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Digitized by the Internet Archive 
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ELEMENTS 
 
 OF 
 
 GtENERAL AND PATHOLOGICAL 
 
 ANATOMY. 
 
ELEMENTS 
 
 oi' 
 
 GENERAL ANE PATHOLOGICAL 
 
 ANATOMY, 
 
 I'llKSKNTINU A 
 
 VIEW OF THE PRESENT STATE OF KNOWLEDGE 
 IN THESE BRANCHES OF SCIENCE. 
 
 15V 
 
 DAVID ClIAIDIE, M.D., E.E.S.E. 
 
 FELLOW OF THE LOYAL COLLEOE OF niYSICIAXS, EHl.N BUlUi H, 
 AND UOXOKAKY COXSELTIXG PHYSICIAN' 
 
 TO THE LOYAL IXFILMALY. 
 
 SECOND EDITKJN, 
 
 ENLARUKC, REVISED, AND IMDROVED. 
 
 P H I L A D E L P n I A ; 
 
 LINDSAY AND BLAKISTON. 
 
 1 <S 51 . 
 

PREFACE 
 
 TO THE FIRST EDITION. 
 
 The value of Morbid Anatomy as the basis of rational Pathology 
 was early recognized by physicians; and the works of Wepfer, 
 Gerard Blasius, Schenke, Pechlin, Harder, Plater, Van der Wiel, 
 and Fantoni, demonstrate the diligence with which the pathologists 
 of the 17th century laboured to investigate the nature and effects 
 of morbid action. The elaborate, but somewhat confused, collection 
 of Bonetus was the first attempt to classify the facts observed by 
 these and previous authors. To Morgagni, however, was reserved 
 the merit of publishing a work, distinguished equally by critical 
 knowledge of the labours of his predecessors and contemporaries, 
 and by accurate personal observation. From the days, indeed, of 
 Fantoni, Valsalva, and Morgagni, to those of Sandifort, Baillie, 
 Meckel, and Laennec, the study of Morbid Anatomy has been as- 
 siduously cultivated by all who were interested in the progress of 
 accurate knowledge. 
 
 At no period, however, has this department of science been pur- 
 sued with greater zeal than during the last twenty years, in the 
 course of which the observation and collection of pathological facts 
 has engrossed the attention of numerous observers, both in this 
 country and in France and Germany. Of this the result has been, 
 more accurate distinction of diseases formerly confounded, fuller 
 and more precise information regarding those which were imper- 
 fectly known, and an extraordinary accumulation of matter on all 
 topics. In some instances the boundaries of tbe science have been 
 extended ; in others, departments already known have been more 
 
VI 
 
 PREFACE. 
 
 diligently explored; and if the result has not at all times been ab- 
 solute discovery, some advantage has accrued from the correction 
 or the modification of former statements. 
 
 The advantage to the science at large has nevertheless been ac- 
 companied with great and increasing inconvenience to the student. 
 The recorded information is scattered through so many volumes, 
 that the usual period allotted to the acquisition of knowledge is 
 quite inadequate to consult them in the most cursory manner. 
 Many of the most valuable papers also are contained in periodical 
 works, in which it is not always easy to peruse them. In short, so 
 great is the accumulation of materials, yet so dispersed and mul- 
 tiplied, that the most intrepid diligence is disconcerted, and the 
 most indefatigable perseverance is exhausted. 
 
 To alleviate, if not to remove, some of these difficulties, the most 
 obvious plan is to classify the principal facts, which it is important 
 for the student to know ; to reduce to general heads the numerous, 
 isolated, and not unfrequently unarranged facts, recorded by diffe- 
 rent observers ; to reconcile what is discordant ; to explain what is 
 anomalous ; to distinguish the essential from the accidental, — the 
 important from the trivial ; and to exhibit in a connected and sys- 
 tematic shape those deductions and inferences, which are justified 
 by accurate analytic comparison of the best authenticated facts. 
 Though these are the objects which have been held in view in the 
 composition of the present volume, it can only be determined by 
 others, with what success they have been attained. 
 
 In the arrangement of the materials of which it consists, I found 
 it impossible to adopt the methods in ordinary use. Without pre- 
 tending to determine the comparative merits of the methods of 
 Baillie, Conradi, Meckel, and Cruveilhier, each of which has pecu- 
 liar advantages, I may be permitted to observe, that the first ob- 
 ject in tracing the progress and effects of pathological processes is 
 to fix the boundary between what is sound and what is morbid, and 
 that every morbid process always bears some relation to the proper 
 characters of the texture in a sound state. For these reasons, I 
 have chosen as the basis of arrangement, the distinctions of the com- 
 
PREFACE. 
 
 vn 
 
 ponent tissues of the animal body, as derived from the similitude 
 and difference of their anatomical characters ; and, though the ad- 
 vantages of this method have been recognized by John Hunter, 
 Carmichael Smyth, Bichat, Dr Thomson, and Bedard, I am not 
 aware that any complete system of pathological anatomy has been 
 hitherto constructed according to its principles. The present at- 
 tempt is, I believe, the first instance, in which it has been carried to 
 the length of a full though elementary treatise. 
 
 It is almost superfluous to enter into any detailed account of the 
 principles on which this work is composed. In describing both the 
 sound and morbid states of the different organic tissues, I have in 
 general indicated the sources of my information. On the subject 
 of the normal or healthy states, without neglecting the labours of 
 previous authors, it has been my study to give accurate descriptions 
 of the objects from frequent and careful personal dissection. What- 
 ever I have stated on my own authority has been from repeated and 
 rather elaborate examination ; and if I have erred or misrepresent- 
 ed, it is not from carelessness or indiflference in the endeavour to 
 insure accuracy. 
 
 In describing the pathological changes incident to each tissue, it 
 has been my study not so much to speak from personal observation, 
 as to generalize with fidelity the results of the researches of others. 
 In a subject so extensive and so complicated as Morbid Anatomy, 
 individual observation and research are of little avail, unless as they 
 tend to confirm, to correct, or to modify the results obtained by 
 other inquirers. The duty of the author of an elementary treatise 
 in such circumstances is chiefly to compare and generalize these re- 
 sults. For these reasons, I have seldom spoken of what I have 
 seen myself, unless where that tended either to confirm some un- 
 certain inference ; to settle some controverted or ambiguous point ; 
 or to verily views, in favour of which information was either scanty, 
 deficient, or contradictory. I must, however, say, that, in adducing 
 the testimony of other observers, I have in no instance spoken on 
 subjects which I have not taken care to verify myself. Of every 
 morbid change described, the description is derived in some instan- 
 
Vlll 
 
 PEEFACE. 
 
 ces from repeated inspection, — in all from more or less personal 
 examination of its physical and anatomical characters. Of my own 
 observation, however, I say nothing, but leave the reader to judge 
 both of its extent and its accuracy. 
 
 Though I have been thus studious to avoid intentional errors, it 
 is possible that many have been committed in the course of the vo- 
 lume, both from ignorance and from oversight. These I will not 
 extenuate by any apology derived either from the ditliculty and com- 
 plicated nature of the subject, or from the calls of other professional 
 engagements. When such apology is admissible, its first interpre- 
 tation is, — that the author should have left the undertaking to some 
 one better qualified by opportunities and attainments to execute it 
 creditably. On some points I have gone less into detail than the 
 nature of the subject may seem to require ; on others unnecessary 
 diffuseness may be perceived ; and in some, perhaps, omissions may 
 be detected. 
 
 In the section on the Diseases of the Nerves, though I refer to 
 the cases of Mojon and Covercelli, I confess that I had at the time 
 some doubts regarding the connection between existence of the tu- 
 mour and the epileptic motions. Since that sheet was printed I 
 met with the remarkable case of Dr Short,* which has tended to 
 remove these doubts ; and I have elsewhere offered a conjecture on 
 the connection between these tumours and the sensation called 
 epileptic aura. This it was unnecessary to notice, had not my 
 friend, Mr William Wood, attaching to the conjecture more value 
 than it really merited, resumed with his usual acuteness the inves- 
 tigation of a subject, on which he was the first to communicate ex- 
 act information. The monograph of Mr Wood, published in the 
 third volume of the Edinburgh Medico-Chirurgical Transactions, 
 is now not only the fullest, but the best account of the neuroraatic 
 tubercle ; and had it been composed previous to the sheet in which 
 the account in the present volume is contained, would have enabled 
 me to give a much better description of that disease. 
 
 To the peculiar disease of the intestinal mucous membrane in 
 
 * Medical Essays and Observations, Vol. iv. p. 416. 
 
PREFACE. 
 
 IX 
 
 children described by Dr Crampton, I have not assigned a separate 
 place in the text, from difficulty of understanding its exact nature. 
 In some of the cases recorded by that physician, the villi seemed 
 converted into tubercles. In others the presence of pustular ulcers 
 not unlike small-pox seems to indicate the usual follicular disease 
 of that membrane. And in others the granular appearance of the 
 villous membrane appears to correspond with the usual effects of 
 dysenteric inflammation. These appearances the ingenious author 
 of the account ascribes to inflammation operating on the strumous 
 habit.* 
 
 The work of Dr Abercrombie on the Pathology of the Intestinal 
 Canal, I did not receive till the sheets on the diseases of the Mu- 
 cous and Serous Membranes were printed. It was therefore im- 
 possible for me to avail myself of the researches of that acute 
 observer. 
 
 On one department of Pathological Anatomy the reader will 
 find little or no information in the present volume. I allude to 
 local diseases, and to those varieties of malformation which consist 
 in misapplications of the component parts of organs. These, it is 
 almost superfluous to remark, cannot, without violation of the prin- 
 ciples of arrangement, be introduced in a work on General Ana- 
 tomy ; and I have therefore, however reluctantly, excluded them 
 almost entirely, unless so far as their general characters could be 
 stated. 
 
 Farther, it was my intention to conclude the work with an ac- 
 count of the healthy structure and the morbid changes of the glan- 
 dular system. I found it, however, difficult to give such a general 
 sketch of the healthy anatomy of these oi’gans as would be appli- 
 cable to all without being untrue of any, — and by no means easy, 
 without swelling a volume already too large, to exhibit such a view 
 of the anormal deviations as would be either just or useful. This, 
 therefore, I am obliged to defer for the present. 
 
 Lastly, The limits within which it is requisite to confine this 
 work, principally intended for the student of pathology, have com- 
 
 Dublin Reports, Vol. ii. p. 286. 
 
X 
 
 PREFACE. 
 
 pelletl me to touch very cursorily on many points, which, from 
 their importance, would have required fuller details. Though I 
 have throughout been solicitous to present the unbroken chain of 
 evidence, on which the inferences and deductions are made to rest, 
 I have often been obliged to state the latter only, and in a form 
 perhaps too dogmatic, with the view of saving the time of the 
 reader. In no instance, however, has this been done without 
 deliberate examination of the authorities for every fact, and of the 
 evidences for each conclusion. On ordinary points, on which 
 pathological opinion is unanimous, I have been sparing of reference, 
 or omitted it entirely. On subjects, on the contrary, on which 
 information is doubtful and scanty, or on which there is room for 
 diversity of sentiment, I have, by referring the reader to the best 
 sources, enabled him to appreciate the validity of the conclusions 
 stated. Without attempting, however, to refer to all the authori- 
 ties extant, w'hich must have uselessly enlarged the work, I have 
 directed him chiefly to those which are at once most useful and 
 most accessible. 
 
 Edinburgh, ith November 1828. 
 
ADVERTISEMENT. 
 
 In preparing the present Edition all the materials of the first 
 have been employed. But they have been greatly increased by 
 the introduction of new matter under the proper heads, in order 
 to carry forward to the present time the information acquired 
 since the appearance of the first edition. Numerous rectifications, 
 both in healthy and morbid anatomy, have also been made. 
 
 Besides the changes now mentioned, two new books have been 
 added ; one on the Structure and Morbid States of the Glands ; the 
 other on the Structure and Morbid States of the Lungs and Heart. 
 
 The object of the author throughout the volume has been to 
 communicate precise and useful information in a perspicuous and 
 methodical manner. Of the difficulties attending the undertaking 
 he is fully aware ; and it is possible, that, after all endeavours to 
 render the work perfect, it may still present defects. In a subject 
 so extensive and complicated as morbid anatomy, and which is cul- 
 tivated by so many assiduous inquirers, the difficulty of presenting 
 the most recent views must always be great. This, however, the 
 author has studied to do, so far as the limits of the work permit. 
 
 Novelty, however, is not the only object which the author of a 
 work on pathological anatomy should keep in view. His great 
 object must be to furnish correct statements and useful information 
 on the nature and distinctive characters of diseases. On this ac- 
 count the author has adhered, as formerly, to the principle of judi- 
 cious selection. 
 
XU 
 
 ADVERTISEMENT. 
 
 By some it may be expected that this work should have been 
 illustrated with delineations, more especially in reference to mi- 
 croscopical anatomy. These, however, would have added so much 
 to the expense of the work, without otherwise increasing its value, 
 that it was thought best for the present to dispense with their 
 assistance. The most effectual way to obtain information in mi- 
 croscopical anatomy is for the student to take frequent opportuni- 
 ties of examining, by the microscope, the textures in their healthy 
 and diseased states. In this, as in all other branches of knowledge, 
 nothing can be compared to practice and experience ; and no in- 
 formation is equal to that which is obtained by frequent personal 
 observation. 
 
 In conclusion, the author trusts, that while the work in its pre- 
 sent form may be useful to students and practitioners, it is still 
 more worthy of that degree of favour, with which it was received 
 by those distinguished members of the profession, whose approba- 
 tion it must always be an honour to obtain. 
 
 20, Queen Street, 
 ith Novemler 1847. 
 
CONTENTS 
 
 BOOK I. 
 
 SIMPLE ELEMENTARY TISSUES. 
 
 CHAPTER I. 
 
 Division of the Textures, . . . Page 1 
 
 CHAPTER II. 
 
 The Fluids, ..... 18 
 
 Morbid States of the Fluids, , . . 24 
 
 CHAPTER HI. 
 
 Filamentous or Cellular Tissue, . . . .30 
 
 The Diseases of Cellular Tissue, ... 35 
 
 CHAPTER IV. 
 
 Adipose Tissue, . . . . .49 
 
 Diseases of Adipose Tissue, .... 55 
 
 CHAPTER V. 
 
 Ai-teiy, — Ai-terial Tissue, . . . .76 
 
 Diseases of Ai-teries, . . . . 87 
 
 CHAPTER VI. 
 
 Vein, — Venous Tissue, . . .112 
 
 Diseases of Veins, .... 124 
 
 CHAPTER VII. 
 
 System of CapUIary Vessels, — Terminations of Ai’teries, — Origins of 
 Veins, ...... 131 
 
 Diseased States of Capillary Vessels, . . . 136 
 
 CHAPTER VIII. 
 
 Erectile Tissue, ..... 1G9 
 
 Diseases of Erectile System, .... 176 
 
 CHAPTER IX. 
 
 System of Exhalants, . . . .187 
 
 Diseases of Exhalants, .... 190 
 
XIV 
 
 CONTENTS. 
 
 CHAPTER X. 
 
 Lymphatic System, 
 
 Diseases of the Lpnpliatic System, 
 
 Page 204 
 210 
 
 CHAPTER XI. 
 
 Lymphatic Glaiul or Ganglion, 
 Diseases of Lymphatic Glands, 
 
 215 
 
 217 
 
 CHAPTER XII. 
 
 Organization and Structure distinguished. 
 
 253 
 
 BOOK II. 
 
 NERVOUS SYSTEM. 
 
 CHAPTER I. 
 
 Section I. — Tlie Central Portion of Nervous System, — The Brain, 228 
 Section II. — Morbid States of the Brain, . . 277 
 
 CHAPTER II. 
 
 Section I. — Nerve, — Nervous Tissue, . . 359 
 
 Section II. — Diseased States of Nerves, . . 379 
 
 BOOK III. 
 
 KINETIC TEXTURES.— STEREOMORPHIC 
 TEXTURES. 
 
 CHAPTER I. 
 
 Flesh, Muscle, — Muscular Tissue, . . . 395 
 
 Diseased States of Muscular System, . . . 401 
 
 CHAPTER II. 
 
 Sinew, Tendon, 
 
 Diseased States of Tendon, 
 
 412 
 
 413 
 
 CHAPTER HI. 
 
 White Fibrous System, 
 
 Diseased States of White Fibrous System, 
 
 414 
 
 417 
 
 CHAPTER IV. 
 
 Yellow Fibrous System and Morbid States, 
 
 4 
 
 420 
 
CONTENTS. XV 
 
 CHAPTER V. 
 
 Bone, ..... Page 427 
 
 Diseased States of Bone, .... 444 
 
 CHAPTER VI. 
 
 Gristle, Cai’tilage, ..... 490 
 
 Diseased States of Cartilage, . . . 492 
 
 CHAPTER VII. 
 
 Fibro-CartUage, ..... 494 
 
 Diseased States of Fibi’o-Cartilage, . . 495 
 
 BOOK lY. 
 
 MEMBRANOUS OR INVESTING TEXTURES. 
 
 CHAPTER I. 
 
 Section I. — Skin, ..... 497 
 
 Section II. — Diseased States of Skin, . . . 504 
 
 CHAPTER II. 
 
 Section I. — IMiicous Membrane, — Villons Membrane, . 548 
 
 Section II. — Diseased States of Mucous Membrane, . 566 
 
 CHAPTER HI. 
 
 Section I. — Serous Membrane, — Transparent Membrane, . 683 
 
 Section II. — Diseased States of Serous Membrane, . 697 
 
 CHAPTER IV. 
 
 Section I. — Sjmovial Membrane, .... 746 
 
 Section II. — Diseased States of Synovial Membrane, . 748 
 
 BOOK V. 
 
 THE GLANDS. 
 
 CHAPTER I. 
 
 Section I. — Glands in general, . . 757 
 
 Section II. — Structiu-e of Individual Glands, . , 775 
 
 § I. The Salivary Glands, . . . 775 
 
 § IT. The Pancreas, . . . , 775 
 
XVI 
 
 CONTENTS. 
 
 § III. The Liver, .... Page 777 
 
 § IV. The Kidneys, .... 731 
 
 § V. The Testes, .... 805 
 
 § VI. The Mamma, .... 810 
 
 CHAPTER II. 
 
 Morbid States of the Glandular Organs, . . 811 
 
 Section II. — Morbid States of Lacrymal and Salivary Glands, . 813 
 
 Section III. — Morbid States of Pancreas, . . 831 
 
 Section IV. — Morbid States of Liver, . . . 853 
 
 Morbid States of Gall-Bladder and Ducts, . . 919 
 
 Section V. — Morbid States of the Kidney, . . . 929 
 
 Section VI. — Morbid States of the Female Mamma, . 963 
 
 Section VII. — Morbid States of the Testis, . . 967 
 
 Section VIII. — Morbid States of Prostate Gland, . 971 
 
 BOOK VI. 
 
 THE I;UNGS AND HEART. 
 
 CHAPTER I. 
 
 The Lungs, . .... 973 
 
 Section I.— -Minute Stractm-e of the Sound Lung, . 973 
 
 Section II.— Morbid States of the Lungs, . . .981 
 
 CHAPTER II. 
 
 Section I.— The Heart,— The Endocardium, . . 1042 
 
 Section II. — Morbid States of the Heart, . . . 1043 
 
 Index, 
 
 1067 
 
ELEMENTS 
 
 OF 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 BOOK I. 
 
 CHAPTER 1. 
 
 DIVISION OF THE TEXTURES. 
 
 The Human Body has been said to consist of solid and fluid 
 parts, the former of which are organized, and determine the shape 
 of the body and its parts. In the same manner the solid parts 
 were distinguished into simple and vital ; the first of which were 
 believed to possess only the general properties of matter, as weight, 
 cohesion, elasticity, flexibility, &c. but to be destitute of sensibility 
 and mobility, the great characteristics of the vital solids. Under 
 the head of vital solids it is evident that the brain, cerebellum^ spi- 
 nal chord, and nervous branches on the one hand, and the whole 
 of the muscles on the other, were comprehended. Of the simple 
 solids, on the contrary, bone, tooth, cartilage, tendon, and liga- 
 ment were conceived to be examples. This division, which was 
 made at a time when the attention of physicians was more attracted 
 by physical and mathematical, than by physiological and vital pro- 
 perties, may now be safely set aside, while we adopt another which, 
 though less scholastic, is more suited to the nature of living bodies. 
 
 In the living body, it may be observed, there is no solid which 
 is not alive, and which does not possess vital properties ; and there 
 is no vital solid which does not possess all the properties ascribed 
 to the simple solid, or the usual attributes of inanimate matter. 
 The great characteristic of living or organic bodies is, that every 
 substance which enters into their composition possesses not only 
 the usual properties of matter, as weight, cohesion, flexibility, elas- 
 ticity, &c., but also peculiar properties not found in inorganic bo- 
 
 A 
 
2 
 
 GENERAL PATHOLOGICAL ANATOMY. 
 
 dies, and which have therefore been termed indiscriminately animal 
 or living properties. 
 
 Every animal body consists of several kinds of organic sub- 
 stance, which differ from each other in various modes, and each 
 of which is characterized by peculiar properties. In the human 
 body, and in those of all raammiferous animals, these various kinds 
 of organic substances are believed to be presented in their most 
 perfect state ; and it is to these more especially that the attention 
 of the pathologist is directed, and from their examination that his 
 knowledge is derived. 
 
