.--.c^Tijr-irT I VM/V i 3NI3I03W jo Aavaan ivnoiivn jnisiqjw jo Aavaan ivnoiivn j n i d i o j »io JNijioiw jo Aavaan ivnoiivn jnisiqiw jo Aavaan ivnoiivn jnidiqswio h?\ E NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAllI J = 'v Having thus pointed out the more common cadavarous appearances of the lungs, with the view of drawing the distinction between them and the alterations which are real- ly pathological, I proceed to speak of the latter. The chief of them are hypertrophy, atrophy, emphysema, oedema, pneumony, and phthisis: of these, the two last are by far the most common. Hypertrophy of the Lungs Is manifested by an augmentation of their volume, and uu increase in the consistency of their tissue. It is very sel- dom exhibited by both lungs at once, but is more common- ly seen on one side only; in cases where accident or dis- ease of some duration, as empyema, has produced a collapsed and permanent atrophy of the lung on the other side. The lung here takes on an increase of vitality and energy, as well as of volume, in order to execute its double task. Under this view the condition can scarcely be regarded as a disease, Laennec, vol. i. p. 284. f Anat. Gen. vol. ii. p. 65. HYPERTROPHY. 227 and is similar to what occurs under corresponding circum- stances in other double organs, as the kidneys, the testicles, and the mammas, when one has been destroyed. It would appear indeed from the report of M. Laennec,* that any cause rendering one lung useless for a few months, will be productive of an increased organic development of the other lung. He met with it in one case where empyema had prevailed for six months only, being caused by a softened tuberculous mass rupturing its way into the pleura, and pro- ducing inflammation there. It is the result also of hydro- thorax, of the collapse of the chest following severe pleurisies and extensive pulmonary excavations; and of that condition of the pleura called pneumo-thorax, which is a collection of gas of some kind in it. It is more than probable, though extremely difficult to prove by inspection, owing to the minuteness of the object; that each air cell in hypertrophy of the lung is enlarged, and its parietes thickened. The texture of the lung becomes more firm and elastic, and it, instead of subsiding on the opening of the thorax, remains more stationary than usual; and, in some cases, escapes upon the removal of the sternum, as if it had been confined in a cavity too small for it. The mediastinum, in these cases, is generally pushed from the middle line of the thorax over towards the side of the col- lapsed lung, and the heart consequently also. In a subject brought to our dissecting-rooms many years ago, (about 1818,) where empyema prevailed on one side, the thorax was unusually prominent and rounded upon the other side, owing to this unusual evolution of the sound lung. Atrophy of the Lung. In ordinary cases of general emaciation of the body, the Jung is one of those organs whose size and condition are not * Id. vol. i. p. 285. 228 IRRITATIONS OP THE PULMONARY TISSUE. sensibly affected; its atrophy, therefore, is more immediately the result of causes acting locally upon the lung itself, as pressure from without as just stated, from effusions of diffe- rent kinds into the cavity of the pleura; and the develope- ment of diseased masses within its substance. In several of these cases of atrophy of the lung, which I have examined after death, the lung was pushed to the back of the thorax, was lying in a state of perfect collapse along the sides of the dorsal vertebrae, and reduced to a thin flat cake, having a hard fleshy feel. Confined to this restrained position for some time, it loses its permeability and power of expansion, so that in inspirations, only a very small quan- tity of air is introduced into it. Another great obstacle to its dilatation, probably the most important and effectual one is, that the coating of coagulable lymph with which it is covered, becomes converted into a strong organized mem- brane of a somewhat fibrous structure, which will not yield to the expansive tendency of the lung. This factitious mem- brane which covers the lung, also modifies very sensibly the shape of the thorax. For, when the absorption of the effused fluid begins, as the dilatation of the lung does not keep pace with it, the thorax is pressed in by the weight of the atmos- phere acting on its surface; and it finally becomes flattened on that side, or caved in, as is spoken in common language. This depression of it is arrested at a certain point, and then it remains stationary during the residue of life, the space be- tween the lung and the ribs being filled up with pus. This constitutes a chronic form of empyema, which seems to be perfectly consistent with general good health, and which, if ascertained during life, it would be exceedingly improper to interfere with by an operation; as no good could result, and the constitution would be thrown into great disturbance, by a new inflammation supervening on the pleura, from the ad- mission of air. In some cases it has happened that the pus of empyema being entirely absorbed, the depression of the ribs, has ATROPHY. 229 brought the factitious membrane on the lung, in contact with that on the pleura covering the ribs; and an intimate adhesion has followed, which has identified the two factitious membranes and at the end of some months they have ac- quired the consistence and all the characters of a fibrous or fibro cartilaginous production.* The following dissection will illustrate what I may call a dormant empyema, from its not awakening any symptoms of an unpleasant kind.in the system. In May, 1822, I was called upon to examine a boy aged fourteen at Mr. Hatt's boarding-school in Market Street near Ninth, the leading character of his last illness, had been pain in the abdomen with fever. His physicians were Drs. Chapman and De- wees. We found nothing out of order, or in a diseased state in the abdomen. This is my note of the dissection, and, in reflecting on it at the present day, I think it very proba- ble from the symptoms, that there were some pathological changes there; but I had not the light of information at that time which enabled me to see them. To our great surprise, though there had been no indication of either an acute or chronic thoracic disease, we yet found the left pleura filled with well elaborated pus of a suitable colour and consistence; and the corresponding lung reduced to a tubercle about the size of the fist, with a small part collapsed and adhering along the spine. To account for this, it appeared upon inquiry, that this young gentleman had a pleurisy in Paris two years before. His general health had been subsequently re-established, and he seemed like any other boy of the same age. Though, at the time of dissection, the state of the lung and of the pleura seemed sufficient to account for death, and the difficulty was the aberration of symptoms, yet I am now satisfied of the con- clusion being erroneous. I think it more probable, that the system had become accommodated to that state of the thorax, -■ Laen. vol. ii. p. 121. 230 IRRITATIONS OP THE PULMONARY TISSUE. and that if I had been a better pathologist, some more satis- factory cause of death would have been discovered. I am now fully convinced, that if an officious surgeon had opened this pleura, to let out the pus; and had thrown in his detergent washes, that a renewed inflammation, hectic fever, and death would have followed from it. The disease was evi- dently dormant and required no treatment. The following case which occurred to me in the practice of the Philadelphia Alms House, will illustrate the effect upon the general health of a patient, when an opening is made either artificially or naturally for the relief of the em- pyema. It will also show, how careful a physician should be in interfering with such collections of matter: unless the patient be so distressed in his respiration, from the accumu- lation of pus; as to make its evacuation of primary importance to the expansion of the opposite lung, so as to admit a suf- ficient volume of air. In which case we substitute one evil for another, a renewed inflammation, hectic fever and death at a remote time; for that death which threatens to come in- stantly, without a mechanical relief, of the lung on the sound side. Philadelphia Alms House, May 4th, 1825.—Charles Shaw, aged 28 years, was admitted a patient in this institu- tion on the 25th of January, 1825, labouring under symp- toms of pneumonic irritation, as cough, mucous expectoration, difficult respiration, hectic fever, &c. He stated, that some months previously he was attacked by pleurisy, of unusual violence, in the city of Lancaster, where he then resided; which terminated by the formation of pus between the pleu- ra pulmonalis and costalis. On examination, a scirrhous ulcer was discovered on the left side, about the sixth rib, mid-way between the sternum and spine, through which a small quantity of puriform matter was constantly issuing. As the symptoms became daily more urgent and distress- EMPYEMA. 231 ing, and particularly the respiration, which was extremely laborious; it was conjectured, that a large quantity of mat- ter had formed in the left cavity of the thorax, and was pre- vented from escaping through the narrow and tortuous opening, that with difficulty admitted a probe. According- ly, about two weeks after the patient's admission, an open- ing was made in the direction of the sinus; and, as had been anticipated, a quantity of puriform matter was discharged, amounting to two pints at least. The respiration was imme- diately relieved, and in a little time his general health was considerably improved. The wound was kept open by means of a tent, which was occasionally removed to give vent to the pus. After a while, however, the discharge from the side became very much increased, with a return of hectic accompanied with profuse night sweats, and great emaciation: he was gradually exhausted, and expired on the night of the third day of May. No local means were resorted to, to arrest the discharge, till a few weeks before his death, when stimulating injections were employed. At this time, however, he was too much exhausted to derive benefit from any kind of treatment. On the dissection of Shaw, the left lung was found in a collapsed state lying along side of the thoracic vertebrae, and covered by a thick coat of coagulating lymph, or rather by the same kind of membrane which lines an ancient fis- tula. This membrane was so strong, that no effort of the lung at expansion could possibly have stretched it out. The pleura costalis, was also in a state of chronic inflammation, and much thickened. The left cavity of the thorax, was much below its usual capaciousness, owing to the diminution of its circumference, by the extreme depression of the ribs, and the ascent of the diaphragm: it did not appear capable of containing more than a quart of fluid, in addition to the col- lapsed lung. From this case it would appear, that the natural cure of empyema, where an opening exists for the discharge of pus 232 IRRITATIONS OF THE PULMONARY TISSUE. through the parietes of the thorax, is by a contraction of that side of the thorax from the circumference to the centre; and, as there is no tendency to heal it by granulations from the pleura, nature might, perhaps, finally obliterate the ca- vity by contracting it; but, unfortunately, the patient's health is generally exhausted, and he dies before this can be done. In the case of Shaw the injections were of no use; neither could they possibly have been so, at any period of this dis- ease; and their effect, being irritating, would of course in- crease a discharge already too profuse. A week before his death, I therefore ordered the injection to be discontinued; and also forbade that any means should be taken to get the pus out of the thorax, from a belief that the least irritating body applied to the pleura would be its own secretion. Not- withstanding this, not two gills of pus were found in the cavity after death. While on the subject of empyema, I may state cursori- ly, that sometimes the tendency of the matter, from its ex- cessive quantity, is to find its way outwardly through the parietes of the thorax, and it will be seen bulging out the intercostal spaces. I met with one case where it formed a large bag on the side, just over the lowest ribs; and, from the necessity of the patient for air, there could be no alternative for evacuating the matter by puncture. In empyema and other effusions into the cavity of the tho- rax, where the quantity of fluid has been less considerable, and adhesions have occurred between the lungs and the sides; the primitive volume of the lung is never restored, although respiration be re-established in the most perfect manner.* This will account for the shortness of breath which persons thus circumstanced suffer, on undue exercise, or in ascend- ing an eminence. In addition to the collapse and atrophy of the lung, occa- sioned by pressure from a fluid in the pleura, tubercles de- * Laennec, vol. i. p. 287. EMPHYSEMA OF THE LUNGS. 233 Veloping themselves in its tissue will produce the same de- gree of diminution in its respirable surface, by occupying the spaces of the air cells. In these cases, the air cells be- tween the tubercles are frequently in a healthy state, and do not seem either compressed or pushed aside, but removed by a species of atrophy; and as the whole volume of the lung is not increased, but rather diminished, it is evident that the atrophy of the lung is equivalent to the aggregate quantity of the tubercles developed in its structure, which are some- times very numerous, and of different sizes. Emphysema of the Lungs. Emphysema of the lungs is of two kinds, the one con- sists in the distention by air of the air cells of the lungs; and the other in a distention by air of the common cellu- lar substance, holding the air cells and the lobules together. The characters of pulmonary emphysema have generally been taken from the last; but it appears from the observa- tions of M. Laennec,* that the former is a very common condition with the asthmatic, though it has heretofore been supposed a rare complaint. In emphysema of the air vesicles, they become much larger than usual, and much less uniform in their shape: some are the size of millet seed, and are by far the most numerous; others equal in volume a flax-seed; and others are of different gradations of size, up to that of a kidney bean. In the approximation to the latter size, it is probable, that several primitive cells have suffered a rupture of their par- titions, and by that means concur to form a single large chamber; but, in some cases, they are evidently formed by the dilatation of a single one. In the celebrated work of Dr. Baillie, on Morbid Anato- Laennec, vol. i. p. 289. 30 234 IRRITATIONS OF PULMONARY TISSUE- my, there is an excellent representation of this pathological change in the air cells of a lung. According to the plate, they occupy the whole lung; are of very different and irre- gular shapes; and the largest of them do not seem to be more than two or three lines, in their greatest diameter. The structure thus altered, has according to the comparison of Dr. Baillie,* an analogy with the air cells of the lungs in am- phibious animals. In some cases, the cells near the surface of the lungs are so much enlarged, that they project beyond their general periphery, and have the appearance of a number of thin glo- bular vesicles the size of cherry stones; and they adhere by a pedicle, which communicates with the adjoining branches of the bronchia and cells. Thp branches of the bronchia and especially the smaller ones, are also sometimes dilated in lungs where emphysema exists. It is a very rare complaint:t I am not aware that a case of the kind ever presented itself to my notice. It is, however, easy to conceive of the same cause which produces distention of the cells, also producing an enlargement of the bronchia. Emphysema may exist, partially or generally, in one or both lungs at the same time. Like hypertrophy, it increases the volume of the lung, and seems to make it too large for the thorax; so that, upon opening the latter, the lung escapes from it in part, instead of collapsing. When the lung is squeezed, the air escapes with more difficulty than in the healthy state, and its crepitation resembles more the slow passing of air from a bellows. If put into water, an emphy- sematous lung does not sink so deep as a sound one, and often seems to float on the surface, scarcely displacing any of the water. While the cells of the lungs are in this state, the disease consists in a permanent and excessive distention of them. * P. 43. f Laennec, vol. i. p. 292 EMPHYSEMA OP THE LUNGS. 235 This, by increasing still more, or by occurring too rapidly, produces a rupture of their parietes, and an infiltration of air into the connecting cellular substance, as in common sub- cutaneous emphysema. In this state vesicles filled with air, which may be displaced by pushing, are seen on the surface of the lung, and vary in size from a line to twelve or fifteen lines in diameter. When the infiltration of air oc- curs, however, at the union of several interlobular partitions, the air becomes fixed there, and cannot be transferred from place to place.* These several infiltrations of air from rup- tured cells are generally superficial; and do not extend them- selves much into the thickness of the lung, by following the sheaths of the bronchial branches, and of the pulmonary vessels; except in very rare cases. It sometimes happens that a rupture of the air cells will occur in the depth of a lung; and a large globular accumu- lation of air is the consequence, which is manifested on the surface of the lung, by an irregular projection. This cavity contains generally a little clotted or decomposed blood, and the cells bordering it are in a collapsed state. An emphysematous lung is less humid than a sound one, and is destitute commonly of the cadaverous engorgement about its root which was alluded to; unless it be complicated at the time of death, with peripneumony. When the affec- tion is confined to one lung, it becomes much larger than the other, and displaces the heart and mediastinum. In this case the thorax of the corresponding side is protruded, and more elevated, and when struck, it is also more sonorous than the other When the affection is equal on both sides, the sound is equivalent, and is well heard every where; the whole thorax becomes of a cylindrical or globular shape, the sternum is held high up, and the intercostal spaces are enlarged. I have a patient, a young gentleman of twelve, who having had asthma from early infancy; the conforma- * Laennec. vol. i. p. 291. 236 IRRITATIONS OF THE PULMONARY TISSUE. tion of his thorax is precisely what is now stated, being evi- dently much modified by the disease. The most usual cause of cellular emphysema of the lungs is that form of catarrh called dry,* from the trifling expecto- ration attending it; and which is marked by a tumefaction of the lining membrane of the fine bronchial branches, with an expectoration of pearl-coloured mucus. The dilatation of the air cells, according to the theory of M. Laennec,t is produced in the following manner: as the office of inspi- ration, owing to the greater force of its muscles, is executed with more vigour than that of expiration; it often happens that the air which has by inhalation, surmounted the ob- struction of mucus, and the tumefaction of the bronchial ramifications; cannot find its way back again from the cells of the lungs, except partially; and renewed inspirations only add to its quantity, from the same cause. Again, as cold air is introduced, especially in winter, it expands in volume when it has got into the cells. These two causes then, a difficulty in the return of air, and its expansion by the heat of the lungs, produce a permanent and preternatural dilata- tion of their air vesicles, and the disease called emphyse- ma is the consequence. Emphysema may also arise from the exertion of the lungs, in playing upon wind instruments; or from any other violent exercise of respiration, making it necessary to hold the breath for a long time, with simultaneous efforts to expel it. Hence singing, screaming, hallooing, produce the same effect. Tumours of the thorax developed within its cavity tume- factions of the bronchial glands, or aneurisms of the aorta, also produce the same effect; and, it is stated by M. Laen- nec, not to be uncommon to find some cells dilated, where tubercles of a moderate volume prevail in the lungs. The se >ond form of emphysema, it has been stated, is called interlobular, from the air being extravasated from the * Laennec, vol. i. p. 171. fid. p. 302. EMPHYSEMA OP THE LUNGS. 237 air cells by a rupture of their parietes; and insinuated into the partition of common cellular substance, holding the lo- bules together. These partitions, from the almost inappre- ciable thickness which they naturally have, are thus swollen out to a breadth of from one line to twelve; traverse in this state the surface of the lung, and penetrate some distance into its thickness. Such infiltrations of air, frequently fol- low the course of the pulmonary vessels, especially the super- ficial ones; and form bubbles resembling a chaplet, along them. Bubbles of air are also found beneath the pulmona- ry pleura; and when this interlobular emphysema occurs near the root of the lung, it passes on to the mediastinum, from there to the neck, and to the intermuscular and sub- cutaneous cellular tissue of the whole body. I once met with interlobular emphysema in an infant who had died from croup. This affection, it is admitted, is the consequence of a rup- ture of air cells, yet the places of rupture cannot be seen; and it very rarely happens, that there is a dilatation of the air cells along with it. By inflating and drying a lung with this affection, and afterwards removing slices of it with a knife, the situation of the air becomes very apparent, as well as the perfect integrity of the air vesicles themselves, of the affected lobules. The same causes which produce the vesicular emphysema also occasion the interlobular, as all violent exertions of the organs of respiration in the discharge of their natural func- tions; and it is also supposed that the air may be developed there also, as in other parts of the cellular substance of the body. * It is a remarkable fact, that the cases of coinci- dence in the vesicular and the interlobular emphysema, at the same time, in the same lung are so rare; this may arise from the induration and thickening of the pulmonary tex- ture which takes place in the former. * Laennec, vol. i. p. 342. [ 238 ] QZdema of the Lungs. CEdema, in this case, is a serous infiltration which per- vades the pulmonary tissue, and diminishes remarkably its permeability to the air. It is said* to be a very common disease, yet it is but little known, perhaps owing to the im- perfect manner in which observations have been made upon it, by most pathologists. It is seldom a primary affection, but most commonly, one of the attendants of such chronic diseases as dropsies, and organic affections of the heart. It is also a consequence of severe peripneumony. Its anatomical characters are as follow:—The colour of the lung becomes of a pale gray, or pale yellow; its vessels contain less blood than usual; and it does not collapse upon the opening of the thorax. It crepitates as in health; the finger will make a slight indentation into it, and from it when cut, there issues an abundant, transparent, and almost co- lourless serosity, with but little froth, except in recent cases. It is frequently blended with acute peripneumony, and is considered by M. Broussais as a grade of that affection. Peripneumony. This is an acute inflammation of the substance of the lungs. It is frequently uncombined with an inflammation of the pleura covering them; when combined with it, the disease is a pleuropneumony. Though the gradations of this affec- tion are numerous, yet the more prominent stages of it are three: suffocation, (engorgement,) hepatization, and pu- rulent infiltration. 1. Peripneumonj^, in the stage of suffocation, makes the lung heavier than usual, of a much greater firmness than na- * Laen. vol. i. p. 349. PERIPNEUMONY. 239 tural, and of a livid or violet colour. Its crepitation on pressure, though it still continues, is much diminished; and it feels evidently like a body engorged with a liquid; and it retains the impression of the fingers. When cut through, its tissue internally is of the same dark red or livid hue with the surface, and is found infiltrated with a bloody serosity which flows freely, and is frothy and muddy. The spongy texture of the lung is not entirely extinguished, with the ex- ception of some few places, which have advanced to the se- cond stage, or that of hepatization. 2. The term hepatization, expressive of the second stage of peripneumony, is derived from the resemblance of it to the liver, in compactness and weight. The lung in this state presents internally a red colour, varying in places in the in- tensity of its shade, from a violet to a blood red. There is a strong contrast between this and the bronchial ramifica- tions, the blood vessels, the colouring matter of the lung, and the interlobular partitions of cellular substance; which are more distinct than usual, and frequently are free from in- flammation. Little or nothing escapes from the surface of incisions of a lung thus situated; and, on scraping them, a little bloody serosity may be forced out, with occasionally some white puriform matter. The vesicular arrangement of the lung is extinguished. A cut or lacerated surface exhibits in the place of air cells, a granular arrangement consisting in small red rounded masses, considered by M. Laennec,* as the vesicles themselves transformed into solid grains, by the thickening of their parietes and the stuffing (infarctus) of their cavities. In pneumonic subjects of this grade, the lung does not col- lapse upon the opening of the thorax, owing to its universal inflammation and its being completely destitute of air. It is not, however, more voluminous than in the natural state, neither is the corresponding side of the thorax; which, ac- cording to M. Laennec, establishes a great difference be- ■ Laen, vol. L p. 387 240 IRRITATIONS OF THE PULMONARY TISSUE. tween the signs of a pneumony and of a pleurisy. On this subject a very sharp controversy has arisen between M. Laennec and M. Broussais; the latter asserting that the lung is sometimes so tumefied as to have the marks of the ribs upon it: which is both denied by M. Laennec and declared by him to be impossible, from the ribs and intercostal mus- cles, being on exactly the same plane. 3. In the third degree of pneumony, that of purulent in- filtration; the pulmonary tissue, besides the state last de- scribed, assumes a pale yellow colour, like straw. First of all are seen small yellow points of pus: these points after- wards coalesce, and the whole lung becomes of a citron co- lour. From the incisions which may be made into it, there issues a yellow opaque, viscid, purulent, fluid; by no means so disagreeable as the pus, from an external wound. The substance of the lung becomes much more soft and hu- mid than in the red hepatization; the granular texture is ef- faced, and before the process is finished, the lung will re- solve itself into a soft grume by pressure from the fingers. The inferior parts of the lung are the most common loca- tion of pneumony; and when it invades the whole lung, it starts usually from these points. The various degrees which have been set forth may exist at the same time in the oppo- site lung, and in different places of the same one. The right lung is more subject to this affection, and indeed to all others than the left;* also, the lungs may be only partially affected and not generally, by the irritation being confined to a cir- cumscribed spot. Of Abscess of the Lungs. This affection has been called vomica by the older wri- ters in medicine, and till lately was considered as rather a common termination of pulmonary inflammations. The ob- * Laen. vol. i. p. 406. ABSCESS OP THE LUNGS. 241 servations of M. Laennec and others, have now settled the question upon the ground, that instead of being common, it is one of the rarest pathological conditions. On several hundred peripneumonic subjects, M. Laennec has met only five or six times with purulent foci; and, in my own ob- servations on probably more than fifteen hundred dead bo- dies of different kinds and ages, I remember to have seen it only twice, and then it was but small. The parietes of such abscesses are formed of the contiguous pulmonary substance infiltrated with pus, and in a state of semi-putrid softening, which decreases from the abscess outwardly in every direc- tion. It has been remarked,* in purulent collections, that the inflammation prevails in a part only of a lung, and not in the whole; it is supposed that the following rationale of the circumstance may be given. In universal inflammation, death occurs before the matter can collect into one or more foci; but nature and art together, can succeed against a par- tial inflammation for a longer time, and even cure it when it has gone into the state of suppuration; as done by M. Laen- nec,t in eighteen out of twenty eases. There is but little doubt now, that the supposed frequency of vomica has arisen from the prevalence of tubercles, soft- ened down and discharged by expectoration; but the anato- mical characters of these are essentially different, as I shall show; and also the constitutional symptoms. Gangrene of the lung is next in order; it also is an ex- tremely rare affection. It may be either partial or general: in the latter case death follows in a very short time, pre- ceded by extreme prostration, and intolerably foetid, green expectoration. The lung diminishes in consistence, and is found of various shades of colour, from a light green to a dark one almost black, with a mixture of brown. Some * Laen. vol. i. p. 408, f Id. p. 400 31 242 IRRITATIONS OF THE PULMONARY TISSUE. parts of the lung are so softened, as to be in the state of pu- trescence. I have seen it but seldom, and then it was partial. It does not seem to be so much the result of a highly active inflammation, as of a tendency to gangrene;* hence, the in- flammatory changes around it are inconsiderable, and seem to be rather a consequence, than the cause of the gangrene*. * Laen. vol. i. p. 443. * [ 243 ] CHAPTER XIV. IRRITATIONS OF THE PULMONARY TISSUE. PHTHISIS PULMONALIS. This affection is a slow disorganization of the pulmonary tissue, occasioned by the development in it, of a number of masses of matter, called tubercles. Similar masses are frequently found in the thickness of the alimentary canal, along its line of junction with the peritoneum, scattered over the surface of the latter, in the spleen, the liver, in the lymphatic glands, in the brain, and in other parts of the body. But it is principally, and most frequently in the pul- monary tissue that they exist, and go clearly through those stages of development and subsequent dissolution which characterize them. A Tubercle, when examined chemically, seems to be co- agulated albumen, containing an excess of alkali, which is manifested by its turning green, vegetable blues. When plunged into boiling water, into an acid, or into strong spi- rits of wine; it, like all other animal textures containing much albumen, becomes opaque and more firm than it was previously. No pus can be detected in it, in its early stages. It is only in the later ones that the surrounding pulmonary texture, becomes evidently inflamed, and the tubercular masses softened; and that the expectorated matter consists in a mixture of the latter, with the purulent secretion of the ad- joining parts. These facts may be ascertained by receiving the expectoration into a vessel filled with cold water,, when 2 14 IRRITATIONS OF THE PULMONARY TISSUE. the pus will be found precipitated to the bottom, and charac- terized by its globules, and pulverulence.* The principal difference between tubercles is their relative state of aggregation. Some are found disseminated and perfectly distinct from one another; and in this state have been called by M. Laennec and Bayle miliary tuberculous granulations. In such cases they do not exceed the size of a millet seed, and may be recognised by their ovoidal shape and colourless transparency. Others are found collected into masses, or, in the technical language of anatomy, are agglomerated. And lastly, there exists what is called a tu- berculous infiltration. In some subjects, we find exclusive- ly one of these forr.is, and in others, all of them at once: so that whatever may be the mere mechanical condition and arrangement, the pathological one is identical in all. Not- withstanding this obvious inference, the subject has been very much complicated; by a most learned and excellent writer, Mr. Bayle,t making several distinct species; which he declares are of a nature entirely different, though he ad- mits their occasional union in some subjects. These species, in the phraseology of Mr. Bayle, are, 1. Tuberculous Phthisis, (agglomerated;) 2. Granular Phthi- sis, (disseminated;) 3. Phthisis with melanosis, (tubercules covered with the pigmentum nigrum of the lungs.) 4. Ul- cerous Phthisis, (cavities from gangrene;) 5. Calculous Phthi- sis. 6. Cancerous Phthisis. The old fashion of infinitesimal differences in diseases has scarcely been more fully exem- plified, in a modern book of celebrity, than in these six dis- tinct pathological forms of phthisis pulmorralis. The first three are evidently of the same nature, to wit, that of tu- bercle; and the three last have scarcely any thing in com- mon with phthisis, but that of being seated in the same organ. * Gendrin, vol. ii. p. 598. f Bayle, Phthisis. Pulm. p. 21—24, Paris, 1810. PHTHISIS PULMONALIS. 245 According to the computation of Mr. Bayle, these various forms of phthisis observed, in nine hundred patients, the fol- lowing proportions to one another:— Tuberculous Phthisis, Granular, do. Melanosis, do. Ulcerous, do. Calculous, do. Cancerous, do. Considering the three first to be all modes of what we call tubercle, it follows that this mode of chronic derangement in the structure of the lung, is about ninety-eight and a half per centum on the whole, of those forms called phthisis by Mr. Bayle. When tubercles exist in the disseminated state, they con- sist in innumerable granuli dispersed throughout the lung: are from a scarcely perceptible magnitude to that of one or two lines in diameter; and are separated from one another by the intermediate air vesicles-of the lung, seemingly in a healthy state. It is thus that we find them in the foetus for the most part, or the very young infant, where they have been congenital. These granuli are semi-diaphanous; when cut, they shine, and are of the colour of ground glass, but much more lustrous. Some of them are contiguous immedi- ately to the pulmonary tissue, others are enveloped by a distinct membrane or cyst separating it from them.* They adhere intimately to the pulmonary structure, and cannot be detached without tearing it. They have no apparent vas- cular organization, though they, no doubt, derive their growth from an interstitial circulation, as many parts of the body do even in a state of health. In this, however, there is some difference of opinion; for Mr. Bayle says that they are pierced by capillary blood vessels, and M. Laennec,t 624 \ - 183 \ 879 72^ 14 4 3 Laennec, vol. i. p. 21: t Bayle, vol. i- 5%5. 346 IRRITATIONS OP THE PULMONARY TISSUE. that they grow by intussusception. I am disposed to be- lieve that the latter is the case at first: but as they increase in size, either by individual solitary growth, or by adhering to the contiguous ones; it is likely that vessels will be found penetrating their interstices to a limited extent, as in other tumours. In a short time after a tubercle is evolved, its centre becomes a dark yellow point, from some change in its organization; and the tubercle itself diminishes in transpa- rency, and becomes of a milky colour. The tubercles in this state are called crude, and it is probable that they fre- quently remain so for a considerable time, without a mate- rial change in their organization. There is then, so little constitutional disturbance from them, and the physical symp- toms of their existence are so equivocal, that they are fre- quently unsuspected. Tubercles are evolved in the cellular substance of the lungs, between the air cells and lobules; so that the two latter are not obstructed, but rather compressed, and are slightly indurated where they border on the tubercle. As the proper pulmonary tissue is but little impaired in this state, the function of respiration is duly performed, with the exception of being somewhat hurried from ex- ercise. Agglomerated tubercles are formed from the dissemi- nated ones coming into contact as they grow, and then coa- lescing. The intervening portions of the lung become more indurated; are infiltrated also with tuberculous mat- ter, and become identified with the general mass of tu- bercle. By this mechanism, balls or masses of the latter are found of all sizes, from that of a disseminated tubercle to a hen's egg, and even much larger. The structure in its arrangement may be compared to the particles of pudding stone, with their intermediate cement; it being recollected that the cement itself is finally assimilated to the tubercu- lous nature itself. PHTHISIS PULMONALIS. 247 As the agglomerated tubercles progress towards liquefac- tion and dissolution, the tuberculous infiltrations are made extensively into the adjoining pulmonary tissue. Frequently, however, these infiltrations occur, without the preliminary step of disseminated or agglomerated tubercles. Under what- ever circumstances tuberculous infiltrations are made, the affected pulmonary tissue becomes more compact than usual, grayish, semi-transparent, and cuts with a smooth polished surface. The air cells are obstructed; the bronchial branches alone remain pervious, being only partially obstructed by a tumefaction of their lining membrane. It very seldom happens that a lung is reduced universally to this tuberculous state, but is rather interspersed with such morbid degenerations. Under these circumstances, the blood vessels distributed to the affected lung are obliterated, in the substance of those morbid degenerations, as proved by injections; but they remain in the small portions of pulmo- nary tissue, that continues permeable in the midst of the surrounding changes of structure; and also in the bridles of cellular substance, which may pass through the latter. Tuberculous Infiltration consists in the interstitial de- posite of tuberculous matter in the substance of the lungs, which is followed by a closure of the air vesicles, and a con- densation of the pulmonary texture. Like other forms of tuberculous degeneration, it also shows itself in other organs besides the lungs, so that it is not peculiar to them. It has been observed in the thickness of the digestive tube, in the serous membranes, and also in pseudo membranes. I have met with two cases of pulmonary consumption, where there was a species of hardness and elasticity along the whole ali- mentary canal, which I have never been able to give a so- lution of, unless it came from an interstitial deposite of tu- berculous atoms. This notion is encouraged by the fact, that it is very common for the ulcers in the intestines of phthisical patients, to have small miliary tubercles at their bottom. 24S IRRITATIONS OF THE PULMONARY TISSUE. The colour of tubercles is affected by several circumstances: jaundice will tinge them, and especially when they are situ- ated in the liver; adjoining mortification gives ihem a dark brown tinge: the black matter found in the lungs, by being blended with them, gives them a grayish colour, and causes the dispersion of black points in their substance. Whatever may be the form under which tuberculous mat- ter shows itself, whether disseminated, agglomerated, or in- filtrated, it has one uniform termination—that of softening itself into a liquid state. This process begins in the centre of the mass, and always advances by degrees to the circum- ference. The preliminary change is into a soft, cheesy con- sistence; becoming more and more diffluent, until finally it obtains the thickness and liquidity Of pus. In some instan- ces, it has the consistence of well elaborated pus; in others, it resembles in a measure butter-milk, from one part being more fluid and serous like, while the other is opaque, and re- sembles curds or soft cheese. The latter is said to be espe- cially the case in scrofulous subjects. When the matter has become thoroughly softened, it finds its way into one or moreof the bronchial tubes leading towards it. This is effected not by a separate process of ulceration, but by the tube itself and the adjacent vesicular structure of the lung having also undergone the tuberculous degeneration, by an infiltration into their structure. They consequently soften along with the primary tubercles. An excavation is thus formed by a discharge into the bronchia of the softened tubercle,and by its expectoration; which excavation becomes a permanent fistula. It rarely happens that there is a single excavation; for as there are many tubercles scattered through the lung, they each, according to their state of maturity, execute the same process of softening either simultaneously or successively. The larger tubercles, or cavities, are for the most part sur- rounded by smaller ones, which are later in maturing, and PHTHISIS PULMONALIS. 249 as they progress, empty into the large ones. In this way the pulmonary structure, frequently, in the advanced stages of consumption, exhibits a collection of numerous excavations, communicating by means of tortuous canals or anfractuosities, which pass from one end of the lung to the other. The supe- rior lobes of the lungs are most prone to this kind of destruc- tion, and we often find them excavated into large tuberculous cavities, while the remainder of the lung presents its tubercles in the crude state. These pulmonary excavations are some- times as large as the fist, and are occasionally so numerous that scarcely any part of a lobe is left except its periphery. They are often traversed by columns, resembling in shape the columnae carneas of the heart, and passing from side to side. These columns are smaller in the middle, and are formed of pulmonary tissue condensed, and infiltrated with tuberculous matter. Blood vessels, in some very rare cases, are found in the interior of these columns, but almost obli- terated. As a tuberculous excavation becomes emptied, its sides or periphery secrete and line themselves completely, with a false membrane, which is of an opaque white; thin, of a uni- form surface, and of a soft, friable consistence. It resembles very much the false membrane which lines fistulae in other parts of the body, and seems to be of an albuminous charac- ter. In some instances it is not a complete lining; but is ra- ther interspersed in patches separated from one another, more transparent, less friable, and adhering closely to the parietes of the excavation; also the thickness is unequal, and it bears a closer resemblance to coagulating lymph. The lining mem- brane of this second form is occasionally found below the first; in which case the latter is loose and lacerated in seve- ral places. In some instances the pulmonary excavation is destitute of a lining membrane entirely; its parietes being formed by pulmonary tissue, red, hardened, and infiltrated with tuberculous matter at different degrees of development. 250 IRRITATIONS OF THE PULMONARY TISSUE. It is concluded, from these several circumstances,* that the lining membrane described first, is only the more perfect form of the second, which is finally changed into it; and that, when thus changed, its tendency is to become detached from the excavation, and to be replaced by one of a new production; and that, when loosened and lacerated, the lining membrane is discharged in the expectorations. It is thought by Mr. Bayle, that the secretion from these lining membranes, forms the habitual expectoration of con- sumptive patients after the debris or wrecks of the softened tubercles, have been got up. This, though a very natural inference, is not fully established; for M. Laennec asserts that these excavations are frequently entirely empty; in which I agree with him: and that, when otherwise, the con- tained matter resembles much less the substance expecto- rated, than that in the bronchial tubes does. He therefore infers, that it is this bronchial mucus, augmented and vitiated by the irritation of the lining membrane of the lungs, which is really the expectorated matter. One thing I have frequent- ly remarked, that the muciparous follicles of the trachea and bronchia are invariably much enlarged in consumption; and, like the follicles of other canals, indicate their irritation by this test. There is a condition of the excavation which has obtained rather objectionably the name of encysted tubercle, t Its essence seems to be a mere conversion of the lining mem- brane into a semi-cartilaginous substance. In this state it ad- heres to the surrounding structure with great tenacity, and cannot be detached from it without dissection, or laceration. In some rare cases, an ossification of a partial kind in it has been observed.£ The cysts which surround tubercles, some- times get into this semi-cartilaginous state before the soften- ing of the tubercle. It occurs more frequently in the bron- chial glands than elsewhere. Laen. vol. i. p. 548. j Id. 549. -i Bayle, p. 22. PHTHISIS PULMONALIS. 251 As tubercles increase in volume, they push aside the large blood vessels of the part, and flatten them in a measure, where they assist in forming the parietes of an excavation. Where branches of these blood vessels penetrate into the tubercu- lous mass, they are obliterated* before the latter is matured, and their orifices are so well secured that an injection of them properly managed, will not penetrate into the excava- tion.! The bronchia, on the contrary, become incorporated with the tubercle, and finally dissolved along with it, and their extremities retain a free communication with it, so that it is rather uncommon to see even a small excavation which has not several bronchial orifices looking into it. These tubes are scarcely ever opened on their sides, but have their ends on a line with the walls of the excavation. It is a very uncommon thing for death to occur from tu- bercles in the crude state, and before they have opened a pas- sage into the adjoining bronchia. Hence, where we find sub- jects in this condition they generally have been victims to some other malady of a more pressing kind; otherwise the tuber- cles are very numerous, and by the quantity of space they occupy, interfere with the proper discharge of the pulmonary functions. When there are but very few tubercles, they are sometimes all found in the state of softening; and emptying into the bronchia. But, according to my own experience and that of pathologists generally, by far the most common condition of the lungs at the time of death; is to have tu- bercles in the various stages of development and progress, from the first evolution of a scarcely perceptible magnitude and organization, to the state of pulmonary excavation. We hence find some of them as miliary grains, transparent, co- lourless, and looking like atoms of cartilage; others more voluminous, opaque, and yellow in the centre; others sof- tened into a curdy matter; others almost removed by expec- * Baillie, Morb. Anat., Albany, 1795, p. 35. r Lacn. vol. i. p. 547 252 IRRITATIONS OF THE PULMONARY TISSUE. toration: and besides which, there are portions of lung infil- trated with tuberculous matter. Most commonly the greatest devastation is in the summit of the right lung, which seems to be particularly disposed to disorganization at this point. It frequently happens that so long as the air is kept from the tubercles, no very evident sign of their existence will be present; but the admission of atmospheric air disposing them, as it does all other animal productions or excretions, to pu- trefaction; they then become irritating, and cause hectic fe- ver. Tuberculous collections with a sanious pus, are always found in the substance of the lungs or in the pleura, when the hectic fever has been violent, long, consumptive, and at- tended with foetid excretions.