a passage to the uterus, though small. Contractions sometimes take place in consequence of ulceration, and the cicatrix has proved a great impe- diment to parturition. They also differ widely from vol. ii. 57 450 those cases in which the menstrual blood is accumu- lated in the vagina and uterus from the hymen being imperforate—the evils arising from which are re- moved by a spontaneous rupture of the membrane, or by its division with the knife.—Morgagni, xlvi. 12. It is impossible to determine how often the uterus might have been wanting in women who had never menstruated. Two cases, however, particularly oc- cur to mv recollection, in which this deficiency was demonstrated by a post mortem examination. One of these individuals was dissected by our Columbus, and the other by his distinguished fellow citizen Fro- mondus. This circumstance convinces me that many other women, who had never menstruated, might have been found without a uterus, had their bodies been examined after death. However extraordinary this opinion may appear, yet if there were no other instance of this defect, it would be a most remarkable coincidence that these two examples should have oc- curred to anatomists of Cremona. In Columbus's case there was only a portion of vagina, consequently it might be compared with .the former of the two examined by me. Fromondus relates that the vagina was imperforate in his exam- ple, therefore the latter of my two cases admits of comparison with it. If an attempt to divide the mal- formed parts, in the woman spoken of by Columbus, had been made, some viscus at the fundus of the va- gina would have been wounded. In the case describ- ed by Fromondus the septum was so interwoven with solid fibres as to approach the nature of carti- lage ; and, on its being divided, great hazard of wounding the rectum or bladder would have been incurred.*—13. * An interesting case of deficiency of the uterus has been relat- ed by G. W. Stein. The subject of this imperfection was a lady, twenty-five years of age, who had been married five years, but 451 i The following case affords an instance of the sides of the vagina having united. Adhesion between the parietes of the vagina, and between the Fallopian tube and ovary. A woman seventy years of age, who had been af- flicted with asthma for a long time, died in the hos- pital, from peripneumony, about the middle of March 1752. Dissection. The fimbriated extremity of one of the Fallopian tubes adhered to the ovary ; and the orifice of the other tube, at its loose extremity, was impervious. The parietes of the uterus were thick, and its inner surface was somewhat moist. The fun- dus of this organ, and the lower part of the cervix, were of a brown colour, but the remainder was white. The cervix was narrower than usual, and the osculum* extremely small. had never menstruated. She presented the most perfect charac- teristics of the female form, being slender and delicate, the mammae were prominent, the complexion fair, and the counte- nance animated. The parts were divided, when it was disco- vered that there was no uterus. The divided parts# reunited, and no injury ensued.—Med. and Ph. Journal, Dec. 1819. Schmucker met with a case in which there was no uterus, but the ovaria and Fallopian tubes were situated in a mass of loose cellular texture. In a case quoted from Engel, the genitals were closed, and there was no uterus; but the Fallopian tubes and ovaria were attached to the bladder. The mammas were large. Pott has given the particulars respecting a woman from whose groins he removed the ovaria, mistaking them for diseased glands. She lost her feminine character. The mammae, which had been full, sunk away, she acquired an increase of muscularity, and, indeed, her general appearance, became somewhat man-like. A single ovary appears sufficient to preserve the-peculiarities of the female character, and to fulfil their office as subservient to generation. M. Chaussin has related, that on examining the body of a woman he found only one ovarium, though she had borne twelve children.—Ed. 452 The whole of the vagina, except the commence- ment and termination, was perfectly like a solid cylinder consisting of a white and hard substance, so that it was impossible to distinguish the former pari- etes from the intervening substance. Although the diameter of the vagina did not appear to be lessened, its length did not exceed three digits. The tendon of the trochlearis muscle of one eye adhered to its trochlea.—Morgagni, lxvii. 9. This consolidation of the vagina I believe had arisen from ulceration, or from laceration during la- bour.—10. Diseases of the ovaria. Case 1. Ovaria shrunk ; an hydatid attached to the ovary. A woman, about forty years of age, who had for- merly been affected with apoplexy, experienced a recurrence of the attack, and it proved fatal. This circumstance happened when I was teaching anatomy in 1725; but no parts were brought into the college except the urinary and genital organs. Dissection. The trunk of the aorta between the kidneys exhibited some very slight rudiments of os- seous laminae. The kidneys, though not very fat externally, were loaded with fatty substance between the papillae. Both the ovaria were shrivelled, but the right was by far the most meager. An hydatid, the size and figure of a chestnut, was attached to this ovarium ; and, within thickened coats, it contained a brownish watery fluid. Buried in the left ovary we found a round cellule, made up of white and thickened parietes, which were uneven internally, and contained a small quantity of humour. There were none of the natural vesicles in either ovary. Morgagni, xlvi. 29. 453 As these vesiculae are indispensable to generation, whether they are regarded as ova, or, rather, un- dergo conversion into corpora lutaea, as is generally believed, it is precisely the same thing in reference to conception, whether they are totally wanting, or are deficient of that fluid which it is necessary they should contain. Therefore we are not to be sur- prised that a young woman enjoying good health, and married to a young man of a robust constitution, was barren; for, on examination after death, Val- lisneri found all the vesicles full of a turbid and fuliginous matter which had but little fluidity. Alexander Bonis mentioned to me some particu- lars concerning another young woman who died within an hour after her first delivery, but who would probably have ceased to bear children had she lived. The ovaria, indeed, exhibited numerous vesicles of various sizes, filled with a pellucid hu- mour ; but every vesicle also contained a small white corpuscle. I am more especially induced to notice this observation, to point out that the appear- ance is the effect of disease, and must not be con- sidered a proof that the vesicle had become fcecun- dated, as some authors of eminence have regarded it.—30. Case 2. Ovarium converted into a congeries of cysts and abscesses; adhesion within the uterus ; hydatids on the tubes. A woman, apparently about forty years of age, afflicted with a violent thoracic disease, was brought into the hospital of St. Mary de Morte, about the end of April 1706, and died before she had detailed 454 the symptoms which attended the course of the disease. Dissection. Although of a good habit of body I observed that there was no appearance of mam- mae except the nipple and areola, and that there were no rugae upon the abdomen; so that she had never borne children. 1 perceived also that the hypogastrium, and adjacent part of the umbilical region were somewhat elevated. On opening the abdomen I found that this appearance was occasion- ed by a tumour the size of a very large fist; and the intestines lying upon it were urged upwards and outwards. It was situated in the middle of the pelvis, and was of a roundish figure; and though it had a tuberose surface, yet some parts were smooth. At first it appeared to be an enlarged uterus, but, in reality, it consisted of the left ovary, which had ac- quired this bulk. The dense coat of this organ was rendered uneven by small abscesses, some of which, having spontaneously opened, discharged white pus, and others were filled with the same matter. From the body of the ovary, bloody ichor mixed with pus, could be expressed. When the mass was quite laid open and agitated for some time in water, I clearly distinguished some fibres and vessels, and one or two cells the size of a small grape.' Within a black in- vesting membrane, these cells contained something like coagulated blood. The remaining, and by much the greater portion of this body—indeed, nearly the whole of the solid part was a congeries of reddish vesicles, crowded together very closely, incredible in number, extremely small, and all of them distend- ed with a filthy serous fluid. The odour which the tumour exhaled was not very fetid. Both the tubes were in a natural state, except in having hydatids attached to their outer surface. That part of the uterus contiguous to the tumour. 455 had not become diseased except in its external mem- brane ; but within its cavity I observed that the an- terior parietes were conjoined to the posterior by the intervention of small membranes. The other ovary was rather small, uneven on its surface, and had only one vesicle contiguous to it, which, however, was of a considerable size, and in- cluded a small quantity of serous fluid within its thickened coats. The remainder of it was white and hard, and from a circumscribed spot a little white pus exuded.—Morgagni, xxxix. 37. The ovary, when greatly enlarged, has been found to consist of round capsules filled with a viscid and purulent fluid.—lxv. 16. Disease occurs so much more frequently in the human ovaria than in those of brutes, that it is natu- ral to suppose that most of these lesions do not oc- cur without the passions of the mind exerting some influence in their production ; for the influence which these passions have in retarding or disturbing the course of the humours is by no means unknown. To this cause we may add the monthly determina- tion of blood to the uterus and circumjacent parts ; and this we know frequently deviates from the in- tention of nature in various ways. In conjunction with these causes, we must also recollect the bulk and weight of the pregnant uterus, by which, when the woman stands or sits down, the ovaria are pressed closely against the bones of the pelvis. This effect, however, is produced, more particularly, when the uterus contracts very strongly in a difficult labour ; or when it contracts irregularly, in an easy and natural labour, from the improper interference of an unskilful midwife.—xxxix. 38. Hydatids have frequently been found attached to these bodies.—40. 456 Dropsy of the ovaria. The ovaria are often so enlarged that the promi- nence of the abdomen resembles its appearance in ascites, of which circumstance the following case, communicated by Manfredi, affords an example. Case 1. A woman supposed to be afflicted with ascites, died. Dissection. The abdomen was not occupied by an effused fluid, but with a tumour of the left ovary. This mass weighed twenty-four pounds, being filled, in a great measure, with a viscid and black humour, which would very properly admit of comparison with the dirty water flowing in the channels of a city. The other contents of the tumour were en- closed in vesicles of unequal magnitudes, and which did not communicate. Some of them were filled with yellow matter, some with viscid matter, and others with lymph, which did not coagulate on be- ing exposed to heat. Although only connected with the left side of the uterus, yet it was quite immovea- ble, to which side soever the body turned, for it gave off an appendage, consisting of numerous hydatids, which descended between the uterus and intestine, and completely filled the lower part of the pelvis.* Morgagni, xxxix. 39. In conjecturing the nature of other obscure dis- eases as well as this, we must combine many symp- * Although it is not mentioned that any prolapsus of the va- gina existed in this case, the process of diseased ovary, descend- ing between the rectum and posterior part of the uterus, seems to elucidate one of the causes of inversio vaginae.—Ed. 457 toms, because some one of them may be absent, as in the preceding case, for the moveableness of the tumour has usually been placed among the diagnos- tic symptoms of ovarian dropsy. Perhaps, indeed, at the earlier period of the disease, not only this moveableness might have existed, but that semicircu- lar figure, which was supposed by Brechtfeld to dis- tinguish dropsy of the ovary from that of the Fallopian tube, might also have been observed. I have no doubt, however, that when the disease is in an advanced state, the tumour arising from a dropsy in. the tube approaches the oval or spherical form as much as an aneurism of the aorta. The more frequent examples of tumours in the human ovary have occurred on the left side.—40. The following instance of prodigious expansion of the ovary is quoted from Willis. Case 2. The abdomen of a widow began to swell, but her appetite and strength were unimpaired, her habit of body was not cachectic, and the urine was natural- ly excreted. At the expiration of five years the abdomen was exceedingly bulky, but, in consequence of its being prominent on the right side, it had an uneven appearance. She was not conscious of any sense of fluctuation on turning from side to side. A few years afterwards, although the abdomen was so extended as to reach a span below the knees, yet the feet were not tumid, nor was the face much dis- coloured. She had no thirst, except slightly in the morning; the pulse was not febrile, nor was there any inquietude during sleep. However, at the end of twelve years the feet swelled, ulcerated, and be- came gangrenous, from which circumstance, in con- junction with the unmitigated nature of the principal disease, she died. vol. n. 50 458 Dissection. No fluid was found in the thorax or in the abdominal cavity, but an enormous quantity was contained within a membraneous sac originating from the right ovarium. It had only a single cavity, and its parietes consisted of two coats, the outer be- ing thick, white, and constituted of tenacious fibres. The spermatic vessels, on this side, were enlarged to twelve times their usual size.—Morgagni, lxv. 16. Manv of these cases are on record, and in some of them, as well as in the preceding, the quantity of fluid accumulated was excessively large. Ried- linus mentions an instance of this description, in which the abdomen began to swell on the left side, at which period the patient conceived, notwithstand- ing this affection, and was happily delivered. She continued active and robust, even in the latter part of the disease, and, with the exception of being in- commoded by the great tumefaction of the abdo- men, she experienced nothing which gave her unea- siness. In a case related by Vacher, six or seven years before the patient's death, the symptoms commenced with pain in the epigastrium on the left side. Scha- cherus describes a case in which, at the commence- ment, there was an indescribable pain in the abdo- men, and afterwards tumefaction gradually took place, and the weight of this tumour was accustomed to fall on that side to which the posture of the body inclined it. The two patients last referred to suf- fered greatly within the latter period of the disease, at which time they were unable to rest, except by supporting themselves upon their knees, inclining their bodies forward, and placing their heads upon the bed underneath them. In the case described by Schacherus the cyst had ruptured in some places, so that ascites was combined with hydrops ovarii— a circumstance which has happened in other instan- ces. 459 Gullman relates the case of a maiden in whom this disease had existed fifteen years, and had ex- tended greatly, yet she enjoyed perfect health, and her menses were regular. In the two last years of her life, however, she was frequently seized with lipothymiae : and two women whose bodies were dis- sected by Mauchartus had been similarly affected. Targioni saw an extremely large dropsy of the ovarium in a matron who had been afflicted with the disease thirty-four years. Whilst it was compatible with the time of life, she had an excessive discharge of catamenia. Ultimately she had frequent vomitings, and experienced some difficulty of breathing from ascending stairs; but she was capable of moving about, and of decumbence on either side or upon the back without any inconvenience, though, after death, the sac was found to occupy the whole abdomen, and to contain a quantity of water estimated at about a hundred and fifty pints. Fluctuation had never been perceptible.—Morgagni, xxxviii. 64. Ludovicus Saltzman has recorded an instance of a woman in whom, after long-continued suppression of menses, the abdomen became gradually elevated from the left hypogastrium towards the correspond- ing hypochondrium. All the symptoms of ascites were absent and the face was of a pretty good colour. She fell to the ground with some force, and from that period symptoms of ascites commenced, and she soon died. In the abdomen, besides a great quantity of water and pus, a large tumour was found covering the viscera. It consisted of numerous cysts, which varied in size as well as in the matter with which they were filled. The common coat of the tumour had formed membraneous adhesions to the contigu- ous parts, and was united to the uterus.* Morgagni, lxv. 16. * When an ovarium becomes the seat of dropsy, the fluid may be chiefly contained in a single cyst, or dispersed through aeon- 460 Hitherto 1 have exclusively referred to cases re- specting which no doubt could be entertained of their being ovarian dropsies. I shall now subjoin some cases in which there was some uncertainty as to their nature. Brehmius mentions a large sac, full of a watery fluid, and closely attached to the urinary bladder. The patient had been afflicted with the disease four- siderable number. Sometimes the ovary is wholly converted into a number of cells, which, at one time, are distinct, and at another, they communicate feely. One of the most descriptive cases of ovarian dropsy is related in the Philosophical Transac- tions, anno 1681. A hundred and twelve pounds offluid are said to have been found in the ovary, and the appearance resembled that of forty bladders, of different animals, placed together. The cysts, in these cases, contain either a serous fluid, which some- times is mixed with slimy matter, or they are occupied by a thick ropy fluid, or a kind of jelly ; and different cysts in the same ovari- um will sometimes contain dissimilar fluids, and occasionally mas- ses of solid matter. In general, the disease is slow in its formation, and, as Morgagni has shown, it is for the most part incurable. He has adverted, however, to some instances, in which, at least for a time, the disease appeared to be removed: and the following appears to me an example of spontaneous recovery. About ten years ago, a married lady, somewhat above thirty years of age, who had borne children, consulted me respecting a tumour in the right side, which seemed, unequivocally, to arise from ova- rian dropsy. It gradually enlarged, and acquired the bulk of the pregnant uterus at seven months, though chiefly confined to the right side of the abdomen. The functions of the uterus ceased for several years. At length, after an interval of six or seven years, she perceived a more rapid increase of size than had been observed before, and, in process of time, it proved that she was pregnant. She underwent parturition very fa- vourably, and when I saw her twelve months afterwards, the original tumour had nearly disappeared. From the time of labour, some new process commenced by which the deposited fluid had been absorbed. At the time when this circumstance happened she resided at a distance, so that I had not an oppor- tunity of ascertaining whether there were any indications of the cyst havin g ruptured, and of the fluid having been effused into the abdomen, but this is not improbable.—Ed. 461 teen years. He also describes a case in which the' sac was attached to the fundus uteri. The younger Du Verney met with two instances of a large cyst ascending from the side of the uterus and embracing the ovary.—xxxviii. 65. Some of the examples of dropsy of the Fallopian tube are unquestionable, but others appear to be of an equivocal nature. Among those respecting which there is no uncertainty, I may refer to one inserted in the Bibliotheca Anatomica. The right Fallopian tube was so dilated as to contain a hundred and twelve pints of water. The patient was a maiden, and she had laboured under the disease for eighteen years. The cases of a doubtful nature might have been dropsy of the ovarium, as the description of them is not sufficiently definite.—66. By attentively collecting the symptoms of encysted dropsies, we shall observe how much they coincide with each other, and also with dropsy of the perito- neum. If the abdomen had possessed considerable bulk for a long time; if the tumour has increased by a slow progress, without occasioning much inconve- nience, or much alteration in the colour of the skin ; if purging and diuretic medicines afford no allevia- tion ; if the lower limbs have not become anasarcous till the latter period of the disease ; we may infer that the woman does not labour under ascites, but is affected with some more circumscribed dropsy. However, it does not follow that she is not the sub- ject of encysted dropsy, should any one of these symptoms be absent. In reference to the symptoms by which the drop- sies in question may be distinguished, I have little to say. There is such a proximity between the ovaria, the tubes, and the ligaments by which they are con- nected together, and such a necessity for the func- tions of them all in the process of generation, that 462 it is impossible to deduce any certain inferences either from the situation of the tumour, or from an imperfection of the generative faculty, which of these parts is dropsical. When a tumour arises in the situation of the ova- rium, we may be led to suspect that it is dropsical; but, occasionally, this organ is extremely enlarged in its structure. Gandolphus found each of these bodies equal to the size ojf a man's head, and of a uniformly compact texture ; "and one ovary, in another woman, he found much larger, for it weighed fifteen pounds. Nevertheless, when we attentively weigh the symp- toms, and deliberate upon all the circumstances which have preceded and which accompany the disease, I think that we shall be able to discriminate between these two affections.—67. Having adverted to the treatment of dropsy of the peritoneum, I shall subjoin a few remarks rela- tive to the management of those dropsical affections which are included in a sac, and contained in the cavity of the abdomen. No surgeon was more experienced in the opera- tion of paracentesis than tne younger Du Verney, and he expressly denies having ever seen any one cured who was afflicted with an encysted dropsy; but he affirms that he has known many instances of women being carried off in a very short period after the water had been removed, though previously they had experienced no other inconvenience than that which arose from the cumbersomeness of the abdo- men, and thus, apparently, they might have lived for a long time. Several other surgeons have witnessed the same catastrophe from paracentesis under these circumstances. This event is not to be wondered at, if air is ad- mitted to the remaining fluid, or into contact with the membranes, already relaxed, vitiated, or ulce- 463 rated. The water that has been drawn off a second or a third time, or that issues from the aperture, has been found greatly altered in its quality, and this change has probably arisen from the admission of air. It has been observed green, black, turbid, pu- rulent, feculent, and somewhat bloody ; or it has ex- haled an offensive odour. Tulpius saw nine pints of water and pus in the tubes. In the ovaria, Maggi and Dodi found a fetid humour ; and Du Verney observed the inner surface of the sac full of abscesses. Even should there be no appearance of pus, no offensive odour, nor any ulceration, yet hydatids are often adherent internal- ly, or the water or other matter is divided into nu- merous smaller sacs. To draw off all the fluid from the larger sac, which contained all the others, Trew found it necessary to open the membraneous septa more than ten times ; but it is impossible to discri- minate these smaller sacculi, and pierce them, with- out danger of wounding the intestines. As already observed, innumerable hydatids may be included ; the cells, instead of containing water, may be occu- pied by matter like soft cheese or poultice ; or the ovarium also may be scirrhous. Without adverting to other considerations, it will be evident from the preceding observations that paracentesis may not only be useless, but actually injurious to the misera- ble woman.—68. Even should there be only one sac, and that not divided by septa, not containing abscesses nor tu- mours, nor occupied by cells containing a diversity of matter, the propriety of paracentesis is extremely doubtful. It has been found that omentum, intes- tine, or some other viscus, may intervene, or a part of the fluid may escape into the cavity of the ab- domen. Gangrene or suppuration in the sac has been apprehended, or it has been feared that the 464 fluid will accumulate again, as it does in other folli- cular tumours. Whilst revising these observations, a case occur- red to me in which the sac burst during a violent fit of laughter, by which the abdomen was violently agitated. The patient was conscious of the disrup- tion, and immediately the tumour became softer. She felt an unusual weight in the lower part of the abdomen, with a sense of fluctuation, which had never existed before, and she also observed a sen- sation of weight falling to that side on which she turned herself. Bv the aid of remedies a copious discharge of serum from the kidneys and intestines was obtained, and the symptoms disappeared, so that, during fifteen days, she appeared to enjoy perfect health. However, from that period the tu- mour again arose, and acquired its previous bulk and tension. She retained, as before, a healthy countenance, her feet were not tumid, and, indeed, she was active, robust, and in good health, with the exception that some parts of the abdomen were occasionally uneasy, that she was encumbered by the bulk of the abdomen, and the catamenial flux diminished. In order that the cyst, therefore, after discharging its original fluid, should not again be- come distended by a fresh accumulation, it is neces- sary to destroy or extirpate it, as is done with ex- ternal follicles. The first of these operations, on a large sac among the viscera, certainly could not be borne. The second, indeed, has been proposed by some practitioners who were encouraged by the well-known but extraordinary cure effected by Abr. Cyprianus ; but whether any one has made the at- tempt within these thirty years since it was pro- posed I cannot determine. If it were certain that the cyst had but one root, and that a small one, a ligature might be placed round it without much 465 difficulty, but if it were adherent to other parts, or attached by a broad basis, what could be done ? —69. If asked whether we can indulge no hopes of curing an internal encysted dropsy, I reply, that the younger Du Verney supposed he had been suc- cessful in curing a maiden, in whom, after drawing off the water, he imagined that the parietes of the cyst had coalesced. And in another case an immu- nity was obtained for two years. But these might possibly have been instances of peritoneal dropsy, especially as he has distinctly stated that he never witnessed a recovery when it was certain tljat the dropsy had been encysted.—70. Probably it will be preferable to adopt only pal- liative means till we are taught some more certain method of cure than we possess at present. It is proper to avoid those motions or postures of the body which may cause the cyst to press greatly on the viscera, or the viscera on the cyst. That the sac might easily be ruptured has been shown by its having occurred from violent laughter. Powerful expedients, such as emetics and purgatives, should be avoided; for there are cases on record which render it probable that the cyst has ruptured in the act of vomiting.—71. I believe that no rational expectation of curing encysted dropsies can be entertained, except when some accidental circumstances conspire with the ef- forts of nature to promote that desirable issue. Villus relates a case in which the patient was thus fortunate. After labouring fourteen years under extreme bulkiness of the abdomen, the woman fell upon that part. She perceived a cracking noise in the left epigastric region similar to that of the bursting of a drum, and she began to discharge, at intervals, vast quantities of inodorous urine. The vol u. 59 466 tumefaction of the abdomen vanished within nine days, and she soon recovered a state of good health. Morgagni, lxv. 18. In the body of a man who for two years had been considered ascitic, Weszpremus found an enor- mous cyst, the neck of which was implanted be- tween the bladder and rectum, and the remaining portion was connected to the adjacent parts by means of cellular substance. It was filled with fluid, which exhaled a powerful odour, and in which large hydatids floated.*—lxv. 16. Ovaria containing hair. Hairs have been found in the ovaria on many oc- casions, and cases have been described by Bauhin, Blasius, Wepfer, Veronicus, Stalpart, Haller, and others. Fifty-three years ago an instance occurred to Manfredi, concerning which he communicated to me the following particulars. The tumour was of a globular figure, the size of a large egg, and at- tached to the right ovary. It was invested with a white and almost cartilaginous*coat, which in some places was pretty thin and of a blackish colour. Within this globe a ball of hairs, was concealed. These hairs were quite disjoined from the Coat, and were smeared over with a substance which re- sembled suet. Within the conglomerated hairs, too, there was a kind of nucleus, from which some ves- sels proceeded into the continued substance of the ovarium. I do not recollect that vessels and a nu- cleus resembling these mentioned by Manfredi have been observed by other anatomists; nor do I re- member that any other surgeon has witnessed the * Although Morgagni has placed this case among encysted dropsies, I apprehend that it was a large hydatid cyst.—Ed, 467 circumstances remarked by Bauhin, namely white hairs fixed in the surrounding coat, but none on the pubis, though the woman had passed the age of pu- berty and even borne a child. Whilst revising this letter I met with a program- me entitled De Ovarii Tumore Piloso, published at Leipsic in 1735, by P. G. Schacherus, who not only mentions other observers of hairs, and of fatty matter, in the ovaria of women, especially on the -right side, but he describes the same appearance as having been found by him in the left ovary, which was considerably enlarged. He describes the hairs as having proceeded from the inner surface of the thickened coat. Targioni saw these hairs inherent by one of their heads in the thick and tenacious coat, precisely as they grow upon the skin. From what cause these hairs are found within the ovary, if they really are hairs, is difficult to explain; but the difli- culty is not greater than in accounting for their ge- neration within other parts. Cornelius Celsus men- tions that in tumours of the thyroid gland, hairs mixed with small bones are sometimes included ; and others quoted by Heister have seen them in various places. I have already related that I once found hairs within the transverse process of the dura ma- ter.—Morgagni, xxxix. 41, Malformations in both sexes. Valsalva has related the case of a man who was dumb, without an imperfection in the faculty of hearing. He had no hairs upon his face, breast, axillae, or on the scrotum; and, on the pubis, there were only a few scattered hairs at the root of the penis. He died of acute fever at the age of thirty- five. All the organs of generation were attentively examined, but they exhibited no trace of defective structure.—Morgagni, xlvi. 2. 468 Valsalva has not stated whether this man had the generative faculty or not, nor has he said that he was without hairs from birth; but it is probable that this was the case, and that he was led to examine the parts of generation on that account. As there was no apparent deficiency in those parts, this obser- vation appears to imply that the cause by which the semen is rendered capable of fcecundation, and by which the body becomes hairy, must exist in the in- visible structure of the parts by which the seminal fluid is secreted or perfected. We certainly observe both these circumstances happen together at the time of puberty, that is, when these internal struc- tures begin to be sufficiently developed. Some \ery slight appearances in the cutis of wo- men, if they had existed from birth, and been per- petual, have sometimes convinced me of their steri- lity. I have seen three women in whom there was nothing which did not promise fcecundity, yet, though married to men enjoying excellent health, they were barren. In one of them, contrary to what would have been supposed from her kind of life, age, and habit of body, I found the skin by no means smooth and soft; and in the other two the cuticle was con- stantly falling off in scales and scurf.—3. In an infant six months old, the left ovary and Fallopian tube were found within the sinus by which the ligamentum teres of the uterus passes out of the pelvis.—lxvii. 2. 