 At an early period of the study of anatomy, the human body 
 was distinguished into various kinds of animal substance ; and we 
 find even in the writings of Jacopo Berenger of Carpi, (1521), 
 but more distinctly in the great work of Vesalius, an enumera- 
 tion and general description of the different kinds of substance 
 found to constitute the human body. The example given by these 
 founders of the science was imitated to a greater or less extent, 
 and in different degrees of perfection by succeeding systematists ; 
 and we find in the works of Riolan,* * * § Adrian Spigel,| Caspar 
 and Thomas Bartholin, J Dionis,§ Marchettis,|| Willis,*!! and 
 Winslow,** but especially in the bulky compilation of Samuel 
 CoLLiNS,tt various attempts to communicate a just idea of the in- 
 
 * Joannis Riolani Ambiaiii Medici Parisiensis Opera Omnia. Parisiis, 1610. Folio. 
 
 + Adriani Spigelii de Corporis Humani Fabrica, libri x. 4to, 1632. 
 
 J Thomse Bartholini, Anatomia Reformata, ex [Casparis Bartholin! Parentis Insti- 
 tutionibus omniumque Recentionom et propriis observationibus. 8vo, Hagse Comi- 
 tum, 1660. 
 
 § The Anatomy of Human Bodies improved, &c., publicly demonstrated in the 
 Royal Garden at Paris, by Monsieur Dionis, Chief Surgeon to the late Dauphiness, 
 and to the present Duchess of Burgundy. Translated from the third edition. Lon- 
 don, 1703. 
 
 II Dominici de Alarchettis Anatomia. Batav. 1652, 4to. 
 
 ^ Thoma; Willis, M. D. Opera Omnia. Amstelsedami, 1682. 4to. Pharmaceutice 
 Rationalis. This treatise contains much information on the anatomical structure of 
 the textures and organs. 
 
 ** Exposition Anatomique de la Structm’e du Corps Humain. Par Jacques-Benigne 
 Winslow, de I’Academie Royale, &c. &c. A Paris, 1732. 4to. 
 
 A System of Anatomy treating of the Body of Man, Beasts, Birds, Fish, Insects, 
 and Plants, illustrated with many Schemes, consisting of a variety of elegant Figures 
 drawn from the Life, and engraven in twenty-four folio Copperplates. By Samuel 
 Collins, Doctor of Physic, Physician-in-Ordinary to his late Majesty of blessed memory, 
 and Fellow of the King’s most famous College of Physicians in London, and formerly 
 a Fellow of the Royal Foundation of Trinity College, in the most flourishing Univer- 
 sity of Cambridge. In the Savoy, printed by Thomas Newcomb, 1685. Two vo- 
 lumes folio. 
 
DIVISION OF THE TEXTURES. 
 
 3 
 
 timate structure and properties of the several animal textures. In 
 general, however, these notices are meagre and scanty. Sometimes 
 they are too generalizing, and hastily refer every variety of texture 
 to one or two hypothetical elements ; too often they consist of fan- 
 ciful conjectures substituted for accurate observation ; and they are 
 never so clear and satisfactory as to alford useful instruction to the 
 pathological inquirer. 
 
 Marcello Malpighi, born in 1628, professor of medicine succes- 
 sively in the universities of Bologna, of Pisa, and of Messina, and 
 finally invited to Rome as physician to Innocent XII., was the first 
 anatomist in whose hands the knowledge of intimate structure be- 
 came a science of accurate observation. In this manner (1660) he 
 investigated assiduously the minute structure of the lungs and the 
 disposition of their vessels ; he examined the omentum, (1661), and 
 inquired into the manner in which fat and marrow are secreted ; 
 he studiously endeavoured (1665) to unfold by dissection and mi- 
 croscopical observation the minute structure of the brain ; he de- 
 monstrated the organization of the skin, and considered its con- 
 stituents as the organ of touch ; he studied the structure of bone, 
 and exposed the errors of Gagliardi ; he traced the formation and 
 explained the structure of the teeth ; and he finally carried his 
 researches into the substance of the liver, the spleen, the kidneys, 
 and the conglobate glands, (1666.) In these delicate and difficult 
 inquiries, the observations of Malpighi are in general faithful to 
 nature, and his descriptions accurate. The information which he 
 collected was new and curious, and it is communicated in perspi- 
 cuous language, and in an interesting manner. He may he justly 
 regarded as the founder of that part of anatomical science which 
 treats of structure and organization ; and even in the present day 
 his writings on this subject are by no means destitute either of in- 
 terest or instruction. 
 
 About the same time (1641) the researches of De Graaf and 
 Ruysch tended to throw some light on the intimate structure of 
 several organs. De Graaf, who was young, while Malpighi was 
 declining in years, (1664), studied particularly the structure of the 
 pancreas, and of the organs of generation in both sexes, (1668), 
 and at once removed many popular errors, and communicated a 
 large proportion of accurate information. Had he not been cut 
 off at the early age of thirty-two, (1673), it cannot be doubted that 
 
4 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 his zeal in prosecuting the true knowledge of minute structure 
 would have greatly advanced this department of anatomy, 
 
 Frederic Ruysch, (1638), professor of anatomy and surgery 
 at Amsterdam, was more fortunate. Assiduously devoted during 
 a long life to the cultivation of anatomy, and eminent for the per- 
 fection to which he carried the art of injecting, he was enabled to 
 obtain more correct views than his predecessors of the arrangement 
 of minute vessels in the interior of organs, and to demonstrate 
 peculiarities of organization, which had escaped the scrutiny of 
 previous anatomists. Scarcely a part or texture of the human 
 body eluded the penetration of his syringe ; and his discoveries 
 were proportionally great, (1665), His researches on the lungs, 
 on the vascular structure of the skin, of the bones and their epi- 
 physes, of the spleen, of the glans penis, the clitoris, (1691), and the 
 womb, impregnated and unirapregnated, were sufficient to give him 
 the reputation of a most able and accurate anatomist, (1701). 
 These, however, were but a limited part of his anatomical labours. 
 He studied the minute structure of the brain, (1715); he demon- 
 strated the organization of the choroid plexus ; he described the 
 state of the hair when affected with Polish plait ; he proved the 
 vascular structure of the teeth; he injected the dura mater, the 
 pleura, the pericardium, and peritoneum; he investigated the 
 structure of the synovial apparatus placed in the interior of the 
 joints, and he discovered many curious particulars relating to the 
 lacteals, the lymphatics, and the lymphatic glands. So assiduously, 
 indeed, did Ruysch study by injection the tissues and organs of 
 the animal body, that it is less easy to say what he did than what 
 he neglected. We are indebted to him for many of the facts of 
 which anatomy at the present day consists, (1731.) 
 
 The labours of these ingenious and indefatigable inquirers added 
 considerably to the stock of accurate knowledge, and tended to dif- 
 fuse a taste for correct observation in the study of the minute struc- 
 ture of the parts of the animal body. Not much, however, had 
 been done for the arrangement of the materials thus collected. 
 Though many isolated facts had been established, and several cu- 
 rious discoveries had been made, they were not yet digested in that 
 systematic order which renders them useful to the purposes of pa- 
 thology. 
 
 It is in the great work of Haller (1757), that we recognise the 
 first traces of a better spirit and more philosophical views. This 
 
 3 
 
DIVISION OF THE TEXTURES. 
 
 5 
 
 accomplished scholar and indefatigable observer was the first who 
 attempted to present, in a collected form, the most correct informa- 
 tion on the intimate structure of the animal tissues. Assiduous in 
 his cultivation of anatomy, and deeply impressed with the necessity 
 of accuracy in research, Haller scrutinized with the eye of rigorous 
 observation every point in anatomical structure advanced by his 
 predecessors and contemporaries. In his description of the cellular 
 web, of the adipose membrane, of arterial texture of the veins, of 
 the structure of the heart, of that of the brain and nerves, of the 
 lungs, of the minute structure of the muscles, of the membranes, 
 and of the organs in general, the reader perceives, that, while Hal- 
 ler did not disdain to avail himself of the results of previous and 
 coeval inquiry, he scrupulously avoided adopting what he had not 
 verified by personal observation. The work which he modestly 
 styled Elements of Physiology shows, that, in extent of information 
 and soundness of judgment, he had no rival in the day in which he 
 lived ; and though something has been added to science since his 
 death, it is more by the combined efforts of many than by the la- 
 bours of any individual. 
 
 Amidst so much excellence it was unfortunate that the vain 
 search after an elementary fibre or rudiment, into which every va- 
 riety of animal substance was supposed to be resolved, led him to 
 indulge in some fanciful conjecture and gratuitous generalization.* 
 
 The distinction of the animal body into separate kinds of texture 
 (1757), thus introduced and recognised, was confined principally to 
 anatomy and physiology. The merit of applying them to pathology 
 is divided between William Hunter, William Cullen, and John 
 Hunter. The first, in a paper on Emphysema, in the second vo- 
 lume of the Medical Observations and Inquiries (1762,) gave in 
 1757 an ingenious account of the difference between the cellular tex- 
 
 * It will scarcely be credited that Haller could speak of this hypothetical fibre in 
 the following terms. quo communi nomine multiplex genus elementorum 
 
 comprehendimus, et cujus discrimina continuo exponemus, communis toti humano 
 corpori materies est, etiam, ut alibi ostendemus, cerebro et medullae spinaU. Fragilis 
 aut molhs, elastica, aut penitus pirltacea, longa absque fere latitudine, vel lata ut 
 longitudini par fere latitude sit, ossa, cartilagines, membranas, vasa, ligamenta, tendines, 
 musculos, nerves, cellulosum textum, viscerum parenchymata, piles et ungues sola 
 constituit.” Here it is represented as constituting the most opposite animal substances, 
 and entering into the composition of every texture. The composition of this ideal fibre 
 is not less wonderful. “ Invisibilis ea fibra, quam sola mentis acie attingimus, ex soils 
 elementis terreis et glutine, non ex minoribus fibris composita, cum sui similibus abit 
 in duo conspicua elementa solida corporis animalis.” 
 
fi 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 ture and the adipose membrane, with some observations on the serous 
 membranes, and showed in what manner the respective properties 
 of each tend to modify their different morbid states. In the Noso- 
 logy, Physiology, and First Lines of Dr Cullen, (1765, 1769), we 
 find the author making frequent allusion to the organic properties of 
 the various substances which enter into the composition of the animal 
 body, (1777), and employing these distinctions as the foundation of 
 his Pathology. In the hands of John Hunter this system was carried 
 to still greater perfection ; and his work on Inflammation contains 
 the rudiment of many of the improvements which Pathology has 
 derived from this source. 
 
 General anatomy was thus beginning to attain insensibly the 
 form of a science, and to be cultivated with assiduity as the surest 
 basis of pathological knowledge. I must not omit to mention, that 
 in the time of the elder Hunter and Cullen it underwent a valu- 
 able improvement in the hands of an ingenious foreigner. This 
 consisted in the systematic and connected view which Andrew 
 Bonn of Amsterdam delineated of the mutual connections of the 
 membranes of the human body. In his Inaugural Dissertation, 
 De Continuationibus Memhranarum, published at Leyden in 1763, 
 this author, after some preliminary observations on membranes in 
 general, and on their structure and organization, unfolds the struc- 
 ture of the skin and its component parts, as ascertained by the best 
 anatomists. He then proceeds to trace its continuation or transi- 
 tion into the mucous membranes, which he regards as productions 
 of the skin ; 1.9^, By the eyelids into the lacrymal passages ; 2d, 
 Into the external ear-hole ; 3<7, Into the nasal passages in the form 
 of the Schneiderian, or pituitary membrane ; Adh, Into the mouth, 
 throat, and Eustachian tube and tympanal cavity ; 6th^ By the 
 larynx and windpipe into the bronchial tubes and lungs ; 6/A, By 
 the pharynx and oesophagus into the stomach and bowels, where, 
 at the lower extremity of the rectum, its continuity with the skin 
 may again be traced. He concludes this part of his essay with a 
 sliort view of the transition of the skin into the mucous membrane 
 of the urinary and genital organs, or what has since been named 
 the genito-urinary surface. This may be regarded as the first di- 
 vision of his subject. 
 
 In the second, in which he treats of the membranes beneath the 
 skin, he considers, 1st, Those of the muscles, as the cellular mem- 
 brane and aponeurotic expansions ; 2d, The periosteum and peri- 
 
 4 
 
DIVISION OF THE TEXTURES. 
 
 7 
 
 chondrium, with tlieir modifications and uses ; and shows that one 
 or other of these membranes invests and connects every bone of the 
 skeleton. 
 
 In the third division he places the internal membranes of cavities, 
 or those which are now denominated serous and fibro-serous mem- 
 branes. He first traces at great length the course and divisions of 
 the dura mater and -pia mater, and contends that they accompany 
 each nerve and nervous branch ; then examines the coui'se of the 
 pleura and pericardium, and the relations of the mediastinum ; and? 
 lastly, he describes the extent of the peritoneum and its several di- 
 visions in connection with the organs contained in the abdominal 
 cavity.* 
 
 The quantity of accurate information which Bonn has here col- 
 lected, and the new and interesting views which he communicates 
 are truly wonderful. This essay is one of the best specimens of 
 correct and useful generalization which can be imagined ; and it is 
 an example of the capricious nature of scientific reputation, that, 
 while the work of Bichat, which was published forty years after, 
 though little more than the thesis of Bonn expanded, has given its 
 author an imperishable name, the small treatise of Bonn is equally 
 unknown and unregarded, and has scarcely served to rescue his 
 name from utter oblivion. 
 
 I have already alluded to the application of the distinctions of 
 general anatomj^ to pathology in the writings of Cullen and John 
 Hunter (1790). A more complete specimen of this was given in 
 1790 by Dr Carmichael Smith. In a paper published in the se- 
 cond volume of the Medical Communications of London, f this 
 physician took a view of the phenomena and peculiarities of inflam- 
 mation as they are observed in the different sorts of organic sub- 
 stance found in the animal body. This may be regarded as the 
 first systematic attempt in this country to trace the influence w'hich 
 different peculiarities of structure exercise on the phenomena and 
 progress of morbid action. 
 
 After this time various attempts were made to enumerate and 
 
 * Specimen Anatomico-Medicum Inaugurate de Continuationibus Membranarum, 
 quod publicae ac solemni disquisitioni submisit, Andreas Bonn, Amsteladamo Batavus 
 ad diem 14 Octobris 1763. Extat in Thesauro Dissertationum, Programmatum, alio- 
 rumque Opusculorum Selectorum, Eduardi Sandifort, M. D., &c. Vol. II. Rotterodami, 
 1769, xii. p. 265. 
 
 f Transactions of a Society for Promoting Medical Knowledge, Vol. II. London, 
 1790. 
 
8 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 classify the several animal substances of which the human body 
 consists, and to describe, in general terms, their obvious and dis- 
 tinctive characters and properties. M. Pinel, in his NosograpMe 
 Philosophique, first published in 1798, made the distinctions of the 
 membranes and other animal tissues the foundation of his arrange- 
 ment and pathology. 
 
 Soon after Xavier Bichat, (1800), in his Treatise on the Mem- 
 branes, gave a neat and comprehensive view of the general structure 
 of these tissues, and of their connection with the vital and morbid 
 processes carried on at their respective surfaces. This, however, 
 was merely the introduction to a work still more extensive and ela- 
 borate. In his Treatise on the Membranes he confined himself to 
 the examination of the structure and properties of the mucous, se- 
 rous, and fibrous membranes, and a short view of the fibro-mucous 
 and fibro-serous tissues. In his General Anatomy, which appear- 
 ed in 1801, he delineated the first, and perhaps the most perfect 
 arrangement of the different organic textures of the human body 
 that has yet appeared. 
 
 This author considers the human body as an assemblage of many 
 different organs (1801), each of which consists of a greater or smaller 
 number of animal substances, which, though thus combined in the 
 formation, or entering into the composition of the same part or or- 
 gan, are very different in structure and properties from each other. 
 Each of these distinct forms of animal matter he calls a tissue or 
 
 texture, {textus, tela ;) and he refers the whole of those which ana- 
 tomists have enumerated, or which accurate discrimination can dis- 
 tinguish in the human body, to twenty-one general heads. 
 
 ( Subcutaneous, connecting the skin to the subjacent parts. 
 
 Subserous, connecting the serous or transparent membranes to the contiguous 
 parts. 
 
 Sulrmucous, connecting the mucous membranes to the subjacent parts. 
 Arterial, surrounding and enclosing arteries. 
 
 Venous, ... ... veins. 
 
 Excretory, ... ... excretory ducts. 
 
 Enveloping, surrounding and enclosing organs. 
 
 L Penetrating, entering into the substance of organs. 
 
 ' a Animal life. 
 h Organic life. 
 
 •-1 
 
 J -f! 
 W .£ 
 
 o .3 
 
 . 
 
 .-I 3 
 
 CC 
 
 2 and 3. Nervous. 
 
 4. Arterial. 
 
 5. Venous. 
 
 6. Exhalant. 
 
 7. Absorbent. 
 
 8. Osseous. 
 
 9. Medullary. 
 
 i Absorbent vessels. 
 
 ( Absorbent glands, 
 j Bones proper, long, flat, and short. 
 
 \ Teeth. 
 
 i Marrow of short and Hat bones, or the ends of long bones. 
 ( Marrow of the shafts, or bodies of long bones. 
 
DIYISION OF THE TEXTURES. 
 
 9 
 
 10. C.4RTILAGINOUS. 
 
 Ch 
 
 w 
 
 Articular ends of movable bones. 
 
 Articular surfaces of immovable bones. 
 
 Ribs, Larynx, Nasal Partition, &c. 
 f Periosteum. 
 
 Dura Mater. 
 
 Sclerotic. 
 
 Albuginea. 
 
 I Membrane of Kidneys, Spleen, &c. 
 , i Scapulo-humeral articulation. 
 Fibrous Capsules. | ui/fe^oral articulation. 
 
 r, .. , i Palms of hand and foot. 
 Partial. | 
 
 General. Annular ligaments. 
 Enveloping. 
 
 Proper Fibrous 
 Membranes. 
 
 Fibrous Sheaths. 
 
 Aponeuroses. 
 
 ( at By broad surface. 
 < Arched. 
 
 ( y By isolated fibres. 
 
 
 I 
 
 f Simple. 
 
 Tendons. -< 
 
 ( Compound. 
 
 r ■ ^ { Regularly fasciculated, 
 
 igamen s. j fasciculated. 
 
 Membranous. Fibro-cartilages of the 
 
 Ears. 
 
 Nose. 
 
 Trachea. 
 
 ( Eyelids. 
 
 A 1 ( Interarticular, those of the knee-joint, lower jaw. 
 
 r icu ar. | Jjjt 0 j.yertebral fibrocai'tilages. 
 
 Tendinous. 
 
 13 and 14. (a Animal life, all the voluntary muscles. 
 
 Muscular, j h Organic hfe, e. g. heart, stomach, and intestines. 
 
 15. Mucous, comprehending the gastro-pulmonary mucous surface, and genito- 
 urinary mucous surface. 
 
 16. Serous, comprehending the arachnoid membrane, pleura, pericardium, perito- 
 nseum, and vaginal coat. 
 
 17. Synovial. 
 
 1 8. Glandular, comprehending the secreting glands only. 
 
 1 9. Dermoid or Cutaneous. 
 
 20. Epidermoid or Cuticular. 
 
 21. Pilous or Hairy. 
 
 These different forms of animal substance he considers as the 
 organic elements, or proximate principles, to use the language of 
 chemistry, into which animal bodies may be resolved. These ele- 
 mentary tissues he again refers to two great orders, — one general- 
 ly distributed and everywhere present, so as to form an integrant 
 part of every other animal substance. To this order, which he 
 termed general or generating systems, he referred cellular mem- 
 brane, arterial and venous tissue, the nerves, and the exhalants and 
 absorbents. The substances of the second kind, which are placed 
 in determinate situations, and confined to particular regions, con- 
 sist of the bones, cartilages, fibrous substances, muscles, and 
 muscular parts, the mucous, serous, and synovial membranes, 
 glandular organs, the skin and its appendages, the nails, hair, &c. 
 
10 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 All the substances of this latter order consist of a peculiar matter, 
 by which they are distinguished, and more or fewer of the general 
 tissues. 
 
 As the structure and properties of the same elementary tissue 
 are nearly the same in whatever region of the body it is found, or 
 undergo only such modifications as its peculiar use or local con- 
 nections render requisite, a just idea of the structure of the human 
 body suggests the propriety of considering the extent, disposition, 
 structure, and most obvious properties, mechanical and vital, of 
 each tissue by itself. The examination of these circumstances con- 
 stitutes the subject of his General Anatomy, a work which, in ori- 
 ginality of plan, and general excellence of performance, notwith- 
 standing occasional defects and errors, has not yet been surpassed. 
 
 The arrangement, however, of Bichat has been found incorrect 
 or inconvenient ; and various alterations or modifications of it have 
 been proposed by subsequent authors. The first which we shall 
 notice is that proposed by Dupuytren and Richerand, which has 
 been generally esteemed in France as more correct and compre- 
 hensive. It may be exhibited in the following tabular form : — 
 
 1. Cellular. 
 
 2. Vascular, 
 
 3. Nervous, 
 
 4. Osseous. 
 
 5. Fibrous, 
 
 C. Muscular, 
 
 7. Erectile. 
 
 8. Mucous. 
 
 9. Serous. 
 
 10. Horny or Epidermal, 
 
 11. Parenchymatous, 
 
 ( Arterial. 
 
 < Venous. 
 
 ( Lymphatic. 
 
 I Cerebral, 
 j Gangliar. 
 
 ( Fibrous. 
 
 < Fibro cartilaginous. 
 ( Dermoid. 
 
 i Voluntary. 
 
 \ Involuntary. 
 
 ( Pilous. 
 
 ( Epidermal, 
 i Parenchymatous. 
 ( Glandular. 
 