* Complications of Pulmonary Consumption ivith Maladies in other organs. It is a matter of general observation, that phthisical pa- tients seldom come to an end of their existence until they reach the last stage of marasmus. It is from such extreme emaciations that the name consumption has been taken. This extreme emaciation is principally observable, in the muscles and in the cellular substance and adipose matter: they all disappear to such an extent as to be only the remains of themselves. The skin is drawn tightly over the bones, and observes their outline so nearly that the common expression has been got from it, of an individual being merely skin and bone. If it be pressed upon one place, by the position of the patient for an undue length of time, it ulcerates and cannot be healed readily again. On the sacrum large sloughs are thrown off, which add much to the misery and horror of the patient's situation. The nervous system remains of its ordinary vo- lume, excepting the small particles of fat being absorbed which exist in the sheaths of the nerves: but the peculiar * Brossais, Phlesym. f 'liron. vol. ii. p. 240. PULMONARY CONSUMPTION. 253 texture of the nervous system, both brain and nerves, is never seen to greater advantage than in consumptive subjects, where the general exemption from fat, and the almost total disappearance of red blood, leave every fibre white, shining, and perfectly distinct. The peculiarly healthy state of the nervous system will account for the unusually acute percep- tions of both mind and body, which are seldom lost until the patient is almost in the last agony. With the exception of the kidneys, my own impression is, that the glandular System of the abdomen is generally in a state of emaciation; when no particular disease manifests it- self in them, causing their tumefaction. The parietes of all the hollow viscera are evidently much reduced in thickness, as any one may readily ascertain who will examine them by inflation. M. Laennec is of a different opinion, both on this point and on. the preceding, from me. The bones remain of the same length, but diminish in circumference, and in the size of their articular extremities; the marrow is removed from them in great part, and serum takes its place: they be- come specifically lighter, and of a beautiful whiteness. They make, generally, very handsome and clear skeletons. The shape of the thorax is evidently much affected: it be- comes long and narrow, and the intercostal spaces are so much depressed, as to form long deep grooves between the ribs. This is produced, in part, by the extreme emaciation of the patient, and in part by pleuritic adhesions, which are very common in the last stages of phthisis; and, as the vo- lume of the lungs is then considerably diminished, the pa- rietes of the thorax are pressed in by the weight of the at- mosphere. The volume of the heart seems also to diminish along with the quantity of blood: it loses all the adipose matter on its surface, and becomes remarkable for its smallness and for the firmness of its texture. The large blood vessels connect- ed to it are generally of a healthy texture and highly elas- tic: and they contain, for the most part, clots of lymph, al- 254 IRRITATIONS OF THE PULMONARY TISSUE. most uncoloured by blood, and assuming their shape, pene- trating even for some distance into their ramifications. Such of the serous membranes as remain in their normal state, have a polished brightness, and, like the skin, are al- most ex-sanguine (ex sangue.) The most remarkable, however, of the cadaverous appear- ances of patients, dying from pulmonary consumption, is the very obvious tendency of the other viscera to a chronic dis- organization, and most frequently from the development of tuberculous disease, in some form or other. It is therefore very unusual to see a patient dying from pure solitary phthi- sis: almost invariably one or more of the other viscera have responded to the suffering of the lungs. The alimentary canal is very frequently the seat of these pathological sympathies. If the phthisis has been rapid, and violently inflammatory; it is attended with a high grade of gastric inflammation, marked by a deep redness of the mu- cous coat of the stomach, by contraction, and hardness of this viscus, and by red patches in the mucous membrane of the intestines.* On the contrary, if its progress be chro- nic, and of the ordinary duration, great numbers of tu- bercles, about the size of mustard seed or smaller, will be developed in the intestinal canal (especially the ileum,) be- neath the peritoneum, and in the thickness of the mucous and muscular coats. These tubercles terminate in ulcera- tions, which proceed from within outwardly, spread into one another, and become of various sizes, from a line or two to that of one or more inches. The ulcers have edges elevated, ragged, and injected; and their bottom, when large, is frequently formed only by the peritoneum: the perforation of which sometimes take place, and would do so more fre- quently, if while the ulceration was going on within, a se- cretion of coagulating lymph was not thickening the out- side of the intestine, so as to anticipate the progress of the * Brouss, vol. ii. p. 240. PULMONARY CONSUMPTION. 255 ulcer, and raise a barrier against it. These ulcers are described in the account of the mucous membranes. Not- withstanding this salutary provision to prevent a perforation of the gut, it sometimes happens, that it is not sufficient; and the stercoraceous matter being effused into the peritoneum, causes an acute peritonitis with tympanites. Perforation, however, does not necessarily expose the cavity of the ab- domen; for where the ulceration can no longer be antici- pated by the deposite of lymph on the surface, and in the thickness of the peritoneum, that part' of the intestine will glue itself to an adjoining surface of intestine or of some- thing else: and will thus gain a new barrier, which is ei- ther perfectly effectual, or else the perforation by progres- sion will pass only from one fold of intestine into another, so that the integrity of the peritoneal cavity is still main- tained. These intestinal ulcerations generally give rise to the colliquative diarrhoea of consumptive patients, though they are not always followed by it, and especially if the colon is not the seat of them, or only so to a moderate degree. One of the most distressing sympathetic lesions of struc- ture in phthisis, is an excoriation of the mouth and pharynx, by aphthae, which are also seen occasionally in the nose, in the ears, and even on the vulva. They first begin by an al- teration of the mucous membrane of the part, which becomes red; and is covered with an innumerable quantity of small white chalk-coloured plates: these plates at length fall off, and the mucous membrane is seen to be excoriated, and with a great number of fine ulcers, probably of its mucous folli- cles. These aphthae differ from such as exist in acute fevers, inasmuch as the latter first come as little transparent vesicles, filled with serum, which burst and are then followed by small white ulcers, with elevated edges and a conical base. I have no doubt that these also are lesions of the mucous follicles; but the difference is, that these follicles in the be- ginning of a complaint are in the healthy state, whereas in consumption, they have been previously affected by the tuberculous diathesis / 256 IRRITATIONS OF THE PULMONARY TISSUE. Scirrhosity, and tuberculous degenerescence of the mesen- teric glands, are almost always the attendants of ulcerated intestines, in the same way as the bronchial glands are en- larged and diseased in phthisis. The opinion is generally received, and has been sanctioned by Bordeau, that phthisis frequently gives rise to fistula in ano; and that the latter ex- ercises a salutary influence over it, and retards its fatal term. On this point M. Laennec, out of his immense experience and exact observations, states that he has seldom met with this coincidence, and that it has appeared most frequently without influence on its progress.* I may state, that my ob- servations coincide with his. The liver often sympathizes with the disorganization of the lungs. Sometimes it becomes yellow, voluminous, and fat. The presence of the latter is proved by its greasing the knife with which it is cut, and also by porous paper, when applied to it in a heated dried state, absorbing the fatty mat- ter, and thus evincing its presence. The spleen is often hardened, surrounded by peritoneal adhesions, and has tu- berculous matter in it. The kidneys are more exempt from sympathetic morbid derangement than other viscera. The serous membranes often sympathize with tubercular consumption of the lungs. First of all, such patients are very subject to slight attacks of pleurisy, manifested during life, and on dissection after death. The contiguous surfaces of pleura are found adherent more or less generally: fre- quently the costal pleura, when free from the pulmonary, is covered with a layer of recent or of old coagulating lymph, penetrated with specks of blood, and roughened by filaments adhering to it. From eight to sixteen ounces of serum in the pleura are very common, showing clearly the inflammato- ry action which has been going on. Chronic inflammations of the peritoneum and arachnoidea are not uncommon. The pericardium also suffers sometimes. Op. Cit. vol. i. p. 560 PULMONARY CONSUMPTION. 257 The heart, besides being reduced in size and increased in firmness of texture, is very apt to have small white plates upon its surface, of a fibrous nature, and readily passing to the state of cartilage.* They may be torn off easily, as they do not penetrate into its structure. A lesion of the larynx is also very common in phthisis. On some occasions the lining membrane of it is only thick- ened and slightly injected; but on others it presents the ap- pearance of aphthae, like those of the mouth and pharynx, ending in ulcerations. Frequently the beginning of them is a small tubercle, in the thickness of the mucous mem- brane or beneath it. These ulcerations are of various sizes, from a small speck, to two or three lines in diameter; and they frequently penetrate the whole thickness of the mu- cous membrane, exposing thereby the cartilages of the la- rynx, and sometimes producing a caries of them, especially the arytenoids. The trachea and the bronchia, are also the seats of such ulcerations, but by no means so frequently as the larynx. It is the occurrence of these ulcerations along the air passages which produces the hoarseness, and the gradual ex- tinction of voice in consumptive patients. The following tabular view from Mr. Bayle,t will present some of these coincident disorganizations in a more fami- liar way. In one hundred examinations of phthisical pa- tients in the year 1804, (An. XII.) he found: Larynx Healthy, in 83 Do. Ulcerated, - - - - 17 Ulcerations of Intestines, in 67 Alimentary Canal Healthy, - - 33 Bayle, p. 62. fid. p. 58. 33 [ 258 ] Nature of Phthisis. I do not propose to enter at large upon this subject, I therefore merely state in outline, that highly respectable au- thorities* assert, that the development of tubercles in the lungs is not an act of inflammation; but the result of a tu- berculous disposition; and that, when inflammation is com- bined with it, the inflammation is of a date posterior to the tubercles. For my own part, I am not disposed to adopt this opinion. I rather view tubercles as a form of chronic in- flammation, to which evidently all parts of the body are lia- ble; but especially the lungs, from the peculiarity of their texture, and the quantity of lymphatic vessels entering into their composition. Like most other preternatural produc- tions of the body, resulting from sub-inflammation of its tissues, tubercles, after having reached a certain state of ma- turity lose their feeble powers of life, and are removed by the process of softening described; which, if it took place on the surface of the body, would be called ulceration, from its analogy with it. It is at the same time admitted that some persons and families are more disposed to this chronic, or sub-inflammation of the lungs, than others; but the admission does not lead us farther, in regard to the pri- mary nature of the malady, than a similar admission con- cerning sore eyes, or any other hereditary dispositions would do. So long as the fact remains well established, that any one may by exposure become a victim to tubercular consump- tion; and, that it is always more prevalent where evident in- flammations of the lungs are most common; the inference ap- pears to me unavoidable, that it is not more ingenerate than any other of the thousand ills that flesh is heir to, and ^ Laennec, vol. i. p. 578, Bayle, Gendrin, &c. NATURE OP PHTHISIS. 259 that from the mode of its development and progress, it is a slow or sub-inflammation of the lungs, commencing general- ly, first of all, from an irritation of their mucous membrane. For a development of these arguments in a masterly and ir- resistible way, see Broussais Examen des Doctrines, from page 684 to 694; and Chronic Phlegmasia, passim. [ 260 ;j CHAPTER XV. IRRITATIONS OF THE HEART. The organic alterations in the texture and mechanism of the heart were formerly thought to be rather unfrequent; but improved and multiplied observations in later years, on this important class of diseases, have proved, satisfactorily, that they are by no means uncommon; that all periods of life are subject to them; that they are the almost inevitable inheritance of advanced age; and that they frequently lay the foundation of, or complicate other affections. The essay of M. Corvisart* may be considered as intro- ducing these subjects to the notice of modern pathologists, and demonstrating their importance. Its celebrity is well deserved, and though affected somewhat by an eccentric theory of the venereal disease being generally the cause of the organic alterations in the heart, it has stood well the test of time, and will continue to be esteemed for the facts and narratives which it contains. This book, like the more celebrated one of Morgagni, shows that facts stated with simplicity and honesty, are the property and the useful in- heritance of all succeeding times, and that they may be ap- plied as well at one period as another; a lesson for us when narrating symptoms and pathological appearances, to state them detached from all theories and notions, if we wish them to be useful to others. All the tissues composing the heart are the subjects of disease and inflammation. The pericardium is liable to pe- ricarditis and hydro-pericarditis; the lining membrane i." * Organic Diseases of the Heart, Philadelphia, 1812, translated from the French- PERICARDITIS. 261 subject to inflammations acute and chronic, polypous con- cretions, and ossifications of the valves. The morbid alte- rations of the muscular structure are acute inflammations, (Carditis;) and chronic ones, (Endurcissement, or harden- ing,) as in other muscles; Dilatation of one or all of its ca- vities, either partially or generally; Increase in their thick- ness, (Hypertrophy;) Diminution of their consistence, (Ramollissement, or softening.) To these morbid states may be added congenital malformations, as an imperfection of its cavities, and an abnormal position of its large blood vessels. Pericarditis. Pericarditis, called so from the membrane which enve- lopes the heart, is an inflammation either acute or chronic, of the serous membrane of the pericardium, and may be either general, which is, perhaps, its most usual form, or partial. It is, unquestionably, a disease of much more fre- quent occurrence than is commonly suspected, and is very apt to be combined with irritations of the muscular tissue of the heart, and with pleuritis. The leading anatomical characters in this affection in the acute stage, are a concrete fibrinous exhalation on both parts of the pericardium, a vas- cular injection of the latter, and a sero-purulent effusion into its cavity. The redness and vascular injection of the pericardium which attends its inflammations is very rarely general: for the most part, it is either partially in spots of various dia- meters; or punctated by numerous points of red blood, grouped and scattered all over it. I have repeatedly seen cases where, even this punctated redness was very faint and limited. As in all other cases, almost, of acute inflam- mation in serous membranes, the pericardium itself is not increased in thickness, tumid, or infiltrated, and the fibn- 262 IRRITATIONS OP THE HEART. nous layer which covers it may be pealed off readily, so as to leave it smooth and apparently in a healthy state. The fibrinous layer resulting from this inflammation, is generally spread over the whole surface of the opposite faces of the pericardium, both on the heart, and on its large vessels as far as their line of junction, with the peri- cardium. It is not of a uniform thickness as in pleuritis, or regular on its surface, but is rough and flocculent; which, no doubt, comes from the action of the heart drawing it out into filaments, and making an attrition of the opposite membranes. This exudation of lymph is thicker than it is in pleuritis, but has the same colour, a pale yellow; and a consistence which preserves to it permanently, even when removed, a membranous condition. The serous fluid which is poured into the cavity of the pe- ricardium while this fibrinous secretion is going on, is limped, of a light citron colour, and frequently clear. It is, how- ever, in some cases found with fragments of the fibrinous secretion floating in it, and also turbid from a mixture with pus. I have seen it in all these forms, limpid and clear, limpid with flocculi of lymph or fibrine in it, and turbid from a mixture with pus. The distinction is, besides, of no great consequence in a practical light, as the affection is still essentially the same, and merely varies in the degree of its violence in different persons. There is good reason to believe, that the quantity of serosity varies considerably in the different stages of this complaint. It is not unusual at the beginning of the malady for it to amount to a pint;* and in a case narrated by Corvisart, there were nearly two pints, t When the violence of the inflammation begins to subside, the serosity is absorbed, so that frequently at the termination of one of these attacks, the quantity left, has been found very inconsiderable. I have seen it amounting to only three or four drachms, and even less. It has been i * Laen. vol. ii. p. 653. j Op. CH. p. 45. PERICARDITIS. 263 very properly remarked, that here lies a distinction between the anatomical characters of pericarditis, and of pleurisy and peritonitis; for in the two latter, the quantity of serum is generally fifteen or twenty times as great as that of the fibrinous secretion.* The explanation may, I think, be af- forded in the following way: from the limited extent of the pericardium, and the subordinate influence which its irritations exercise on other parts of the system; death from it alone is rather unusual, at least in the early periods of the inflammation, when the serosity is abundant; but the reverse is true of the universal inflammations of the pleura and of the peritoneum. The system perishes early under their irritation, and consequently a proportionate quantity of serum is found after death. If the irritation of these membranes be only partial, and death follow at a remote period, my impression from repeated observations is, that the quantity of serum, as in pericarditis, is but small; al- lowance being made for the cadaverous percolation, which, of course, will occur here as in all other cases. The secretion from the pericardium is in some cases san- guinolent, along with the sero-fibrinous: this, of course, will affect the colour of the latter, and tinge it of a red co- lour, the intensity of which will depend on the quantity of red particles of blood effused. It marks a higher degree of inflammation still, which has been designated under the term haemorrhagic. When the latter is comparatively mild, the redness of the fibrinous layer is not universal, but merely in spots and punctated, or in points, as we of- ten see it in pleurisy. When a pericarditis is partial, that is to say, limits itself to a single portion of the pericardium, the local phenomena are the same as in general pericarditis; so that it is not worth while to make a particular case of it. When the inflammatory action of pericarditis has sub- * Laen. vol. ii. p. 654. 264 IRRITATIONS OF THE HEART. sided fully, the fibrinous layer is converted by a process of time, into cellular substance closely allied to the nature of a serous membrane, and an adhesion is formed between the opposite faces of the pericardium. Frequently this adhesion is so close, that the pericardium cannot be sepa- rated without dissection from the heart: on other occasions, however, these adhesions are elongated, so as to allow of a separation of one inch or more. This is more frequently the consequence of partial than of universal pericarditis. In addition to these forms of pericarditis, it is not uncom- mon to meet with such as observe a more chronic and less active character. They are manifested by the internal or se- rous lamina of the pericardium, being highly and universally reddened by small spots of blood interspersed over it and very near one another, looking as if they had been laid on with a pencil. Most commonly with this appearance, there is an absence of the coat of fibrine, and even when it does exist, it is soft, thin, and resembles a layer of consistent pus. There is, at the same time, a lactescent puriform serum fill- ing up the cavity of the pericardium. M. Laennec* is of opinion that the close adhesions of the pericardium to the heart, for the most part, come from this grade of inflam- mation when the secretion is absorbed, and that the long adhesions are the result of more acute inflammation. Sometimes tubercles show themselves in the false mem- brane, resulting from pericarditis; but they are of course the consequence of a transition into the chronic stage. On the surface of the heart we not unfrequently meet with white opaque plates of from a few lines to two or three inches in diameter, and of the thickness of a finger nail, they have a soft semi-cartilaginous texture, and are placed super- ficially upon the serous membrane of the heart to which they adhere very intimately, and sometimes seem to be identified with it. There is good reason to believe that they are the result of chronic inflammation of a very low grade. • Op- C,]r. vol. ji. p. 658. PERICARDITIS. 265 In chronic pericarditis it is by no means unusual to find the muscular structure of the heart affected. As in other cases of chronic muscular inflammation, this state may be recognized by the hardness of the heart to the feel, by its whiteness as if it had been soaked in water for some hours, by its elasticity which will keep its cavities expanded, and by its easy lacerability. It is somewhat remarkable that M. Laennec, with all his excellence as a pathologist, should not have seen in these appearances an inflammatory action, but re- jects the notion of the latter, merely because pus is not found between the fasciculi of its fibres, as if pus were an essential character of inflammation on all occasions. A great difficulty in the treatment of pericarditis is the ob- scurity of its symptoms: several of the most skilful practi- tioners of Paris, as Laennec,* Recamier, and others, have declared that in their practice followed by a dissection of the patients after death, they have found themselves quite as often mistaken, as correct in a belief of the existence of this malady. Corvisart suggested that this obscurity might arise from its complication with other diseases which masked its symptoms; but the most simple cases have been found equally obscure with the combined ones. The probability therefore is, that pericarditis in many cases, exercises a very light and equivocal influence on the system at large, while in others a great disturbance is excited, which ends in death. The latter cases may generally be known by a volumi- nous and loudly sounding pulsation of the heart, interrupt- ed at intervals by reduced pulsations and diminished noise; this state is attended with an intermittent and contracted pulse, sometimes scarcely perceptible, and contrasting re- markably with the voluminous beat of the heart. The pa- tient also suffers dyspnoea, pain, an unspeakable anguish, and is incapable of locomotion without its producing fainting; but these symptoms are not diagnostic, as congestions of * Laen. vol. ii. p. 660. 34 266 IRRITATIONS OF THE HEART. blood in the heart and polypous concretions which result from them, give rise to the same. The uncertainty of the symptoms of pericarditis exists both in the acute and chronic stage. M. Laennec, in com- menting on this uncertainty, draws a happy and critical dis- tinction between the words divining and recognising dis- ease: the latter he thinks should not be employed when the signs are uncertain, and when it happens to the physician to find his opinions as often false as they are true.* Contrary to the received opinions in medicine, it would seem, that old adhesions of the pericardium are of little con- sequence; for the authority just alluded to informs us, that he has opened a multitude of subjects, who had never made a complaint of disturbance in their respiration and circula- tion, and who had presented no sign of it in their last sick- ness, yet in whom there was an intimate and total adherence of the heart or of the lungs. Hydro-Pericarditis. This disease is an accumulation of serum in the pericar- dium, and varies in quantity in different subjects. When small it may regarded as the effect of the dying state, or of that immediately consequent to death, and in this way it is suf- ficiently common; it is also not unfrequently connected with anasarca and other dropsies; but the pure uncombined hy- dro-pericarditis, without evidences of local inflammation, is very uncommon. When it exists, the serum is of a citron colour, and is in quantity from one to two pounds; though Corvisart reports a case where he found eight pounds:t it is limpid, clear, and inodorous. Dropsy of the pericardium, like its inflammation, is an ob- scure affection: sometimes no evident derangement of the * Laen. vol. ii. p. 660. f op. cit. p. 63. HYDRO-PERICARDITIS. 267 system exists, and when symptoms do arise, they are com- mon to it with other diseases. The stethoscope does not in- dicate it, except the accumulation amounts to at least one pint.* Some consolation may be derived for the obscu- rity of the diagnostics of this complaint, from the fact that pure dropsy of the pericardium is generally a consecutive disease; and consequently in its treatment we ought to look after the primary malady. In its nature it seems to be iden- tical with hydrocele, and would, perhaps produce as little inconvenience, were it not from its mechanical interference with the offices of respiration and of circulation. Various operations have been proposed for its relief, consisting essen- tially in a puncture of the pericardium through the intercostal spaces, and the drawing off of the water. From the disease being rare, and the diagnostic unsettled, experience on this point is very limited and unsatisfactory. M. Laennect has proposed perforation of the sternum with a trepan, just above the xiphoid cartilage, which would afford the opportunity of recognising positively the disease before the pericardium was opened. This operation being destitute of danger, seems plausible; and he has recognised also, that it might be useful when the disease was ascertained and the water let out, to throw some slightly stimulating injections in, to obtain a cure. It is rather difficult to fix a standard of the precise quan- tity of serum which constitutes a hydro-pericarditis; for we seldom open subjects, in which there is not from one drachm to an ounce of transparent water in the pericardium. Cor- visart has upon an average of a great number of individuals dead from every species of disease, suggested as a rule, '' that when the serosity exceeds six or seven ounces, it should be considered a dropsy." If the quantity be less considerable, amourting to only a few spoonfuls, it is very probable, that the liquid has been effused during the last moments of life, and is an effect of the struggles with death. • Laen. vol. ii. p. 670. t Laen. vol. ii. p. 671. | 26S ] Of Pneumo-Pericarditis. This disease is a collection of air in the pericardium, and is stated by the French pathologists* to be not an unfrequent oc- currence in the living body, and is often met with in the dead; care being taken in the latter instance not to confound it with the development of gas, one of the phenomena of pu- trefaction. I am not myself aware of having seen it, but the probability is, that like many other scientific observations, it has passed unnoticed when it did occur, from my attention not being especially directed to it, by previous information on the subject. The quantity of air thus collected, is very variable; and its chemical nature has not been examined into. It co-ex- ists with hydro-pericarditis most commonly, though it may be alone also. When the pericardium is opened, it escapes with a light whizzing noise. Its signs in the living subject are doubtful and unsettled. It may sometimes be recognised by a resonance of unusual clearness upon the percussion of the lower part of the ster- num, coming on suddenly; and by a noise of fluctuation de- termined by the pulsations of the heart, and by forced in- spirations. M. Laennec states,t that in nearly all the cases where the pulsations of the heart can be heard at a certain distance from the thorax; the phenomenon is owing to a momentary development of gas, which is most frequently promptly removed; and whose presence in the pericardium does not give rise to any serious accident. In some very rare cases, the noise of the heart thus communicated has been heard at the distance of several feet, even in the ad- joining chamber; but, it is very common to hear it at a dis- tance, of from two to ten inches from the thorax of the in- dividual. % * Bertin, Malad. du Coeur Paris, 1824, p. 278. | Latnnec, vol. ii. p. 672. 7 Id. p. 454. PNEUMO-PERICARDITIS. 269 It would appear that the palpitations of the heart called nervous, are generated in this way, and that a paroxysm is apt to be produced by walking quickly, or by ascending a flight of stairs. It is a state of comparatively little danger. In twenty subjects presented to M. Laennec, with palpita- tions which could be heard from two inches to two feet, only four had organic diseases of the heart: with the re- mainder it disappeared, and many of them returned to per- fect health. It is an axiom in pathology, that all the noises within the body heard by the naked ear, are due to the movements of some part which is in contact directly or indirectly with a gas. This notion corresponds perfectly well with a similar law in physics, for the experiment must be familiar to all, that a bell rung in vacuo does not produce sound by its vibrations, neither does it when surrounded by solid mate- ria. Under this class of phenomena, we then rank palpi- tations heard at a distance; borborygmi in the intestinal ca- nal, the crackling of the cellular substance in emphysema, the cracking of the joints in rheumatic affections by the de- velopment of air in them, the disease being called pneumo- arthrosis; the crepitation which follows contusions and frac- tures:* and the artificial cracking of the joints of the fingers by stretching them, a process which in eastern countries, where the art of bathing is carried to the highest perfection; can be extended by the adepts in it to every joint in the body, as I have been informed by a gentleman, who underwent the experiment, and who described it along with the warmth of the bath, as producing the most delightful sensations of indolence and exhaustion. We proceed, in the next place, to treat of the diseases of the muscular substance of the heart itself, which may exist either alone or combined with the affections of the pericar- cardium. • Laennec, vol. ii. 457. [ 270 ] Carditis. Carditis is an inflammation of the muscular substance of the heart, and is either general or partial. It very rarely presents itself in that acute form which generates pus, its inflammation in this respect closely resembling that of other muscular tissues. Meckel, however, saw it thus in a man of fifty years, whose heart had pus infiltrated between its muscular fibres.* M. Laennec met on one occasion with an abscess the size of a bean, in the parietes of the left ventri- cle; it was combined with pericarditis, and occurred in a child of twelve years; and in a man of rank who became a pauper from the disturbances of the French revolution, and died in the Hospital called La Charite, he found an albu- minous exudation the colour of pus, and the consistence of the white of egg cooked, interposed Between the fasciculi of the left ventricle. I have myself never met with these forms of disease in the heart, and have reason to think from that circumstance, that they are very unusual, at least in this city. And if, with M. Laennec,! we consider the presence of pus as the only incontestable sign of inflammation, the heart will be found sufficiently exempt from such a malady. I cannot, however, agree to any such limitation; it is carrying pa- thology centuries backward, and merging it in the period where heat, redness, pain, and tumefaction were considered the indispensable and inseparable phenomena of inflamma- tion, and a common bile as its fixed and unchangeable type; a doctrine which has served more to mystify medicine, and to embarrass its principles than any other which ever exist- ed. Let us for a moment glance at the inflammations of other tissues; do we not find their high irritations, frequent- ly existing without pus in their interstices; the muscles * Mem. Acad. Berlin, 1756, from Laennec, vol. ii. p. 555. f Laennec, vol. ii. p. 535. MOLLESCENCE. 271 changing their colour, becoming brown, easy to tear, and sometimes converted into a soft mass without cohesion,' and in a semi-fluid state? Do not the brain, the liver, the spleen, and other organs present the same condition in their irritations? On the contrary, if inflammations of less vio- lence and more duration assail the same muscles, their na- tural brown is changed to a light olive or drab colour, they are harder to the touch, but at the same time tear much more easily than in health, and sometimes they undergo car- tilaginous and bony degenerations, making them entirely useless as organs of locomotion. If with the more improved school of pathology we ad- mit these several conditions of organs as the evidences of inflammation, we can have no hesitation in applying the same principles to the heart; and we shall have as a conse- quence the acknowledged cases of carditis vastly augment- ed. For my own part, I am fully inclined to this course, convinced by these and other reasons of its propriety, and I therefore range in the same line, Mollescence, (Ramollis- sement;) Hardening, (Endurcissement;) Ossifications, Hy- pertrophy, Dilatation, and Aneurism, all of them being but modifications of the act of inflammation, depending upon its degree and stage. Having settled this point, at least for the time, we may now proceed to discuss the other organic alterations in the texture of the heart. Mollescence or Ramollissement of the Heart. I have adopted the French term, in designating the di- minished consistency of the heart, as rather more expres- sive than the corresponding English word softening. The softening of all the tissues of the body under the act of in- flammation, is a French observation in pathology, made by Laennec,* and well deserves to be designated in the lan- guage of the country which first informed us of it. Having * Laen. vol. ii- p. 535 272 IRRITATIONS OF THE HEART. / adopted it elsewhere; I may, therefore, with sufficient pro- priety, apply it also to the heart. This disease is recognised by the following anatomical characters: The heart is flaccid and collapsed, and so weakened in its texture, that in squeezing it between the ends of the fingers, they will penetrate into the ventricles. It is seldom found gorged with blood, but is only half full on the opening of the body. Its colour, for the most part, departs signally from what is natural, sometimes it is in- creased in intensity to a violet blue, which is especially the case in severe continued fevers, but more commonly it takes a yellow hue, analagous to that of dead leaves in the au- tumn. This affection has been found both general and in patches: sometimes it does not go beyond the circumference of a single cavity, and it is very apt to exist along with dilata- tions. Mr. Bertin* has stated his persuasion, that it never exists without a pathological condition of the external or internal membranes. M. Laennec,t after rejecting the idea of M. Bertin and Bouillaud, of this being ah inflammatory affection, reasons on it in the following exceptionable way: stating, That it is an affection sui generis, resulting from a disturbed nutri- tion of the organ, whereby its solid materials diminish, while the liquid or semi-fluid ones increase in proportion: and that the means of curing it are directly opposed to such as suit inflammatory affections. That we often see muscles softened to a moderate degree in a crowd of acute and chro- nic diseases, which state may be distinguished during life by feeling them, and their firmness returning in a few days afterwards, very suddenly. M. Laennec admits at the same time, that the softening of the heart is analogous to the white softening of the brain, and to the gelatinous transparent one of the mucous membrane of the stomach. J * Page 399. j Vol. ii. p. 540. ; Vol. ii. p. 541. INDURATION OF THE HEART. 273 What is still more singular in him, as a profound and expe- rienced pathologist is, his admission that bones, cartilages, and fibrous tissues generally, become soft by inflammation from the quantity of lymph deposited in them at the time; but, on the contrary, the soft tissues, in which he includes the muscles, brain, and some others; that they harden. Thus, he makes the evidence of inflammatory characters to depend upon mere consistence. This is obviously opposed to what is now known on the subject; for consistence depends ra- ther upon the peculiar texture of the part affected, and the grade of its irritation, than upon what M. Laennec would call an affection sui generis: a mode of expression which, though seemingly candid and scientific, is merely a subter- fuge for all kinds of professional prejudice and blindness. The symptoms of ramollissement of the heart are not of an exclusive kind, and are therefore common with those of other affections of the same organ. The leading ones are a pale and yellowish complexion, the skin dry and shri- velled, the lips without colour. If the affection be acute, the pulse is feeble, precipitate, and small, and there is a tendency to faintings; but if it be chronic, the pulse is feeble, soft, and languid. The impulsion of the heart is feeble, sometimes almost inappreciable, and the sound of its contractions is more dull, more obscure, and more ob- tuse than in the natural state; but they vary in their preci- pitancy, according to the disease being acute or chronic. As it is most frequently co-existent with dilatation of the ventricles, the sound becomes still less notable. Induration of the Heart or Endurcissement. The aggregate of examples of induration of the heart is so large, that this mode of its chronic irritation may be considered sufficiently common, and, like the softening of 35 274 IRRITATIONS OP THE HBAKT the same organ, it is frequently attended with a dilatation of its cavities, and also with an increase in the thickness of their parietes. Lieutaud, in his Historia Anatomico Medica, and Morgagni in his Morbid Anatomy, have introduced many cases of it taken by the first from his contemporaries and predecessors, and by Morgagni, from his personal ex- aminations of bodies; and in the present times, the cases re- ported are so abundant, that with my own private observa- tions, this anatomical lesion is quite familiar. The induration of the heart has been presented to anato* mists, in various stages, from one slightly beyond the natu- ral state, to a cartilaginous hardness, and even an ossific one partially. In the case of a female, aged fifty-five, recorded by Corvisart,* the parietes of the right auricle and ventri- cle were so much thicker than natural, and so compact, that they supported themselves without collapsing; were elastic, yielded with difficulty to pressure, and were spon- taneously reinstated upon its removal. The cavity of the left ventricle was greatly distended, and its parietes had, at least, double the natural thickness. They were supported like an arch, and formed a very elastic fleshy box, which sounded when struck, like a dice box. The muscular tex- ture of the ventricle retained its natural colour and appear- ance, and did not seem converted either into an osseous or cartilaginous substance; yet it was so indurated, that the scalpel, on cutting it, made a crepitating noise. In another case related by M. Corvisart,! the patient be- ing sixty-four years old, was taken with difficulty of breath- ing and violent suffocations, which lasting two months, in- duced him to enter the Clinical Hospital. The impulsion of the heart against the thorax was very strong, but there were no palpitations, and the pulse was small, concentrated, and irregularly intermittent. Four months after the commencement of these symp* * Op. Cit. p. 140, t Op. Cit. p. 143. INDURATION OP THE HEART. 275 toms the patient died; and was examined. The heart was much larger than natural, especially the right auricle and ventricle, and the opening between them was also dilated. The left auricle was very large, the ostium venosum dilated, and the mitral valves cartilaginous. The walls .of the left ventricle were, at least, an inch in thickness, and very firm. The apex of the heart to a certain height, and in all the thickness of its substance, was cartilaginous; the columnae carneae were also cartilaginous. It would appear from the report of M. Laennec,* that the resounding of the heart like a dice box when struck, and its hypertrophy generally go together: the induration, however, may exist, either with an increase or diminution of the cavity affected. A universal induration of the heart has not as yet been observed in many cases; more commonly it is partial, and very seldom goes beyond one half of the organ: sometimes the external, and on other occasions the internal face of it is the seat of this change; and it may prevail, partially, in one of the cavities alone. In a case reported by M. Ber- tin, there was a softening of the right ventricle; and an in- duration of the left,t and in another, some of the columnae carneae were soft and others hard. The colour sometimes is not changed at all from the na- tural standard. * Vol. ii, p. 532. * Page 404. [ 276 ] CHAPTER XVI. IRRITATIONS OF THE HEART {Continued.) Having in the preceding chapter considered the patholo- gical conditions of the pericardium and some of the altera- tions in texture of the substance itself of the heart; we shall proceed in the next place to consider other modes of lesion which affect the capacity, thickness, and texture, of its cavi- ties. Dilatations of the Heart. This malady is an enlargement of one or more of the ca- vities of this organ. In regard to mere capaciousness, it is met with to a slight degree in most old persons, especially such as have led irregular intemperate lives. In that stage it is not attended with much inconvenience, though the af- fection be permanent. It occurs also not unfrequently in young persons from the age of twelve to twenty-five; in them it is, I think, for the most part, temporary, and may be removed by reduced diet, by diminishing the quantity of blood, and refraining from violent exercise for some months. I have at least, in several cases, cured the symptoms indica- tive of it by such a course. This affection is also called aneurism of the heart, and its precise state is somewhat modified in different cases. In one form it is attended with an increased thickening in the parietes of the cayity dilated; this is the most common: in DILATATIONS OF THE HEART. 277 another the parietes are much thinner, this is rather rare; fre- quently there is no sensible alteration in the thickness of the parietes; and lastly, a very rare form, and which, perhaps, above all the others, deserves the name of aneurism is, that where there is a pouch or cul de sac projecting from the ca- vity affected, and communicating with it. As stated when speaking of the derangements in the tex- ture of the heart, this condition of it is very frequently com- plicated with induration or ramollissement, and the colour is sometimes violet, and on other occasions more pale than usual, depending upon the acuteness or chronicity of the affection. It is, I think, more frequently found in the ventricles than in the auricles, and generally both of the former are dilated at a time. It is rather unusual to see a universal dilatation of all the cavities at once, though a specimen in the anato- mical museum presented some years ago by Dr. Parrish to Dr. Wistar, is of that kind. A similar case is described by A. Burns,* where the heart cleaned from pericardium, lungs and fat, weighed two pounds, was larger than that of an ox, and all the cavities were equally dilated; but they, as well as the vessels, were of the usual thickness. The causes which give rise to dilatation of the heart are of- ten a resistance to the passing of blood through it, occasioned by some obstacle in the large vessels leading from it. This point M. Bertint says he has made out by observations ex- tremely numerous. If the obstacle be permanent, as a con- traction of the orifices of the large arteries, the dilatation itself will be permanent; but if on the contrary it be temporary, as that of a stasis of blood in the lungs, from inflammation or some particular exercise of them, then the dilatation is re- moved with the cause productive of it. I have, however, no doubt that even when there is no obstacle to the current of blood, if the heart get into a state of chronic .inflammation * Burns, Diseases of the Heart, Edin, 1809, p. 47. t Bertin, Malad. du Coeur, P- ^78, 278 IRRITATIONS OF THE HEART. in its parietes, its muscular fibres will lose their contracti- lity somewhat, and will yield to the ordinary resistance of the blood vessels, so that the cavities will become distended and enlarged. M. Laennec thinks that dilatation is more common among women than men, owing to the parietes of their ventricles being naturally thinner. Hypertrophy of the Heart. The term hypertrophy has been very generally applied to express an excessive growth or disproportionate nutrition of parts of the human body, without an obvious morbid change of texture, and the heart like other organs is subject to this condition of nutritive irritation. This state is manifested by an increase in the thickness of the parietes of the heart, and its cavities either remain sta- tionary, or they may be enlarged or diminished, for there is no rule on this point. Generally the affection is bounded to the ventricles and especially the left; the auricles but rare- ly participate in it, and are found commonly in their natural condition. M. Laennec* states, that he has in some cases seen the left ventricle at its base twelve or eighteen lines in thick- ness. This thickness, however, generally diminishes to- wards the apex of the heart, and is seldom universal in the cavity. The columnae carneae and the chordae tendineae are frequently disposed to participate in the affection. The mus- cular substance of the ventricle increases very much in the firmness of its texture, and its colour becomes of a deeper red. The cavity of the ventricle often appears to have lost in capaciousness what the parietes have gained thickness; and in some instances, where the heart was twice the size of the * Loc. Cit. vol. ii. p. 499. HYPERTROPHY OF THE HEART. 279 fist of the subject, the ventricle would scarcely lodge an almond. In extreme cases of hypertrophy the heart has been found four times the size of the fist of the subject; as the fist is generally considered equal in magnitude to a heart perfectly healthy, the heart consequently had increased four times its natural bulk. In these instances its proportionate shape is much altered and its position is transverse; generally, in the cases which I have seen, it occupied principally the left side of the thorax, and shoved backwards the left lung. Allan Burns states, that he had seen a heart which weighed seve- ral pounds and yet the cavities was not more capacious than usual.