469 SECTION VI. Utero-gestation. Unnatural phenomena in relation to pregnancy and labour ; and malformation and disease of the fetus and secundines. Medical practitioners not very unfrequently mis- take true pregnancy for a false conception, or moles for genuine impregnation. The symptom of natural pregnancy derived from the motion of the fcetus in utero is unequivocal; and whoever has once clearly perceived its movements by applying his hand to the abdomen, will never be imposed upon by flatus in the intestines, nor by any other motion. The move- ments of the living fcetus are totally unlike every other motion. In the early months this symptom does not exist, and sometimes the other evidences of pregnancy are likewise absent. Even in the latter months the movement in question may be impercep- tible, from the weakness of the fcetus, or some other cause. I recollect having been consulted respecting a young woman from whose breast a tumour had been extirpated. From the period at which this operation was performed, the abdoinen began to protuberate, and it continued enlarging till the time of my visit, when nine months had elapsed. The mammary tumour had been considered of a cance- rous nature, and suspicion was entertained that the same disease had affected the uterus. I carefully examined the abdomen, and the uterus seemed to be pregnant, but 1 perceived no motion. The presence of the relatives did not allow me to dip my heated hand in cold water, as I should otherwise have done, for by a cold hand the fcetal movement is generally 470 excited. I therefore recommended her physician to act with caution, though every one supposed the pa- tient to be in a state of virginity. Soon afterwards, however, she was delivered of a child. A protuberance of the navel has been mentioned as another sign of pregnancy, but this is equivocal, as it frequently accompanies ascites, and other tu- mours by which the intestines are forced upwards. Some women, indeed, uniformly become dropsical when they are breeding, and much care is necessary to distinguish the pregnancy before violent measures are adopted to remove the hydropic affection. There are many, likewise, who rely upon a symp- tom proposed in the Aphorisms of Hippocrates. He says—Que utero gerunt, his uteri os comprimitur. Tnis indication certainly is useful within the early months, when that which is demonstrative cannot appear, and I have successfully availed myself of it; but the opportunity has not often been allowed, be- cause the women of this country are generally averse to such examinations. However, it is necessary to be cautious on this point, because there are diseases of the uterus in which the osculum is closed. For the same reason I did not think it sufficient if, with some constriction of the orifice, an exten- sion of the corona was perceptible; or if the weight of the uterus, felt whilst the woman stood erect, appeared to be increased ; or if the orifice was directed backwards. For, although, when the symp- tom first mentioned exists, these circumstances afford corroborative evidence of pregnancy, yet I appre- hend that no great reliance can be placed upon them, unless there is an immunity from all the symptoms of disease in the uterus.—Morgagni, xlviii. 3. If the woman has previously been pregnant, inqui- ry should be instituted whether the symptoms now 171 resemble those which then indicated utero-gestation. From a disregard to this circumstance, (and indeed it is sometimes fallacious,) I have known physicians err; and this will be demonstrated by the three fol- lowing cases.—4. Case 1. The evidence of utero-gestation suspended by hemorrhage. A married woman became pregnant, and experi- enced inconveniences similar to those which had ac- companied former conceptions; consequently she entertained no doubt respecting her situation. About the third month the enlargement of the uterus be- came perceptible, and at the same period a great quantity of blood was effused from the haemorrhoidal vessels. The abdominal fulness considerably abated, from which circumstance it was supposed that the woman had been deceived; and though, on the ces- sation of haemorrhage, the abdomen began again to tumify, utero-gestation was not suspected. At length she had a recurrence of haemorrhage, accompanied with fever, and then she herself, as well as her phy- sicians, relinquished every idea of pregnancy. Blood was abstracted from the arm, and afterwards from the foot, and purgatives were administered. How- ever, a few hours only had elapsed after she had taken these medicines, when a dead fcetus was ex- truded. The following morning, August 29, 1727, the fcetus and secundines were brought to me. Its length was six digits, and that of the funis umbilicalis was nine, but the latter was so exceedingly slender as to resemble a thread of moderate thickness. The body was well formed, and at the time of being ex- pelled it was of a white colour; but when brought to me it had become brown. Nearly all the viscera 472 cxjiibited a pallid and decayed colour, and the liver especially, was of an excessively pale yellow. The urinary bladder and the large intestines were empty. Whatever part of the fcetus or of the funis was cut into, no blood, nor even a tinge of blood, was dis- coverable, but oblong cells containing black and al- most fluid blood were apparent through the mem- braneous surface of the placenta, which was very large in proportion to the size of the fcetus. Though the body of the fcetus was neither flaccid externally, nor covered with rugose integuments, and although neither it nor the secundiucs exhaled an offensive odour, yet unquestionably it had remained a considerable time dead in utero. Other instances, as well as this, demonstrate that a dead fcetus may be retained even for several months without putre- faction, and without yielding any disagreeable smell. Morgagni, xlviii. 5. The sudden effusion of a large quantity of blood had rendered the fcetus and its funis exsanguis, and had reduced the latter to its state of extreme exility. However, as there was supposed to be no fcetus in this case the mistake of the physicians was some- what more excusable than in the following in- stance.—6. Case 2. Absence of the demonstrative symptoms of utero-gesta- tion in consequence of bleeding. A woman supposed herself pregnant, and was sanctioned in this opinion by her usual symptoms. The physician entertained an opinion that she was plethoric, and abstracted a pound of blood from the arm. After this depletion the enlargement of the abdomen was not proportionate to the advancing stages of utero-gestation; nor did the woman distin- 473 guish the motion of the fcetus, at the usual time, there- fore the physician expressed a decided opinion that the womb did not entertain a fcetus, but a false con- ception. Alarmed by this statement, she requested my opinion without communicating any thing which had transpired with her physician. Her countenance was healthy, and in every respect she experienced sensations resembling those attendant upon former pregnancies except in the two points just named. Under these circumstances I pronounced that she was with child, and that the detraction of so large a quantity of blood had diminished the strength of the fcetus, and retarded its growth. I also intimated that as the fcetus was in so languid a state, unless the mother recruited by a proper method of living, ac- companied with cheerfulness of mind, she was in great danger of not completing the term of utero- gestation. These opinions proved to be correct, but the advice was inculcated too late, for having de- parted into the country, a bloody discharge came on at the expiration of a few days, pains followed, and a dead fcetus was expelled at the time of voiding feces. The fcetus was slender and not offensive in smell—Morgagni, xlviii. 7. Physicians who commit an error of judgment are entitled to forgiveness provided they do not join con- tumacy with their mistake, as he did to whom I have alluded in the foregoing detail; but, in the same place, 1 met with a much more tractable practition- er, who attended the individual to whom the follow- ing particulars refer. The case occurred in 1721.—8. Case 3. Abortion ; the ovum accompanied by a fiesh-like concretion. A fcetus was expelled in an immature and lifeless \'c.l. ij. 60 474 state, and the case deserves greater accuracy of de- tail, because a mole was thrown off at the same time. The subject of this abortion was a matron of a moderately good habit of body, and of a middling size, but having a disposition to sanguineous ple- thora. She was the happy mother of numerous progeny, and she had also occasionally miscarried. After her last delivery, which was followed by excessive lochial discharge, she passed the winter in a very dejected state of mind. In April, from the ordinary symptoms, joined with suppression of menses, she supposed that she had again conceived. These symptoms were followed by so great a loss of appetite, that, in general, she could only eat in the evening, and then with difficulty ; whatever food she took in the morning was vomited. About the thirteenth of June uterine haemorrhage came on, and the measures adopted to suppress it were unavail- ing. I was consulted about the middle of July, when the discharge continued ; but it chiefly flowed in the night, whilst she either lay supine or upon the left side. Besides that discharged in the night a large quantity of coagulated blood came away when she first arose, but afterwards, during the day, whether she sat or walked, or was conducted about the city in a carriage, she lost little blood. Whilst labouring under these circumstances, an unexpected misfortune, which befel her husband, proved a violent cause of additional grief. On the first night, indeed, after this calamity, there was al- most a cessation of haemorrhage, but during suc- ceeding nights it flowed more plentifully than be- fore. In consequence of such profuse and frequent effusions of blood, no person believed it possible that the uterus could be in a gravid state, and the pa- tient herself ceased to cherish that opinion. Nevertheless, 1 frequently intimated to the phy- 475 sician that in reference to a woman who abounded so much with blood, it was necessary for us to sus- pend our opinion. I reminded him also that all the usual signs of pregnancy had preceded, and that no trace of abortion had been discovered. As her general strength was somewhat impaired, and the former measures had not succeeded in moderating the discharge, sulphuric acid was administered. Her appetite improved, and a much smaller quantity of blood was discharged. It was now the end of August, and the mammae became tumid as in former pregnancies, so that the patient herself, as well as others, inclined again to tne idea of pregnancy which had been relinquished. She frequently experienced an unusual pricking sensation in the uterus, which distressed her mind, and I desired to examine the abdomen accurately with my hand. On doing this my uneasiness in- creased, as I perceived that the uterus was not acuminated towards the umbilicus, but extended transversely, and was painful on pressure, especially in the right iliac region; and on this ground I ex- pressed to her husband, and to the physician, that there appeared to be a false conception in utero, as well as a fcetus. However, I directed that the same plan of treatment should be pursued, avoiding power- ful stimulants and astringents, moderating the hae- morrhage, preserving the woman's strength by main- taining quietude of mind and body, and administering proper nutriment. A few days afterwards, while the woman was erect, the membranes suddenly ruptured, and the water did not differ from that usually discharged in labour, but the quantity was somewhat redundant. On examination, the os uteri was found closed, we therefore waited for labour pains, which did not commence till the fourth day. The mola was first 476 expelled, and afterwards a lifeless fcetus. An inter- val of three hours elapsed before the secundines came away, and their ejection was accomplished with difficulty, and attended with considerable effusion of blood. The patient, however, recovered, and sur- vived twenty-nine years, when she died of ulcera- tion of the uterus and vagina—a disease which com- menced only within a few years. Hartman and Gutterman have related cases in which the natural ovum was accompanied with a false conception; and in them abortion had long been preceded by copious haemorrhages. When the mola had been washed from the blood which adhered to it, its thickness did not exceed two digits, but it was somewhat longer, and when cut into it presented a rather spongy and fleshy ap- pearance. The foetus was of the female sex, and Avas not quite nine digits in length; the head and neck were blackish, as if from a contusion, but its smell was not offensive. I was only permitted to open the abdomen, and the chief motive for ceding to me this privilege was, that I might examine the organs of generation, for, owing to the prominence of the clitoris, which at this age usually covers the rimula, the distress of the parents was aggravated under an idea of having been bereft of a son. Morgagni, xlviii. 9. The waters which in this case preceded the la- bour pains, undoubtedly proceeded from the amnion, but sometimes water escapes which I believe had accumulated between the chorion and amnion, and the discharge of it is uninjurious. The membranes rupturing too early is not uniformly followed by a difficult labour, though, in general, the progress is less favourable than it would otherwise have been, whether this be considered as cause or effect.—10. 477 Mole, or false conceptions. Both the true and spurious molae may be joined with a fcetus, and may cause abortion either by irri- tating the uterus, or by occupying a very consi- derable part of its cavity; or they may form inde- pendently of impregnation, and enlarge to such a degree as to resemble pregnancy. The illegitimate or spurious may be produced in the virgin uterus; the legitimate or true cannot take place without pre- vious sexual intercourse. The spurious are formed from extravasated blood coagulating and lodging in the cavity of the uterus, or from some excrescence. When they arise from the latter source, they are known by a base or pe- duncle, by which they had been continued from the uterus, or, at least, from the blood-vessels which shoot into them. Those of the former species much more frequently occur than those of the latter, and they originate in the same way as concretions in the vessels and heart. They are most likely to form in females whose catamenia are copious, or who are the subjects of uterine haemorrhages. But before I amplify on the subject of moles, I shall detail a case in which the polypous concretions which formed in the uterus were of a remarkable descrip- tion.—11. Case 4. Membraniform substances discharged during menstrua- tion. An illustrious matron in my native country, who possessed a healthy countenance, and a good habit of body, miscarried several times in the early months of pregnancy. Within the intervals of these abor- 478 tions she had often completed the term of utero-ges- tation, and produced living offspring, and even twins, but not without troublesome labours. Between these parturient seasons she generally was affected with a mild form of leucorrhcea, and about the time^quidis- tantfrom the menstrual periods, she also had a slight stillicidium of. blood, which the conjugal embrace renewed. When she had passed her thirty-fourth year the leucorrhoea ceased, but she became the subject of another form of disease, which, during two years, recurred, at intervals, and in the last three months of the year 1723, and the first montlTof the follow- ing year, it accompanied menstruation. At those periods she suffered pains resembling those of labour, and the discharge was more copious than usual; and about the middle of its course, a substance resem- bling a portion of membrane was ejected from the uterus. Its form and magnitude perfectly corres- ponded with the cavity of that organ. It was mode- rately convex externally, and there were numerous filaments that appeared to have been broken off from the parts to which they had adhered. Inter- nally the substance was hollow ; and this surface was smooth and moist, as if an aqueous fluid had occupi- ed it. Its ejection was followed by a great quantity of lochia; and whenever it was divided into small pieces and thrown off at different times, the pain and lochial discharge were repeated. During the four months alluded to she was separated from her hus- band, but in March she became pregnant, though she did not carry the fcetus beyond June. However, the consequence of this conception was that in the three following months, her catamenia flowed natu- rally and without uneasiness. In October she did not menstruate, and about the beginning of November the pains returned and were accompanied with the expulsion of a body similar to that which has been 479 described, and with all its attendant circumstances. The phenomena long continued to recur at stated intervals, and when I visited Forli, in one of the fol- lowing years, I saw a substance which had been ex- pelled, consisting of a concretion in form of a triangu- lar purse. At length the disease ceased spontaneously on account of the patient's advanced age; for when a cessation of the menses occurred, the morbid produc- tions ceased also, without leaving any symptom of erosion in the uterus, nor was any other inconve- nience felt during the remainder of life, which was protracted to the age of seventy. Morgagni, xlviii. 12. Conformably with my promise I shall add a few remarks relative to the true molae. The most learn- ed men of the present age all denominate those true moles which cannot be produced independently of a previous conception. Some believe that they may be a production of the foetus and secundines, others of the placenta only, if from any cause the appear- ance of these parts is so altered that they represent a kind of fleshy mass, or a mass exceeding the solidi- ty of animal substance, or a congeries of vesicles. Ruysch has demonstrated that in the placenta both these conversions may happen. He intimates that the placentulae of very small foetuses frequently remain in the uterus, and being compressed by that organ, their figure becomes essentially altered, and their substance resembles the hardest flesh. He also met with a placenta, at a more advanced period, which had partly degenerated into vesicles full of a watery fluid. But they do not exclusively belong to the placenta, for Ruysch many times saw a vesicle in the funis umbilicahs, and sometimes he saw the chord so full of vesiculae, ut totus [funiculus] videre- tur. savs he. concatenatio vesicularum aqueo humore 480 refertarum.. An instance occurred to Vallisneri in which a placenta was discharged from the uterus after a vast number of vesicles, so that unless we suppose them to have belonged to another fcetus they do not appear to have been formed from con- version of the placenta ; and the same inference may be drawn from the observations of others, for in- stance, those of Guttermann. It may be doubted whether the degeneracy of the placenta into vesicles is effected after the expul- sion of the fcetus, or whilst it remains in utero. I may observe on this subject that in the placenta of a fcetus of four months, which had been extruded with the fcetus, I saw a vesicle full of water. Though it has been stated above, that neither of these kinds of molse is produced independently of conception, and therefore certainly not in the virgin, yet the utmost skill and attention are requisite in their examination. Nor is prudence in giving an opinion less necessary if a woman, said to have had no sexual intercourse, should discharge a body from the uterus, which, at first sight, may appear to be- long to one of these species. It perhaps might not be a placenta but a mere concretion of blood, or some excrescence which resembled flesh, or the vesi- cles of which I have spoken in a former article. In speaking of dropsy of the uterus it is mentioned that the disease has been removed by the expulsion of a great quantity of hydatids, and although this has happened at a very advanced age, it has been imputed to retention of the placenta. Rideux has described a case in which, though the mola was of a different description, he considered it attributable to the same cause. It was expelled by a widow in the seventy-fourth year of her age, and he believed that it had been conceived in her fifty-fourth year, when she experienced a sudden cessation of the catamenia, 481 which up to that period had been perfectly regular. This individual bore her ninth child in the fifty-first year of her life. It may admit of consideration whether in this way we may, in some measure, explain the facts related by Vallisneri, respecting a woman who was the mother of many children, the last of which she bore when she was supposed to be nearly fifty years of age. In her seventy-second year she discharged a placenta from the uterus, to which a shapeless mass of flesh, a pound in weight, was at- tached. At the upper part there was a resemblance of a small eye; and in the interior there were con- volutions similar to those of fcetal intestines. We may infer from the preceding observations that should any thing be discharged from the uterus of a widow, which either approaches the nature of a true mole, or which really is a mole of that de- scription, we must not immediately doubt her chas- tity, though her husband may long have been dead. For, as has been already observed, the placentula might have remained in the uterus after an abortion which had scarcely been observed. And although this cannot happen in the virgin state, we must seri- ously deliberate upon all the circumstances to guard against deception. Fleshy excrescences may form; and concretions of blood often present appearances of vascularity—sometimes they appear to contain fatty substance—and Hartmann observed in one of them not only a resemblance of many coats inter- mixed with fibres and vessels, but also of an adipose cuticle; and a vesicle containing jelly occupied the interior of the concretion. Schlierbachius saw a mole in some degree vascular, and at the same time filled with GOpious hydatids, which appeared to be intermingled with a large quantity of fat. There- fore we must carefully distinguish organic structures vol. n. 61 482 from substances which merely resemble them, for genuine fibres, vessels, coats, and an investing bladder cannot exist without the interposition of man. In- deed a bladder of this kind would be the most legiti- mate of all molae as it is the involucrum of an em- bryo. This, therefore, cannot exist in virgins; nor, so far as I know, that which might be called mola vesicularis, (consisting of vesicles clustered like grapes), of which I have already treated.—13. Abortion. I have already detailed three cases of abortion, and shall now speak on this subject very concisely. Indeed, it would be an endless task to recount all the causes of this occurrence derived from the foetus and secundines, or from diseases in the mother. Some of the morbid appearances presented by the placenta have been described, I shall therefore now only advert to such as are either the cause of abor- tion, or which render that abortion dangerous. Thickening and induration of the placenta un- doubtedly occasion miscarriages. Its increased bulk renders the space within the uterus too narrow for the fcetus; and, in consequence of its hardness, the fcetus is deprived of nutriment and perishes—a cir- cumstance which Abraham Vater saw confirmed by an observation of scirrhous placenta. It has been thought, that, when the fcetus is dead, if the placenta remain in the uterus and adhere to that organ, it may itself receive nutriment from the uterus, and, by that means, become still thicker than it was be- fore ; but on the contrary, there are cases in which, on account of the supply of nutriment being inter- cepted, both the placenta and fcetus are surprisingly extenuated. This fact has been partially shown by the observations of Hoyerus and Moekringius, but it 483 is more clearly evinced in the following instance, which was communicated to me by a friend.—17. Case 5. Abortion from grief A woman, just entering the fifth month of preg- nancy, was abruptly informed of her husband's de- cease, and this intelligence instantly overwhelmed her with grief and terror. At first she observed that the movements of the fcetus were languid— afterwards they ceased entirely—and she miscarried on the eighth day subsequent to the cessation of motion. The placenta and the dead fcetus, as well as the funis umbilicalis, were surprisingly slender. The fcetus was white, and though there was an appear- ance of vessels in the funis, they were nearly dry. Morgagni, xlviii. 18. We learn from Stahl that abortion, which arises from other causes besides mental emotion, often re- curs about the same period of utero-gestation as it happened before; and he informs us also, that this recurrence has been counteracted by proper expe- dients. I recollect no instance, however, in which the premature expulsions of the ovum were more nu- merous than in that related by Schulzius. The first miscarriage was brought on by a sudden and power- ful affection of the mind three months after concep- tion, and twenty-three times it recurred at about the same period, though every mean likely to prevent it was employed. These cases show the influence which passions of the mind exert in exciting abortion. In the case re- lated by me, I believe that fluids were readily car- ried from the fcetus and placenta to the mother, but those passing from the mother to the ovum were 484 not conveyed without difficulty, as, in consequence of her distressed state of mind, the mother was incapa- ble of transmitting to the gravid uterus a sufficient supply of nutriment. On the contrary, the extreme tubuli of the placen- tula and the uterus having contracted from the sud- den chill of death, blood has been obstructed in its return from foetuses that were in other respects healthy. This blood having accumulated in the liver, that viscus had become greatly distended, and blood had ultimately been effused into the cavity of the abdomen.—19. I have observed this circumstance in foetal calves, when the cows had been killed in an early stage of impregnation; but I do not know whether it is liable to nappen to foetuses more advanced.—20. 22. Certainly those injuries which the fcetus sustains from the hardness of the placenta are only observed in the early months of utero-gestation, unless the placenta should become universally hard, or be ren- dered unfit for its office in some other way. I think there can be no reason to doubt that the same cause by which a part of the placenta is vitiated may oc- casion more extensive lesion in this substance. The subjoined observations will show what has fallen under my notice on this subject.—22. Case 6. Disease in the placenta ; morbid softness of texture in the fetal liver and kidneys. In June 1731, a mature fcetus, whose movements the mother had not perceived for two days, was born dead. Dissection. When I inspected the hollow surface of the placenta, I observed within its substance, at the distance of two digits from the insertion of the 485 funis, a body of a whitish yellow colour; and when cut into it appeared as if it were compacted of thick membranes, laid one upon another. It was not larger than the last joint of my little finger, therefore we could not impute the death of the fcetus to it. Nor did it appear sufficient to account for the viscera being so extremely soft, that not only the liver be- came fluid by a mere touch, but, the coat of the kid- neys being divided, the substance was effused under the appearance of red poultice.—Morgagni, xlviii. 23. Case 7. Disease in the placenta. Twins that were healthy and lively were born at the proper time in June 1740. On examining the secundines attentively, one of the placentae, not far from its edge, exhibited a white body the diameter of my thumb, proceeding from the convex to the concave surface, so that it was equally visible from both surfaces. There was a similar body on the other placenta, but it did not ex- ceed the size of a vetch.—Morgagni, xlviii. 24. Though the twins were equally healthy, there is no doubt that the substances observed in the placen- ta were the result of disease, and, in conjunction with the facts before-mentioned, they show that the pla- centa is liable to more than one description of lesion, besides those more familiar to common people. Should this disease extend itself to a considerable degree, there appears no reason to doubt that it may be a cause of abortion, and of the death of the fcetus. From scirrhus of the placenta this catastrophe gene- rally results; and, probably, in process of time, the morbid changes observed by me would have degene- rated into that state. Fickius saw the substance of the placenta so scirrhous as to be incapable of per- 486 forming its functions; and Albrechtus witnessed small tumours scattered through the placenta. Internally they were of a whitish colour, very similar to scir- rhous glands; and in their interstices, about the origin of the funis, there was an hydatid full of a yellowish humour. In a corresponding situation Ro- ederer saw a larger vesicle, the fundus of which con- sisted of the substance of the placenta, and was full of a rather soft scirrhus. The funis umbilicalis may be a cause of abortion, not only from being corrupted, but also from an ex- cess of thickness or thinness, of shortness or of length. An example of the first and second cause is noticed by Ruysch, who describes the first as being not very unfrequent. Examples of the other causes are recorded in the Sepulchretum. Littre has related an instance in which the funis was so contorted that it not only was reduced one half in thickness, but was equally diminished in length. A funis that is very long is liable to be convoluted in the form of a halter, or to be knotted so as to con- stringe its own vessels and obstruct the circulation in it.—25. I shall cursorily advert to some other affections from which the lives of aborting women are endan- gered. In the first months of utero-gestation the placenta is very small, but having a large quantity of blood adhering to them when expelled at the time of an abortion, they appear larger than they really are. Physicians who do not attend to this circumstance, expect a fcetus corresponding in size with the placenta, but, if one had existed, probably it might have escaped imperceptibly in consequence of its diminutive size, or it might have been dissolved. Besides, the placenta may actually increase to an unnatural bulk after the little fcetus is dead, and, on that account, more likely to elude observation. 487 When deception has happened, medicines have been administered with the vain intention of expelling the fcetus, to the serious detriment of the mother.—26. Unnaturally close adhesion of the placenta to the uterus is another circumstance much more perilous than that just noticed. The following instance ex- emplifies the danger attendant upon this occurrence. Case 8. Retention of the placenta. A pregnant woman, thirty-three years of age, having repeatedly lifted a heavy weight, expelled the fcetus at the expiration of seven or eight months, but the secundines did not follow. The next day she was seized with rigour and fever, which pro- gressively increased, and a few days afterwards diffi- culty of respiration was conjoined with the febrile symptoms. Matter, extremely offensive, was dis- charged from the genital organs, with some portions of the secundines. Ultimately the patient was seized with convulsions and hiccough, the abdomen became exceedingly tumid, and she died on the eleventh day after delivery. Dissection. The intestines and stomach were found to be so full of flatus, that the latter organ oc- cupied four times as much space as it-usually does in the natural state. On opening the uterus a large portion of the placenta offered itself to view. Part of it protruded through the os uteri, and another part was so closely attached to the uterus that it could scarcely be separated ev'en with the aid of the scalpel. This portion was condensed into a very hard and extremely fetid body. That part of the uterus to which it adhered was the seat of inflamma- tion, which penetrated rather deeply, and also ex- tended through the remainder of the inner surface, though its degree was slight.— Valsalva, xlviii. 28 488 Ruysch has admonished us not to be over hasty to extract the placenta when it is attached to tha uterus, nor, indeed, did he or his followers want examples of very serious mischief, and even of death having ensued from the violence of a hasty extraction. However, we likewise observe the evils which arise from adhesion of the placenta to the uterus, and its being retained. Though I do not presume to settle the controversies which helve been agitated among our countrymen on this point, there is the utmost occasion for experience and prudence, according to the exigency of the case, to prevent us from violating either of the precepts of Celsus.— He says, satius esse anceps auxilium experiri, quam nullum: also, nee subire speciem ejus vi occise, quam sors ipsius interemit. The most considerate men are afraid of violence, and, after weighing the arguments on both sides, they agree that it is the best practice to wait a little. It has been repeatedly observed that removal of the woman from one place to another, has occasion- ed the expulsion of the secundines. More than once I have seen this happen whilst she was carried from the obstetrical chair to the bed. Midwives who uro-e women to violent exertions to expel the placenta as soon as slight pains have commenced, often occasion serious evil. For nature, gradually adapting all things for an easy delivery, disposes the connexion between the uterus and placenta for their more easy disjunc- tion ; but if time is not allowed, the quantity of blood accumulated around the placenta, renders the detachment more difficult.