 In this enumeration several important differences from that of 
 Bichat will be recognized. It presents altogether nineteen sepa- 
 rate tissues, of which five are so decidedly peculiar, that they do 
 not admit of being associated with any similar, and consequently 
 form distinct systems by themselves ; while the other fourteen are 
 referred to the general heads of vascular, nervous, fibrous, muscu- 
 lar, horny, or parenchymatous systems. The result of this ar- 
 rangement is to diminish the number of organic systems from 
 
DIVISION OF THE TEXTURES. 
 
 11 
 
 twenty-one to eleven, one of which, the erectile, comprehending the 
 peculiar structure of the cavernous body, the clitoris, the nipple, 
 and the spleen, is not found in the original arrangement of Bichat, 
 hut has been added by MM. Dupuytren and Richerand. 
 
 A less neat and elegant arrangement is that given by Hippoly- 
 tus Cloquet, who admits in the human body the following fifteen 
 tissues: 1. The cellular; 2. The membranous; 3. The vascular, 
 including blood-vessels, and lymphatics; 4. Bone; 5. Cartilage; 
 6. Fibro- cartilage ; 7. Ligament; 8. Muscle; 9. Tendon; 10. 
 Aponeurosis, or fascia; 11. Nerve; 12. Glandular structure; 13. 
 Follicle; 14. Lymphatic ganglion, or gland; 15. The Viscera. 
 It is evident that the last mentioned term is greatly too vague, and 
 that the structure which it is intended to denote may be either 
 united with several of those already noticed, or is so different or 
 opposite in different situations, that admitting it as a separate tis- 
 sue becomes of no use whatever in a correct classification. 
 
 N ot unlike to the arrangement of MM. Richerand and Dupuy- 
 tren is that proposed by John Frederic Meckel, who looked on the 
 arrangement of Bichat as too detailed, and embarrassed with toa 
 many and minute distinctions. According to this anatomist, the 
 medullary system should be united with the cellular ; the synovial 
 should be viewed as a modification of the serous system ; the pilous 
 and epidermal systems ought not to be separated from the cutane- 
 ous or dermal ; and even this last, along with the glandular and mu- 
 cous, ought to be referred to the same general head. According 
 to these principles all the organized substances composing the hu- 
 man body are referred by iMeckel to the following ten heads : — 
 
 Against this arrangement Mayer, professor of anatomy at Bonn, 
 has urged the following objections : — That it is impossible to con- 
 sider the scarf-skin, or cuticle, and the hairs, as of the same or si- 
 milar structure with the cutaneous tissue in general : that glandu;- 
 lar structure cannot be regarded as pertaining to the same order 
 with the mucous membranes ; that the fibro-cartilages ought nei- 
 ther in this arrangement nor in that of Bichat to be considered as 
 distinct from cartilage ; and that in both several parts of the ani- 
 
 1. Mucous, or cellular. 
 
 6. Fibro-cartilaginous. 
 
 7 . Fibrous. 
 
 8. Muscular. 
 
 9. Serous. 
 
 10. Cutaneous. 
 
 2. Vascular. 
 
 3. Nervous. 
 
 4. Osseous. 
 
 o. Cartilaginous. 
 
12 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 mal body are omitted, or can have no convenient place of refer- 
 ence. Mayer therefore reduces the twenty-one tissues of Bichat to 
 seven, and adds an eighth, comprehending the crystalline lens, the 
 cornea, epidermis, hair, nails, &c, to which he gives the general 
 name of lamellar tissue. The classification of organic tissues given 
 by this anatomist would stand in the following order: — * 
 
 I. Lamellar. 
 
 ( Crystalline lens. Cornea. 
 
 Cuticle. 
 
 Hair, nails in whatever form, as claws, bill, hoof. 
 Horns, scales, &c. 
 
 I Teeth. 
 
 II. Filamentous. 
 Cellular. 
 
 1. Cellular system, 
 
 2. Adipose system, 
 
 3. Medullary system, 
 
 4. Serous system, 
 
 5. Synovial, 
 
 6. Vascular, 
 
 7. Dermoid, 
 
 8. Mucous, 
 
 f 1. Cellular system, S, Cellulosum. 
 
 S. Adiposum. 
 
 Medullare. 
 
 Serosum. 
 
 Synoviale. 
 
 Vasculosum. 
 
 Dermodeum. 
 
 Alucosum. 
 
 9. Structure of the womb and reservoirs of secreted 
 fluids. Uterus. 
 
 1. Hard membrane, Dura meninx. Dura mater. 
 
 2. Periosteum. 
 
 3. Cartilage. 
 
 4. Proper membrane of intestinal tube, T. Nervosa. 
 
 5. Membrane of synovial capsules. 
 
 TIL Fibrous. -{ 6. Ligaments. 
 
 7. Sheaths, Vaginae tendinum. 
 
 8. Aponeurosis, Fascia. 
 
 9. T'endon. 
 
 10. Neurilema. 
 
 11. Soft membrane, Meninx tenuis, Pia mater. 
 
 To these may be added a series of parts pertaining at once to the fibrous and the 
 filamentous cellular system, since their structure presents a predomination of fibrous 
 filaments. These are, 
 
 1. The Sclerotic. 
 
 2. The Tunica albuginea of the testicle. 
 
 3. The Proper tunic of the spleen and kidneys. 
 
 4. The Cellulo-fibrous sheath of conglomerate and conglobate 
 
 glands. 
 
 5. The Corpus cavernosum and C. spongiosum. 
 
 IV. Cartilaginous. 
 
 V. Osseous. 
 
 1. Lymphatic ganglion or glands. 
 
 VI. Glandular. 2. « Granular glands, or those provided with excreting duct, the 
 lacrymal gland, the salivary glands, the pancreas, liver, 
 kidneys. 
 
 ji Glandular organs without excreting duct, as the spleen, thy- 
 mus, renal capsules. 
 
 These three forms of glandular organs are considered by Professor Mayer as combi- 
 nations of minute lympihatics, or blood-vessels, or both united. 
 
 VII. MuscuL.iR. 1. Animal or voluntary. 
 
 2. Organic or involuntary. 
 
 VIII. Nervous. 
 
 * Sur ITIistoIogie, avec une division nouvelle des tissus du corps humain. Par le 
 Docteur Mayer, Prof. d’Anatomie et de Physiologie. Bonn, 1819. — Journal de Me- 
 decine, &c. Vol. XII. 193, XII. 99. 
 
DIVISION OF THE TEXTURES. 
 
 13 
 
 This arrangement, which is undoubtedly very elaborate, and per- 
 haps more comprehensive than either that of Bichat or any other 
 author, is not, however, quite faultless. It may be doubted whe- 
 ther the lens is an organic body at all, and it is certainly much less 
 an organic substance than the cornea, with which it is arranged. 
 Cellular and cutaneous tissue are certainly not so similar as to ad- 
 mit of being referred to the same rank ; and the organs destined 
 to contain secreted fluids are so opposite and different in structure, 
 that it appears rather violent to connect them in one group. The 
 proper membrane of the intestinal tube is, according to the result 
 of my observations, nothing but the corion of the villous mem- 
 brane ; at least I cannot conceive any other part to which the de- 
 scription will apply ; and surely the soft cerebral membrane {jpia 
 mater) cannot justly be associated with such substances as liga- 
 ments, tendons, or aponeurotic sheaths. 
 
 The system termed glandular by Professor Mayer is still more 
 awkwardly situate. For not only is it doubtful with what justice 
 the lymphatic glands are associated with the proper secreting glands, 
 but the latter are themselves much varied in structure and anato- 
 mical characters ; and as to the old notion of glandular structure 
 being merely an expansion of vessels arranged in a peculiar man- 
 ner, I fear that is not only too general to be true, but that there is 
 no tissue in the human body which might not be defined in the 
 same manner. 
 
 In the formation of any arrangement of the organic tissues of 
 which the human body consists, two extremes must be sedulously 
 avoided. First, care should be taken not to diminish too much 
 the number of individual or distinct tissues, and to avoid the use- 
 less and unnatural system of referring the several substances em- 
 ployed in the construction of the human body to a small number 
 of general heads. This was the error of the ancient physiologists, 
 who, from a wish to simplify more than nature admitted, referred 
 the various animal substances to an elementary fibre or fibres, 
 which they imagined formed the basis or ground-work of the whole 
 animal organization. 
 
 The second extreme which ought to be avoided in this matter is 
 the practice of dividing the substances of the animal body into a 
 greater number of distinct kinds and species than is convenient or 
 necessary. Very superficial inspection, indeed, shows that they are 
 not the same either in anatomical or physical characters, or in che- 
 
14 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 niical composition, and that the idea of considering one tissue as a 
 modification of another, or one animal substance as forming or ge- 
 nerating another, is, if not unnatural and impossible, at least much 
 more remote from the truth, than to consider them as actually dif- 
 fering in kind, and possessing the properties of a separate form of 
 organized matter. This, therefore, though an evil in its way, is 
 one of much less injurious consequence than the former, which, by 
 its generalizing spirit, has a tendency to supersede investigation, 
 and to consider the nature of the animal tissues as sufficiently esta- 
 blished. This pei'haps was the error of Bichat, if his arrangement 
 is chargeable with fault. But with still greater justice it may be 
 said, that the recent attempts at classification, like the imperfect 
 ones of the ancient physiologists, are to be blamed in diminishing 
 too much the number of separate tissues, and in delivering arrange- 
 ments, the principles of which are more general and comprehensive 
 than nature warrants. 
 
 It may indeed be assumed as a safe principle, that all the sub- 
 stances employed in the construction of the animal body, which ara 
 not very obviously alike, may be considered as separate or distinct 
 proximate principles, till careful examination shall show that they 
 ought to be associated with others. This indeed defeats the pur- 
 pose of classification, which is useful in proportion as it discovers 
 genuine analogies and general resemblances for the purpose of 
 communicating knowledge with facility ; but it also prevents the 
 approach or insinuation of error, by the caution with which it ex- 
 amines, and the discrimination with which it adopts. 
 
 In the short view which I propose here to take of the organic 
 tissues, I shall not adhere scrupulously to either of those arrange- 
 ments which I have already noticed, but attempt to modify that of 
 Bichat, which is perhaps the least objectionable, by adopting as 
 many of the suggestions of his commentators and followers as the 
 nature of the subject and personal observation may seem to autho- 
 rize. In the course of this exposition I shall have frequent occa- 
 sion to refer to the best and most complete commentary that has 
 yet appeared, — that by Professor Bedard, who has availed himself 
 of the researches of J. F. Meckel, and Dr J. Gordon of Edinburgh, 
 the Prodrome of Mascagni, the Histologic of Mayer, and the View 
 of Bock. 
 
 The human body consists of solid and fluid substances, the for- 
 mer of which are organized, and determine the shape of the body 
 
DIVISION OF THE TEXTURES. 
 
 15 
 
 and its parts. These organized solids are not in a strict physical 
 sense solid and impenetrable. Most of them are soft, compressible, 
 and elastic, by reason of the fluid matter contained in their inter- 
 stices; and when deprived of this by desiccation, they shrink in 
 various degrees, and lose both bulk and weight. The general 
 ratio of the fluid to the solid parts varies from 7 to 1, to 9 to 1. 
 An adult carcass weighing perhaps from 9 to 10 stones, has been 
 reduced by desiccation to 7^ lbs. A human body may be reduced 
 to nearly the weight of its skeleton, which varies from 150 ounces 
 = 9f lbs. to 200 ounces = 12^ lbs. 
 
 These organized solids agree in the possession of certain gene- 
 ral characters. Their internal structure consists of a union of 
 solid and liquid matter, which is observed to exude in drops more 
 or less abundant from the surface of sections. The solid parts are 
 generally arranged in the form of collateral lines, sometimes ob- 
 lique, sometimes perfectly parallel, sometimes mutually intersect- 
 ing. Such lines are denominated fibres^ and occasionally filaments. 
 In other instances the solids are observed to consist of minute glo- 
 bular or spheroidal particles, which are shown by the microscope 
 to be cells or membranous cavities with a central nucleus, connect- 
 ed generally by delicate filaments. Most of these solids anatomists 
 and microscopical observers have attempted to resolve into what they 
 conceive to be an ultimate fibre or last element ; but this inquiry 
 leads beyond the bounds of strict observation. 
 
 Most of the solids may be demonstrated to be penetrated by mi- 
 nute ramifying tubes or blood-vessels, which traverse their sub- 
 stance in every direction, and in which is contained the greater 
 part, perhaps the whole, of the fluid matter found in the solids. 
 In a few, in which i-amifying vessels cannot be positively demon- 
 strated, their existence is inferred by analogy from those in which 
 they can. The filamentous, fibrous, or globular or cellular ar- 
 rangement, with the distribution of arborescent vessels, constitutes 
 organization. Tbe substances so constructed are named organized 
 tissues {tela, textus,) or textures, or simply tissues. 
 
 The organized solids also resemble each other in chemical con- 
 stitution. They may be resolved into proximate principles, either 
 the same or very closely allied. The proximate principles most 
 generally found are albumen, fibrin, and gelatine, one or other 
 of which, sometimes more, form the basis of every tissue of the 
 human body. Next to these are mucus, and oily or adipose mat- 
 ter. Osmazome or extractive matter is found in certain tissues. 
 
IG 
 
 GENERAL AND PATHOLOGICAL ANATOMY, 
 
 And lastly, several saline substances, as phosphate of lime, carbo- 
 nate of lime, soda, hydrochlorate of soda, are found in variable 
 proportions in most of them. Of these principles albumen and 
 fibrin, which are closely allied and pass into each other, are the 
 most common and abundant. Osmazome, which is probably a mo- 
 dification of fibrin, is less frequent. These also are contained in 
 the blood, and are derived from that fluid. Gelatine, though not 
 found in the blood, is nevertheless a principle of extensive dis- 
 tribution, being found in skin, cellular tissue, tendon, cartilage, 
 and bone. These proximate principles are resolved, in ultimate 
 analysis, into carbon, oxygen, hydrogen, azote, phosphorus, and 
 sulphur. From the saline substances, calcium, potassium, sodium, 
 chlorine, iron, and manganese may be obtained. 
 
 Mulder maintains the existence of another element named pro- 
 teine, obtained by a particular process from albumen. Its cha- 
 racter is that it is a common element to albumen, fibrin, and various 
 of the elements of the tissxies. 
 
 The different organized solids which enter into the composition 
 of the human body may be referred to the following seventeen 
 simple tissues. Filamentous or cellular tissue, including the or- 
 dinary cellular membrane and adipose membrane ; artery, vein, 
 with their minute communications, termed capillary vessels, and 
 the erectile vessels ; lymphatic vessel and gland ; nerve, plexus, 
 and ganglion ; brain ; muscle ; white fibrous system, including li- 
 gament, periosteum, and fascia; yellow fibrous system, including 
 the yellow ligaments, &c. ; bone and tooth ; gristle or cartilage ; 
 fibro-cartilage ; skin ; mucous membrane ; serous membrane ; sy- 
 novial membrane ; compound membranes, for instance the fibro- 
 mucous, and fibro -serous ; and lastly, the peculiar matter which 
 forms the liver, the kidneys, the female breast, the testicle, and 
 other organs termed glands. To these may be added the compound 
 textures or organs ; in which two or more simple textures are 
 united ; as the heart and lungs ; the larynx ; the stomach, duodenum^ 
 and alimentary canal ; the bladder, prostate gland, and penis ; 
 and the female organs of generation, as the uterus, ovaries. Fal- 
 lopian tubes, and vagina with appendages. 
 
 These tissues may be distinguished into orders, according to the 
 mode of their distribution in the animal frame. Several, for in- 
 stance filamentous tissue, artery and vein, lymphatic vessel, and 
 nerve, are most extensively distributed, and enter into the compo- 
 
DIVISION OF THE TEXTURES. 
 
 17 
 
 sition of all the other simple tissues. To these, therefore, which 
 are named by Bichat general or generating systems, the character 
 of textures of distribution may be applied. A second order, con- 
 sisting of substances confined to particular regions and organs, and 
 placed in determinate situations, viz. brain, muscle, white fibrous 
 system, yellow fibrous system, bone, cartilage, fibro-cartilage, and 
 gland, may be denominated particular tissues. To a third order, 
 consisting of substances which assume the form of a thin mem- 
 brane, expanded over many different tissues and organs, may be 
 referred skin, mucous membrane, serous membrane, and synovial 
 membrane, under the denomination of enveloping tissues. It may 
 indeed be objected, that the circumstance of mechanical disposition 
 is insufficient to communicate a distinctive or appropriate character, 
 and several of the tissues referred to the second head, e. g. fascia., 
 must, on this principle, be referred to the third. The objection is 
 not unreasonable. But it may be answered, that it is almost vain to 
 expect an arrangement entirely faultless ; and the present is con- 
 venient in being on the whole more natural, and therefore more 
 easily remembered, than any other. A distinct idea of it may be 
 formed from the following tabular view. 
 
 General 
 
 or 
 
 Common 
 
 Tissues. 
 
 Particular 
 
 Tissues. 
 
 Enveloping 
 
 Tissues. 
 
 Compound 
 
 Organs. 
 
 Filamentous Tissue. 
 Artery. 
 
 Vein. 
 
 Capillary VesseL 
 
 I Lymphatic Vessel. 
 
 I IS erve. 
 
 ' Brain. 
 
 Muscle. 
 
 White Fibre. 
 
 Yellow Fibre. 
 
 Bone. 
 
 Cartilage. 
 
 Fibro-Cartilage. 
 
 L Gland. 
 
 i Skin. 
 
 Mucous Membrane. 
 Serous Membrane. 
 Synovial Membrane. 
 
 ' 
 
 Organs of Digestion. 
 
 Organs of Respiration 
 and Circ'ilation. 
 
 - Organs of Urinary Ex- 
 cretion and Reproduc- 
 tion. 
 
 Organs of Sensation. 
 
 ( Ligament. 
 
 ^ Periosteum.' 
 t Fascia. 
 
 j Yellow Ligaments, 
 j Ligamentum Nuchae. 
 Tooth. 
 
 1 Tongue, GSsophagus, 
 
 < Stomach, Duodenum, 
 ( Ileum, and Colon. 
 
 i Larynx, Trachea, Lungs, 
 ( and Heart. 
 
 1 Ureter, Bladder, Penis, 
 
 < &c. Uterus, Ovaries, 
 ( Fallopian Tubes. 
 
 ( Eye ; Nasal Passages ; 
 
 < Ear ; Tongue, and 
 ( Palate. 
 
 B 
 
18 
 
 GENERAL AND PATHOLOGICAL ANATOIHY. 
 
 CHAPTER II. 
 
 THE FLUIDS OF THE HUMAN BODY. 
 
 Section I. 
 
 The solid or organized textures contain fluids, some for pur- 
 ])Oses within the system, others destined to be expelled from it. I 
 shall give a short account of the characters and properties of the 
 principal fluids of the body, preparatory to a view of their morbid 
 states. 
 
 The fluids of the animal body are various, but may be distin- 
 guished into three sorts; the circulating nutritious fluid named 
 the blood, the fluids which are incessantly mixed with the blood for 
 its renewal, and those which are separated from it by secretion. 
 
 The blood is well known to be a viscid liquid, of red colour, 
 peculiar odour, and saline, something nauseous taste. Its tempe- 
 rature in the living body is about 97° ; its specific gravity is about 
 105 to water as 100. Its quantity is in the adult considerable, 
 varying from 8 or 10 to 80 or 100 pounds; the average is about 
 30 pounds. 
 
 According to the results of microscopic observation, it consists 
 of red particles suspended in a serous or sero-albuminous fluid. 
 On the shape of these red particles various opinions have been main- 
 tained. Generally represented as globular, Hewson describes them 
 as flattened spheroids, or lenticular bodies, a view which is con- 
 firmed by the observations of Prevost and Dumas, Bedard, of 
 Plodgkin and Lister, and Mr Wharton Jones. The opinion of 
 Home and Young, that the flattening of these globules is a process 
 posterior to the discharge of the fluid, is not improbable. These 
 particles have since the time of Hewson been almost universally 
 represented as consisting of a central transparent whitish globule, 
 inclosed in a red translucent vesicle, which gives them the shape of 
 an oblate spheroid. In man and the mammalia they are circular 
 discs, often with a depression on the sides. The diameter of these 
 particles is estimated, by the subdivided scale of Kater, the mi- 
 crometer of Wollaston, and the eriometer of Young, at j-ggo? 
 by the common micrometer, at Tygg of an inch. {Phil. Trans.) 
 Mr Gulliver estimates the average thickness of the human blood- 
 
FLUIDS OF THE HUMAN BODY. 
 
 19 
 
 col’puscle at islooth part of an English inch, and the diameter at 
 ^ioo' This description applies to the blood circulating in the ves- 
 sels. 
 
 The flattening of the corpuscles is greatest in reptiles, amphibia, 
 and Ashes ; and it is most remarkable in the salamander. In birds 
 the red globules are flattened, but in less degree than in the am- 
 phibia. 
 
 The red particles are largest in the amphibia. In birds, rep- 
 tiles, and Ashes they are smaller. In mammalia they are smallest. 
 (Gulliver apud Hewson, p. 236.) 
 
 Discharged from the vessels, it exhales, during the process of 
 cooling, a thin watery vapour, consisting of water suspending ani- 
 mal matter capable of impressing the sense of smell, and under- 
 going decomposition. During the same space it is observed to be 
 converted into a Arm mass, which, though still soft and elastic, is 
 entirely void of fluidity. As this process advances, a thin watery 
 fluid, straw-coloured, not perfectly transparent, is observed to ex- 
 ude from every part of the solid mass, which also diminishes in 
 size, till at length it is found floating like a tolerably thick cake in 
 the thin watery fluid. The thick solid mass is named the clot or 
 coagulum ; the watery fluid is denominated serum ; and the process 
 of the separation, which is spontaneous, is termed coagulation. The 
 blood at the same time is said to discharge carbonic acid. 
 