* The causes of hypertrophy are thought to bet habitual accu- mulation of blood in its cavities, either from moral or from physical influence, hence certain exercises of the organs of respiration, and their diseases give rise to it; it may, how- ever, also come of itself. When it has existed for some time, it in turn influences the condition of other organs; giving rise to apoplexy, to encephalitis, and to cerebral con- gestions and irritations generally. J In this way have fallen three illustrious men in medicine, Malpighi, Cabanis, and Ramazzini. It also disposes to bleeding from the nose. When the right ventricle is affected, pulmonary apoplexies and haemorrhages result from the additional impulsion com- municated to the blood, as it flows into the lungs. Ossifications of the Heart. Ossifications of the muscular structure of the heart are unusual. In my own sphere of observation, I have noticed but one instance of it, and that occurred in a double male foetus where there were several other abnormal arrangements * Diseases of the Heart, f Bertin, p. 349. ± Bertin, p. 351. 280 IRRITATIONS OF THE HEART. of the viscera, as most commonly happens, where two foe- tuses adhere to one another.* M. Laennec, notwithstand- ing his very numerous pathological researches says, that he never met with an instance of ossified muscular structure of the heart. The celebrated Corvisart quotes no instance coming under his personal observation. M. Bertin's expe- rience does not seem to exceed that of one or two cases, and those of a very limited extent in the ossification. As our collective experience together involves the result of many thousand cadaverous autopsies, it is clear that the instances are comparatively but few where this mode of disease occurs: not that the structure itself is incapable of it, but that the os- sification incommodes so much the functions of the heart in conducting the circulation, that life is extinguished generally in the very early stages of the disease, before it has become well marked. Cases, however, do occur from time to time. Several of them are narrated succinctly by Lieutaud,! taken from dif- ferent writers. These ossifications were, for the most part, partial, and found stuck away in the thickness of the mus- cular substance, especially of the ventricles and in their sep- tum. In some instances, from the small quantity of animal matter in them, they resembled calcareous concretions more than organized ossifications. Albertini met with a case of ossified auricle; the late Al- lan Burns saw a perfect ossification of the ventricles; Haller was called upon to see a young man immediately before death, in whom there was no pulsation of the radial arteries, though that of the carotids was very perceptible. On dis- section the heart was found of its natural size; the inferior part of the right ventricle was ossified, and the most fleshy parts of the left ventricle; also the valves of the aorta and pulmonary artery. In the journal of medicine for 1806, in * North Am. Med. and Surg. Journal, vol. ii, p. 395, * Anat. Museum for Preparation. f Lieutaud, Hist. Anat. vol. ii. p. 39. OSSIFICATIONS OP THE HEART- 281 Paris, the following highly interesting case is communicated by M. Renauldin. A student of law, of severe attention to his studies, joined to an abstemious course of living, and aged twenty-three years, experienced at last continued head- ache, frequent dyspepsia, with a respiration habitually some- what difficult. Being attacked with peripneumony, he re- covered; but afterwards, on the slightest exercise, he expe- rienced lively and frequent palpitations of the heart, and was in other respects so infirm that he was compelled to keep his bed. He at length died. On dissection, the lungs were found sound; but on attempting to cut the left ventricle, a great resistance was experienced, occasioned by the entire change of this part into a real petrifaction, which had a gra- velly appearance in certain places, and resembled in others a saline crystallization. The granuli of this species of gravel were very near one another, and became larger as they receded from the surface of the ventricle; so that internally they were continuous with the fleshy columns. The latter were also petrified, were much augmented in size, and looked like stalactites placed in different directions. The thickness of the left ventricle was also augmented. The right ventricle was sound. The large arterial trunks of the heart were also sound, but the temporal, the maxillary, and a part of the ra- dial on each side were ossified. The ossification of the heart in this case was of very unu- sual extent, and is probably narrated in too unqualified a manner; as we cannot conceive how the ventricle could pul- sate, if it were entirely changed into a petrifaction. The ac- count, however, is admitted by the French pathologists, Corvisart, Laennec, and Bertin, as correct and authentic, being quoted by them as such. Also, as the state of the left au- ricle is not alluded to, the probability is, that it at least re- tained the natural structure, and supplied in part the defi- ciency of the circulating powers arising from the vitiated state of the left ventricle. A very remarkable instance of this kind will presently be quoted from Allan Burns. 36 2S2 IRRITATIONS OF THE HEART. An inferior degree of induration, amounting to a cartila- ginous change of texture, is more common than ossification. Several instances of this kind will be found recorded by the gentlemen whose names have been so serviceable to me in the composition of this paper.* It occurs indeed not unfre- quently on the internal face or periphery of the ventricles,! especially the left, in the form of cartilaginous plates, which seem to be identical with the lining membrane, and inter- posed between it and the muscular substance of the heart. M. Kreysiz has reported a case in which he found such an incrustation ossified. J Upon a review of the several circumstances connected with ossifications of the substance of the heart, it would seem that they are to be ranged in the same line with the indurated state formerly alluded to; the commencement of the affection being hypertrophy or a nutritive irritation, the middle stage indu- ration, and the terminating one ossification, which of course must be rare as the patient inevitably perishes in a vast ma- jority of cases before this stage is reached, from the heart not being able to carry on the circulation. As every jour- ney, however long, is composed of intermediate steps, so are the disorganizations of the heart: the differences between the steps are almost imperceptible, but the two extremes are at the widest points of separation; so that it scarcely ap- pears possible for the same line of march to connect them, and yet such is the case. Bordenave reports, that he met with a person whose heart was almost completely ossified. I am not, however, in pos- session of the details of this case, having got it from Portal. § Mr. Allan Burns, from circumstances of an unaccountable kind, considering the limited opportunities of dissection in Scotland, speaks in very familiar terms of derangements in * Corvisart, p. 138, et seq. Bertin, p. 401. Laennec, yoI. ii. p. 566 ■J-Laen. vol. ii. p. 568. ■i. Laen. loc. cit. § Anat. Medicate. OSSIFICATIONS OF THE HEART. 283 the structure of the heart, which have come under his no- tice. Yet he is generally considered, by his countrymen and others, very good, and sufficiently accurate authority to be freely quoted. In one case, he says that he found the ventricles mere calcareous moulds, and in another, both of them were cartilaginous; but in only one case, has he found an auricle in any degree deranged: meaning, I presume, in a similar manner; he has never met with a single instance, in which both the auricles and the ventricles were at the same time affected.* A case reported by him is equally, if not more astonish- ing than those of Bordenave and Renauldin; and, having eve- ry evidence of accurate and cautious statement about it, goes far to prove, that the auricles have great power in sus- taining the circulation, when the ventricles are incapacitated from it by a gradual change of structure. It occurred in a poor woman aged sixty, and named Margaret Henderson, who was treated in the Glasgow Hospital for dyspnoea, anx- iety in the chest, and attacks of breathlessness, during which she became of a livid hue. She was under the continued ne- cessity of a semi-erect position, with feeble and intermittent pulse for a few days before her death, though previously it had been regular. On dissection, the pericardium was found loaded with an enormous quantity of fat, and of an opaque dusky hue, with ragged spiculae of bone projecting from its surface, and making it very irregular. It adhered closely to the parts around, and seemed incorporated with the substance of the ventricles. Over the whole extent of the la,tter it was ossi- fied; and the ventricles themselves, except about a cubic inch at the apex of the heart were ossified, and as firm as the skull, the ossified part forming a broad belt. Some of the columnae carneae were also changed into solid bone. Both auricles were healthy, but thicker than usual; and, so far a? *0p Cit p V ,'S-1 IRRITATIONS OF THE HEART. the examination of the remainder of the vascular system ex* tended, it also was healthy. The preparation was given to Dr. Munro.* Mr. Burns remarks, that the ventricle may be ossified, and may be as rigid as stone; and yet the blood may find its way into the arteries, and be fairly circulated through all the parts of the body, provided the auricle remains healthy. But as there are no valves between the auricles and the veins, a considerable quantity of blood becomes refluent on the contraction of the auricle; and thereby produces a pulsation in the neck, and an undulation in the epigastrium. In these cases, an evident provision is made for the inaction of the ventricles, by the muscular structure of the auricle, being invariably augmented, firmer and stronger. In plate 5th, of Baillie's Morbid Anatomy, is represented a heart considerably enlarged, and with an ossification, which covered from fifteen to twenty lines in breadth of the right auricle and ventricle; and extended from the inferior end of the descending cava, to the apex of the heart, being in all five inches or more in length. The original communication of the case, was by Dr. Simmons.! It radiated at each end in broad digitations, which there increased its extent very considerably. The facts now quoted, will be sufficient to illustrate the ossific tendency of the muscular structure of the heart, in its chronic irritations; and that, however, improbable it may be at first sight, yet, the circulation of the blood is consistent with an inaction of the ventricles, in consequence of the au- ricles assuming a vicarious function. Polypi of the Heart. There are two kinds of productions found in the heart, and designated by the term polypus. One is very com- * Loo. Cit. p. 128. t Medical Communications, vol. i. p. 228. POLYI"! OF THE HEART. 285 mon, especially in chronic complaints, where there is a great deficiency of red particles in the blood; and is an inorga- nized accretion of the fibrine or albuminous part of the blood, precisely such as takes place in similar cases, where blood is drawn from the arm into a cup, and is allowed to settle. This appearance, from phlebotomy in old dropsies, is often mistaken for active inflammation; and seems, indeed, to justify the use of the lancet to any extent: whereas it is in fact, only an indication of the paucity of the red globules, which are not in sufficient number to colour the fibrine, and to prevent its uniting in a homogeneous mass. Such accretions of fibrine, are found most generally in the right side of the heart, and are colourless very frequent- ly. They extend themselves into the large veins, and into the pulmonary artery, following its branches; but they have no other connexion with the heart, than that of being entangled in the columnae carneae, and in the irregularities of its inte- rior surface. Generally, their formation is subsequent to death, but there are strong reasons for believing, that they sometimes form a long time before this event. Besides many others of a subordinate but satisfactory character, there are some very prominent and conclusive. They are the extreme tenacity of these accretions, which have a firm- ness, but little less than that of muscle; a colour of various shades from a light flesh one to a violet; whereas the recent accretion is easily torn, and is of a uniform colour: then there is an evident tendency to a vascular organization of the accretion,* as in many other abnormal productions. Lastly, the fleshy columns of the heart'have been found flattened considerably by them, which could not occur after death. The second kind of polypus is absolutely attached to some part of the substance of the heart, by a continuation of struc- ture. As observations of this kind, many of which are on * Laennec, vol. ii. 595. 2S6 IRRITATIONS OF THE HEART. record, are questioned by some writers, a direct evidence on the subject will be more satisfactory than a chain of rea- soning; I therefore refer to a preparation which was for some time in my charge, and which I have repeatedly examined carefully.* This patient was twenty-six years of age, and suffered the extirpation of a scirrhous testicle the size of an ostrich egg, in the Pennsylvania Hospital, September, 1819. He died in eight months afterwards, from the scirrhous affec- tion being repeated to an enormous extent, in the lympha- tic glands of the loins; at least, this is the inference I obtain from the Drs. description, and from having seen two cases in many respects similar. Dr. Coates goes on to state, that the vena cava was dis- tended to an enormous size, and nearly filled by the polypus, which measured five inches and a half in length, and nine- tenths of an inch in thickness, tapering gradually to both ends. It adhered apparently to the anterior side of the vena cava; but when torn away, left the surface smooth. It was afterwards apparent, that the connexion was by means of processes of the same nature, extending into a number of small veins entering into the cava on that side, from the scirrhous tumour in the abdomen. The two ends of the po- lypus were firmly attached, the lower one to the bottom of a cavity with smooth edges, and which was probably the re- mains of an obliterated vein. The upper end of the poly- pus was by accident cut off before its attachment was seen, in consequence of the heart being removed; but it was af- terwards ascertained, that it adhered to the edge of the Eus- tachian valve, by a strong dense pedicle resembling the lining membrane of the auricle and vein, and three lines in diameter. The texture of the polypus was fibrinous, dense, and firm. In 1822, a girl of sixteen was admitted into the Hotel Dieu * See the Phila. Journal of Med. and Pbys. vol. iv. p. 336, for the year 1822. paper by Dr. B. H. Coate-?. POLYPI OF THE HEART. 287 of Paris, for two enormous tumours upon the right shoul- der, and in the arm pit of the same side. Having died there, she was opened. The right auricle of the heart was found filled in great part, with a soft gelatinous clot, having in its centre vesicles filled with a semi-concrete fluid; and it was traversed by an infinitude of vessels injected of a bright red or black. This polypus extended into the right ventri- cle, into the ascending and the descending vena cava, and into the right subclavian and jugular veins, and confounded itself in a measure with their parietes, which were much dilated. A man aged thirty-six years: entered into La Charite, in 1817, for symptoms of aortic aneurism, under which he died. On examination, the right cavities of the heart, besides having fresh coagula, contained shreds of a fibro- albuminous matter organized, and adhering so strongly to the parietes, that they could only be separated by lacerating them. These shreds prolonged themselves into the ascend- ing and descending cava, and almost obstructed the orifice of the pulmonary artery.* These cases ought to put the question at rest about the formation of organized, and adherent polypi in the heart. They have been found more commonly on the right side, in the right auricle; and the venae cavae; probably from the partial stasis of blood, which sometimes, perhaps fre- quently occurs there, especially in diseased lungs. The fact besides is sufficiently familiar, that in large aneurisms, the stasis of blood which occurs in them, occasions a depo- site of the coagulating lymph in concentric layers. There are indeed, but few of the large blood vessels of the body, which have not been found obstructed by such coagula. Haller* saw, in a woman of forty years, the ascending cava between the emulgent, and the iliac veins shut up by an ad- herent coagulum, and the current of blood was passed up- * Bert. p. 448. j Opus. Pathol, Observ. p= 23, 288 IRRITATIONS OF THE HEART. wards by the right spermatic vein, which was in a state of extreme dilatation. M. Laennec, has met with three cases of the ascending cava, obliterated by a coagulum adhering to it for three or four inches, in such way as to allow a very partial circulation upwards: the carotid artery has been found occupied by similar coagula;* also the aorta.! The case seems in fine to be sufficiently made out, that besides the polypi, or accretions of the fibrinous part of the blood, which follow death, similar accretions occur during life. And that many of them have been found organized in the heart, and in the large blood vessels, both arteries and veins; and adhering by a continuity of substance to the pa- rietes of these cavities; sometimes obstructing them com- pletely, and turning the current of blood into other channels. * Bertin, p. 446. Laennec, vol. ii. 591 to 592. | Am. Med. Jour. No. 5. [ 289 ] CHAPTER XVII. IRRITATIONS OF THE HEART. {Continued.) OSSIFICATIONS OF THE VALVES. The partial ossification of the valves of the heart is a very common affection in old age, and frequently presents itself also in the middle term of life. It is known to every anatomist, that the orifice of communication between the auricles and the ventricles is defined by a fibrous ring, from which the tricuspid and the mitral valves spring; and that in the case of each orifice, the muscular fibres of the cor- responding side of the heart form loops, the extremities of which, as a general rule, are attached to the fibrous ring forming the orifice. The fibrous structure of the ring is continued into that of the valve, and the loose margins of the valve are attached by a continuation of the fibrous structure, called chordae tendineae, to the projections of the muscular structure of the heart called columnae carneae. A fibrous structure also forms the orifice of the pulmo- nary and of the aortic artery, and this fibrous structure is continued measurably into the semi-lunar valves. The basis of all the valves of the heart being thus laid in fibrous structure, their mechanism is completed by their surfaces being formed by a continuation of the thin, smooth, and shining serous membrane, which lines the cavities of the heart, and of the blood vessels. This combination of fibrous and of serous structure has been denominated by 37 290 IRRITATIONS OP THE HEART. Corvisart fibro-serous, * and is supposed, from its particular character, to be the cause of the indurations and ossifica- tions, so often found in the valvular structure of the heart: the fibrous matter exhibiting the same tendency there, that it does in other parts of the system. The ossifications, however, in the heart, as in other parts of the body, which attend a pathological state, present this difference from the ossifications arising from the physiolo- gical tendencies of the body. In the latter, the precursor of bone is mucilage, and then cartilage; but in a diseased condition, the deposite of bone is not preceded in this way. It is indeed primary: the calcareous matter brought to the part by the circulation, seems to be absolved abruptly and instantly from the laws of vital affinities, and to be governed by those of mere physical chemistry; which occasions its deposite in masses, either in plates of a small size, or in grains resembling, strongly, an imperfect crystallization. The quantity of animal matter in these bony deposites, is most commonly at its minimum, and scarcely appreciable. The grit, so often found in the pineal gland, is a striking example of this; and we frequently have the ossifications of the valves of the heart quite as unalloyed. It is, there- fore, from general and well marked similitude, that such concretions are familiarly called grit, and stone. An irri- tated state of secretory surfaces gives rise to the same phe- nomenon. The calcareous matter in the secretion seems to be absolved suddenly from the laws of vitalism, and to be immediately subjected to those of crystallization; as far as this process can go on, with other matters intervening be- tween the atoms to be crystallized. The difference, how- ever, in this case is, that the concretion does not adhere to the surface which secretes it, but is washed off, perhaps, as soon as it is formed. In many cases of calcareous deposite in the heart, the * Org. Dis. of the Heart, Phil. 1812, p. 158. OSSIFICATIONS OF THE VALVES. 291 atoms arc not aggregated, but seem rather to be deposited in the interstices of the part; very much in the same physi- cal state, however, as when they are aggregated, and leaving the inference that these atoms are also deficient in that pro- portion of gelatine which usually enters into the composi- tion of bone. In several experiments which I have tried on the subject, I have been struck with the efficiency of a mucilage in preventing the precipitation, and the consequent return to a crystallized state of a strong saline solution. This will explain why the r.alcareous matter of bone, does not present itself in a sort of crystallized state; while the enamel of the teeth, which have scarcely an appreciable quantity of animal matter in them, evidently have their atoms arranged on the plan of crystals. Under these con- siderations, the question very naturally arises, whether fibrous membranes in a state of irritation have not a dispo- sition to secrete calcareous matter to the exclusion of gela- tinous? and whether it is not owing to this trait, that calca- reous concretions almost pure, are more common on them than in other parts of the body. The most frequent situations of these ossifications of the fibrous structure of the heart are, the mitral valve between the left auricle and left ventricle; and the semi-lunar valves at the orifice of the aorta. Ossifications, though sometimes witnessed on the tricuspid valve, and on the semi-lunars of the pulmonary artery, are yet rather uncommon, and co- exist generally with an unnatural communication between the right and the left sides of the heart,* from which M. Bertin has drawn the inference, that the arterial blood has much to do in the production of them by its irritating in- fluence. Unusual, indeed, as pathological changes are there, the cartilaginous induration is more common than the os- seous. Ossifications of the semi-lunar valves of the pulmo- nary artery, and of the tricuspid valves, have been seen by * Ber:. p. 21". 292 IRRITATIONS OF THE HEART. Morgagni, by Corvisart, Bertin, Laennec, Burns, and se- veral others; so that there ought to be no doubt of their oc- casional occurrence, though they are almost incomparably more rare than those of the left side. This infrequency of ossified valves on the right side of the heart, induced Bichat to deny its occurrence there on any occasion. For a summary of some such observations, of a very inte- resting kind, M. Laennec may be consulted with advantage.* The anatomical characters of valvular ossifications are as follow: When the valves are entirely affected, they fre- quently are enlarged so much as to form a sort of irregular pad around the orifice to which they belong, and at the same time the orifice is diminished in its diameter; sometimes, indeed, reduced to a few lines. The ossification is origi- nally formed in the thickness of the valve, and it, for some time, will be smoothly covered by it; but in the progress of its growth, the asperities of the ossification pierce the valve, and are then exposed naked to the current of blood. The valve in this state is sometimes so ragged, that it looks at a little distance like an irregular jagged ulceration, and when felt, is rough and hard to the hand, strongly resembling small fragments of stone in the multitude of its asperities. The most usual form in which we see ossifications of the aortic valves is in small graniform masses in greater or less number, and placed at their base; or in their edges, especial- ly where the corpuscles of Arantius are. I have in several instances seen an ossification about the size of a grain of wheat in the angle between two adjoining valves, and ad- hering to their margins, in such way as to prevent their accurate closure, on the re-action of the artery. It is not uncommon to see the osseous induration extending all along the base of the semi-lunar valves, and thus forming an almost continued circle: the removal of which, would Vol. ii. p. 67 ' OSSIFICATIONS OF THE VALVES. 293 be attended by that of the valves from the identity and close connexion of the two. Where these several mechanical conditions of ossification have increased much in size, the valves become permanent- ly and rigidly fixed in their positions, and are not changed from them except very inconsiderably; certainly not enough to check the reflux of the blood from the aorta, while the latter is re-acting on its contents. Even small ossifications will present the rigid closure of the valves, and produce some derangement in the circulation, as was found to be the case with the late Dr. Wistar, where there was an ossifica- tion at the junction of two valves. The progress of ossifi- cations of the semi-lunar valves, is sometimes such, that it leaves only a small orifice for the passage of the blood. Morgagni saw in a girl of sixteen, who had been sick from birth, the valves of the pulmonary artery so ossified, swollen, and united, that there was scarcely space enough to admit a small bean. Corvisart has often seen constrictions from this cause of the large arterial orifices, and I have myself, not unfrequently met with them. He relates* a case, an abridg- ment of which deserves being introduced at this place. A washerwoman, aged 73, was put under his charge in 1803. Six years before that, she had while walking, experienced such difficulty in breathing, and palpitations of the heart, that she was obliged to stop short. The frequent renewal of these symptoms, with oedema of the legs, and irregular pulse, compelled her to seek refuge in the Hospital, at the time stated. She had been there but thirteen days, when she died, apparently suffocated. On examination after death, her heart was found not much larger than usual, and there was half a pound of serum in the pericardium. The left ventricle was so hard and elastic, that it retained permanently, a nearly cylindrical shape. The mitral valve, along with the corresponding ostium ve- " Page 172. 294 IRRITATIONS OF THE HEART. nosum, were ossified at several points. The semi-lunar valves of the aorta were indurated, ossified, and thickened in such a manner, by the calcareous deposite between their laminae, that they were fixed in their state of depression; and their loose edges approached so as to come in contact, and block up the aperture of the vessel. The current of blood would thus have been completely obstructed, had not one of the valves still retained merely enough flexibility at its base, to permit an opening of only one or two lines, for the blood to pass through. In regard to the valves placed between the auricles and the ventricles, their induration is found also in all the stages and states, from a cartilaginous to an osseous condition. The cartilaginous state is sometimes confined to the chordae ten- dineae, and to the fibrous ring at the base of the valve; and presents the appearance of a smooth, but unequal circular pad, which constricts the ostium venosum. On other occa- sions this cartilaginous, or fibro-cartilaginous change is found along the margins of the mitral, and tricuspid valve, and diffused through their thickness. In its texture it resembles strongly the semi-lunar cartilages of the knee joint. The osseous induration of the mitral, and tricuspid valves is varied in its position and mechanical shape, in the same way with the cartilaginous; and like it is formed primitively, between the two laminae of the valves. It is, however, dis- posed to much greater inequalities of thickness: and not un- frequently its rough points are denuded, and so ragged, that they look like a caries. In ossifications of the edges of the mi- tral valve, their jagged edges are sometimes found adherent; and indeed blended together to such an extent, that the ori- fice between the auricle and ventricle, is converted into a sort of narrow canal or slit, into which a large quill cannot be easily introduced. [ 295 ] Vegetations of the Heart. These are wart-like productions, from the lining membrane of the heart, which are observed to grow from all its valves, and from the auricles, particularly the left. They are met with much more frequently on the semi-lunar valves of the aorta, than elsewhere. These productions, by their number and the size to which they grow, sometimes form a serious ob- struction to the circulation of the blood. They strongly resemble common warts, especially such as arise from a venereal cause on the organs of generation, and in their vicinity. It was from this resemblance, that M. Corvisart, took up the notion of their venereal origin, and suggested the advantage, when their diagnostics could be established, of instituting an atisyphilitic course of treat- ment. I may merely state, that this idea has not been adopted; and, that they are not supposed by the pathologists of the present day, to be caused by syphilis. Their colour is commonly of a yellowish white with a tinge of red; and their size varies from that of a millet seed to a pea. Their surface is not unfrequently rough, so that it resembles a strawberry, from the multitude of little tuberosities upon it; and sometimes they are elongated into cylinders. They exist in greater or less numbers in different subjects, and are sometimes so abundant as to give a granular appearance to the valve, or surface which they cover. Their texture resembles very closely, that of the polypi of the heart; consequently some of them have about the con- sistence of coagulated lymph, while others are much more firm. They frequently contain in their centre a dark spot, as if produced from blood, and sometimes a clot of blood is actually found there. They adhere with considerable tena- city to the lining membrane of the heart, wherever they arise, and seem to be continuous and identified with it: when soft, 296 IRRITATIONS OF THE HEART. they may be scraped off with the handle of the scalpel; but when hard they require cutting to be removed. These vegetations, or warty excrescences from the lining membrane of the heart, have been variously accounted for, M. Laennec* says, that they arise from an irregularity in the motion of the blood; and being formed out of precipi- tated coagulating lymph, they become organized by a pro- cess of absorption, and of nutrition, analagous to that which occurs in false membranes. On this point, M. Bertin! re- < marks, that he has no doubt of such being the case some- times; but he also thinks, that they may come originally from inflammation, followed by an albuminous secretion from the lining membrane. This is indeed rendered the more probable, from serous membranes when inflamed pre- senting the same kind of albuminous granulations. More- over, as the inflammation of the left cavities of the heart, and of the aorta is more common than that of the right ca- vities, and of the pulmonary artery, we are led to the infe- rence, that as these vegetations are found more frequently in the former, so they are the result of inflammation in a ma- jority of cases. My own experience on the subject, is too limited to permit me to decide, which of these authorities ought to prevail. I have no doubt, that they are both right in regard to particular cases. There are other species of vegetations found within the heart, and called by M. Laennec globular, from their shape. I imagine that they are very rare, as I have never met with them; yet as they constitute one of the interesting patholo- gical conditions of the heart, it will be proper to say a word or two concerning them. They are of a spheroidal or oval shape, and vary in size from a pea to a pigeon's egg. Their exterior surface is even, smooth, and of a yellowish white; they contain sometimes matter resembling half fluid blood, on other occasions pure blood, or that kind of fibrinous sub- * Laennec, vol. ii. p, 620. f Bertin, p. 219. RUPTURE OF THE HEART. 297 stance which occupies old aneurismal sacs, they have also been found with a sort of puriform matter in them. These globular productions are found most usually at the inferior part of the ventricles near their apex, and in the sinus of the auricles; and they invariably adhere to the pa- rietes of these cavities. Their adherence is accomplished by means of a pedicle of a very irregular form, which is in- terlaced with the columnae carneae, and may sometimes be detached from them without rupture. It is very difficult to account for the mode of their forma- tion: it would seem almost as if the matter in them was of an irritating quality to the lining membrane of the heart, and that the latter took on a secretion of lymph for the purpose of enclosing it in a cyst, so as to render it harmless. M. Laennec states, that the first time he ever met with it, he was reminded of a singular case reported by a fellow student of his as follows: A girl in a moment of violent grief swallowed an ounce of arsenic, but escaped very unexpectedly from its effects. The following year, being in a similar state of mind, she took arsenic again, but was not so fortunate in escaping. On examining her body, after death, the effects of the recent dose were obvious on the stomach; and besides them a cyst was found, which seemed just detached from the vicinity of the pylorus, where the traces of its adhesion were still per- ceptible. This cyst contained an ounce of arsenic crystal- lized, and had the consistence of an ancient false membrane. It was supposed to have been formed around the arsenic by the sudden inflammation which followed the first dose, and that the patient owed the preservation of her life to its en- veloping the poison. Rupture of the Heart. This is rather an unusual affection, but it every now and then happens in consequence of a violent effort; of a fit of anger, and other strong emotions. Dr. Physick informed 298 IRRITATIONS OP THE HEART. me that he knew a man of seventy, who, having married a young girl; the night of the wedding he died suddenly in bed, and on examination it was ascertained to have proceeded from a rupture of the heart. Many cases of ruptured heart have been found connected with its previous ulceration at the spot; hence some anatomists are disposed to think that ulceration is its most common cause. Rupture has also been found to arise from aneurisms, from softening of the heart, and from blows on the chest. It also occurs where the parietes of the heart have been thinned by an excessive dilatation. In the winter of 1821-22, a gentleman aged about forty, by profession a lawyer, in passing through his kitchen stopped to say a word to the cook. He drew a sigh and fell down dead. On examination, a small triangular laceration was found in the front of the right ventricle, through which the blood had escaped. The part was shown to me after- wards by the late Dr. Lawrence: but, on the death of the latter, the preparation was by some means lost. The large blood vessels of the heart are also subject to rupture within the cavity of the pericardium. M. Portal has seen a rupture of the descending cava at its junction with the right auricle, in a young woman who died suddenly in a cold bath. I have narrated in chapter 10th, in consequence of its con- nexion with the history of the natural colour of the gastric mucous membrane, an interesting case of rupture of the aorta occurring under my own observation. To this the reader is referred again for an account of the change of structure in the part, and of the appearances generally on dissection. If we consider the natural thinness of the auricles between the musculi pectinati, and that of the right ventricle in cer- tain spots where there is a large quantity of fat covering the heart, it seems rather remarkable that rupture of the heart is so uncommon an accident. This, however, is not only the case, but the right ventricle is not so often ruptured as the left; neither are the auricles so often ruptured as the ven- tricles. [ 299 ] CHAPTER XVIII. DISSECTIONS, ILLUSTRATING THE PATHOLOGY OF THE THORAX. Croup. The following dissection exhibited, with remarkable dis- tinctness, the state of the respiratory organs in this affec- tion. The history of it, . s communicated by Dr. Jackson, the attending physician,* is as follows: E. M. a healthy, robust infant, aged one year, was seized, Feb. 1st. 1829, with catarrh and inflammation of the tonsils. Emetics and purgatives were administered; they operated favourably, and an apparent amendment ensued. On the 5th, the res- piration became stridulous and laboured—venesection with the warm bath ad deliquium was practised, which again produced an abatement of the symptoms. On the morn- inn of the 7th, Dr. Jackson was called into consultation on the case: the respiration was then exceedingly laboured; accompanied with the peculiar sound of croup; stridulous, dry, and unattended with any mucous rattle; cough dry. The tonsils were enlarged, a small ulcer on each; the fauces were red, but had no appearance of membranous exuda- tion, as is often seen in cases of croup commencing in cy- nanche tonsillaris. Sixty leeches were applied to the throat, and a warm bath administered, with three grains of calomel every half hour—after the leeches, a blister to the throat. No im- Ymer. Jour. No. 8. August, 1829. 300 PATHOLOGY OP THE thorax. provement was manifested. In the evening, twenty drops of hive -syrup every hour were added to the former treat- ment, and calomel, one grain every hour. At the same time muriatic acid was applied to the fauces by means of a brush, as recommended by Bretonneau; in the belief, that, although no exudation was discernible in the fauces, it existed in the larynx, and blocked up the glottis, into which the air was introduced with great difficulty. 8th.—Some improvement—mucous secretion established in fauces and trachea, the respiration easier and less stridu- lous. Mucous ronchus, or rattle, throughout both lungs; thorax resonant; pulse frequent; cheeks flushed. Blister directed to each side of the thorax—calomel, with hive sy- rup continued. A secretion of viscid mucus in fauces, copious during the day—and was removed by swabbing— bowels opened several times during the day; discharges dark green—pediluvium at night, with poultices to legs. During the day, infant more animated and lively. 9th.—Became much worse in the night: in exploring the chest, the mucous ronchus or rattle, that existed the pre- vious day, had disappeared, and no respiratory murmur was distinguishable, yet the chest was resonant on percussion— respiration exceedingly laboured, and requiring strong mus- cular exertion—continued to grow worse, and expired suf- focated towards noon." Autopsy, February 9th, twenty-four hours after death.—Present Dr. Jackson; weather cold, and no visible putrefaction. On opening the thorax, the lungs did not collapse, though there was no unnatural adhesion. Interlo- bular emphysema existed throughout the lungs, which was manifested by bubbles of air collected on their surface in clusters, and in strings or chaplets following the division of their lobuli. One of these strings traversed completely the circumference next to the ribs, of the left inferior lobe. There was also a considerable emphysema around the root of both lungs. Throughout the inferior lobe of each lung CROUP. 301 there was a high sanguineous congestion, such as exists in the acute stage of peripneumony, and which gave a solidi- dity approaching to the sanguineous hepatization. This congestion was of a greater intensity at and about the root of the lungs. The remaining lobes were of a light spongy texture, and, except for their emphysematous state, seemed sufficiently fit to carry on respiration. The emphysema had passed into the anterior and supe- rior mediastinum behind the sternum, and thence below the fascia profunda cervicis, into the root of the neck, up the trachea to the larynx. Having taken out together all the respiratory organs, and laid open the trachea and bronchia, there was found a perfect and entire lining of coagulating lymph, extending from the superior margin of the glottis, through the larynx, trachea, and bronchia, into the lungs. This membrane be- came thicker and thicker in its progress downwards; and could be traced satisfactorily into the secondary branches of the bronchia. It adhered with tenacity to the larynx, and upper half of the trachea; but not so much so as to prevent its being pulled off in a state perfectly distinct. In the lower part of the trachea, and in the bronchia, the mem- brane was so loose, that it separated with the greatest faci- lity, but retained perfectly its tubular shape. The mucous membrane of the larynx, trachea, and bron- chia, beneath this lining, was highly injected with blood, and inflamed, presenting an appearance rather rougher than common. In the bronchia it was of a scarlet colour, which increased in intensity the farther the bronchia penetrated into the lungs, until their ramifications became so small, as to prevent their being satisfactorily traced. The augmen- tation of colour was very abrupt, beyond the terminations of the lining membrane of lymph. The ramifications of the bronchia contained a sero-purulent fluid mixed with air. For an illustration of this case, see Plate IV. 302 PATHOLOGY OF THE THORAX. Ulceration of Epiglottis Cartilage, and of the margins of Glottis; Disseminated Tubercle, and Emphysema of Lungs; Scirrhous Liver. A gentleman, aged about fifty, rather free in the use of alcoholic drinks, supposed to take about a pint daily in com- mon, has had for some time symptoms of dyspepsia, attend- ed with borborygmus, &c; a short time before death, his bowels became very irritable. The circumstances, howe- ver, which seemed to lead immediately to death, were in- anition, and extreme marasmus, arising from an inability to swallow any thing without great difficulty, and extreme pain, and a disposition of the pharynx to return the food to the mouth. He was also troubled with excessive and in- cessant coughing, and expectorated a reddish mucus, having a fleshy appearance. He had no night sweats, no hectic fe- ver, no pain about the thorax, excepting a continued one which seemed to be at the root of the neck just above the clavicles. There was nothing unusual in his respiration, or in the sonoriety of his thorax when struck. The autopsy was made, November 30th, 1828, about thir- ty-six hours after death, along with his physician, Dr. S. Jackson. Exterior aspect.—General pallidness, and extreme ma- rasmus, with some putrefaction about the abdominal muscles. Neck.—Pharynx and oesophagus healthy, the epiglottis cartilage was removed by ulceration down to a level almost with the root of the tongue; its ulcerated edge was bare, and the mucous membrane in a ragged state, having separated a little from the ulcerated edge of the cartilage. From the epiglottis, an ulceration, of the doubling forming the upper margin of the glottis, extended on each side to the arytenoid cartilages. The rima glottidis was larger than usual, and the blood vessels about the glottis and root of the tongue seemed to be in a state of chronic congestion. ULCERATION OF EPIGLOTTIS. 303 Thorax.—The heart of common size; the tricuspid, the mitral, and the aortic valves had undergone a partial carti- laginous degeneration; the two last more than the first. Aqua pericardii about one ounce; white concretions of lymph in the right cavities of the heart. Lungs presented disseminated tubercles throughout: the intervening pulmonary structure being still respirable. In the summit of the right lung were some small pulmonary excavations, from eight to twelve lines in diameter, and there was a pleuritic adhesion at the same place. Lungs were also congested and heavy. At their lower edges there was a well-marked interlobular emphysema; there were no tubercles there. Abdomen.—Liver diminished one-half in size, of a light yellow colour, and looking as if each of its acini had under- gone a tuberculous change. The gall bladder filled with a thick ropy mucus coloured deeply by bile. The mucous coat of the stomach had the light slaty tinge indicative of its chronic phlegmasia, but no unusual vascular appearances. The small intestines, especially the ileum, presented several chronic ulcers of various sizes; some of which had almost perforated it. The large intestine sound. Other viscera of abdomen not obviously altered. Head not examined. Peripneumony, with Tubercles and Emphysema of the Lungs. A black man, aged about thirty, had suffered during the winter with violent cough, of five months' duration.- He died suddenly with symptoms of difficult breathing, which lasted only a day or two. I examined him on the 13th of May, 1829, along with Dr. Togno, his physician. The thorax, before it was opened, gave out a heavy, fleshy sound on the right side and beneath the sternum. There was not much emaciation, the muscular system being well developed. 301 PATHOLOGY OF THE THORAX. The abdominal viscera were universally sound; the sto- mach on its mucous coat was of a light pink colour. Thorax.—The right lung presented universal but old pleuritic adhesions. Its'substance was red, carnified, or nearly solid, and irrespirable. It presented, when cut into, some small cysts of puriform matter and many small tu- bercles in the first or semi-transparent state about the size of a pin's head. The volume of this lung was diminished one-third in its size. The left lung did not collapse on open- ing the chest; much of its vesicular structure was solidified and red, with the same sort of transparent tubercles diffused through it. The emphysema of the lung was very conspi- cuous on this side of the thorax, and was manifested by very small globules of air covering its surface under the pleura, and which could not be made to disappear upon pressure. It is probable that this emphysema produced the sudden death. The heart was more than a half larger than common, in all its cavities; and the left ventricle was in a state of hyper- trophy. The substance of the heart was whitish and hard; its cavities not being disposed to collapse. It had that sort of induration of structure, which is the frequent attendant of its chronic irritations. There was a white patch of ten or twelve lines in diameter, on its front surface. The right auricle and the two ventricles were filled to dis- tention with a white, firm coagulum of fibrine; which was interwoven with their irregularities, and extended for a foot or more into the contiguous large vessels, to wit, the venae cavae, the pulmonary artery, and the aorta. Chronic Catarrh, and healed Tubercles. November 4th, 1827. Magdalen Asylum. Examined for Dr. Meigs.—A man about fifty years old, who had served as waiter and guardian there. His case had not been re- * CHRONIC CATARRH, AND HEALED TUBERCLES. 305 gularly attended to, so that the symptoms were not much known; except the principal one, that of his having suffered from catarrh for many years. I found the lung on the left side healthy in its structure, but with very extensive adhe- sions to the thorax; which gave it, on percussion, a sort of semi-obtuse sound. On the right, the periphery of the pleu- ra was sound; but the lung was tumefied in its centre, with a few small tubercles in it, not evolved: and at the apex of the same lung there was a cicatrization, such as is represent- ed by Laennec. At the bottom of the cicatrization was a knot six or eight lines in diameter, which seemed to be the remains of an old tuberculous mass, or of a pulmonary ca- vity. The preparation is in the Anatomical Museum. Phthisis Pulmonalis. Mr. S. has been under the treatment of Dr. Isaac Hays for the last two months, for pulmonary consumption. He had no cough, no expectoration, no pain in the breast, the leading symptoms have been progressive emaciation, reach- ing at last to an extreme point, and most profuse perspira- tions at night. So far from diarrhea, his bowels have been constipated. Examined February 1st, 1828, twenty hours after death: present, Drs. Hays and Samuel Jackson. Thorax.