*—29. * The safe delivery of the placenta is a very important part of obstetric practice, and various causes occur .to prevent its expulsion within the usual time. It maybe retained from a de- ficiency of contractile power in the uterus—from its irregular contraction, constituting what is denominated the hour-glass 489 Impropriety of rupturing the membranes prematurely. When the membranes are so thick and firm as to retard the birth, their laceration may be necessary, but mid wives are exceedingly reprehensible when they are so impatient as to rupture them without ab- solute necessity. In consequence of a premature ef- fusion of the liquor amnii, it often happens that the labour, instead of being an easy and natural one, be- comes protracted. Sometimes these officious prac- titioners render a labour fatal, when without im- proper interference it might only have been a difficult one. Encouraging the patient to fruitless exertions, and administering articles which excite the uterus to vehement contractions, or, at least, which stimulate the vascular and nervous systems, will have a tendency to induce a ratal termination. This ob- servation will apply to those cases in which the pas- sages are not sufficiently dilated either in consequence of its being the first labour and the woman advanced in life, or because the pelvis is narrow. It is also ap- plicable to cases in which the capacity of the pelvis is diminished by tumours, and also to those in which the fcetus does not present favourably for its expul- contraction—and from organic lesions, affecting the uterus and placenta, and occasioning morbid adhesion between them. It is probable that, in general, this is the result of adhesive inflam- mation. The inner surface of the uterus, when inflamed, mani- fests a considerable tendency to the effusion of coagulable lymph, and if inflammatory action should arise, where the pla- centa is attached, during utero-gestation, lymph may be thrown out and become organized, and in this way occasion unnatural firmness of union between the parts in question. However, Morgagni has very properly adverted to the effects of misma- nagement, and undoubtedly, many of the anomalous occurrences relating to the foetus and placenta, which attend labour, and often endanger the patient's life, are owing to the culpable officious- ness of the accoucheur.—Ed. vol. II. 62 490 sion. Under these circumstances the fcetus cannot be propelled through the natural passages, and from the improper treatment which has been adverted to, the uterus may rupture, and the child escape into the abdomen. The rupture of the uterus is a more frequent oc- currence than many suppose, and as the child does not invariably escape into the abdominal cavity, this laceration should be placed among the other causes of unexpected death occurring soon after delivery. —30. The indirect position of the foetus is one cause of rupture of the uterus, and this obliquity generally happens from the same inclination of the uterus it- self. De venter has shown how important it is to distinguish the situation of the uterus by examining the os uteri in parturient women; because difficult labours often arise from the obliqueness of the womb.—31. Sometimes parturition is rendered dangerous from a concurrence of several causes. Besides those al- luded to, the cervix uteri may be obstructed by an excrescence, the os uteri may have acquired the hardness of cartilage, or the funis umbilicalis may be extremely short, a circumstance which might oc- casion the placenta to separate too early, or the funis itself might be broken. On one occasion Stegman- nus saw the funis scarcely six digits in length. Indeed the sources of difficulty on these occasions are innumerable, and it will be proper to speak of one of the principal ones, namely, the death of the fcetus, because it is a very frequent cause.—39. The first difficulty which presents itself here is, to determine that the fcetus is actually dead. The discharge of meconium has been regarded as one of the signs, but this may arise from an unnatural posi- tion of the fcetus, so that its abdominal parietes be- 491 ing compressed, the resistance of the sphincter ani is easily overcome. It has been supposed that the want of pulsation in the umbilical chord may be con- sidered as an indication of the death of the fcetus. The pulsations in the fingers of the surgeon are lia- ble to render this circumstance fallacious. It may occasionally be useful for the practitioner to compare the number of pulsations with those of his own radial artery ; so that if they coincide, he may be certain that the pulsation which seemed to be in the funis, is in his own digital arteries. Nor, indeed, must it be immediately inferred that the foetus is dead, though pulsation is imperceptible; for at one period the fcetus may be exceedingly languid, but it may soon regain its strength. Coldness and lividness of a limb which may protrude, and the imperceptible- ness of its pulsations are not sufficient proofs of the child's life being extinct. The limb may be so com- pressed by the contracted os uteri, that gangrene may commence, and the cuticle begin to separate, without its being certain that life is extinguished, tbough it must be considered in the utmost danger. At Breslaw a protruding arm was amputated, be- cause, in consequence of the lividness and coldness of the limb, it was supposed that the fcetus was dead ; nevertheless on the third day it was born alive.—40. Among the most decisive evidences of the death of the fcetus must be enumerated the very easy separation of the cuticle, and the escape of matter from the uterus having a cadaverous odour. When from the concurrence of evident causes with the more characteristic symptoms, practitioners agree that death has taken place, some perplexity arises in determining whether the fcetus should be extract- ed immediately, or whether the result of other means should be waited for. Though our plans must vary according to circumstances, it is scarcely possible to 492 avoid censure, in the use of a doubtful expedient, unless we act in concord with the prevailing opinions of the most distinguished practitioners, especially if the advantage of skilful and experienced consultation cannot be obtained. It is not sufficient to save the life of the patient, but we must guard against injury to the uterus. Some years ago I was consulted respecting a lady who four times underwent parturition very satisfac- torily. In the fifth she had occasion for assistance, and though the surgeon ought to have extracted the infant by the feet, as they presented, yet he pushed them upwards, and endeavoured to turn the head to the uterine orifice. The patient was a delicate wo- man, and having been exceedingly distressed by the long-continued and violent efforts of the surgeon, dangerous inflammatory fever subsequently came on, and in the three following births the hand presented itself instead of the head. It is probable that this unnatural presentation was owing to an injury sus- tained by a particular part of the uterus, which pre- vented this organ from supporting or expelling the foetus equally. Therefore, if there are no circumstances which demand an expeditious delivery, and the position of the fcetus is not unfavourable, in my opinion time should be allowed; and during uterine action it is sometimes useful to assist the exertions of the mother by applying the hands dexterously and cautiously to the belly. Occasionally the pains recur very tardily, or instead of being natural, they are convulsive and opposite to our purpose. Under these circumstances we must endeavour to allay the latter, and to promote the former, if these objects are attainable. An opiate will often fulfil the former indication; and natural pains may sometimes be excited by suitable enemata, 493 and by friction of the abdomen. If these are insuf- ficient, something may be administered internally to solicit rather than to stimulate nature, avoiding every thing which can agitate the woman, and excite dan- ger.—41. Whenever signs of putrefaction in the fcetus come on, it may be imprudent to procrastinate delivery. If the liquor amnii is dicharged, the putrefactive pro- cess takes place more rapidly than if the membranes remain entire, and many unfavourable consequences arise from it. Numerous cases, indeed, are on re- cord, in which foetal bones have been discharged from the anus, or removed from abscesses of the abdomen, and from these circumstances it appears that decomposition of the fcetal body does not always produce acute fever in the mother. In some cases the fcetal bones have been carried in the uterus for several years.—42. Lameness subsequent to parturition. Puerperal women frequently complain of pain in the region of the trochanter major, and probably the obturator internus muscle, which is contiguous to the uterus on the inner surface of the pelvis, may be bruised, or injured in some other way, by the violent pains of childbirth. And in the efforts of a difficult labour, this might happen to other muscles situated within the pelvis, near the gravid uterus, especially the iliacus internus and the psoas muscles. As these muscles proceed to the trochanter minor and raise the thigh, they may occasion not only pain, like the obturator, but also a difficulty of raising the thigh, and the degree of injury, as well as the dura- tion, will be proportionate to the severity of injury sustained. Sometimes the inconvenience does not cease—a fact which I observed in. an illustrious ma- 494 tron whose continued lameness owed its origin to a difficult labour. I have already adverted to the inclination of the uterus to one side—a circumstance which has been supposed to occasion lameness.—33. Some of the causes of death subsequent to delivery. I shall now subjoin a few remarks in relation to females after delivery. Case 1. Fatal consequences from an affection of the mind ; the ligaments of the pelvis relaxed. The woman to whom the following particulars relate, was subject to hysteria, her countenance was unhealthy, and she had borne some children. She was again in a state of pregnancy, and cherished an apprehension that parturition would prove fatal. Sne was particularly solicitous for a boy, and on its being imprudently mentioned to her, by the husband, that the offspring was a female, her mind was so deeply affected, that her pulse sunk, her body be- came cold, and within an hour and half she died. The secundines had not been removed. On the 12th of August 1707, twenty-four hours after death, I examined the body. Dissection. From the mouth and nostrils a large quantity of fluid escaped, which had an unpleasant smell. The abdomen was as much tumefied as I recollect to have ever witnessed it in ascites, and when the cavity was opened, it was observed that this tumefaction was chiefly owing to the stomach and intestines being distended with flatus, and to the bulk of the uterus, which rose above the pelvic cavity. Some bloody serum had been effused into 495 the pelvis, and the vessels beneath the skin of the thighs, near the pudendum, were turgid with blood. The symphysis pubis was excessively loose, and on its being divided, some fluid escaped. Nearly the same facts were presented when we afterwards examined the junction of the ileum with the sacrum. Lifting up the uterus a large mass of coagulated blood was discharged from the vagina. The nymphae were nearly obliterated, which probably was owing to their extenuation during labour. The lacunae of the external parts abounded with a whitish hu- mour, and a considerable quantity could be pressed out of them. Lymphatics were conspicuous on the uterus, and the corpus luteum was visible in one of the ovaria. On the surface of each ovarium there was a small foramen through which a slender probe could be passed into the interior parts; and in the ovary which contained the corpus luteum, there was a roundish bony cell occupied by a bloody humour. The Fallopian tubes were longer than they generally are. The parietes of the vagina were extenuated, and the vagina itself was wider, but not shorter than natural. The os uteri was of a blackish red colour, and in some places lacerated. The placenta had adhered to the upper part of the fundus uteri in such a way as to cover the aper- tures of both the tubes. It adhered to the uterus in some measure at the time of inspection, and in those places the foramina of the uterus were open; but where the placenta had been detached, these orifices were exceedingly contracted. There was no blood in the sinuses with which these orifices communicated. Both lobes of the lungs were of a whitish colour inclining to lividness. The heart was indescribably flaccid, and scarcely contained any blood.—Morgagni, xlviii. 44. It cannot be denied that a considerable quantity 496 of blood had escaped from the uterus in consequence of the partial separation of the placenta; but I ap- prehend that the quantity was not so great as to have destroyed life. Instead of the vessels being almost empty, as Tabarranus found them in a woman who died of flooding within a few hours after de- livery, some of them were turgid. There was not a gradual subsidence of pulse and temperature, but an instant cessation on receiving the unpleasant intelligence; and communications of that nature are always improper at such periods, but more particu- larly when the patient is subject to hysterical affec- tions. The accumulation of flatus in the stomach and intestines, in this instance, preceded the hae- , morrhage: in other cases they have been found co- existent. The relaxation of the symphyses of the pelvis in the parturient woman, is not a very rare occurrence, and does not proceed from rachitis, lues venerea, or cachexy : at least, neither of these diatheses pre- vailed in the case before us. Nor did they exist in a matron to whom I was related, who after partu- rition complained of pain at the symphysis pubis, and on examination I found the bones manifestly dis- tant from each other ; at other times the bones were not disjoined. Innumerable instances of this kind are extant, and in some of them the ossa pubis were an inch apart. Santorini found that he could easily lay his thumb between these bones in some women who had recently been delivered. Before delivery there is a gradual disposition in these junctures to relaxation. This circumstance has not only been perceptible to the finger but has been confirmed by dissection. In two women, one of whom had conceived five months, and the other seven, the cartilage between the ossa pubis was not only found thicker than usual, but was imbued with 497 an unctuous secretion. These appearances were most obvious in the second, in whom, even without a knife, and only by a slight effort of the hand, one of the ossa ilii was pulled away from the sacrum. —45. In the case which has just been detailed, and in the instance of the uterus having acquired the thick- ness of half a span, related by Sandenius, a fatal termination speedily occurred; and in cases of spha- celation of the uterus, death soon takes place. However, puerperal women are not only liable to be carried off' by diseases which are quick in their progress, but they sometimes die from protracted diseases. This has been exemplified in a case of slow fever excited by an abscess of the ovary and Fallopian tube. In consequence of laborious utero- gestation, and difficult childbirth, these parts occa- sionally sustain essential injury. During pregnancy, inflammation has sometimes been excited in the omentum, from the pressure of the uterus and other viscera upon it. After delivery I have found this membrane converted into an ob- long and almost scirrhous tumour. The patient oc- casionally suffers violent pain from it, and always ex- periences inconvenience. There are other affec- tions remaining after rather difficult labours, which are exceedingly troublesome though not painful. Lameness, prolapsus uteri, and incontinence of urine, have been spoken of; and tumours resembling hae- morrhoids, situated at the orifice of the vagina, are said to originate from this cause.—46. Unnatural formations and diseases in the fetus. The misfortunes attendant upon childbirth do not exclusively relate to the mother; for the fcetus is not only liable to be stillborn, but it may be malforra- vol. 11. 63 498 ed, or affected with some considerable disease. I have already alluded to some of the causes of death, and on the subject of monstrosity 1 prefer the de- tail of observations, to pursuing the controversy con- cerning their origin which has been agitated in the present age.—47. Case 1. Acephalous fetus. The mother of the mpnstrous fcetus about to be described had borne several children, the boys being in every respect perfect, but the girls, of whom there were two, were deaf, and consequently dumb. At length she wasdelivered of a female foetus, which, with the exception of the interior part of the belly, and the lower limbs, was more like a toad than a girl. It was not quite a span in length. The body and interior parts were perfect. The neck was entirely wanting, so that the chin was contiguous to the mid- dle of the thorax, and scarcely a digit from the car- tilago ensiformis. The eyes were perfect, but the external ears were placed much lower than they usually are, and touched the upper parts of the shoulders. The mouth was gaping; the nose was imperfect at its upper part, for the root of it, and the forehead were totally deficient. Added to these horrid appearances, the abdomen protuberated like a purse, hanging downwards ; and in the middle of it the umbilicus was naturally situated. The up- per limbs were so united to the sternum that they could not be extended. On the posterior surface of the body the spine presented three gibbosities; the upper corresponding with the head, the middle one with the thorax, and the lower with the abdomen. 499 The abdominal viscera were contained in its re- laxed parietes, as in a kind of sac. The head was a confused heap, having neither the usual bones of the calvaria, nor the cavity of the cranium. There were, indeed, bones of an irregular figure, some small, and others a little larger, connected together by an intricate network of muscles. No trace of the brain was discoverable, except certain bodies which, in their external aspect, finely resembled the nates and testes of the cerebrum, but their inner texture appeared intermediate between glandular and spongy substance. If the brain had not been deficient, and the girl had lived, she must have been deaf like her sisters, because both the internal auditory foramina were closed by a very firm mem- brane, so that the most slender nervous filament could not pass. Although nerves were distributed through the thorax, abdomen, and limbs, as usual, no medulla spinalis was discoverable, nor any part whence the nerves originated. For in tracing even the largest nerves, as the crural, for instance, when they ap- proached the spine, they gradually became more slender, and were fixed into it, but through the whole course of the spine not only was the medulla wanting, but there was no cavity. Valsalva, xlviii. 48. Case 2. Acephalous fetus ; spina bifida. A monster which had been born two or three days before, was shown to me by a surgeon in February 1746. The mother had borne some well-formed children, but with this fcetus she had an unusually difficult labour, and ultimately the child was deliver- ed by the feet. 500 Although the woman thought that she had com- pleted the full term of utero-gestation, the fcetus did not appear to be full-sized, and it was without brain. There was no neck, and scarcely any fore- head. From that place, instead of its being cover- ed with the common integuments, a reddish mem- brane originated. It spread over the whole upper part of the head, which was not protuberant, and it passed down the middle of the back, narrowing as it descended, till it reached near the bottom of the thorax. Beneath this posterior part of the mem- brane there were two bony ridges, one of which proceeded from each side of the head, and *they were less elevated in proportion as they receded from it, at the same time approaching each other. They indicated a bifid spine. At the sides of the membrane there was no defi- ciency of common integuments, which were furnish- ed with hair on both sides of the head; and the ears were contiguous to the shoulders. There was a large quantity of fat beneath the skin, and the thoracic and abdominal viscera were natural. Beneath the red membrane upon the head there was nothing like brain, except an appearance in the form of two little horns. These bodies were thick, soft, and of a red colour, one on each side of the cranium, resting on the posterior roof of the orbit. When cut into, they appeared to contain a kind of mucous matter, as well as coagulated blood. The anterior roof of the orbit, the bones of the sin- ciput, and the posterior part of the os occipitis, were wanting. The temporal bones were extended downwards and backwards, and at the foramina of these bones which the auditory nerves enter, I sought in vain for the beginning of these nerves, as I did for the 501 ( others usually found in the basis cranii. Consequent- ly I was less surprised, when, on examining the eyes, I found the optic nerves more slender than usual, and apparently terminating within the erbits. The eyes, it may be observed, as well as the eye- brows, were well formed. The tongue was long and narrow, corresponding with an elongation of the lower jaw. Three of the cervical vertebrae were deficient, and the remainder were so crowded upon each other that parts of some of them were united into one sub- stance with contiguous parts of others. Similar con- solidation had taken place between the bodies of two or three of the upper vertebrae of the thorax. From this part the spine curved towards the left side, and afterwards towards the opposite. On the right side there were only eleven ribs, but on the left there were twelve. With respect to vertebrae, there were eleven dorsal and six lumbar. The circumstance, however, most worthy of no- tice was, that the spine was really bifid. With the exception of the lower lumbar, the bony matter which, added to the bodies of the vertebrae, forms the tube, was collected on both sides and expanded : consequently there was no tube and no spinal mar- row.—Morgagni, xlviii. 50. In the the same year, 1746, Philip Baroni sent me the following observation. Case 3. Acephalous fetus ; spina bifida. A monstrous girl was brought forth in the begin- ning of the sixth month after conception. The mother was thirty six years of age ; her complex- ion was unhealthy and she was greatly emaciated in consequence of over-exertion and unwholesome diet. 502 Beyond the eyebrows there was neither forehead nor head; the nose was depressed; the mouth gaping; the outer ears were contiguous to the should- ers, and the right very much inclined downwards. There was neither neck nor chin, for the face, be- low the ears and mouth, terminated immediately in the chest. The greater part of the abdomen was not in- vested with the abdominal muscles and common in- teguments, but with a loose membrane extending in the form of a very large purse. The muscles and integuments, gradually extenuated, at length appeared to degenerate into this membrane; and being pellucid from its thinness, the liver and intes- tines were seen hanging outwards. The right thumb was wanting. The dorsal region was covered with hairs, and at its upper part, mid- way between the scapulae, there was a large and deep fissure, gaping like a mouth. It was formed by a defect in the vertebrae at that part. From the occiput, a little above this rima, a kind of flat muscle arose. Its basis was broad, and being unconnected with other parts, it partially covered the eyes and nose when it was extended forwards; and, if carried to the posterior parts, it covered the back quite to the loins. In figure and magnitude it was similar to the tongue of a male adult.—Morgagni, xlviii. 52. In 1735 I had an opportunity of seeing a mon- strous fcetus at Padua; and the following is a de- scription of its peculiarities so far as they were ob- servable without dissection. Case 4. A matron, forty-one years of age, enjoying pretty good health, and the mother of several well-formed children, produced a monstrous infant. Many of the 503 symptoms attendant upon former pregnancies were absent, and she did not perceive the motions of the fcetus. In the latter months a hard and circumscrib- ed tumour, like a distended oblong bladder, was generally perceptible in the hypogastrium, but it soon vanished. Labour, at length, came on, and the fcetus and secundines were expelled together, with unusual facility. The placenta appeared small; the amnion con- tained a yellowish and turbid water, and the dead infant appeared as long as those generally are which are expelled between the fifth and sixth months. Its face was very long, and from the middle of the lower part of the forehead a fleshy globe projected. Be- neath this mass the eyes were situated, and, as the nose was wanting, they were contiguous to each other. They were not covered with eyelids, but with a transparent membrane. The mouth was in its proper place, but gaped so as to show the incisor teeth. The abdomen was open in the middle, and the intestines protruded. The common integuments were also open at the loins. Both the upper and lower limbs were distorted.—Morgagni, xlviii. 53. This woman had never experienced any mental impression to which the deformity of her offspring could be ascribed. Though there are some cases in which it appears scarcely possible to avoid admitting the influence of imagination, which influence has been allowed to exist by the most distinguished men, yet I am not disposed to attribute every monstrous fcetus to this source. In the fcetus just described the protrusion of the intestines from the abdomen must be ascribed to the circumstance that this part had never been suffi- ciently closed; for Harvey saw the same part open in embryos of animals denominated perfect; and I have noticed the same fact in those of dogs. 504 When it is merely closed by the peritoneum, the peristaltic motion of the intestines is visible through it, as has been asserted by Ruysch, who has three observations relating to imperfections of this kind. The preceding examples of monstrosity relate to a deficiency of parts; but I shall subjoin others in which there was a redundance of some parts, with a deficiency of others, or in which the superfluity existed independently of any such defect. Double fetus. Trombelli formerly sent me the account of an in- stance of twins united. They were not only con- joined externally, but there was the deficiency in the abdominal parietes just adverted to, and their inner structures were intermixed. The case has been published by Vallisneri in his elaborate volume on generation.—54. The following specimen of redundant structure was observed by Mediavia. Case 5. Double liver. An infant was born at Padua about the beginning of July, 1736. On the right side, and a little above the navel, there was a tumour the size of a man's fist. It was devoid of skin, for, being elevated in the circumference, it terminated in a kind of promi- nent border. The tumour was unequal, and yielded to the touch, so that it appeared to consist of the intestines. At first the child neither sucked nor voided excrement, but soon afterwards it effected both. A degree of lividness had been perceived in the tumour, and, at length, it became completely gangrenous. Part of the recti muscles sloughed 505 away with the surface of the tumour, and the infant died on the thirty-fifth day after its birth. Dissection. The liver was double. One liver oc- cupied the usual situation, and, though rather small, was divided into very long lobes. The other was larger but shapeless; and was joined to the former by a thick membrane. It was annexed to the trunk of the vena portae, but its veins proceeded below the other liver into the vena cava. It extended to such a degree as to force out the peritoneum, which ad- hered to it; and constituted the protuberance of which I have spoken. However, although the liver was double, there was no appearance of a gall-blad- der. The small intestines were in a natural state, but the colon was contracted.—Morgagni, xlviii. 55. In March 1745 a two-headed calf was sent to me from the mountains, but on account of the distance, and with a view to preserve it, most of the abdominal viscera had been removed. The heads and necks, as well as the body, appeared perfectly natural. The spines, as they proceeded from the necks, continued distinct in the thorax, but they gradually approximated, and, below the thorax, were conjoined. The transverse processes occupied the intervals of the spines, and became shorter in the order of their approximation, and corresponded with the ribs in thickness,' breadth, and situation. In the same interval passed the descending trunk of the aorta, which was very large, in consequence of two being united. As far as the interval continued the aorta gave off three intercostal arteries instead of two; and one of them was distributed to the interspace itself. Both tra- cheae were divided into double bronchia, and each cavity of the chest contained two lungs of a large size. There were two thymus glands. A single pericardium contained two hearts, quite disjoined vol. n. 64 506 from each other. That surface of the left which was contiguous to the right was excavated to receive the natural convexity of the other. The right pre- sented its usual surface to the spine, but that surface of the left which is usually turned to the spine pre- sented to the other heart, and was concave, as I have just stated.—57. Fissured palate. Infants are sometimes born without a palate, or having a fissure in the palate, in consequence of which the mouth is less appropriate for sucking. Maloet relates that a child born without a palate lived fifteen days by putting milk into its mouth with a spoon ; and Petit mentions instances of chil- dren born with a fissured palate being preserved by sucking the teat of a goat, giving them the dug when half full of milk. The teat, under these circumstances, closed the fissure of the palate. This method was adopted for those who could not have accustomed themselves to the inconveniences in sucking and swallowing, which are the necessary consequence of a fissured palate. With the hope of accustoming the child to bear these inconveni- ences, or, at least, of preserving it longer, on one occasion I caused nutritive clysters to be administer- ed.—60. Jaundice. This disease is manifest to the eye, but the cause is uncertain. Almost all children are slightly jaun- diced a little after birth, but occasionally the new- born infant is very considerably affected with this disease. If the cause of the slight icteric affection were ascertained, I think there would generally be 507 some means of conjecturing the cause of the more violent. Fifteen children of my own became yellow soon after their birth, and some of them in a considerable degree. The disease was spontaneously carried off in all them. If we must assign a common cause for this occur- rence, it is probable that our attention should be directed to the umbilical vein. In consequence of its being divided or tied, some contraction in the vena portae, into which it is continued, may result; or on account of its being deprived of the blood which returns from the placenta, the secretion of bile in the liver may be retarded till this viscus be- comes gradually accustomed to its new mode of action, and is adapted to the separation of bile. This opinion, however, rests upon conjecture, but therp remain other sources of disease which may be confirmed by dissection.—60. Premature obliteration of the ductus arteriosus and foramen ovale ; and also, their remaining open. Among the remarks made by Cowper in his ap- pendix to the anatomy of the human body, I recol- lect to have read that many of the individuals in whom he found the ductus arteriosus and the fora- men ovale closed too soon, had suffered numerous diseases, such as inflammation of the head, of the parts in the neck, and of the lungs. Therefore when new-born infants are attacked with these affections, without any manifest cause having pre- ceded, there will be no absurdity in suspecting this premature occlusion. The reverse of this preternatural structure, namely, the passages in question, never wholly clos- ing, not unfrequently *occurs. Others, as well as 508 myself, have often found the foramen ovale open, and sometimes the diameter of the opening has not even decreased. We may infer that the same thing happens to the ductus arteriosus also. If some bodies sustain these defects without ma- nifest suffering, it is probable that there are many more which cannot.—61. Valve of the foramen ovale wanting. In the body of an infant which died when not more than fifteen days old, but of what disease was unknown, the following appearances were ob- served. Dissection. The heart and vessels about it were surprisingly distended with blood. Those parts of the umbilical vessels which are within the abdomen, and the ductus arteriosus were open; and the fora- men ovale was not merely open, but entirely without its valve, so that not the smallest trace of it was discoverable on the most attentive examination. Morgagni, xlviii. 