 The clot, if divided and washed in water often changed, or in 
 alcohol or aqua potassce, may be deprived of its red colour, and 
 made to assume a gray or bluish-white tint. This gray mass, 
 which is tough, coherent, opaque, and more or less dense, homo- 
 geneous, but void of traces of organic structure, consists chiefly of 
 albumen or flbrin, or a substance partaking of several of the cha- 
 racters of both. To this substance the blood owes its viscidity and 
 its property of spontaneous coagulation ; and from the circumstance 
 of its resemblance to the lymph or albuminous fluid which is effused 
 from wounds and inflamed surfaces, and to the fibrin of muscle, and 
 tbe albumen of many of the tissues, it may be regarded as the most 
 vital and nutritious part of that fluid. It is a mistake, neverthe- 
 less, to assert, as is done by Bedard and others, that this substance 
 presents to the microscope the aspect and structure of muscular 
 fibre. Its aspect is by no means so regular as this, nor can its par- 
 ticles be said to present traces of organic structure or arrangement. 
 
 The red matter removed by washing is a mixture of serum, of 
 globules, and of a peculiar colouring matter. Modern chemistry 
 
20 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 shows that the latter is a paiticular substance, insoluble in water, 
 but susceptible of suspension in it to an extreme extent, and con- 
 sisting of animal matter combined with peroxide of iron. It is 
 distinguished by the name of zoohematine. Deprived of this, the 
 globules are estimated by Bauer at g of inch in diameter. 
 
 The serum, with the taste and odour of the blood, rather alka- 
 line, coagulates at 162° F. or on the addition of acids, nitrate of 
 silver, or corrosive sublimate, and then resembles boiled white of 
 egg. The coagulated matter is albumen ; and a little water con- 
 taining soda and salts of soda may be separated. It is a remark- 
 able difference between this albumen, which is suspended in the 
 serum, and that which constitutes the clot, that while the former 
 requires heat as a re-agent, the latter assumes the solid form spon- 
 taneously. 
 
 The proportion of serum to clot varies in different animals, in 
 different individuals, and in different states of the system, healthy 
 and morbid. 
 
 In the human body a quantity of five ounces of blood usually fur- 
 nishes about one ounce and two drachms, or one ounce and four 
 drachms of serum. In inflammatory diseases the amount of the se- 
 rum is usually increased. Thus in acute rheumatism and in pneu- 
 monia, if the huffy coat be thick and strong, the serum afforded by 
 five ounces amounts to one ounce and six drachms, or two ounces. 
 In fever, again, the proportion of serum is diminished. Thus five 
 ounces of blood will afford not more than one ounce, or only six 
 drachms of serum. At advanced periods of the disease, for in- 
 stance after the first eight days or towards the close of the first sep- 
 tenary period, the serum afforded by five ounces is not more than 
 six or four drachms ; and in some instances it is about three drachms 
 or two drachms, or not more than one and a half. 
 
 In these circumstances the clot is less firm than usual, and is 
 loose and flabby. 
 
 In purpura most commonly no serum is separated ; and the clot 
 appears alone as a mass of gelatinised blood imperfectly coagulated. 
 
 These phenomena depend on the degree of the coagulating 
 power ; and they may be taken to measure its force. Thus in the 
 healthy state, and in certain inflammatory diseases, the coagulating 
 power is greatest. In fever the coagulating power is weakened in 
 proportion as the disease advances. And in purpura and at the 
 close of fever the coagulating power is very nearly null. 
 
 This, however, is merely the relation of the serum to the clot. 
 
FLUIDS OF THE HUMAN BODY. 
 
 21 
 
 when under spontaneous coagulation. After this is completed, the 
 clot still retains so much serum, that it must be subjected to re- 
 peated pressure, or to evaporation, or both, before the clot can be 
 obtained in a solid and dry state, quite free from serum. When this 
 has been done, it is found that the spontaneously coagulable part 
 of the blood is always much less than the fluid part ; in other words, 
 that it is in the ratio of minority to the serum, or numerically in 
 the ratio of 13 to 87 in 100 parts of blood. 
 
 Liquid fibrin, or the spontaneously coagulable part of the blood, 
 is most abundant in warm-blooded animals ; and among these it is 
 more abundant in the blood of birds than in that of the mammalia. 
 In fishes it is very scanty ; and it is sparing also in the blood of the 
 reptile family. In fishes and reptiles it is more in the form of a 
 liquid gore, viscid and semifluid, but scarcely coagulating, than in 
 that of blood. 
 
 It is a well-known fact that in frogs the blood does not coagu- 
 late on exposure of the vessels to air, as it does in the mammalia. 
 This must be owing either to the blood of these animals containing 
 a much smaller proportion of fibrin than that of the mammalia, or 
 the fibrin having much less coagulating power. In either case it 
 comes to the same result. 
 
 This has been supposed by De Saissy and others to bear some 
 relation to the state of respiration in these several classes ; and the 
 idea seems accordant with the facts. In birds the function of re- 
 spiration is most fully developed. In reptiles and fishes it is very 
 imperfectly* developed. 
 
 When blood drawn from the veins of a person labouring under 
 acute rheumatism and other inflammatory diseases is undergoing 
 coagulation in a glass vessel, a colourless fluid may be perceived 
 round the edge of the surface ; and after anhnterval of four or five 
 minutes, a bluish appearance is observed, forming an upper layer 
 of the blood, in consequence of the subsidence of the red particles 
 to a certain distance below the surface, and the clear liquor being 
 left between the place of the red particles and the edge of the ves- 
 sel. This liquid may be collected by a spoon and placed in another 
 vessel, where it is first clear, though opalescent, viscid, and homo- 
 geneous. After some time, however, it undergoes separation into 
 two parts ; one coagulated, the other fluid. The coagulated part is 
 the fibrin of the blood or that which is spontaneously coagulable ; 
 the fluid part the serum. The opalescent liquor has been named 
 liquor sanguinis, (Babington.) 
 
22 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Gmelin, Chevreul, and Lecanu obtained from the blood stearine 
 and elaine. 
 
 The colour of the blood varies in different parts of the system. 
 In the left auricle, ventricle, and arterial trunks generally, its co- 
 lour is bright scarlet, a tint which it loses in the capillary vessels. 
 In the veins, venous trunks, right auricle, right ventricle, and pul- 
 monary artery, its colour is a dark or purple-red, or modena. As 
 it moves from the trunk and branches through the minute divisions 
 of the pulmonai'y artery, it gradually parts with this tint ; and in 
 the branches of the pulmonary veins it is found to have acquired 
 the bright scarlet colour which it has in the left auricle, ventricle, 
 and aorta. Hence the modena or dark-coloured blood is distin- 
 guished as venous, or proper to the veins ; and the bright red or 
 scarlet-coloured as proper to the arteries. 
 
 In the foetus, the blood contains little coagulable matter ; and 
 this principle is entirely wanting in the blood of the menstrual dis- 
 charge. 
 
 The fluids received by the blood are chyle and lymph. Chyle 
 is derived from chyme, a gray pulpy substance, formed from the 
 alimentary mass in the stomach and duodenum. Detached from 
 this substance, and received by the chyliferous tubes, it is whitish 
 and scarcely coagulable. In the mesenteric glands it becomes 
 more coagulable, and assumes a rose colour. Lastly, in the thoracic 
 duct, and before joining the mass of blood, it is distinctly rose-co- 
 loured, coagulable, and globular in its particles. In the branches 
 of the pulmonary artery it appears to become perfect blood. Lymph 
 is a colourless, viscid, albuminous fluid, imperfectly known. 
 
 Of the fluids separated from the blood, all cannot be said to be- 
 long to the animal body. Several, for instance the perspired fluid 
 of the skin and lungs, the fluid of the cutaneous and mucous fol- 
 licles, and the urine, become, after secretion, foreign to the body, 
 and require to be removed. Those belonging to the body are such 
 as are prepared for some purpose within it, and after this are either 
 re-absorbed, or, being decomposed, are expelled. Of the former 
 kind, fat, serum of serous membranes, and synovia, afford examples. 
 To the latter description belong tears, saliva, pancreatic fluid, bile, 
 the seminal fluid of the male, and the milk of the female, all of 
 which are the result of a distinct glandular secretion for a specific 
 purpose, after which they are expelled from the economy. 
 
 The urine, though also the result of glandular secretion, is ne> 
 vertheless exempt from this rule, and though separated from arterial 
 
FLUIDS OF THE HUMAN BODY. 
 
 23 
 
 blood, is forthwith eliminated. Its chief purpose seems to be to afford 
 a convenient vehicle for ridding the system of superfluous azote, and 
 to maintain the due proportion between this and the other ultimate 
 principles, carbon, hydrogen, and oxygen. The fluids which fulfil 
 a purpose in the economy are regarded as secretory, and are re- 
 markable for a predominance of alkali; those which do not, are 
 excrementitial, and are generally acid. 
 
 Bile, the secreted product of the liver, may be regarded as a 
 choleate of soda with taurine ; both containing sulphur. 
 
 Urine may be regarded as urea suspended or dissolved in water. 
 Urea is the peculiar and characteristic element of the secretion. 
 It contains also a little uric acid, which is probably produced from 
 the urea, as it can scarcely be said to be a constituent of healthy 
 urine. The other ingredients are saline matters common to the 
 blood and the urine, or complementary between these fluids. 
 
 The density of healthy urine varies from 1015 to 1033, water 
 being as 1000 ; and the average, as determined from the examina- 
 tion of the urine in fifty instances of persons in good health, is at 
 the highest 1.026, and at the lowest 1017. The general average, 
 therefore, amounts to 1022. If it he stated between 1022 and 1026 
 it cannot be far wrong. This is understood while the quantity dis- 
 charged daily is from 45 to 53 ounces, which is about the general 
 average in healthy individuals who consume liquids at the ordinary 
 rate. 
 
 This density above that of water urine owes to the presence of 
 urea and saline matters. If the urea and saline matters be in- 
 creased, the density of the urine is increased ; and if they be di- 
 minished, the density of the urine is also diminished. 
 
 It may be here observed that urea is the form which the elements 
 of the fibro-albuminous parts of the blood assume after these fibro- 
 albuminous have been employed in repairing the waste of the 
 tissues. If we compare the proximate chemical principles of al- 
 bumen with those of urea, we shall see that the latter are the com- 
 plement of the former. Thus 
 
 Hydrogen. Carbon. Oxygen. Azote. 
 
 Albumen consists of 7.77 50.00 26.66 15.55 
 
 Urea consists of . 6.66 20.00 26.66 46.66 
 
 Thus while albumen and urea contain the same proportion of oxy- 
 gen, the former contains one-seventh more hydrogen, three-fifths 
 more carbon, and one-third less azote. It is known that the former 
 proportions are employed in repairing the waste of the albuminous 
 tissues, especially the muscular system, and while carbon and oxy- 
 
24 
 
 GENERAL AND PATHOLOGICAL AKATOMY. 
 
 gen^are discharged by the lungs, and carbon, oxygen, and hydro- 
 gen by the liver, the large superfluous portion of nitrogen not re- 
 quired is left in the form of urea, to pass through the blood, and 
 by means of the kidneys to be expelled from the system. 
 
 In the healthy state urine is always acid when discharged. It is 
 prone, however, to undergo the putrefactive decomposition ; and 
 then its acid reaction disappears, and it becomes alkaline. This 
 change is much favoured if not wholly occasioned by the presence 
 of mucus, purulent matter, or other azotized substances ; for if the 
 urine be filtered so as to remove these substances, and placed in a 
 close vessel, secluded from the air, it may be preserved for a long 
 time without undergoing change or presenting any odour indicat- 
 ing the presence of decomposition. 
 
 Section II. 
 
 A. The morbid states of the blood are mostly, if not all, connected 
 with morbid states of the system at large, of the organs of respiration, 
 or the organs of secretion. The most important are the following. 
 
 1 . In diseases of plethora it has been supposed that the blood is 
 more abundant than usual in quantity, and that its fibrine is in- 
 creased in proportion. The first point it is not easy to deter- 
 mine. The fibrine, however, is not increased. The red globules 
 are stated by Andral to be the only element in which an increase 
 actually takes place. In 31 blood-lettings he found for the medium 
 the cypher 141 in 1000, 127 in 1000 being the average of health; 
 for the minimum, 131 ; and for the maximum, 154. There is, in 
 short, in the blood of the plethoric an increased amount of red glo- 
 bules, and a great deal less water than the aveTage. 
 
 . 2. In chlorosis, dyspeptic and other diseases in which the leading 
 character is anaemia^ the red globules are diminished in propor- 
 tion. Andral found, as the medium of the cypher for the globules 
 in fifteen cases of incipient anaemia, the number 1 09, and in twenty- 
 four cases of confirmed anaemia, the number 65. In spontaneous 
 anaemia, mild or violent, the globules alone are diminished; the 
 fibrine and the albumen of the serum preserving their normal pro- 
 portion. In hemorrhagic anaemia, at first the globules only are 
 diminished. But if the morbid condition continue, the fibrine and 
 the albumen of the serum are also diminished. There is a form of 
 anaemia which may be called toxic, as it depends on the influence 
 of the mineral poisons. In that from lead, Andral finds that the 
 
FLUIDS OF THE HUSL4N BODY. 
 
 25 
 
 red globules are as much diminished as in spontaneous ansemia, 
 while the fibrine and albumen preserve their normal proportions. 
 
 In chlorosis it is a curious fact that the blood is occasionally 
 buffy. This Andral ascribes to the circumstance, that in these 
 patients, v. hile the blood loses its colouring matter, it preserves all 
 its fibrine. It must be observed, nevertheless, that in many chlo- 
 rotic patients, processes are present which give the blood the ten- 
 dency to the buffy coat. 
 
 It is also to be observed that in renal dropsy ofttimes, while the 
 blood is deteriorated by diminution of red particles, and while the 
 patient is pale and dropsical, yet blood if drawn presents the huffy 
 coat. This merely shows that the blood is altogether in an unna- 
 tural and probably diseased condition. The textures are unable 
 to take from it the fibrine which they do in the healthy state, and 
 hence this fibrine remains ready to be separated in the form of 
 buffy coat. 
 
 3. State of the blood in inflammatory diseases. — In inflammation the 
 blood assumes the property of forming what is called the buffy coat, 
 {tunica coriacea). This consists in the clot presenting at its surface a 
 covering variable in thickness, whitish-grey in colour, and of con- 
 siderable toughness. In the slightest degree it is very thin, and a 
 mere pellicle. In more considerable degrees of inflammation, it is 
 thicker, as thick as a shilling or a half-crown piece, and firm and te- 
 nacious. In the most intense degree, it is as thick as a crown piece 
 or a penny piece ; extremely firm, hollow on the top and elevated 
 at the edges ; and being contracted from the circumference to the 
 centre, it is much cupped. This condition of the blood is most 
 common in acute rheumatism, pneumonia, pleurisy, peritonitis, he- 
 patitis, disease of the kidney, the early stage of pulmonary con- 
 sumption, and similar disorders. It is also observed during preg- 
 nancy. 
 
 The cause of the buffy coat has been a subject of great inquiry ; 
 but regarding it little is ascertained. It may often be observed in 
 the act of formation, by the surface of the blood drawn, as it is co- 
 agulating, assuming a peculiar bluish colour, which is evidently 
 dependent on the liquor sanguinis undergoing spontaneous coagu- 
 lation, wliile the red part of the blood subsides from it. In gene- 
 ral the blood coagulates more slowly in inflammatory diseases than 
 in the healthy state. But the rate of the diminution does not cor- 
 respond to the amount of the buffy coat. If, however, we bear this 
 fact in remembrance, that when it takes place as in inflammatory 
 
26 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 diseases and in pregnancy, there is in the vessels of some part of 
 the body a process of separating fibrin or fluid fibrin in the shape 
 of lymph, which afterwards undergoes spontaneous coagulation, it 
 may be regarded as most probable, that, while the process of nor- 
 mal nutrition, that is, deposition of fluid fibrin in the different tex- 
 tures and organs, is suspended or diminished, the albuminous mat- 
 ter which ought to be employed in this process is left free in the 
 blood, and therefore is found in that fluid. 
 
 Buffy blood is less thick than healthy blood ; but its liquor san- 
 guinis contains more fibrin. The red globules are very numerous, 
 and they are aggregated rapidly and closely. (W. Jones, Ed. Med. 
 and Surg. Journal, lx.) 
 
 In fever, and especially in typhous fever, the blood loses part of 
 its spontaneously coagulating property. The serum is diminished 
 in quantity, or rather is not separated from the clot, which is loose, 
 flaccid, and commonly dark-coloured, and as it were semifluid. 
 
 4. Oil in the blood . — In certain states of the system the serum is 
 observed to he turbid, opalescent in colour, and not unlike milk. 
 The clot is then in general of a peculiar pink colour, whether from 
 some intrinsic change, or the optical effect of the milky serum. 
 This state of the serum is owing to its being mixed with fatty mat- 
 ter, or rather oil. If serum of this kind be agitated in a phial with 
 a quantity of sulphuric ether, the latter dissolves the oil, which 
 is after some time found floating in the form of a clear yellow oil 
 on the surface of the serum, which is then clear and of its usual 
 characters. The oil may be then withdrawn by the pipette or 
 poured off, and is found to leave on paper an oleaginous stain. 
 
 This state of the blood, which was originally observed by Tul- 
 pius, Schenke, Morgagni, and Hewson and several of his friends,* 
 and afterwards by Dr Traill, Dr Ziegler, and Dr Christison, takes 
 place in various wasting diseases, and is often observed in granular 
 degeneration of the kidney. The oil appears to be mixed with the 
 serum in the form of an emulsion. It is most usual in corpulent 
 persons ; and appears especially, or has been noticed mostly, when 
 they are attacked by disease. It is connected also with an im- 
 perfect state of digestion. 
 
 5. In jaundice and various diseases of the liver, even in inflamma- 
 tion of the liver affecting the lower surface of the organ and the 
 
 * Experimental Inquiries, Part the First, containing an Inquiry into the Properties 
 of the Blood, with Remarks on some of its Morbid Appearances. 3d Edition. By 
 'VViliiam Hewson, F. R. S. London, 1780. Pp. I9I. 
 
 4 
 
FLUIDS OF THE HUMAN BODY. 
 
 27 
 
 vicinity of the capsule of Glisson, the serum occasionally presents 
 a considerable proportion of bile. It is then of a pale green colour ; 
 and on the addition of hydrochloric acid, it undergoes immediate 
 coagulation, with the formation of a bright grass-green precipitate. 
 
 6. Urea is found in the blood in instances of granular disease of 
 the kidney, and those cerebral and urinary affections in which the 
 secretion of the kidneys is suspended or suppressed. It may be de- 
 tached from the serum by treating the latter with nitric acid, when 
 crystals of nitrate of urea are found. 
 
 7. Purulent matter is found in the blood in certain diseases in 
 which suppuration is going on at the internal surface of a membrane 
 or in the interior of an organ. The most usual preceding state, 
 however, is inflammation and suppuration of a vein or veins, and 
 the secondary effects thence resulting, especially suppuration with- 
 in one of the joints. If the blood in cases of this kind be inspect- 
 ed under the microscrope, it is observed to present globules of puru- 
 lent matter. In certain forms of disease of the spleen, purulent 
 matter is found mixed with the blood in the veins after death, to 
 which this state leads. 
 
 B. Of chyle and lymph the morbid states are too little known to 
 speak of them with certainty. 
 
 C. Of the morbid changes of bile also very little is known. 
 During the process of digestion it is decomposed ; at least in the 
 healthy state it is never seen pure in the intestinal discharges. 
 
 The bile is liable to be formed into concretions or gall-stones, 
 varying in size. When small these are numerous ; when large 
 there may be only one or at most two. A large sized gall-stone 
 is one that is one inch or more in diameter. These bodies consist 
 of inspissated bile, cholesterine, and colouring matter. 
 
 D. The morbid states of the urine are manifold. They may be 
 referred to the following heads. 1. Increase in the proportion of 
 nitrogenous matter, e. g. urea increased in quantity generally with 
 formation of uric acid ; 2. Diminished cohesion of elements of urea ; 
 3. Increase in saline matter ; and 4. By the presence of new sub- 
 stances, as albumen, purulent matter, sugar, &c. 
 
 1. The first and most usual is excess of urea, generally with uric 
 acid. The urine, if allowed to evaporate in a watch-glass, one or 
 two drops of nitric acid having been previously poured on it, pre- 
 sents in no long time crystals of nitrate of urea. At the same time 
 uric acid is usually deposited fi’om the urine. 
 
 2. Another form of disorder consists in the formation of urate of 
 
28 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 ammonia. The uric acid being formed in the urine as in the last 
 case, it is probable that part of the urea itself is decomposed, the 
 nitrogen and hydrogen combining to form ammonia. This takes 
 place in birds and serpents at all times, and carnivorous animals 
 and tbe human body when living mostly on animal food. 
 
 3. A form more intense still is denoted by the formation of carbo- 
 nate of ammonia. There can be little doubt that when this pro- 
 duct appeal’s, it is the result of the spontaneous decomposition of 
 the urea ; the carbon and oxygen forming carbonic acid, and the 
 nitrogen and hydrogen ammonia. 
 
 4. A form still different is indicated by the formation of phosphate 
 of ammonia and magnesia. The causes and the mechanism of this 
 production are not well known. It is only known that it takes 
 place most readily under a state of the system of impaired strength ; 
 that the urine is either not acid or speedily becomes alcaline ; and 
 that the urine is most prone to the putrefactive decomposition. As 
 the addition of ammonia to urine causes a precipitate of phosphate 
 of lime, there is strong reason to believe that the urea is first de- 
 composed and its hydrogen and azote made to furnish ammonia, 
 and that this latter substance causes the precipitate either of phos- 
 phate of lime or phosphate of magnesia according to circumstances. 
 