—Lungs adhering universally on both sides, so that we had to tear them off from thorax; pleura pulmona- lis, and costalis identified by the adhesion, so that the pleura costalis was stripped from the ribs, on raising the lungs to examine them. Lungs hard, inelastic, and literally filled with crude tubercles, from one to three or four lines dia- meter: some few of them had begun to soften, and they were, for the most part, distinct from one another. A very small quantity of permeable, respirable lung was found at the under part of the inferior lobe of each lung; but so lit- tle, that it was a matter of surprise, that he could have lived to such a stage of disease. 39 306 PATHOLOGY OP THE THORAX. Heart of healthy size and structure. Surface had on it at the apex, a white patch of nine lines in diameter, somewhat fungous; and there was another white patch, oblong, but not fungous, on the right auricle. A white, or drab coloured coagulum in right auricle, extending into venae cavae, a si- milar one in right ventricle, passing into pulmonary artery, and following its ramifications. Abdomen.—Peritoneum healthy, stomach contained one quart of gas. Mucous coat smeared with mucus, and of a light pink tint; some large veins in the cellular coat in patches. Thickness of mucous coat normal, and its con- sistence was also normal at the small curvature, but some- what softened at large. At cul de sac it was so soft, that it could be scraped away with the finger. Small intestines healthy. Large intestines; coats atte- nuated: mucous coat so soft, that it could be removed by scraping with the back of the scissors. Small ulcerations, with elevated, ragged, injected margins, and white unequal bottoms, reaching -to the cellular coat, surrounded the loose edges of the ileo colic valve. No ulceration elsewhere. Vascular injection in the region of the ileo colic valve. Else- where the large intestine was semi-transparent, and of a light pearl colour. Liver healthy. Phthisis Pulmonalis. Mr. G., aged about fifty years. External Appearance.—Marasmus to the last degree, thorax long, narrow, intercostal spaces sunk in, pectoral muscles drawn into axilla, muscles shining through skin. Abdomen drawn in towards spine. Thorax.—Heart of common size, right auricle filled with blood, more than half of which was a transparent yellow fibrine, extending into the right ventricle, and looking as if it had been formed some time before death. Ossifications of small size about the root of the aorta, and semi-lunar valves. A polypus, seven or eight inches long, half an inch in dia- PHTHISIS PULMONALIS. 307 meter, transparent and yellow like the preceding, was drawn from the aorta, and was found with branches corresponding with those from the arch of the aorta. About half an ounce of yellow transparent serum in pericardium; no inflamma- tion of latter. Lungs.—Old strong adhesion, universally connecting the periphery of lungs on each side of thorax to the pleura cos- talis. Many dry tubercles in each lung, from a line or two to eight or ten in diameter, several empty pulmonary exca- vations from dissolved tubercles on each side. The lower portions of the lungs did not contain so many tubercles and excavations as upper; but still they were numerous. Abdomen.—Peritoneum healthy generally. Stomach.—Mucous coat somewhat thicker than usual, and looking as if it had suffered very generally from old phlogosis, a patch near pylorus, about three inches diameter, where the vascularity was very considerable. Small intestine. Duodenum healthy. Jejunum and ileum abounding in large ulcers of mucous coat, which went around the circuit of the gut, and were from twelve to eigh- teen lines wide. On the peritoneal surface, corresponding * with these ulcers, there had been a secretion of recent coagu- lating lymph; as if to wall up, and to repair the cavity of the intestine. Where these ulcers on the different folds of the intestine were contiguous, the intestines adhered to one ano- ther by the coagulating lymph. Large intestine. The beginning of colon on internal face covered for some five or six inches by ulcerations, also the adjoining part of ileum, the remainder of large intestine healthy. Mesenteric glands much enlarged. Other viscera of abdo- men healthy. Mr. G. had a pleurisy twenty years previously. His health had been declining for the last two years. His symptoms were principally pain in the abdomen, but no diarrhea. He had a slight cough, and not much expectoration. The head was not examined. L 308 ] Phthisis Pulmonalis in an Infant aged three months. An infant son of S. G., aged three months, about three weeks ago was seized with catarrhal symptoms, manifested by frequent cough, distressed respiration, quick frequent pulse, fever. There was no disposition to perspiration at any time during its malady. It was treated by low diet, repeated bleeding, leeching to the thorax, a blister, purging, and dia- phoretics. Autopsy, Dec. 16, 1827, assisted by the attending physi- cian Dr. Shoemaker. External Appearance—By no means emaciated. Thorax.—The sub-cutaneous cellular adipose substance over the left pectoralis major, had a common phlegmonous cavity of about one drachm in capaciousness; supposed to have arisen from the blister. The greater part of the pus had been discharged by an ulceration of the skin. No well marked secretion of lymph bounded the abscess; the fat contiguous to it was like adipocere, and the little granules of it were separated from one another. The pleurae were per- fectly sound and contained no serum. The lungs were packed throughout their whole substance with crude tuber- cles, which had pushed the air cells aside: some of the tuber- cles were insulated, and other in clusters; the single tuber- cles were from a quarter of a line to three lines broad, and the clusters were of various sizes none of them exceeding in extent three or four lines. These tubercles were interspersed through the lung so as to resemble a plum-pudding, and to leave but small interstices between them for the air vesicles. The lungs were rendered so hard by the abundance of the tubercles, that they collapsed but very little when the thorax was opened. None of the tubercles were in a state of sup- puration; but, by pressing the lung, a purulent matter or mu- cus could be squeezed to the surface in small quantities. No inflammation of lining membrane of trachea, glands about PHTHISIS PULMONALIS. 309 the bifurcation of the latter hard, tuberculous, and considera- bly enlarged. Heart.—Pericardium contained ^ij, of light coloured transparent serum, but had no sign of inflammation. Heart healthy; right auricle filled with a coagulum of red blood. Foramen ovale admitted at upper margin a common probe. Abdomen.—Peritoneum healthy. The liver of a light yellow, gall bladder contained a thick tar coloured mucus with bile. Stomach and intestines entirely healthy: there seemed to be scarcely any red blood about them; for inside and out they were almost white, or at least of the lightest sienna ground. There was not the slightest tendency to ul- ceration in the mucous coat of the small intestines, or mark of irritation; neither were the mesenteric glands in any way enlarged. Head and spine not examined. Phthisis Pulmonalis. Mrs. R., aged forty, has for several years been subject, during the winter, to inflammation of the thorax, which kept her in a delicate, emaciated state. This winter she has had repeated haemorrhages from the lungs, marked by the usual symptoms; and a short time before she died, she lost much blood from piles, which inflamed and ulcerated. February 9th, 1829, I examined her in the presence of her attending physicians, Drs. James and J. Randolph. Thorax.—The left pleura contained a pint and a half of turbid serum; of a dark colour, as if tinged with blood, and slightly inspissated with pus: the pleura itself was heal- thy, excepting several specks of Ecchymosed blood under it, both on the thorax and lung; it was also rather opaque: left lung healthy. Right lung had an old peripheral adhesion all around it. It was generally sound and healthy, but a space of the under lobe four inches square, had a puruloid infiltration into its substance, mixed with small tubercular excavations, and with the natural air vesicles. 310 PATHOLOGY OF THE THORAX. Heart.—Healthy in texture and size; but the parietes of the ventricles were reduced to one third of the usual thick- ness. Abdomen.—Viscera sound, no ulceration in intestines. The internal coat of the stomach had not the villous ap- pearance which is usual, but rather a smooth, white, porcelain- like condition, interspersed with veins containing black blood. She had not, it appears, been incommoded by gastric symptoms. In the omentum majus, and along the great curvature of the stomach, under the peritoneum, were several spots a few lines in diameter, of ecchymosed blood, which with the ecchymosis under the pleura, showed the disposition of the haemorrhagic irritation of the mucous membrane of the lungs, to be repeated elsewhere. She was four months gone in pregnancy. Pleuritis, and Meningitis from Measles. An infant daughter, aged fourteen months, of Mr. F. was seized, six weeks ago, with measles, in a mild form, from which she seemed to have almost recovered. A fortnight ago, severe catarrhal symptoms came on, followed, after a few days, with strabismus; but no delirium or local heat of unusual degree about the head. The heat of the skin, gene- rally, was very great. During the progress of the disease, the child was bled, and was also leeched on the temples. Head.—Dura mater adhered with great tenacity to the bones,.as is common at this period of life. The arachnoid membrane over the whole circumference of the encephalon, was of a yellowish purulent colour, from the deposite be- neath it of a matter which seemed to be pus, serum, and coagulable lymph mixed; and which had, therefore, a gela- tinous consistence. Upon separating the convolutions of the brain, the same kind of matter was found extending to the very bottom of them all, and in some places forming PLEURITIS AND MENINGITIS FROM MEASLES. 311 purulent foci, between the contiguous surfaces of the pia ma- ter. This observation would seem to prove, that the affection was of the pia mater; and that the secretion occurred from its surface which is most free, to wit, the one next the arach- noidea. If it had been an affection of the arachnoidea, we sliould scarcely have seen the secretion of pus penetrating to the bottom of the convolutions of the cerebrum; but it would be on the free surface of the tunica arachnoidea, from a principle common to inflamed membranes, to wit, that of secreting their morbid productions from the free surface. The brain was in a soft mushy state, and had many vas- cular points about it, giving the appearance of congestion. There was a drachm of turbid serum in each ventricle; un- der the posterior part of the velum interpositum there was the same sort of sero-purulent effusion just alluded to. Thorax.—Lungs white like those of a veal, and did not collapse much on opening the thorax. Some slight accu- mulation of blood about their roots; but the structure was soft, spongy throughout, and by no means hepatized. No serum in either pleura. The right pleura presented a recent and easily lacerable adhesion of its posterior part, between the lung and chest. The pleura costalis universally on that side had been highly inflamed, and was completely imbued with red blood which had been extravasated into its texture. Some of the patches of blood were a complete ecchymosis of ten or twelve lines in diameter running into one another. In the posterior inferior part of the pleura, a layer of recent coagu- lable lymph, four or five lines thick, and from two to three inches broad existed, adhering by one surface to the lung, and by the other to the pleura, and having a vascular com- munication with both, at least, so the specks and points of blood on its surface led me to infer. The heart was healthy. . The viscera of the abdomen were very pallid, and the hollow ones semi-transparent. The mucous coat of the sto- 312 PATHOLOGY OF THE THORAX. mach and large intestines could be scraped off very easily with the thumb nail, or the handle of a scalpel. The mu- ciparous glands were not visible. The liver was of a dull yellow colour. Abdominal viscera in other respects healthy. Pleuritis, Peripneumonia, and Pericarditis. H. E., aged twenty-two months, was taken with cough and hoarseness on the 26th of January, 1826. His mother sup- posed it to be croup, and administered antimonial wine so as to vomit him six or seven times. I was called in a day or two afterwards. His symptoms were then hoarseness, occa- sional cough, laborious and hurried respiration attended with an unusual elevation of the thorax during inspiration; pulse frequent, small, and not strong; not much heat of skin. Be- tween this period and his death, which occurred Feb. 2nd, he was treated with frequent cathartics, with expectorants, and with diaphoretics. He was blistered largely on the breast, and had spirits of turpentine rubbed upon the parietes of the thorax. A close examination of him three times a day did not, on any occasion, indicate the necessity of bleed- ing. Autopsy.—Left lung hepatized throughout by inflamma- tion; pleura of the same side had on its costal circumfe- rence a coat of coagulating lymph, one and a half lines thick. Right lung healthy in its structure, a coat of coagulable lymph on the pleura costalis opposite to this lung. The pericardium contained half an ounce of serum, and had suffered universally with recent pericarditis, which showed itself in a general lining of coagulating lymph. Brain somewhat congested; slight watery effusion under tunica arachnoidea of upper surface of hemispheres. No water in ventricles beyond what might be accounted for from infiltration after death. [313 ] Pleuritis and Carditis. In the dissection of a mulatto boy aged fifteen, I found the pleura costalis on the leftside adhering universally to the pleura pulmonalis by a recent layer of lymph; which, by the infiltration of serum into it, was reduced to a yellow, thin, gelatinous mass four lines in thickness, and resembling drop- sical cellular substance. The pleura on the right had also been inflamed, but the adhesions were trifling, and it contained about twenty ounces or more of a yellowish transparent serum. The texture of the lungs was sound. The heart was en- larged at least one half beyond its common size, in the case of each cavity, and had a hard elastic condition, such as oc- curs to it, when there has been an inflammation in its sub- stance. The pericardium was sound. Hydrothorax. In the dissection of a male subject aged fifty, Dec. 1824, the following condition of the viscera existed: Three quarts of water in left pleura; left lung collapsed. Pleura costalis and diaphragmalis studded over and coated with coagulable lymph. The right pleura contained eight ounces of water; the pericardium three ounces, but there were no signs of coagulable lymph in it. The abdomen contained one quart of water with a small quantity of pus. Intestines and stomach anasarcous, a few shreds of lymph on intestines. Lower and upper extremi- ties very much distended with anasarca, left lower extremi- ty much more so than the other. Ventricles of brain contained three drachms of serum. Albumen in considerable quantity, detected by heat in the serum of the pleura, pericardium, and abdomen. Little or none in extremities, or in that of brain. Much in urine. 40 314 PATHOLOGY OF THE THORAX, Hypertrophy and Enlargement of Heart, followed by Sudden Death from Agitation of Mind. A shoemaker aged about fifty, complained for two or three years of pain in the left breast from time to time, when over fatigued or exposed. Retaining his flesh, he was considered by his friends as hypochondriac. In the afternoon of March 22nd, 1823, he took a walk, and, on his return was informed of his having lost by theft, a pair of boots and a pair of shoes. He was much agitated at the news; in a little time com- plained of feeling unwell; requested to be conducted to his bed, and in ten or twelve minutes afterwards died. Dr. Huston having been called in at the moment of his illness, administered some sp. corn. cerv. to him with no ef- fect. Autopsy forty hours after death.—By squeezing on the chest, a considerable quantity of frothy mucus, amount- ing to several ounces, was discharged from his mouth by Dr. H. some time previous to the examination. Exterior Aspect.—Perfect rigidity of limbs, settling of much blood on the back of the neck, and about upper parts of chest. Lips blue and congested. Respiratory Apparatus.—Sound of thorax somewhat ob- tuse to percussion, on left side near middle. Lungs of a deep bluish or modena from the great congestion of blood in them; collapsed only inconsiderably on opening of thorax; trachea, bronchia, and lungs filled with frothy mucus. The capil- lary veins of the serous or sub-serous tissue distended almost to haemorrhage. The same in regard to mucous membrane of whole respiratory apparatus; also to lungs, trachea, larynx, and root of tongue. About three ounces of straw coloured serum in each pleura. Nothing like tubercles or derange- ment of lungs, except from the recent accident. Circulatory Apparatus.—Heart enlarged to nearly twice the natural size, with hypertrophy and dilatation together. HYPERTROPHY AND ENLARGEMENT OP HEART. 315 Aorta from orifice to innominata enlarged to two or three times its usual capacity. Internal membrane thickened, softened, and cartilaginiform, interspersed with specks of beginning ossification. Middle coat also increased in thick- ness, but diminished so much in density that it yielded as if it were half rotten; external coat sound. Semi-lunar valves thickened as if from chronic inflammation, but no ossifica- tion in them. Blood collected in abundance in great vessels, but still fluid; a pint of it was discharged,before the thorax was opened, from the veins of the base of the cranium, the brain having been previously examined. Abdomen.—Viscera in a healthy state. The gastric mu- cous membrane throughout, of a uniform light claret colour, or perhaps speaking more exactly, like a recent stain of claret upon white linen; with the exception of the summits of the rugae, where a deep claret colour was prevalent along each one of them. The stomach contained his dinner, which seemed to have been of soup and bread; and an inspissated thick coat of mucus was spread over it. When this was re- moved, small punctated patches of red blood were seen in the capillaries of the mucous coat. This is sometimes mis- taken for inflammation. The mucous membrane of natural consistence,and thickness: I could not, however,'tear it up in shreds after the way spoken of by Louis; though with the end of the scalpel slid along, I could raise it. The brain was highly congested with blood, as in an apo- plectic state, but there was no extravasation. A chronic thickening and inflammation of the arachnoidea was percep- tible on the summits of the hemispheres: at the posterior part of the velum interpositum and in lateral ventricles. Two or three drachms of serum were found in each lateral ventricle. The commissura mollis was absent, as is com- monly the case, where there are effusions of water in ventri- cles. [ 316 ] Hypertrophy of Heart, and Mollescence of Stomach. Jan. 13th, 1829.—The Rev. Mr.----, aged forty-three, of a large stature, six feet, and robust in proportion, from an early period of life has been subject to palpitations of the heart, which are said to be hereditary in the family. For the last two years dyspepsia was added to his other com- plaint; and he was reduced very much. A few weeks ago he had some dropsical effusion into the lower extremities, which after a while disappeared. A few days before his death he was seized with an inflammation of the scrotum and testicles. Autopsy thirty-two hours after death, in the presence of the attending physician, Dr. S. Tucker, and Mr. R. Dorsey, student of medicine. Weather cold. Abdomen.—Enormously distended with flatus: muscles of, somewhat putrefied. Colon in its whole length distend- ed almost to bursting with flatus; and, on an average, from three and a half to four inches in diameter. On the ascend- ing part, a patch of recently extravasated blood, two inches in diameter, existed on the peritoneal coat. It probably came from a vessel ruptured by the over distention. The eolon contained liquid faeces of a yellow colour, which ad- hered to its parietes. Small intestines also distended with flatus, and contained a yellow, bilious faeces. Stomach distended with flatus. There were several dark spots on it, such as occur in old gastric affections; and its veins were moderately injected with blood. The whole mucous coat of its left half was in such a state of mollescence that it could be scraped off readily with the thumb-nail, be- ing only in a slight degree more tenacious than common mucus, and it was there of a kind of chocolate colour. The other half of the mucous coat had a slight greenish tinge; HYPERTROPHY OF HEART. 317 and the boundaries between it and the mollescence were well defined by a change of colour and of consistence. Spleen healthy. Liver healthy, but rather light-coloured. Thorax.—Lungs, texture of perfectly sound: an old pleu- ritic adhesion over several inches of the right one. No con- gestion of blood in them. Heart but little inferior in size to a small bullock's heart; all its cavities were dilated, and had their parietes thickened; the ventricles to twice the natural thickness, and the auricles to three times. Vessels of the heart healthy. There was a slight pericarditis manifested by some films of coagulated lymph; and by a turbid serous effusion, amount- ing to about two ounces. The other cavities not examined. Inflammation of the Internal Membrane of the Heart and Aortitis, with Chronic Pleuritis and Pericarditis. Anne Ebner, aged fourteen, a domestic in the family of Mr. Otis, portrait painter, has for some time had unpleasant symptoms about the thorax; the leading one of which was difficulty of breathing on ascending a flight of stairs, or upon severe exercise, and irregularity in the action of the heart and in the pulse. Having died, I examined her about twen- ty-four hours after death; being assisted by Drs. Samuel Tucker and Charles D. Meigs. Universal adhesion of the pleura costalis to the pleura pulmonalis, apparently for the most part of ancient standing. The heart in mass, larger than that of the largest male adult. Universal adhesion of pericardium to the heart; the sub- stance of the heart of a whitish colour, hard and elastic. Each of the cavities of the heart dilated to twice or three times the natural standard. The left ventricle rather more enlarged than the other cavities; hypertrophy of all the cavities. The lining membrane of each, of a white, shining 318 PATHOLOGY' OF THE THORAX. appearance, and thicker than usual. In the left auricle, for the extent of two square inches, on its inferior surface, the lining membrane was studded with small granulations of coagulating lymph. Hypertrophy of the mitral valves. On the auricular side they were covered with small granulations of coagulating lymph. The aorta, near its root, had a distinct layer of coagu- lating lymph, which could be raised up in shreds, being peculiarly distinct from the lining membrane of the artery. The same appearance was visible in the pulmonary arte- ry, but the layer of lymph, not quite so separable from the lining membrane, as in the aorta. The right lung congested in its upper lobe. The peritoneal coat of the liver thickened, and covered with coagulating lymph. The ascending cava was free from any investment of coagulating lymph. The mucous coat of the stomach, of the small, and of the large intes- tines, red and congested; the jejunum, of a red rose colour. The liver considerably enlarged. There were no evidences of inflammation in the lower part of the aorta, and in the small vessels. This is one of the few instances, of genuine and indisputa- ble inflammation of the lining membrane of the heart and aorta, that I have met with. It was here not so much indi- cated by redness, as by the effusion of coagulating lymph. In Dec. 1828, I met with a subject of advanced age, where the aorta internally was so highly inflamed, as to be of a deep lake or crimson colour. Pericarditis. Alms House, July 10th, 1827.—William Johnson, a co- loured man, middle stature, had, on my taking charge of the surgical department, scrofulous indurations of the lym- phatic glands on each side of the neck, larger than a hen's PERICARDITIS. 319 egg. He had, also, a suppurating lymphatic gland in the right axilla. I treated him for about two months Avith iodine, and derived no very obvious results. About the first of this month, he complained of more de- bility than usual, and of a loss of appetite; his bowels be- came loose. Three or four days before his death, the latter symptoms increased into a dysentery, and he died very sud- denly on the night of the 9th inst. I examined him about ten hours after death. The lym- phatic indurations of the neck were suppurating. Thorax.—A pint of red serum in the pleura on one side, the other side healthy. Universal pericarditis, con- sisting in a red spongy coat of coagulating lymph; nearly one quart of water tinged red by blood in pericardium. There had been no symptoms apparent to the medical attendants of local affection of the heart, not even pain; and no well marked difficulty of breathing, except the day before his death: though, from the appearance, I should suppose, that the disease had been on him for, at least, two or three weeks. Abdomen.—Nothing remarkable about it, except the mu- cous coat of the colon, which was tinged of a sooty or lead colour, as in cases of old inflammation. A Case of Rheumatism with Metastasis, producing Car- ditis, Pericarditis, Peripneumonia, and Pleuritis. A young lady in Market Street, '• A. B., aged eight years, of a delicate habit, began on the 16th November, 1827, to com- plain of a cold; that is, she had a slight sore throat, cough, and a general soreness over the body. She was dieted, and took a dose of castor oil by the direction of her mother.— 17th. —She remained pretty much the same. ISth.—Her feet and hands were observed to swell, and were very slightly inflamed, though not painful:"they were sore to the 320 PATHOLOGY OF THE THORAX. touch. 19th.—The first day of my visiting her. She complains of a severe pain in her right groin; a small tu- mour is observed here; the soreness of this part excessive. Purged with calomel and magnesia, and the part bathed with warm sweet oil. 20th.—The pain and soreness of the groin much mitigated; but the chest is suffering from severe pain accompanied by great oppression. Was blooded; the blood very sizy. 21st.—Ail her symptoms much relieved. 22d.—Pain in the groin nearly gone; could bear the part touched, and move her limb without much suffering. In the evening I was sent for, but being engaged, I requested my friend, Dr. Hays, to visit her for me. He found her sitting on her mother's lap, being unable to lie down. She complained of pain in the region of the heart, with difficul- ty of breathing. Her pulse was frequent, but not corded; the respiration was short, pain being experienced, when an attempt was made to draw down the diaphragm. A me- tastasis of the disease having evidently taken place to the heart and diaphragm, revulsives were ordered with the hope of relieving these parts. A large sinapism was applied over the chest, which afforded prompt relief, and on my visit the next morning I found her free from pain. During that and the two succeeding days, she improved so much as to be able to be about; and nothing but a little debility seemed to re- main. But on the twenty-fifth, she exposed herself several times, by walking, without additional covering, through a long, cold entry, by the ill-directed advice of the servant, in whose charge she was left for a few hours: the conse- quence was, that on Monday the 26th, she was attacked with a severe pain at the extremity of the xiphoid carti- lage, accompanied by great distress in respiration, and total inability to lie down. I ordered a sinapism applied over the pained part, which very promptly relieved her. 27th. Her stomach much harassed by sickness and vomiting; the groin free from pain, as was the part upon which the sina- pism was applied yesterday. After the stomach had conti- RHEUMATISM WITH METASTASIS. 321 nued for an hour or two in the situation just stated, it would suddenly be reconciled, and the top of the left shoulder would now be the seat of excruciating pain, which in turn would become easy by a return of the disease to the stomach, which would now be sick as before; or the pain would fix itself in the left side near the margin of the false ribs; and thus the affection would alternate a number of times in the twenty-four hours. 28th.—Stomach very sick, with some difficulty of breathing. In the after part of the day, these symptoms became very much more severe; so much so in- deed, that there was now violent and frequent vomiting. A white tenacious mucus in considerable quantity was even- tually thrown up, which, at the moment, afforded great re- lief. I was present at this time; and from the great abate- ment of her distress, I indulged a hope it would be perma- nent; but in about an hour after I had left her apparently much improved, I was suddenly called to her; and before I could reach the house, she was a corpse. " During the whole progress of this disease, the arterial system was but little affected: the pulse, with the exception of the last day, was neither frequent nor tense; yet it bore evacuations remarkably well, as far as they were pursued. Bleeding, leeching, and purging, were in turn ordered: as were, with some vigour, blistering and the repeated appli- cation of rubefacients. " The cough, which attended through the whole course of the complaint, was always found to be augmented, whenever the chest became the seat of attack. Expectoration was difficult, requiring numerous efforts to bring up a small quantity of white tenacious mucus; but this little always appeared to afford some relief. " It was truly astonishing to see with what suddenness the disease would shift its seat, and with what severity it would affect the part to which it would translate itself. When the stomach became the seat, it would instantly produce violent sickness, and sometimes pretty severe vomiting, which 41 322 PATHOLOGY OF THE THORAX. would continue for several hours. After this, it might, in an instant, be transported to the diaphragm, lungs, or pleu- ra. When here, she would experience severe pain, great difficulty of breathing, and almost incessant coughing, and an inability to lie down. " From these parts it would return to the stomach, attend- ed by the usual consequences of extreme sickness, or dis- tressing vomiting; or, more fortunately, it might take its flight to the point of the shoulder, where it would tarry the longest, and of course with the lesser inconvenience. On the twenty-eighth, it attacked the stomach with unusual violence; and after the severe vomiting mentioned above, it seized upon the heart, and death almost instantly followed. For after it had left the stomach, she desired to be seated upon her mother's lap, where she had not been more than five minutes, before she shrieked violently from pain seated in the region of the heart; she stiffened all her limbs by a sudden effort, and in a moment died. " It is worthy of remark, that the child's parents are both sufferers from rheumatism, and that she had several times before been attacked with the disease; and also that eigh- teen months before her death, she had had chorea Sancti Viti, which continued for three or four months, and was cured by the repeated administration of purgatives, princi- pally cremor tartar and jalap in combination."* Autopsy, thirty-eight hours after death, in the presence of her physicians, Drs. Dewees and Hays. Exterior Aspect.—Colour as usual after death; no great marasmus; pupils dilated; expression of countenance tran- quil. Head.—Membranes of brain natural; cerebrum natural; cerebellum somewhat softer than usual; not a drop of water in ventricles of brain. * Amer. Jour. Med. Sciences, vol. ii. p. 473, communicated l>v Di Dewees. RHEUMATISM WITH METASTASIS. 323 Medulla Spinalis.—Membranes natural; it seemed hard- er than usual, and its elasticity was so considerable that it would suffer an extension of two inches, followed immedi- ately by an equivalent contraction. The rugae on its surface very perceptible. Its elasticity was independent of the dura mater, for it continued in the same when the latter was slit up both before and behind. The dura mater contained about two drachms of fluid, one half of which was blood, and the other the serum peculiar to this cavity. The upper and the lower enlargements of the medulla spinalis, (renflements,) where the nerves of the upper and of the lower extremities come off, were unusually developed. Thorax.—Heart twice as large as usual, and adhering by a thick coat of lymph to the pericardium, excepting a small extent of the right ventricle, and the whole of the right au- ricle. Two ounces of straw-coloured serum in pericardium. The texture of the heart was sensibly altered; its parietes being almost universally thickened; of a light colour, about that of veal flesh; so rigid as not to collapse after the man- ner of a healthy heart upon the evacuation of its contents; and cutting in the crisp semi-cartilaginous manner peculiar to inflamed muscles. I did not detect any inflammation of its lining membrane: the right cavities contained coagula of red blood. The left pectoralis major muscle had been the seat of pain; it was found not altered in colour, but the texture had un- dergone the same pathological change with that of the heart. The pleura of the region behind it, had some filaments of co- agulating lymph passing between it and the corresponding surface of the lung. The whole circumference of the pleura on both sides of the body had lost the smooth shining condi- tion of the normal state, presented here and there specks and pellicles of lymph, and was slightly turbid. Each ca- vity contained about two ounces of a straw-coloured, trans- parent serum. 324 PATHOLOGY OF THE THORAX. The thymus gland was natural, being about the size of it in early infancy. The right lung was heavy, fleshy, and had lost one half of its spongy character; the blood being infiltrated into its cel- lular substance, and identified with the organ. The left lung was also partially solidified with blood, but by no means to so high a degree as the right, for its spongy character still predominated: it was pushed to the back of the thorax by the augmented heart. Abdomen.—Peritoneal surface universally healthy. Stomach.—Of a pink colour on its mucous membrane, especially along the ridges and sides of the rugae; being two or three degrees lighter than that of Mr. W. J., reported at page 122. It seemed entirely healthy, and had abundant rugae. ' Small Intestines.—Duodenum healthy; the jejunum and ileum, in the greater part of their extent, were reddened by a turgid state of the capillary veins, but there was.neither ulceration, ecchymosis, or thickening. They were smeared with mucus, and had some appearance of irritation, but pos- sibly the latter might have arisen solely from retrograde congestion, by the arrest of the circulation at the heart. The congested state of the lungs would favour the opinion; but in that case one would infer that the stomach also should have been congested with venous blood, which was not the fact. Large Intestines.—Spasmodically contracted, and con- tained only mucus. Liver.—Peritoneal coat somewhat turbid, a little thicker than natural, and abounding in large, distinct absorbents; granular substance, (acini,) not so distinct as usual, hard, co- hering strongly, and somewhat intermixed with that resist- ing yellowish matter, constituting what has been called the fat liver. * Had this state of the liver a connexion with the * Having once tried it by experimenting, I am of opinion that this mat- ter is not adipose, but a modification of coagulating lymph. RHEUMATISM WITH METASTASIS. 325 chorea, or with the long course of purging instituted for the cure of the latter? Gall Bladder.—Contained a thin, yellowish mucus; cel- lular coat increased to three lines in thickness by the infil- tration of a gelatiniform fluid. Spleen healthy. Kidneys not examined. [ 326 ] CHAPTER XIX. GENERAL PATHOLOGY OF NERVOUS SYSTEM. The very extensive distribution of the nervous system, its intimate intertexture with all the solids, and the conti- nued requisition by the latter upon its influence, for the due performance of their functions, render it among the most interesting tissues of the body. One of its most striking features, is the variety which it exhibits in the different classes of animals. In man and the mammalia it consists of a cerebrum, a cerebellum, a pons varolii, medulla oblongata, and medulla spinalis, and from these, numerous cords pass to all parts of the body. The brain in man is much greater in proportion to the spinal marrow than in any other animal, and the spinal marrow predominates much in its thickness over the nerves which proceed from it. In some fishes the brain scarcely exceeds in size the medulla oblongata. In the molluscae there is only a brain, which sends off nerves as radii from a centre, to ganglions scattered over the body, almost as large as the brain itself. In insects the brain is scarcely larger than one of the numerous swellings of the spinal marrow, and sends off its nerves in the same way. In polypi there is no regular and distinct nervous system, and hence it appears that the lower we descend in the scale of animals, the less this sys- tem is to be found concentrated in a particular region, and the more it is diffused over the whole body. This general view of the invariable presence of the ner- vous system in different animals, proves the necessity of its existing in order that animal life may be possessed: and it GENERAL PATHOLOGY OF NERVOUS SYSTEM. 327 also exhibits another important feature, that it is suscepti- ble of a great variety of exterior modifications, without having its essential characters impaired. It is also observed, in regard to this system, that the less it is accumulated in centres, the less important its integrity is to the life of the animal; for example, a toad or a tortoise has comparatively a small brain, which exercises so slight an influence on the general condition of the animal, that its removal will not prevent life from being sustained in its usual relations and vigour, for many months afterwards. There are many spe- cies of worms and insects, which on being cut into two or more parts, each of those parts becomes an independent ani- mal, possessing its own sensations and distinct powers of life. And many of the zoophytes, on being divided into very small pieces, from the general diffusion of the nervous prin- ciple in them, have a distinct existence communicated to each section. It is only when we approach the higher orders of animals, that the integrity of the nervous system and the presence of its central parts, become indispensable to life; and that this necessity is more strongly perceived, the larger that the brain is, in proportion to its ramifications. The foregoing facts render it probable that the nervous system is analogous in all animals: and we may conclude it to be nearly the same in all parts of the same animal, from the metastasis of function which occasionally has occurred where a sense has been lost either naturally or by accident. It would seem, therefore, that the varieties of its functions depend upon the peculiar character and arrangement of the organ supplied with nervous matter. We are also furnished with another idea from examining the state of the nervous system in different animals; namely, that, as in polypi, &c, a new animal can be generated from a section of an old one; so it is evident that each part possesses integral properties, and consequently must have the principles or modifications of its nervous system blended together: but in man and all other mammalia, these modifications have each their parti- 328 GENERAL PATHOLOGY OF NERVOUS SYSTEM. ' cular throne or habitation, as the eye that by which we see, the tongue that by which we taste, and so on of the other senses. We find, moreover, by experiment, that other locations of functions take place in the latter animals, that the brain is the seat of intelligence, the medulla oblongata of the prin- ciple of respiration, and that the medulla spinalis is the im- mediate seat of life to all other parts.- Be it allowed that such localities of vital functions do exist, of which there seems to me to be so little doubt, why may not the different parts of the brain afford settled positions to the moral fa- culties, as asserted by the phrenologists? It has been considered probable, that nearly all of the nerves have an increase of matter, as they get farther from their origin in the brain or spinal marrow: this accounts for the sensibility met with every where on the surface of the body, so diffused and minute in its division, that the finest needle cannot be introduced without causing pain. Though it be true, that this opinion of the extreme termina- tions of nerves being larger or containing more matter in the aggregate, than the trunks from which they emanate, is opposed by the common appearances on dissection; for there we find that as ramifications pass off the nerve is diminished: yet it is difficult to explain the universal sensibility of dif- ferent organs, without supposing some such arrangement. The fibres of muscles, the surface of the skin, and other sen- sitive parts, may possibly, receive something like a coat- ing of nervous matter. If this be the case, the medulla derived from the brain and spine is sufficient to furnish the whole body, as it may possess a plasticity and ductility somewhat like that of gold: which the natural philosophers tell us is such that a grain of the metal may be beaten out to cover a surface of several feet square; and one cubic inch is sufficient, to gild completely a wire; long enough to surround the globe. The celebrated Hunter, in his view of the vitality of the GENERAL PATHOLOGY OF NERVOUS SYSTEM. 329 blood, admits unequivocally the general diffusion of a ner- vous matter through the whole system, though he does not undertake to describe the mode of arrangement. His words are, " I consider that something similar to the materials of the brain is diffused through the body, and even contained in the blood: between this and the brain a communication is kept up through the nerves. I have therefore adopted terms explanatory of this theory; calling the brain the materia vitse coascervata, the nerves the chordse internuncio, and that diffused through the body the materia vitas diffusa. Of this latter every part of an animal has its portion. It is, as it were, diffused through the whole solids and fluids, making a necessary constituent part of them, and forming with them a perfect whole; giving to both the power of pre- servation, the susceptibility of impression, and from their construction, giving them consequent reciprocal action. This is the matter which principally composes the brain; and where there is a brain, there must necessarily be parts to connect it with the rest of the body, which are the nerves; and the use of the nerves is to continue, and therefore con- vey, the impression or the action from one to the other. These parts of communication must necessarily be of the same matter; for any other matter could not continue the same action. " From this it may be understood, that nothing material is conveyed from the brain by the nerves, nor, vice versa, from the body to the brain: for if that was exactly the case, it would not be necessary for the nerves to be of the same materials with the brain; but as we find the nerves of the same materials, it is a presumptive proof that they only continue the same action which they receive at either end." Conceding this materia vitse diffusa to be a coating of nervous matter over the whole structure of the body, we can, from its degree of profusion, estimate, and even anticipate, the sensibility of different organs; the latter quality be- ing small when the matter is sparingly diffused, and highly 42 330 GENERAL PATHOLOGY OF NERVOUS SYSTEM. exquisite, when it is abundant. In this view of the subject, we see the reason for the accumulation of the pulpy ner- vous matter of the retina; the materia vitae diffusa has to appear there in the form of a continuous membrane, in or- der that a delicacy of sensibility might be given to the or- gan, suited to receive an impression so inconceivably fee- ble, as that occasioned by the matter of light. This latter substance, travelling at the immense velocity of two hun- dred thousand miles in one second, though it has been con- centrated in focus upon focus, with a view of determining whether in such a condensed condition it possesses any appre- ciable momentum, has always escaped the test of the most delicate instruments. An organ of this exquisitely refined sensibility, is alone capable of responding to a stimulus so exceedingly subtile, that it is even questioned whether it is matter, or merely a quality of it. The structure and expansion of the auditory nerve, a pulpy distribution on the internal surface of the labyrinth, resembling the retina, affords a parallel, in some measure, to the optic, by depending for the performance of its peculiar functions on a degree of sensibility, capable of feeling the most delicate vibrations of the air. It is not important at present to enter further into the in- vestigation whether the nervous principle is supplied to each molecule of the body or not, the fact that each part has sensibility being sufficient. But the question is, whether this sensibility be inherent in every part of the human frame; or distant, and its origin to be looked for elsewhere? The following experiments will, I think, prove the latter hypothesis. Section I.—Experiment on the Nervous System. The admirable work of Le Gallois on the principle of life, has formed the basis of many interesting inquiries on this GENERAL PATHOLOGY OP NERVOUS SYSTEM. 331 subject in different quarters of the world; and from the ge- neral result of his observations and experiments, the follow- ing conclusions seem to be established. First, That the principle of all inspiratory motions, resides in that part of the medulla oblongata vvhich gives rise to the nerves of the eighth pair. Secondly, That the principle which animates every part of the body, resides in that part of the medulla spinalis, from which the nerves of that part originate. Thirdly, That it is likewise from the medulla spinalis, that the heart receives the principle of its life and of its power; but in the whole medulla, and not in a circumscribed portion of it. With the view of testing the accuracy of these conclusions, the following experiments were executed some years ago. They were undertaken with no desire to establish particular theories or to controvert them, but merely to arrive at sound and useful inductions, and to compare them with the state- ments of the celebrated French physiologist just named.* Experiment 1st.—Took a kitten four days old, and di- vided the spinal marrow between the occipital foramen and first cervical vertebra; this instantly stopped respiration. The animal was much agitated, and gaped frequently. At the end of ten minutes, when sensibility had almost ceased, the larynx was divided from the os hyoides, and the lungs artificially inflated. By continuing the inflation for five mi- nutes, the animal was evidently much revived. At the end of twenty-five minutes (sensation and the power of motion continuing,) the spine was divided between the tenth and eleventh dorsal vertebrae. At thirty minutes each of the parts thus separated retained sensibility and motion: but all sympathy between them was destroyed, as an impression * These experiments and some others, were performed with the assist- ance and in behalf of two candidates of the University; Elias Buckner of Virginia, and the late J. P. Freeman of Philadelphia, who subsequently made them the subjects of their inaugural essays, 332 GENERAL PATHOLOGY OF NERVOUS SYSTEM. made upon the fore parts produced no effect upon the hinder, and vice versa. At forty minutes, the posterior extremities were insensible: at forty-five minutes the anterior parts ma- nifested sensibility when violently pinched: at fifty-two mi- nutes no signs of life remained. Artificial respiration was kept up by intervals till this time. From the quantity of blood lost, and the appearance of the heart, it was pretty certain that death resulted from the haemorrhage. At sixty minutes, the action of the heart continued, although its cavities were completely emptied of blood, and filled with air. Experiment 2d.