62. This case was communicated to me by Jano Plan- ci, and the, appearance was totally preternatural. It is evident that when the part is wanting which the blood urges on the left side, so as either to close the orifice, or to cover it partially; the motion of the blood which is required in breathing animals, must be disordered in the principal organ. If this perver- sion is not diminished, the action of the.heart, as well as the motion of the blood, must, at length, be impeded.—63. A wide and almost unbeaten track lies open, to investigate the diseases of new-born infants by accu- rate dissections after death, as well as by attentive observations during life. A degree of caution is necessary in recording 509 these appearances, for some which are natural, have been related as the fatal disease. This observation applies to the close adhesion of the dura mater to tne cranium. However, if the advantages resulting from a diligent study of anatomy were confined to the discrimination of natural and preternatural struc- ture, in the investigation of the causes of disease, certainly it ought to be held in high estimation. The bodies of young infants have many peculiari- ties besides those which I have noticed, and who- ever desires to investigate thejr obscure diseases, to detect those appearances which are really morbid, and compare them with the symptoms, ought to habituate himself to the dissection of their bodies. This is requisite to enable him to remove or allevi- ate their diseases ; and, where this is impracticable, at least, it will assist him in the prognosis.* * In the fifth volume of the Medico-Chirurgical Transactions, Mr. Lawrence has written a paper on monstrous productions which, at least, is valuable in the facts which it concentrates. " The imperfect organizations of a more striking kind," he says, "most ef which come under the notion commonly affixed to the term monster, may be arranged under the four divisions of 1, unnatural formations; or 2, unusual position of certain or- gans ; or 3, of deficiency ; or 4, redundance of certain parts. The kinds of monstrosity are not kept distinct in each case : they may all be united in one specimen, and the want of one part is often attended with unnatural position of another," &c. He introduces this article by relating the particulars of an acephalous foetus which lived from Sunday till the following Thursday, and a little nourishment was given to it by the hand. It voided urine twice in the first day, ttnd once a day afterwards, and it had three dark-coloured evacuations. The medulla spina- lis was continued for about an inch above the foramen magnum, swelling out into a small bulb, which formed a soft tumour on the basis of the skull. All the nerves from the fifth to the ninth were connected to this tumour. This acephalous monster was a female, and the cases which presented themselves to Soem- mering, as well as Morgagni, were mostly of that sex. I have one instance of it in my own possession. In the first two cases related in the text, Morgagni has expressly said that there was 510 In the writings of Wepfer there is an example of a fatal symptom upon which a prediction was found- ed which accorded with anatomy, and the fact has been witnessed by myself. When the death of in- fants is at hand, I have no£* only seen deep sulci about the lainbdoidal and sagittal sutures, but also a small indentation near the junction of the coronary and saggital sutures. This arises from the brain having collapsed, and, in consequence of its connex- ions with the dura mater, by subsiding it draws in- wards whatever of a membraneous nature remains in the interstices of the sutures, and consequently produces the furrows and the pit which have been mentioned.—64. a total deficiency of medulla spinalis, as well as of brain: yet there was the natural distribution of nerves ; gnd, indeed, other parts of the body were well formed. Morgagni's observations on fissured palate may lead to a supposition that the act of sucking is attended with extraordi- nary difficulty. In the examples of this deficiency which have occurred to me, there was probably a little inconvenience at first, but the infant very soon learned to suck with the utmost facility. Morgagni implies that imagination or some powerful action of the mind, may sometimes be the cause of these deviations from nature. The mind of the parent certainly may affect the vitality of the foetus, but I see no foundation whatever for sup- posing that its configuration admits of being modified through the same agency. It frequently happens that the mind has un- dergone very strong emotion, and, in consequence of the vulgar prepossession, the mother expects a malformed offspring; but I never knew, or heard of a well-authenticated instance in which the expected deviation occurred. On the contrary, it usually happens when the mother is perfectly unconscious of any un- favourable impression, till some naevus upon the infant's skin, or something defective or redundant in other parts, leads her to suppose that some powerful emotion in her own mind must have occasioned it. Perhaps, however, one of the strongest arguments against mental influence is derived from the fact that quadrupeds and birds are liable to all these malformations, malpositions, defects, and superfluities.—Ed. CHAPTER V. FEVER, TUMOURS, DISEASES AND INJURIES OF BONES AND JOINTS, STRANGULATION, AND POISONING.* SECTION I. Fever. Of all diseases fever is the most frequent, and presents itself under the greatest diversity of form. Much has already been said on this subject when treating on other diseases, consequently but little re- mains to be adduced. In most of the dases selected from the papers of Valsalva, it may excite surprise, that, after violent febrile affections, or those which are destructive to life unexpectedly soon, scarcely any morbid appearance is discoverable which bears a proportion to their violence, and sometimes there has been no apparent lesion. Morgagni, Epist. xlix. Art. 1. In the body of a man who had been affected with febris lenta there was a calculus in the gall-bladder, the lungs were variegated with black spots, the blood in the dead body was extremely grumous, but in the ventricles of the heart it was coagulated. Valsalva, xlix. 2. * Although the subjects included in this chapter have no greater affinity to each other, than to any of the preceding chapters, yet, being residuary articles, I thought it better to as- sociate them than to multiply divisions.—Ed. 512 A boy died emaciated. There was adhesion be- tween the pericardium and heart; and the lymph effused presented a granulated appearance. Valsalva, xlix. 4. A woman, about thirty years of age, who had long been affected with double tertain fever, received a blow on the abdomen with a stick. She was ad- mitted into the hospital, and only complained of pain in the abdomen. On the third day she became de- lirious, the disease daily increased, and at length she died. Dissection. The liver was pale and indurated, and the gall-bladder contained about three ounces of black bile. The posterior part of the lungs present- ed a very red appearance.— Valsalva, xlix. 6. In the fourth case there was no morbid appear- ance which accounted for the fever; and in the fifth, the febrile symptoms arose from peripneumony.— 8. 10. A man, forty years of age, while recovering from a wound on the tibia, was seized with acute fever, which increasing in violence, he died. No morbid appearance was observed, except that the blood re- tained its natural fluidity.— Valsalva, xlix. 12. A nobleman, about forty years of age, subject to constipation of the bowels, was seized with fever, which was attended with no other symptoms than continual anxiety of mind and watchfulness. In the course of the fourteenth day headach came on, and he died. Dissection. The fundus of the stomach was tinged with a black colour; the intestines, especially the colon, were contracted; and the blood was greatly coagulated.— Valsalva, xlix. 14. To these cases Morgagni has subjoined instances which fell beneath his own observation, or under the notice of his friends. 513 Case 8. Hectic fever, from disease in the brain and spinal marrow. A man became greatly emaciated, and on that account many persons supposed that he was affected with phthisis. At length he was admitted into this hospital, and died in March 1747. Dissection. The abdominal and thoracic viscera were in a healthy state. The dura mater was thick- ened, and the cerebrum was exceedingly flaccid. When about to demonstrate the spinal marrow I observed that the dura mater, in this part, could not be drawn off so easily as at other times. In sepa- rating it from the tunica arachnoides I was under the necessity of proceeding cautiously, to avoid lacera- tion. The skin on this body was exceedingly hard, as it generally is in turbid subjects. Morgagni, xlix. 16. The firmness of the cutis mentioned in the preced- ing case is very evident when tried with a knife or needle, not only in phthisical persons, but in others who have been greatly emaciated.—17. Case 9. Hectic fever from organic lesions. The body of an old man whose extreme emacia- tion was attributed to senile marasmus, was brought into the college in January 1741. Dissection. The mesenteric glands were not so minute as they generally are at the advanced age of this individual, and the iliac vessels, from their origin to the thigh, were surrounded by a chain of enlarged glands. Some of these glands were two or three digits long, and proportionably thick; but when cut vol. n. 65 514 into they did not appear to deviate from the natural texture of lymphatic glands. The membranes of the spleen were thickened, and, for an extent of two digits, they were indurated and partially osseous. The origin of the splenic artery was somewhat con- tracted. The bladder was so distended with urine as to rise above the pubis; its coats were thickened, and, when compressed with the hand, the urine was expelled with difficulty,—indeed, the whole could not be forced out, and the impediment appeared to con- sist of an enlargement of the prostate gland, and its projecting into the bladder. The heart was desti- tute of fat, pale coloured, and not smooth on its sur- face. The valves of the aorta were indurated, and the vessel itself had bony laminae beneath its inner coat, at a small distance from the valves. But through its whole course it was beset with opaque spots, and they were continued through the iliac branches. When the carotid arteries had ascended one half their length, they were contorted like a cochlea, and then immediately regained their former straight course.—Morgagni, xlix. 18. There is no cause of emaciation more frequent than obstruction in the mesenteric glands. This ob- struction may arise from the primary or ultimate glands of the mesentery being alone affected, or they may be diseased promiscuously. An example of the first kind is given by Fantohus, and the man in whom it occurred had been confined during se- veral months under hectic fever. After death Fan- tonus found chyle only in what he describes as the vasa lactea primi generis; it being obstructed in its farther progress by the glands which these vessels enter. Cowper met with an example of the second description in a lean heifer, in which two enlarged glands compressed the receptaculum chyli. Exam- ples of the third species, derived from bodies which 515 had been affected with atrophy and hectic fever are common. Fabricius has recorded the dissection of a woman in whom the mesenteric glands had disappeared, and she was reported to have died of marasmus. In old people these glands decrease in size, and pro- bably some impediment to the transmission of chyle may result from this cause.—19. There are some species of fever in which it is desirable that a degree of collapse should happen. In the case of a young woman labouring under acute fever, perspiration came on, and the acuteness of the symptoms subsided, but the fever continued upwards of a hundred days. The fulness of her face continued, and she was never pallid : there- fore, when the fever appeared to have ceased, and she had risen from bed, it again discovered itself, as had been expected. At length, the febrile symp- toms and the plenitude of the body disappeared together. However, it must be admitted that there are numerous instances of fever in which perspi- ration, and other evacuations, have proved criti- cal.—20. Epidemic fevers exist under so great a variety of circumstances that a skilful physician will not ad- here pertinaciously to any predetermined opinion, but will observe attentively, and not infer from a single observation, or an accidental recovery, the treatment which ought to be pursued in other cases. I saw a woman who laboured under continued fever, and after blood had been withdrawn from the arm, the symptoms immediately became more violent. The blood contained but little serum; and the accession of symptoms proved to be a pa- roxysm of ague. From being continued fever, it assumed the intermittent type, and soon disappear- ed. This conversion, however, was fortuitous, and 516 not attributable to the loss of blood Such cases often occur in practice. The prevailing opinion that an eruption round the mouth indicates a crisis in fever, is not so unequivo- cal as the deposition of red particles from the urine ; and occasionally there is an appearance of similar particles floating on the surface of the urine at the same time. It sometimes happens, though very rarely, that these particles are whitish. They pre- sented this appearance in a young man in whom malignant fever, accompanied with petechias, began to decline.—21. The individual alluded to had been bled by vene- section and cupping four times. The blood was un- naturally fluid, and its crassamentum softer than usual; and after the third bleeding the serum was of a white colour. In the following month another young man was affected with fever which tended to the malignant form, and the blood abstracted on the third and fifth days exhibited a whitish serum. In the blood first drawn there were only a few drops of serum, and the crassamentum was hard, and covered with a moderately thick crust; but on the fifth day, the coaguluru was softer than natural, and covered with a crust as thick as the crassamentum itself. It was not hard, but so tough that it could scarcely be cut with a knife. In those malignant fevers in which sandy particles appeared, I neither observed a whitish serum nor a very soft crassamentum; but the latter was sometimes more dense than usual: and in one person, in whom, at other times, it was of a soft consistence, the coagulum was firm. Morgagni, xlix. 22. The following case, for which I am indebted to Mediavia, tends to show that a great quantity of blood is sometimes united with malignancy, and aug- ments the violence of the symptoms.—23. 517 Case 10. A woman, fifty years of age, having been very evidently attacked with malignant fever, was brought into the hospital. During the first six days the pulse was small and obscure* though it afterwards became more developed. Urgent dyspnoea and pal- pitation of the heart coming on, she died within two days. No part was opened except the thorax. Dissection. The left ventricle of the heart con- tained half-coagulated blood ; and not only was there such an accumulation of blood in the right ventricle as to distend the cavity, but it formed a dense concretion, and resisted the knife as much as the most tenacious crust of blood drawn from pleu- ritic patients.—Morgagni, xlix. 24. It has been supposed that some acids taken into the stomach have a tendency to promote coagula- tion of the blood. I shall subjoin a few observations which were at- tentively made upon the blood drawn by venesec- tion. On other occasions I have met with blood which exhaled a nauseous acid odour, but though I have bled in several malignant diseases, I never ob- served an acid odour arising from that blood. I distinguished it, indeed, in a woman who laboured under continued fever, and also in a man and boy who were affected with mild tertian fever. Though I perceived this odour in the blood drawn from the man, four hours after its abstraction, yet at the ex- piration of seven hours it could scarcely be detect- ed, which showed that the acidity existed in parti- cles more volatile than those which occasioned it in the blood of other persons, in which the odour was powerful at the expiration of twelve hours. I have observed the same odour where there has been no e 518 fever, for instance, in a case of periodical headach, and in an instance of scabies. In other cases of the latter disease the acidity did not exist. Morgagni, xlix. 25. In the following case whicji occurred at Padua ten years ago, the blood was said to be cold. Case 11. Catharine B., a married woman of a sanguineous temperament, who menstruated regularly even when suckling, laboured under inflammatory fever in the spring and autumn of twelve successive years, and on this account she was often bled. In her twenty- ninth year, at the time of menstruation, she received the unexpected intelligence of a fatal accident hav- ing befallen her brother. At the moment of receiv- ing this information she fainted, and on recovering, she perceived that the catamenial flux had been checked. However, on the following day there was a discharge of a coloured fluid, which occasionally recurred for some months. In the spring of ten successive years she had an attack of double tertian, and these accessions were carried off by repeated bleedings and the administra- tion of peruvian bark; and after the lapse of these ten years she was seized with febrile affections near- ly of the same description, but accompanied with violent pain of the abdomen. With other measures to subdue these symptoms she was bled six times. The serum of the blood was of a saffron colour, and the crassamentum was hard and incrusted ; but though the fever and other symptoms were mitigat- ed, they were not removed till uterine haemorrhage supervened on the fortieth day of the febrile attack, from which period she speedily recovered. She menstruated naturally for twenty months, and enjoy- ed extremely good health. After that time, namely • 519 in the autumn of 1749, owing to fatigue of body and anxiety of mind, she was affected with nausea, watch- fulness, head-ach, and lassitude. In the succeeding winter, the following symptoms were added to those just mentioned. The upper parts of the body felt hot while the inferior parts were cold. She experi- enced occasional horripilatio ; she was suddenly rous- ed in the night under a sensation of alarm accom- panied with tremour; and she became subject to vertigo. In the year 1750, when she was in her forty-third year, the menses which had always been copious, and often extremely hot, began to diminish, and at length the discharge was perfectly cold. Me- diavia was consulted at this period, and after open- ing the bowels, he directed blood-letting, and the circumstance for which this case is detailed then manifested itself. She said that the blood felt like ice sliding down her arm, and the surgeon's hand was sensibly affected by the coldness. The serum was small in quantity and of a yellow colour ; the crassa- mentum was black and viscid. Blood withdrawn from the foot in the evening had the same coldness as that which had previously been abstracted. Morgagni, xlix. 26. In 1758, some years after the period included within the preceding report, and when this woman had attained her fifty-first year, menstruation ceased. She enjoyed good health, except that she experienc- ed a constant sensation of icy coldness in the abdo- men, and, sometimes, when this sensation ascended to the thorax, it induced such difficulty of respiration that the abstraction of a considerable quantity of blood was necessary.—27. By other persons the blood has been observed cold.—28. Fever sometimes exists without being accompa- nied with an augmentation of temperature. When 520 I resided at Bologna a man was seized every day with chilliness, and though it was not followed by any elevation of temperature, it was considered as a febrile attack. A woman, fifty years of age, was received into the hospital of St. Mary de Morte, and, at a parti- cular hour every night, she was seized with rigour, trembling, and obscurity of pulsation; and the9e symptoms continued through the night without being followed by any febrile heat. At other times she had transient attacks of a similar nature. The dis- ease had existed for twenty days when peruvian bark was resorted to, and by this medicine the dis- ease was cured.—Morgagni, xlix. 29. It occasionally happens that the paroxysms of in- termittent fevers are accompanied by the most alarm- ing symptoms. This was demonstrated in a patient of rank to whom Vallisneri and myself were called. He was affected with a most dangerous tertain fever, and we saw him during the second accession. He was incapable of speaking, and was totally insen- sible. He had stertor, and very difficult respiration, and was entirely like a person in apoplexy except that there was subsultus tendinum ; and the pulse was very indistinct and unresisting. Our hopes of his restoration rested exclusively upon the circum- stance of his having recovered from a similar attack three days before. At the commencement of the night his pulse became less unfavourable, the skin became moist, and before morning all the dangerous symptoms had disappeared. As soon as the remis- sion commenced I gave him half an ounce of bark, and afterwards an ounce and a half, divided into much smaller quantities, and distributed into proper intervals. By this means the return of the paroxysms was prevented.—30. Although these comatose symptoms usually come 521 on in the early paroxysms, this is not uniformly the case. Among the indications of their approach may be observed stammering, or mutilation of words, or one substituted for another, as sometimes occurs when a slight apoplectic affection is about to degene- rate into paralysis of the tongue. During an exacerbation of fever, in addition to the symptoms which have been mentioned, the mouth has been evidently distorted, and in succeeding parox- ysms this affection has increased, so as to terminate in apoplexy and paralysis of the side. Whenever such symptoms occur, during intermittent fever, bark must be administered in the remission, as in other cases.—31. I have not so many obervations to communicate on this subject as on others, because there is some hazard in dissecting persons who die from fever. This, indeed, has been disputed by authors, but it is unquestionable that fatal consequences have re- sulted. In this theatre, a young man, of a robust habit, had partly dissected the body of a man who died of petechial fever, and he was seized with the same affection, and died. In 1717 Vulpius opened the body of a woman who died of apoplexy, which came on during the progress of malignant fever, and I stood by to demonstrate the situation of the visce- ra to the auditors. The body was quite cold, and though, when the abdomen was opened, no very un- pleasant odour ascended, nor was there any disease except an entangled state of the intestines, yet I immediately felt an unusual degree of languor, bor- dering upon syncope ; and we had scarcely returned home when both of us were seized with febrile shuddering and chilliness, succeeded by a hot skin*. Morgagni, xlix. 32. * The reason assigned by Morgagni accounts for his pathology VOL. H. 66 522 SECTION II. Tumours. Many instances of tumour presented themselves to Valsalva, some of which he did not record, and of fever not being very satisfactory. Perhaps, indeed, there is no disease in which the deviations from healthy structure are less uniform than in fever. Though morbid appearances might, in general, be discovered by examination after death, yet it is often difficult to say whether they were the cause or the conse- quence of the febrile affection. Generally there is some deter- mination of blood to the head, but though resembling inflam- mation, it does not exhibit the usual characters of phrenitis. However, inflammation has been found in the brain or viscera in these cases, and has terminated in abscess and gangrene. That excellent anatomist, Dr. Macartney, states as the result of his anatomical examinations of persons who died of typhus fever, that the morbid appearances are not those of common visceral inflammation. According as the head, lungs, or abdominal vis- cera, were engaged in the disease he met with, 1st. Fulness or distention of the vessels of the brain, espe- cially of the veins; and some water was effused on the surface, and into the cavities of this organ. 2ndly. The same species of congestion in the lungs, and different degrees of effusion into the cavities of the pleura and pericardium. 3rdly. Venous congestion in the liver, spleen, or alimentary canal; sometimes a bloodshot appearance or spots of extrava- sation in the mucous coat, more particularly in the stomach and first coils of the intestines. In some instances a more generally pulpy, or swollen, and discoloured state of the mucous coat of the alimentary canal. These congestions were always of a pur- ple or venous colour, and the blood throughout the body ap- peared to be accumulated in the venous system, and had little tendency to coagulate. The mucous coat of the intestines often becomes inflamed in lever, and not unfrequently ulcerates. I have met with these appearances in several cases, and in one instance of ty- phus fever, from which the patient had nearly recovered, symptoms of enteritis unexpectedly came on, and the patient 523 others have either been published by himself or re- lated by me in preceding articles. Case 1. Carcinomatous tumour of the mamma. A maiden, fifty years of age, of a lively disposi- tion, and in whom menstruation had ceased for some years, had a cancerous tumour of the right side, near the armpit. It increased greatly in breadth and length, and ultimately reached the axilla; and the contiguous limb became cedematous. To this affection cough was added, and was accompanied with mucous expectoration, difficulty of breathing, and urgent thirst. At length she died. Dissection. The tumour had not apparently in- jured the parts upon which it was situated, to any great depth. On cutting into the neighbouring arm, a large quantity of serum issued from the cells of the adipose membrane. died within a very short time. On examination I found the mucous coat of the intestines ulcerated, and, in one part, the parietes were perforated, and the contents of these viscera were effused into the abdominal cavity. It appeared that the acute symptoms came on when the peritoneal coat gave way. In the exanthemata, especially in scarlet fever, I believe the mucous surface of the alimentary canal often is greatly diseased. This has recently been manifested in a severe case of scarla- tina anginosa in one of my own children. The throat, mouth, and nose were extensively ulcerated, and the tumid and tender state of the abdomen, indicated that inflammatory action per- vaded the intestines. Soon after convalescence began, and sloughs were thrown off from the mouth, the stools presented a very bloody appearance, and were loaded with flakes of dark coloured substance somewhat like the incrustations which had lined the cheeks, gums, and palate, and been removed. It very rarely happens that there are not strong evidences of topical disease in fever, but I have recently attended a most severe and protracted case of synochus in which I was never able to detect any local affection.—Ed. 524 The corresponding cavity of the thorax was filled with serum in which numerous concretions floated. The lung there was so compressed, that, at first sight, it appeared to be wanting; and the heart was extremely small. The fundus of the stomach was greatly extended, the spleen was very small, the liver inclined to a brown colour, and the gall-bladder was slender and empty. The ovaria were white and indurated. Valsalva, 1. 4. The tumefaction of the arm arose from compres- sion of the axillary vein. Other instances might be adduced in which an external cancerous tumour has been attended with a difficulty of breathing, and hy- drothorax.—5. The following observation tends to elucidate some of the circumstances attendant upon scirrhus de- generating into carcinomatous ulceration, and to ex- hibit its consequences. The patient was of a me- lancholic temperament, which is always unfriendly to the removal of these diseases.—Morgagni, 1. 47. Case 2. A country woman, fifty years of age, received a blow upon her left breast. A month afterwards a tumour discovered itself, and an effort was made to counteract its increase by compression with a con- cave plate of lead. By the seventh month after receiving the blow, however, it had so enlarged as to extend from the upper part of the breast— where it was thicker, harder, and of a more irregu- lar figure—to below the areola, which was nearly concealed among the transverse rugae. When the humerus was lifted up there was some pain in the axilla, and the whole of the adjacent limb was cede- matous. These circumstances, combined with the 525 adust and melancholic disposition of the woman, were considered unfavourable to the removal of the tumour ; but her robust strength of body, her in- trepidity of mind, and her extreme sufferings, led to its extirpation ; and, till the seventh day, the ope- ration seemed to have been successful. At this time inflammation and sloughing came on, and des- troyed all the remaining cellular texture of the breast, and also that part of the pectoral muscle situated beneath the breast, as well as the external and internal intercostal muscles : so that the costal pleura was denuded to an extent of five digits. The cartilage of the fourth rib became black, and was nearly disjoined from the sternum: the ulcer discharged an offensive ichorous pus; the cedema of the adjacent limb increased, and the limb itself became motionless and nearly insensible. The legs became tumid; the frequency of the pulse, the thirst, and watchfulness increased. To these symp- toms were added diarrhoea, impaired appetite, de- cay of strength, difficult and frequent respiration, and continued somnolency. The symptoms last mentioned were succeeded by four protracted fe- brile paroxysms, which were extremely violent in degree, and conjoined with rigors. They recurred after an interval of about ten hours, and ultimately the woman was carried off by them. Dissection. The corpse was generally flaccid, and there was no oedema of the limbs. The spleen was slightly enlarged, black, and flabby ; and the uterus was extremely hard. Both cavities of the thorax contained a large quantity of fluid, particu- larly the left. The lung corresponding with the ulcer was dry and almost scirrhous, and adhered closely to the pleura at that part; and this mem- brane was united much more firmly to the ribs than is natural, and where it was exposed to the atmos- 526 phere, it had become callous. The axillary glands were converted into a scirrhous mass, of great firm- ness and of a livid colour; and the cellular mem- brane investing it, was changed into a kind of stea- toma. The circumstance of these tumours having com- pressed the vessels and nerves, elucidated the cause of the partial paralysis, and the obstinate oedema. Morgagni, 1. 48. I have seen numerous instances of tumours on the penis, and anus, as well as on the female genital organs, but have not had an opportunity of dissect- ing them. I was present when Valsalva amputaled a cancerous tumour which occupied the glans and a large portion of the penis. He apprehended that the penis or the arteries might retract, but neither of these circumstances happened, and he secured the vessels by ligature.—1. 50. Cases have occurred in which almost all the con- globate glands of the body have been scirrhous. This was observed by Zinnius in the body of an in- fant, and some parts of the cerebrum were indurated also.—Ixviii. 13. The following is an example of tumour which almost resembled cancer, but was not of that na- ture. Case 3. Tumour of the breast containing bone. Tubercles formed in one of the breasts of a nun at Padua. At first they were at a distance from each other, but, at length, they coalesced, and ex- hibited such inequality of surface, and were so pain- ful, as to be considered of a cancerous nature. A tumour the size of a walnut was extirpated, after having existed for thirty years, and was found to 527 consist of many little pieces of bone of various sizes, and not disposed in any regular order. Betwixt the pieces was interposed a substance almost like liga- ment, and when dried it assumed a black colour; but the bony fragments were white. The breast healed.—Morgagni, 1. 41. I supposed that this body originated from the coats of the lactiferous ducts, the blood-vessels, or some other membraneous structure, having become ossified.—42. The Sepulchretum contains an example of the breast having become universally bony. Mammary tumours are not confined to the fe- male, but sometimes they arise on the male breast also ; and, in their incipient state, nothing has been found of so much service as keeping the arm in a quiescent state for a long time.—44. Gouty concretions in the breast. On the upper part of the right mamilla of a gen- tlemen, a substance like a small gland projected. Within twelve months it had enlarged to the size of a fist, and was very hard; and two months after- wards it burst. The integuments and fleshy fibres appeared to have constituted a kind of shell which contained matter in some places resembling a cal- careous concretion, but in other parts the concretion was of a softer texture. The father and grandfather of this patient had been subject to gout, but the patient himself had never observed any other symptom of it than a transient pain in the great toe. His other physicians coincided with me in the opinion that the gouty matter, which in the ancestors of this patient had been deposited by glands in the joints, had been secreted by the mammary gland. 