 5. Other morbid products are purpuric acid, purpurate of am- 
 monia, oxalate of lime. 
 
 6. Blood may be contained in the urine either in consequence of 
 wounds and injuries of the kidneys, ureters, bladder, or prostate 
 gland, or in consequence of calculi in any of these parts, or inflam- 
 matory and hemorrhagic diseases. The urine is either like blood, 
 containing a considerable proportion of that liquid, or it is only of 
 a dark brown colour, coagulable by heat or acids, and presenting 
 to the microscope blood-globules. The physician has most fre- 
 quent occasion to see it in the latter state; and sometimes the urine 
 is clear, but depositing the colouring matter of the blood at the 
 bottom of the vessel. This I have observed during scarlet fever, 
 at its close, and especially during the dropsical affection which often 
 succeeds that disorder. 
 
 7. Albumen is contained in urine in the form of serum or serous 
 urine. It is known by tbe urine being paler than usual, by its 
 specific gravity being lowered, that is, being below 1015, generally 
 about 1009, 1010, or 1011, and by being coagulable on the ap- 
 plication of heat between 160° and 212° F. The proportion of 
 
 serum varies from one-tenth to one-fifth, in which case it forms a 
 
 3 
 
FLUIDS OF THE HUMAN BODY. 
 
 29 
 
 dense firm jelly adhering to the tube.* The presence of albumen 
 always denotes more or less disease of the kidney, particularly the 
 granular degeneration described by Dr Bright ; and, with certain ex- 
 ceptions, the greater the amount of the coagulum, the more intense 
 and decided is the degree of degeneration. In scarlet fever it oc- 
 casionally indicates merely a state of the kidney allied to acute 
 inflammation. 
 
 8. Purulent matter is contained in the urine In various purulent 
 or puriform affections of the kidneys and bladder. Its presence is 
 known by being observed at the bottom of the vessel after the urine 
 has been allowed to rest for some time. When the urine is first 
 voided it is tru-bid and opaque with numerous Jlocculi, and the 
 colour is generally pale straw with an opalescent tint. After stand- 
 ing some time the upper portion becomes clear, and a layer more 
 or less thick of yellow or wliitish grey purulent matter is ob- 
 served at the bottom of the tube or glass jar. The supernatant 
 urine is often coagulable by the application of heat or the addition 
 of acids. The lower deposit may be recognised by the eye to be 
 purulent matter with shreds of lymph ; but it is more easily seen by 
 a good glass ; and the microscope exhibits distinctly the purulent 
 globules. 
 
 In this state of the urine, as in the last, the patient feels frequent 
 and urgent calls to empty the bladder, in which accordingly the 
 urine seldom accumulates beyond two or three ounces. 
 
 9. Melituria . — Sugar is the most important foreign or new substance 
 which may be found in the urine. The secretion has in that state, 
 when voided, a smell of whey, or milk, or new hay, less agreeable, 
 however, and somewhat nauseous. . Its colour is generally a pale 
 honey yellow, but in some instances it is as deep as that of porter. 
 Its density is always increased, being generally above 1020, and 
 rising from that to 1030, or 1035, or 1050. This is caused by 
 the considerable increase of the solid matters ; for not only is there 
 a new substance in the sugar contained, but the urea is increased 
 in quantity and is rarely diminished. It is supposed, however, 
 that in saccharine urine the urea is diminished as the disease ad- 
 vances. 
 
 The presence of saccharine matter in urine constitutes the patho- 
 logical character of the disease named diabetes. With the increase 
 in the amount of urea and the presence of this new element, the 
 quantity of the whole secretion is greatly increased, so that within 
 
 * Elements of Practice of Medicine, VoL IT. p. 1122. 
 
30 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 24 hours the amount of urine voided is about six or seven times 
 greater than in the state of health. 
 
 The presence of saccharine matter in the urine enables it, by the 
 addition of yeast, to undergo fermentation and furnish alcohol. 
 
 In this state of the urine, saccharine matter is found also in the 
 gastric juice, and in the blood ; and may be obtained from the fluids 
 by chemical analysis. There is, tlierefore, the best reason to be- 
 lieve, that sugar, when it appears in the urine, is previously formed 
 in the stomach by some great perversion in the digestive and as- 
 similative power. 
 
 CHAPTER III. 
 
 FILAMENTOUS OR CELLULAR TISSUE. ( Tela cellulosa , — Tissii cel- 
 lulaire , — Tissu muqueux of Bordeu, — Corqms Cribrosum^ Hip- 
 pocratis, — Corps Cribleux of F ouquet, — Reticular membrane of 
 William Hunter.) 
 
 Section I. 
 
 The general distribution of the filamentous or cellular tissue 
 was first maintained by Haller, and Charles Augustus de Bergen, 
 and afterwards made the subject of more elaborate discussion by 
 William Hunter and Bordeu. It may be described as a substance 
 consisting of very minute thready lines, which follow no uniform 
 or invariable direction, but which, when gently raised by the for- 
 ceps, present the appearance of a confused and irregular net-work. 
 As these minute lines cross each other, they form between them 
 spaces of a figure not easily determined, and perhaps not uniform. 
 By some authors these spaces or intervals have been named cells ; 
 but, accurately speaking, the term is not fortunately applied. The 
 component lines, which do not exceed the size of the silk-worm 
 threads, are so slender, that they do not form those distinct parti- 
 tions which the term cell implies ; and though by forcible disten- 
 sion, such as takes place in insufflation or separation by forceps, 
 cavities appear to be formed, these, it will be found, are artificial, 
 and result from the separation of an infinity of the slender fila- 
 ments of which the part is composed. These interlineal spaces ne- 
 cessarily communicate on every side with each other ; and indeed 
 the most distinct way of forming a true idea of the structure of the 
 cellular tissue is to suppose a certain space of the animal body 
 
FILAMENTOUS OR CELLULAR TISSUE. 
 
 31 
 
 which is divided and intersected into an infinite multitude of mi- 
 nute spaces, {areolcB^) by slender thready lines crossing each other. 
 
 This description, originally derived from personal observation, 
 led me to apply to this tissue the name of filamentous as more ap- 
 propriate than that of cellular, by which it is generally known. I 
 find, however, that in this I am anticipated by Charles Augustus 
 de Bergen, the most accurate observer who has treated of its ana- 
 tomical structure. His description is so faithful, that it should he 
 known to the student of general anatomy. ‘‘ Alteram vero non 
 adeo distincte saltern paucissimis, ut mihi videtur, ohservatam.” 
 He alludes here to the filamentous as distinct from the adipose 
 tissue. “ Ubi sic dicta cellulosa ex innumera atque intricatissima 
 congerie staminum aut filamentorum, nullatenus celkdas pingue- 
 dinem continentes efibrmantium, componitur ; quae tenerrima mi- 
 rifice oblique disposita, inexplicabili adeo contentu viscerum om- 
 nium et musculorum substantiam internam perreptant, ut nihil 
 certi, vel microcospiis adjutus, hie effari queas; quam proin substan- 
 tiam. filamentosam vocabo.”* 
 
 The interstitial spaces resulting from the interlacement of these 
 filaments do not exist as distinct cavities in the healthy state, so that 
 they cannot be said to contain any substance solid or fluid. But 
 when an incision is made into this tissue in the living body, it is 
 found, that, if we except those fluids which issue from divided ves- 
 sels, nothing is observed to escape, but a thin exhalation or vapour, 
 which is evidently of an aqueous nature. This is what some au- 
 thors have termed, from its resemblance to the serous part of the 
 blood, the cellular serosity, (Bichat,) and the quantity of which has 
 been greatly exaggerated. In the living body it appears not to 
 exist as a distinct fluid, but merely as a thin vapour, which com- 
 municates to the tissue the moist appearance which it possesses. 
 
 This fluid is understood to be derived from the minute colourless 
 capillaries named exlialants ; and it is supposed to he no sooner pour- 
 ed forth in an insensible manner, than it is removed by the absorb- 
 ing power either of lymphatics, according to the followers of the 
 Hunterian hypothesis, or of minute veins, according to Magendie. 
 It is of no great moment whether this process of absorption be ascrib- 
 ed to lymphatics or to veins, or be understood, as is probably the 
 truth, to be effected by both. It is sufficient to remark, that, what- 
 ever serous fluid is secreted into the insterstitial spaces or cells of 
 
 * CaroU August! a Bergen, Progranima de Membrana Cellulosa. Francofurti ad 
 Viadrum, de 21 Aug. 1732. Apud Haller, Disputat. Anatomic. Select., VoL III. p. 
 82. 
 
32 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the filamentous tissue, makes no long abode in that situation, but 
 in the healthy state is speedily removed ; so that if we suppose ex- 
 halation, absorption must be also admitted ; and the filamentous 
 tissue is therefore represented as the seat of an incessant exhalation 
 and absorption. 
 
 The serous fluid of the filamentous tissue varies in quantity in 
 different regions. In the cellular tissue of those parts which are 
 free from fat, as in the eyelids, the prepuce, the nymph<B and lahia^ 
 and the scrotum, it is said to he somewhat more abundant than in 
 others. The peculiar structure of those parts, which is cellular, 
 may render any excess of serous fluid more conspicuous ; for it is 
 matter of observation, that in many persons otherwise healthy these 
 parts are not unfrequently distended with serous fluid. On the 
 other hand, it must be remarked that the submucous cellular tissue, 
 and that which surrounds arteries, veins, and excreting ducts, which 
 is delicate in substance and compact in structure, contains but a 
 small proportion of serous fluid, and does not readily admit its 
 presence. 
 
 This fluid has been generally said to be of an albuminous nature ; 
 and if it be identical with the serum of the blood, from which it is 
 believed to be secreted, this character is not unjustly given it. 
 Bichat, who maintained this opinion, injected alcohol into the fila- 
 mentous tissue of an animal previously rendered emphysematous, 
 and found in various parts whitish Jlocculi, which he regarded as 
 coagulated albumen. He also obtained the same result by immers- 
 ing a portion of the scrotum in weak nitric acid ; and when a con- 
 siderable quantity of this tissue was boiled, it furnisbed much 
 whitish foam, which Bichat regarded as albuminous.* These ex- 
 periments, however, are liable to this objection, that the effects in 
 question may have arisen from coagulation of part of the filamen- 
 tous tissue itself, which contains a considerable proportion of albu- 
 minous matter. The best mode of determining the point is to ob- 
 tain the fluid apart, and to try the effects of the usual tests on it 
 when isolated from the tissue in which it is lodged. 
 
 The description here given applies to the proper filamentous 
 tissue. This substance was shown by Ruysch, and afterwards by 
 William Hunter and Mascagni, to be penetrated by arteries and 
 veins. Exhalants, absorbents, and nerves, it is also said to receive. 
 The arteries certainly belong in the healthy state to the order of 
 colourless capillaries, which is nearly the same with exhalants. It 
 
 ’ Anatomie General, Tome i. p. 50. 
 
FILAJiIENTOUS OR CELLULAR TISSUE. 
 
 33 
 
 does not appear that the nervous twigs observed to pass through 
 this tissue are lost in it, for in general they have been traced to 
 some contiguous part. 
 
 Such are the general properties of this tissue considered as an 
 elementary organic substance extensively diffused through the body. 
 In particular regions it undergoes some modifications, which may 
 be referred to the following heads. 1. Beneath the skin, or rather 
 under the adipose membrane ; the subcutaneous and intermuscular 
 cellular tissue ; 2. Beneath the villous or mucous membranes ; the 
 submucous cellular tissue ; 3. Beneath the serous membranes ; the 
 subserous cellular tissue ; 4. Round blood-vessels, excreting ducts, 
 or other organs ; the enclosing tissue, vascular sheaths, &c. ; 5. In 
 the substance of organs ; the penetrating cellular tissue. 
 
 The situation of the subcutaneous filamentous tissue deserves 
 particular notice. Though generally represented as below the 
 skin, it is not immediately under this membranous covering. The 
 skin rests on the adipose membrane, beneath which again is placed 
 the filamentous tissue, extending like a web over the muscles and 
 blood-vessels, penetrating between the fibres and bundles of the 
 former, surrounding the tendons and ligaments, and connected by 
 these productions with a deep-seated layer, on which the muscles 
 move, where they do not adhere to the periosteum and to bones. 
 
 The extensive distribution of the subcutaneous filamentous tis- 
 sue, the mutual connection"'of its parts, and its ready communica- 
 tion with the filamentous tissue of the mucous and serous mem- 
 branes, were demonstrated by Haller, William Hunter, and Bor- 
 deu, and have been clearly explained by Portal and Bichat. The 
 principal points worthy of attention may be stated in the following 
 manner. 
 
 The filamentous tissue of the head and face communicate fi’eely 
 with each other, and with that of the brain by the cranial openings, 
 and with the submucous tissue of the eyelids, nostrils, lips, and the 
 inner surface of the mouth and cheeks. It communicates also with 
 the subcutaneous tissue of the neck all round ; and at the angle of 
 the jaw in the vicinity of the parotid gland is the common point of 
 re-union. To this anatomical fact is referred the frequency of 
 swellings and purulent collections in the region of the parotid in 
 the course of various diseases of the head, face, and neck. 
 
 The filamentous tissue of the neck may be viewed as the con- 
 necting medium between that of the head and trunk. From the 
 
 c 
 
34 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 former region it may be traced downwards along the back, loins, 
 breasts sides, flanks, and belly. At the cervical region, and be- 
 tween the shoulders, it is dense and abundant ; and, surrounding 
 the dorsal part of the vertebral column it is connected with the 
 mediastinal tissue, the submucous tissue of the lungs, and the sub- 
 serous tissue of the costal pleura. At the fore part of the neck it 
 is in like manner connected with the abundant tissue of the pectoral 
 region, and hy means of that surrounding the larynx and trachea, 
 Is^, M'ith the submucous tissue of the bronchi ; and, 2d, with the 
 anterior mediastinum. Passing downwards, the same commu- 
 nication may be traced with the intermuscular tissue of the loins 
 and helly, the tissue surrounding the lumbar and sacral por- 
 tion of the vertebral column, that connecting the mesentery and 
 large vessels to the vertebrae, and extending all round under the 
 muscular peritonaeum, and into the pelvis, where, hy means of the 
 tissue at the posterior surface of the abdominal muscles, at the an- 
 terior surface of the iliacus internus^ and through the obturator hole 
 and ischiatic notch, it communicates with the filamentous tissue of 
 the lower extremities. From the rectum and branches of the is- 
 chium it is coniinued along the perinaeum hy the urethra, and into 
 the scrotum. 
 
 In the whole of this course it is abundant in the space before the 
 vertebrae round the psocB and iliacus internus muscles, and round 
 the bladder, rectum, prostate gland, and womb. The tissue sur- 
 rounding the vertebral column communicates with that in the in- 
 terior of the column by the intervertebral holes. 
 
 The arm-pit may be considered as the point of union between 
 the filamentous tissue of the trunk and that of the upper extremi- 
 ties, while the groin is the corresponding spot for the lower extre- 
 mities. These facts should be kept in mind in observing the phe- 
 nomena of diseases of this tissue. 
 
 Notwithstanding this general connection, however, certain parts 
 of the tissue are so dense and close as to diminish greatly the fa- 
 cility of communication. Thus along the median line it is so firm, 
 that air injected invariably stops, unless impelled by a force ade- 
 quate to tear open its filaments, and water is rarely found etfused 
 in this situation. In the neighbourhood of some parts of the ske- 
 leton also, as at the crest of the ilium, over the great trochanter, 
 and on the shin, the filamentous tissue is very dense and coherent. 
 
 In chemical composition it consists principally of gelatin, but 
 contains some albuminous matter. 
 
FILAMENTOUS OR CELLULAR TISSUE. 
 
 35 
 
 Section II. 
 
 The filamentous tissue is liable to inflammation, acute and chro- 
 nic, circumscribed, and with exudation of lymph, or difinsive and 
 spreading, generally without this exudation, and with the produc- 
 tion of purulent matter ; to induration ; to hemorrhage ; to serous 
 infiltration; to aerial distension; and to new growths. 
 
 1. Inflammation of the subcutaneous tissue when circumscribed 
 constitutes phlegmon, a name applied rather in reference to our 
 observation of it near the surface of the body, than with a view to 
 the natural relation between an organized texture and its patholo- 
 gical processes. 
 
 In other situations, as it is seldom recognized before it has pass- 
 ed to the stage of suppuration, inflammation of cellular tissue is 
 generally implied in those abscesses or collections of purulent mat- 
 ter, {apostemata^ abscessus), acute or chronic, which frequently 
 form in the human body. 
 
 Various facts, nevertheless, show that inflammation of the fila- 
 • mentous tissue is a process consisting of several stages. At first 
 the vessels become distended with blood, which moves rather slow- 
 ly and is accompanied with a throbbing or beating sensation. This 
 is attended with more or less swelling of the part, heat, and pain ; 
 and if it be near the surface, with redness. In the second place, 
 the distended and overloaded state of the vessels never continues 
 long without giving rise to more or less change in the blood in the 
 part Serum is poured out into the cells, often sero-albuminous 
 fluid ; sometimes blood even is extravasated. The sero-albuminous 
 fluid is separated into lymph and serum. The former gives rise 
 to the hardness usually observed. Thirdly, if the process con- 
 tinue, the secretion of sero-albuminous fluid is followed by that of 
 purulent matter ; and sometimes the serum first eflFused appears to 
 be afterwards converted into purulent matter. 
 
 This purulent matter is usually contained within a body of 
 lymph more or less regular ; and which forms a sort of boundary 
 between it and the sound or uninflamed part of the tissue. If this 
 boundary be complete so as to surround and inclose the purulent 
 matter, it is denominated a cyst. This may take place either in 
 acute or in chronic inflammation. 
 
 After the matter has been deposited in the manner now described, 
 it evinces a tendency to proceed towards the nearest surface. This 
 may be either the skin or any of the mucous membranes. At first 
 
36 
 
 GENERAL AND rATHOLOGICAL ANATOMY. 
 
 it may be seated at so gx-eat a dejxth that it is impossible to recog- 
 nize its presence. In a short time, however, it may he felt by the 
 practised finger. In most cases, even where there is much hard- 
 ness, it is generally possible to predicate the presence of purulent 
 matter. The tendency to advance to the surface is connected with 
 a tendency in other parts of the purulent tumour to contract ; and 
 as the former process advances, the latter keeps pace with it, so that 
 in general, when the tumour bxxrsts or is opened, the extent of the 
 bottom of the abscess has sensibly aixd considerably been dimi- 
 nished. 
 
 If inflammation of cellular tissue do not terminate in suppura- 
 tion, nor is resolved, it tei’minates in effusion of lymph, with con- 
 cretion or agglutination of its filaments through a space more or 
 less extensive. This is known by slight swelling, hardness, and 
 immobility of the part. The phenomena of inflammation in this 
 tissue are best observed in deep wounds, which divide a conside- 
 I’able extent of it. If the wound be what is called simply incised, 
 the constitution good, and the inflammation moderate, lymph is 
 effused, and the cut edges are mxited by what was anciently named 
 the first intention. This mode of union was termed by John Hun- 
 ter adhesive inflammation, (p. 226,) and union by adhesion. 
 
 It is not always, howevei’, that the process is so simple. When 
 the wound is extensive or complicated, and involves the cellular 
 web of several different tissues, the lymph effused is inadequate to 
 effect reunion at once ; and another process term.ed granulation 
 takes place. The basis of this indeed consists in exudation of 
 lymph, which is effused in minute masses of no definite form, and 
 which are soon peneti'ated by blood-vessels, and thereby become 
 organized, (Hunter, p. 477.) Their surface becomes covered with 
 more or less lymph, which, as they increase in size, causes them 
 mutually to cohere ; and by the successive production, growth and 
 union of these granular bodies, the divided surfaces are made even- 
 tually to unite. The process of granulation in the filamentous 
 tissue is accompanied with more or less suppuration ; but as the 
 granulations coalesce, this is gradually diminished. 
 
 2. The second form of inflammation occuri’ing in filamentous 
 tissue is when it spreads, or is diffused along the membi’ane, or 
 throxigh its substance. John Hunter was aware of the tendency 
 which the inflammatory process in certain circumstances manifests 
 to spread ; and referring it to a sympathetic disposition in the sur- 
 rounding parts, suggests an illustration in the opposite qualities of 
 
FILA5IENT0US OE CELLULAR TISSUE. 
 
 37 
 
 dry and damp paper. “ If dry,” says he, “ then it will not spread ; 
 it will be confined to its point ; but if damp, it will spread, being 
 atti’acted by the surrounding damp to which it has an affinity,” (p. 
 262.) Though this is a mere illustration, and is a statement of a 
 physical, not a physiological phenomenon, it affords no imperfect 
 idea of the distinction between the limited or circumscribed, and 
 the spreading or diffused inflammation. 
 
 Two circumstances, however, appear to have perplexed the prin- 
 ciples both of this author and of his successors. The first of these 
 was the sense in which the terms erysipelas and erysipelatous in- 
 flammation w'ere to be understood ; the second the constant search 
 for final causes, or ultimate intentions. By most physicians and 
 surgeons, previous to the time of Carmichael Smyth and Willan, 
 and even later, every spreading inflammation was termed erysipe- 
 latous, whether it existed in skin, mucous membrane, serous mem- 
 brane, or cellular tissue ; and the character of nomenclature was 
 derived, not from the texture, but from the supposed nature of the 
 morbid process. This practice, if not positively wrong, was at- 
 tended with confusion in arrangement and description ; and it is 
 well that the general usage of correct pathologists has now re- 
 stricted the term to inflammation of a particular tissue. The 
 second source of confusion in the views of Hunter consisted in his 
 regarding the exudation of lymph as an invariable barrier against 
 the diffusion of the morbid process. This exudation doubtless 
 constitutes the character of the limited form of inflammation ; but 
 Hunter appears to have forgotten that, in certain circumstances, as 
 in the sort of inflammation now considered, this barrier does not 
 exist, and the morbid process therefore spreads, or is diffused over 
 the membrane. It is further evident from what he says, (p. 271, 
 272, and 367,) that he regarded the spreading inflammation of the 
 cellular membrane as erysipelas attacking that tissue, and that he 
 considered its pathological peculiarity to consist in the absence of 
 lymphy effusion, and the consequent want of limitation. Though 
 it may be disputing about a name only, to question this, it is per- 
 haps better to regard this form of inflammation as entirely different 
 from erysipelas, which must be referred to the outer surface of the 
 corion; and to represent it as a process tending to spread without 
 adequate effusion of coagulable lymph. 
 