—Took a rabbit four days old, and divided its spinal marrow between the occipital bone and atlas, with a needle. Respiration was immediately suspended, and the animal became convulsed, struggled, and gaped; its strength rapidly diminished, and in three minutes life was almost ex- tinguished. Artificial inflation of the lungs being now com- menced, in two minutes the animal was much revived, and became still more lively as the process went on. At seven minutes from the commencement of the experiment, a wire was passed through the whole of the spinal column, which immediately extinguished the sensibility and motion of the whole body. With a view of ascertaining the condition of the circulation, a hind leg was amputated, which furnished no blood, and the femoral artery, on being exposed, was found flaccid and empty. Blood was slowly discharged from the veins. The head showed signs of sensibility and life by gaping, as if in a respiratory effort. Experiment 3d. —Took a rabbit of the same age as in the preceding experiment, and under similar circumstances we divided the spinal marrow in the same place: respiration was immediately suspended. In two and a half minutes the animal had almost expired. Artificial respiration was now commenced, and in half a minute afterwards, sensibility re- turned and the animal revived: we continued the inflation for six minutes, with the effect'of full restoration to the ge- GENERAL PATHOLOGY OP NERVOUS SYSTEM. 333 neral functions of life. During this period, whenever a ces- sation of the inflation occurred, the animal lost its sensibility and struggled as if for breath.—We now made an incision between the last dorsal and first lumbar vertebrae, and through this opening was passed a large wire, down to the end of the spinal column. The lower extremities were immediately deprived of sensibility and life: the circulation was also sus- pended in the parts, as amputation of the hind leg produced no haemorrhage. The inflation of the lungs being continued; two minutes afterwards we passed the wire through the up- per portion of the spinal marrow, and sensibility and life, with the circulation, were immediately destroyed in the up- per extremities. Experiment 4th.—The spinal marrow of a kitten was divided as in the preceding experiment, and the same phe- nomena occurred; namely, instantaneous suspension of res- piration, tremors over the whole body, gaping of the mouth, &c. At the end of ten minutes, sensibility became almost exhausted, and the inflation was commenced, which being continued four minutes, revived the animal. The carotids were now laid bare, and the circulation was seen to go on rapidly. But on suspending the inflation for a few moments, the action of the heart became much enfeebled, and the blood assumed a dark colour, which soon changed to a florid, on resuming the inflation. This was repeated several times, and always with the same result. At the end of thirty-eight minutes the carotid and verte- bral arteries were tied up, and decapitation performed be- tween the third and fourth cervical vertebrae. A few drops of dark blood issued from the vertebral arteries, which in- creased in quantity, and changed in colour, upon inflating the lungs. The mouth continuing to gap, at forty-five mi- nutes the thorax was opened; in doing which, such was the acuteness of sensibility and the power of motion in the ani- mal, that its legs were confined to prevent its struggles. The action of the heart went on violently, and during the 334 GENERAL PATHOLOGY OF NERVOUS SYSTEM. suspension of the inflation, its left cavities were filled with dark blood, which soon changed to florid on resuming the inflation. At fifty minutes a leg was amputated which yielded a few drops of blood. The inflation was persevered in for a few minutes, and the animal revived astonishingly, sensibility being manifested on the slightest touch. At sixty-five minutes we destroyed the cervical parts of the spinal marrow, by passing a wire through the vertebral canal to the first dorsal vertebra. Upon inserting the wire great pain was evinced; but as soon as it passed down, all sensibi- lity became extinct in the anterior, while it still continued in the posterior extremities, though it was much diminished. At seventy minutes the wire was pushed through the whole spinal canal, and instant extinction of all the symptoms of life took place. The inflation was resumed for several mi- nutes without any effect. At seventy-seven minutes the heart contained dark blood, and feebly pulsated when we left it. Experiment 5th.—Laid bare the larynx of a kitten, and separated it from the os hyoides—the cranium was next re- moved and the cerebrum extracted, which produced no im- portant effect. The cerebellum was then taken out, and the animal still continued to respire perfectly and freely for ten minutes. It stood strong and firmly on its feet, exhibiting symptoms of violent pain, and making several efforts to cry, with partial success. At the expiration of seventeen mi- nutes the medulla oblongata was extracted, which put an im- mediate stop to respiration. At twenty minutes we com- menced the inflation of the lungs, which being continued for eight minutes, the animal was observed to be dead, evidently from the loss of blood. Experiment 6th.—Took a rabbit four days old, and re- moved the upper portion of the cranium. The brain was then cut off in slices, and though a considerable quantity of blood was lost, the animal still retained strength to stand and to crawl about. The cerebrum and the cerebellum being re- GENERAL FATHOLOGY OF NERVOUS SYSTEM. 335 moved in the same manner, respiration still continued. In eight minutes, we removed the medulla oblongata, when res- piration immediately ceasing, the animal became weak and fell down, showing littie sensibility. Three minutes afterwards, we inflated the lungs, and in one minute the animal was much revived. In two minutes we examined the contents of the tho- rax, and finding the action of the heart to continue, a wire was passed through the spinal marrow, which was followed by an immediate cessation of sensibility and of the circulation. But it is to be observed that the heart continued to dilate and contract feebly. Experiment 7th.—After dividing the spinal marrow of a kitten, between the last dorsal and first lumbar vertebrae, a probe was introduced, and all the spinal marrow destroyed as far as the first dorsal. The action of the intercostal mus- cles immediately ceased—a laborious and imperfect respira- tion was carried on for a few minutes, which was suceeeded by gapings. Sensibility appeared completely lost in the body, and in four minutes afterwards much impaired in the anterior, though it was still considerable in the posterior ex- tremities. At five minutes we commenced inflation, and at seven minutes the posterior parts were sensible to the least touch, the gapings still continuing. At ten minutes we de- stroyed the lumbar portion by running a wire clown the ca- nal to the tail. This produced an instant loss of sensibility in the hinder parts, while the anterior continued still sensi- ble. At fifteen minutes the spinal marrow was divided at the first cervical vertebra, which produced no obvious ef- fect. At seventeen minutes, sensibility was still perceptible in the anterior parts, and gaping continued. At eighteen minutes, we destroyed the cervical portion, when life im- mediately ceased. Experiment 8th.—Dissected down and put ligatures upon the sympathetic and par vagum nerves of a kitten. The ani- mal appeared to be in the most excruciating agony; and soon ceased to cry and to breathe, though it made strong efforts 336 GENERAL PATHOLOGY OP NERVOUS SYSTEM. to do both. At the end of five minutes the ligatures were removed, and the larynx exposed: the rima glottidis was ri- gidly closed, which accounts for the stoppage of the breath. At the end of eleven minutes, when the animal appeared en- tirely exhausted, a tube was passed into the trachea, and in- flation commenced. After a few strokes of the piston, the animal began a voluntary respiration through the blow-pipe. At twenty-five minutes the spinal marrow was separated at the first cervical vertebra, which put an immediate stop to respiration. At thirty minutes sensibility continued strong, when a probe was passed in at the cervical vertebra, and run through the whole length of the spine, which produced an immediate extinction of life in every part. Experiment 9th.—Laid open the abdomen of a kitten, and tied up the aorta just below the coeliac artery. In ten minutes sensibility was much impaired in the posterior ex- tremities, though by no means extinguished. The posterior extremities were now separated from the body between the first and second lumbar vertebrae, and when thus separated they exhibited sensibility for two minutes. At twenty mi- nutes the animal stood on its fore feet, respiration and cir- culation being pretty free. The spinal marrow was now divided at the first cervical vertebra, which, as usual, pro- duced a suspension of respiration. At twenty-three minutes we commenced inflation, and at twenty-five minutes ampu- tated a leg, which afforded a little blood. At twenty-seven minutes decapitation was performed. Three minutes after- wards we recommenced inflation, and the anterior parts ex- hibited signs of sensibility when pinched; the head gaped. At thirty-three minutes destroyed all the spinal marrow, which extinguished life entirely. At forty minutes we opened the thorax, and observed the heart pulsating; and on wounding the aorta, dark blood issued. Experiment 10th.—Opened the abdomen, and put liga- tures under the aorta and vena cava, leaving them loose. We next dissected down, and tied up the carotid arteries GENERAL PATHOLOGY OP NERVOUS SYSTEM. 337 and jugular veins, separated the larynx, and introduced a tube for the purpose of inflating the lungs, through which the animal breathed. In ten minutes we divided the spinal marrow at the first cervical vertebra, which put an imme- diate stop to respiration. At the end of fourteen minutes we commenced inflation, and at seventeen minutes decapi- tated, and continued the inflation. At twenty-two minutes the ligatures were tied, which had been previously fixed on the aorta and vena cava, and then we cut off the posterior parts at the last dorsal vertebra. At thirty-nine minutes sensibility was very manifest, the inflation being continued. At forty-two minutes we opened the thorax, and found the heart to beat regularly and strongly. One of the internal mam- mary arteries having been divided accidentally, bled freely per saltum. At fifty minutes, the circulation going on vi- gorously, the venae cavae were seen carrying dark blood to the heart, and the pulmonary veins returning vermilion-co- loured. The auricles contracted synchronously, and emptied themselves completely. The ventricles did the same. At fifty-five minutes, sensibility was very much impaired. One leg, being amputated, did not bleed, although the ac- tion of the heart appeared regular and vigorous. At fifty- seven minutes, the aorta being cut, bled freely of vermi- lion-coloured blood, which caused a gradual diminution in the action of the heart. At sixty-two minutes, however, it had so completely ceased, as not to be excited by the point of a needle; though on blowing air into it from the vena cava, its contractions were feebly renewed. It appears to me, that the foregoing experiments pretty clearly establish the validity of the three positions assumed; That the medulla oblongata is essential to voluntary respi- ration,—that the spinal marrow is immediately connected in its functions with the vitality of all the parts to which it sends nerves,—and that the heart is indebted to the spinal marrow for its ability to carry on the circulation. To cor« 43 338 GENERAL PATHOLOGY OF NERVOUS SYSTEM. roborate these points however more fully, let us review the bearing of the several experiments. First, In the first, second, third, and fourth, as the object of inquiry was to ascertain the influence of the medulla oblon- gata on respiration, a section was made with a needle just be- low the occipital bone, and a suspension of breathing immedi- ately took place. This proves that the organs of respira- tion are put in motion by an influence derived somewhere from within the cranium, and that however indispensable the integrity of the phrenic and the intercostal nerves may be to their action, still the primum mobile is not in them or the parts of the spinal marrow to which they belong. Next it was desirable to ascertain what part of the ence- phalon maintained the process. Experiments fifth and sixth prove it to be the upper part of the medulla oblongata, near the origin of the par vagum and glosso-pharyngeal nerve; for in each of them the suc- sessive removal by slices of the cerebrum and cerebellum did not arrest respiration. The moment, however, that the medulla oblongata was injured, a stop to this process was the consequence. We are thus led to a beautiful and important conclusion in physiology: one which, from the unequivocal character of the proofs brought to its support, is justly entitled to the greatest attention; and which ought to enter into all our reasonings upon the symptoms connected with apoplexy and other affections of the brain attended with compression of its substance. It is highly probable, from the cavity of the cranium being completely filled, that any deposits of blood within it by increasing the aggregate mass of con- tents, or any diminution of its capacity by a part being de- pressed, which is equivalent thereto, will cause itself to be felt throughout the substance of the brain: the compression being communicated not only to parts immediately conti- guous, but also, by a juxta-position of particles, to the GENERAL PATHOLOGY OP NERVOUS SYSTEM. 339 whole mass. If this reasoning be correct, we may under- stand in what manner respiration is affected by compres- sion on the medulla oblongata, notwithstanding the effusion or depression may take place at a very remote situation from it. Conceding this, is it not proper to make perfo- rations in the cranium, to relieve compression, by allowing the brain more space, though we may not be assured that the effused fluid will be exposed? In relation to this part of our subject is an observation made in experiment eighth.-—A ligature placed on the par vagum stopped respiration, by producing a spasm of the rima glottidis; and a blow-pipe introduced into the trachea, simply by keeping the passage for the air open, restored the function. Secondly, As regards the influence of the spinal marrow upon the life of other parts. In experiment second, a wire passed through the whole of the spinal column, immediate- ly extinguished sensation, motion, and circulation through- out the body. In experiment third, a wire, passed through the lumbar portion of the spinal marrow, destroyed life in the lower extremities. The same injury inflicted on the dorsal portion produced the same effect on the upper ex- tremities. Experiments fourth, sixth, seventh, eighth, and ninth, all demonstrate the same principle, by similar re- sults. Thirdly, In regard to the manner in which the action of the heart is kept up.* The greater part of the experiments show the circulation to have ceased along with the destruc- tion of the spinal marrow: But the seventh, taken with the other, brings forward an interesting fact, namely, that the action of the heart is not sustained by any particular por- tion of the medulla spinalis, but by the whole of it, each section contributing its nervous influence. * By action of the heart is meant that degree of vigour in it necessary to maintain the circulation, and not simply its diastole and systole. 340 GENERAL PATHOLOGY OP NERVOUS SYSTEM. In one set of experiments we have seen the circulation sustained by the upper part of the medulla spinalis, the lower being destroyed, while in another by the lower part of the medulla spinalis, the upper being destroyed; and in the seventh, the circulation was kept up by the extreme portions, that is, the cervical and lumbar, the dorsal being demolished. Connected with the influence exercised in this manner over the heart is a singular circumstance. To keep up a vigorous circulation where one part of the medulla spinalis is destroyed, it appears only necessary to curtail its extent. This may be done either by putting ligatures on the great arteries, or what is still more surprising, by cutting off the head of the animal. To conclude, it will be seen by the re- sult of these experiments, that whether the nervous matter is diffused through the whole system, as believed by Mr. Hunter, or not, the fact is equally well established that the spinal marrow and the medulla oblongata give to it life and activity. Shortly after the publication of Le Gallois's Memoir on the seat of the principle of life, an English physiologist of distinction, Wilson Philip, undertook to prove that Le Gallois's experiments were invalidated by his own, and that when an animal was previously stunned by a blow on the oc- ciput, and the medulla spinalis destroyed by hot iron, or dis- sected out, that the results were different from a destruction of the same by pushing a wire down the spinal canal. To test the validity of these objections, the following experi- ments were executed, vvhich, in their result, tended to esta- blish still more fully M. Le Gallois's opinions. Experiment 11th.—A rabbit was rendered insensible by a blow on the occiput, but not motionless, so that the breath- ing still continued. The medulla spinalis opened, and de- stroyed by a wire, as hot as one of a size for the experiment could be kept. On introducing it afterwards through the foramen magnum into the brain, the breathing immediately GENERAL PATHOLOGY OP NERVOUS SYSTEM. 341 ceased. The femoral artery was laid bare, about two or three minutes after respiration had ceased. The beating of the ar- tery was evident. On opening it, a dark-coloured blood flowed from it freely. We now had recourse to artificial in- flation of the lungs. When it had been employed for half a minute, the blood which continued to flow copiously from the artery, became of a highly florid colour. The other fe- moral artery was then opened, from which florid blood also flowed freely. When about an ounce of blood had flowed from the vessels, the inflation of the lungs was discontinued, and the blood again flowed of a dark colour. It continued to flow from the femoral arteries altogether for seven mi- nutes. Three minutes after the blood had ceased to flow from them, the artificial respiration being continued, ope of the carotid arteries was opened, from which a florid blood flowed in a copious stream, to the amount of a drachm and a half. The flow from the carotid artery ceased in eleven minutes after the femoral artery had been opened. Most of the blood was now of course evacuated. A good deal had been lost in opening the spine, which always happens. The left auricle and ventricle were found nearly empty: the blood which remained in them was florid. The right auricle and ventricle were full of dark blood. Experiment 12th.—Took a rabbit twelve days old, and rendered it insensible by a blow upon the occiput. We then opened the spine, and passed a hot wire into the brain and through the whole extent of the spinal marrow. Sensibility and voluntary motion were immediately destroyed. We now exposed the carotids: their appearance pale and rather flat: we divided them: blood discharged slowly, and of a dark colour. We now commenced artificial inflation of the lungs: no change in the colour of the blood produced: the quantity discharged was about half a drachm. Examined thorax: motion of the heart continued. Two minutes after resorting to artificial respiration, no effect was produced by it on the action of the heart. We now opened the abdomen. 342 GENERAL PATHOLOGY OF NERVOUS SYSTEM. and exposed the aorta: on cutting it, the blood which flowed was dark. Recommenced artificial respiration: no change pro- duced in its colour. The action of the heart had now almost ceased, and was not invigorated by continuing respiration. Experiment 13th.—A rabbit, same age as above, was rendered insensible by a blow upon the occiput. We opened the spine, and passed a hot wire into the brain, and then down the spinal marrow. Respiration ceased, and sensibility and motion were lost. One minute afterwards we exposed the fe- moral artery and divided it—blood followed of a dark colour and small in quantity. Two minutes after we commenced artificial respiration, and continued one minute and a half. Blood not changed in colour. We next exposed the carotids, and divided them: about ten drops of blood were discharged; colour dark. Examined the thorax; action of the heart con- tinues; continued respiration; no fl that it exists much more in the old than in the youthful and middle aged. In forty^three cases quoted by Lallemand, thirty-one were more than forty years old; and in the majority of the remainder, being from ten to forty, the brain had suffered from percussion. M. Rostan consi- ders it as most unusual among persons under thirty years of age; judging from his personal experience, upon a large po- pulation of every age.t Duration.—From the observation of M. Lallemand,% it appears, that about one half of the patients attacked with ramollissement, and who perish from it, die within the first seven days from the commencement of the attack; rather more than a fourth in the second week; about one sixth in the third week; and the remainder at intervals of months. Some individuals, indeed, there is reason to believe, bear this disorganization in its forming stage about them, in a chronic state for years. § This form sometimes occurs where there has been a previous attack of apoplexy, imper- fectly resolved, and also in the case of mental derangement. The most essential circumstances in determining the length of an attack, are the seat of it, the extent, and the mode of treatment. If superficial, it may last for a very long time> without producing death, and be also, extensive; whereas, if it be near the centre of a hemisphere, it kills in a short time, even where small in extent. M. Rostan || has seen a case which had destroyed the whole of a lobe, and killed the patient in two days. * Rostan, 155. | Id. p. 183. * Lallem. p. 217. S Rostan, p. 153. il Id. p. 154. MOLLESCENCE OR RAMOLLISSEMENT. 381 It seems to be barely within the reach of possibility for this affection to terminate by resolution. M. Rostan, how- ever, met with one case,* where, from the symptoms, there was reason to believe that this had occurred; the chief ob- jection to the inference is, that as cerebral congestion is at- tended with similar symptoms, the complaint may have been the latter, and not ramollissement; it occurred in a fe- male of seventy-six years. But general experience is in fa- vour of death, being the inevitable lot of individuals affect- ed with softening of the cerebral tissue, in spite of every mode of treatment. Situation.—In forty-six observations of Lallemand,t sixteen had the Ramollissement in the periphery of the ce- rebrum in the cortical matter; thirteen had them in the corpora striata, and in the thalami nervorum opticorum; four in the cerebral protuberance, (pons varolii;) eight in the fibrous or white substance; and five with mixed situations. It is then worthy of recollection, that the principal ten- dency to the disease, is in the ash-coloured substance; as thirty-three out of forty-six patients had it there exclusive- ly, or in parts, where there is a predominance of this sub- stance. It is evident to the anatomist, that this distribution corresponds with the distribution of-vascularity in the brain; as vessels are always more abundant in the ash-coloured sub- stance. In these cases, many of them had also arachnitis, and it was evident that the inflammation of the cerebral sub- stance was due to that of the arachnoid membrane in con- tact with it. There is some little difference of experience about the frequency of its situation in the septum lucidum; M. Rostan has seen it there but once;t whereas, Abercrom- bie has repeatedly witnessed it there. My own personal experience tends to a coincidence with that of Mr. A. Unfortunately, I have not kept a full record of observations; but it has for many years been perfectly well known to me, * Id. p. 215. f Id. p. 161, 382 IRRITATIONS OF ENCEPHALON. that the septum lucidum and the fornix, are frequently re- duced into a pulpy semi-fluid state, and especially in drop1- sy where there is effusion into the lateral ventricles. Hence, I invariably avoid dropsical subjects, in a demonstration of the brain. This may be accounted for, as cerebral dropsy is a conse- quence of arachnitis; and, as ramollissement also attends arachnitis, the parietes of the ventricles will, of course, (both the white and ashy substance,) where they are lined by the arachnoidea, be softened, and the fornix and septum will come in for their share. The different experience of anatomists on the existence of the commissura mollis, as the adhesion between the thalami is called, may now be ex- plained on the same principle; it being most generally dis- solved, in inflammations attended with ramollissement; whereas, it is generally entire and perfect, where there has been no disease of the brain. The extent of ramollissement varies remarkably: in some it is not larger than a bean, while in others it invades a whole lobe or even more. The middle size is perhaps the most frequent. The shape of such affections is indeterminate, sometimes being spherical, on other occasions oblong, and again of some other figure. Frequently, indeed, the limits cannot be traced in a very precise manner, as the centre is softer than the circumference, and the latter is blended in- sensibly into the surrounding healthy structure. It may exist at different places in the same hemisphere, and present in each a different degree of intensity, and also different ap- pearances from the quantity of blood extravasated entering into their composition respectively. It is very frequently the concomitant of apoplectic effusion of blood, and forms for the latter an envelope. It also at- tends cancer of the brain, scirrhus, arachnitis, and in fact all of its pathological conditions. M. Rostan* says that the ar* ' Rostan, p. 162, MOLLESCENCE OR RAMOLLISSEMENT. 383 teries of the brain are commonly ossified when this organ is softened. The same excellent authority informs us, that ra- mollissement is, of all diseases, the most disposed to give rise to a collection of serosity in the ventricles; and he thinks that it occurs precisely on the same principle that effusions occur from other serous membranes when the viscera with which they are connected, suffer from acute or chronic in- flammation.* Symptoms.—The symptoms of ramollissement may be di- vided into primary and into consecutive, or into a first and second period. I do not propose to dwell on either of these in detail, but in a general manner, merely with the view of completing the subject. Primary Symptoms.—The most obvious are a fixed ex- cruciating pain of the head, lasting for weeks or even months, remitting occasionally in its violence, and sometimes inter- mitting entirely. There is vertigo, with a diminution in one or all of the powers of myotility, a weakness in the several faculties of the mind, hypochondriasm, sleepiness. A dimi- nution of the sense of touch; sometimes, however, an augmen- tation of it, making the slightest application painful. The ears ring, the sight is often perverted and sometimes entirely suspended. In fine, all the animal and intellectual functions depending upon the brain for their proper execution, are put out of their usual train. Consecutive Symptoms.—The symptoms of the first stage having proceeded for a greater or less time, are at length succeeded by an aggravated form of them. A perfect pa- ralysis of one or more parts of the body ensues; the intellec- tual and sensitive functions are annihilated, and the patient sinks into an irretrievable coma. Muscular stiffness or con- vulsion, is uncommon. In some cases this extremity of symptoms comes on at once and abruptly; in others the se- veral individual faculties of myotility, sensation, and intel- lect, are lost Successively and by rather a slow progress, * Rostan, p. 303, 384 IRRITATIONS OF ENCEPHALON. Mr. Abercrombie relates the case presently to be quoted, of a lady who spent the evening before her death in the enjoy- ment of a social circle, in whom, upon dissection, a very considerable part of a hemisphere of the cerebrum was in a state of softening. I have also met with a case somewhat similar, which will be presented to the reader in due time. The primary symptoms in her had lasted for some years: so little, however, was she aware of their fatal tendency, that she married during their progress. It has already been stated, that the locality of affections of the brain according to Delaye, Foville, and Pinel Grand- champ, it was supposed, could be ascertained by certain ge- neral signs. As for instance, that when the cortical sub- stance alone was injured, the motility of the muscular ap- paratus of the body was not affected, but only the intellec- tual faculties: and on the contrary, when the white substance was affected, the motility suffered; and that both intellec- tual and locomotive powers became deranged, when both white and cortical substance were impaired. The inference was hence established, that the cortical matter directed the operations of intellect, and the medullary those of muscular motility. Should then the assertions of M. M. Gall and Spurzheim, prove correct, we may at a future day, when observations are more multiplied, be able to pronounce with certainty on the part of the surface of the cerebrum that is in a pathological state, by learning what intellectual faculties are deranged or impaired. In this we shall accomplish for the periphery of the cerebrum, what the pathologists just alluded to have done for its centre; when they declare that in injuries of the cor- pora striata, the inferior extremity of the opposite side be- comes paralyzed, while in those of the thalami nervorum op- ticorum the paralysis is manifested in the pectoral extremity, and that a hemiplegia attends the morbid lesion of both the corpus and the thalamus. The disease whose symptoms closely resemble those of MOLLESCENCE OR RAMOLLISSEMENT. 385 ramollissement, are apoplexy, sanguineous congestion, arach- nitis, cancer, tubercles, tumours of the dura mater, or from the internal face of the cranium. In most organs, and es- pecially in the brain, it is much easier to ascertain that a dis- ease of some kind or other exists in them, that they do not execute their offices perfectly, than it is to learn the precise nature of the affection. General indications of disease are easily seized upon, but special ones are to be found out only by the intelligent and attentive. 1 may illustrate this by a familiar comparison: In a machinary consisting of many parts or wheels, if a part ceases to execute its office, it is rea- dily seen, but it requires a special examination to find out the nature of the injury sustained by that part or wheel; whether an axle or one of its cogs be broken, or some other derange- ment has taken place. But as, in the human body, we can- not expose to view its internal organs as we would those of a piece of mechanism; we are constrained to rely entirely upon symptoms, as indications of a healthy or unhealthy action, and upon the mode of access of these symptoms for distin- guishing one affection from another. In ramollissement of the brain, the symptoms though pro- gressive, seldom follow a regular and continuous march: there are alternatives of improvements and of relapses, in the in- tellectual and motive faculties, and the symptoms take time to evolve themselves. The invasion of apoplexy, on the con- trary, is rapid and general; the powers of mind and of mo- tion are precipitated at once into a profound lethargy, and the discharges of faeces and of urine become involuntary. A comatose paralytic state, then, is the first symptom of apoplexy, and the last of ramollissement; in mild cases of the former, this state recedes, and a solution of the symptoms occurs; whereas, when ramollissement has advanced far enough to induce the same state, it seldom or never becomes ameliorated. Cancer of the brain is attended with lancinating pains, in- '• rmiftent at first at long intervals, and then approximating 49 3S6 IRRITATIONS OF ENCEPHALOX. until they become daily. In its progress, which sometimes lasts for years; palsy, epilepsy, and convulsions are evolved, the skin becomes yellow, and the limbs are the seat of lanci- nating pains like the head-ach.* Tubercles and tumours pressing upon the brain, are principally distinguished by the chronicity of the symptoms. The following case of mollescence, already alluded to, the details of vvhich are given by Dr. Abercrombie,t is almost unique in the history of cerebral affections, in regard to the quantity of cerebral, substance that was in a state of disorga- nization, indeed total decomposition previous to death; and if it did not seem to be presented under circumstances of sufficient authenticity, might well be called in question. Be- ing rather too long for full insertion, I shall condense it so as to present the leading features of the symptoms, and of the dissection. A young lady between her fourteenth and seventeenth years, had suffered much from chronic ophthalmia. In her eighteenth year, she had paralysis of the face, marked by the mouth being drawn to the right side, impaired vision of the left eye, diminished power of contraction in the left orbicularis oculi, and numbness of the corresponding side of the face. For this she was bled generally and topically, and purged freely; which relieved her in six or eight days. Some time after, she had a repetition of the attack, which subsided in the same manner. Subsequently, she suffered frequently for a day or two at a time from giddiness, indis- tinct vision, and vomiting. In the month of June, 1822, being then in her nineteenth year, while at the dinner table, she fell senseless from her chair; her muscles were in a state of rigidity, (fixidity,) without convulsion; and she remained in this state for two hours. Six months afterwards she had a similar attack, followed by a third in two months, and a fourth in four months after that again. From the first of ' Rostan, p. 474 t Aber. 178. MOLLESCENCE OR RAMOLLISSEMENT. 367 these paroxysms, her giddiness increased, attended with head-ach, referred to the left temple and to the left ear, and followed by watery discharges froni the latter. On the fourth paroxysm, her vision became indistinct: a resort to sea-bath- ing increased the head-ach, and amaurosis followed. An emetic administered for the latter, was followed by a recur- rence of the comatose paroxysms every day, for a fortnight at a time, followed by an intermission for a fortnight. They lasted from half an hour to an hour; her general health, how- ever, continued so good, that she married in February, 1824, about twenty months from the period of her first attack. At this time she was put upon the use of stramonium, with an amendment of symptoms. Two months after marriage she spent the evening with a party in the house of a friend, and the next morning was found dead in her bed. On examination, it was found that the whole of the left hemisphere, excepting its periphery of cortical matter, was reduced into a soft, pultaceous mass, mixed with portions of a pellucid albuminous substance. What, however, is very remarkable, the left lateral ventricle remained entire in the midst of this destruction of the parts around it; being sepa- rated from the diseased mass by a thin septum. On the ex- ternal part of this hemisphere, lying over the petrous bone, and adhering firmly to the dura mater, there was a tumour the size of a pigeon's egg, composed of a reddish, soft, flesh- coloured matter, and of a semi-pellucid, albuminous sub- stance, in nodules of various degrees of firmness. The right hemisphere was considerably softened on the inner part of the anterior lobe. The left hemisphere seemed to be consi- derably enlarged, and the right proportionably diminished in size. The cerebellum was healthy, and the optic nerves softer than natural. It is an interesting fact in pathology, that the lower ani- mals are, like man, subject to ramollissement of the ence- phalon and of the spinal marrow. M. Dupuy, professor at 3SS IRRITATIONS OF ENCEPHALON. the veterinary establishment of Alfort, near Paris, seems in the course of five or six years' experience, to have ascer- tained that very satisfactorily.* According to his experience, the encephalon is never af- fected alone in those animals, but is attended with softening of the medulla spinalis at the same time. He has seen twen- ty cases of the latter, and only two of the former; so that the spinal affection in animals would seem to outnumber the cere- bral, as much as the cerebral in man outnumbers the spinal. The ramollissement of the brain occurred in the cortical sub- stance; and of the spinal marrow in the swellings where the fasciculi of nerves to the extremities are given off. In the horse it was more frequent in the posterior swelling, from which the hind legs are supplied with nerves. M. Lalle- mand thinks that some explanation of these situations may be given by the reflection, that it is not the organ of thought which predominates in animals over the rest of the nervous system, as it does in man. The colour, consistence, appearance, and qualities of this affection in animals would seem to be the same as in man, and the result of inflammation. The symptoms were trem- bling of the limbs, weakness, intermittent or continued con- vulsive movements; a tetanic stiffness of the neck, lower jaw, or extremities, and especially the posterior. The horses presented a remarkable gesture, which, in the phraseology of veterinaries, is called pushing against the wall: support- ing the head firmly against a resisting body, and pushing for- ward u ith the hind-legs, they withdrew the fore-legs from the ground, and would sometimes remain for an hour in this arched position. When the tetanic spasm was withdrawn, they would then tumble down. They were disposed to re- new the position as frequently as they could, until finally they were prevented, by paralysis invading the hinder extre- mities. ' Lallem. p. 508. i [ 389 ] CHAPTER XXIII. IRRITATIONS OF MEDULLA SPINALIS. PHLEGMASIA. The pathological changes of the medulla spinalis bear a very close analogy with those of the encephalon, as may be supposed from the similitude of structure. They are, however, not so frequently met with. I have, myself, no doubt that this comparative scarcity in part, exists in nature; but I am also satisfied, that if persons were more in the ha- bit of examining the spinal marrow after death, it would be found much more frequently diseased in its membranes or substance, than we at present are inclined to admit. In re- gard at least to my own experience, I must say, that arach- nitis of the spinal marrow is, by no means, a rare com- plaint in persons of all ages; and frequently exists where the symptoms indicative of it, have either been passed over, or not properly appreciated during life. Acute inflammation of the substance of the cord, has not been often described. It has been found more usually com- plicated with mechanical injuries done to the spinal column, and attended with fracture or dislocation of the vertebrae. In a case vvhich 1 examined in the summer of 1826, where the individual, a robust man, had broken his neck at the junction of the seventh cervical, with the first dorsal vertebra, bv being jostled from his cart, and where death occurred 390 IRRITATIONS OP MEDULLA SPINALIS. on the third or fourth day after the accident, a good deal of extravasated blood was found in the cavity of the spine, and some also in that of the dura mater, of the region injured. The spinal marrow itself was mashed, or rather, so com- pletely demolished at the seat of the injury, that its life there, must have been instantly destroyed. As is usual in such cases, there was a complete destitution of myotility and sensibility, in the parts of the body supplied with nerves from the spinal marrow, below the lesion. In a case narrated by M. Sendrin,* where the injury had been inflicted on the fourth and fifth dorsal vertebrae, by the fall of a piece of timber upon a carpenter; (the examination being made twenty-six hours after death,) the muscles on the side of the spinous processes of the region injured, were red, softened, and infiltrated with blood and serosity. The fourth and fifth spinous processes were fractured, and much other injury done to the ligamentous structure of the vertebrae. The posterior mediastinum was infiltrated with pus around the seat of the injury. The spinal marrow at that point presented a superficial softening, four inches long by one line in depth, and having the colour of wine lees. The right lung was infiltrated in its middle lobe, with a large quantity of black blood, and had its tissue of a red violet hue. In the cases of acute inflammation of the spinal cord, re- ported by Dr. Abercrombie and 011ivier,t where the affec- tion had arisen without mechanical violence, the tunica arachnoidea of the cord in the cases generally, had a coat- ing of coagulating lymph upon it, more or less blended with pus, and in some instances, the latter was found in conside- rable quantities within the dura mater. The substance of the cord itself, was affected to various degrees in different individuals: in some, it was only somewhat softer than common, and this in distinct spots; from this comparative- * Vol. i. p. 347. | Traite de la Moelle Epiniere, Paris, 1827. PHLEGMASIA. 391 ly limited pathological stare, it* was found in all the grada- tions, to a perfect diffluent ramollissement for several inches: sometimes confining itself to the anterior columns, and some- times to the posterior; and on other occasions, affecting both the anterior and the posterior columns. The testimony of pathologists and writers of the present day, is, I think, decidedly in favour of the acute inflamma- tory affections of the medulla spinalis, being disposed to end in a softening or melting down, as it were, of the struc- ture. The disease ends fatally in from a week to two months, or more. In some instances, it begins like a rheu- matic affection of the back, but generally it ends by a de- clared palsy, both of touch and myotility, which is more or less general in the limbs, and in the trunk of the body. Chronic Inflammation. This affection is productive of precisely the same changes of organization, which occur in the medulla spinalis under similar circumstances. When the irritation is rather mild, and persists for a long time, the tissue of the spinal marrow becomes indurated, and acquires a reddish colour, which is subsequently converted into a deep yellow. Sometimes we find the tenacity of the part in proportion to the induration; on other occasions, it becomes more brittle and friable than natural. In the case of a man aged fifty-nine, who had some symptoms of spinal affection from early life, the posterior half of the spinal cord was in this indurated but brittle state, while the anterior half was reduced to a yellowish diffluent pulp.* This case, I think, proves clearly that both indura- tion and ramollissement of a chronic kind may be considered as different stages of the same affection; the induration being finished by a softening in the same way as we see frequently to occur in tumours. ■ Gendrin,. vol. ii. p. 168, 392 IRRITATIONS OF MEDULLA SPINALIS. The question is not yet fully Settled among pathologists, whether the indurated state of the spinal marrow, without vascular injection, ought to be received as an evidence of in- flammation. Upon general principles, I am much disposed to adopt the opinion; for we constantly see a similar change of structure in other organs, and under circumstances of an inflammatory nature, progressing, however, with great slow- ness. The consistence and hardness to which I here have reference, is about equal to that of the white of an egg, hard- ened by boiling water. In one case, Bergamaschi * found it of this consistence, with the spinal vessels gorged with red blood. M. Ollivier, in an epileptic girl whom he dis- sected, found it in a similar condition, but without injec- tion of it or its mucous membranes. M. Portal t has nar- rated a highly interesting case of this kind as occurring to himself, and in which the inflammatory nature of the affec- tion would seem to have been pretty clearly marked. His words are as follow: " The late Marquis of Causan, of a dry and sensitive temperament, experienced at first formications in the fingers of the right hand, followed by a similar sensa- tion in the foot of the same side. The sensibility of the fin- gers decreased, but they retained their motility: the insen- sibility was prolonged to the hand and the foot. These parts became emaciated and cold; and the mischief extended to the hand and to the leg; notwithstanding which, the patient continued to walk. .The arm and the thigh of the affected side then went into a marasmus, and the marquis remained in that state for a year, still continuing his exercise, though in his chamber, by means of a crutch. In the mean time, the ends of the fingers and of the toes, on the left side, began to be affected in a way similar to those on the right, and the disease progressed upwards after the same process; the fore-arm and the legs being first affected, and the arms and thighs subsequently. Ollivier, loc. cit. ' Ar>.v .Med. vol. iv. p. 11; PHLEGMASIA, 393 " The marquis was thus forced to keep his bed, being de- prived of all motion in the extremities, and in the trunk. He breathed and swallowed easily, and for some time the other functions were properly executed; but gradually the sight dimmed, and finally became extinct; the hearing be- came hard, and also ceased. The patient still articulated badly a few words, and could swallow a few spoonfuls of broth or of jelly at a time; the pulse was then slow, hard, and unequal. From this grade the malady still progressed slowly. The respiration, from being free became slow; the deglutition was more and more difficult; the pulse diminished to forty, thirty, and even ten pulsations in a minute: finally, the patient died. " On the examination of the body after death, all its or- gans, even the brain, were found in a natural state; but that portion of the medulla spinalis contained within the cervical vertebrae, was reduced to a cartilaginous consistence; and the membranes of this spot were very red, and much in- flamed." It sometimes happens that the tissue of the spinal marrow, like that of the brain, after it has suffered a long time from chronic inflammation, will be found on death as red as it is in acute inflammation of a few days' standing. This has been observed both where the spinal marrow was irritated by violence,* and where the disease has been spontaneous.t Generally, it will be found that the symptoms indicated at first a slow progress in the malady, and that subsequently they have been rapidly developed, so as to assume an acute character; for example, the limb which previously had been paralytic and motionless, will become convulsed. ' Gendrin, vol. ii. p. 174. f Portal, vol. iv. p. 116, 50 394 IRRITATIONS OF MEDULLA SPINALIS. Ramollissement of Spinal Cord. From what has been just stated on the acute and chronic inflammations of the spinal cord, the inference will be rea- dily presented to the mind, that the pathological change called ramollissement, like that of the brain, is a consequence of both chronic and of acute inflammation. It is one of those conditions which the nervous pulp of the brain and of the spinal marrow seems much more disposed to run into, during a state of irritation, than into any other, excepting mere sanguineous, congestion. This may arise principally from their peculiar consistence as well as from their peculiar structure. This affection of the spinal marrow, like those of the brain, is sometimes confined to one half or to one side only, and therefore manifests itself on one side of the body only; but from the smallness of the cord the affection gene- rally lasts in this exclusive way for a few days, and is then transmitted or communicated to the other side also. Being destined to preside over the functions of sentiment and my- otility in the trunk and limbs, its derangements are mani- fested by the lesions of these functions, by their being exe- cuted either in excess, in diminution, or by their being per- verted. According to M. Pinel, where the ramollissement is inflammatory, there are convulsions, with general pheno- mena of reaction; but, if it be the contrary, or atonic, M. Foville states that there is first a diminution, and then a complete loss of sentiment and myotility.