528 In proportion as this matter was removed, it again formed till the whole tumour was extirpated,—46. Case 4. Tumour of the breast removed by compressing its blood-vessels. An aged country woman, exceedingly squalid and emaciated, lay in the hospital of incurables at Bologna. The cause of all her complaints was a tumour of the right breast, and in form and mag- nitude it resembled the human brain. It was univer- sally ulcerated ; and in several places, amid its red and bloody substance, it exhibited numerous bodies like glands, white, oblong, and smooth, and equal in size to the largest grapes. Owing to the debili- tated condition of the woman, Valsalva did not think any method of removal could be attempted except by first compressing the base of the tumour by means of a bandage. The bandage was applied, and its tightness increased every day, so that the supply of nutriment being intercepted, the edges of the tumour soon began to slough, and the base daily lessened. This plan was persevered in for a considerable time, and the tumour, reduced to a very small size, was, at length, safely extirpated. The wound cicatrized, and the woman was dis- missed greatly improved in health. A year or two afterwards she presented herself again, looking extremely well for her age, but a very small tumour had arisen beneath the skin of the breast, and, as the large one commenced in the same way, she re- quested its removal. Valsalva complied with her wishes, but he expressed an apprehension that fresh tumours would appear in other parts, and that they would be very likely to form in the uterus.—1. 16. 529 Temporary reputation has been gained by various methods of removing cancer, but ultimate success has not corresponded with the fame of the practi- tioner; and when the prolongation of life, and the entreaties of the patient, demand the removal of the disease, excision is to be preferred. It happens but rarely, however, that the extirpation of cancer is, in every respect, successful; for although the wound may cicatrize the disease usually returns in the same part, or in some other. Case 5. Valsalva informed me that a maiden had a small protuberance on the ankle, and for more than six- teen years it occasioned most violent pain. Making an incision into the part, he found a body like a small gland, of a texture apparently intermediate between conglobate and conglomerate glands. After its re- moval, she did not suffer any more pain.—1. 15. Case 6. Hydatid tumour of the neck. On one of the bodies I used for public anatomical demonstration in 1750, there was a small tumour on the left side of the os hyoides. The tumour being laid quite bare, and detached from the left corner of the os hyoides, to which it was externally connected, represented a congeries of hydatids, not larger than the last joint of the little finger. Having pricked the edge of.it, a somewhat turbid fluid immediately issued.—Morgagni, 1. 18. Had the man lived much longer, this might have increased so as to constitute a large tumour. How- ever, I think that productions of this description are to be numbered with those which, in their inci- vol. ii. 67 530 pient state, may be dispersed without great difficul- ty.—19. Case 7. Adipose tumour of the nates. A man had a small tumour form in the common integuments of the nates. He was perfectly igno- rant respecting its cause, and it gradually increased till it acquired the size of a child's head. It was of a globular form, was attached to the buttock by a short peduncle, and had the same appearance as the rest of the skin. It was not the seat of pain, hard- ness, fluctuation, or pulsation. Valsalva removed it, and I dissected the mass in his presence. The peduncle consisted of four or five cylindrical bodies, the thickness of the little finger. Tracing the course of these bodies, I saw that the tumour was nothing else than a production of them ; for, be- coming very thick, unequal, and tortuous, and under- going numerous subdivisions, they made up the whole bulk of the tumour. However, they were easily disjoined by the fingers, and in their nature and structure they resembled the membrana adiposa. No blood-vessels were visible except at the upper part, and there they were of a small size. The whole tumour was invested with a pretty thick skin, which admitted of division into two laminae. Morgagni, 1. 23. This case is quite distinct from encysted tumours, in which the fatty substance is contained in a single follicle, and is reproduced after removal, if the cyst itself is not destroyed. But in the preceding case the fat was included in the membraneous cells, and was of the same texture as the adipose membrane itself.—24. 531 Case 8. A tumour existed upon the thigh of a woman who died in the hospital early in 1755. It present- ed externally an hemispherical protuberance, and its other half was buried beneath the skin. When the skin was divided, the tumour was found to consist of an excrescence of the adipose membrane. Morgagni, lxviii. 6. Case 9. A man consulted me respecting a tumour of a considerable size, which was pendulous from the thigh, and had nearly the form of a fig. It was of a soft consistence, and was unequal in consequence of hemispherical protuberances, which, however, were not larger than the point of a man's little fin- ger. When extirpated it weighed five ounces, and on examination it was found, like the former, to be an excrescence of the adipose membrane. The pe- duncle was of the same nature as that which has been described above.—Morgagni, lxviii. 8. Adipose tumours have sometimes enlarged to the weight of sixty pounds.*—9. Excrescences of a nature similar to those of which I have just spoken exist not only in the adipose mem- brane, but also in membranes situated internally, and particularly the omentum.—Morgagni, 1. 25. * Tumours of this description are designated by Mr. Aberne- thy adipose sarcoma, and they occur so frequently that it was scarcely necessary to adduce the foregoing examples. In the medical records of this country we have had instances of adi- pose tumours weighing upwards of 20 lb. and I recently saw one removed from the abdominal parietes of a man, by Sir Ast- ley Cooper, and this tumour weighed 37 lb. 10 oz. The pa- tient recovered without any untoward symptoms. See Medico? *'hirurgical Transactions, vol. xi.—Ed. 532 Small tumours have unquestionably been found on the tongue, but enlarged papillae are liable to be mistaken for tubercles or verrucae.—26. Strumous enlargement of the glands. Strumous tumours form upon different parts of the body, but especially in the glands of the neck. It has been said that they originate from mesenteric disease, but although this is pretty generally the case, it is not universally so.—28. The following case was communicated to me by Laurence Mariani and his son-in-law Joseph Boni, in 1752. Case 10. A youth, fifteen years of age, who had been healthy from infancy, began to observe an enlarge- ment of the small glands in the neck, three months after a severe mental impression. Not only were the salivary and axillary glands affected, but others on the back, thorax, and especially about the clavi- cles, in which parts they had acquired the magni- tude of a pigeon's egg. Tumours of the same description were afterwards perceived in the integuments of the abdomen, and even in the abdominal cavity, where they were per- ceptible to the hand. They were all free from pain, except one tumour three digits long, and of a livid hue, which was situated upon the pectoral mus- cle. This tumour was somewhat painful on being touched. The parts within the abdomen were also painful on pressure, especially on the left side, where there was great tension and resistance. He had acute pain in the knees, symptomatic fever, and watchfulness ; and in the progress of the disease, which was rapid, he became greatly ema- ciated. 533 _ Dissection. The external tumours were found to be seated in the membrana adiposa, which, in those parts, was closely connected to the subjacent muscles. All of them were full of a whitish matter, which, in part, was rather fluid, but most of it was solid and sebaceous. Some of the more prominent of these abscesses, as those for instance, which adhered to the pectoral muscles, making one continued body with the axillary glands, when cut into, discharged a yellowish purulent matter. The whole omentum was beset with hard^corpus- cles full of white matter. Similar strumous tubera, from the size of a hen's egg to that of a pigeon, oc- cupied the peritoneum, the pancreas, and mesentery. The tunica adiposa of the kidneys was exceedingly thickened—towards the vertebras it was two digits thick, and at the opposite parts five digits ; being uni- versally distended with the same kind of matter as that of which I have spoken. The left kidney, with the addition of a hard and strumous line which in- tersected that matter, weighed about thirty-six oun- ces. Not only were the adipose appendiculae of the colon affected with tubercles of the same descrip- tion, but even the ligamentous bands. In some places the glands of the small intestines were enlarged. In the mediastinum there was one tumour of the same species as those described. It was as large as a hen's egg, and compressed the trachea. There were many others of a smaller size. The outer sur- face of the lungs exhibited hard and stony globules, the size of grains of barley. Posteriorly these vis- cera were hollowed out by strumous tumours situated in the costal pleura, and the exterior surface of the right auricle of the heart was granulated by similar corpuscles. In general, these tumours were encysted, and the\ were distended with a tophaceous, hard, and rather 534 sebaceous matter, deposited within the cells of the adipose membrane, besides the equally hard glandu- lar bodies which have been described. Morgagni, lxviii. 12. Some of these tumours occur in parts where, in the natural state, glands are not visible. They have been seated upon the mesentery, the omentum, the stomach, the intestines, the pancreas, the urinary bladder, the peritoneum, the liver, the spleen, the kidneys,, the ligaments of the uterus, the diaphragm, the mediastinum, and even the dura mater of the cerebrum. The contents of these strumous glands vary, but sometimes, except in being enlarged, their texture does not appear unnatural.—14. Bronchocele. It is said by John Friend, that enlargement of the thyroid gland, which has improperly been denomi- nated bronchocele, ought to be regarded as a stru- mous affection. In the great number of swelled necks which I have dissected, and which were sup- posed to be examples of bronchocele, I have uni- formly found the disease in the thyroid gland. How- ever, the lesions of this gland are extremely various. Morgagni, 1. 30. In the neck of one woman, dissected in 1741, the enlarged gland was somewhat roundish in its figure, and totally conglobate. Its texture was hard, and even scirrhous. In some places a white substance was intermixed with substance of a brown fleshy colour.—31. In the same gland of another woman, I saw many pretty large portions of a white substance intermixed with the substance of both lobes, but especially the right. The left lobe contained a cyst, consisting of a thick and white coat, and containing a yellow hu- mour, of a somewhat dense consistence.—32. 535 In the neck of a man dissected about the same time, one lobe of the thyroid gland was larger than the other. The enlargement was occasioned by a membraneous bladder, half-buried in its substance, and when it was perforated, a viscid and yellow fluid resembling bile was discharged.—33. The thyroid gland of a woman, larger and more prominent than it usually is, was removed for de- monstration, and exhibited globules partially protu- berant, and in part buried within the glandular sub- stance. They were of a round figure but of diffe- rent magnitudes, the largest being equal to the bulk of a middling-sized grape. They contained a limpid fluid like water.—34. In the thyroid gland of another woman I found a small white body the size of a vetch, having nearly a bony hardness.—35. Many other anatomists have met with hard bodies in this gland, and sometimes the gland itself has been found bony. The body of a young man, who died of ascites, was brought into the theatre in 1747. The thyroid gland was thicker than usual, and the lower part of one of its lobes was indurated. This was found to arise from round vesicles full of mucus.—36. On one occasion the thyroid gland was much en- larged, and it appeared to be made up of small lobes in the middle of which was found a globule full of fluid which greatly resembled oil of almonds. —xxiii. 4. Enlargement of the thyroid gland occurs most fre- quently in females. Sometimes it takes place in one lobe only, but this circumstance must not lead us to infer that the gland is not solitary, for the same thing occasionally happens in the liver and spleen.— 1. 37. There is a species of tumefaction which some- 536 times occupies the limbs, and even the structure of the muscles becomes changed in a surprising degree. A nobleman of this place was affected with this disease in one of his legs. SECTION III. Diseases and Injuries of Bones and Joints. Exostosis. From tumours of soft parts we proceed to those of the bones, and 1 prefer comprehending them under the general term exostosis.—Morgagni, I. 56. This arrangement, however, is not sufficient, ex- cept in a general way, because there is great discre- pancy in the nature of the tumours which form on bony structures. In some there appears nothing un- natural besides an enlargement or excrescence of the bones, and this Mery considered as the common ex- ostosis, and Bidloo as the only form deserving the name ; but there are other cases in which the tu- mour is united*with caries, and to these productions the same appellation has been applied. However, both kinds will admit of subdivision, for the tumour which is not carious is either composed of a dense and solid substance, or of a substance wholly cellu- lar or spongy.* The latter appearance was observ- ed by Ruysch in a thigh bone which was increased * Morgagni distinctly alludes to the two forms of exostosis periosteal and medullary. The former arising from a deposi- tion of osseous matter between the periosteum and bone, and the latter from the medullary membrane and cancellated struc- ture of the bone.—Ed. 537 an inch in thickness. The same author, too, has de- lineated a tibia, the exterior substance of which was very thick, hard, and compact; but its interior was cavernous. The tumours of a carious bone are either the consequence of caries from external in- jury, or, as it more frequently happens, from an un- healthy condition of the fluids, whether that condi- tion be owing to lues venerea or to any other cause. These tumours differ from each other, whether we consider the diversity in the magnitude of the cells, or the variety of matter contained in them. When the enlargement takes place at a joint, though it might not contain any thing unnatural, yet the protuberance itself may impede the motions of the joint by stretching the tendons situated upon it. This effect, however, has not always resulted. Concerning a Roman matron, Eustacnius relates that the inferior processes of the femur had acquir- ed the size of the largest human head, nevertheless she retained the free use of the joint. Though the processes were so enlarged, yet they preserved their natural figure. Sometimes this articular sur- face has become flat ; or, instead of being convex, it has been somewhat excavated, when the mo- tion of the joint must necessarily be impeded.—57.„ Exostosis is not confined to the bones of the limbs. I have seen an example of it in the clavicle, which had formerly received a blow. The protu- berating bony substance was of a large size, and of a spheroidal figure.—58. A thickened and indurated state of the ligaments is liable to be mistaken for exostosis. Boerhaave suggested that the true exostosis may arise from obstruction in the periosteum, and it afterwards becoming bony; or in consequence of the lamellae of the bones receding from each other. He wit- vol. n. 68 538 nessed the bones of the cranium four times thicker than they usually are, and wholly fungous, so as to resemble pumice stone. Duhamel excited the first- mentioned species of exostosis in living animals, and examined the parts in their various degrees of indu- ration ; but he was unable to produce spongy exos- tosis. Relative to that kind of exostosis which has been ascribed to a recession of the bony laminae, it has been thought this could not happen while they remained hard and rigid; but that they must have returned to the nature of cartilage*. Many exam- ples of this change certainly are extant. In cases of spina ventosa, not only in children but in adults, Heister more than once found the bone soft enough to admit of being cut with a knife, and he supposes this degeneracy of structure may arise from the ve- nereal disease, scrofula, smallpox, and even rick- ets ; for it is certain that rickety children are liable to an expansion of the extremities of bones. Heister thinks that the bony laminae are softened by the morbid humours, and when soften- ed that they are urged outwards by the accu- mulation and pressure of those fluids. I have scarce- ly any doubt that this explanation or a similar one, will be adopted in reference to those tumours which are surrounded by soft bony lamellae, though some hesitation may be felt with respect to those in which though the laminae were perceived to be univer- sally rigid and hard: the bulk, nevertheless, con- tinued to increase.*—59. * That expansion of the bones which has been designated spina ventosa cannot, with propriety, be regarded as exostosis. It generally appears to be a scrofulous disease, originating in the cancellous structure, and particularly affects bones, or por- tions of bones, which have a spongy texture, as the extremities of the cylindrical bones, and the bones of the carpus and tar- sus.—Ed. 539 Case 1. Medullary exostosis. On the femur of a man brought into the college for dissection in 1732, there was a spheroidal tumour. When cut with a saw in a longitudinal direction, I found that it consisted of bony cells, which abound- ed with a liquid medullary oil, of a yellow colour; and the cavity of the bone corresponding with the protuberance was filled with a large quantity of the same kind of oil. Although the weather was cold, and other fluids were frozen, yet a part of this oil had not concreted in the least. In the farther cavity of the bone the marrow was of a reddish colour and concreted.—60. Whether the altered quality of the medullary oil in and about the exostosis, was the consequence of- that bony tumour, or had preceded it, I leave unde- termined.—61. In numerous instances blood has been found ex- travasated in the medulla of bones. A case fell under the notice of Morand in which the os femoris, at the external trochanter, and the extremity of the fibula, were enlarged. The calvaria also had ac- quired twice its natural thickness; but when the blood, lying between the two tables, was removed by continued pressure, the cranium became very thin.—Morgagni, lxviii. 4. Mollities ossium. In a case which occurred to Ludwig, some of the bones had become so soft as to yield to the slightest impression of the finger; and others were so ex- tenuated in their external laminae that the subjacent cells could easily be seen through them. In the 540 former the outer lamina was, in some places, re- duced to the form of a membraneous sheath. This was the case with the femur and tibia. Their solid substance had been absorbed, and probably was evacuated with the urine, for there was a surprising quantity of sediment in this fluid, and it was of a peculiar nature, being of a white colour, cretaceous, and soluble in vinegar and other acids. Morgagni, lxviii. 4. Case 2. A woman who had completed her fiftieth year was attacked with pain in the lower jaw, some- times accompanied with profuse haemorrhage from an abscess in the neck, to which, had the bleeding not ceased, it was intended to apply the actual cautery. Soon afterwards she was afflicted with pains in the bones, and when she had undergone that suffering for a long time, she complained, as often as she was moved, that her bones were broken; and the persons who stood near, heard a crepitus in the articulations at the time. The bones of the lower limbs began to bend as if they were made of wax. Dissection. The ossa innominata, the ossa fe- moris and tibiae, the bones composing the arch of the cranium, the ribs, the bones of the feet, and of other parts were found to be as flexible as if they had been made up of pretty thick paper. On their surface they were spongy, and in some places, inter- nally, they were carious. They admitted the scalpel like cartilage ; and all the bones which yielded to the force that bent or compressed them, discharged a fluid similar to diluted blood.— Valsalva, lviii. 4. Valsalva preserved these bones, and I observed that the oblong ones were curved into the form of 541 an arch, and the bones which constituted the vault of the cranium were flattened. All the bones were of a bad colour and exhaled an offensive odour, be- cause they could not be cleaned internally. Morgagni, 5. In other cases the bones have become flexible like fleshy substance, and were impregnated with a bloody serum. Haller relates an instance in which the fibula had become entirely fleshy, or like soft cartilage, though the periosteum had not undergone any change. The bone was tumid and internally carious. In a case related by Boerhaave the bones are said to have been reduced to a pultaceous con- sistence.*—6. * Little more is known respecting the nature of that extraor- dinary flexibility of the bones which constitutes mollities os- sium, except- that there is a deficiency of earthy matter in them, either in consequence of excessive absorption, or of a defect of ossific secretion. The strongest cylindrical bones may be re- duced to a cartilaginous softness, and admit of being bent in any direction; consequently the disease differs from rickets, in which the bones become distorted by slow degrees, and retain their natural inflexibility. The melancholy spectacle which rickety children often pre- sent, cannot but awaken the liveliest compassion. There are many circumstances which often impart to the disease a strumous character, but its causes are involved in so much intricacy, that it has been attributed to scurvy, syphilis, dentition, and various other sources, as well as- scrofula. There is little doubt that the causes vary, and musi be sought for in the peculiar cir- cumstances attendant upon individual cases. The means by which children regain perfect health after having shown a rachitic disposition in the distortion of their limbs, the enlarge- ment of the articular epiphyses, and their general expression, would lead us to suppose that it sometimes, at least, exists in- dependently of any specific diathesis. The process of repara- tion in rachitis has been elucidated in an interesting paper by Mr. Stanley, published in the seventh volume of the Medico Chirurgical Transactions.—Ed, 542 Fragilitas ossium. The bones sometimes become brittle. In a wo- man, who by a slight effort had fractured the os humeri, and soon afterwards the os femoris, Lovi- sius found the bones dry and fragile. The medulla was likewise dry, friable, and quite loose from the parietes of the bony cavities. She was sixty years of age, cheerful, and had enjoyed good health ex- cept having been afflicted with cancer in the mam- mae.*—Morgagni, lviii. 7. Caries. An old woman in the hospital of incurables at Bologna had so much of the left os sincipitis, and of the neighbouring part of the os frontis destroyed by venereal caries, that the brain was denuded to an extent of three digits in every direction. It could be distinctly observed that the brain and radial ar- teries pulsated together. The woman was not af- fected with conyulson, paralysis, or any other symp- toms of lesion of the brain or of its membranes. Morgacrni, lviii. 11. It is surprising that this disease in the bones some- * As in the diseases referred to in the preceding note there is a deficiency of lime, in fragilitas ossium the proportion of animal matter seems defective. It is most frequently an atten- dant upon advanced age, and the morbid brittleness is so ex- traordinary, that the os humeri has been fractured by the pa- tient's merely leaning upon the arm of another person. A lady, seventy years of age, who appeared in good general health, is said to have fractured the os femoris by kneeling down; and on being taken hold of to carry her away, without any violence, the os humeri was broken. I have known the bones fractured by the sudden action of the muscles, and, indeed, a case is on record in which the patient could not turn in bed without breaking some bones.—Ed. 543 times happens whilst the muscles and integuments, above the bone, betray no morbid appearance ; but, in other cases, the muscles and integuments above, and the membranes of the brain beneath, partici- pate in the disease.—12. Morbid appearances in the joints from gout and other affections. Gout is a disease which generally attacks the rich, but dissections are usually performed on the bodies of the poor; therefore the observations re- lating to gout, in anatomical writings, are much fewer than those which relate to most other diseases. Examples of this disease have been adduced in for- mer parts of this work, and therefore I have but few to subjoin.—Morgagni, lvii. 1. Case 3. Disease in the cartilages of the hip, supposed to arise from arthritis. A woman had frequently been affected with sciatic pains in the joint of the right femur, and on that side she was lame and somewhat distorted. Dissection. The head of the os femoris was not rounded into a globular form, but was depressed; and instead of being covered by a smooth and white cartilage, this substance was of an ash colour. At the posterior part the cartilage was deficient, so that the bone exhibited numerous roundish and protube- rant particles. The inner surface of the acetabulum was bloody, and its supercilium had two bony laminae, not of a very small size, imbedded within its natural cartilaginous and ligamentous substance. Morgagni, lvii. 2. Here there was no disease or deposition of cal- 544 careous matter around the joint, but the whole dis- ease was situated within it. Fernelius believed that the arthritic humour never, or, at least, very seldom penetrated the cavity of the joints, but affected the surrounding ligaments, mem- branes, and tendons; and in a priest afflicted with gout, Valsalva found the calcareous matter had been deposited in the theca of the tendons of the fingers; but there cannot be a doubt that the glands which secrete the synovia sometimes deposite the chalky substance, when the blood is loaded with its parti- cles. When it has accumulated within the joint and has concreted, the bones become separated from each other, the ligaments and skin burst, and the concreted substance is removed in pieces from the joint.—3. The feet are more frequently affected with gout than other parts of the body, which may arise from their greater exposure to cold, the pressure of tight shoes, the languid state of circulation, and diseases in the absorbents. Brasavolus has related the cases of two illustrious young men, who began to suffer from gout when they were only fifteen years of age. I am less sur- prised at this circumstance in consequence of having seen little children who were afflicted with severe pains in their joints before they had fully emerged from infancy; and I knew, at the same time, that their father, grandfather, and great-grandfather, had been subject to the gout.—4. Paroxysms of gout suspend other diseases. It frequently happens that a paroxysm of the gout suspends or removes other disorders, which are uncontrollable by every artificial expedient. The wife of Gerbezius, who, for a long time, had suffered severe pains in the thorax and stomach, obtained 545 immediate relief from them bv the supervention of gout. My own eyes were affected with inflamma- tion which approached chemosis, and I had employ- ed various remedies without deriving any advantage from them. After bathing the feet in warm water, and using gentle frictions, for two evenings, the gout attacked me in the joint of the toe. The pain gra- dually increased, and the ophthalmia immediately abated, and in a few days wholly disappeared. On the contrary, when gout is repelled from the limbs, it occasionally produces the most alarming symp- toms ; and sometimes fatal consequences ensue from its invading some of the viscera of the abdomen, of the thorax, or the brain.—9. Case 4. Metastasis of gout; renal calculi. George Cornell', a cardinal of the Roman church, was subject to pains in the joints, and in the kidneys. Having voided some calculi he lost all symptoms of the kidneys' being affected, but, at times, his arthri- tic complaints returned. His bowels were constipat- ed, he had a sense of heaviness of the head, accom- panied with dulness of hearing, with a propensity to sleep, and frequent swoonings; and his advanced age and corpulence prevented him from taking his wonted exercise. In this state he had scarcely pass- ed his sixty-fourth year, when he lost his appetite, and was attacked with an arthritic paroxysm. His right hand and left knee began to swell, and at that period he received intelligence of the death of his brother to whom he was strongly attached, and the event occasioned him an incredible degree of grief. The gout ceased in the limbs; tightness and oppres- sion at the praecordia, and difficulty of respiration came on; and occasionally he was attacked with vol. n. 69 546 sudden paroxysms during which the functions of the brain and heart were partially suspended. His pulse became intermittent, and though in one day, while the knee swelled, the pulse improved, yet the pow- ers of life were so much impaired that he died soon afterwards. Dissection. The mesentery and small intestines were loaded with fat. The stomach was large and its coats extenuated. The gall-bladder was small, and contained a calculus; and its coats were so thin and flabby as to lacerate by a touch. Both the kid- neys exceeded their natural size, but the right was the largest, and, with the investing fat, it almost equalled the size of a man's head. It contained eleven calculi, and most of them were ramified, and of considerable magnitude. The left contained a solitary branched calculus. In appearance these cal- culi resembled black coral, and that part of the sub- stance of the kidneys which lay in contact with them was hard and callous. The cartilages of the trachea were hard, the aorta was somewhat dilated in the thorax, and in its course through the thorax and abdomen, some ossification had taken place. The blood in the heart was frothy. Serum was deposited within the cranium, and the whole substance of the cerebrum was exceedingly flaccid.—Morgagni, lvii. 10. In this case there was great complication of dis- ease. The deliquia and intermission of the pulse were ascribable to the state of the aorta, whilst the power of the heart itself was impaired by the condition of the brain. The blood circulating through the body was not healthy, for a stomach so lax and extenuated would be incapable of pro- perly digesting the alimentary substances. Nor were the intestines in a suitable condition to convert those substances into chyle, for no bile descended 547 into them from the gall-bladder, and only a small quantity had been transmitted thither for a long time, and that was of an unhealthy quality. This circumstance was demonstrated by the calculus, the smallness of the gall-bladder, and the constipation of the bowels. Renal calculi are a frequent con- comitant of gout.-^ll. As there is a considerable analogy between rheu- matism and gout, I shall subjoin two observations in relation to that disease. In the dissection of a rheumatic patient, Drelin- court found a gelatinous substance concreted on the surface of the muscles, two or three ducats in thick- ness.—16. I am indebted to Mediavia for the following case. Case 5. v Morbid appearances after rheumatism. A young man, who was a goldsmith, had violent pain in his right lumbar region, and it yielded to no remedy. A year having elapsed, the pain began to attack the left side also, and he experienced some pain in his neck which seemed to be rheumatic. An inability to move his legs followed, the abdomen became tympanitic, and he died about the middle of April 1753. Dissection. We were only permitted to examine those parts in the loins which had been the seat of the obstinate and violent pain. In the cells of the adipose membrane some watery fluid was deposit- ed. When the tendon of the latissimus dorsi was removed, we observed that the thick fleshy mass which affords a common origin to the sacro lumbahs and longissimus dorsi muscles was greatly discolour- 548 ed, so that, for the space of five digits, it resembled old furniture made of the nut-tree. This appear- ance was observable also in the subjacent sacro- lumbalis, and in the quadratus lumborum muscles. The fibres within this space were astonishingly flabby, and were disjoined by numerous coagula of blood. These disorders were increasingly manifest in proportion as the muscles were situated near the spine. Both loins were affected, but the disease was slightest on the left side.—Morgagni, lvii. 17. The affection of the neck may be accounted for from the circumstance that the longissimi muscles, whose origins were found diseased, are continued to the neck. The inability to move the limbs may be ascribed to an affection of some of the nerves which contribute to form the crural; and possibly the disease might also have extended to the psoas muscles.