 Another point in the pathology of this disorder may be here 
 noticed. Certain facts favour the notion, thiit it consists in affec- 
 
38 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 tion of the adipose membrane, as distinct from the filamentous tis- 
 saie. Thus, dilfuse inflammation occurs mostly in those parts in 
 which the adipose membrane is abundant, e. g. in the neck, on the 
 chest between the two pectoral muscles, in the ann-pits, in the ex- 
 tremities immediately beneath the skin, and on the buttock at the 
 verge of the anus. In the following passage Hunter seems to have 
 this in view. “ The cellular membrane, free from the adipose, ap- 
 pears to be more susceptible of the adhesive inflammation than the 
 adipose membrane, and much more readily passes into the suppu- 
 rative. Thus we see that the cellular membrane connecting parts 
 together as muscles, and the cellular membrane connecting the 
 adipose to muscles, easily inflames, and runs readily into suppura- 
 tion, and, as it were, separates the muscles from their lateral con- 
 nections, and even separates the adipose from the muscles, while 
 the skin and adipose membrane shall only be highly inflamed,” (p. 
 234.) 
 
 Diffuse inflammation of the filamentous tissue has been described 
 by Kirkland, (p. 282, Vol. II.) Willan, Thomson, and Copland 
 Hutchinson, under the name of phlegmomid erysipelas, noticed by 
 various authors as inflammation of the fascia, (Abernethy, Kirk- 
 land, 268,) and was fully investigated by Dr Duncan Junior in 
 1823, under its proper denomination. 
 
 Its general characters are diffuse swelling spreading over the 
 limb or affected region, compressible, but not elastic, often doughy ; 
 deep-seated pain, with an oppressive sensation of weight; and ten- 
 sion of the skin, sometimes with a dull red tinge, not unfrequently 
 without change of colour. At a period, varying from the fifth to 
 the tenth day, the swelling presents in sundry parts a peculiar, 
 compressible, but not very elastic character, as if the subjacent tis- 
 sues were floating in a fluid or semi-fluid matter. 
 
 If the affected part or limb be examined after death, the whole 
 cellular tissue, subcutaneous and intermuscular, is found enlarged, 
 gray, or ash-coloured, and distended with blood-coloured fluid or 
 serum, sero-purulent or purulent matter. It is detached exten- 
 sively from the several tissues which it connects in the healthy- 
 state. Between the muscles are long sinuous caverns filled with 
 dirty ash-coloured fluid ; sloughs or mortified shreds are seen 
 here and there hanging from aponeurotic sheaths, tendons, or even 
 blood-vessels ; and, while in most cases shreds or filaments of the 
 subcutaneous or subfascial cellular tissue are the only traces of its 
 
FILAMENTOUS OE CELLULAE TISSUE. 
 
 39 
 
 existence, in not a few instances the muscles are detached from the 
 periosteum, and the periosteum from the bone. These shreds 
 are mortified pieces of sloughs or filamentous tissue ; and corre- 
 spond to the pieces of wet tow mentioned by Hunter and Sir E. 
 Home, and the wads of wet chamois leather noticed by Mr James. 
 
 This process is attended with much disturbance in the circula- 
 tion, loss of appetite, heat, thirst, dry skin, and more or less de- 
 rangement of the intellectual functions. Towards the close of the 
 disease, the pulse becomes quick, small, and sometimes intermit- 
 ting ; the strength of the muscular system is greatly impaired ; the 
 raving is accompanied with muttering, and starting of the tendons, 
 and alternates with stupor ; and the breathing becomes quick, 
 panting, and laborious, or slow, languid and interrupted, and ter- 
 minates in death. 
 
 This may he regarded as the most severe form of the disease. 
 In such circumstances its duration varies. It appears from the re- 
 sult of Dr Duncan’s observations, that death does not take place 
 before the sixth day, but may occur on any subsequent one to the 
 twelfth or fifteenth. Perhaps in the average number of cases, the 
 seventh, eighth, or ninth may be stated as the day on which the 
 termination occurs. In milder cases it may terminate in resolution 
 or in abscess. When the latter result takes place, the inflamma- 
 tory action changes its character, and instead of spreading, shows 
 a tendency to stop. Lymph is effused ; healthy purulent matter is 
 formed ; and adhesion taking place in one or more points, the dis- 
 ease terminates in phlegmonic suppuration and granulation. 
 
 When recovery takes place after suppuration and sloughing of 
 the cellular tissue, it is effected partly by direct adhesion taking 
 place between the muscles, or their cellular substance, partly by 
 the formation of new cellular tissue, similar to the new membranes 
 formed on the serous surfaces. The former is the cause of the 
 stiflfness, immobility, and condensation of parts after this inflamma- 
 tion has taken place. 
 
 In some instances the circumscribed, or limited, and the spread- 
 ing forms of inflammation may be combined. The latter proceeds 
 at one part of the affected tissue ; while the limited, with lymphy 
 exudation and adhesion, takes place at another. This appears to 
 be the variety of those tedious cases in which the disease is pro- 
 longed for weeks, and the patient either recovers, or ultimately 
 dies hectic. 
 
40 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Diffuse infiainmation may occur in any part of the filamentous 
 tissue of the whole body, and may affect either the subcutaneous 
 and superficial, or the intermuscular and deep-seated layer. But 
 the regions in which it is most commonly observed may be enu- 
 merated in the following order : — 
 
 a. The neck and throat. (Case by Wells in Transactions of a 
 Society, Vol. III. p. 360, and by Wilson, p. 367. Angina inter- 
 na of Kirkland, Vol. II. p. 158, and James, p. 187, &c.) 
 
 In persons, generally females, of full gross habit and bloated 
 appearance, swelling diffuse, deep-seated, on the side of the neck 
 towards the angle of the jaw, causing much pain in the side of the 
 head ; attended with much fever, general disorder, loss of appetite, 
 raving, stupor, or coma. It terminates in sloughs of the tissue, 
 foul, ill-conditioned purulent matter ; does not point, but may 
 burst internally, and cause suffocation. In some cases death takes 
 place from the constitutional disorder with the affection of the brain. 
 
 b. The breast, or outer surface of the chest and arm-pit and the 
 side ; abscess in the axilla of Kirkland. Several cases in Dr Dun- 
 can’s Essay. Diffuse painful swelling of the side occurring in mid- 
 dle-aged subjects, male or female, terminating in suppuration all 
 over the side, or between the pectoral muscles, or in the arm-pit. 
 
 c. An upper extremity, and passing to the arm-pit and side of 
 the chest. This is the form which takes place after venesection, 
 after punctured wounds in dissecting, or the application of animal 
 matter or fluid to a wounded surface. 
 
 d. An inferior extremity. The swelled leg of puerperal women 
 is to be referred to this head, (see Hunter, p. 204.) Certain in- 
 juries of the foot and toes, more especially when the fibrous tissues 
 have been much lacerated, appear also to be of the same kind. 
 The phlegmonoid erysipelas of the lower extremities of seamen, as 
 described by Mr Copland Hutchinson, comes under this head. 
 
 e. The buttock and the perinaeum. {Proctia, phyma of the an- 
 cients. Proctitis^ Proctalgia and Clunesia of the nosologists. Sup- 
 puration gangreneuse of the French. Described by Pott in his 2d 
 section on Fistula ani, p- 49. Case given by Plunter in his 3d 
 chapter, section xiv., on the use of the adhesive inflammation. Ab- 
 scess anum of Mr James, p, 189.) In persons of gross ha- 
 bit, either naturally or rendered so by intemperance, hard diffuse 
 swelling of the verge of the anus on each side, skin doughy and 
 
 unresisting, sometimes colourless, generally of a dusky red or pur- 
 
 s 
 
FILAJMENTOUS OR CELLULAR TISSUE. 
 
 41 
 
 plish colour, -with shivering, sickness, vomiting, great restlessness, 
 heat, and thirst ; pulse at first hard, quick, full and jarring, after- 
 wards weak, fluttering, and irregular ; brown tongue and mental 
 disorder. After three, four, or five days, a small quantity of ill- 
 conditioned matter, and sloughs of the cellular and adipose mem- 
 brane are formed. This inflammation may spread along the ure- 
 thral and scrotal filamentous tissue, and form the urethral abscess 
 (abscessus juxta ureihram) of Mr James. Of this an instructive 
 example is related by John Hunter at the passage above referred 
 to. The disease is distinguished according to him by the combina- 
 tion of the suppurative with the erysipelatous spreading inflamma- 
 tion. “ It is not so circumscribed as the former ; nor does it 
 spread along the skin like the latter. But the skin is shining and 
 oedematous ; and the inflammation goes deep into the filamentous 
 tissue, and forms dusky, fetid, purulent fluid, sometimes with air in 
 a bag or abscess, without previous adhesion.” The inflammation 
 may pass downward and forward into the scrotum and beside the 
 urethra, and upwards by the dense filamentous tissue of the belly 
 and loins ; and when openings are made, either artificially or by 
 the process of ulceration, matter is discharged, and the mortified 
 membrane hangs out like v/et dirty tow. (Hunter, p. 368.) Yet, 
 notwithstanding this extensive destruction both of filamentous tissue 
 and even of skin, it is remarkable that the rectum generally escapes. 
 
 f. When this disease appears in other parts of the body after 
 wounds with foul instruments, bites of poisonous animals, as the 
 rattlesnake or the cobra di capello, morbid animal secretions, or 
 the juice of the acrid plants, applied in any manner to the exposed 
 corion, its characters and phenomena may be easily understood 
 from the description already given. 
 
 g. I am uncertain whether to this head should be referred the 
 peculiar fatal inflammation which succeeds punctured and lacerated 
 wounds of the extremities, compound fractures with much contu- 
 sion, compound luxations and severe gun-shot wounds. This is 
 commonly regarded as gangrene, and is familiarly termed trau- 
 matic gangi-ene. It consists, however, in a peculiar form of inflam- 
 mation, spreading rapidly along the subcutaneous and intermuscu- 
 lar cellular tissue, accompanied with emphysematous distension, 
 and causing great constitutional disturbance, in which disorder of 
 the brain and its functions are conspicuous characters. Death ge- 
 nerally takes place before any of the tissues are mortified, in con- 
 
42 
 
 GENERAL AND PATHOLOGICAL AJS'ATOMY. 
 
 sequence of the violence of the constitutional symptoms, chiefly the 
 affection of the brain. 
 
 3. Inflammation of a chronic natwre is not uncommon in the fila- 
 mentous tissue. In the ordinary acute form, the process is attend- 
 ed with more or less pain and swelling, and proceeds quickly to 
 suppuration. In other circumstances, however, little or no pain is 
 felt; swelling is not perceived till late ; and the first intimation of 
 the existence of the disease is a collection of purulent matter, which, 
 when discharged, is not homogeneous, but consists of flaky or cuVd- 
 like shreds floating in a thinnish watery fluid. This constitutes 
 the cold abscess (^apostema frigidum) of the surgeons of the Saracen 
 school, and is the chronic abscess of modern surgeons. (Boyer.) 
 
 The cold abscess may be formed in any part of filamentous tis- 
 sue ; but it is most frequent where this tissue is loose and abun- 
 dant. Seldom seen in the head, it is frequent in the neck, in the 
 chest, in the back, especially in the lumbar region, and in the ex- 
 tremities. I have seen this tumour most generally in the loins, 
 where it is liable to be confounded with lumbar abscess ; in the 
 cellular tissue of the glutcci muscles ; and in the thigh and leg, 
 especially the posterior and internal region. In these situations it 
 is not unfrequently the cause of sinuous cavities, which are difficult 
 to be healed. Several of the forms of lumbar abscess, in which 
 there is no affection of the vertebrae or of their ligaments, are ex- 
 amples of this abscess occurring in the abundant loose filamentous 
 tissue, which connects the mesentery, the large vessels, and the 
 psoae muscles to the spine. Boyer also states that they are some- 
 times seen in the filamentous tissue which connects the serous 
 membranes of the chest and belly to the walls of these cavities. Of 
 the latter I have seen one instance simulating hernia, and by the 
 destruction which it caused of the fibres of the recti muscles, actu- 
 ally leaving a space through which the intestines were protruded. 
 
 Ileo-c(Bcal Abscess. {Apostema Ileo-ccecale .) — The filamentous 
 tissue connecting the posterior surface of the caecum to the lum- 
 bar muscles is occasionally the seat of inflammation and suppu- 
 ration, apparently of a chronic character. Swelling and fulness 
 take place slowly in the space round the caecum. At length 
 pain is felt ; and when the part is examined a doughy solid 
 tumour is reeognized in the right iliac region, while dulness on 
 percussion is observed. The pulse is at this time a little quicker 
 than natural, (86-90) ; the skin is dry ; the tongue is furred ; the 
 abdomen is a little full ; and the bowels are slow or obstinately 
 
FILAMENTOUS OR CELLULAR TISSUE. 
 
 43 
 
 bound. These symptoms increase until fever is established, with 
 more considerable pain of the right iliac region and abdomen in 
 general, and the sense of a hard firm resisting mass in the right 
 iliac region. The swelling may terminate fatally at this time ; or 
 it may end in suppuration, either into the interior of the caecum, or 
 round the caecum, and into the iliac fossa, or with an outlet in the 
 region on the surface of the belly. The disease shall be consider- 
 ed more fully under affections of the caecum, to which it belongs. 
 
 4. Hemorrhage. Effusion of blood into the filamentous tissue 
 independent of external violence is not common. Of spontaneous 
 and idiopathic hemorrhage no authentic example has been record- 
 ed. It occurs, however, in a secondary manner in land and sea 
 scurvy, {Purpura and Scorbutus), In the former disease it is 
 rarely to any great extent, save when the complaint has terminated 
 fatally with large and repeated hemorrhage from the mucous, mem- 
 branes. In sea scurvy it is at once frequent and considerable. 
 Scarcely a case of this disorder attains any height, without much 
 effusion of blood into the subcutaneous and intermuscular filamen- 
 tous tissue. On this effusion in general depend the hard, livid tu- 
 mours, deep in the limbs, with which sea scurvy is attended. The 
 cause of this hemorrhage, or rather the state of the vessels which 
 gives rise to it, is not well known. That the blood is probably al- 
 tered, may be inferred from the fact, that it is dark-coloured, im- 
 perfectly coagulated and grumous, and does not separate into clot 
 and serum ; hut the capillaries of the tissue are much affected, cer- 
 tainly overloaded, probably disorganized. 
 
 Similar effusion is occasionally found in the filamentous tissue in 
 malignant agues, remittents, especially those of tropical countries, 
 and sometimes in the fever of temperate regions. Extravasation of 
 blood, dark-coloured and semi -coagulated, are observed in cases of 
 typhous fever during had epidemics, and in broken and impaired 
 constitutions. The patches vary from the size of a pea, or a six- 
 penny piece, to large irregular shaped masses one or two inches 
 square, and sometimes larger. These effusions take place in the 
 cellular tissue beneath the skin, in the intermuscular, and some- 
 times apparently among the muscles themselves. These it is impor- 
 tant to distinguish from the effects of blows and falls. They are 
 common in bad cases of typhous fever. But it is possible that they 
 may be aggravated by pressure. 
 
 5. Induration. H Endurcissement du Tissu Celhdaire of Andiy, 
 
44 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Auvity, &c. Engelure. Scleroma of Chaussier, (ax7~.rioc,jiJM ; cxX^igos.) 
 Skin-bound of Underwood and Burns. Compact oedema of M. 
 Leger and other French authors. First observed by John An- 
 drew Uzembezius in 1718, this affection was not accurately de- 
 scribed till 1780, when Denman and Underwood in England, and 
 Doublet in France, published the result of their observations. In 
 1787 it was fully investigated by Andry, in a memoir crowned by 
 the prize of the Royal Society of Medicine of Paris ; and after- 
 wards, in 1789, in those of Auvity and Hulme. Since this it has 
 undergone the successive researches of Naudeau and Bard in 
 France, Went, Henke, Golis, &c. in Germany, Liherali and Pal- 
 letta in Italy, and again of Trocon, Leger, Denis, and Breschet in 
 France. Notwithstanding the research of these several inquirers, 
 however, the nature of this change in the filamentous tissue is still 
 imperfectly understood. 
 
 It has hitherto been observed only in infants, and very often im- 
 mediately after birth. According to Leger, it appears most fre- 
 quently eight, twelve, or twenty-four hours after, and very seldom 
 takes place later than the seventh day. Generally in the legs, not 
 so often in the arms; the soft parts become unusually firm, dense, 
 and diffusely swelled either continuously or in patches. The skin 
 over these parts is hard, rough, and does not move easily ; and it 
 assumes a red, purple, or violet colour, which when pressed gives 
 place to a yellow tint, with more or less depression. The same 
 change is very generally remarked in the cheeks, the skin of which 
 becomes quite immovable ; and it appears successively in the belly 
 and chest, the integuments of which feel as stiff as a hoard. At 
 the same time the surface, especially the extremities, are unusually 
 cold ; the pulse is quick and very small ; the breathing is much 
 constrained and panting ; the infant ceases to cry, becomes blue in 
 the face, and seems to expire suffocated. 
 
 The duration of the disease varies. The greatest number of in- 
 fants die on the first, second, or third day from the date of attack. 
 In less rapid cases death takes place about the tenth or twelfth day, 
 and in some so late as the twenty-first day. 
 
 After death the surface of the body appears in general hard, 
 firm, and leathery, and presents a violet or brownish colour, inter- 
 spersed with yellow patches. The cheeks, the extremities, and 
 other parts affected during life are firm, rigid, and immovable. 
 The subjacent filamentous tissue is very dense and granular, and 
 
FILAMENTOUS OR CELLULAR TISSUE. 
 
 45 
 
 when cut communicates the sensation as if it were like collared 
 brawn. From the sections slowly oozes a reddish serous fluid, 
 which coagulates quickly ; and in the tissue itself may be observed 
 grayish or yellowish granules, which give the brawny aspect and 
 sensation already mentioned. (Leger.) The greatest firmness and 
 induration are generally remarked in the outer region of the legs, 
 and in the dorsal region of the foot and hand ; and this gives the 
 members the air of a peculiar twist or distortion. The adipose 
 membrane appears to be not much less the seat of this disease than 
 the filamentous tissue. 
 
 The bodies of infants cut off" by this disease are small, being of 
 the'medium height of seventeen inches ; and all the organs are im- 
 perfectly developed. Thus the lungs are hard, marbled, uncrepi- 
 tating, and sink in water ; the windpipe is small, and the alimen- 
 tary canal is shorter than usual in healthy infants of the same age. 
 The heart, however, is large, and generally contains blood in clots. 
 ’Yas. foramen ovale is often open, and the arterial duct is never 
 closed. The pericardium, and frequently the cavities of the serous 
 membranes, contain more or less serous fluid. 
 
 The nature of this moi’bid change is unknown. The old notion 
 of Uzembezius revived by Andry and Auvity, that it was occasion- 
 ed by coagulation of the fluids frozen by extreme cold, is com- 
 pletely contradicted by the fact recorded by Leger, that among for- 
 ty-four infants dead during the month of June 1823 in the Found- 
 ling Hospital of Paris, twenty-one were cut off by induration of the 
 cellular tissue. The notion of Alard, that it is allied with the 
 glandular disease of Barbadoes, scarcely deserves mention. On 
 the contrary, its early occurrence after birth, the imperfect deve- 
 lopement of the several organs, especially of the lungs, its occa- 
 sional appearance previous to birth, and its fi'equency among infants 
 born before the full time, (Palletta,) show that it bears some rela- 
 tion to the foetal mode of existence. The peculiar nature of the fi- 
 lamentous tissue in the foetus and in the new-born infant may have 
 some influence in the production of this malady. 
 
 6. Serous infiltration, {oedema^ anasarca.) Under the operation 
 of various causes, as exposure to cold, the use of mercury, inflamma- 
 tion, or injury, the quantity of serous fluid in the filamentous tissue 
 may be considerably increased; and this increase gives rise to a pale, 
 white, or wan-coloured and cold swelling of the skin, which is dis- 
 tinguished by receiving the impression of the finger or any other sub- 
 
46 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 stance forcibly applied. The swelling may be local, or confined to 
 one arm, to one leg, to a hand, to part of a limb, to the scrotum, to 
 the face, or so forth ; or it may extend in different degrees to the 
 greater part or the whole of the person. In the former case it is 
 termed (Edema^ {othynMa) or swelling ; in the latter it receives 
 the name of Anasarca^ (u5gwv|/ ava <ragx«, dropsy in the flesh,) and 
 is the aqua intercus of the Romans. It was the white or pale and 
 blanched colour of this sort of swelling which procured for it the 
 name of Leucophlegmatia or white inflammation 
 
 among the ancient physicians. 
 
 The fluid of the filamentous tissue may coagulate spontaneously, 
 (Blackall, 263 ;) but it always undergoes coagulation on the appli- 
 cation of heat or the addition of re-agents. 
 
 The preternatural increase of the cellular serosity now mention- 
 ed is supposed to arise either from diminished absorption or in- 
 creased exhalation. This point will be considered afterwards when 
 speaking of the exhalants. 
 