* The derangements of the two last are either general or par- tial in affections of the medulla spinalis, and it is from those states that we are brought to infer the extent and locality of the disease. When it occupies the dorsal and lumbar por- tions, the trunk, the rectum, the urinary bladder, the geni- tals, and the inferior extremities, are the seats of the morbid * Rostan, p, 187. PHLEGMASIA. 395 phenomena: and when it is situated in the upper part of the neck, these phenomena include the thoracic extremities in their range. From this, it will be seen, that the symptoms of disease radiate from the medulla spinalis along the fasci- culi of nerves detached from it, to the various points of the body. The following case will serve to illustrate this subject, and the complications to which inflammation of the spinal mar- row is subject. Mr. Benjamin R. C, aged forty-three, had for many years, twelve or fifteen, been subject to intermittent convul- sions, considered to be epileptic; and, when walking, had an awkward, tottering gait. During the last year of his life the convulsions became less frequent; but he finally died in a state of extreme marasmus, evidently connected with them. Exterior Aspect.—Skin of a leaden colour. Lower ex- tremities dropsical. Head.—Tunica arachnoidea thickened and opaque in se- veral places: in the fissures between the convolutions, it was separated from the pia mater by water, and at the interior face of the hemispheres, by bubbles of air, possibly from pu- trefaction. There was an abundance of serum also beneath the arachnoidea around the medulla oblongata. I may men- tion it in passing, that from this case I learned that it is the adhesion of the tunica arachnoidea to the pia mater, within the first cervical vertebra, which prevents water from passing into the spinal canal from the cranium. The pia mater was healthy. The cerebrum had its corti- cal substance softer than usual: the medullary was very plas- tic, yet tough and soft, and had many points of red blood in it. The lateral ventricles contained each about two drachms of serum; tunica arachnoidea thickened on corpus callosum; marasmus and softening .of the fornix;—plexus choroides, large and having several vesicles in it; its veins were filled with dark blood, looking as if it had been stagnated and then soaked in water, for some time previous to death. 396 IRRITATIONS OF MEDULLA SPINALIS. The cerebellum was very soft. The medulla spinalis soft from one end to the other; in the region of the cauda equina it was reduced for an inch into a semi-fluid state. Its cineritious, and medullary struc- ture parted readily from one another by scraping with a knife handle. The most posterior fasciculi were very distinct. Tunica arachnoidea somewhat thickened, and opaque in places, and contained about three drachms of serum between it and the pia mater. The abdomen was natural; and as there had not been any pectoral symptoms, we did not examine the thorax. This autopsy was made thirty-three hours after death, for Dr. Chapman the attending physician. There was no per- ceptible putrefaction, and the body had been kept over a tub of ice; yet as the weather was warm, perhaps it might have assisted in softening the tissue of the brain, and of the me- dulla spinalis. A very interesting case of softening of the spinal marrow, and which suits well our present purpose, is narrated by M. Pinel, fils.* A girl aged 27, in good health, named Maria Brisset, serving as a domestic in a family, was accused of having committed a theft, and though innocent was sent off. Her menses, which had been flowing for three days, were in- stantly stopped, and she returned to her parents in profound grief for the discredit attached to her. On the third day afterwards she was found in bed in a state of perfect coma, both in regard to sensation and intel- ligence. Being taken to the H6tel Dieu, her stupor disap- peared in a month and a half, but she remained in a state of mania, which occasioned her transfer to the Salpetriere, Au- gust 18th, 1818. The symptoms then were, astonished look, difficult articulation, slow painful answers, which were rarely exact; inertness, but not palsy of all the limbs; an al- most continual repose, automatic life; sometimes she hadac* * Rostan, p. 191. PHLEGMASIA. 397 cessions of rage and of impatience. The organic functions were completely and energetically executed. For fifteen months she continued in nearly the same state, only be- coming very corpulent. On the 15th of January, 1820, she was suddenly seized with convulsions. The next day she exhibited frothing at the mouth, the eyes turned backwards, grinding of the teeth, tetanic closure of the jaws, profound coma, convulsive jerks of the trunk repeated three or four times a minute. The limbs were immoveable, and did not participate in the convulsions of the trunk. "The pulse full, frequent, irregular, and tumultuous; the respiration short, embarrassed, and hurried; the alvine evacuations involuntary. The whole body covered with ap abundant sweat, of a strong durable smell, and rising in vapour above the patient. For three days the convulsions of the trunk were continually repeated, seeming stronger in the day, and accompanied with a paroxysm of fever, and the other symptoms continued. At the end of this time the patient died." Autopsy thirty-six hours after death. Head.—Cranium thick and injected; the dura mater thin, almost diaphanous; the longitudinal sinus gorged with blood; the arachnoid presented in all the extent of the frontal and parietal region, the traces of an ancient inflammation, an- nounced by thickening, by layers of lymph, by a purulent serosity, and close and general adhesions to the cortical sub- stance. The cerebrum and the cerebellum examined with care, offered nothing unusual, only the ventricles contained a little serum, and the cerebral substance was firm. Spinal Marrow.—The membranes were healthy, but the substance itself was reduced to a yellowish, inodorous, and diffluent pulp, from the fourth cervical to the first lumbar vertebra. In the lumbar region the spinal marrow resumed its ordinary consistence, and was bathed somewhat in a red- dish serosity. 398 IRRITATIONS OP MEDULLA SPINALIS. The abdominal and thoracic viscera were healthy; the ute- rus was very small. Many cases of a similar kind are recorded by patholo- gists, and I may refer particularly to the writings of M. Rostan,* and to those of Dr. Abercrombie,t but such as I have narrated will be sufficient to illustrate the type of ra- mollissement of the spinal marrow. Dissolution and Removal of the Spinal Cord. Another state to which the spinal cord is subject, is a par- tial deficiency. I have not met with it myself, but several cases are recorded by medical writers. Mr. Copeland,| met with one where the patient, a man, suffered paraplegia, dysuria, obstinacy of the bowels, and a feeling of tightness across his belly, as if a broad band had been bound tightly around it. His health had suffered for a year, and the com- mencement of his indisposition was attributed to a sprain of the back, from lifting a heavy weight. After a confinement to bed of three months from a perfect paraplegia, he died with gangrenous nates. On autopsy after death, the verte- brae were found in a perfectly healthy state; but within the last dorsal, and the first lumbar vertebrae, the spinal cord was entirely wanting for more than two inches; and the membranes, which there formed an empty bag, were unusual- ly vascular, and much thickened. In Majendie's Journal of Physiology, a case is recorded in which the arms during life had suffered a loss of myotility, but retained their sensibili- ty, and the legs were not affected. This patient, at the au- topsy, presented a spinal cord, which had become quite li- quid through two thirds of the dorsal, and one third of the cervical region. * Rostan, from page 186 to 201, inclusively. f Diseases of Brain and Spinal Marrow, from page 340 to 351, in«lu« sively. * Dis, of Spine PHLEGMASIA. 399 In a child eight years of age, who died of extreme maras- mus with caries of the vertebrae, but without loss either of sensibility or motion of the limbs; Ollivier found four inches of the cord entirely wanting. Velpau has recorded several similar cases. These are very singular instances of devia- tion from the usual routine of symptoms in diseases of the spine, and are well suited to perplex the pathologist in ac- counting for them. I am inclined to believe that the cord, before its entire removal at places, must have gone through the process of ramollissement and liquefaction described in a former part of this chapter, and the condition of it is there- fore to be referred to that pathological change: this, how- ever, does not account for the anomaly of symptoms. M. Rullier of Paris, has communicated a very remarkable case, where the middle third of the medulla spinalis was in a diffluent limpid state. The individual, aged forty-four, had the symptoms of the disease on him for ten years: they ad- vanced very gradually until they settled down into a perma- nent contraction, with aching of the upper extremities. He walked on the Boulevards, however, a few days before death, and possessed his intellectual and moral faculties unimpaired, and his passion for sexual intercourse.* Apoplexy of Spine. The next affection of the spinal marrow which I think it useful to describe is apoplexy. The symptoms of paralysis here, and want of sensation in the part below, come on with considerable rapidity in many cases, and it may be known principally by that circumstance. The effusion of blood is, I believe, much more frequent on the outer side of the dura mater than within it, and the symptoms would seem to arise principally from compression of the spinal marrow. This * Jour. For. Med. Science, vol. iii. p. 593. Phi' 400 IRRITATIONS OP MEDULLA SPINALIS. affection is sometimes spontaneous, but more frequently it results from violence as, a blow, a fall, or a strain. A mo- ment's reference to the anatomy of the spine, will explain to us the greater frequency of extravasation on the outer side of the membranes, than in the substance of the medul- la spinalis. The latter is, when compared with the brain, very deficient in blood vessels, and especially large ones; its natural texture is firmer, and its pia mater is a perfect coat, and possessed of much more strength than the pia mater of the brain: this allows it to support much better such blood vessels as ramify on its surface, and in the substance of the cord. But on the outer side of the dura mater, loose from it, and adhering to the posterior faces of the vertebrae, exist those numerous veins designated as the sinuses of the verte- bral column; other veins also are found on the bony bridges of the vertebrae. In both cases they have very thin parietes, and are easily ruptured by mechanical violence, or by conges- tion: they seem to be formed, principally, from the internal membrane of the veins, and to have only a very thin exter- nal coat. Corresponding in office to the sinuses of the dura mater of the brain, they differ from them in this point of structure, that they are too weak to bear much distention without rupturing. Haemorrhage from these sinuses, then, I believe to be the most frequent cause of apoplexy of the spinal canal. The following cases will illustrate the conse- quences of this affection. " A child aged seven days, September 1st, 1818; was ob- served not to suck, and appeared as if he were prevented by something which impeded the motion of his tongue. Through the following day he cried frequently, and still did not suck; in the evening he was seen by Mr. White, who found the jaw clinched by spasm, but by very little force it could be opened. On the third day he was seized with convulsion, which recurred at various intervals, sometimes in the form of tonic spasm of the whole body, and sometimes of violent PHLEGMASIA. 401 convulsive agitation. On the fourth the convulsion conti- nued, and he died in the afternoon. Inspection.—No disease could be detected in the brain. In the spinal canal, there was found a long and very firm coagulum of blood, lying between the bones and the mem- branes of the cord on the posterior part, and extending the whole length of the cervical portion.* It was my misfortune in August, 1S28, to lose a child of three weeks, under similar circumstances. Some hesitation in sucking had exhibited itself, occasionally, almost from the day of his birth, and seemed to arise from a suspension of respiration for a few moments at a time. On the eighth day, these suspensions of respiration became more frequent, more protracted and obvious, and during their continuance, were attended with a drawing up of the arms and legs, with a slight spasmodic motion, and some frothing at the mouth, together with blackness of visage. When the res- piration was restored, it was followed by cries of distress, like screaming. A lethargic disposition supervened, which, for the first twenty-four hours would yield to the adminis- tration of nourishment; it then became profound, and lasted so for the next day, 24 hours, when death followed. The lethargy was attended, during its whole course, by the dis- order in respiration, and slight spasm of the extremities. Towards the last, the intervals of respiration became so long, and the infant was so perfectly motionless, that on several occasions, life was supposed by those around to have ceased. From the simultaneous absence of all my friends, on whose accuracy, as pathologists, I could rely; an examination of the body was unfortunately not made: I can only, there- fore, deduce the inference, that there must have been some important lesion of the spinal marrow or brain arising, pro- bably from extravasated blood. While on this subject, I may state, that the frequent examination of still-born infants, * Aber. p. 362 51 402 IRRITATIONS OF MEDULLA SPINALIS. or those who have died in a few days after birth, has con- vinced me, that a very common cause of death, is an extra- vasation of blood; I may indeed say, in so many words, apoplexy of the brain, and perhaps of the spinal marrow. Though of the latter, I am not so well assured from actual observation, probably, from having permitted many oppor- tunities of verifying the opinion, to pass unheeded, in con- sequence of not having my attention especially directed to the state of the spinal marrow, as well as to that of the brain. This apoplectic state of the brain in children, I have thought to arise from the same cause vvhich produces the tumefied ecchymosed scalp, to wit, undue retention of the head in the pelvis of the mother, and the continued con- tractions of the uterus driving and accumulating the blood in it. The following note I have transcribed from my dia- ry of dissections. It was written in 1825, without any view to a theory, and under no expectation of making it a subject of publication: it may, therefore, be considered, as an observation, affected by no other bias than a desire of hold- ing an accurate opinion on a very important subject. " I have now examined on various occasions, about seven still- born children, one of them being a gestation of seven months. I have found, invariably, ecchymosis of the cel- lular substance connecting the integuments of the head, to the pericranium; generally it was much diffused: and along with this, I have always found a considerable effusion of blood under the pia mater and over it, arising from rupture of its blood vessels. In some of those cases, the coagulum of red blood formed a layer over almost the whole of the cerebrum. One of the most extensive cases of extravasa- tion had the child's head of unusual dimensions, the hori- zontal circumference of the cranium being fifteen inches, and the diagonal one being sixteen and three fourths. The labour in this case had lasted twenty-four hours, and was brought to an end by the administration of one scruple of PHLEGMASIA. 403 rirgot, which in fifteen minutes began to take effect. In this case, as well as in another of still birth, where the child was a very fine one, I think it right to state that I had some apprehensions of the dose of ergot having assisted, at least, in the fatal consequences to the child; by causing an incessant violent contraction of the uterus, until the expul- sion of the child; and consequently forcing the blood into its head, as the latter passed through the pelvis." In January, 1825, I examined for Dr. Shoemaker, an ex- perienced accoucheur of this city, a child, aged ten days, of Mr. B. After a very natural delivery and perfect health for a week; this infant was taken with violent crying, dif- ficulty of respiration, and blueness of the face and body. On examination after death, we found the veins of the pia mater congested in the highest degree with blood, and the latter extravasated in spots, under the pia mater, and beneath the parietal bone, between it and the dura mater. The scalp in this case was not ecchymosed, as is usual where blood is extravasated in the cranium. We could only conjecture the period of this pathological condition, to have been con- temporaneous with the passage of the child's head through the pelvis. The preceding cases may be considered as illustrative of apoplectic effusion upon the brain, and perhaps, also, upon the spinal marrow of children; at any rate, there can be no ob- jection to the first reported by Mr. White. The following will represent the apoplexy of the spine in adults. " Olli- vier reports, that a lady, aged forty, had head-ach and pain of the back; after a few days the pain of the back became very acute, and violent convulsion took place, which was fatal, after continuing five or six hours. All was sound in the brain, but extensive extravasation of blood was found in the spinal canal, which was most abundant about the seat of the pain. A gentleman, aged sixty-one, had just arrived in Paris, +>om a long journey, when he complained of pain in hif 404 IRRITATIONS OF MEDULLA SPINALIS. back extending from the cervical vertebrae quite to the sa- crum. After a few hours he was seized with paraplegia, and incontinence of urine and faeces; and he died while the physician was talking to him, who had been sent for on the occurrence of the palsy. There was extensive extrava- sation of blood in the spinal canal, under the membranes of the cord. At the lower part it formed a mass like a bouil- lie of bullock's blood, in which the substance of the cord could not be distinguished, as far as the third dorsal verte- bra; and above this, where the cord was entire, it was of a deep red colour, and very soft. * A gentleman died of a disease which was considered as apoplectic, but in which he retained his mental faculties to the last. No disease was discovered in the brain, but there was a great quantity of extravasated blood in the spinal ca- nal.t These cases will be sufficient to illustrate the affection with vvhich we are occupied: I have no doubt that it is of more frequent occurrence than what we suppose, in con- sequence of the too general neglect of examining the spine in our autopsies, and that many of the cases of paralysis of the trunk and limbs, where there is a sudden loss of myo- tility and sense of touch, with retention of the intellect, de- pend upon rupture of some of the blood vessels of the spi- nal canal, and the compression of the spinal marrow. * Gaulter de Claubray, Jour. Gen. de Med. 1828. f Du Hamel Reg. Societ. Acad. Histor. An. 1683, sect. 5, cap. 2, p. 264. Id. 364, [ 405 ] CHAPTER XXIV. IRRITATIONS OF THE NERVES. PHLEGMASIA. The nervous cords, like other parts of the body, are sub- ject to the various grades of inflammation and their conse- quences; and the ischiatic nerve, from the pelvis downwards, seems to be especially liable to such attacks. Sometimes the inflammation is confined to a space of a few lines in length, but on other occasions it extends for several inches. The augmentation of local sensibility, and the pain in these cases are extreme; and there is generally a sense of numbness and an inability to use the muscles of the part. The anatomical characters of these inflammations, are a lively red colour, and a high vascular injection, vvhich be- comes the more minute and intense in approaching to the centre of the phlegmasia. The capillaries which run longi- tudinally, are united by a multitude of fine transverse ca- pillaries, vvhich M. Gendrin* says no artificial injection in the natural state can make evident. The nerve becomes tu- mefied, its filaments more separated than in the healthy state, and its interstitial cellular substance infiltrated with serosity. When the inflammation is very intense, the nerve becomes of a uniform brown or violet colour, and infiltrated with red blood. The distinctness of the vascular injection is lost, ex- * Gendrin, vol ii. p. 142, 406 IRRITATIONS OF THE NERVES. cept upon the boundaries of the phlegmasia. The nerve be- comes harder to the touch, but at the same time its consist- ence and strength are so diminished that it tears through rea- dily. Its peculiar texture is lost; it becomes homogeneous, and resembles a cord of inflamed cellular substance. In some of the dissections of persons who had died from inflamed nerves, reported by M. Gendrin,* pus was found infiltrated between the fasciculi of nervous cords and also in the sur- rounding cellular substance along the track of the nerve. In these persons the disorganization of the nervous fibrilla was short of what occurs in the most active inflammations, where they, as just stated, are converted into a homogeneous mass. It appears from the experiments of M. Gendrin, that the inflammation of a nerve, when artificially excited, produces also an inflammation of the organ to which it is distributed: thus that of the fifth pair makes the eye inflame; that of the par vagum, the stomach, but not the lungs; that of the sper- matic nerves, the testicles. But in the extremities the con- sequences are not the same, but only a serous infiltration, ra- ther inconsiderable, and occurring only when a considerable J.ength of nerve is affected with phlegmasia. « Sub-Inflammation. Chronic inflammations of the nervous cords are much less known than one would suppose: this may arise from the comparative infrequency of such diseases; but I am also dis- posed to think that the cases of it have been overlooked or mistaken when they did occur. Like acute inflammation, it may be confined to a spot or be extended for several inches along the nervous cord. The pain is excruciating and en- during; never intermits entirely, but only remits. The dis- ease has for its anatomical characters, enlargement of the part affected, augmentation of density and vascularity, indu- * Gendrin, vol. ii. p. 148, PHLEGMASIA. 407 ration and friability. The cellular substance forming the sheath of the nerve, and holding its fasciculi together, is also thickened, indurated, and becomes infiltrated. When in London, in 1821, I saw Sir Astley Cooper ex- tirpate a tumour of this kind from one .of the nerves of the fore arm; it was about the size of a small nutmeg. He mentioned, that he had, on several other occasions, ex- tirpated similar tumours. Coutugno* once found an infiltration of the ischiatic nerve, in an individual who had been subject to pain along the course of this organ. In a case reported by Mr. War- drop, where amputation was performed on a gentleman wounded at Badajoz, to relieve him from violent pains, which he felt along the course of the radial nerve, down to the fingers; this nerve was found tumefied and hard, and the remains of a ball between its filaments above the el- bow. It would seem also that this chronic inflammation of nerves is the attendant of large ulcers of the legs. M. Gendrin found it in the saphenus nerve of an old man, attend- ed by varicose ulcers, where the ulceration occupied one half of the length of the lower extremity. This individual had died from apoplexy. Mr. Swant also reports a case of am- putation for a large fungous ulcer of the leg in a woman, aged forty-three. On dissection of the limb, the external popli- teal nerve, (Nervous Peroneus,) and the internal peroned Cutaneus were tumefied, and in a state of chronic inflam- mation. J The nerves are found, occasionally, in a state of maras- mus. This is especially the case with the optic* where the eye has been lost. It seldom extends beyond the junction of the nerve with its fellow. The nerve in this state is re- duced to one third of its common size, is of a drab colour, and has lost all the nervous matter entering into its com- position. * De Iscliiade Nervosa. 1770. t Pathol, of Nerv. System, London, 1822, Gendrin, vol. ii. p. 180. [ 408 ] CHAPTER XXV. DISSECTIONS ILLUSTRATING THE PATHOLOGY OF THE ENCEPHALON AND MEDULLA SPINALIS. APOPLEXY WITH FRACTURE OF CERVICAL VERTEBRA. Autopsy four hours after death. Alms House, Oct. 10th, 1828.—Dodge, a man aged fifty- six, of intemperate habits, and who had been treated a short time before for mania a potu, fell into the dock, as was sup- posed, in a fit of intoxication. This occurred on Wednes- day evening, the 8th inst.; he was taken out and brought to the Alms House. The symptoms were perfect paralysis of the whole body, from the neck downwards; weak pulse, cold skin: he had enough rationality left to give an account of himself. The head was distorted, the chin inclining over to the right side. The deformity could be removed, but it returned on his being left alone. Some stimulating articles were given, which seemed to recruit his strength at first. The next day he became comatose, and died this day at 12 o'c. Autopsy at 4 P. M. Exterior habit full. No putrefaction. Head.—In cutting up the scalp, much blood flowed from the divided vessels. Dura mater healthy. Tunica arach- noidea opaque, and raised from pia mater on convexities of hemispheres, and elsewhere by serum, bagging it up like a blister. It was remarkably opaque and thickened at the bot- tom of the fourth ventricle. Just above the left orbitar pro- cess of os frontis, there was an indentation of brain large APOPLEXY. 409 enough to receive the end of the finger transversely. The tunica arachnoidea and pia mater at this point had coalesced, become softened and yellowish, and the adjacent cortical sub- stance seemed also softened; the medullary matter beneath this was harder than elsewhere, approaching to the state of a cicatrix in the brain, perhaps from some old inflammation. The pia mater of surface and ventricles much congested with blood along the whole right side of falx major; and on the same side of upper surface of tentorium, there was a la- mina of recently effused blood in a state of coagulation, cover- ing completely this membrane. It could not be traced to the rupture of any vessel in particular, but seemed rather a tran- sudation, but of this I could not be certain, as there had been no previous injection into the vessels to fill them, for greater satisfaction. The corresponding parts of the left side were free from such effusion, except a spot of a line or two on the flat side of the left hemisphere. Substance of brain of usual consistence. Two drachms of water in ventricles, their arachnoidea being also thickened. Several drachms of serum also at base of brain. Thorax.—Pulmonary tissue sound, excepting the usual congestion of blood in sudden death. Surface adhering closely universally, on both sides to the thorax and medias- tinum, by an old pleuritic inflammation. Heart of common size, but its muscular texture was so weak that I thrust xny fingers through the ventricles without difficulty, and lacerated them easily into strips: a great deal of blood had been col- lected into its right side, which ran out on cutting the large vessels. Abdomen.—Ancientand close peritoneal adhesion between the whole transverse colon, and the corresponding parietes of abdomen, and also between the latter and the front surface of the stomach. In both cases much of the omentum was en- gaged in forming these adhesions, and an adhesion also ex- isted between the whole upper surface of the liver, and the diaphragm. Mucous coat of stomach thickened, much cor- 52 410 PATHOLOGY OF ENCEPHALON. rugated, having much mucus on it, and presenting a rough granulated appearance. Summits of rugae, and left end, pre- sented the punctated redness so common in old drunkards. Stomach empty. Intestines filled with gas. Spine.—A perfect fracture of the intervertebral matter existed between the bodies of the third and fourth cervical vertebrae, it being torn from both bones into a plate. The intervertebral matter was also ruptured between the fourth and fifth vertebrae, the ligamentous fastenings of the third, fourth, and fifth, oblique process were torn up, and along with them the periosteum. The adjoining muscles were infil- trated with blood, and also the whole cellular substance join- ing the pharynx and upper part of oesophagus, to cervical vertebrae. On the outer side of the part of the dura mater correspond- ing to the injured vertebrae there was extravasated blood. There was no extravasation within. The medulla spinalis was healthy and sound: but opposite to the fractured verte- brae in the centre of the left half, for an inch there was blended with the cortical interior an inconsiderable effusion of blood, so faint that it could only be ascertained as such by comparing it with the cortex above and below. It seemed also slightly softened. On the right side it was healthy in the corresponding spot, and as usual. Puerperal Convulsions. Oct. 20th, 1824.—I examined for Drs. Hodge and Dewees, the body of a patient who had died of puerperal convulsions, at the full period of utero gestation. The patient was aged twenty-five, had a vigorous frame, and was in her first preg- nancy. She was ill for thirty-six hours. The practitioner who had been in attendance before these gentlemen, had ad- ministered copious doses of laudanum, the quantity not known. The night of her death she was delivered by Dr. Hodge with the forceps. TETANUS. 411 Appearances.—A deep and extensive ecchymosis had formed across the root of the neck, and extended to the shoulders. On the upper surface of the brain, an irregu- lar patch of blood, of two inches square, was extravasated under the pia mater. The extravasation extended to the bot- tom of the convolutions. The vessels of the brain were tur- gid with blood. Having at the time my attention directed to the precise line of reflection of the peritoneum between the uterus and the bladder during the state of pregnancy, with the view to a new manner proposed by Dr. Physick, of executing the Cae- sarean operation, I observed that it passed from the lower part of the neck of the uterus to the bladder. Without difficulty, I dissected the peritoneum from the bladder, raised it from the cervix uteri, and then cut through the latter into the cavity of the uterus. The uterus was about half the pregnant size, being occupied by the placenta, and somewhat distended with gas. Tetanus. March 23d, 1828.—J. Davis, aged twelve years, a stout boy in the employment of Mr. W. Fry, printer, in passing through the yard twelve or fourteen days ago, struck the fore part of his right thigh against a rough piece of wood, which made an angular laceration of the integuments, each side of which was about an inch long. He continued to attend to his duties till Monday, the 17th, when Dr. Chapman saw him: he then had something like sore throat, for which a cathartic was directed. On Satur- day morning he came under the care of Dr. Jackson, who found him in a general tetanic state, and prescribed a hundred or more leeches to the spine; but owing to a difficulty in ob- taining them, the prescription was only partially executed. He also gave two hundred drops of laudanum at once, with a progressive increase of fifty drops additional, every hour and a half. In the evening, the boy had taken fifteen hun- 412 PATHOLOGY OF ENCEPHALON. dred drops, without any mitigation. As he had not an eva- cuation for several days, an injection of spirits of turpen- tine was prescribed. This did not act for some time, till at length, a pinch of snuff was given to the boy, at his urgent request; the bowels then gave way, and a free purging en- sued. He died in a spasm about nine o'clock, on Saturday evening.* Autopsy, eighteen hours after death, assisted by Dr. Jackson. The laceration was of the integuments covering the in- ternal edge of the middle of the rectus femoris. Upon dis- secting them up from the fascia, the injury seemed to have gone to the fascia: the wound was black, owing to a cup having been applied to it, and its bottom was hardened from the intermixture of coagulating lymph with fat. On raising the fascia from the rectus muscle, I found that the fascia, though it looked entire, had been perforated, the hole being now closed; and between it and the muscle a small splinter existed, half an inch long, and a line or two wide, surround- ed by a deposite of coagulating lymph. The muscle, itself, bore no mark of disorganization or change of structure; but at the point alluded to, it felt hard, like a knot, for a space of six lines in diameter. Integuments of head bled freely on being cut. Dura ma- ter much drier than usual—tunica arachnoidea and pia mater also much drier than common; the latter much congested in its veins. Ventricles contained only a little halitus; cor- tical substance throughout of a deep drab colour, and along with the medullary very much congested. Substance of brain and the nerves firm and hard. There was a great deal of vascular congestion along the spinal canal: the parts cut, on opening the latter, bled very freely. The spinal mar- row and its membranes congested; the former was remark- * The details of this case are more fully communicated by Dr. Jackson, in vol. iii. p. 321, Am. Jour, Med. Sciences. TETANUS. 413 ably hard and firm, feeling almost tendinous. There was nothing like inflammation in it, or its membranes, and they were all dry, there being no dropsical effusion. Thorax.—Heart natural, it contained scarcely any blood, and no coagula; the want of the former was probably occa- sioned by its being in a fluid state, and much having been lost in the examination of the brain. The left lung was col- lapsed to one half the size of the other, though elastic; and adhered every where by long, strong, old adhesions, and short ones to the thorax. There was no recollection of a pleu- risy having occurred at any time of his life. Abdomen.—Intestines and stomach extremely distended with gas, and some escaped from the peritoneum: the peri- toneum healthy. Liver and spleen healthy. Some parts of the small intestines were much contracted, others col- lapsed. The colon was lined internally with a thick coat of very foetid bilious faeces. The mucous membrane of the stomach in its cardiac half was of a flesh or light pink sienna colour; the other half pearly yellow: the former part was thickened, and so soft, that it scraped off readily with the finger nail; the latter somewhat softened, but not to any remarkable extent. Did the congestion of the central nervous system depend upon the laudanum, or upon the disease, or both? Tetanus. A carpenter, aged about 26, thick and well set, and ra- ther intemperate, in jumping from the roof of a house upon a scaffold, April 28th, 1828, ran a nail into the left foot; through his shoe. The inconvenience which he suffered from it was not so great as to cause him to stop work. Near- ly a fortnight afterwards, May 11th, he was in the river to bathe. Wednesday, May the 14th, he began to feel some stiff- ness in the jaws. Dr. Samuel Fox was called in the next day, in the afternoon: he then had perfect opisthotonos with 414 PATHOLOGY OF ENCEPHALON. intermittent spasm of the limbs. The course of treatment by the doctor was to cut open freely the skin of the punc- tured part, and to cauterize it then with caustic alkali. A blister was drawn upon the back of his neck; fifty grains of opium, ten grains at a time, were administered in the course of the night, until he ceased to be able to swallow, and next morning a suppository of sixty grains was given. In the forenoon he was bled 20 ounces; that night, at eight o'clock, he died, May 16th. May 17th, autopsy in fifteen hours after death, assisted by Dr. Fox. Part injured.—The nail had penetrated the sole of the left foot, at the anterior end of the fifth metatarsal bone; the incision of the skin still open and ecchymosed. The sub- cutaneous fat condensed by lymph, interspersed with small spots of red blood; no vestige in it of passage made by the nail. On dissecting this fat away, a hole of two lines diame- ter was found in the anterior end of the fifth metatarsal bone, which penetrated to its centre, and contained a small bit of sole leather, looking as if it had been cut out with a small punch. The nail had penetrated about three lines on the outer side of the nerve of the little toe, just behind the synovial membrane, so that neither the nerve, the ten- dons, nor the cavity of the joint, were lacerated by it, and it had stopped somewhat short of the upper surface of the bone. Much pain had been felt at the corresponding point of the upper surface of the foot, and it had been blistered. Head.—Countenance placid, collection of blood about mouth and face. Scalp bled freely on being cut, and the temporal regions were in almost an ecchymosed state, from the abundance of blood in the veins small and large. Bone and pericranium congested also. Dura mater healthy; sinuses abounding in blood. Arach- noidea here and there somewhat turbid, probably from his intemperate habits; a little serum beneath it. Pia mater much congested, with some spots of ecchymosis. Cerebrum TETANUS. 415 and cerebellum, when sliced, bled freely from the cut ves- sels in dots, being both much congested: we thought that they were also somewhat softer than usual, but not univer- sally so. Ventricles healthy, but plexus choroides distended. Medulla Spinalis.—The vertebral sinuses highly con- gested, with blood accumulated in them, and partially ecchy- mosed from their fulness. Membranes healthy, and not unusually occupied with blood. Medulla spinalis itself, about the consistence of the brain, being universally some- what softer than common. Thorax. —Heart empty, larger than usual, the lungs al- most black behind from congestion of blood; the blood be- ing fluid, it had probably subsided after death, from heart into lungs through pul. artery. Some old pleuritic adhe- sions on the right side. In left lung some small ossified tu- bercles near its fissure on surface. Vessels of parietes con- gested. Abdomen.—Much flatus; no striking congestion of ves- sels. Mucous coat of stomach having very little mucus on it, and so soft, that it could be scraped off very readily with the knife handle. No marked injection of it, with the ex- ception of some claret-coloured streaks in the course of its rugae. Intestines healthy; some hardened faeces in colon. Liver rather small, and of an olive brown. The abdomen and thorax, were examined before the brain and spinal marrow, but no large vessels were cut. The impression from this case was, that the brain and me- dulla spinalis were the suffering organs, though there was no very strongly marked disorganization: the most obvious change being in the undue softness, which, however, was only a little below the standard. Can tetanus differ from other affections, by its being a universal irritation of the brain and medulla spinalis? and, which runs its course in too short a time to admit of much disorganization? Did the congestion depend upon the opium? 416 PATHOLOGY OF ENCEPHALON. Tetanus. Edwin Bailey, aged 26, of a robust, muscular appear- ance, came into the Alms House Infirmary, July 12th, 1829, labouring under tetanus, (opisthotonos.) Ten days pre- viously, he had punctured his foot with a nail: on the fifth day, spasms supervened. His treatment had been, large quantities of tinctura opii, to the amount, as his friend stated, of "Z\. every half hour. His treatment in this infir- mary, was commenced at noon. It consisted of bleeding from both arms, to the amount of 5lvi.; application of ice to the head, previously shaved; and the free administration of brandy. At 2 o'clock his pulse was 160; ixiij. of blood were taken, and brandy given. At 3 o'clock he died. Examination eighteen hours after death. Head. — On opening the cranium, the blood vessels of the pia mater did not appear unusually distended. Several bubbles of air were seen on the right side; and a few on the left, in the vessels, with some emphysema. The brain was firm, and congested: at a small distance the medullary matter appeared of a light pink colour: ji. of transparent serum was found in each of the lateral ventri- cles. The plexus choroides was almost empty of blood; the fornix rather softer than usual: the texture of the cere- bellum was firm and natural. There was a settling of blood on the integuments of the back. Medulla Spinalis.—The vascularity of the membranes was found in a normal state; the thoracic portion of the arachnoid membrane, turbid, and thickened in spots on the posterior face of medulla: four small, bony and cartilaginous bodies, a line or two in diameter, were seen adhering to the arach- noid membrane. There was a sensible softening of the thoracic portion of the medulla, contrasting very obvious- ly with the cervical and lumbar portions. MANIA. 417 This softening was satisfactorily ascertained by pressure, by scraping, and also by tearing the medulla spinalis into strings or slips. The softened portion was of a light pink colour internally, like the brain. Head and lungs natural. Stomach enormously large, distended by gas to the amount of two quarts, and containing a pint of mucus and brandy: its mucous coat was entirely covered with a thick, tenacious layer of mucus, mixed with coagulating lymph. The an- terior face of mucous coat gangrenous, of a green colour, and diminished consistency. The same disposition to secrete lymph and mucus was ob- served in the duodenum. Liver and spleen healthy. Intestines healthy. Place of Injury.—The nail had penetrated the external margin of the sole of the foot, near the cuboid bone, avoid- ing the fascia, and the puncture could be traced by the tu- mefaction and ecchymosis surrounding its course upward to the trunk of nervus communicans tibiae, where it lies at the external side of the foot. The point of the nail seemed here to have stopped in the thickness of the nerve, which was in a state of inflammation. Mania. Miss-----, aged nineteen, has for four months been af- fected with a decided and violent mania, manifesting itself by eccentric notions and conduct on all subjects. Among other things her desire to escape from her friends was inces- sant; and she on several occasions made attempts at suicide, by plunging a knife at her bosom, by twisting things around her neck, and by sub-mersion. Her mind, previous to this in- disposition, was well developed, gay, and vigorous; and was strongly impressed with piety. About eighteen months ago she was thrown from a carriage, and received a contusion on 53 418 PATHOLOGY OF ENCEPHALON. the head; but Dr. Parrish who attended her then, stated that no serious consequences seemed to ally themselves to this ac- cident, and she recovered fully from it. She had been treated by repeated venesection to a large amount at a time, by cupping and leeching to the head, by blisters over it, and latterly by the application of tartar eme- tic ointment to the scalp, which had produced the usual sore- ness of it. Autopsy twenty-four hours after death. October 15th, 1828, assisted by Drs. Parrish, Otto, and Randolph. Exterior Aspect.—Marasmus moderate. Head.—Well developed, and of good shape, forehead full. The scalp was thickened, indurated to the feel by the irritating applications that had been made to it; cut very ea- sily, and also lacerated easily, so that the stitches in sewing it, were disposed to cut their way out much more readily than usual; it also was watery, as a great deal of serum exuded from it, and was easily torn up from the pericranium. Dura mater natural. Pia mater contained in its veins about the usual quantity of blood, probably somewhat more. Tunica arachnoidea healthy generally, but had beneath it, along the gutters, between the convolutions on the top of hemispheres, a collection of serum raising it into serpentine vesications: where it gets beneath the corpus callosum and fornix it was opaque, and also at bottom of fourth ventricle. One of the veins of the pia mater on the borders of the lon- gitudinal sinus, had a cylinder two inches long, of coagulated lymph in it. Cerebrum.—No change in cortical matter, except it could be rubbed off perhaps with rather more ease than usual. The medullary matter was hard, resisting pressure, but could be lacerated easily, a great deal of serum escaped from its cut surfaces, and these were also thickly interspersed with dots of blood escaping from the vessels. The corpus stria- tum appeared larger than usual, and some calibres of blood vessels parallel with one another, and in contact were seen ARACHNITIS. 419 traversing its thickness below: they were at least half a line in diameter, perfectly patulous and round, and about five or six in number. The ventricles contained but a few drops of serum. The cerebellum was nearly natural. The obvious patho- logical changes in it were a consistence softer than usual, much softer to the feel, and more lacerable than the cerebrum, and it also contained rather more serum in its interstices than natural, but not so much as the brain: its blood vessels were by no means so numerous and visible. Other cavities were not examined, as the request of the family was confined to the head, and no other symptoms than those of derangement were manifested. In this dissection, I considered the sub-arachnoid effusion the partially turbid arachnoid membrane, and interstitial water of the cerebrum, the vascularity, and other abnormal states as pathological; being the result and evidences of ir- ritation in the encephalon. If the greater hardness and the infiltrated state of the brain, and its easy laceration be not an evidence of chronic inflammation, how is it, that the same condition of the scalp, evidently produced by irritating applications to it, should be considered a form of chronic in- flammation? Arachnitis of the Brain and Spinal Marrow, with Pul- monary Consumption. N. M. a black girl, aged twenty, a domestic in the family of a merchant of this city, was taken unwell about the mid- dle of July, 1827. The symptoms which appeared were a dry husky skin, with not much heat in it; pulse frequent; difficulty of breathing on ascending a flight of stairs; slight head-ach; no appetite; bowels regular; menstruation regular up to the last period; tongue indicating no derangement in the viscera of digestion; a sound of the thorax somewhat flattened on percussion on the right side under the clavicle. 420 PATHOLOGY OF ENCEPHALON- I directed her a diurnal diet, consisting in milk one pint, mixed with water one pint, and bread four ounces, which was continued for one month, with an evident improvement in the symptoms; for she became stronger; the expression of countenance was better, and her breathing easier. I observed, however, the frequency of pulse to continue; it was seldom less than 140, and generally 160 in the minute. As she was extremely diffident, I often charged her with being agi- tated, but this she denied. There being, however, no local pain, except in the head, and that slight, I must confess that notwithstanding her assertions, I attributed much to agita- tion. The symptoms seemed at the expiration of the month to have worn away so completely, with the exception of the state of pulse, that I gave her permission to live more freely, indeed almost as usual, and discontinued my visits. The only medicinal application during this month was a blister upon the upper front part of the chest, which was kept open for some days. I saw nothing of her afterwards till about the middle of September, and supposed her well: I was then informed to the contrary; and as, in consequence of a newspaper para- graph, the tea of liverwort had begun to excite considerable attention for pulmonary affections, her mistress desired its exhibition in her case. This was conceded, and persevered in for fifteen or twenty days, without the slightest benefit, except that she thought her head relieved by it. About the close of the administration of this remedy, her stomach be- came exceedingly disordered, and rejected every thing for a day or two, when its extreme irritability ceased, but with an entire loss of appetite. October 15th, 1827.—At this period the symptoms are, one eye turned from its axis, squinting, double vision; arti- culation rather slow; does not complain of pain in the head; pulse one hundred and sixty; respiration rather easy and ARACHNITIS. 