—18. ' There are other affections of joints besides those which arise from gout. Case. 6. Disease of the cartilages of the knee. In the knee of a woman, who died from apoplexy, that part of the cartilaginous crust of the patella, corresponding with the external condyle of the fe- mur, appeared as if it had been rubbed away, and was marked with slight and small parallel furrows, as if the point of a chisel had been drawn along it. A great number of globules were prominent within the joint. The five largest were nearly equal in magnitude to middling-sized grapes, and of the re- mainder, upwards of twenty, some were a little smaller, and others very much so. The larger ad- hered to a cartilaginous crust, or rather to the fim- briae of a synovial gland, which closely covered the 549 cartilage in some recesses of the bones; and the smaller were adherent to the capsular ligament. These bodies were white, and had a smooth sur- face ; some of them were bony, and others con- tained a bony nucleus beneath a cartilaginous crust. Morgagni, lvii. 14. Cartilage ulcerated ; loose bodies in the joint. In another case I found the cartilage of the pa- tella eroded to a small extent. Haller found one of the articular processes of the lower maxilla strip- ped of its cartilaginous crust, and the lunated carti- lage was almost half destroyed and perforated. In consequence of attrition, the cartilages which had been removed were converted into nearly twenty half-bony globules, which were loose in the cavity of the joint.—15. Injuries of the bones and joints. Fracture of the hip-joint. So far as I am aware, fracture of the neck of the os femoris was first observed by Parey. It is dis- tinguishable from ' dislocation with some difficulty, and, owing to the various impediments which present themselves, the reunion of this fracture takes place but seldom. Ruysch dissected the bodies of eight persons whose lameness had been attributed to luxa- tion, but he found a fracture of the femur at its neck. Cases have also been mentioned by Chesel- den, Erndlius, and Borstius. Ruysch has demon- strated the head of the bone reunited with the fe- mur by means of strong ligaments, which occupied the place of the cervix.—lvi. 2. 4. Salzmannus states that luxation of the hip joint happens with most facility when the ligaments are 558 relaxed from gout, when there is paralysis of the surrounding muscles, when the acetabulum is large or its margin is fractured or imperfect, or when tumours have arisen within it. For though the cause itself may be insufficient to force the head of the femur out of the acetabulum, yet, if any exter- nal violence should then be applied, dislocation will readily ensue. It has also happened, as in the case related by Nicolaus, that the ligamentum teres has been totally wanting.—5. When the os femoris is dislocated, or its cervix k fractured, and the bone remains displaced, a new acetabulum is sometimes formed. In a work pub- lished under the auspices of Gaubius,* a case is re- lated in which both thigh bones were dislocated. The head of the right femur was sound, but that of the left was destroyed by caries. A new aceta- bulum in the ossa ilii, corresponded with each of the heads. The left was slightly hollowed out, but the right was very deep. The old acetabula were near- ly obliterated.—6. The following instances confirm some of the pre- ceding remarks. Case 7. Luxation accompanied with laxity of the ligamentum teres. A woman, sixty years of age, labouring under diffi- culty of breathing, dislocated the os femoris by a fall. Fever came on, which increased the dyspnoea, and she died on the eleventh day. Dissection. The liver was indurated and there was fluid in the thoracic cavities. The luxation of the femur appeared to have arisen from relaxation of the ligamentum teres.— Valsalva, Ivi. 7. * De modo quo ossa se vicinis accommodant partib. § 42. 551 The following ease was communicated to me by my pupils. Case 8. Fracture of the cervix mistaken for dislocation. A countryman having fallen from a tree was sup- posed to have dislocated his femur. The surgeons attempted to reduce it, but their efforts were in vain, and some of the young men, who had repeat- edly heard me state that from external force a frac- ture of the cervix happens more easily than a luxa- tion, ventured to suggest that it was a case of frac- ture. The senior surgeons, however, would not re- linquish their first opinion; but at the end of two months, when the man had not risen from bed, he was seized with thoracic disease and died. Dissection. The cervix was observed to be frac- tured through the middle, so that one half adhered to the head and remained in the acetabulum. Morgagni, lvi. 9. Case 9. Tlie cervix of the femur absorbed after fracture. A woman, about forty years of age, lame on the left side, had recently received a violent contusion on the lower ribs, and being seized with fever she was carried off within fifteen days. Dissection. The left leg was four digits shorter than the right, and the heel was turned outwards. The right iliac vein was wider than it usually is, whilst the left and its branches were exceedingly slender, and pale. On opening the vena cava, in- stead of the orifice of this iliac vein I found a line which defined its coalition, and in this line two or three small orifices communicated with the iliac 552 vein; and having cut into it, I observed a kind of fasciculus of fibres projecting internally. Quite to the ham the vein appeared a third smaller than the opposite; and though the coats did not coalesce, blood had coagulated between them. The os femo- ris was deprived of its head and neck. The former remained in the acetabulum, though the cartilage with which both these parts were incrusted was ul- cerated in places, and the bony substance of the head was not quite healthy. There remained no trace of the cervix, with the exception of some osse- ous fragments adhering to very thick and hard liga- ments, into which the capsule appeared to have been converted. At least, these ligaments were produced from the margin of the acetabulum and extended to that part of the upper extremity of the femur whence the cervix formerly arose; and they con- nected the femur to that margin. The cavity be- tween them, instead of being occupied by the cervix, was filled with a small quantity of matter of a thick- ish consistence, and of a fleshy colour. The os innominatum, on the left side, projected forwards more than the right: consequently it was probable that the same external violence which had fractured the cervix of the os femoris at a very early period of this woman's life, had also luxated the os innominatum.—Morgagni, lvi. 10. The disappearance of the cervix is attributable to the long-continued friction of the broken bones. When the periosteum has been lacerated by a frac- ture, it frequently becomes thickened and hardened; and it may be perceived by the preceding case, that the same thing occasionally happens to the ligaments. Extenuation of the iliac veins was observed in ano- ther lame woman.* The os femoris in this woman * Vide page 402. 553 could not have receded far from the acetabulum, in consequence of the connecting ligaments.—11. Case 10. A secondary acetabulum formed in consequence of an old dislocation ; retention of urine accompanied with a stillicidium. A lame woman, nearly eighty years of age, died from apoplexy, or rather, perhaps, from the effects of apoplexy. For as the bladder was paralyzed, the attendants were deceived by a constant dribbling of urine, so that the state of this viscus was neglected, and after death it was found so distended with urine as to reach the umbilicus, and to occupy both iliac regions. She had been lame on the left side, and the corresponding leg was not only shorter than the right, but was much extenuated : the knee, too, was turned inwards, and the heel outwards. The veins of the opposite limb were very large, and the limb itself presented a good appearance. On exposing the left hip-joint, we found that the head of the femur, instead of being globular as usual, was almost flat, was somewhat enlarged, and was not furnished with any round ligament. It was received into an acetabulum less hollow than usual, but incrusted with cartilage. At the anterior border of this acetabu- lum there was another cavity much less, than the former, with which nothing on the right side corres- ponded. Though the left acetabulum was neither higher nor lower than the right, nor was it situated more posteriorly, yet it was at a greater distance from the symphysis pubis, for the left os ilium was much more distant than the right. Morgagni, lvi. 12. By comparing this case with the observations of other surgeons, I have no doubt that the acetabulum vol. ir. 70 551 in which the head of the femur lodged had been hollowed out by the head of that bone, which long before had been displaced from its natural socket, of which a vestige yet remained. The smallness of this cavity may be accounted for from its office hav- ing ceased in early life, or from an increased deposi- tion of bony substance having partly filled it, as hap- pens in the alveoli after the removal of teeth.—13. Case 11. Secondary acetabulum from an old dislocation. The subject of this case was born with an equality of limbs, but he had been lame nearly the whole of his life. When very young his mother perceived that he suffered pain in the right limb, and after that eriod it became shorter; but though lame, by habit e was able to walk with ease and celerity. Dissection. The anterior half of the original ace- tabulum remained, and in its fundus there was a substance of a pale reddish colour, which seemed morbid, and somewhat resembled glandular textures. The other half was filled with a bony substance. Above this old acetabulum, on the outer surface of the os ilium, another cavity was formed. It was constructed of a white and firm substance resembling ligament, but the structure of the border appeared of an intermediate nature between cartilage and ligament. This surface of the acetabulum was smooth except at the lower part, which was occu- pied by a reddish and not very small substance, ascer- tained to be muciparous gland. There was no liga- mentum teres connected with the head of the fe- mur, nor was this head of the usual form, magnitude, or smoothness. The bony substance was deprived of its cartilage. The surface was firm, hard, of a white colour, and granulated as urinary calculi some- times are. I 555 The spine was a little distorted in consequence of the weight of the body being thrown to the left side.—Morgagni, lvi. 14. In other works similar instances of what is de- nominated analogous articulation are recorded ; and numerous cases of dislocation from external injury, and from disease in the acetabulum, are extant*—15. Case 12. Disease in the ligamentum teres. An elderly woman was so lame, in consequence of a contusion on the coxendix, that she was confined to bed for a long time. Pain throughout the body, and gangrene of the nates coming on, she died. Dissection. The liver was tuberculated, and the valves of the heart were ossified. On examining the hip of the lame side, the ligamentum teres was found thinner and less firm than usual, and was almost wholly tinged with a pale red colour. Morgagni, lvi. 17. Case 13. Diminution of the iliac artery ; slight disease in the cartilage of the hip-joint. Another old woman crooked from age, and ac- * In the formation of a new acetabulum under these circum- stances, the resources of nature are beautifully exemplified. Not only is a cavity formed by the process of absorption, but ossific secretion takes place in the circumference, so that the joint may become adequate to the ordinary purposes of locomo- tion. In Morgagni's instances, indeed, the border of the new acetabulum was not bony, but its structure was perhaps equally efficient for the prevention of displacement. In his Practical Observations in Surgery and Morbid Anato- my, Mr. Howship has not only related instances of the formation of a new acetabulum, but he has delineated the appearance with his usual accuracy.—Ed. 556 customed to walk as if she was lame, fell down stairs and injured her head; and this accident occasioned her death. Dissection. The left iliac artery was much smaller than the right, and through nearly the whole course from the place at which the hypogastric artery is given off to that where the iliac emerges from the abdomen, its parietes were so thin that it resembled a vein. There was nothing discoverable in the joint to account for the lameness, unless we can allow that two spots, of a brownish colour, similar to the marks occasioned by a slight contusion, might tend to produce it.—Morgagni, lvi. 18. Lameness sometimes arises from diastasis or a separation of the os sacrum from the os innominatum, of which circumstance Bassius has adduced examples from children who were lame.'—22. In the cavity of the acetabulum, the size and figure of the ligamentum teres and head of the femur, may be impaired in various ways. Tumours raa^ form in the ligament or in any other part of the acetabu- lum. The synovial gland is sometimes diseased, and if it enlarges considerably, the limb will be elongated. The capsular ligament is susceptible of disease; and paralysis and other affections of the muscles may be a cause of lameness, as well as the shortening of the limb, which sometimes results from fracture of the os femoris. The muscles occasionally act with such force that the trochanter minor has been detached by them. Ingrassius has described a case in which this circumstance happened to a young man in the exercise of tilting.—23, 24. Diseases and injuries of the knee. The knee, as well as other parts beneath the fe- mur, is liable to most of the affections which have been mentioned.—25. 557 In cases of rupture of the tendons which extend the leg, or of fracture of the patella, time is of more advantage than might be expected. In an instance of fractured patella, attended by Jerom Vandelli, the union had been effected so as to leave the inter- val of a digit only, between the disunited portions of the bone. The man was able to use his limb freely. He slipped down, however, and bending the leg vio- lently, the united parts were again disjoined, and could not be brought into a state of approximation. But after a long period, the patient was able to walk with celerity, and had not much lameness. Between the broken parts there was about sufficient space to receive the breadth of two thumbs, and this interval was about a digit in depth. I have seen other cases of the same description, and do not doubt that the extension of the limb was in a great measure effected by the lateral parts of the aponeurosis, belonging to the extensor muscles of the leg, which envelopes the patella.—27. Fractures. In the reunion of fractured bones the callus ap- pears to be formed by the external and internal periosteum. Some applications are supposed to be capable of softening callus. Duhamel states that dripping of water, which in other respects is useful, when too freely used has sometimes softened callus to such a degree that the extremities of the bone, previously consolidated, were spontaneously disjoin- ed. Saltzman has related an instance which is worthy of being mentioned. A soldier had been cured of fracture of the tibia, and the limb had be- come so firm that he could walk without the least inconvenience. Eight months afterwards, he was seized with acute fever, and it was observed that 558 while the fever was counteracted by the usual re- medies, the* extremities of the bones were spon- taneously separated. Soon after the fever sub- sided, the tibia regained its previous firmness. Though on examining it in the dead body, the callus may be found larger in diameter than the bone, it is sometimes much more brittle. In tex- ture, also, it does not resemble the hard bone, but is of a spongy nature like the diploe of the skull. —29. On boiling in a lixivium bone which had been fractured but long reunited, the callus has-been soft- ened, and the fractured parts have separated. Separation of epiphyses. The separation of the epiphyses from the bones, a circumstance which easily takes place in children, may be mistaken for fracture. This mistake was actually committed by an experienced surgeon, in the case of a boy of noble family. Perceiving both the wrists tumid, and observing that beneath a kind of fluctuating secretion, the extremities of the radius and ulna were moveable, he accused the servant of having suffered the child to fall out of her hands so that both its arms were broken. She denied this accusation, and my opinion was solicited. Having heard that the child had undergone a severe form of smallpox a little before, I convinced the surgeon that this was an instance of separation of the epi- physes in consequence of disease in the periosteum connecting them with the bones—a result of small- pox not very unfrequent. The child was soon per- fectly cured. Nobody has witnessed a greater number of in- stances of the separation of epiphyses from an in- ternal cause, in one season, than Poupart did in 559 that multitude of scorbutic patients which crowded the hospital at Paris in 1699. In consequence of this disjunction, it happened that if these patients were moved, the bones and their epiphyses were heard to rub against each other. Morgagni, lvi. 34. SECTION IV. On the Effects of Strangulation, with some Experiments on Nerves and Blood-vessels. Suffocation from internal disease has been advert- ed to in the first volume, but it is well known that the same effect may be occasioned by causes which are/fexternal and adventitious. Case 1. A woman, twenty-one years of age, was suspend- ed at the gallows. Dissection. The integuments of the back, loins, and nates, were in some places reddish, and in others livid. The mouth was distorted, and the whole of the face was at first livid, but on opening the external jugular veins it soon became pale. This circumstance showed that the blood retained its natural fluidity, which accounted for the livid- ness of the supine parts. The surface of the lungs, towards the back, presented the appearance of slight inflammation.— Valsalva, xix. 3. Case 2. A highwayman, twenty-three years of age, was 560 executed in the same way as the woman just spoken of, and the body was given for public dissection. Dissection. The eyes were half open. Some of the posterior parts were red and others livid. There was nothing worthy of notice internally, except that the lungs presented the red appearance attendant on inflammation.— Valsalva, xix. 5. Case 3. The individual to whom the following particulars relate had been publickly hanged. Dissection. The eyes were open and turgid, and the face was rather livid. Some lacteals were ob- served in the abdomen, about the lumbar glands, in which they appeared to terminate. The lungs adhered very closely to the pleura, and were some- what red at their posterior part. The vessels of the dura mater were rather turgid.— Valsalva, xif. 7. Case 4. A slender and middle-aged man, who had been subject, at intervals, and especially when walking, to a difficulty of breathing, and troublesome cough, was hanged for theft. Dissection. The abdomen being opened for pub- lic demonstration, some lacteals were observable in the mesentery. The lungs were diversified with blackish spots, and the upper part of the right lung firmly adhered to the costal pleura. This part of the lung, to the extent of an apple, was indurated, and was tinged with a peculiar redness, as if it had been inflamed. The pericardium contained scarcely half an ounce of fluid. The violent pressure of the halter on the neck, had broken through the muscles which connect the 561 os hyoides with the larynx and the neighbouring parts, so that this bone was separated from the larynx. The vessels on the inner surface of the skin which covered the cranium were turgid with blood. In consequence of congestion of blood, the muscles and other parts about the eyes appeared as if they were inflamed, and each retina was suffused with a sanguineous colour. In one ear, the mem- brana tympani, with the annexed ossicula, was tinged with blood; the tympanum of the other car was less tinged than the former, but it exhibited greater red- ness than usual.— Valsalva, xix. b*. Although, perhaps, the dark-coloured spots in the lungs may be ascribed to suffocation, yet the more considerable affection of these viscera certain- ly ought not to be attributed to that source. Morgagni, 9. The vessels of the brain were not turgid, and this circumstance may be accounted for from the halter's having been loosed and the internal jugular veins liberated, in consequence of which, the far greater part of the blood, which was fluid, readily flowed out of the sinuses and the large veins which open into them, whilst it remained in the more dis- tant and the smaller vessels. Littre found the membrana tympani, on one side, not only bloody as in the case related by Valsalva, but also lacerated, so that half an ounce of blood was discharged. In the bodies of some persons who had been hang- ed, that celebrated anatomist Phil: Conr: Fabricius observed that the anterior lamella of the cornea re- ceded from the posterior.—11. From the cause in question, the parts situated in the neck sustain a diversity of lesion in different cases. In some persons one or other of the muscles are ruptured, in some the cartilages of the larynx VOL. n. 71 562 are broken, in some the upper vertebrae are luxated or rather fractured, but others escape all these in- juries.—12. Case 5. In a man who had been hanged, the sternothyroi- dei and hyo-thyroidei muscles were so lacerated that, about the annular cartilage, nothing except membraneous substance remained in their place, and the cartilage itself was fractured. The pleura, on the left side, was beset with numerous hard tuber- cles, some of which were equal in size to a lentil, some to a vetch, and others to a bean. Valsalva, xix. 13. These tubercles were owing to a disease readily contracted from the unwholesomeness of a dungeon, where the man had been confined for about a year. Some of the tubercles were of a cartilaginous soli- dity. As I dissected this body, in the college at Bo- logna, in 1703, with Valsalva, I recollect that por- tions of the lung, on the side of the chest corres- ponding with the diseased pleura, contained a small quantity of a reddish humour. Few persons who nave long been detained in prison come out healthy, owing to the insalubrious air, often conjoined with bad provisions; and also with constant grief, and an inactive life. The lower part of the trachea has been torn from the larynx by the halter, and the larynx is sometimes fractured. It has been a subject of controversy whether the vertebrae are dislocated or not, and I may observe that neither Valsalva nor myself have ever found them dislocated or fractured. Morgagni, 17. 563 Case 6. A young man, twenty-four years of age, was hang- ed in 1705, and his body was given for public dissec* tion. Dissection. The muscles of the larynx were very slightly injured. The small blood-vessels of the head were as turgid as if they had been injected, and presented an elegant appearance. However, I found nothing unnatural within the cranium. The sinuses of the dura mater were empty, and this circum- stance did not surprise me, because, in consequence of the head having been cut off, a great quantity of blood had flowed from the jugular veins. Morgagni, xix. 15. The scrotum presented an appearance like that occasioned by sugillatio, and it arose from the blood having flowed into the vessels that were the least compressed, during the suspension of the body. In one of the following cases not only was the scrotum affected in the same way, but the penis was tense.— 16. . Case 7. Two thieves, a middle-aged man and a young man, were executed in the same way in 1706. Their bo- dies were taken down from the gallows sooner than usual, namely, within four hours after the termina- tion of life; and being brought for dissection, they were still warm, notwithstanding the extreme cold- ness of the season. Dissection. When the body of the middle-aged man was opened, and a longitudinal incision made into the trunk of the aorta below the renal arteries, it was observed that a considerable quantity of blood flowed both from the upper and lower orifices of the trunk. The accompanying trunk of the vena cava 564 was extremely distended with blood. Through a considerable track, the intestinum ileum exhibited a kind of livid redness; and, within this part, the bowel contained some lumbrici teres. Morgagni, xix. 17. I was unwilling to suffer the last mentioned cir- cumstance to pass unnoticed, because even in stran- gled dogs I have observed an appearance resembling inflammation in that part of the bowel where lum- brici lodged, so that the phlogistic colour, accompa- nied with some extuberance of the intestine, defined their situation. The man in question, certainly had not complained of intestinal uneasiness, so that some motion of the worms, after his death, appears to have excited a determination of the fluid blood to that part. We may infer from this fact, that when, on opening bodies, we observe any part of the intes- tines exhibiting a colour like that which has been described, we must not immediately attribute it to inflammation or gangrene, unless the symptoms which preceded death, and the circumstances associated with the appearance, concur to support that opi- nion; because the colour may occasionally be pro- duced after death, especially when the blood is fluid.—18. Case 8. In the body of the young malefactor just referred to, the state of the scrotum resembled ecchymosis, and the penis remained tense, though about six hours had elapsed from the time of the man's death to that at which the body was opened. It was still warm and the blood fluid. The lacteal vessels were full of chyle, and the valves were distinguishable like little knots.—Morgagni, xix. 19. Erection of the penis has often been observed in 565 strangulated men, and 1 remember that the same circumstance occurred when both the carotid arte- ries were tied in living dogs. As I have now. a favourable opportunity of com- municating the experiments of Valsalva on the constriction of the arteries of the neck, I shall avail myself of it, for they so far relate to the sub- ject under consideration, as to assist us in forming an opinion respecting the causes to which the death of hanged persons is generally attributed. As the results of these experiments have varied in the hands of different persons, even from very an- cient times, we must commence our history far back ; and to ascertain the truth, we must reflect upon the ancient and modern experiments and com- pare them together.—20. Aristotle has been considered by many as the first who mentions tying both the carotid arteries, but I believe the internal jugular veins are described by him, and not the carotids.—21. Mountebanks and other persons have practised deceptions by tying a string round the jugular veins and nerves of a goat, so that they could privately tighten or relax the ligature at pleasure. By this means, the animal at one moment would fall down insensible and motionless, and presently afterwards leap up again. Valverdus says, caroditibus obstructis, $ive quavis tandem ratione occlusis, statim obdormisci- mus. Cujus quidem periculum fecisse Realdum Co- lumbum Pisis anno 1544, ipse vidi in adolescente quo- dam infrequenti nobilium virorum corona, non minori eorum terrore, quam nostrum risu, qui id incantamenti vi ejfici, ipsis persuadebamus.—22. It appears from Ruffus Ephesius that the result of compressing the arteries in the neck was known to the ancients. He says, arterias per collum subeun- tes, carotidas. id est somniferas, antiquos nominasse. 566 quoniam compresse hominem sopore gravabant, vocem- que adimebant. The cause of sleep, and of the loss of voice has been referred to the nerves being tied up with the artery, and it will be proper to examine the experiments of Valsalva, whicn having been re- lated in a former work, it will be unnecessary to re- cite. Since they were published,. Ensius observed that on tying these nerves, in a very young whelp, all sensibility was instantly lost; and whatever may be the cause, others have occasionally witnessed not only the same result, but even death, as I have re- lated in the anatomical epistle alluded to. It be- hoves us, however, to direct more particular atten- tion to that which is observed much more frequently^ and indeed, almost universally. When Brunnerus lately repeated these experiments on a dog, and on rabbits, he never observed any thing of that nature, but rather the contrary; and his experience should be compared with that of most anatomists who have performed the experiments, particularly with the observations of Valsalva. In my remarks upon the latter I have intimated that the ligatures with which the nerves are constricted, do not all produce the same effect, and that the animals in which these nerves were cut asunder, survived longer than those in which the nerves were tied. I have also shown that they have been occasionally deceived who sup- pose the par vagum in brutes descends through the neck, disjoined from the intercostals, so that one might be tied without the other, as in the human subject. And the greater part of those who have attempted to explain the experiments, or have no- ticed them and the discussions on the subject, ap- pear not to have sufficiently regarded my admo- nition. We shall proceed, however, to consider the ex- periments of Galen and others upon the blood-ves- 567 sels in the neck being tied without the nerves. I mention Galen, because if any person before him tied these vessels independently of the nerves, no information respecting those instances has reached me.—23. Galen informs us that when the arteries are tied distinctly, neither aphonia nor sleepiness results ; and since the time of Hippocrates, most others, who had but little skill in dissection, have borne the same testimony. Galen also states that when the veins are tied no function is apparently lost. He applied a ligature to the carotid arteries, and the animal did not appear to suffer from it either immediately or through the day; but in one instance, having com- pelled the dog to run, which for a time he did with- out difficulty, he at length became languid, and was soon afterwards quite incapable of proceeding. Van Swieten reports that he tied the carotid arteries of a dog, but could not observe that he sustained any injury; for, eight days afterwards, he found him lively and active. Emettus writes, that a dog in which he tied not only the carotids but the jugular veins also, remained in perfect health and vivacity for some weeks. He often repeated the experi- ment, and, though none of the dogs were seized with apoplexy, nor did any of them die, yet it sometimes happened that, for the space of two hours, the ani- mals appeared sleepy. It will be observed, how- ever, tnat the dog, both of whose carotids were tied by Dionis, remained sleepy for some days after the constriction, though he regained his former strength and readiness for action. On the contrary, there are many who report con- sequences different from those related by Galen. Avicenna, for instance, says that the apoplectic veins (for that appellation the Arabians gave to the caro- tid arteries,) being tied, sense and motion are instant- 568 ly abolished. Among others we might also quote the experiment of Drelincurt, which sufficiently contradicts that of Galen. He thus describes it. Arteriis carotids constrictis, necdum reclusis, penduloque molossi capite extra mensam, veternus ilium oppressit; at erecto capite, sinistraque aperta carotide, molossus sese concussit et exagitavit.—24. Amid these discrepances we shall do well to ad- vert to three experiments performed by Valsalva. He tied both carotids of a dog in the lower part of the neck. The animal did not appear to sustain any injury in the motion of his limbs, but his head re- mained hanging down, and he manifested a degree of dulness. On the following night a large quantity of saliva was discharged from his mouth, and in the morning the hebetude was removed, and the dog appeared to have a cheerful aspect. He ate the food offered him greedily, though he had some diffi- culty in swallowing. In this way he passed through five days tolerably well, occasionally moving all the parts of his body with facility, and walking about the house. At length the lips and head, as well as the anterior parts of the neck, began to swell; and though he still discharged a large quantity of serum from his mouth, yet the swelling continued to in- crease, his strength failed, and he died on the sixth day. On dissecting the neck it appeared that some of the lacerated parts began to be attacked with gangrene, and that there was not the least passage for any thing through the constricted arteries. The internal jugular veins contained a little grumous blood internally, but all the veins traversing the head, exterior to the cranium, were turgid with blood, though there was only a small quantity in the vessels of the brain. The brain itself, in other respects, had a very natural appearance. The tumour that occu- 569 pied all the external parts of the neck and head was occasioned by a deposition of serum which in its colour and consistence resembled jelly.