 7. Emphysema. Pneumatosis spontanea et traumatica., Cullen. 
 The filamentous tissue may be distended with air, which causes 
 a uniform swelling, crepitating or emitting a crackling sound when 
 pressed. The situations in which this aerial swelling may take 
 place vary according to the cause by which it is produced. It may 
 take place spontaneously (Baillie,) when it is commonly general, 
 and is supposed to depend on a process of secretion from the blood- 
 vessels. It may arise from rupture or laceration of the mucous 
 membrane of the larynx or windpipe, (De Villars, Cheselden, 
 Holyoke, O’Brien,) when the swelling appears chiefly over the face, 
 neck, and upper part of the chest. It may succeed a broken rib, 
 or any injury of the lungs, (Littre, Berger, W illiam Hunter, Ches- 
 ton, Leake, Gooch, Halliday,) when it appears sometimes over the 
 neck, face, and chest, sometimes over the chest and side only. It 
 may arise from rupture of the bronchial membrane during violent 
 efforts, (Blagden, Hicks, Simmons;) and in this manner emphysema 
 happens in puerperal women. Lastly, it may appear as an effect of 
 gangrenous inflammation and mortification, when it is confined sole- 
 ly to the affected limb. In the latter case the air is produced by 
 the decomposition of the serum of the blood in the morbid parts. 
 
 8. Vascular Sarcoma, Abernethy. The tumour known under 
 this name is, of all the new growths incident to the animal tis- 
 sues, the most simple in structure. I refer it to this head for two 
 
 4 
 
FILAMENTOUS OR CELLULAR TISSUE. 
 
 47 
 
 reasons. I 5 /, It appears to occur chiefly where filamentous or cel- 
 lular tissue is found ; and when it occurs among muscles, or in the 
 substance of organs, it appears still to he referable to the filamentous 
 tissue, which enters into the composition of the texture, in which 
 it appears. 2rf, The structure of this tumour is principally fila- 
 mentous tissue condensed or modified by the local morbid action. 
 Every instance of vascular sarcoma may be viewed as a new deve- 
 lopement and hypertrophic augmentation of its proper substance in 
 a particular point of the filamentous tissue. The tumour is always 
 liberally supplied with blood from vessels which, if not more nu- 
 merous, are greatly larger and more capacious than in the natural 
 state ; and if this be not the cause of the unusual deposition of sub- 
 stance, it must be regarded as the channel by which the additional 
 matter is conveyed. It is also possible that the irritation resulting 
 from the first effusion of blood, or other coagulable matter, which, 
 according to Mr Ahernethy, is the usual cause of tumours, may 
 excite the vessels of the neighbouring parts so much as to cause 
 their capacity to be enlarged, and to convey a more copious supply 
 of blood. This cause of the great vascularity, and its influence in 
 increasing the size of the tumour, are particularly insisted on by 
 Mr John Bell, and afterwards by Mr Ahernethy. 
 
 The vascular sarcoma is enclosed in a thin capsule, which is 
 formed of filamentous tissue much condensed by the pressure of the 
 enclosed tumour. It may occur in any part or organ of the hu- 
 man body where filamentous tissue penetrates ; but it is also found 
 in the female breast, in the testicle of the male, and in the absor- 
 bent glands of both sexes. When it occurs in the testicle the ves- 
 sels are said to be numerous and small. When it affects the fe- 
 male breast the vessels seem to be rather large than numerous, and 
 the organization appears less complete. (Abernethy.) 
 
 9. Melanosis. The black deposite named Melanosis is often 
 found in this tissue ; and perhaps when it is said to occur in the 
 interior of muscles, glands, and other tissues, it is in their filamen- 
 tous substance that it is deposited. As it is, however, still more 
 frequent in the adipose membrane, the points of its histoi'y deserv- 
 ing notice shall be introduced under that head. 
 
 10. Tubercle. I am uncertain whether to this tissue should be 
 referred every variety of the small painful bodies situate beneath 
 the skin, so well described by Mr Wood.* Though situate, as de- 
 
 * Edinburgh Medical and Surgical Journal, Vol. VTII. p. 83 and 429. 
 
48 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 scribed by Mr Wood, in tbe subcutaneous cellular tissue, some 
 facts tend to confirm the notion originally entertained by Camper,* 
 that it is a morbid growth seated in one of the subcutaneous nerves, 
 or probably in its neurilema.f 
 
 11. Cysts. Bichat has taken considerable pains to show the in- 
 fluence of this tissue on the formation of cysts. These, it is well 
 known, are shut sacs containing fluids of different sorts. But how- 
 ever these fluids may differ, the containing cyst, which is a secret- 
 ing membrane, has been regarded as formed of condensed and mo- 
 dified filamentous tissue. Against this doctrine Bichat urges the 
 following objections. 1. Cysts are analogous in all respects to 
 serous membranes, and should therefore have the same origin. 2. 
 This mechanical hypothesis of their origin, in which all the vessels 
 ought to be obliterated, does not accord with the exhaling and ab- 
 sorbing function of cysts, nor with their mode of inflammation. 3. 
 If these sacs are formed by the mutual application and agglutina- 
 tion or adhesion of cells, (that is, of the filaments,) the contiguous 
 tissue ought to be diminished, or to disappear when they are bulky, 
 which is not observed to take place. 4. If cysts are formed by 
 condensation of the filamentous tissue, and if their fluid is effused 
 by exhalation, this fluid ought to exist in the organ which separates 
 them from the blood. 
 
 For these reasons he infers that cysts begin at first to be deve- 
 loped, and to grow in the midst of the filamentous tissue, according 
 to laws analogous to those of the growth of parts in general, and 
 which appear to be unknown aberrations, or unnatural applica- 
 tions of these laws. When the cyst is once formed, the process of 
 exhalation commences, and though scanty at first, it increases as 
 the cyst enlarges. In short, the formation and growth of the or- 
 gan precedes the accumulation of the fluid. 
 
 12. Degeneration. This term is obviously vague and indefinite. 
 Under it, however, Sandifort has described in the body of a female 
 infant a preternatural state of the cellular tissue of the breast, back, 
 and axillary regions.^; In some respects this change resembles the 
 disease described above as induration. In others, however, it was 
 different. 
 
 * Demonstrationum Anatomico-Pathologicarum, Lib. i. p. 11. 
 
 + Ed. Journal, Vol. XI. p. 468. 
 
 J Observationes Anatomico-Pathologicse Eduardi Sandifort, Lib. iv. cajj. ii. p. 24. 
 Lugdimi Batavorum, 1777. 4to 
 
ADIPOSE TISSUE. 
 
 49 
 
 CHAPTER IV. 
 
 ADIPOSE TISSUE, ( Tela adiposa , — Tissu adipeux , — Tissu graisseux.) 
 
 Section I, 
 
 The separate existence of an adipose membrane was suspected 
 by Malpighi, distinctly taught by He Bergen and Morgagni, and 
 demonstrated by William Hunter. It was, however, confounded 
 with the filamentous tissue, under the general name of cellular 
 membrane, adipose membrane, and cellular fat, by Winslow, by 
 Portal, by Bichat, and most of the continental anatomists, till dis- 
 tinguished and positively described by M. Bedard himself. 
 
 According to the dissections of De Bergen and Morgagni, the 
 demonstrations of Hunter, and the observations of M. Bedard, its 
 structure consists of rounded packets or parcels separated fi-om 
 each other by furrows of various depth, of a figure irregularly oval, 
 or rather spheroidal, varying in diameter from a line to half an 
 inch, according to the degree of corpulence and the part submitted 
 to examination. Each packet is composed of small spheroidal par- 
 ticles, which may be easily separated by dissection, and which are 
 said to consist again of an assemblage of vesicles still more minute, 
 and agglomerated together by very fine and delicate cellular tissue. 
 The appearance of these ultimate vesicles is minutely described by 
 Wolff in the subcutaneous fat, and by Clop ton Havers* and Monro 
 in the marrow of bones, in which the two last authors compared 
 them to strings of minute pearls. If the fat with which these ve- 
 sicles are generally distended should disappear, as happens in 
 dropsy, the vesicles collapse, their cavity is obliterated, and they 
 are confounded with the contiguous cellular tissue, without leaving 
 any trace of their existence. 
 
 Hunter, however, asserts, that in such circumstances the cellular 
 tissue differs from the tissue of adipose vesicles, in containing no 
 similar cavities ; and justly remarks that the latter is much more 
 fleshy and ligamentous than the filamentous tissue, and contends, 
 that though the adipose receptacles are empty and collapsed, they 
 still exist. When the skin is dissected fi’om the adipose membrane 
 
 * Osteologia Nova; or some New Observations on the Bones and the Parts belong- 
 ing to them. By Cloptcn Havers, M. D., F. R. S. London, 1691. 8vo. P.167. 
 
50 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 it is always possible to distinguish the latter from the filamentous 
 tissue, even if it contain no fat, by the toughness of its fibres, and 
 the coarseness of the web which they make. 
 
 The distinguishing characters between the cellular or filamentous 
 and the adipose tissue may be stated in the following manner. 
 \st^ The vesicles of the adipose membrane are closed all round, 
 and, unlike the cellular tissue, they cannot be generally penetrated 
 by fluids which are made to enter them. If the temperature of a 
 portion of adipose membrane be raised by means of warm water to 
 the liquefying point of the contents, they will remain unmoved so 
 long as the structure of the vesicles is not injured by the heat. If, 
 again, an adipose packet be exposed to a solar heat of + 40 centigr. 
 though the fat be completely liquefied, not a drop will escape, un- 
 til the vesicles are divided or otherwise opened, when it appears in 
 abundance. The adipose matter, therefore, though fluid or semi- 
 fluid in the living body, does not, like dropsical infiltration, obey 
 the impulse of gravity. 2d, The adipose vesicles do not form, like 
 cellular tissue, a continuous whole, but are simply in mutual con- 
 tiguity. This arrangement is demonstrated by actual inspection, 
 but becomes more conspicuous in the case of dropsical effusions, 
 when the filamentous tissue interposed between the adipose mole- 
 cules is completely infiltrated, while the latter are entirely unafiect- 
 ed. 3(7. Tile anatomical situation of the adipose tissue is different 
 from that of the filamentous tissue. The former is found, ls7. In a 
 considerable layer immediately beneath the skin ; 2d, Between the 
 peritoneal folds which form the omentum and mesentery ; 3(7, Be- 
 tween the serous and muscular tissues of the heart ; and 47A, Round 
 each kidney. 
 
 In each of these situations it varies in quantity and in physical 
 properties. In the least corpulent persons a portion of fat is depo- 
 sited in the adipose membrane of the cheeks, orbits, palms of the 
 hand, soles of the feet, pulp of the fingers and toes, flexures of the 
 joints, round the kidney, beneath the cardiac serous membrane, and 
 between the layers of the mesentery and omentum. In the more 
 corpulent, and chiefly in females, it is found not merely in these 
 situations, but extended in a layer of some thickness almost uni- 
 formly over the whole person ; but is very abundant in the neck, 
 breasts, belly, mons veneris, and flexures of the joints. 
 
 Besides the delicate cellular tissue by which the packets and 
 vesicles are united, the adipose tissue receives arterial and venous 
 
ADIPOSE TISSUE. 
 
 51 
 
 branches, the arrangement of which has been described by various 
 authors from Malpighi, who gave the first accurate account,* * * § to 
 Mascagni, to whom we are indebted for the most recent. Accord- 
 ing to the latter, who has also delineated these vessels, the fxirrow 
 or space between each packet contains an artery and vein, which 
 being subdivided penetrates between the minute grains or particles 
 of which the packet is composed, and furnishes each with a small 
 artery and vein. The effect of this arrangement is, that each indi- 
 vidual grain or adipose particle is supported by its artery and vein 
 as by a foot-stalk or peduncle, and that those of the same packet are 
 kept together not only by contact, but by the community of rami- 
 fications from the same vessel. These grains are so closely attach- 
 ed, that Mascagni, who examined them with a good lens, compares 
 them to a cluster of fish-spawn, {un aggruppimento di uova). Grutz- 
 macher found much the same arrangement in the grains and vesi- 
 cles of the marrow of bones, f 
 
 It has been supposed that the adipose tissue receives nervous fila- 
 ments, and Mascagni conceives he has demonstrated its lymphatics. 
 Both points, however, are so problematical, that of neither of these 
 tissues is the distribution known. 
 
 The substance contained in these vesicles is entirely inorganic. 
 Always solid in the dead body, it has been represented as fluid 
 during life by Winslow,]; Haller, § Portal, || Bichat,1F and most au- 
 
 * Malpighi’s description is not much less accurate than that of Mascagni. “ Vasa 
 sanguinea expandunter in ramos arhorum adinstar, quorum extremitatibus appendun- 
 tur memhranosi sacculi, seu lobuli, pinguedinosis globulis referti, qui veluti folia ramis 
 adnata arboris exactam figuram complent.” — “ Per has membranas excurrunt minima 
 vasa in modum retis expansa, quae tenue omentum representant. Haec a venis et ar- 
 teriis, ut videre potui, ortum ducunt, et non tantum levitur exterius piguedinis lobulos, 
 Bed etiam intime penetrant, et pinguedinosis globulis nectuntur.” — “ Quandoque autem 
 co-operiuntur levi superextensa membrana, ita ut in conspectum non erumpant ; emer- 
 gunt autem, quotiescunque vetustate et carie membranosae portiones corrumpuntur. Per 
 hanc eandem membranam diramificantur adiposa vasa in omento reperta, quse pingue- 
 dine turgent, si pracipue in de recenti mactato animali inspiciantur.” — De Omento, 
 Pingueiline et Adiposis Ductibus, p. 41. 
 
 -f- De Ossium Medulla, 1748. Extat in HaUer, Vol. VI. p. 390. 
 
 J “ La graisse on matiere graisseuse est plus coulante dans les vivans que dans les 
 morts.” — Winslow, Traite des Tegumens, sec. 73. 
 
 § Elementa Physiologiae, Lib. i. sect. 4. 
 
 II “ La chaleur de la vie maintient la graisse dans une espece de fluidite ; eUe se flge 
 par le froid de la mort ; ce qui fait qu’eUe est compacte dans les cadavres.” — Portal, 
 Tome ii. p. 17. 
 
 ^ “ La graisse est presque toujours solide et figee dans les cadavres, mais sur le vi. 
 vant elle s’approche plus de I’etat liquide, an moins dans certains parties, comme aux 
 
52 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 thors on anatomy. The last writer indeed states, that under the 
 skin it is more consistent, and that in various living animals he 
 never found it so fluid as is represented. The truth is, that in the 
 human body, and in most mammiferous animals during life, the fat 
 is neither fluid nor semifluid. It is simply soft, yielding, and com- 
 pressible, with a slight degree of transparency or rather translu- 
 cence. This is easily established by observing it during incisions 
 through the adipose membrane, either in the human body or in the 
 lower animals. 
 
 The properties and composition of fat form a subject for chemi- 
 cal rather than anatomical inquiry ; and in this respect its nature 
 has been particularly investigated by M. Chevreul. According to 
 the researches of this chemist, fat consists essentially of two proxi- 
 mate principles, stearine (?sa^, seburn^ sapo), and elaine, (^eXaiov, 
 oleum.) The former is a solid substance, colourless, tasteless, and 
 almost inodorous, soluble in alcohol, and preserving its solidity at 
 a temperature of 138° centigrade. Elaine, on the contrary, though 
 colourless, or at most of a yellow tint, and lighter than water, is 
 fluid at a temperature of from 17° to 18° centigrade, and is great- 
 ly more soluble in alcohol. Of this substance marrow appears to 
 be merely a modification ; and the membranous cavities or medul- 
 lary membrane in which it is contained may be viewed as an intra- 
 osseous adipose tissue. 
 
 Little doubt can be entertained that animal fat is the result of a 
 process of secretion. But it is no easy matter to determine the 
 mode in which this is effected. Malpighi, departing, however, 
 from strict observation, imagined a set of ducts issuing from glands, 
 in which he conceived the fat to be elaborated and prepared. To 
 this he appears to have been led by his study of the lymphatic 
 glands, and inability to comprehend how the process of secretion 
 could be performed by arteries only. This doctrine, however, was 
 overthrown by the strong arguments which Ruysch derived from 
 his injections ; and Malpighi himself afterwards acknowledged its 
 weakness and renounced it. In short, neither the glands nor the 
 ducts of the adipose membrane have ever been seen. 
 
 Winslow, though willing to adopt the notion of Malpighi, ad- 
 mits, however, that the particular organ by which the fat is sepa- 
 rated from the blood was unknown. Haller, on the contrary, aware 
 
 environs du cceur, des gros vaisseaux, &c. Sous la peau elle est constamment plus 
 consistante.” — Anatomie General, Tome I. p. 59. 
 
 4 
 
ADIPOSE TISSUE. 
 
 53 
 
 of tiie permeability of the arteries, and their direct communication 
 with the cells of the adipose tissue, and trusting to the testimony 
 of Malpighi, Ruysch, Glisson, and Morgagni, that it existed in the 
 arterial blood, saw no difficulty in the notion of secretion, or rather 
 of a process of separation ; and upon much the same grounds the 
 opinion is adopted by Portal and others. Bichat, again, contends, 
 that no fat can be recognized in the arterial blood, and adduces the 
 fact, that none can be distinguished in blood drawn from the tem- 
 poral artery. It may be doubted, nevertheless, whether adequate 
 means to ascertain this point were adopted. Gmelin obtained from 
 blood cholesterine, stearine, elaine, and stearic acid. Chevreul 
 obtained from fibrin, by means of ether, a fatty matter. Lecanu 
 found in large quantities of blood small proportions of crystal- 
 lizable fatty and oily matter; and lastly. Dr R. D. Thomson and 
 others have since that shown, that after meals of certain kinds 
 of food the blood contains adipose and oily matter. From these 
 facts it may be inferred, that adipose matter is conveyed in mi- 
 nute quantities into the blood, and is rapidly deposited from the 
 vessels in various parts of the adipose tissue, where it is afterwards 
 found. From the phenomena of various diseases also, and those 
 of the hybernating animals, which retire in the beginning of win- 
 ter fat and heavy, and come out in spring meagre and extenu- 
 ated, there is reason to believe that fat is absorbed by the veins and 
 lymphatics. 
 
 It must be observed, nevertheless, that fat or oily matter is found 
 in the free state, and in appreciable quantity, only in certain condi- 
 tions of the system ; and as arteries are not habitually opened for 
 blood-letting, the circumstance of fat or oil not being observed in cer- 
 tain cases of arteriotomy, forms only a degree of negative evidence. 
 This result is not at variance with the facts observed, as already 
 stated, by Hewson* * * § and Dr Traill,f who found oily matter in ve- 
 nous blood in two instances, or with those observed by Mr An- 
 derson,! Dr Ziegler, Dr Christison,§ and myself, all of whom have 
 
 * Hewson’s Experimental Inquiries, p. 191, loco citato. 
 
 + On the presence of Oil in Human Blood. By Thomas Stewart Traill, M. D. 
 Edin. Med. and Surgical Journal, XVII., 236, 637, and XIX. 319. 
 
 On White or Milk-like Serum. Edin. Med. and Surgical Journal, Vol. XXXIII. 
 p. 215. 
 
 § On the Causes of the Milky and Whey-like Appearance sometimes observed in 
 the Blood. By R. Christison, AI. D. &c. Edin. Med. and Sure. Journal, Vol. 
 XXXIII. p. 274. 
 
54 
 
 GENERAL AND PATEOLOGICAL ANATOMY. 
 
 found tlie blood in certain morbid states to contain oil. In wounds 
 in the human body during life, and in living animals, oily par- 
 ticles may be seen floating on the surface of the blood ; but these 
 proceed from division of the adipose vesicles. 
 
 That fat does not exist in the arterial blood in health, or is in very 
 minute quantity, may be therefore admitted as an established point. 
 The idea that it is separated, or strained from this fluid, therefore, 
 must also be gratuitous ; and as such it is viewed by Bichat, who 
 considers the deposition of fat as the eflrect of exhalation. This, it 
 must be confessed, is little more than a different name for the pro- 
 cess termed by Haller secretion. Lastly, an opinion has been deli- 
 vered by Mascagni, that, while the arteries deposit or pour forth 
 an imperfect or crude oily fluid, the lymphatics absorb the thin 
 parts, and leave the residue in a more solid and perfect form. 
 
 In conclusion, all that can be affirmed regarding the formation 
 of this substance is, that it is deposited by the blood-vessels, but by 
 what particular process, or in what form, is entirely unknown. Tlie 
 process by which the arteries of the adipose membrane secrete fat 
 appears to be equally mysterious as that by which the vessels of 
 muscle deposit fibrine, those of bone deposit osseous matter, and 
 those of cartilage form that animal substance. 
 
 It appears, therefore, that the adipose tissue may be distinguish- 
 ed into two elements, one organic and secreting ; the other, inor- 
 ganic and secreted. 
 
 The adipose membrane is one of the most extensively distributed 
 tissues in the animal body; and this circumstance, with its peculiar 
 organic and physiological properties, exercises remarkable influence 
 on its inflammatory and other morbid states. 
 
 In distribution it may be distinguished in the following manner. 
 1. The subcutaneous adipose tissue, extended in a uniform layer, 
 variable in thickness, beneath the skin all over the body, excepting 
 at certain parts where the skin communicates with the mucous 
 membrane, as the eyelids, the lips, the penis of the male, the labia 
 in the female, where there is no adipose tissue, and beneath the 
 hairy scalp, where the adipose tissue is extremely thin ; 2. the pe- 
 riangial adipose tissue, surrounding and enclosing the large blood- 
 vessels and nerves in the trunk and extremities, forming a sort of 
 sheath to these organs, and sustaining their nutrient vessels, (yasa 
 vasorum) ; 3. the subserous adipose tissue, deposited, more or less 
 abundantly, beneath the different serous membranes, and between 
 
ADIPOSE TISSUE. 
 