421 tranquil; no pain in thorax. Percussion beneath the right clavicle, produces a heavy fleshy sound. On the application of stethoscope no respiration heard there, but it is heard in other parts of the same lung. Sound and respiration of right lung good. No complaint of abdomen. Loss of appetite. I directed the renewal of the blister to the thorax, and or- dered tinct. benz. comp. gtt. xxx. three times a day. A few days after this she became incapable of discharging her urine; the bladder distended and produced the excessive pain, attending that state. Her articulation was broken by sobs and cries, with stuttering and thick speech. The lower extremities became motionless, though extremely painful when touched or moved abruptly; and the other symptoms of cerebral disease increased. The bladder was relieved of a pint and a half of very foetid urine by the catheter, to which instrument I resorted every day afterwards so long as she lived, from the incapability of discharging the urine still continuing, attended with pain and extreme foetor. For two days before death she became comatose, like one under the influence of laudanum, and died, November 4th, 1827, by a very gradual and easy extinction of life. I examined her twenty-five hours after death, in company with Dr. Meigs, stating to him previously that I had expe- rienced much difficulty in satisfying myself, on the diagnos- tics of the disease. That I felt assured, from percussion and auscultation, that the right lung under the clavicle was car- nified, as in consumption; but that she never had any thing like night sweats from the beginning to the end of her sick- ness, no local pain, no cough of any constancy, and no ex- pectoration. The symptoms in fact of hectic fever had ne- ver been evolved; latterly she had on two or three occasions spit up a very trifling quantity of matter resembling a soft- ened tubercle, but this was all. I also told the doctor, that to account for the symptoms, we, on the principles of phy- siological medicine, ought to find the brain about the corpora 422 PATHOLOGY OF ENCEPHALON. striata and thalami softened or diseased, and also the medul- la spinalis in the same way. Autopsy.—Middle atrophy; with a very tranquil expres- sion of face; frame well developed. Head.—Dura mater presented the appearance of being half dried on the top of hemispheres. Pia mater congested with red blood. Arachnoidea at basis of brain much thick- ened by coagulating lymph, identified with its structure; this was more eminently the case about the chiasm of the optic nerves and the inferior part of the third ventricle. The ventricles contained about one ounce of serum; the for- nix was in a pulpy, soft state, and the septum lucidum was stretched and resolved here and there into fasciculi of fibres, forming a very imperfect partition between the ven- tricles. The arachnoidea of ventricles not obviously thick- ened. Corpora striata softened. An inflammatory adhe- sion injected with red blood and cylindrical, caused the tha- lami to adhere; possibly this adhesion might have been the commissura mollis; but if so, it was lower down and farther forward than usual, and much stronger. Substance of brain showed numerous red points of cut vessels. Nothing re- markable about cerebellum, pons, and medulla oblongata; ex- cept that wherever the arachnoidea stretched from eminence to eminence it was thickened and inflamed. Medulla Spinalis.—Dura mater natural; tunica arachnoidea inflamed in its whole length and thickened, adhering very closely to pia mater, and to the roots of the spinal nerves. Texture of medulla softer at places than natural. Thorax.—Right lung carnified in its upper lobe, and ad- hering to the thorax where it gave out the flattened sound; raw tubercles in great abundance through its structure, but none of them softened; permeable imperfectly to air in its two lower lobes. Left lung permeable every where, but abounding in immature tubercles from a line to three in dia- meter; none of them softened. Heart natural. CHRONIC MENINGITIS. 423 Abdomen.—Liver healthy, with the exception of a few tubercular masses interspersed in it. Stomach contained a thin, dark-coloured fluid, smelling disagreeably; mucous coat somewhat browned, and the lymphatic glands along its les- ser curvature, and in lesser omentum, enlarged and tuber- culous; some of them were seen in the thickness of the sto- mach, along its lesser curvature, from one to two lines broad. Intestines generally healthy; at least the marks of disease were not evident, with the exception of a light slate-colour at their upper part in the mucous coat. Organs of genera- tion generally healthy; the internal coat of uterus injected with blood, and could be raised easily with the point of a knife. By an oversight I neglected to look at the mucous coat of the ileo-colic junction, and at that of the bladder; vvhich latter organ, at the time of death, contained some of the dreadfully foetid urine, a little of vvhich escaping by pres- sure made the room almost intolerable to us. I consider this case to have been one of the most satisfac- tory for elucidating the location of disease by the lesion of function, or in other words, for illustrating physiological medicine. Without the squinting, and without the paraly- sis of the bladder, it would have been very difficult to ascer- tain what was going on in the brain and spinal marrow. Chronic Meningitis. Alms House.—A patient, aged about fifty, of intemperate profligate habits, came into the House for a red scaly erup- tion all over the body, supposed to be secondary syphilis. He was very much emaciated, and extremely low. After being in the House a couple of days, he was suddenly seized with stupor, and died the next day. Autopsy, May 13th, 1828, twenty-four hours after death. Head.—Pia and dura mater natural. Arachnoidea turbid universally, and slightly thickened in places, especially 424 PATHOLOGY OF ENCEPHALON. about the basis of the cranium. On the convexities of the hemispheres it was raised up from one to five or six lines in diameter, by the deposition of serum between it and the pia mater. The serum had been deposited more or less under the whole of it, and as deep as the bottom of the convolutions of the cerebrum. This character was so strongly marked, that it might, with propriety, be called an external hydroce- phalus. There were two or three drachms of serum in each lateral ventricle, and the arachnoidea in these was also opaque, and somewhat thickened. Encephalon of common consist- ence generally, with the exception of one or two places, about the bottom of the hemispheres, and the corpora striata, which seemed somewhat softer than usual. The opacity of the arachnoid was visible down the medulla spinalis, as far as it could be seen from the cavity of the cranium. Thorax.—Slight cartilaginous degeneration of the valves of the heart. Some pleuritic inflammation and adhesions: a few crude and small tubercles in the lungs. Abdomen.—Liver yellow and dry, as in old drunkards. Stomach—Mucous membrane of, somewhat softened, and co- vered with thick mucus, and presenting the punctated red- ness of old drunkards. Duodenum—Mucous coat indurated in thin spots, resembling a scirrhous condition of the muci- parous apparatus. Chronic Meningitis, attended with shaking of Limbs, commonly called dumb Palsy, and Paralysis of the Tongue. Mary Noble, aged about forty, has been a resident of the Alms House since 1823. During this time her complaints have manifested themselves principally by an unsteady tre- mulous motion in the limbs, and weakness in them. For the last two years her tongue has been so paralytic, that she could not speak, and she has kept almost entirely in bed. CHRONIC MENINGITIS. 425 Her senses and intelligence have not been strikingly im- paired, and there have not been convulsions at any time, or loss of myotility in the limbs. Autopsy twenty hours after death. June 14th, 182S. Exterior Habit.—Emaciation considerable. Head.—Tunica arachnoidea raised on each side, like a large vesication, from all the tops of the hemispheres, and opaque. The water beneath of a light straw colour, and penetrating to the bottom of the convolutions, and separating them a line or more from one another. Cineritious matter of convolu- tions softened; fibrous matter of the brain plastic but tough, and not so ready as usual, from a sort of agglutation, to sub- mit to tearing in a fixed direction. Thalamus and corpus striatum I thought somewhat tougher or harder than usual. Half an ounce of straw-coloured fluid in each lateral ventricle; tunica arachnoidea opaque under fornix, where it enters. Pons varolii and medulla oblongata, also hardened somewhat beyond what is natural. Cerebellum softer than natural. A small ossification existed under the longitudinal sinus. Medulla Spinalis.—Membranes healthy; medulla very hard and fibrous, so that by taking it at one end, it was easy to tear off an indefinite number of strips from it, going from one end to the other, like a piece of white oak or of hickory wood. Thorax.—Heart sound. Right lung collapsed conside- rably, and a large quantity of gas escaped in a puff from the pleura, when cut into. Lung adhered at places by long fila- ments to side; had several tubercles in it, with some small pulmonary cavities containing puruloid matter, and of various sizes, from a pea to a nutmeg. The pleura opaque, thickened, rough, and contained a pint or more of purulent, opaque se- rum. The left pleura was healthy; but the left lung also contained tubercles and small occluded pulmonary cavities filled with puruloid matter, like the right. No symptoms of consumption had been manifested. Abdomen.—No striking derangement about its viscera 54 426 PATHOLOGY OF ENCEPHALON. generally. The ileum was injected with blood, and on cutting it open many ulcers were seen on its mucous coat, with ragged elevated edges and high vascular injection around as is usual. Some few ulcers were in the beginning of the colon. Mollescence of Hemispheres of Cerebrum. Samuel Waggoner, aged sixteen, a resident of the town of Bellefonte in Pennsylvania, received at harvest time, 1827, a slight blow at the internal canthus of the left eye. In a short time afterwards a tumour began to show itself at the part; and which, in its progress, protruded the eye ball and destroyed its vision. Last winter he was brought to town to be consigned to the professional care of Dr. Isaac Hays of the Eye Infirmary. He was then transferred to the Alms House, and put under the charge of Dr. Gibson; who, on Dec. 19th, 1S27, in the presence of the clinical class, ex- tirpated the tumour, and along with it the eye ball. In this operation, all the contents of the orbit were removed, and a part of the inferior margin of the orbit, which was in a sof- tened ulcerated state. The tumour was spheroidal, from two to two and a half inches in diameter. Was semi-transparent, traversed by small ligamentous fibres, and had the consistence of thick glue, when permitted to cool after being boiled. It was principally albuminous, as it coagulated, and became opaque on immersion in sp. wine. I did not see Waggoner after- wards till May 1st, when the surgical wards of the house devolved upon me in the usual routine of arrangement. The tumour had, in the mean time, resumed its growth, had swollen enormously that side of the.face, resembled in struc- ture the first one, and was subject to occasional bleeding. It was a flattened oval of five inches in diameter, and had a fun- gous appearance. It filled up the orbit, had either displaced or removed the whole anterior parietes of the upper jaw. as MOLLESCENCE OP HEMISPHERES OF CEREBRUM. 427 Well as of the side of the nose, and also occupied the antrum, and had shoved downwards the left corner of the mouth. The patient at this time, as might be expected, was weak- ened and emaciated, his appetite was indifferent. He, how- ever, took his exercise daily, by walking in the ward or in the court; his intellects were good, not obviously impaired, and neither were his senses. He was sometimes sprightly when he could withdraw his reflections from his horrible condition. Considering his case hopeless, I prescribed for two or three weeks, only common cerate dressing, and black drop at night. In the mean time, the discharges from the tumour became so offensive, that to correct them I directed it to be washed once or twice daily, with pyroligneous acid. Persisting in this application for a week, I was struck in the progress of it, with the tendency of the tumour to slough. It encouraged me to keep on with the acid; and the tumour still diminishing in size, by the detachment continually of large sloughs, I had at length the pleasure of seeing almost the whole of the tumour, with the exception of some deep-seated parts of but small thickness, entirely removed; and, what was quite as unexpected, even the edges of the skin began to cicatrize. The falling off of the tumour left a frightful excavation in the place of the upper jaw; one side of vvhich exposed the left nostril in its whole length, the septum being see., from anterior to posterior margin. In the progress of the tumour and of its sloughing, Wag- goner had pain in the face and also in the forehead, especially the left; and this pain continued with remissions till his death, vvhich occurred June 19th, 182S, at nine o'c. A. M. Till the day before his death, he took his exercise as usual. On no occasion had he a symptom of paralysis partial or ge- neral, nor of convulsion, nor interruption to his urine. His senses were perfect and also his intelligence. In my attend- ance I often directed such questions as might inform me of derangement of the cerebral structure, if any existed, and 128 PATHOLOGY OP ENCEPHALON. invariably the replies only alluded to the pain in his forehead1. The evening before his death he vomited freely, and threw up some bilious matter. The want of cerebral symptoms, the sloughing of the tumour, and the favourable time of his life excited some conjectures on the possible recovery of the patient. Autopsy, June 20th, 1S2S, twenty-seven hours after death. Head.—The centre of the anterior left lobe of the brain was found resolved into a soft putrilage, equivalent to about six eighths of the whole lobe. The periphery of the lobe enveloped this mass, the bottom of the lobe was not more than two lines in thickness at most points, and at one point it was perforated by the ramollissement, and led to an ulce- ration of the orbitar process of the frontis communicating with the cavity of the orbit. The parietes of the ramollis- sement was six or eight lines thick above. The whole cor- pus striatum of that side was dissolved, and the ramollisse- ment consequently invaded the parietes of the left lateral ventricle. About one third of the right anterior lobe, bordering upon the anterior margin of the corpus collosum was also dissolved in the same way; and about one half of the corpus striatum of that side. Adhesion of the pia mater, of an in- flammatory kind, existed between the flat sides of the ante- rior lobes, and thereby the ramollissement of the two lobes formed a common mass. The whole of the fornix was dis- solved and of the septum lucidum, and a thin lamina of the under surface of the corpus callosum. The entire cerebrum was several degrees below the common consistence, both in the cortical and medulla substance. The cortical covering of the convolutions over the anterior two thirds of the cere- brum, was of a light pea green colour, the remainder was of the natural colour. The putrilage, or ramollissement, consisted in bits of ce- rebral matter, mixed with serum and red blood; its bounda- MOLLESCENCE OP HEMISPHERES OF CEREBRUM- 429 ries were not well defined. In the centre of the mass it was diffluent, and became, as it receded from the centre, less and less so, until it blended insensibly with the surround- ing cerebral matter. The cerebellum was sound. The arachnoidea of the whole base of the brain was thickened and opaque, and in that state surrounded the nerves of the base. On the under surface of the cerebel- lum, of the pons varolii, and of the medulla oblongata, it was not only thickened and opaque, but had a coating of purulent coagulated lymph. The red inflammation of the pia mater, was very conspi- spicuous where the ramollissement of the two lobes coales- ced, and on the under surface of the left lobe, where its pe- riphery was so thin. At the latter spot the dura mater was ulcerated through to the extent of twelve lines or more in diameter. Beneath the ulceration of the dura mater, at the side of the ethmoidal gutter, was the ulceration just alluded to, of the orbitar process of the os frontis, to an extent equal to the hole, in the dura mater. It was not, however, a single hole in the bone, but several of different sizes, giving it a riddled appearance, and forming a communication between the cavi- ty of the orbit, and of the cranium. I am not certain whe- ther any part of the dissolved brain, actually found its way before death into the orbit through these holes: there was, however, no impediment, unless it might arise from their being rather too small. There is no doubt, that a probe might have been passed from the orbit into the verv centre of the ramollissement, if the communication had been sus- pected before death. The thorax was perfectly sound, and no disease was ob- servable in the abdomen. The bladder was distended with urine. The medulla spinalis and its membranes were perfectly *ound. I was struck with the facilitv with which the. me- 430 PATHOLOGY OP ENCEPHALON. dulla spinalis, after its membranes were pealed off, could be divided from one end to another into an indefinite number of strings or cords, running parallel with one another like the fibres of a piece of white oak. I imagine that this test will be found to prove its healthiness when there is a doubt of its being too hard or too soft. The remarks upon this case are; 1st, that no satisfactory date can be assigned for the commencement of the softening or its cause. I am induced to consider it as a consequence of the tumour of the orbit, whose development after the operation caused the absorption of the orbitar process of the os frontis and irritation of the adjacent part of the brain, and of its membranes. 2nd.—It is surprising that such cerebral disorganization was followed, neither by suspensions, or derangement of intellect, of the senses, nor of myotility. 3rd.—That the tumour should have sloughed so com- pletely away under the application of pyroligneous acid. Does not this indicate some unknown power in it over such tumours well worthy of farther inquiry and experiment? 4th.—The second progress of the tumour reduced the ca- vity of the antrum, of the orbit, and of the left nostril into one large excavation, the whole periphery of which was exposed at the time of death. This tumour, though it shoved the bones opposed to it out of their places, and caused them to drop off; as, for example, all the exterior side of the left nostril, and the parietes of the antrum, above and in front, as well as the left os nasi, and nasal pro- cess of os frontis, did yet secrete patches of bone in its own thickness, and formed for itself an imperfect shell at the back and external side of the antrum, perhaps by the distention of the latter. The septum narium did not give way, but was pushed over to the right side as far as it could L 431 ] Inflammation of the Brain, with Softening of the Ce- rebellum. "J. II., a respectable grocer in Southwark, forty-seven years of age, of full habit, inclined to corpulency; head re- markably large, and neck short; after exposure to cold and wet, was affected with violent efforts to vomit, with great pain at the epigastrium, and considerable pain over the eye- brows. He had taken calomel and jalap, Warner's gout cor- dial, Bateman's drops, and various other spirituous and aroma- tic drinks. These only increasing the vomiting and pain, had, by the advice of a bleeder, 16 ounces of blood taken from his arm, and eight cups applied to his forehead. Friday, April 11th, I was requested to see him. Found him com- plaining of intense pain of the head, but particularly at its anterior and posterior parts: great nausea, and constant ef- forts to vomit, but discharging nothing but a mouthful or two of coloured water; pain at the epigastrium, not increased upon pressure. Head hot; temporal and carotid arteries throbbed violently; face and lips of a purplish hue; pulse full, slow, and somewhat tense; bowels constipated; tongue furred and moist; slight redness of point and edges. I imme- diately drew off from the arm 20 ounces of blood; directed cold to be kept constantly applied to the head, and, to abate the irritability of the stomach—R. Sub-mur. hydrarg. gr. x. div. in pil. No. v. One to be taken every hour. Afternoon.— Vomiting and nausea entirely ceased; pain of head continues unabated; tongue somewhat cleaner; all the other symptoms the same as in the morning; drew off from the arm 20 ounces of blood; continue cold to head, and direct the compound sen- na tea to open the bowels. " Saturday, April 12th.—Pain in head much abated; the bowels had been copiously opened; the discharge being of a dark colour; head still hot; pulse smaller, softer, quicker; tongue dry and brown in the centre; gastric uneasiness gone; slight suffusion of the eyes; intellect good; directed sub-mur. 432 PATHOLOGY OP ENCEPHALON. hyd. o-rs. iij- every third, hour; cold to the head to be conti- nued. Afternoon.—Head painful and hot; pulse as at last visit; bowels continue regularly open. Directed a blister to the nape of the neck; head to be shaved, and cold appli- cations to be continued. " Sunday, April 13th.r—Blister has drawn; head less pain- ful; cooler; intellect good; pulse more natural; bowels open. The head has not been shaved, according to the directions of yesterday. Continue cold to head. Afternoon.—Pain of the head returned with great violence; pulse quick and fre- quent, tense—left eye appears more protuberant than right; skin rather hot; tongue dry and brown, with difficulty pro- truded. The head has not yet been shaved, and for the last twelve hours the cold to the head has not been kept applied with sufficient regularity; ordered leeches to temples. " Monday, April 14th.—Leeches had not been applied until this morning, and then only twelve. The patient, how- ever, appears somewhat better. Ordered, to open bowels, comp. senna tea; sinapisms to lower extremities; leeches to temples repeated. " Tuesday, April 15th.—Patient much worse; lays in a half comatose state; when roused, answers regularly to ques- tions, then falls back into stupor; eyes suffused, pupils con- tracted, but dilate readily on the admission of light; pulse contracted, quick, and tense. Directed vss. sixteen ounces; cold to be continued to head; and an enema, to open the bow- els. Dr. Klapp was at this date requested to see the patient with me. Afternoon.—Good deal of the tenderness of epi- gastrium; other symptoms as in the morning. Directed four- teen cups over the stomach; blisters to calves of legs; conti- nue cold to head. Evening.—Patient worse; stupor; hot head; suffused eyes; pulse quick and tense; picking at bed- clothes; breathing slow and irregular, but no shorter; during the night great restlessness and delirium; at seven o'clock had fifty leeches applied to the anterior part of the scalp, at which part the pain was most complained of: the remainder INFLAMMATION OF THE BRAIN. 433 to be covered with a blister. It may be mentioned, that when the patient was directed to-day to protrude his tongue, he invariably forgot to draw it in, until directed to do so. " Wednesday, April 16th.—Patient better; head cooler; pulse softer and more regular; blister begins to draw; bow- els constipated; calomel x. grs., to be taken and followed by comp. senna tea. " Thursday, April 17th.—Continues better; returns ra- tional answers, when roused; bowels have been fully acted upon; pulse regular: the discharges from the bowels are foe- tid, very dark-coloured. Continue senna tea. Sense of hear- ing rather dull. "Friday, April 18th.—Continues apparently better; pulse regular; head cool; complains of blister on the head; bowels, during last night, copiously opened; discharges still black and foetid, and large in quantity; skin dry; tongue moist; slightly furred; protruded with ease, and fully; ap- pears inclined to sleep, but desires something to eat; direct- ed a few spoonfuls of thin gruel; and B. sacc. limonis recent. ris. carb. pot. q. s. ad sat.; aq. purae; ?iv. spir. nitr. dulc. ^iss. M. Table spoonful to be taken every hour; sinapisms to the feet; the blisters on the head to be dressed. " Saturday, April 19th.—Patient perfectly rational, with the exception, that when directed to present the right hand, he invariably presents the opposite, and vice versa; in the same manner, when directed to draw up one leg, it is al- ways the opposite which he moves; if the arm or leg, intend- ed, be touched, it is still always the opposite which is moved. There are many circumstances which lead to the belief that the genital organs experience a good deal of excitement; skin natural in temperature; tongue slightly furred; pulse ra- ther quick and frequent; patient has entire command over all his muscles, so far as respects the mere circumstance of putting them in action. Continue medicine. Afternoon— 4 o'clock.—Restless; breathing rather hurried; tongue dry, and dark-coloured in the centre; some degree of muttering; =i5 431 PATHOLOGY OF ENCEPHALON- delirium. 7 o'clock.—More composed; pupils somewhat di- lated; dress head with ung. lyttae vesicat. 10 o'clock.—Stu- por has returned; the motion and sound of lips in breathing same as in a person smoking; when roused, answers exactly to questions; but is averse from being disturbed. " Sunday, April 20th.—Same state as last night. 4 o'clock, P. M.— Respiration laborious; unequal dilatation of pupils; strabismus; left side paralyzed; pulse frequent, weak. 7 o'clock.—Stertor; rattling noise in throat; both pupils widely dilated. 7 o'clock.—Death without convulsions. "Post Mortem Examination, twenty hours after death.— Scalp and bones of the skull of uncommon thickness; dura ma- ter engorged with blood; on cutting around this membrane, and attempting to separate the falciform process, found an unnatural adhesion, laterally, between this and the surface of the brain, a portion of vvhich latter was removed, adhering to the falx before^ it could be drawn out from fissure; tunica arachnoidea, on upper surface of brain, thickened, opaque; considerable effusion of serum beneath it; on cutting into the medullary portion of the brain, its surface was covered by innumerable minute points of blood. The cortical part of cerebrum of a much darker colour than natural. Six or eight ounces of serum in the ventricles, and at the basis of brain; plexus choroides loaded with blood; rest of cerebrum natu- ral; at the basis of brain, arachnoid membrane much thick- ened by the effusion of coagulable lymph; presented a jelly- like appearance; at the posterior and inferior part of cere- bellum softening to the size of about a dollar, and of some depth; the substance of the cerebellum being reduced to the consistency of thin starch; the lower portion of the medulla oblongata, or rather the commencement of medulla spinalis, appeared contracted in size, and much denser than natural. Dissection allowed to be carried no farther." The preceding case occurred to Dr. D. F. Condie, and was communicated to me by him, with permission to use it as I thought best. I 435 ] Secretory Irritations of the Arachnoidea and Pia Mater. Hydrocephalus, in an acute state, generally runs its course in from seven to eleven days, at least we have the very sa- tisfactory observations of M. M. Parent et Martinet for ad- vancing this opinion, and it is marked by those disordered actions of the locomotive, sensitive, and intellectual apparatus which distinguish other cerebral affections. In it there is a peculiar expression of surprise or of stupor in the face; the pupils are either dilated or contracted, the eye is injected, turned from its axis, and rolls about conti- nually; sometimes there is a paralysis of the eyelids. The face is in a state of trismus, or of convulsion, and injected. Head-ach, delirium, coma, and stupor are amongst the most frequent and satisfactory symptoms. The locomotive ap- paratus may be affected in a variety of ways: sometimes there is a state of contraction, with a local or general rigidity; on other occasions a general or local paralysis. Sometimes there is a restlessness amounting only to inquietude, and at other times there is a convulsion either partial or general. The stomach is affected with nausea and vomiting, the cir- culation is disturbed as in other severe affections, the respi- ratory functions, except there be a complication, present nothing peculiar. On the dissection of patients who die from acute hydro- cephalus, we find redness of the arachnoid membrane, with a thickening, opacity, and increased density of its structure, exsudations of various kinds on its surface, as purulent, sero- purulent, gelatinous; and layers of coagulating lymph. We moreover find an effusion of serum beneath the arachnoid in the cellular substance, uniting it to the pia mater, and also in the ventricles. This serous effusion seldom goes be- yond an ounce, but sometimes it reaches to six ounces. With these facts before us touching acute hydrocephalus. 43G PATHOLOGV OF ENCEPHALON. or in other words acute arachnitis, showing how formidable and rapid is its progress: and how complete is the subversion which it produces of all the moral and of the physical facul- ties connected with the brain; we are put to great difficulty in reconciling with it, the phenomena of chronic hydroce- phalus, and in believing that the two are the same disease. Chronic hydrocephalus sometimes begins during uterine life, and expands the head of an infant to the size of that of an adult. I once met with it in this state, where it produced a laceration of the cervix uteri and the death of the mother; the cranium is now in the anatomical museum. Most com- monly, however, it begins in a few months after birth, and goes on to increase for years, until finally the head is swol- len into an enormous mass, vvhich the individual is incapa- ble of supporting, and he therefore is confined to a recum- bent posture. The disease having reached a certain point, will remain stationary for a long time; but generally it ends by some slight violence, accident, or exposure, giving rise to symptoms of acute hydrocephalus and the patient dies rapidly under their influence. In these cases of chronic hydroce- phalus, the ossification of the cranium is incomplete, the su- tures and the fontanelles remain open much beyond the usual time, and if nature finally succeeds in putting a complete bony case around the brain, it is commonly by the aid of some extra pieces. The brain itself is not augmented in quantity; but by the large secretion of water into its lateral ventricles, it is distended into a thin sac, whose parietes are sometimes not more than a line or two thick. Cases of an almost incredible accumulation of water are reported. Frabicius Hildanus, for example,* narrates one which lasted for fifteen years, where the head measured an ell in circumference, and was found to contain eighteeen pints of water; and I have myself seen in Edinburgh a cra- nium, which, judging from its extraordinary size, I should * Diet, des Sc. Med,, vol. xxii. 248 CHRONIC HYDROCEPHALUS. 437 suppose, had contained at least ten or twelve pints. The grand source of surprise in these cases is, that vitality should continue long enough to allow of such an extremity of dis- ease, in an organ generally so essential to life. In what light then, are we to view chronic hydrocephalus?—surely not as an inflammation, for if it were such, we should then have the general derangement and prostration of mental and physical functions usually dependent upon an inflammation, and it would be impossible for the disease to advance to such an extreme. It appears to me to be one of the purest exam- ples of a secretory irritation: merely that slight exaltation of action, whereby the exhalents of the arachnoid membrane, pass off their serous fluid rather more rapidly, than it can be absorbed; and the irregularity between exhalation and ab- sorption being kept up for years, finally produces an im- mense excess of the former, as in chronic hydrocele and as- cites. The analogy goes indeed still farther; for as hydro- cele and ascites do exist without disease of the generative and digestive organs, so chronic hydrocephalus being a pure meningeal affection, the essential features in the structure of the brain, are but little, if at all impaired; and the stretching of it out has no greater effect upon its organic functions, than an extra dilatation of the stomach would have upon digestion. The following case will at least serve to illustrate the posi- tion which this affection should hold in our pathological doc- trines; and for the opportunity of instruction which it af- forded me, I am much indebted to Dr. J. K. Mitchell, who attended the patient in his last illness. Chronic Hydrocephalus. Autopsy, December 14th, 1828, eighteen hours after death. Weather moderate. Master M., aged eight and a half years, had his head no larger than usual at the period of his birth. At the age of six weeks, symptoms of hydrocephalus were manifested, 43S PATHOLOGY OF ENCEPHALON. for which he underwent an active treatment vvhich was con- tinued for some time. As he advanced in age he began to walk; his head continued to grow inordinately; his stature was not much affected, and he reached almost the size which is common to boys of eight years. He could walk, run, and participated in the amusements common to childhood; was sent to school, where he learned very readily the sub- jects usually taught; was remarkably smart, sprightly, and intelligent in his conversation; was very fond of music, and learned readily a variety of tunes; his memory was also ex- cellent. For a long time after birth, the sutures of the cranium were open, and the fontanelles unusually large; the ossifica- tion was, however, finally completed, and the cranium be- came firm. The size of his head was so great that he at- tracted much attention; and he was apt to fall, especially for- wards, from readily losing his equlibrium. Dec. 12th, 1828, he fell against a door, and bruised his forehead on the left side considerably. In an hour after- wards he vomited, became very sick, and took to bed, and died the next evening about nine o'clock. The subsequent day, at three P. M. we proceeded to examine his head. Its dimensions were as follows: the largest horizontal circumfe- rence of the cranium, measured around the frontal and pa- rietal protuberances, twenty-eight inches; peripheral dis- tance between meatus auditorii externi, nineteen and a half inches; peripheral distance from root of nose to occipital pro- tuberance nineteen and a half inches. Diameters measured with Callipers.—Antero-posterior, 9 3-10 inches.—Between parietal protuberances, 7 1-2 do.— Between temples, back part, 7 do.—From chin to vertex, 10 do.—Between meatus auditorii externi, 5 do. The bones of the cranium were of the thickness common to children of his age, and the sutures firmly fastened, the sagittal was continued to the root of the nose. There was an os triquetrum on each side of the coronal suture, but no CHRONIC HYDROCEPHALUS. 439 other supernumerary pieces. The integuments of the head were thin and stretched. The dura mater adhered firmly to the cranium, especially along the sutures. The pia mater was vascular; no patho- logical state was perceptible in the arachnoidea, either inter- nally or externally. The convolutions were much shallower than usual, being about a third the common depth. The lateral ventricles, together, contained five pints of limpid, transparent serum, and were distended into perfect bags; the thickness of the cerebrum around them varied in places from four to eight lines. Having made a long cut from the above into each lateral ventricle, I found the me- dullary surface of the ventricles disposed to separate itself from the contiguous part of the cerebrum. The corpus cal- losum was thinned to about one line, and stretched to the breadth of an inch and a half, and its raphe was semi-dia- phanous. Beginning, therefore, at the corpus callosum, we peeled the upper circumference of the lateral ventricle off, as one would tear off paper from a wall: we continued to trace the layer along, and stripped off in the same way the lower circumference of the same ventricle, the layer coming off successively from the hippocampi, and from the thalamus; we found this layer continuous with the fornix, which was raised up in the progress of this peeling process. I endea- voured to strip, by the same process, the surface of the tu- bercula quadrigemina and the valve of the cerebellum, by the continuation of structure with the surface of the thala- mus, but it failed. The process was executed on both lateral ventricles with equal facility; so that a medullary layer, one line in thick- ness, was stripped off completely from the whole periphery of each lateral ventricle, beginning at the corpus callosum and ending at the internal side of the thalami. It is worthy of specific notice, that a cineritious layer of the same thick- ness, and continuous with the other, came off from the sur- face of the corpus striatum. 440 PATHOLOGY OF ENCEPHALON. The septum lucidum was wanting in great measure, there being a free communication of the lateral ventricles of some inches in diameter between the corpus callosum and the for- nix. The margin of the imperfect partition formed by the septum was rounded, and had no appearance of laceration. The cineritious substance of the cerebrum was softened, and followed the pia mater in stripping off this membrane. But the cineritious substance could not be detached clearly from the sub-cineritious medullary substance, in consequence of their intimate coalition. Taking then the thickness of the cerebrum into view, from its surface to the surface of the lateral ventricles, there were evidently made out three layers of matter, the external cineritious, then the sub-cineritious medullary layer form- ing the convolutions and their bases, and then the layer of medullary matter forming the periphery of the ventricles. These two layers of medullary matter seemed perfectly dis- tinct from one another, 1st, By the almost spontaneous se- paration which they made when it first attracted our atten- tion, and then the perfect facility with which the ventricu- lar layer was stripped off universally from the other. 2dly, In examining the vascular arrangement, it appeared that the adjacent surface of each had their capillaries branching out distinctly, as is the case with contiguous but distinct mem- branes elsewhere. The capillaries of the encephalon were generally congest- ed with red blood. The cerebellum, pons, crura, and the base of the encephalon were healthy. There was no sub- arachnoid infiltration any where, the convolutions being close and compacted. The examination was not extended beyond the head. For preparations of peripheral layer of ventricles, see Anatomical Museum. This was the only part we were per- mitted to bring away. I am indebted to Dr. Mitchell, for the following personal history of the patient, in a letter to myself. CHRONIC HYDROCEPHALUS. 441 i{ William M. was born in Philadelphia, on the 4th of June, 1820, the fourth child of his parents. Although his entrance into the world was tedious, no remarkable difficulty attended his birth, nor was there at first perceived any pecu- liarity in his conformation. When about six weeks old, in- cessant cries and a distressing restlessness indicated the ex- istence of pain; and in a few hours he became incapable of drawing nourishment from his mother, making many fruit- less essays with a smacking sound. A physician, after ex- amining his mouth, and dividing the frenum linguae, ex- pressed some fears of the occurrence of disease of the brain. Severe and protracted diarrhoea soon followed, and a very manifest enlargement of the head confirmed the opinion of the medical adviser. " After a variety of treatment, the general health of the child was restored, and continued unimpaired until about a month before his decease, which happened on the 13th of December, 1828, when in the ninth year of his age. During the whole of this period of nearly eight years, his head con- tinued to enlarge without being connected with the slightest head-ach, or any functional derangement whatever. The bones of the cranium became firmly united, and the fonta- nelles closed in his fifth year. "When fifteen months old the child spoke well, and at eighteen months was able to sing a variety of musical airs with tolerable correctness; and always exhibited a strong predilection for music. ft Nearly four years elapsed before he was able to balance himself on his legs, and he was not a confident walker until five years of age. Indeed, the great weight of his head ren- dered him always very liable to falls, and caused him fre- quently to impinge upon his forehead. Sometimes, when at school, he fell backwards from the form. '■' His intellectual faculties generally were very respecta- ble, and his powers of observation rather remarkable. But his memory both of language and sentiments, was such as to 56 442 PATHOLOGY OF ENCEPHALON. create surprise in those who took the pains to converse with him. The following example of his powers of recollection may not be amiss: A customer of his father having been absent two years, returned, and, on his entrance into the shop, saluted as an acquaintance its inmates; but they had forgotten him. On turning to little M----, the latter im- mediately called him by name, inquired kindly about him, and then told him that he had not been to see them for two years. " Of a grave and quiet temperament, he preferred the so- ciety of his seniors, and took little interest in the common pastimes of childhood. Only sedate children were agreea- ble to him. " For so youthful a person, his sentiments and affections were of a lofty character. Seeing the distress of his mother, when commercial affairs took his father to Europe, the child, then five years of age, said, ' Father will soon be back; if he don't come again, I will be a husband to my mother, and will work for her, and take care of her when she is old.' " For two years before his death, little M----became af- fected by religious impressions, which grew stronger and stronger until his death. Often advising others, he present- ed in his own conduct a fine exemplification of his princi- ples, being distinguished among the children of the family and the school, for love of truth and general sincerity of character. At length, even while in full health and vigour, he spoke of death as a thing to be desired; and, when dying, expressed pleasure at the approaching crisis. " On Sunday evening, several weeks before his decease, he was seized with severe nausea and vomiting, which having subsided, returned on the following Sunday, and so on with weekly intervals, until, on Friday, the 12th of December, a severe fall, followed in eight or ten hours by like symptoms, terminated his existence. " During his short illness, he referred all his pain to his stomach, and never complained of head-ach or vertigo. His CHRONIC HYDROCEPHALUS. 443 pulse became gradually slower and more feeble, the tempe- rature of the surface declined: but his mental faculties, and his affections, remained unchanged until he was in articulo mortis. " The singular nature of this case, together with the cu- rious anatomical facts disclosed by your post mortem exa- amination, induced me to make a minute inquiry into the history of the subject of it, previously to the period at which I was called to visit him, which I now beg leave to convey to you." Chronic Hydrocephalus, and Tumour on Cerebellum producing Hemiplegia, Blindness, Deafness, Loss of Touch, fyc. fyc. Mrs. Rebecca D., aetat. about thirty, the mother of two young and healthy children, and of a good constitution, was taken in the spring of 1827, with symptoms of paralysis af- ter some slight indisposition. I saw her in August, and the symptoms were then, intermittent loss of vision in left eye, slow winking on that side, difficulty of hearing, and of arti- culation, loss of taste on left side of tongue, pain in the back part of the head, incessant roaring in her left ear, mouth drawn to right side. Diminished myotility in left upper and lower extremity, and inclination of the body to that side when sitting; in walking across the room with assistance, she invariably swerved from the straight line towards the left side, so that her motion became diagonal to the left. She also complained of pain in the bladder, especially on making water; and whilst 1 was examining this organ a few days afterwards with a catheter, she was suddenly seized with an epileptic fit, to which, under the name of faintings, she had been subject for several months, having had attacks upon any sudden emotion even when a girl. Her functions in other respects, were healthy, and her .nenses regular. 444 PATHOLOGY OF ENCEPHALON. I treated her by adopting repeated leeching to the temples, bleeding from the arm, blisters on back of neck, and on tem- ples; light nutritious diet, with some ligneous teas, as sar- saparilla, valerian, and from time to time, from three to five grains of blue mass or cathartic pills of aloes and calomel daily. She improved so much under this treatment in four or five weeks, that she ceased to occupy her bed habitually, improved in flesh, could, by clinging to the furniture, take her turns around the bed room, and finally got down stairs. The several symptoms stated, all got better, excepting the roaring and pain in the head. With occasional slight changes for better or for worse, she passed through the winter. In the March of 1828, the symp- toms being stationary, Dr. Parrish was joined in consulta- tion, and upon his suggestion, rust of iron was taken to the amount of eight or ten grains three times a day, and an issue was permanently fixed on each side of the head after she had been twice blistered all over it. This treatment was persisted in for two months without benefit; her mouth became sore from the steel rust, and she complained of its heating her stomach. In the progress of this part of the treatment, I observed for the first time, though the symptom might have been constantly present, that there was a loss of sensation in the skin of the left side of the face, from the middle line back- wards, and that the left conjunctiva was also torpid, so that it, like the skin, might be scratched with the end of a straw without her feeling it. Her epileptic paroxysms during all this time recurred ir- regularly at intervals of ten, fifteen, or twenty days. In the latter part of June, 1828, she went into the country by advice, and was absent till about the end of August. On her return, the symptoms were for the most part aggravated. She had become thinner; her stomach rejected frequently its contents; I thought that this might arise from emetics of twenty grains of ipecacuanha each, having been administered CHRONIC HYDROCEPHALUS. 445 to her in the early part of the summer three times a week for four or five weeks in succession, just before she left the city. The value of this opinion will, however, be seen from the dissection. The blindness of the left eye, which for- merly had been only intermittent, now prevailed incessantly, with occasional blindness of the right also, the deafness of the left side had increased with the noise and pain in her head at the back part; insensibility of left side of face the same; to this was added a diminished myotility in it, keep- ing it almost stationary when she talked; left side of tongue insensible to taste, mouth drawn somewhat to right side, myo- tility of left extremities also diminished, but no want of sensi- bility in their integuments. Her menses had now been suspended for four months, and her bowels were disposed to constipation; there was a more frequent recurrence of the epileptic paroxysms. From this period, (August 28th,) till the day of her death, (October 19th, eleven o'clock P. M. in an epileptic fit,) the symptoms increased regularly and gradually, total blindness supervened for a month previous to death; she could no longer sit up out of bed with any comfort, her articulation became thick and slow, her swallowing difficult and slow, and when the food was down it was frequently brought up again involuntarily; and what was remarkable, the process was a sort of ruminating one, for she could immediately af- ter swallow with an appetite, and digest well; this leads us to infer that the mucous coat was sound in its office, and the muscular alone irritable. Her epilepsies occurred three or four times or oftener in the day, sometimes not so often. The night before she died, she became conscious of the presence of a candle in the room, by its light, but she could not distinguish objects. Her intellects never failed; they remained good to the last, excepting that sort of indifference and dulness which always attends a long sickness and soli- tude. Her bladder at various times during my attendance, conti- 446 PATHOLOGY OP ENCEPHALON. nued irritable, but for a few weeks before she died, she ceased to complain of it. About the middle of September, it was ascertained that the interruption to her menses proceeded from pregnancy. By a very gradual process she approached her last moment, becoming weaker and weaker, until life was finally extin- guished in the epileptic paroxysms of the evening of the ISth. Autopsy on the evening of the 20th, twenty hours after death—present Drs. Parrish and Pancoast. Exterior Aspect.