—25. He tied the corresponding arteries in another dog, and witnessed the same drooping posture of the head during the first days. His neck also became some- what swollen ; he manifested similar greediness in taking food, and the same impediment in swallowing as the dog just spoken of ; and some debility of the muscles was manifest. It often happened that blood issued from the wound, and on the day that this circumstance occurred the dog loathed 'his food. However, he appeared to have fully recovered, and was killed and dissected on the twenty-third day from the operation. One of the carotids was slightly lacerated below the ligature, and had frequently poured out blood till within a few days of the dog's being killed, when the wound had become agglutinated. Where the arteries had been compressed by the ligatures, the parietes adhered together, and were hardened into ligament like the umbilical vessels. The obliteration of the canal was so complete, that neither moisture nor air could be transmitted through it, yet none of the collateral arteries were dilated, and this was particularly observed with respect to the vertebral. There was nothing worthy of notice in the brain, except that about the commencement of the spinal marrow a third part of an ounce of a secretion like synovia was found.—26. In a little bitch whose carotids were tied, he ob- served that she was more lively than the former ani- mals, but survived only three days, having an utter aversion to food, and barking at every body. On dissection nothing worthy of notice was met with, though the carotids were closely tied.—27. With respect to Galen it is important that neither 570 of the three dogs on which Valsalva repeated his experiment had either somnolency or aphonia. Val- salva accounted for the swelling of the neck and the deposition of serum in one dog, from the return of blood being interrupted in that part. To explain the circumstance of no effusion having taken place into the brain, nor the vessels of the brain having become turgid with blood, we have only to recollect the ver- tebral arteries; for though Valsalva did not perceive them to be at all widened, it cannot be denied that they must have received a larger quantity of blood in proportion as the carotids admitted less. They must also have conveyed it to the brain, and into the branches of the carotid arteries; not only into the two posterior branches, which are found to be larger in beasts than in men, but also into many smaller ones, and thus have maintained the proper circula- tion through the brain.—28. I do not know that the occurrence of apoplexy, in the experiments of Galen and of some other per- sons, can be accounted for in any other way than by supposing a diversity o,f distribution in the arteries of different dogs. As to the cause of speedy death from strangula- tion, various opinions have been entertained. It has been attributed to a constriction of the jugular veins, but it must be admitted that the vertebral veins would remain uncompressed. The carotid arteries are situated more inwardly than the internal jugulars, and may resist compression more in consequence of the thickness of their coats and the impetus of the blood with which they are distended. However, the internal jugular veins are also somewhat defended by the jutting of the trachea.—29. In other experiments on the ligature of arteries, the observations of Galen and those of other anato- mists are at variance. The omission of some of the 571 circumstantials is one reason why the experiments do not agree. Pecquet related, that having tied the crural artery, and cut the turgid accompanying vein, the impetus of the blood was so subdued, that at first it issued only in drops, and, at length, ceased to flow; but when the ligature on the artery was re- laxed, blood burst from the vein with its usual force. On two dogs I witnessed the same experiment with Homob. Piso, but the result was not the same as observed by Pecquet. The blood certainly sprang from the vein with greater force when the artery was untied than when constricted by the ligature. When the artery was tied, the impetus of the blood was broken, but it did not cease to flow copiously, and with a jerk, in the first dog, which was lively and strong; and in neither of them did it distil in drops, and much less, cease to flow. In one of them the bleeding could not be entirely suppressed till the ligature, placed under the artery and vein, was or- dered to be drawn tightly round the thigh. Pecquet undoubtedly met with a dog in which the branches that arise from the artery above the situation where the ligature was applied, and communicate with the crural vein, were smaller and fewer than in ours; or perhaps he made the ligature higher than we did, as we applied it a little below the groin. He ought not to have omitted mentioning in what place the ar- tery or thigh was bound, if he desired others to wit- ness the same phenomena as himself. Sometimes, indeed, it happens, that when the author of any ex- periment has omitted no circumstance in describing it, yet they who repeat it evidently make some va- riation, and then, as if no deviation had been made, they wonder that their experiment does not answer. —30. To judge of the accuracy of Galen's experiment of tying the internal jugular veins, without its evi- 572 dently suspending any function, it is necessary to know upon what animal it was made, and in what part of the neck the vein was tied ; on both which points he is silent. When L'Amur tied the jugular veins of dogs below their bifurcations, he observed no sleepiness; but when the ligature was made as near the thorax as possible, the dog fell into a pro- found sleep. I wish we had more facts of this description, and that the eyneriment had been continued for a longer time, but only one or two occur to me at present, and I shall adduce them be- low. They are rather favourable to Galen, as in- deed are those of Emettus and Van Swieten. Other experiments have been made, but they evidently relate to the external jugulars. Though I know that these vessels communicate with the in- ternal, and by that means, as well as by their more direct function, they contribute to the more expedi- tious return of blood from the interior of the cra- nium, yet in this office they are not to be placed in comparison with the internal jugular veins.—31. CEderus tells us that having tied the external ju- gular veins in a dog, the veins above the ligature, did not swell much, nor did the dog suffer much ap- parent injury from the operation. He did not even become dull, but through nearly the whole of the day he was lively and constantly barking, and sur- vived to be the subject of another experiment. Be- low the ligature there was a portion of vessel which disappeared on every act of respiration, but at length filled again. Novesius thought that Lower tied the adhering lymphatic with the vein, and that on its being rup- tured from over distention, it occasioned the quan- tity of limpid serum which resulted from his experi- ment. He, therefore, was careful not to include any thing with the veins, and he observed no injury 573 worthy of notice when the internal and external jugular veins were both constricted.—32. a Among the papers of Valsalva I have not dis- covered any thing relative to the tying of these veins, yet I found other observations relating to them and the carotid arteries that were opened or laid bare, which I shall describe, and shall concisely add what presented itself to me on repeating the same experiments. Valsalva having laid bare the jugular veins, observed that they were distended with blood, but their turgescence decreased during inspiration, and in expiration they again became tur- gid, especially when respiration approached its na- tural state. In other dogs he witnessed the same oc- currence, and perceived that there was a kind of systole and diastole in these veins. Besides, on com- pressing them, he saw the blood which was below the compressed part flow back towards the heart, though it was not urged from above. In another dog he divided the carotid artery, and saw that the blood flowed from the upper part of the dissected artery, and though the impetus was less than from the lower orifice, yet the quantity of blood was not small. From the communications which take place between the branches of both ca- rotids, he expected this circumstance to occur. In 1750 Schlichtingius published some observa- tions which excited several persons to the inquiry why the brain is raised up during expiration and subsides during inspiration ; and when men of con- siderable sagacity at Gottingen and MontpeHer, directed their attention to this point, they concur- red in the previous observation of Valsalva; and by their own experiments, tjiey discovered the same motion in other large veins besides the jugulars. So far as I am acquainted with the subject, nobody 574 had distinguished this motion in veins before Valsal- va.—33. In 1723 I repeated the experiments of Valsalva myself. The integuments of a dog's neck, on the right side, being so separated that the external jugular vein was exposed, a kind of tremulous mo- tion was observed in it, and in the adjacent denuded part of the neck. Fixing my eyes attentively on the vein, and applying my hand to the abdomen, I clear- ly perceived that as often as the muscles were rais- ed by inspiration, the vein at the same time imme- diately became tumid, nor did its fulness decrease before the abdomen subsided in expiration. As these phenomena were contrary to those observed by Valsalva, I repeatedly noticed them with atten- tion. The respiration, indeed, did not return to the natural state, so that on this point I could not com- pare my observations with his. The effect produc- ed by compressing the vein with my finger, coincid- ed with that described by him. We divided the carotid artery and found that haemorrhage ensued from the upper as well as the lower orifice, as it had done in the experiment of Valsalva.—34. We shall now return to the consideration of the cause of death in strangulated persons. Though most anatomists agree with Wepfer in the opinion that apoplexy is immediately produced from the constriction of the jugular veins, owing to its pre- venting the return of blood from the head, whilst some is carried thither by the partially compressed carotids, and still more by the vertebral arteries; but the preceding experiments appear to disprove this sentiment.—35. Cesalpinus says that persons to whom the sus- pension had not proved fatal relate that, as soon as the neck was constricted by the halter, they were seized with stupor, in consequence of which, at 575 length, they felt nothing. Speaking of a man and woman who survived hanging, Wepfer tells us that the woman lay in a state which resembled apo- plexy ; and that the man had not experienced the least pain after the constriction from the halter, and passed some hours as if buried in a profound sleep. A man, upon whose veracity I could rely, informed me that a criminal who hung for some time but did not die, subsequently related that he first perceived sparks flying before his eyes, and soon afterwards became unconscious of every thing, or only felt as if he were asleep. A woman whose neck was bound by thieves so that they believed she was dead, was found with her face swollen and livid, and her mouth frothy. Bleeding saved her life, but many hours elapsed before she was fully restored. I mention these cases that they may be com- pared with the effects of tying the veins, arteries, or nerves in the experiments on dogs; and if they do not afford the explanation, the cause of death from strangulation remains to be discovered.—36. Undoubtedly the circumstances would be widelv different if all the vessels were tied, and it is pro- bable that in the instance of the mountebank and the goat, which has been referred to, the vessels and nerves were compressed together.—37. Besides, it is obvious that in strangled persons, to whom the question now chiefly relates, the trachea is also constringed, and experiments are not necessary to prove that fatal consequences speedily result from a total obstruction of this canal. The entrance of foreign bodies into the larynx has often occasioned immediate death, and on this account we cannot be surprised that many eminent men have attributed the death of hanged persons exclusively to the obstruction of breathing. 576 Therefore, if compression upon the nerves and ves- sels is not thought sufficient in itself to produce the effect in question, it certainly is when constriction of the trachea is combined with it. The circulation of blood through the brain, which, when the carotid arteries and jugular veins are compressed, can but just be maintained by the vertebral arteries and veins, is certainly stopped whenever respiration is totally impeded. Under these circumstances a large quantity of blood also accumulates in the lungs, in the right ventricle of the heart, and in the vena cava. If impeded respiration alone is adequate, within a short time, to stop the circulation of blood, it must necessarily be interrupted in its course through the brain in a much shorter time, in those persons in whom the carotid arteries and jugular veins are constricted by the halter, and when so little blood is conveyed to the brain as scarcely to support the circulation of the vertebral arteries and veins. Before the transmission of blood through the lungs is wholly prevented, if it happen that some blood continues to flow through the carotids, which are less compressed than the jugular veins, so much blood will soon be accumulated in the brain as to occasion a rupture of vessels. This consequence has been observed ; and in a criminal who was hanged, Peter Nanni found that the longitudinal sinus had burst. In persons too who had been strangled, numerous, bloody points were seen in the substance of the brain by Lancisi and myself.—38. This would be the time to speak of suffocation from the vapour of charcoal, or from the gas occa- sionally found in vaults, wells, cellars, and similar places; and in the dog's grotto, la grotta de1 cani, where dogs thrown in are immediately destroyed. But the body of a person whose death had resulted. 577 from this cause, has never been brought to Valsalva or myself.—39. Though neither of us has had an opportunity of dissecting the bodies of persons who have been drowned, yet as I formerly dissected animals of va- rious species, which had been destroyed in that way, I shall relate the appearances presented on dissec- tion.—40. Three guineapigs were drowned. No water was found in the stomach, oesophagus, or trachea, but a little frothy humour could be pressed out of the lungs with the hand. The epiglottis, which in these animals is very short, was not depressed. Three hedge-hogs were placed under water and air-bubbles escaped from their mouths. The ap- pearances on examination resembled those in the guineapigs. In the bronchia of one of thern I found a living worm, which was oblong and slender, and of a white colour. In a mole, which was drowned with great difficul- ty, the stomach contained but little water, and no- thing except a frothy humour could be squeezed from the lungs. A mouse and a dormouse were also drowned, but neither the stomach nor lungs contained water, and the epiglottis was not depressed. Though it has not been distinctly mentioned, I wish it to be under- stood, with respect to all these animals, that the larynx was perfectly unclosed.—41. In some new-born kittens, which lived in the water a long time, I found a considerable quantity of frothy moisture in the lungs. In kittens a few days old, which had been immersed till nearly dead, there was not only a large quantity of frothy mois- ture in the lungs, but the stomach contained some water, and one of them had the stomach greatly dis- tended.—42. vol. n. 73 578 From a variety of observations it appears that much assistance is not to be expected in preventing suffocation from the foramen ovale or canalis arte- riosus being open. In newly-born kittens a con- siderable quantity of water has entered the lungs, and often the stomach ; but in most adult animals neither of these circumstances has generally hap- pened. On both these points, however, there has been some contrariety both in brutes and in the human body. In a few experiments Haller employ- ed coloured water, and in every one of them some of it gained admission into the lungs.—43. Infanticide. I hasten to another subject, namely, the proof as deduced from the result of throwing the lungs into water, whether an infant has been born dead or alive. Respecting this evidence I concur with those who, though employing it, yet know that many ex- ceptions to its accuracy have been observed within a i'ew years. Though Galen demonstrated that the substance of the lungs in foetuses is not only red and dense, but likewise heavy, yet I do not know that any person thought of making the experiment in question till a few lustres previous to my own time. It has been objected concerning van infant which might have been born alive, that the lungs may subside in water if they are not sufficiently dis- tended in consequence of a want of strength in the infant, or if they have been consolidated from dis- ease ; and, on the contrary, the lungs of a still-born infant, may swim on the surface, if the lungs are dis- tended with air which may have been extricated from putrefaction, or perhaps forced in with a view to excite respiration.—45. It is necessary, therefore, to observe whether there are evidences of weakness before we infer, 579 from the subsiding of the lung, that the child has been born dead; and we should likewise inquire into the preceding or present diseases of the mother, the degree of difficulty attendant upon the birth, and other circumstances of this nature. It is evident that we cannot trust to the sign under consideration, if, at any time, we observe that the lungs are not endued with that gravity which is na- tural and peculiar to the fcetus, but with a morbid gravity, owing to their being scirrhous, or inflamed, or so affected with infarction that if they were the lungs of an adult they could not float—a circum- stance which most anatomists, as well as myself, have perceived. That there may sometimes be pulmonary infarc- tions in foetuses is not only indicated by reason, but confirmed by experience. But if suffocation can sometimes charge the lungs with a great quantity of blood in an infant, in the same way that I have stated they have been overwhelmed with it in strangulated adults, yet suf- focation cannot conceal itself under the sign in ques- tion. For though all the external marks of strangu- lation are wanting, yet certainly a very different state of lungs from that which is usual in the fcetus, in addition to their increased bulk, should caution us against too hasty a reliance upon their descent in water. Besides, it can scarcely happen in those who have drawn in air, but that some parts of the lungs will retain so much of it as to make them swim though the other parts descend.—46. Notwithstanding what I have stated with respect to putrefaction, instances have not been wanting in which the fcetal lungs have sunk in water after the highest degree of the putrefactive process.—47. "We must be on our guard too, on another ground, because air might be blown into the lungs of a dead 580 fcetus with the malicious intention of defaming the mother. The appearance of force applied to the dead infant, especially if it does not immediately succeed its decease, is very different from the phe- nomena arising from injury inflicted during life; and if there are no such marks of violence internally, or on the surface of the body, it will tend to refute ca- lumny. If under these circumstances the mother should affirm that she blew air into the lungs, we may with greater readiness credit her statement, provided none of the other circumstances indicate the contrary, and that the distention of the lungs is not greater than could really be produced by that means in a foetus recently dead—circumstances which may be determined by careful experiments instituted for the purpose.—47. SECTION V. Diseases induced by Poisons.* On this subject Valsalva's papers do not afford me any observations. For the ensuing case I am in- debted to Mediavia. * Poisons have been divided into animal, vegetable, mineral, and aerial, and they may exert their influence upon the animal economy by being received into the stomach or rectum, by be- ing inhaled, or by being absorbed from the surface of the body either whilst the skin remains entire, or when there is a solu- tion of continuity from an ulcer or wound. The phenomena resulting from poisonous substances have recently become so much better understood than formerly, that 1 have omitted some of the less interesting parts of Morgagni's letter. Orfila's Toxi- cology, and other publications which embrace this important subject, are so accessible, that my annotaiions to this section will be limited to the relation of two interesting cases which fell under my own notice.—Ed. 581 Mineral poisons. Case 1. Poisoning by arsenic. A woman, sixty years of age, ate some small rolls of almond paste, which contained arsenic, and had been laid for mice. Scarcely had an hour elapsed before she was seized with a sensation as if the sto- mach were distended from flatus. This sensation increased in severity, but copious vomiting and diar- rhoea coming on, she appeared to be relieved. Soon afterwards the uneasiness returned with augmented violence, and was accompanied with deliquia; and within twelve hours she died, rather from prostra- tion of strength, than under very acute pains. The body was inspected, by public authority, the follow- ing day, May 7, 1722. Dissection. The posterior surface of the body was universally black, the body itself was not stiflj nor the abdomen tumid. Some parts of the inner surface of the stomach were eroded, especially at the antrum pylori; and the arsenic itself was seen adhering to the eroded parts between the membra- neous fragments. The duodenum was not wholly exempt from erosion. The lungs were of a blackish hue. There were two concretions in the heart, but with this exception, the blood was fluid, and of a lively red colour, in all the vessels.—Morgagni, lix. 3. With respect to the diseases produced by poisons it happens, as in other cases, that neither the same symptoms nor effects can be expected in all persons, even when the poison is the same. This difference may arise from a diversity in the nature of the solid and fluid parts, especially those which relate to the 582 stomach, to say nothing of the emptiness or fulness of this viscus, or of the different kinds of aliments it might contain. In the Sepulchretum, on the autho- rity of Wepfer, are mentioned the particulars of three individuals who were poisoned. One of them was a little boy two years of age, who had been emaciated by fever; and the others were two girls, nearly arrived at adult age, and enjoying good health. The former ate only two spoonfuls of a pudding which contained arsenic, but his stomach was empty; whilst the two others ate the remainder, but their stomachs were full of meat. The former did not vomit, but the latter retched frequently, especially after vomiting had been promoted. The girls reco- vered, but the strength of the little boy gradually decreased till he died. The stomach was found ul- cerated, and the lungs were of a blackish colour. In dogs that had swallowed arsenic, the stomach was inflamed, and the coats of that viscus were ex- tenuated : the intestines were eroded and perforated, and the cavity contained grumous blood. Mountebanks and jugglers swallow arsenic when their stomachs are full of fat and oily substances; so that serious consequences do not ensue, because these individuals privately vomit it up soon after- wards : but if, contrary to their custom, they are obliged to defer this ejection, they perish. In other cases when arsenic had been taken by mistake, upon a full stomach, fatal consequences have been avert- ed by vomiting. Vomiting has generally resulted from taking arsenic, as well as other poisons; and the symptom next in frequency is prostration of strength, or the circumstances which denote it, as coldness of the extremities or of the whole body, cold perspirations, paleness, and sometimes syncope. The prostration of strength, which arises from the heart sympathizing with the affection of the stomach, 583 is preceded and accompanied with the most distress- ing anxiety. Tormina and singultus have likewise been experienced, as well as a tumid state of the abdomen. In some persons there is thirst; in others, swelling of the tongue, or aphthae, impeded degluti- tion, or a sense of burning heat.—4. In addition to the cases narrated in the Sepulchre- tum, I shall point out numerous others in which fa- tal consequences resulted from mineral poisons. Baeumlinus relates that glass of antimony had been given to a coachman through carelessness. The effects were bloody stools, convulsions, and death. The stomach was abraded, and tinged near the py- lorus with a red spot. Jacobus Fteiix administered tartarized antimony to a dog, and opened him while he vomited. There was violent inflammation at the pylorus to an extent of some inches. Sproegelius relates that having given sublimate to a cat and a rabbit, he witnessed the following re- sults. The cat was slightly convulsed, and died in five minutes; the rabbit, after vomiting, died in- stantaneously. In the cat, the internal coat of the stomach was universally inflamed, but the appear- ances indicated that the more violent inflammation had been situated at the fundus of the stomach. In the rabbit there was no appearance of inflam- mation, nor indeed could this have happened, for as the poison was dissolved in water, it immediately occasioned death by its action on the nerves. When Sproegelius had given sublimate to a dog whose stomach was empty, he found the villous coat, in this animal, every where filled with spicula? of the poison, and consequently partly red and partly livid; and the mouth was in the same state : but the sto- mach, especially about its upper orifice, was greatly inflamed, black, and gangrenous. He opened the 584 animal while it was alive, after it had vomited with violent strainings, combined with inquietude and howling, for an hour or more. In none of these three animals, except the first, has he mentioned the existence of black and coagulated blood in the heart. Jacobus Fcelix administered the same poison, with an equal weight of arsenic, to a dog. The animal instantly vomited twice, and though immediately opened, violent inflammation was observed in the stomach. Another dog to which he had given ar- senic alone, was opened before its death, after hav- ing vomited nine times. He found the same ap- pearance as in the preceding example, especially to- wards the pylorus, and in the adjacent intestines. Sproegelius forced some crude white arsenic into the stomachs of a cat and dog. Straining to vomit being observed in both animals, accompanied with anxiety and convulsions, they were opened before they died. The stomach was inflamed, and blood had been extravasated between the rugae, or among the villi, and had coagulated there : and in the dog this kind of blood surrounded the arsenic. Cobalt, which is an ore of arsenic, having been forced into the stomach of dogs, and vomited by them without any injury, the mouth of another dog, under the same circumstances, was tied. The most violent efforts to vomit came on, accompanied with anxiety, convulsions, and weakness; and, within a few hours, the animal died. The stomach, in some places, was a little livid, and everywhere greatly inflamed. The intestines, likewise, were inflamed, but less so in proportion as they receded from the stomach. In three cases in which cobalt had been taken into the human stomach, as related by Kundmannus, it proved fa- tal within a few hours. All these persons were im- 585 mediately seized with violent tormina, excessive vomitings, and cold sweats. The posterior parts of each body were found livid after death, the stomach was much inflamed, and a bloody fluid oozed from its eroded vessels. The following symptoms and diseased appear- ances were the consequences of taking arsenic. Preussius mentions constriction of the fauces and chest, thirst, heat, gnawings, tormina, prodigious vomiting, and frequent intestinal discharges. Mul- lerus, besides these symptoms and pains of the ab- domen, speaks of the immediate distention of this cavity, and of anxieties. Maurice Hoffman, in addi- tion to the speedy swelling of the abdomen, notices lividness of the face and eyes, and contortions of the neck. Heimreichius mentions continual vomiting for twenty-four hours successively, with horrible cla- mours, tremour of the limbs, and palsy of the feet. Wolffius speaks of severe pains in the stomach and abdomen, joined with cholera morbus. Iiammerus and Quelmalzius mention very severe symptoms. The former speaks of violent vomitings, great weak- ness, and contraction of the limbs; and the latter, of anxieties, cardialgia, swelling of the eyes and of the whole head, very severe lancinating and erod- ing pains of the intestines, heats, and other similar effects. Etmuller relates the case of a girl who had taken arsenic, and who vomited a great quantity of viscid fluids in the beginning of the night, and was found dead the following morning. However, no morbid appearances were detected in the viscera which could be ascribed to the poison, although the sto- mach contained a white powder, which, on being thrown upon burning coals, exhaled an arsenical fume ; and a similar powder, found in the house, very speedily destroyed a cat and a dog. The sto- vol. n. 74 586 mach in both was inflamed, and in the dog it was eroded. The stomach, in the girl, seems to have been pro- tected from both these effects by the quantity of food which she had previously taken, and also of viscid matter which had been secreted; but the in- ternal coat and nerves had been irritated. We have on record examples of the poisonous ef- fects of arsenic having been produced by its appli- cation to the sound skin or to external ulcers. Tyson examined the body of a person wrho had taken arsenic, and the stomach was perforated by an irregular foramen of considerable size. Hoffman found the fundus of the stomach of an old woman ulcerated, sphacelated, and black.—5. Mead entertained the idea that poisons act chiefly upon the nerves, and not upon the blood ; and, in reference to some poisons which occasion death almost instantaneously, this opinion is un- deniable. But as, when poisons affect the nerves, the circulation is either impeded or disordered, the blood will be found in diverse states in different bodies. Mead therefore supposed, that if the cir- culation is suddenly interrupted in consequence of general paralysis from poison, the blood will continue perfectly fluid in the vessels. Sometimes secretion will be suspended, as in other cases of deranged circulation ; and other changes take place on the small vessels through the agency of the ner- vous system. These changes in the blood, besides that they are neither the first effect of poisons nor peculiar to them, may vary exceedingly in different bodies, ac- cording to the various affections of the nerves, and the diverse conditions of the blood itself. In nine rats which had been killed by arsenic, and were sent to me, the auricles of the heart were dis- 587 tended with black blood, which was neither coagu- lated, nor quite so fluid as in the living body. The stomach was very full in all of them, and neither it nor the intestines, as far as appeared outwardly, were inflamed in any one, much less perforated. Ruysch never found the blood coagulated in the human body after taking arsenic, but if there had been sufficient time the stomach was ulcerated. If the persons died earlier, he saw bloody points, distant from each other, throughout the stomach.—9. From mercurial sublimate, erosions of the mouth, oesophagus, and stomach, have been observed, as well as discharge of blood by vomiting and by stool, with tormina, writhings, deliquia, convulsions, and similar symptoms. When this poison has been administered to ani- mals, it has sometimes occasioned death within a few minutes. The observations of Ruysch, united with others alluded to above, render it evident that the first effect of arsenic, or of other corroding poisons, when taken into the stomach, is exerted on the internal coat of the alimentary canal, especially of the sto- mach. The nerves of. this coat are irritated; and, if time be given, the coats themselves are inflamed, ulcerated, and perforated*—10. * Poisoning from arsenic. A young man who had become rather melancholic in conse- quence of the inconstancy of his favourite lass, one morning, at five o'clock, took about an ounce of oxide of arsenic, in a very coarse state. His groans soon afterwards attracted his father to his room, when he complained of severe pain in the stomach, and vomited excessively. At seven o'clock these symptoms con- tinued with unabated severity, and, from the appearance of the matter vomited, his father suspected that he had taken some deleterious drug. However, the youth did not confess his de- linquency till nine o'clock. At this period he was visited by a very respectable medical gentleman, who found him in violent 588 I shall now subjoin a few remarks on vegetable poisons. pain: the pulse was scarcely perceptible, he was excessively thirsty, and had voided two dejections, one of which was bloody. He died at ten o'clock, and on the following day I was requested to attend the inspection of the body. Dissection. Th»* body lay in the posture in which the youth expired, namely, on the right side, the left leg was drawn up, the greater part of the corpse was of a livid hue, but especially the genital organs. The eyes were unclosed, the hands clinch- ed, the mouth tightly shut, the countenance had undergone little alteration, and the temperature was nearly as warm as that of the living body in an unexcited state. On opening the abdo- men wed;d not observe any appearance of peritoneal inflamma- tion ; but the vessels of the stomach and intestines were so turgid as to impart to their coats an unusually vascular appear- ance. The stomach was large and distended, the small intes- tines were inflated, but the colon was contracted. The stomach contained several lumps of arsenic, and a brownish fluid, upon the surface of which floated some castor oil. These contents measured eighteen ounces. The inner coat of the stomach was red throughout, but the degree of inflammation varied. There was no appearance of erosion. The termination of the cuticu- lar lining of the oesophagus was very strongly marked ; and the development of mucous glands throughout the space extending two inches from the pylorus, was very remarkable. The state of the inner coat of the intestines resembled that of the stomach, but the appearance of erythema gradually decreased as they advanced towards the caecum. The lining of the oesophagus was inflamed, especially near the gastric extremity; and this tube contained fluid resembling that found in the stomach. Near the apex of the heart there was a spot of lymph. The heart itself appeared turgid to a great degree, but by slight pressure it became remarkably flaccid, and this circumstance was explained when we opened the organ; for the blood, being perfectly fluid, had escaped into the vessels by pressure. There was not the smallest coagulum in any part of the blood which came under notice. On the attentive examination of the heart I found that within the right ventricle, to the extent of a three- shilling piece, there was an appearance of deep redness, almost as if extravasation had taken place beneath the internal lining of the ventricle ;—and the inner surface of the aorta, for about an inch from its commencement, was not only of a deep red colour, which obviously resulted from inflammation, but spots of lymph also adhered to it.