—No putrefaction, countenance placid; middle marasmus; no settling of blood in face. Head.—Scalp bled freely, on being cut across from ear to ear. Bones of middling thickness. Membranes.—Dura mater of healthy colour and texture, but drier than usual along the middle line of the head; for half an inch or an inch from longitudinal sinus, on either side an unusual number of granular bodies like the glands of Pacchioni, and supposed to be so; they pitted deeply the bones; in the sinus they were not unusually abundant or large. Arachnoidea and pia mater healthy, but they also seemed half dried, and the vessels of the pia mater were not unusually turgid; indeed they were rather collapsed. These membranes adhered very closely to one another, there being no sub-arachnoid effusion; they also adhered to the dura mater along the longitudinal sinus more than usual, seeming to stick to it. The texture of the cerebrum was healthy, except that it seemed rather more collapsed and flaccid than usual. Its ventricles contained together six ounces of a clear transparent serum, and were very much distended by it, the corpus cal- losum being lifted up considerably from the fornix, and the septum so thin that it was almost torn. The fornix adhered more than usual to the velum interpositum, and the latter was turbid or opaque where it passes into the ventricles. The CHRONIC HYDROCEPHALUS. 447 ventricles communicated freely. No thickening of their arachnoidea was perceptible, nor distention of their vessels. Cerebellum.—It was universally very flaccid, so that it could not retain its shape, but flattened itself by its own weight. On the under surface of its crus of the left side, there was a flattened oval tumour which originated from the crus, and had grown to the size of a hen's egg, extending itself forwards upon the side of the pons, and flattening it in. This tumour consisted in a congeries of cells of various sizes, the walls of which were in a semi-cartilaginous state; and some of them contained serum, others a tuberculous-like matter, and others again a red, spongy, bloody matter. The most familiar comparison of it, is with the ovarium in the beginning of its cellular dropsies. This tumour had raised up in its development, a part of the lateral substance of the cerebellum, and the corresponding pia mater and arachnoi- dea; its first aspect was more like a cyst than any thing else, on the side next to the crus of the cerebellum. The tumour had disturbed the position of all the nerves, from the fourth to the ninth inclusively, because in its de- velopment they had to pass along its under surface, and were both displaced and stretched by the circuit they had to perform. The trigeminus was absolutely torn off, except a few filaments, from the attachment of its root at the pons, and was there almost absorbed; and the remainder of its fila- ments were separated and pressed into a flat fasciculus. The medulla oblongata was pushed to the right side by this tu- mour, and bent. Thorax—Pleurae.—Adhesions between right superior lobe and thorax; in other respects healthy. Lungs—Generally sound and healthy; settling of blood at their posterior parts. Right superior lobe contained half- a-dozen separated tubercles, the largest six or eight lines in diameter. They were of that dry, crumbling, cheese-like kind, vvhich look like old crude tubercles aborted, and vvhich are not attended with derangement of the contiguous pulmo- 448 PATHOLOGY OF ENCEPHALON. nary structure, but merely push it aside. Heart—Natural size, firm, and healthy. Abdomen.—Peritoneum healthy. Stomach—mucous coat empty, and of a sienna colour, except about the antrum py- lori, where it was more of a pink colour. Small intestines healthy. Large intestines healthy; contained but little fla- tus, but filled with hard, dry, compacted faeces, which ex- tended itself for some inches into ileum. The uterus was up to the umbilicus, had pushed up the in- testines, and was next to the abdominal parietes, triangular, and contained a foetus of about six months, lying across the abdomen, the head to the left corner, and the buttocks to the right corner. The collection of faeces seemed to have arisen from the uterus pressing on the rectum, as her common po- sition was on the back. Congenital Hydrocephalus forming a Cyst on the back of the Head. June 29th, 1829.— Mrs. H., wife of a shoemaker in Phi- ladelphia, was brought to bed of a female child, by Dr. Mar- sellis after the full term of gestation. There was nothing unusual during the latter, except a fall of the mother about a fortnight before her confinement. The child was nearly the size of an eight months' one, and had appended to the occipital region a tumour larger than the head itself. I saw it, for the first time, two or three days after its birth. The tumour was at that time soft and fluctuating, about nine or ten inches in circumference, and of a spheroidal shape: it was connected, by a pedicle of an inch or more in diameter, to the posterior fontanelle. The fontanelle was the same diameter, and nearly square; and the pedicle of the tumour, having a fibrous feel, seemed to pass through the fontanelle from the interior of the cranium. There was just below this pedicle a small cyst, vvhich contained half an ounce of fluid. The cranium was of little more than half the common size, CONGENITAL HYDROCEPHALUS. 449 the forehead very flat and receding, and the eyes and face projecting and large, as they commonly seem to be in anen- eephalous cases. The anterior fontanelle nearly closed. The occiput was also small, and very much flattened on its under surface. The integuments of the tumour around its pedicle were the common hairy scalp, but the remainder of them were bare smooth skin, thinner at some places than at others, and having at the former the condition of cicatrices. A soft, fleshy mass was felt, half the size of a common fist, in the centre of the tumour, and this mass seemed to spring from the interior of the cranium. The tumour was somewhat excoriated at places, and had here and there thin scabs upon it. On one occasion a scab gave way, and a quantity of se- rum flowed out. It was red, and hotter than other parts of the child's body. The child, in its actions and general condition, resembled other children of the same age: it sucked, it cried, and threw its limbs about. Handling the tumour, or squeezing it, seemed to give pain. Its stomach and bowels were in good order. Taking all the circumstances together, I immediately con- cluded this to be a case of congenital hydrocephalus, which had occurred in the lateral ventricles of the brain, before the ossification of the cranium had advanced much, pro- bably about the fourth or fifth month of uterine life; and that the posterior parts of the hemispheres had been pro- truded backwards, and, by the progress of the disease and the natural growth of the head together, had been converted into cysts containing serum,—that the character, in short, of the disease corresponded with spina bifida. I therefore determined to treat it by evacuating the water. I introduced, for some days in succession, several acu- puncturation needles, and drew off at a trial, through the holes, two or more ounces in a very gradual way, of a thin straw-coloured serum; this, for the time, produced a dimi- 57 450 PATHOLOGY OP ENCEPHALON. nution of the tumour, but it would again become plump in twenty-four hours. The fluid at last became too thick to flow through such orifices, and I then resorted to my lan- cet, which was plunged in obliquely for half an inch, on each side of the tumour, as there appeared to be two cysts. By such means I evacuated these cysts daily. On one occasion, after an intermission of forty-eight hours, I drew off nearly half a pint of serum. While this process was occurring daily, the tumour was kept moistened with brandy and water, as a refrigerant mix- ture: an inflammation, in the mean time was evidently ex- isting in it, being exhibited by the red, vascular injection of its integuments, by its heat, and by its tenderness on pres- sure. On the 10th of July the infant had a convulsion of some minutes; the next day it had another, and also for succeed- ing days: on the 14th it ceased to suck; that day and the next it had many convulsions, and became pale, with frothing at the mouth. It died on the fifteenth, at 5 o'clock, P. M. having lived seventeen days. July 16th, 1829.—Autopsy sixteen hours after death. Weather warm. On exposing this tumour, it turned out to be what I had supposed, a congenite hydrocephalus, vvhich had shoved the posterior lobes of the cerebrum out through the posterior fon- tanelle. The dura mater of the tumour was identified with its integuments; its pia mater was highly inflamed, injected, and adhered universally to the integument. Each posterior lobe was distended into a spherical sac, containing purulent serum, and having its inner surface in a softened disorganized state. The connexion of the sac of the left side with the cor- responding lateral ventricle was traced by a probe and fin- ger, passed from one into the other. But on the right side the sac was insulated, the lateral ventricle of that side being closed by a universal adhesion of its contiguous surfaces. ANENCEPHALOUS FOETUS. 451 The anterior and middle lobes of the cerebrum and the cerebellum, were in situ, and were not inflamed; they were of the usual consistence in infants of that age, and were con- nected to the dilated posterior lobes by a narrow isthmus passing through the posterior fontanelle. Pons and medulla oblongata healthy. No other part than head examined. [Since the preceding form went to press, I have ascertained through a friend who took the actual measurement, that the circumference of the tumour was twelve and a half inches, instead of nine or ten.] Dissection of an Anencephalous Foetus, (Female,) Au- gust 17 th, 1826. This foetus appeared to have been carried for six months. It had no neck, properly speaking; for the base of the head rested upon the upper surface of the thorax, the integu- ments of the face going directly to the front of the breast. The whole posterior half of the spinal canal from one end to the other was deficient, as well as the integuments; in lieu of the latter, was a thin, loose membrane, looking like a cicatrix, and having the transparency of the deciduae. On the membrane being slit open from one end to the other, a total deficiency of spinal marrow was observable: the roots of the nerves, however, remained and adhered to this mem- brane; from which I inferred that it was actually the relics of the membranes of the spinal marrow. Some of these roots were imperfect, but they nearly all had the anterior and the posterior fasciculi. The vault of the cranium was wanting down to the very base—the foramen magnum was defective at its posterior part, from the want of occipital bone behind—the orbitary processes of the os frontis wanting, as well as this bone ge- 452 PATHOLOGY OF ENCEPHALON. nerally, whereby the eyeballs were exposed above. There was no brain—the only vestige of it was a small flattened sac, collapsed upon the base of the cranium, and having a roughness on its internal periphery resembling granulations. The sac I took for the membranes of the brain, and the gra- nulations for the processes of the pia mater. The nerves of the basis of the brain adhered to the bottom of this sac, and then went through their respective foramina. There was nothing wrong in the abdomen or thorax which caught my attention. ipiLo a ? _Z>7Y»m. /rOT JT.vttw* ttr_En9rrayealYJ2ra?«>n- INDEX TO PLATED Plate 1 faces, - page 117. -----2---- .... 164. -----3---- _ _ _ . 171. -----4---- . . _ 299. EXPLANATION OF PLATES. PLATE I. Its object is to illustrate the general colour of the gastro enteric mucous membrane in health and in disease. Fig. 1. A section of the left half of the stomach of a rabbit described in Experiment 5th, page 121. It is of a lake colour approaching vermilion. The deepness of its tinge, shows its state of haematosis during digestion. Fig. 2, Is a section of the right half of the same stomach, of a dull pearl, showing the difference of the tinge or state of hae- matosis. This arises probably from digestion, being chiefly ex- ecuted in the left half of the stomach. Fig. 3, Represents the mucous coat of the stomach of a gen- tleman who died suddenly from an ossification of the coronary arteries of the heart. The case is narrated at page 122, Obser- vation 2nd. The mucous coat is here of a bright brown, or light, warm, sienna colour, which may be considered as the state of the stomach immediately subsequent to digestion, as the individual had taken a jrlass of cream a few hour* previ ouslv. 454 INDEX TO PLATES. Fig. 4. The intestinum jejunum of the same ca»e—it is seen to be of a deeper tinge than the stomach, its state of haematosis being augmented by its containing the articles passed off from the stomach. Fig. 5, Represents the state of the mucous coat of the sto- mach in acute gastritis, see Observation 5th, page 147. Its blood vessels were in a state of extreme congestion, with spots of extravasation into the mucous coat; besides which it was in a black and almost sphacelated condition in many parts. The severity of the irritation may be judged of, from the clots of blood which were found in the stomach. Fig. 6, Represents the state of the cardiac part of the sto- mach, in a case of gastritis of twenty days' continuance, in vvhich the acuteness of the irritation had subsided considerably: see Observation 7th, page 148. The ramiform appearance, a.a.a., represents the veins occupied as they were with blood. The blotches of blood now almost removed are seen at b.b.b.b. Fig. 7, Represents a chronic gastritis, see Observation 9th, page 153. The dilated tortuous state of the blood vessels is here very evident, a. Shows the appearance of the black spots of extravasated blood. Fig. 8, Is the mucous coat of the colon of the same indivi- dual; the appearance of the slate-coloured patches diffused over it is well represented. Fig. 9, Is a portion of the small intestine of the same indi- vidual; it shows the sooty appearance of the peritoneal coat from chronic inflammation. PLATE II. Represents the appearance of the mucous membrane of the stomach, where an acute inflammation followed a chronic one, from intemperance: see Observation 17th, page 164. PL, II. Drawn jram natwt .ICEnj'ct ty JJfrayUm PKATTE m 1 r: \U-^ ■ ' L~ Dnam IhnnNatwv. STEngravcd byJDrcyttni. INDEX TO PLATES. 455 Fig. 1. a.a. The dilated varicose veins of the mucous coat near the cardiac orifice, in the midst of black, slate-coloured spots. These veins filled with blood, and not terminating in larger trunks, but branching out at both extremities, so as to have no regular termination, in which respect they resemble the diploic sinuses of the cranium. b. The deep pink colour and ramiform punctated injection of the stomach generally. Fig. 2. A section of the mucous coat taken from near the pyloric orifice, and showing the same state of inflammation. PLATE in. Represents the appearance, from inflammation, of the muci- parous follicles of the intestinal canal in children. Fig. 1. A section of the colon in Case 5th, page 184. The numerous dots spread over its surface, some of which are indi- cated from the letter a., show the state of the mucous follicles, their enlargement and vesicular condition. This state is pre- vious to ulceration. Fig. 2. A section of the colon of a child who died from de- cided cholera infantum: see Case 2nd, page 178. The letter a. indicates some of the tumid mucous follicles: they resemble the preceding, except in being rather more distinct. Fig. 5. A section of jejunum from Case 1st, page 176, of cholera infantum. The mucous follicles are also seen here very distinctly enlarged, and also ulcerated, a. Points to an ordi- nary erythemoid ulceration of the mucous coat, whereas b. shows the ulcerated tumid mucous follicles. Fig. 4, Is a section of colon from the same subject: the ul- ceration of the mucous follicles is there still more distinct: a. points to some of them. 456 INDEX TO PLATES. PLATE IV. The drawing here was taken from the Case of Croup, narrated at page 299. a. Tongue, b. Trachea, c. c. Tonsil glands, d. Larynx. e. e. Bronchia. The larynx, trachea, and bronchia being slit open, a perfect and entire lining, f.f.f., of coagulating lymph is seen extend- ing from the superior margin of the glottis to the lungs, PLATE TV. Drawl hy J. Dray ton. INDEX. Page Abdomen, dissections of, 191 Abscess of Neck, 50 Abscess of Lungs, 240 Acephalocysts, 365 Acute Gastritis following1 a chronic one, 164 Acute Gastritis, case of, 147, 152 Adipose Secretions, 58 Alimentary Canal in Con- sumption, 254 Animals subject to Molles- cence of Brain, 387 Anencephalous Foetus, 451 Aorta, rupture of, 125 Aortitis, a case of, 317 Apoplexy of Brain, 408 Apoplexy of Spine, 399 Arachnitis, case of, 419 Arsenic, a case of death from, 297 Ascites, case of, 194 Atrophy of Lungs, 227 B Bayle's division of Phthisis, Brain, Pathology of, 244 351 Cancer of Brain, 364 Cartilaginous stale of Brain, 364 Carditis, 270 Cases of Cholera Infantum, 176 Cellular Tissue, Irritations of, 45 ------, Phlegmasia of, 46 ------, Sub-inflammation of, 53 ------, Secretory irritation of, 56 ------, Nutritive irritation of, 58 Cervical Vertebrae, fracture of, 408 Cholera Infantum, 171 Cholica Pictonum, 203 Page Chronic Pericarditis, 264 Chronic Gastritis, 148 Chronic Catarrh, 304 Chronic Inflammation of Brain, 358 Chronic Gastro-Enteritis with Tubercular Mesenteric Glands, 167 Complications of Pulmonary Consumption, 252 Colon, colour of, 122 -----, Exsiccation of, 203 Congenital Hydrocephalus, 448 Congestion of Muc. Memb. from suffocation, 132 Corvisart, 260 Croup, a case of, 299 D Delitescence, 28 Dissolution of Spinal Cord, 398 Diseases of Heart, cases of, 314 Disease, general considera- tions on, 9 Disease Progress of, 11 ------, Termination of, 13 ------, Prognostics of, 15 ------, Treatment of, 17 ------, Forms of, 18 Diagnostic, 14 E Emphysema of Lungs, 233 Empyema, cases of, 228 Encephalon, Mollescence of, 371 Encephalon, Irritations of, 351 Enlargement of Heart, a case of, 314 Erysipelas, 52 Erythemoid Inflammation, 82 Epiglottis, Ulceration of, 302 Experiments on Nervous System, 330 58 45S INDEX. Page Experiments on Muc. Memb. 119 Extra Uterine Pectus, 216 Excavations, Pulmonary, F False Membranes, 249 74 Fever, 43 Fever, a case of, 198 Fistulous Abscesses, 100 Fungiform State of Mucous Membranes, 114 Gangrene, 29 Gangrene of Muc. Memb. 104 Gangrene of Lungs, 241 Gastric lrritation,'cases of, 155, 156 Gastritis, Acute, cases of, 147, 152, 163, 164 Gastro Intestinal Mucous Membrane, colour of, 117 Gastro-Enteritis, Chronic, a case of, 153 (I Haemorrhages, Hemiplegia, case of, Heart, Dilatations of, -----, Induration of, -----, Irritations of, -----, Ossifications of, ---, Vegetations of, -, Mollescence of, —, Rupture of, 30 443 276 273 260 279 195 271 297 208 Hernia, cases of, Hunter's notion of a Ner vous System, 328 Hunter, on Perforations of Stomach, 105 Hydro-Pericarditis,' 266 Hydrothorax, case of, 313 Hydrocephalus, Chronic, cases of, 435 Hypertrophy of Lungs, 227 Hypertrophy of Heart, 278 Hydatids of Brain, 365 Indurations of Heart, Induration of Encephalon, 273 358 Page Indurations of Medulla Spinalis, 39'J Inflammation, Chronic, of Me- dulla Spinalis, 391 Inflammatory Indurations of the Brain, 355 Inflammation Internal, of Heart, 317 Irritation, 22 -------, Forms of, 26 -------, Phenomena of, 28 Intemperance, State of Stomach from, 145 Intus-Susception of Intestines, 207 I. Le Gallois's confirmation of opi- nions, 331 Lymphatic Glands, suppura- tions of, 102 Lumbar Abscess, 217 Lungs, cadaverous condition of, 223 Lungs, Irritations of, 223 M Mania, a case of, 417 Materia Vitae diffusa, 328 Medulla Spinalis, Irritations of, 389 Measles, a case of, 310 Measures used in France, 109 Medulla Spinalis, experiments on, 331 Medulla Oblongata, experi- ments on, 334 Meningitis, case of, 423 Metastasis, case of, 319 Mollescence of Heart, 271 Mollescence of Mucous Mem- branes, 105 Mollescence of Stomach in In- .fants, cases of, 158 Mollescence of Stomach, cases of, 112 Mollescence, Extensive, of Ce- rebrum, a case of, 426 Mollescence of Cerebellum, a case of, 431 Mollescence of Brain, account of, 371 Mollescence of Stomach in adult, 316 Morgagni's acccount of Molles- cence of Brain, 372 Mucous Membranes, Irritations of, 78 INDEX. 459 Page, Mucous Membranes, Sympathies of, 79 ---------------—, Phlegmasia of, 81 ----------------. chronic in- flammation of, 94 -----------------, Ulcerations of, 99 ----------------. Gangrene of, 104 ----------------, Mollescence of, 105 ----------------, Fungus of, 114 -----=-----------, Appearance of, 117 ----------------, Natural co- lour of, 119 —---------------, Passive Con- gestion of, 128 ----------------, Red inflam- mation of, 135 -, Follicular inflammation of, 171 N Nervous System, general patho- logy of, 326 Nervous System, dissections of, 408 Nervous System, effects of its diseases on other parts, 343 Nervous Irritation, 34 Nervous Palpitations, 269 Nerves, Irritations of, 405 ------, Sub-inflammation of, 406 Nutritive Irritation, 36 0 CEdema of Lungs, 238 OEsophagus, Stricture of, 197 Ossification of Coronary Arteries, 122 Ovarium, Suppurated, a case of, 213 Palsy, a case of, 424 Passive congestion of Mucous Membranes, 128 Peripneumony, 238 -------------, a case of, 303 Perforations, 77 Pericarditis, 261 Peritonitis, Acute, cases of, 191 Page Phlegmasia, 28 Phlegmasia of Encephalon, 351 Phlegmasia of Medulla Spinalis, 389 Philip's, Wilson, contradiction to experiments, 340 Phthisis Pulmonalis, account of, 243 Phthisis Pulmonalis, cases of, 305 Physick, Dr., on Yellow Fever, 143 Pleuritis, cases of, 310 Pneumo-Pericarditis, 268 Polypi of Heart, 284 Pseudo-Membranous Inflamma- mation, 87 Puerperal Convulsions, 410 Pus, 30 Pustular Phlegmasia of Mucous Membranes, 91 R Rcederer and Wagler on Crvp- tx, " 92 Ramiform Injection, 97 Red Inflammation of Mucous Membranes, 135 Resolution, 29 Rostan on Mollescence of Ence- phalon, 376 Sanguineous congestion of the Brain, 351 Scirrhus, 29 Scirrhus of Stomach, 200 -------- of colon and Rec- tum, 201 Secretory Irritation, 35 Serous Membranes, Irritations of, 60 -----------------, Sympathies of, 61 -----------------. Phlegmasia of, 6.3 -----------------, Pseudo- membranes, 67 -----------------, Secretions from, 66,75 ----------------, Adhesions, 69,75 -----------------, Sub-inflam- mation of, 72 -----------------, Tubercles, 74 Shivering, 43 Slate-coloured spots, 95 Softening of Brain, 371 Spinal Cord, Mollescence of, 394 460 INDEX. Page Stomach, Consistence of, 108 ------•, Thickness of, 108 Sudden Death from agitation, 314 Sub-inflammation, 32 Suppuration, 29 Sweating, 43 Sympathies of Nervous Sys- tem, 343 Sympathies, 37 T Tetanus, cases of, 411 Tubercles, 243 Tubercles of Brain, 366 Page Tuberculous Infiltration, 247 Tumours, 56 Tumour on Cerebellum, 443 V Ulcers of Mucous Membranes, 99 Ulceration, 29 Umbilicus, discharges at, 206 V Valves of Heart, Ossifications of, 289 Ventricles, Ossifications of, 283 FINIS. In July will be Published BY CAREY, LEA AND CAREY, THE FIRST VOLU.\ft (To be continued at intervals of three months) OF THE ENCYCLOPEDIA AMERICANA: A POPULAR DICTIONARY OF ARTS, SCIENCES, LITERATURE, HISTORY, AND POLITICS, BROUGHT DOWN TO THE PRESENT TIME, ON THE BASIS OF THE SEVENTH EDITION OF THE GERMAN CONVERSATIONS-LEXICON: AND INCLUDING A COPIOUS COLLECTION OF ORIGINAL ARTICLES IN AMERICAN BIOGRAPHY. EDITED BY DR. FRANCIS LIEBER, ASSISTED BY EDWARD WIGGLESWORTH, ESQ. TO BE COMPLETED IN TWELVE LARGE VOLUMES OCTAVO, PRICE TWO DOLLARS AND A HALF EACH. To convey an idea of the nature of this work, the publishers deem it proper to give the following account of the German original, and of what may be expected in the Encyclopaedia Americana. The Conversations-Lexicon, of which the seventh edition in twelve volumes has lately been published in Germany, had its origin about fifteen years since. It was intended to supply a want occasioned by the character of the age, in which the sciences, arts, trades, and the various forms of knowledge and of active life, had become so much extended and diversified, that no individual, certainly no one engaged in business, could become well acquainted with all subjects of general interest; while, on the other hand, the wide diffusion of in- 2 formation rendered such knowledge essential to the character of an accomplished man. The want thus created, was one vvhich no existing works were adequate tofcupply. Books treating of particular branches, such as gazetteers, &c. were of too confined a character; while volu- minous Encyclopaedias were too learned, scientific, and cumbersome, their articles being usually elaborate treatises requiring much study or previous acquaintance with the subject discussed. The object of the conductors of the Conversations-Lexicon was to select from every branch of knowledge what was necessary to be known by a well-informed man, and to give popular views of the more abstruse branches of learning and science, so that their readers might not be incommoded, and deprived of pleasure or improvement, by ignorance of facts or expressions occurring in books of conversation. Such a work, it is obvious, must be of great utility to every class of readers. It has been found so much so in Germany, that it is met with every where, among the learned, the lawyers, the military, artists, mer- chants, mechanics, and in short among men of all stations. The reader may judge how well it is adapted to its object, from the circumstance that though it now consists of twelve volumes, seven editions, com- prising about one hundred thousand copies, have been printed in less than fifteen years. A French translation is now preparing in Brussels. Germany afforded peculiar advantages for the execution of this work, since its object requires that it should be cheap in price, and at the same time contain an immense amount and variety of information. One great advantage of this work is, that when any matter is treated, which has been the subject of dispute and animadversion, the article is written by an advocate of the point in question, and afterwards the various conflicting opinions are stated. In this way, a liberal and im- partial character has been given to' the work. In regard to the work now about to be published, the public may rest assured that every exertion has been used to make it as interesting and valuable to American and English readers, as the original is to readers in Germany. Such articles, as have little interest out of Ger- many, have been omitted, and their places supplied by others adapted to the wants of the American and English public. In all cases this information is brought down to the present time, thus giving the work a very decided advantage over even the very extensive Encyclopaedias heretofore published in this country. The great improvements that have taken place since the chief part of Rees's and the Edinburgh Encyclopaedia was published, will render it desirable even for those who possess those works. There can be no doubt that a work like the Encyclopaedia Ameri- cana will be found peculiarly useful in this country, where the wide diffusion of the blessings of education, and the constant intercourse of all classes, create a great demand for general information. The Publishers feel satisfied, that, by the efforts of the Editors, the work will be so prepared for publication, as to justify in this country the reputation it has obtained in Europe. Dr. Lieber is connected with many of the principal men of letters in Germany; he has resided for a considerable period in England, and is possessed of {.he talents, 3 knowledge, and industry, needful to carry on such a work with suc- cess. Mr. Wigglesworth is a gentleman of ability and acquirements, acquainted with the condition and wants of his own country, and with the literature of Europe; and the Publishers feel assured he is fully competent to give all needful assistance in fitting the work to the pre- sent condition of the United States. But, while they feel confident that the task of translating and arranging the Conversations-Lexicon for publication in America, is in safe and suitable hands, they have not neglected, and will not neglect, any other means, that may come within their power, to make it as complete as possible. In the preparation of the work thus far, the Editors have been aided by many gentlemen of distinguished ability, and for the continuation, no efforts shall be spared to secure the aid of all who can, in anyway, contribute to render it worthy of patronage. The American Biography, which is very extensive, will be fur- nished by Mr. Walsh, who has long paid particular attention to that branch of our literature, and from materials in the collection of vvhich he has been engaged for some years. For obvious reasons, the notices of distinguished Americans will be confined to deceased individuals: the European Biography contains notices of all distinguished living characters, as well as those of past times. In the department of the Fine ,Arts, the work will be exceedingly rich. Great attention was given to this in the German work, and the Editors have been anxious to render it, by the necessary additions, as perfect as possible. To Gentlemen of the Bar, the work will be desirable, as in cases where legal subjects are treated, an account is given of the provisions of American, English, French, Prussian, Austrian, and Civil Law. • The Publishers believe it will be admitted, that this work is one of the cheapest ever published in this country. They have been desirous to render it worthy of a place in the best libraries, while at the same time they have fixed the price so low as to put it within the reach of all who read, with the hope that they may, by an extensive sale, be compensated for the great expenditure incurred in its preparation. -----»H3©e-c----- (TimWtfotts of Uufclfcatfou. I. It will be completed in twelve volumes, of from six to seven hundred pages each, handsomely printed on fine paper, and upon the same type as the pages annexed to this* prospectus. II. The first volume will appear in July, 1829; and a volume will be published every three months, until completed. The work is now so far advanced as to enable the publishers to assure the subscribers, that no delay shall take place. III. The price to subscribers will be two dollars and a half per volume, strongly done up in muslin. *„* Orders for the work will be received by the publishers, or by any of the agents in the annexed list ( 4 ) Letter from George Ticknor, Esq. of Boston. Boston, Nov. 25, 1827. Sik,—I am not acquainted with any book in a foreign language, which, 1 think, may be translated into English and published in the United States, with the needful altera- tions, with so much success as the Conversations-Lexicon, of which so many editions have been published in Germany. It seems to me to be suited, in a particular manner, to the present condition anil wants of this country, because it contains more of that in- formation which is useful and interesting to well-educated persons of all classes, than any other work with which I am conversant, it has made the fortunes of its publishers in Germany. It is about to be adapted to the wants of the rest of the continent, in a French translation just undertaken at Brussels; and I do not doubt, a similar adaptation of it to the United States, would be as fortunate and as successful as was the original work; because, the class of persons to whom it would be interesting, is much greater in this country than it is in Germany. GEORGE TICKNOR. Da. Fbancis Liebeh. Letter from Dr. Charles Fol/en, Inslrucler in German, in Harvard University. Cambridge, Nov. 23, 1827. Sir,—My opinion with respect to the translation of the Dictionary for Conversation into English, as proposed by Dr. Lieber, coincides entirely with the views which this gentleman and several eminent literary men of this country have already expressed. The Dictionary for Conversation owes its excellence, as well as its s:gnal success, prin- cipally to this circumstance, that in Germany every one who aims at distinction in any science or art, commonly devotes himself almost exclusively to his particular pursuit. This devotedness to a single object is apt to be attended with a very imperfect acquaint- ance with other branches of knowledge, and it is this defect which occasioned the ellition of a work which brought within the reach of every one the most interesting re- sults of all the different departments of learning and industry. On the other hand, the profound knowledge contained in the works of those who have made a particular pursuit the object of their life, has enabled the compilers of that Dictionary to pre- sent to the public, in a concise manner, a great number of articles which are gene- rally interesting, without being superficial. It is satisfactory not only to the general reader and scholar, to the philosopher and the historian, but to those also who arc engaged in any particular business or profession, as farmers, mechanics, merchants, physicians, lawyers or theologians. Those articles of the work which do not fully deserve this praise, will certainly be improved in usefulness and interest for this coun- try, by the translator and those literary men who are expected to assist him in this useful and patriotic undertaking. CHARLES FOLLEN. Letter from George Bancroft, Esq. one of the Principals of Round-Hill Seminary, Northampton. Northampton, Dec. 22, 1827. Sir,—I am very glad to hear that you seriously propose to publish the Conversations- Lexicon among us. It is the most convenient book for general reference, with which I am acquainted; and as for its popularity, the sale of more than seventy or a hundred thousand copies of it in Germany, establishes that point. It is for the past, what a newspaper is designed to be for the present,—a general summary of the mo9t interest- ing things known, stated on the best authority, to which access could readily be had. There is one circumstance which I think is much in its favour. We have had Encyclo- pxdias, compiled in France and Great Britain, each containing the current views on natters of science and letters, prevailing respectively in those countries. In the Ger- ( 5 ) man work we shall have the materials a little differently wrought. There has been nothing of the kind at once so popular and so trustworthy. I remain, with best wishes and sincere regards, Respectfully yours, GEORGE BANCROFT, From Edward Everett, Esq. Member of the House of Representatives of the United States. Winter-Hill, Charlestown, Nov. 17, 1827. I entirely concur in the opinion expressed in the foregoing pages, of the merit of the Lexicon for Conversation. It is somewhat of the nature of an Encyclopaedia, in- tended, however, for convenient and popular use. Although, of the great number of articles contained in it, all are not equally well executed, no work, that 1 am acquainted with, contains such an amount and variety of information, in a form so accessible and commodious. The alterations proposed by Dr. Lieber, seem to me calculated to render it still more valuable in this country; and with them, it will be, in my opinion, the best work for convenient general reference, in the English language. So deeply impressed have I been with the merit of the work, that, without having heard of Dr. Lieber's pro- posal to undertake a translation, I had determined to recommend to some of the princi- pal booksellers to endeavour to procure a translator of it. EDWARD EVERETT. Extract from a Letter from Joseph Story, Esq. one of the Judges of the Supreme Court of the United States. Salem, April 26, 1826. Dear Sir,—I wish every success to your excellent undertaking. It will supply a desideratum in our libraries, which I have almost despaired of seeing supplied in my day. Please to consider me a subscriber to the work. Dk. Francis Libber. New-York, July 18, 1828. Gentlemen,—It gives me pleasure to hear of your proposed publication of the Corf versations-Lexicon in English. It has long been a very popular work in Germany; has passed through seven large editions there, and is soon to appear in a French translation, at Brussels. The articles are generally comprehensive, and for the most part very satis- factory; and the work may properly be entitled, a well digested summary and gene- ral dictionary of interesting and useful information, in all departments of knowledge. It will meet the wants of a large portion of our community, and be received, I think, with very general approbation and encouragement. J. F. SCHROEDER. Extract from a Letter from the Rev. Dr. F. C. Shaeffer, of New- York. " Since the first appearance of the Mlgemiene deutsche Real-Encyclopsedie, oder Con- versations-Lexicon in its present form, I have had occasion to use it as a book of refer- ence, and have frequently expressed the opinion, that an English translation of this valuable work, with necessary emendation, would be a great benefit to American readers who are unacquainted with the language of the original. In passing through several editions, it has been much improved; and, on comparing the sixth and seventh edition, it is readily perceived, that the latter, the ground work of the 4 Popular En- cyclopedia,' to be edited by the able Dr. Lieber, is to be considered as far better than a mere reprint." AGENTS FOR THE ENCYCLOPEDIA AMERICANA. MAINE—Augusta, W. Dewey—Hallowell, Glazier, Masters & Co., C. Spalding — Portland, Shirley & Hyde, Samuel Coleman—West Jefferson, F. Sheppard, P. M. —Norway, Ma Barton. NEW-HAMPSHIRE—Portsmouth, /. F. Shores— Concord, Horatio Hill & Co.— Kekne, G. Tilden—Hanover, Hemas Mann—Dover, ret7—Beaufort, B. R. Rythwood— Camden, Alexander Young—Columbia, B. D. Plant, E. W. SJ A. S. Johnston. GEORGIA—Savannah, W. T. Williams—Augusta, Dr. T. J. Wray—Milledge- ville, Thomas F. Green. ALABAMA—Mount Meigs, Montgomery County, C. S. Lucas, M. D.—Tcsca- loosa, D. Woodruff. LOUISIANA—New Orleans, William M'Kean—Baton Rouge,---Henderson. OHIO—Cincinnati, N. & G. Guilford— Steubenville, J. &f B. Turnbull. KENTUCKY—Lexington, Mathew Kennedy—Louisville, Morton & Co. TENNESSEE—Nashville, Robertson & Elliot—Jackson, John Lea—Caledonia, John Travis. MISSISSIPPI—Natchez, F. Beaumont. MISSOURI—St. Louis, T. Houghan. Montreal, //. H. Cunningham—Quebec, Neilson & Cowan—Kingston, J. M'Farlane —York, M. £s" R. Meighan—Mexico, G. Ackermann—St. Thomas, W. P. Furness. Subscriptions received by the same persons for the AMERICAN QUARTERLY REVIEW, the tenth No. of which was published on the first of June, by Carey, Lea & Carey. Terms, five dollars per annum, payable in advance. Also, for tlie AMERICAN JOURNAL OF THE MEDICAL SCIENCES, the seventh No. of which was published on the first of May. ABRAHAMITE.^—ABRIAL- 15 professed before the law of circumcision. The doctrine of the unity of God, and the Lord's prayer, were all which they re- garded in the Bible. Their petition for freedom in religious worship was, how- ever, rejected, because they refused to declare themselves Jews, or members of any of the established Christian sects. The emperor Joseph, less enlightened in matters of religion than is generally be- lieved, drove these honest people, in 1783, from their possessions, because they re- sisted all attempts made for their conver- sion, and dispersed them,by military force, among various places, on the boundaries of Hungary, Transylvania, and Sclavo- nia, where they were compelled to em- brace the Roman Catholic faith, and the men to join the frontier militia. Many of them adhered firmly to their religious principles. Abrantes; a city of 3500 inhabitants, on the right bank of the Tagus, in the province of Estramadura, in Portugal. It is considered as of great military impor- tance on account of its situation on a number of steep hills, forming a defile ; by reason, likewise, of its old castle, con- verted into a citadel; and of the river, which is navigable as far as this place. The Portuguese, in this fortress, braved the Spaniards as early as 17C2. In 1808, the army under Junot arrived at A., after a dangerous and tedious march along the banks of the Tagus, through the woody, mountainous, and barren Beira. Junot ordered the castle, as well as the city, which he found ungarrisoned, to be placed in a state of defence; and, in spite of the great fatigue of his troops, hastened to Lisbon, then occupied by 15,000 Portuguese sol- diers, and inhabited by 350,000 souls. The quickness of his march, and the dar- ing courage with which he took posses- sion of this capital, at the head of only 1500 grenadiers, induced Napoleon to make him duke of Abrantes. At a later period, however, he committed gross mis- takes. At the capitulation of Cintra, A. was surrendered to the English, who made it still stronger. It was, however, of no importance during the remainder of the war, except to Massena, who re- connoitred it at the time when he sat down before the strong position of the duke of Wellington, between Santarein und Pcniche. Abrasax. (See Abraxas.) Abraxas stones, or Abrasax stones, are very numerous, and represent a hu- men body, with the head of a cock and the feet of a reptile, The inscription Abraxas or Abrasax is often found on them, in Greek characters, which betray, how- ever, a foreign origin. Bellermann, in his Essay on the Gems of the Ancients, bearing the Image of Abraxas, Berlin, 1817, declares only those having the above inscriptions to be genuine. The gems which have been imported into Europe from Egypt and Asia, and are also-found in Spain in great abundance, belonged, according to his opinion, to the religious sect of the Basilidians, and were used, partly as means to teach secret doctrines, partly as symbols, partly as amulets or talismans. Grotefend derives the name from the Persian language; Bellermann thinks it to be a composition of the Egyptian words Abrac and Sax, and renders it ' the holy word of bliss,' which reminds us of the Tetragrammaton of the Jews. Different explanations have been proposed by oth- ers. The ancients attempted to give meaning to the word by considering the letters as Greek numerals, which make together 365.—The name of Abraxas stone is, in modern times, applied to a variety of gems that exhibit enigmatical compositions, strange words in foreign characters, as Ablanathanalba, etc., and even to those which bear the emblems of Sabaeism, the sun and moon, with other symbols, which want, however, the char- acteristic type of the Basilidians. These are more properly called Abraxoids. The Basilidian names, seen on many stones of this class, are explained by Bellermann, by the aid of the Semitic languages. The interesting disquisition on this sub- ject of Neander, professor at the univer- sity of Berlin, deserves to be carefully compared with the opinions advanced by Bellermann. Abrial, Andre-Joseph, born March 19, 1750, .at Annonay, department de 1' Ardeche, at present count and peer of France, &c, studied law in Paris, and embraced the principles of the revolution, during which he was, for a long period, commissioner of the executive power in the court of cassation. In 1799, he or- ganized the republican government in Naples. After the 18th of Brumaire, the first consul intrusted him with the ministry of justice, saying, as it is related, " Not I, but the public voice nominates you." After 18 months, he quitted this station, and entered the senat conserva- teur. In 1804, he organized the depart- ment of justice in Italy, when the young Cisalpine republic was again dissolved. In 1811, he was made count of the em- pire, and was for 10 years a member of 1G ABRIAL—ABRUZZO. that committee in the senate, ridicu- lously called commission dc la liberie' in- dividueUe, while it daily submitted, with blind subservience, to the imperial orders. In 1814, Abrial voted for the overthrow of the imperial dynasty. Louis XVIII. made him a peer, and since that time he has voted with some independence in the chamber of peers. Abruzzo, the northern extremity of the kingdom of Naples, is bounded on the north and west by the states of the church, on the east by the Adriatic, on the south by Puglia and Terra di Lavoro. It contains 628,600 inhabitants, and is di- vided into A. ulterior, which comprises the north-western, and A. citerior, which comprises the south-eastern part. The highest part of the chain of the Apennines crosses this mountainous country. In A. ulterior, especially, it is very lofty, with steep cliffs, and throws extraordinary obsta- cles in the way of internal communication. The rivers which rise in A., the Trento, Trontino, etc., generally flow in a direct course into the Adriatic sea, and have (the Pescara and Sangro excepted) the character of torrents. They are often suddenly swollen by the rains, especially in the spring, and then sweep away the bridges and all means of communication. The climate of A. is severe. The sum- mits of the mountains are covered with snow from October to April. Thick woods crown the eminences; the valleys only are productive; and even they (as the inhabitants are mostly shepherds) afford but a very scanty supply of grain. Almond, walnut, and other fruit-trees thrive every where; olives, in the lower regions, near the sea. The finest herds of all kinds of cattle feed on the heights and in the valleys, and constitute the only article of export. The most impor- tant cities are Aquila, Pescara, (both for- tresses,) and Sulmona. The importance of A. consists, principally, in its military sites. Projecting like a bastion 60 geo- graphical miles, far into the territory of the church, it becomes especially impor- tant from the circumstance that but one military road, and that an extremely dif- ficult one to an army, leads into the king- dom. There is, indeed, no one like it across the mountains, from the shore of the Mediterranean to that of the Adriatic sea. The kingdom of Naples, therefore, if well defended, is exposed to serious attacks on two roads only; namely, on that which stretches along the Mediter- ranean sea and the Pontine marshes, from Rome, by Terracina and Capua, to Na- ples ; or on the one which runs along the Adriatic, from Ancona, by way of Atri, Pescara, etc. into the interior. On the latter road, each of the many parallel riv- ers forms an excellent position, where the right wing may always be protected by the sea, the left by the contiguous mountains, from which the flank of the assailants is itself exposed to attack. To force these positions would cost a bold enemy much blood. It would be yet more dangerous to attempt to pass Ter- racina, on the other road, without having possession of A.; for as soon as the army had arrived at Terracina, the rear might be attacked on the left from Rome and the mountains. Finally, should the in- vaders advance by both roads at once, all communication would be destroyed before they reached Pescara, whence a good road leads over the chain to Sul- mona and Teano. They would meet with all the above difficulties, and, at the same time, incur the danger of being de- feated in detail. The possession of A., is, therefore, indispensable for the attack of Naples; to force it, however, would be very difficult. As has been said above, of the roads from the states of the church into this province, only the one from Rie- ti, through Civita ducale to Aquila and Sulmona, is practicable for artillery, and only two others for regular troops, and that with difficulty. All the other ways are nothing more than paths through morasses, where the troops must march in single files, and the cavalry lead their horses. The road from Rieti is, there- fore, the only one on which a serious at- tack can be undertaken; but the strong pass of Antrodocco, and numerous good positions, facilitate its defence. Besides, the thick forests with deep ravines afford advantages for a partisan warfare, in the manner of the guerillas, or the Tyrolese and, had the Neapolitans a warlike spirit, the possession of A., whenever attacked, would not have been obtained without a great sacrifice. But when a people is destitute of courage and energy, when the soldiers, sunk in cowardly apathy, run away at the mere idea of a battle, the most favorable ground will be of no ad- vantage. 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