—Ed. 589 Vegetable poisons. Case 1. A poor woman, about sixty years of age, who had several times attempted to throw herself into the river, drank a quantity of the juice of the Rhodo- daphne in wine. About three hours afterwards she was heard retching violently. She became worse, and Mediavia was called to her about five hours after she had taken the poisonous juice. Her lips, par- ticularly the inferior labium,.were of a brown colour ; and the temperature of the body was somewhat lowered. Her pulse was small, weak, and hard; her voice was inarticulate; yet she pointed to the mat- ter vomited, which was considerable in quantity. She died within four hours after he saw her. On the following day, November the seventeenth, 1745, the Judge of capital offences ordered the body to be in- spected, and Mediavia presided on the occasion. Dissection. The whole posterior parts were of a violet colour. Although it occurred in the month of November, and notwithstanding seventeen hours had elapsed from the time of the woman's death, yet a degree of warmth was perceptible in the thoracic and the abdominal viscera. The latter viscera Avere in a natural state externally, but the veins of the sto- mach, of the omentum, and of part of the intestines annexed to the mesentery, were extremely turgid. The stomach contained a small quantity of green humour; and the rugce, near the antrum pylori, were harder than they usually are. The duodenum con- tained some green fluid similar to that which had been found in the stomach, and it probably consisted of bile united with acid juices. The ri°ht lung was connected to the costal pleura: it was very red posteriorly, and something like coa- 590 gulated blood was observable within its substance. The left lobe was unconnected and collapsed, as if scarcely any air was left within it; and there was but little redness at its back part. There was not the smallest quantity of blood in the ventricles of the heart; but when the larger vessels of this organ were cut into, a large quantity of blood flowed out of them. This blood was neither coagulated, nor was it more fluid than natural. The head was not opened.—Morgagni, lix. 12. Probably the poison had acted upon the stomach and its nerves, and, consequently, on other nerves sympathizing with them. It is not necessary that the stomach should be inflamed to induce those effects which were manifest; for irritation of the nerves may occasion all the appearances. In other cases of death from vegetable poisons no sign of vis- ceral inflammation existed. It must be admitted, however, that sometimes,in- flammation has been discovered. The jejunum and colon were much inflamed by the berries of Solanum. In a case of poisoning by a species of mushroom there Were marks of inflammation about the pylorus, and the vessels of the inner coat of the duodenum were replete with blood. Besides which there were slight excoriations in this membrane, and it was in- flamed at the upper part, and diversified with pur- ple spots. I have also seen inflammation produced by black hellebore.—14. /*• The following is the case to which I allude. Case 2. A man who seemed to be nearly fifty years of age, being in the hospital on account of melancholia, was about to depart, when he took some extract of 591 black hellebore, by which he was considerably purg- ed. In the beginning of the night, at the seventh or eighth hour after taking it, he was attacked with vomitings, and pains of the abdomen; but they were allayed by some warm broth. About the fifth hour of the night those affections returned, and again ap- peared to be relieved. He lay down an hour after- wards, having vomited two or three spoonfuls of a greenish matter. So quietly did he rest afterwards, that none of the patients in the nearest beds heard him; but at the eighth hour they were attracted to his bed-side by a peculiar noise from his mouth, and found him dead. On inquiry I ascertained that he had taken about half a dram of the extract—a quantity which has been administered to other persons without injury. It has been customary, however, to order a quantity of whey to be drunk after taking this medicine, which he had neglected to comply with. Thirty-eight hours after death I inspected the body. Dissection. The limbs were not rigid or contract- ed. In some places, even externally, the stomach and intestines were inflamed; and the intestinum ileum was contracted in some parts and dilated in others. Internally the stomach, with the adjacent part of the oesophagus, was partially inflamed; the intestines, likewise, were inflamed, but the inflamma- tion was not violent in either part. The spleen was a little larger than natural, and so flabby that the inner substance was almost fluid. The bile contain- ed in the gall-bladder was of a pale green colour. A little bloody fluid escaped from the cranium when it was cut into. There was but little blood in the sinuses of the dura mater, or in the larger 592 branches which ramify through the pia mater. The whole cerebrum was extremely soft.* Morgagni, lix. 15. * Poisoning by opium. On the 16th of July 1816, I was requested to attend the ex- amination of another young man who was suspected to have committed suicide by taking opium. He had lived for a year and half with a respectable druggist, and though of a reserved and inactive disposition, the young man was sober and steady. In consequence of his friends objecting to the continuance of an intimacy with a young woman to whom he had long been warmly attached, he appeared rather dejected, but no suspicion arose as to the dreadful purpose he contemplated. On the loth he discharged his duties and took his meals as usual. At eleven o'clock he supped, closed the shop, and retired to bed. Half an hour afterwards he was heard groaning, and was found insensible, and no efforts to rouse him availed. The pupils of the eyes were contracted, he perspired profusely, his pulse was slow and feeble, but every second or third minute he made a deep inspi- ration; and at that moment, the pulse was accelerated. He was bled ; and a dram of sulphas zinci was administered. Other means were likewise employed, but nothing produced any sick- ness. He died about five o'clock, a. m. as if by a gradual ex- tinction of life, without any convulsion. Dissection. We observed that the arm had.bled in the coffin, and blood continued dropping from the orifice. The corpse had the usual cadaverous appearance. On noticing the blood drop- ping, the gentleman with whom he had lived, being present, mentioned that the blood withdrawn from his arm had not co- agulated in the basin. The whole of the small intestines pre- sented an appearance of heightened vascularity. The stomach was removed, and contained, with the supper, a considerable quantity of solid opium. Having taken the stomach away 1 ex- amined it very carefully. The termination of the oesophagus presented a red appearance beneath the cuticular lining. The cardiac portion of the stomach was universally brown, but the tinge was not uniform, for striae were multiplied in every direc- tion. They were of a deep brown colour, varying in size from the width of a crow's quill to that of a swan, ramifying like the larger vessels, and generally following their course. Though the streaks presented this appearance, yet they seemed rather 593 Symptoms which strongly resemble those produc- ed by poisons are often brought on by morbid secre- tions in the body itself. In the appearance of the stomach after death it is sometimes difficult to dis- crim nate betwixt the effects of poisons and injuries which the organ might receive from other sour- ces.—19. Though organic lesion from poison may most fre- quently be observed at the fundus .of the stomach, yet the morbid appearances have sometimes been observed near the oesophagus, or in other parts of the viscus. 4 to have been occasioned by the rugae. The villi on these deeply- coloured parts were so turgid with blood that it oozed from them on the slightest pressure. The mucus covering this ex- tremity of the stomach was so glutinous as to resemble a cuticu- lar or adventitious membrane. Towards the pyloric extremity the colour was variegated—namely, pale, red, and brownish. The reddened and deeper coloured parts principally consisted of prominent and turgid villi. It did not at all resemble the ac- tive inflammation resulting from arsenic, and which has been described; nor was there any appearance of enlarged mucous glands. The pylorus and the commencement of the duodenum appeared to be inflamed, and the glands of the latter were en- larged. There was erythema through the whole mucous sur- face of the intestines. Blood was coagulated in the heart. The vessels of the scalp and of the dura mater were turgid, and blood had been extra- vasated between the dura mater and tunica arachnoides, and was diffused over the posterior lobe of the right hemisphere. Though not connected with the cause of death it is worthy of remark that the foramen ovale was largely open, and there were excrescences on the mitral valves. The morbid characters of this stomach, and of that taken from the person who destroyed himself with arsenic, have been pre- served with the utmost accuracy in the saline solution, an ac- count of which, for the preservation of anatomical specimens I have already published; and six years' experience has fully confirmed the advantages which I then considered myself war- ranted to anticipate.—Ed. VOL. II. '•' 594 A case which has been transferred from Ballonius into the Sepulchretum shows how greatly we may be imposed upon by morbid phenomena in the sto- mach. On examining the body of a person to whom it was suspected that poison had been given, the stomach was found beset with exanthemata, and the physicians were upon the point of asserting that the appearance was owing to poison, when they were informed that the person died of measles, which began to appear on the skin and suddenly vanished. Should powder be found in the stomach, even if adhering to the eroded parts, it should not be deem- ed an unequivocal proof of poison till its poisonous quality has been satisfactorily determined.—20. Animal poisons. The poison from the sting of the scorpion of this country is far less potent than that of the African scorpion. The violent symptoms which arise from it in Africa are rarely met with here, or in other regions not very hot.—28. The noxious effects of the bite of the viper are sometimes very sudden, so that they would appear to be propagated through the medium of the nerves. In small animals destroyed by this poison, the blood has sometimes been found coagulated. At those nor coagula are formed, but the blood retains its fluidity. In some it possessed a lively and bright red colour, in others it was black, and disposed to putrefaction.—33. The usual symptoms arising from the poison of the viper are, vomiting and convulsions, often purging, and bloody urine. The former does not appear at- tributable to inflammation in the stomach, but to an affection of its nerves,—35, 595 Icterus, which so frequently occurs after the bite of the viper, probably arises from the same nervous influence, producing spasmodic constriction in the commencement of the hepatic ducts.—36. The history of Cleopatra has been handed down to show the speedily fatal qualities of the venom of the asp.—37. 46. THE END. INDEX. Abscess in the iliac region Abdomen, cysts in contusion and wounds of - Abdominal viscera, disease in Abortion .... from renal disease Abstinence .... Acetabulum, new Adipose membrane, total removal of Amenorrhoea ... Anasarca .... 203, 206, 525 Antimonj', poisoning by - - - - - 661 Anus, malformations of - - - - 107 Aorta, dilated - - - - - 191, 215 ossified, and ulcerated - - - 319 diseased ----- 35, 363 and tortuous - - - 312 excrescences on the valves of - - 444 inner coat of, tender - 427 ossified - - 26, 278, 365, 396, 513, 546 ossified and ulcerated - - - 275, 404 and dilated - - 319 prominent lines in .... 427 small ----- 26 carotids, and subclavians, dilated - - 371 Aortic valves, thickened and cartilaginous - 19 Apoplectic symptoms during ague - - 520 Apoplexy - 83 vol. it. 76 290 - 250 257 - 373 473, 482 - 286 7 550, 553 86 - 407 598 Arsenic, poisoning by - - - 581, 585, 587 Arteries, unnatural tortuosity of - - 190, 273 hepatic, dilated ... - 168 iliac, diminution of ... 555 Arytenoid cartilage displaced - - - - 361 Ascites - - 164, 169, 202, 226, 237, 232 spontaneous removal of 220 Bile, black - 220,412 Biliary calculi - - 130, 173, 180, 182, 198 discharged by ulceration - - 200 chemical account of 201 and urinary calculi, co-existent - 197 Biliary ducts, calculus in, unattended with jaundice - 193 compressed ... - 179 consolidated - - - - 179 contracted - - - 179, 194 dilatable - - - - 135 dilated - - - 171,374 excrescence in - - - - 193 indurated - - - 179, 194 ossified - - - - - 179 preternatural - 193 spasms of - - - 179, 194' Bladder, abscess in - - - - - 327 blood vessels of, turgid - 34, 274, 275, 413 calculi in - - - - 321 between the coats of - - - 352 coats of, thickened 272, 302, 307, 310, 338,362, 375, 441, 513 and ulcerated - - - 345 disease in - - > 292,447 diverticulum in - 345 effusions of lymph within - 334 fleshy - - - - - - 811 foreign bodies in - - - - 336 fungous flesh in, from calculus - 326 599 Bladder, gangrenous .... 298 lacerated ----- 264 muscular fibres of, enlarged - 286, 300, 362 ., ruptured - - - - - 103 sacculi in - - - 331 and supernumerary chambers in - 348 sphacelated - 343 tubercle in 334 tubercles and excrescences in - - 300 ulcer in, cicatrized ... - 342 and adjacent parts, communication between 325 and vagina, ulceration of 328 and rectum, large hydatid between - 466 Blood, acid - - - - - . - 517 cold......518 fluid after death - - - - 210, 592 frothy ----- 546 Blood-vessels, experiments on - - - 545 Body flexible after death 29 Bones and joints, diseases of - - - 536 Brain, effusion into - - 47, 56, 174, 190, 277, 578 , yellow .... 177 and vessels turgid - 378, 412 pallid in cachectic persons - - - 168 soft ' - - - - - - 190 vessels in, turgid - - - 56,120 yellow in jaundice - - - - 176 Breast bony ------ 527 Bronchia, worm in - - - '- - 577 Bronchial glands, calcareous matter in - - 444 Bronchocele - 534 Bulimia - - - - - - -9 Buonaparte,' morbid appearances in the body of - 27 Cachexy Calculus in the gall-bladder - kidney - 168 196 - 545 600 Calculus in the urinary bladder - 321, 328, 335, 347 symptoms of, from an acrid secretion - 355 Calf, double - - - - - - 505 Caries ------ 542 Carotid arteries tied ----- 565 and subclavian arteries dilated - - 35 Caruncle, seminal, ulceration of - 363 Catamenial flux ----- 406 Cerebellum softened, and cerebrum indurated - - 277 Cerebrum indurated, cerebellum softened - - 277 flaccid - - - - - 512 Choroid plexuses, glandules of, enlarged - - 49 hydatids in - - - - 56 Cirsocele ------ 382 Clitoris, concealed in a tubercle - 447 Cobalt, poisoning by - 584 Colon, dilated - - - - - - 245 Conception, true and false - 447 Constipation ------ 106 Cowper's glands, deficiency of - - 357, 358 ducts of, unnatural ... 359 Cutis, remarkably firm - - - - 512 Deafness, congenital instance of 498 Diabetes - - - - - - 304 Diaphragm and lungs penetrated - - - 261 inflamed, dysphagia from - - - 5 Diarrhoea - - - - - -104 Digestion, diseases of the organs concerned in - - 1 Dropsies, encysted - - 460 Dropsy of the peritoneum - - - 202, 238 of the abdomen 202 fluid of, spontaneous concretion in - - 206 hydatid origin of - - - - 225 Drowning, experiments on 577 Ductus arteriosus open ... - 507 obliterated prematurely - - 507 601 Duodenum, scirrhous - - - - 24 diverticulum in 365 Dura mater firmly adherent - . . 191 haire within - . _ 4(38 longitudinal sinus of, burst - - 576 thickened - 512 vessels of, turgid - 277 Dysentery - - - . . - 77 Dysphagia ------ 6 Encysted dropsies, treatment of - 462 Epigastrium, pulsating tumour in - - - 141 Epiglottis perforated - - - - - 3 deficiency and disease of - - 3 diseased - - - - - 319 and tongue, cicatrices on - - 361 Epiphyses, separation of ... - 576 Eructation excited by friction - - - 126 Exostosis __.--- 536 Fallopian tube adherent to the ovary - 402, 403, 440 and suppurated - 404 dropsy of - - - - 460 impervious - 390, 392 hydatids on - - - 428, 453 inflammation of - - - - 405 roundish body on 449 small bodies attached to - - - 394 and ligamenta lata, vessels turgid in - 403 Fever - - . , - - - - - 51u Foetus, acephalous - - - - - 411 death of - - - - - - 470 defect in the abdominal parietes of - - 503 double - - " - - # - 503 double liver in - 503 skeleton of, discharged - - - - 400 and secundines, malformation and disease in 381 602 Foetus, unnatural formations and diseases in - 411 Foramen ovale closed prematurely 506 open - - 503 valve of, wanting 507 Fractures - 551, 557 Fragilitas ossium - 542 Gall-bladder, air in - 12 air between the coats of 254 calculi in 54, 58, 120, 130, 161, 168, 180, 182, 214, 545 between the coats of 186, 190 central contraction of - 15 coats of, indurated - 16 thickened 165, 186 communicating with the colon - 202 contracted and flabby 334 dilated - - - - 182, 183 distended with a thick white secretion 85 exceedingly small 168 lacerated - - 185 lithotomy of - 200 ruptured - - 264 wanting ... 172 Gastrodynia - - 12 Genital and urinary organs, diseases of 266 Glands, conglobate, scirrhous - - 526 strumous 532 Gout ---.. - 543 calcareous matter from 280 Gouty concretions in the breast - 527 Haematemesis - - 42, 147 Hematocele -Haemorrhoids - - 382 94, 268 Haemorrhage vicarious ... - 78 Hanging - - • - 559 603 Heart, aneurism of . . - 272 42Q auricle of, dilated - - - - 209 carneae columnae enlarged and tendinous - 42a cicatrices on . 235 enlarged . . . 190,312,363,371 flaccid - 56, 73, 160, 224 frothy blood in - . . . 56 75 and pericardium covered with lymph - 43a fat - - - - 58 surface of, ulcerated ... 209 tendinous - 425 valves of, diseased - - . 273, 444 indurated - - - - 415 ossified - - - 313, 555 left ventricle of, thickened - - - 35 Hellehore, poisoning by 590 Hemiplegia - - - - - - 40 Hepatic arteries dilated - ' - - - 168 Hermaphrodite - - _ - - - 435 Hernia * - , - 110,204, 378 appearances mistaken for - - 121, 126 appendix caeci in ... 111,121 at the foramen ovale - - - - 128 sacro-sciatic aperture - - 128 diverticula in - - - - 127 dorsalis - - - - - 129 effects of quicksilver in - - - - 118 femoral - - - - 116, 128 inguinal - - - - - -110 scrotal - - - - - 113 umbilical - - - - 128, 130 of the bladder - - - - 129 liver - - - - - 129 spleen - - - - 129 stomach - - - - - 129 womb - - - - - 129 Hydatids - 202, 221. 227, 235 601 Hydatids in the tunica vaginalis Hydatid tumour of the neck Hydrocele concrete of the tunica albuginea Hydrocephalus Hydrops pericardii 370 - 529 272, 369 - 382 378 - 216 205, 206, 209, 426 Hydrothorax - - 145, 205, 209, 227, 335, 407, 523 and hydrops pericardii ... 370 Hysteria - - - - - - 421 Ileus - - - - - - 103 Iliac region, abscess in - - 290 Ilium os, gun-shot fracture of - - - 253, 260 Infanticide ------ 573 Intervertebral substance ossified - - - 190 Intestinal concretions - - - - 130 glands diseased ... 83, 85 ulcerated in dysentery - - 84 Intestines, abrasion of - - - - 80 abscess between 46 burst - - - - - 238 calculi in - - - - 107 chronic inflammation of - - - 60 coats of, thickened ... 2 coherent by substance almost cartilaginous - 72 diseases of - - - - 41 displaced 73, 427 diverticula of - - - - 112 excessive excretions from - - - 105 excrescences in - - - - 83 haemorrhage from ... 40, 79 inflamed ----- 40 inflammation of, accompanied with spasm - 44 from thoracic inflammation 440 with effusion of blood into the abdominal cavity 410 605 Intestines, laceration of ... 263, 265 membraniform substance in - - 79 malformations at the anus 107 morbid secretions in - - - 103 mortification of . 53, 68 organic lesion in , attended with symptoms of pulmonary disease . - 77 polypi-form, concretions in 77 scirrhus and contraction of - - 85 strictured by a band of lymph 93 tuberculated . - - 227 worms in 99, 100, 116 Intestinum caecum dilated i - 49 colon burst . 94, 102 ileum, diverticulum in - 166 Intus-susception ... 98 Ischuria renalis . 292, 309 vesicalis . 292 Jaundice 173, 179, 195 black or green . 183 blood tinged in - 265 bone tinged in . 177 brain tinged in . 173, 195 in infants . 506 secretions from the nose tinged in - 178 Joints, diseases of . 536 Jugular glands enlarged . - 24 veins tied - 567 motion in - - 573 Kidneys, calculi in 279, 212, 330, 408 cicatrices in - - 236 cysts on - 278, 446 diseases of - - 266 diseased - 319, 332 VOL. 11. 77 606 Kidneys, enlarged 281, 282, 290, 293, 440 and excavated - - - 339 and suppurated - - 267 extenuation of - 270, 281, 282 hydatids on - - 276, 388 lacerated - 213, 264, 265 lobulated - - 271 pain in, occasionally deceptive - - 140 pelvis of, dilated - - 138 pelvis in, double, and two ureters - - 282 and rectum, ulceration between - 282 sand in - - - 59, 138 small - - 282 small and uneven - - - 361 solitary - - 288 suppurated - 216, 266, 333, 343 sympathetically affected - - 288 tubuli of, enlarged - - - 275 tubuli and pelvis dilated - - 307 ulcerated - - - 268 unevenness of surface of - - 276 wanting - - - 282 worms in - - - 288 Knee, cartilages of diseased - - - 548 diseases and injuries of - - 556 Labour, on premature rupture of the membranes in 489 unfavourable, some remarks relative to - 488 Lacteal vessels dilated ----- 564 Larynx and pharynx, carcinomatous tumours of - 2 Larynx, cartilages of, ossified 3 Leucorrhcea - - - - - -410 Ligamentum teres, diseased ... - 555 relaxed ... 550 wanting ... - 555 Liver, abscess in - 169 communicating with the thorax - 16^ burst. - - - - 2 ".4 607 Liver, coats of, cartilaginous - - - - 174 converted into fat - - 175 diminution of - - - - - 174 diseases of - - - - - 221 double ------ 503 enlarged - - - - 145, 166, 227 and furrowed - 444 and tuberculated - - 160, 163 and scirrhous - - 164 flaccid ----- 174 hydatids of - - - 168,173,174,274 indurated - - - - - 118 inflamed - - - - - 52 like boiled liver ... - 424 marbled - - - - - -313 pale.....295,338 and indurated - - - - 70 sacculus on, containing calculi - - 181 sphacelated - - - - - 59 tuberculated - 21, 555 vesicles of air on .. - - 254 Loins, causes of pain in - - - - 291 Lungs adherent to the pleura ... 251 black and ichorous - - - - 14 calcareous matter in - - - 227, 269, 233 cicatrices upon - - - - -414 collapsed ... - 191 infarction of - - - " - 85 flabby ----- 375 nearly scirrhous - " 52° serous fluid in ^" suppuration of 550 Luxations - Lymphatics dilated r - 247 Mammary vein, vanx ot Measles, appearance of, in the stomach Menorrhagia 608 Menses, obstruction of - - - - " 40 Menstruation, membraniform substances expelled during 688 Mesenteric glands diseased - - - - 23 obstruction in 514 veins, orifices of, distended with blood - 78 Mesentery, abscess in - - - 446 diseases of- - - - -13 osseous tumour in - - - 166 punctured wound of - - - 261 tumours in 136, 138, 140 Mind, influence of, in producing abortion - - 483 jaundice - 173, 195 in parturition ... 494 Mola vesicularis ----- 398 Moles.....381, 387, 389 Mollities ossium ----- 539 Monstrosities - - - - - -411 Mouth, diseases of 1 Nephrotomy - - - - - - 290 Nerves, some experiments on 559 Oesophagus, compression of - - - - 6 disease in the glands and coats of - 4 diseases of 1 dilatation of 6 divided ----- 6 paralysis of - 3 ulcerated - - - - - 33 Omentum adherent to the peritoneum - - 19 consolidated - - - - - 65 inflammation of, from pregnancy - - 409 lacerated ... - 222, 263 and mesentery, abscess in - - 46 morbid production in - - - 191 retracted - - - - 165, 427 rolled up - - - - - 21 vesiculated ... - 205 609 Opium, poisoning by - Organs of generation, malformations in Ovaria, coats of, nearly cartilaginous cysts and abscesses in diseased - diseases of - dropsy of . , dry, and without vesicles enlarged ... and convoluted fungous tumours in hair in hydatids on ossification of peculiar bodies in scirrhous - shrunk - - - - 189, and vesiculated - - » and tubes coherent various contents of - vesicles in, containing a morbid fluid wanting - white and indurated Palate, fissured - Pancreas, diseased - diseases of - extenuated ... indurated - thickened and indurated tuberculated - - - - Paralysis - Parturition, lameness subsequent to - unfavourable consequences of Pelvis, ligaments of, relaxed Penis, amputation of ... excessive enlargement of malformations in - 592 - 379 - 56 - 453 411 413 - 452 - 456 - 397 - 30 - 23 - 227 - 467 416, 441. 452 - 387 - 151 151, 402 392, 396, 452 - 56 - 223 - 334 - 453 446 450 - 523 - 505 - 215 - 144 - 160 17 ,25. 413 - 22 - 145 - 433 - 405 - 405 - 406 - 526 - 385 . 366 610 Pericardium adherent to the heart - 19, 52, 210, 252 dropsy of 224 thickened ----- 438 and coated with lymph - 370 Peritoneum, dropsy of - - - - 202, 238 and mesentery, pus between - - 259 and omentum, fluid between - - 250 tuberculated ... 408 Pharynx and larynx, carcinomatous tumours in - - 2 thickened ----- 312 Pia mater, air-bubbles in the vessels of - - 446 inflamed 396 vessels in, distended ... 446 Pineal gland, distended with fluid - - 190 Pituitary gland, contracted - - - - 190 Placenta, disease in - - - - - 485 retention of - - - - - 487 Pleura, callous ----- 525 tuberculated - - - - - 561 Pneumatocele - 382 Pregnancy, signs of - - - - 381 Prostate gland, abscess in- - - - 317 calculi in ... 332 cell in 363 diseases in 292 enlarged - - - 279, 305 excrescence of - - - - 192 middle lobe of, enlarged - - 375 sinuses in .... 3^2 Prostatic calculi - - - - - 318 Rectum, scirrhous prolapsus of Renal arteries, redundant calculi and vesical calculi Retention of urine sympathetic - 90 95 - 166 279 - 286 115,292 ^ . - 116 611 Retention of urine, vicarious excretions in - - 294 with incontinence - - ' - 306 Rheumatism - .... 55 Rhododaphne, poisoning by 589 Ribs, malformation of - 426 Rickets ------ 540 Rumination, human - - - - . n Sarcocele ------ 382 Scrofula ------ 531 Secretions, morbid, effects like poisoning from - - 552 Seminal duct, or sinus in the caruncle, dilated - 114 ducts, diseases in 368 orifice, obliterated - - - - 357 Secundines ___--_ 469 Serum of a saffron colour - - - - 518 Soft palate, ulceration of 1 Solanum, poisoning by ... - 590 Spasmodic affections - 259 Spermatocele - 383 Sphincter ani, divided, consequences of - - 92 Spina bifida ----- 499, 501 ventosa ------ 538 Spinal marrow, disease in - - - - 513 Spine, distortion of - - - - 371, 442 Spleen, cicatrices on ... - 235 diseased - - - - 163, 216 diseases of - - - - - 147 dropsical, or large hydatid in - - - 151 enlarged - - 166,211,339,386,525 and flabby - - - 34 tuberculated - - - 147 extenuated - - - - - 160 flabby......118 hydatids of - - - 154,221 lacerated - - - " - 263 ossified - - - 154,513 prolapsus of - - - °' 612 Spleen, removal of - 160 small - - - - - 365, 523 and disorganized 153 a superfluous one - - 221 suppurated - 154 thickened - - 445 unusual fissures in - - 153 Steatocele - - - - - 382 Stillicidium urinae - 306, 316 Stomach, central contraction of 17, 20, 37, 162, 189 carcinomatous tumours in - - 27 coats of, perforated by succus gastricus 35 nearly cartilaginous - - 36 mortification in - 58 thickened and tuberculated - - 65 the pylorus thickened 69 contracted - - - - 165 diseases of - 7 dilated - - 211 displacement of - 39 erythema of - - 77 excrescences of - 35 fluid in, black - 15 glands of, calcareous 10 glands of, enlarged - - 16, 25, 30, 36 inflamed - - - - 13, 15, 16, 17 inflamed from uterine irritation - 20 lumbrici in • - - % 333 morbid adhesions of, and communications with the colon - - 32 perforation of - 31, 32 polypi of - 37 prolapsus of 38 punctured wounds of - - - 260 pylorus scirrhous - 162 red spots on the inner surface of - 174 ruptured - 365 613 Stomach, scirrhous - 26 scrofulous abscesses in - 21 slightly black - 332 tubercles on 69, 249 tumour in ... - 192 ulceration of 29, 214 from poison - 582 villi of, turgid with blood - - 15 Strangulation - - 559 Subclavian and carotid arteries dilated - 35 Sublimate, poisoning by - 583, 587 Suppression of urine ... - 326 Syphilis - 361, 366 Tenesmus - - - r - - 82 Testes, bony substance in - - 386 diseased - - 135 excrescence in the tunica vaginalis - - 379 enlargement of - - 384 fatty substance in - - 384 in the tunica vaginalis - 381 lesions of, from hernia - 127 tubercles on 277 ,305 and spermatic chord, disease in - 369 Thigh bone, fracture of the neck of - 549 ,551 Thoracic viscera, disease in - - - 373 Thorax, white serum in - - 438 Thyroid gland, cysts in 534 ,535 enlarged - - - - 120 hairs in - 486 osseous bodies in - 535 scirrhous - - 534 Tongue, tubercles on - - 532 Trachea, cartilages of, indurated - 546 fasciculi of fibres in - - 361 Trochlearis muscle adherent to its trochlea - 451 Tubercles, hydatid origin of - - 225 Tumours ~ 522 VOL. H. 7** fe 611 Tumour of the mamma - - - containing bone pulsating, in epigastrio Tunica albuginea testis, tubercles on - - vaginalis, loose body in . - Tympanites - Ureters consolidated - - dilated 200, 306, 319, 332, 338, 339, 347, hydatids in valve-like production in Urethra, bulb of, red - pale . - _ . dilated by mistake - diseases in excrescence in 47 - - 305, filaments in - female, calculus in - - - diseases in - inner coat of, prolapsed glandular bodies in - thickened impediments to the discharge of urine in granules like tobacco in lacunae in, obliterated - lesions in Urinary calculi ----- and biliary calculi coexistent and genital organs, diseases in Urine, discharge of from the rectum excessive secretion of ... retention of and stillicidium of - suppression of - from injury - Urinous effusion into the abdomen perspiration saliva - 523 526 - 142 372 - 376 202 , 250 . 283 368 , 409 276 ,360 360 360 ,361 374 - 448 292 315 320 358 - 321 320 - 321 298 - 118 315 363, 364 359 - 322 327 - 197 266 - 226 304 279, 286 553 292, 309 259 - 292 293 . 293 615 388. Utero-gestation signs of, suspended Uterus, adhesions within bony substance in tubercles in the ligaments of calculi in - cavity of, narrow and appendages, diseases in corona of, wanting diseases of dropsy of - encysted tumours of - enlargement of excrescences in extirpation of fleshy tubercle of hydatids in - the ligaments of inclined to one side inner surface of, uneven ligaments of, nerves obscure in thickened membraneous productions in mouth of, obliterated by an adventitious membrane 402 mucous and serous discharges from 409, 410 glands in, diseased ossified - parietes of the cervix coherent procidentia of, during labour prolapsus and inversion of protuberances within pustules on - purulent discharge from rupture of - scirrhous tumour in scirrhus at the mouth of serum in - - small 469 469 453 ,392 392 - 401 275 - 390 413 215, 221 399 - 400 387 188, 392, 423, 424, 425 429 . -m* - 388 34V399, 400 396,397,411 34, 55, 390, 439 - 445 396, 397 - 438 52 - 402 414 - 423 403 - 435 428 - 388 55, 390 417, 419 490 - 387 1 392 - 415 406, 411, 44f! -- >■* 610 Uterus, sm^11 and inclined to one side - - 24 tubercles in - 407 , 412 tumour on - - 188 at the mouth of - 390 ,392 ulcerated - 307, 407 , 420 and vagina inflamed - 412 vesicles in - - 415 vessels in the ligaments of, varicose - 439 turgid at the orifice of - - 404 Vagina, parietes of, united - 451 prolapsus of - - - 429 sphacelated - 413 tumours at the orifice of - - 497 ulcerated - - 307 ulceration and excrescence of - - - 438 Vas breve dilated - - 149 Veins, epigastric, varix of - - 246 iliac, corrugated - 273 elongated - - 442 morbid production in - 551 mammary, varix of Vein preternatural - - - 247 - 396 Vena portae lacerated - - 264 Vertebrae, cartilages! between, ossified - 191 Vertebral canal, fluid in - - - - 224 Vesiculae seminales- and seminal duels, diseases in 368 calculus in - - - 369 scirrhous - 368 shrunk - - 369 Vicarious excretions - 295 Vobrulus . . . . - - 48 Vomiting, excessive - 14 Worms - - - 563, 443, 100, 101. 115 Wounds of the abdomen .} 257