 55 
 
 their folds, often round blood-vessels, for instance between the pe- 
 ricardium and muscular substance of the heart, betvveen the peri- 
 toneal folds, forming the omentum and the mesentery ; 4. round 
 each kidney ; 5. between the folds of the synovial membranes ; 
 and, 6. the endosteal, or intra-osseous, or the medullary membrane 
 within the canals of the longitudinal bones and the cells of the flat 
 and short bones. 
 
 Section II. 
 
 The pathological relations of the adipose tissue have not been 
 distinctly indicated. 
 
 1. Pimelitis. Is it subject to inflammation ? I have already said 
 that certain facts lead to the inference, that the peculiar phenomena 
 of difluse inflammation may depend on the influence of the adipose 
 membrane. This may be regarded as established by many facts. 
 But it must be observed, at the same time, that the physical proper- 
 ties and the physiological relations of the adipose tissue, combined 
 with its anatomical position, exert a peculiar influence over its mor- 
 bid states. 
 
 In the first place, as the adipose membrane consists of two parts, 
 organic or vital tissue, and an inorganic secreted substance, and as 
 the former bears a small proportion to the latter, the vital proper- 
 ties of the tissue are accordingly much less prominent than the 
 mere physical properties. The component sacculi, or vesicles of 
 the adipose membrane, are not possessed of highly or strongly 
 marked vital powers ; and the vessels distributed to them, which 
 are neither large nor numerous, seem to be merely adequate to 
 their nutrition in ordinary circumstances, but quite unable to main- 
 tain the energies of the tissue when subjected to disease or injury. 
 Pressure or stretching the adipose tissue bears very imperfectly ; 
 and when it is subjected to violence or injury of this kind along 
 with other tissues, as skin, muscle, cellular membrane, or artery, 
 its vitality is destroyed first, and long before these tissues are much 
 afiected. In continued fever {synochus ; typhus,) the adipose 
 membrane of the sacral region is often killed to a large extent long- 
 before the skin is affected ; and its death involves necessarily ul- 
 ceration of the incumbent skin, in order to allow the escape of the 
 dead adipose membrane in the form of a large flat slough. It is 
 perhaps of no great moment whether this imperfect and feeble vital 
 
56 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 energy depends on the want of nerves, or on the smaller number 
 and size of its nutrient vessels. The fact of feeble vitality is well 
 established by many circumstances of daily occurrence, and is fur- 
 ther illustrated, as shall be seen, by the different appearance and 
 effects of the phenomena of inflammation in tissues more completely 
 organized, and endowed also with more active vital properties. 
 
 In the second place, as to anatomical position, the adipose tissue 
 is in many situations of the human body so closely confined, that 
 when inflamed, and consequently distended, it cannot easily expand. 
 This is particularly the case, not only with the subcutaneous fat 
 which is compressed by the skin, but with the dense adipose cushion 
 surrounding the blood-vessels and nerves, which, in the extremi- 
 ties at least, and in the neck, is closely packed and compressed, as 
 it were, by all the incumbent and surrounding tissues, — muscles, 
 fascia, and skin. When we examine the adipose cushion surround- 
 ing the carotid artery in the neck, that accompanying the axillary 
 and brachial artery in the arm-pit and arm, and that enclosing the 
 femoral and popliteal arteries in the leg, it must appear obvious, 
 that little or no space is left in either of these regions for the casual 
 expansion of the adipose membrane, from whatever cause proceed- 
 ing. Not only is the adipose cushion there closely confined by con- 
 densed filamentous tissue, but it is further inclosed and compressed 
 by the incumbent fascia^ muscles, subcutaneous adipose membrane, 
 and skin ; and the degree of tightness may be estimated from the fact, 
 that even when cut into in the healthy state, it is forthwith protruded, 
 and is with difficulty replaced. This tightness is one great cause 
 of the readiness and celeraty with which the adipose tissue in this 
 situation passes so readily into mortification. As it is distended by 
 the inflammatory vascular congestion, and as the surrounding parts 
 do not yield with proportional facility, it is as if inclosed within a 
 long tight ligature, and is in a manner strangled by its own en- 
 largement. This result is clearly illustrated by the effects of in- 
 flammation of the periangial adipose membrane. 
 
 In the third place, the inflammatory states of the adipose mem- 
 brane are not only in themselves of the highest importance, from 
 the anatomical and physiological properties of the tissue itself, but 
 in consequence of the uses to which this tissue is applied in enclos- 
 ing and supporting others, and especially the nutrient vessels 'of 
 blood-vessels, nerves, tendons, and bones, these states may exercise 
 on the economy a roost important influence, which I believe has 
 not hitherto been fully understood. 
 
ADIPOSE TISSUE. 
 
 57 
 
 Inflammation attacking the subcutaneous adipose tissue is liable 
 to produce death, not only in that membrane but in the skin, in- 
 flammation and death in the muscles, inflammation in the subcu- 
 taneous veins, and inflammation and death in the tendons. 
 
 Inflammation attacking the periangial adipose tissue is liable to 
 be followed not only by death in that tissue itself, but by inflam- 
 mation, death, and ulceration of the arterial tunics, and consequent 
 hemorrhage, inflammation of the veins, with obliteration of their 
 canal, and denudation of the nerves. 
 
 Inflammation attacking the medullary or endosteal adipose tissue 
 produces suppuration and causes death in the bone, (^Necrosis,) and 
 in the cancellated tissue the phenomena of the disease named Spina 
 ventosa. 
 
 When inflammation affects the adipose membrane it may assume 
 either the limited or the diffuse form, but is most frequently per- 
 haps seen in the latter state. 
 
 It appears to have been an opinion entertained by Boerhaave 
 and several of his pupils, that phlegmon, or common acute circum- 
 scribed inflammation, is seated in the adipose membrane ; and one 
 of these writers, Hulsebusch, announces this proposition formally 
 in a dissertation. The same doctrine was afterwards taught in this 
 country by Bromfield, who allowed that the adipose membrane is 
 quite distinct from the filamentous tissue,"^ and further believed, 
 that extravasated fluid would sooner be converted into purulent 
 
 * “ I may be singular in what I am going to advance, viz. that in general the adi- 
 pose membrane is the seat of abscesses, especially those that are circumscribed. 
 
 “ I hope T am understood, that I suppose what is generally defined a phlegmon or 
 critical abscess, in which a large quantity of matter is collected, to be formed in the 
 meinbrana adiposa." In the following passage he gives the first description of diffuse 
 inflammation. “ Nevertheless, I am extremely sensible, that the cellular or connect- 
 ing membrane is frequently the seat of mischief, as the receptacle of some extravasat- 
 ed humour, where the fluids in general have a tendency to sphacelation ; and under 
 such circumstances it is well knoTO, that the humour, instead of being collected and 
 forming an abscess, mU be diffused proportionate to the quantity extravasated, and 
 form sloughs, throughout a whole limb, and where probably, the external appearance 
 of sphacelation shall not exceed the size of a crown-piece, the mortification will then 
 discover itself soon after, at a small distance ; and we shall find in the end, that it has 
 not only crept under the skin, but has bmrowed deep between the muscles, and 
 through some of these sphacelated parts, sloughs of an immense length are frequently 
 drawn out, which prove to be the cellular membrane ; in which case, if the patient 
 does not sink under the discharge, the neighbouring parts must, in healing, unavoid- 
 ably unite, and consequently the hmb be abridged of its motion, as far as the free 
 motion of the muscles, one over the other, is hardened by this union.”— Chinirgical 
 Observations, Vol. I. chapter iii. p. 94 and 95. 
 
58 
 
 GENEML AND PATHOLOGICAL ANATOMY. 
 
 matter when lodged in the adipose than in the cellular membrane. 
 It is further remarkable that, while he gives the earliest good de- 
 scription of the phenomena and effects of diffuse or disjunctive in- 
 flammation, he refers the seat of circumscribed inflammation to the 
 adipose membrane, and that of disjunctive inflammation to the cel- 
 lular membrane. The converse of this notion was maintained by 
 J. Hunter, who represents the cellular membrane free from the 
 adipose, to be more susceptible of the adhesive inflammation than 
 the adipose membrane, and much more readily to pass into the 
 suppurative.* This, however, he afterwards in some manner con- 
 troverts by giving the same view of the eflPects of cellular inflam- 
 mation, as that previously furnished by Bromfield. 
 
 All that it appears to me can be concluded at present on this 
 subject is, that, though inflammation with tendency to circumscrip- 
 tion may attack the adipose tissue, yet that tissue is much more 
 liable to assume the diffuse, spreading, and disjunctive form of the 
 disease. 
 
 Among the proofs adduced in favour of this view may be men- 
 tioned the following. In cases of diffuse inflammation affecting the 
 arm, the inflammation spreads along the adipose membrane, pro- 
 ducing sero-purulent secretion and sloughs of the adipose tissue. 
 In cases of inflammation at the verge of the anus, the disease 
 spreads in the same manner, and affects almost exclusively the 
 adipose tissue round the anus and rectum, and along the glutaei 
 muscles. It is in the same manner that the adipose cushion with 
 which the blood-vessels are surrounded is occasionally the seat of 
 a species of bad inflammatory action, terminating in fetid and 
 sloughing suppuration. 
 
 I have in a considerable number of instances observed inflamma- 
 
 * “ The cellular membrane, free from the adipose, appears to be more susceptible 
 of the adhesive inflammation than the adipose membrane, and much more readily 
 passes into the suppurative. Whether this arises from surfaces inflaming more readily 
 than other parts, I will not pretend to say. Thus we see that the cellular membrane 
 connecting parts together as muscles, and the cellular membrane connecting the adi- 
 pose to muscles, easily inflames, and runs readily into suppuration, and as it were se- 
 parates the muscles from their lateral connection, and even separates the adipose from 
 the muscles, while the skin and adipose membrane shall only be highly inflamed ; and 
 the matter so formed must produce ulceration through all this adipose membrane to 
 get to the skin, and then through the skin, in which last-mentioned pai-ts it is much 
 more tedious.” (P. 234, iii. 282, P. ii. Ch. ii. § 3.) Himter appears in this place to 
 have confounded the two kinds of inflammation, the adhesive or limited, and diffuse 
 or suppurating. 
 
ADIPOSE TISSUE. 
 
 59 
 
 tion of the adipose tissue, presenting the external signs described by 
 my late friend. Dr Duncan, Junior, as those of diffuse inflammation 
 of the cellular membrane. The process then produced all the ef- 
 fects now specified, and, by the peculiar manner in which the in- 
 flammatory process spreads along the meshes of the tissue, detached 
 extensively the skin from the muscles, and the muscles and fasfdce 
 from each other, and, in consequence of the intricate manner in 
 which it insinuates itself between the muscles and their fasciculi^ 
 it produced extensive disjunctive destruction of the different parts 
 which it affected. Thus, on the side of the chest, I have seen it 
 first disjoin, and then kill the fibres of the intercostal muscles, and, 
 affecting the pleura costalis at its muscular surface, pass to the ft’ee 
 surface, and give rise to pleurisy and empyema. In the buttock, 
 at the margin of the anus, I have seen it detach the skin com- 
 pletely from the subjacent muscles, dissect round tbe sphincter and 
 levator ani as completely as if done by the knife, and produce 
 such disjunction and separation as to render the whole of the 
 muscles completely useless as organs of motion. 
 
 In the course of these destructive processes, this disease, which 
 though first confined with extreme accuracy to the adipose tissue, 
 eventually affects muscles, tendons, blood-vessels, and nerves, by 
 killing and. detaching that texture which supports and encloses 
 them, and conveys their nutrient blood-vessels, is ever attend- 
 ed with febrile symptoms, remarkable for their character in de- 
 ranging all the functions, and impairing more or less, sometimes 
 very considerably, tbe muscular strength. The pulse is rapid, but 
 generally much oppressed, and though sometimes at the commence- 
 ment sharp, is generally contracted, wiry, and even vermicular. 
 The skin is pungently hot and dry ; the tongue more or less fur- 
 red, with much thirst ; and in severe cases, where the disease as- 
 sumes a violent character, the patient raves or mutters, and some- 
 times passes into a state of typhomania (coma vigil,) or even after- 
 wards coma. The complexion is often of a dingy colour, as it is 
 in typhous fever, or in cases of traumatic gangrene, or in cases of 
 death by animal poisoning ; and the eyes, though they may be free 
 from injection, are generally suffused, watery, and turbid. At the 
 same time, almost all the great secretions are more or less com- 
 pletely suspended, or as it were locked up, by the perverted and 
 diminished action of the capillary vessels. The skin is dry and im- 
 perspirable, and only at the termination of the disorder betrays the 
 
60 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 existence of clammy moisture. The urine is scanty and clear till 
 the close, when it becomes sedimentous. No cathartic medicines, 
 however powerful, can produce feculent discharges from the intes- 
 tines, and all that escapes is a watery secretion with minute black 
 specks, grains, and patches of undecomposed bile, without the cha- 
 racteristic feculent odour or aspect. 
 
 The peculiar characters of this form of fever have procured for 
 it, from Dr Butter* the name of Irritative, and from Mr Travers, f 
 that of Constitutional Irritation ; denominations which may be per- 
 fectly correct, if they either denoted a new form of general disor- 
 der, or established as a new principle in pathology, the circumstance, 
 that when any individual texture is in a morbid state, it gives rise 
 to derangement, perversion, and irregularity, in the motions of the 
 sanguiferous system and the dependent secretions. It appears to 
 me that there is in this nothing new nor even singular, when we 
 know, that it is an established principle in physiology and patho- 
 logy, that all the textures of the animal body are so allied, that one 
 cannot be long in an unhealthy state without inducing general dis- 
 order, and that all the properties and actions of these textures are 
 so intimately associated, that those of one organ are almost never 
 impaired or perverted, without betraying the existence of this im- 
 pairment or perversion, by disorder in the motions and actions of 
 the sanguiferous system, and, its great dependent, the secreting ap- 
 paratus of the different organs. 
 
 The disease, however, is not in all cases a simple and exclusive 
 affection of one tissue ; and the singular feature of this inflamma- 
 tion is, that, either simultaneously or successively, it affects a con- 
 siderable number of different tissues. It hence results that the con- 
 comitant symptoms are by no means uniform, and assume various 
 types according to the tissues affected. 
 
 Thus, in inflammation of the adipose tissue, the disease is very 
 liable to attack the filamentous tissue, which it disjoins and destroys 
 in the manner already described. It also very commonly attacks 
 the veins ; and the symptoms are then complicated with those of 
 venous inflammation ; and may eventually give rise to the second- 
 ary suppurations observed to ensue on that disoruer. The venous 
 
 * Remarks on Irritative Fever. By .John Butter, M. D., F. R. S., &c. Devonpoit, 
 
 1826, 8vo. pp. 302. ,7 t, c? 
 
 •f An Inquiry concerning Constitutional Irritation. By Benjamin Travers, F. R. S. 
 
 London, 1826, 8vo, pp. 556. 
 
ADIPOSE TISSUE. 
 
 61 
 
 tunics are then observed to be thickened, and sometimes adhering, 
 with obliteration of the canal ; and in several instances matter, or 
 lymph, or both, are found within the veins. Lastly, it may produce 
 denudation of the arteries exactly as a broad ligature, or any fo- 
 reign substance in the neighbourhood of, or around the arterial 
 tubes, and in this manner induce erosion, and rupture of the artery 
 with fatal hemorrhage. 
 
 In ordinary circumstances, the course of phenomena appears to 
 be nearly the following. Sometimes without previous warning, in 
 other instances after slight sensations of chilness and languor, or 
 even after distinct shivering, heavy dull pain is felt in one part par- 
 ticularly, as the neck, the breast, or an extremity, according to the 
 situation which the disease affects. This painful sensation spreads 
 or extends, amounting to stiff soreness of the whole region, with 
 more or less tenderness of the integuments. If the part is exa- 
 mined, it is found affected with diffuse or extensive swelling, com- 
 pressible, but not very elastic, considerable tension of the skin, 
 great heat, and in some instances a dull red tinge. In some in- 
 stances the skin retains its natural colour, — a circumstance which 
 is to be ascribed to the depth of the inflammatory action, and per- 
 haps the early period of the disease. In some it is of a faint red, 
 inclining to yellow or orange, which becomes more distinct when 
 pressure is applied ; and in some the disease passes through every 
 stage without even producing redness of the skin. In others long 
 red patches, of no determinate shape, may be remarked ; but this 
 appearance is more common when the superficial adipose tissue is 
 affected, and when the disease is verging to suppuration. These 
 symptoms, which may be considered as indicating the first or in- 
 flammatory stage, last from thirty hours to three or four days, — ■ 
 seventy-two, eighty, or ninety-six hours. 
 
 As they proceed, the swelling increases and may become more 
 prominent at one part than another, but still retains its diffuse and 
 shapeless character. The pain, which is continual, becomes occa- 
 sionally more acute, and is attended with an insufferable sensation 
 of oppressive weight. If the disease affect an extremity, the pa- 
 tient feels as much difficulty in raising it as if it were a dead mass, 
 or unconnected with his person. At length, about the fifth, sixth, 
 or seventh day, according to the rapidity of the disease, the swell- 
 ing presents in sundry parts a peculiar compressible, but not very 
 elastic character, as if the subjacent tissues were floating in some 
 fluid or semifluid matter. 
 
62 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 At this period the constitutional symptoms, which consist in quick 
 sharp pulse, great heat, thirst, loss of appetite, languor, and some- 
 times delirium, assume the appearance of extreme oppression and 
 mortal weakness. The pulse becomes much quicker, small and 
 fluttering, sometimes intermittent ; the tongue, which had previ- 
 ously been covered with a thick, gray, or yellow, moist, viscid fur, 
 or was red and glossy, is covered with a rough fur, dry, brown, and 
 hard, yet the patient is insensible of thirst. The skin is dry, or 
 partially moistened with cold unctuous sweats ; the urine is scanty 
 and high-coloured, sometimes entirely suppressed, or passes with 
 the stools involuntarily ; low mutturing alternates with stupor ; 
 the breathing becomes quick, panting, and laborious, or slow, lan- 
 guid, and interrupted, and terminates in death. 
 
 If the affected part or limb be examined after death, the whole 
 subcutaneous adipose tissue, and the intermuscular cellular tissue, 
 are found enlarged, gray, or ash-coloured, and distended with 
 blood-coloured fluid, oily serum, or sero-purulent, or purulent 
 matter. It is detached, in general, extensively from the several 
 organs which it connects in the healthy state. Between the mus- 
 cles, which are dark-coloured, softened, lacerable, and emit a fetid 
 odour, are found long sinuous caverns filled with dirty ash-co- 
 loured purulent fluid ; sloughs or mortified shreds are seen here 
 and there hanging from aponeurotic sheaths, tendons, or even 
 blood-vessels ; and while in most cases shreds or filaments of the 
 subcutaneous adipose and the cellular tissue are the only traces of 
 its existence, in not a few instances the muscles are detached from 
 the periosteum, and the periosteum from the bone. These shreds 
 or filaments are mortified pieces or sloughs of adipose membrane 
 and cellular tissue, and correspond to the pieces of wet tow men- 
 tioned by Hunter and Sir E. Home, and the wads of wet shamoy 
 leather noticed by Mr James. 
 
 This may be regarded as the most exquisite and severe form of 
 the disease. Its duration in such circumstances varies. It appears 
 from the result of Dr Duncan’s observations, that death does not 
 take place before the sixth day, but may occur in any subsequent 
 one to the twelfth or fifteenth. Perhaps in the average number of 
 cases, the seventh, eighth, or ninth may be stated as the day on 
 which the termination occurs. 
 
 In milder cases it may terminate in resolution. The general 
 
 swelling subsides slowly, the pain disappears, the skin becomes 
 
 ] 
 
ADIPOSE TISSUE. 
 
 63 
 
 cool ; and the constitutional symptoms decline upon the eruption 
 of a copious sweat, a cutaneous disease or other critical action. 
 
 It may terminate in abscess. The inflammatory action changes 
 its character, and, instead of spreading, shows a disposition to stop. 
 Lymph is effused, healthy purulent matter is formed, and adhesion 
 taking place in one or more points, the disease terminates in phleg- 
 monic suppuration. 
 
 In some instances the spreading and limited may be combined. 
 The spreading or diffuse inflammation proceeds at one part of the 
 affected tissue, while the limited with lymphy effusion and adhesion 
 appears at another. This appears to be the fact in those tedious 
 cases in which the disease is prolonged for weeks, and the patient 
 either recovers, or ultimately dies hectic. 
 
 When recovery takes place after suppuration and sloughing of 
 the adipose and cellular tissue, it is effected partly by direct adhe- 
 sion taking place between the muscles or their cellular substance, 
 and the skin, partly by the formation of new cellular tissue similar 
 to those new membranes which are formed in the serous surfaces. 
 The former is the cause of the stiffness, immobility, and condensa- 
 tion of parts after this inflammation has taken place. 
 
 The causes of this disease are not well known. There is reason 
 to believe that it requires for its production a peculiar state of the 
 constitution ; for it more readily attacks the bloated and those of 
 broken constitutions than the spare and the vigorous ; it is more 
 common and more severe in the corpulent and plethoric than in 
 those of healthy and active habits; it is more common in those 
 liable to mental inquietude and peevishness than to those of equable 
 or indifferent temperament ; and the same exciting cause which 
 produces in a young and healthy subject a common phlegmonic 
 abscess, will be follov/ed in a sallow or middle-aged person, of dry 
 or unctuous skin, with a fatal inflammation of the dift’use character. 
 Something also appears to be attributable to epidemic influence ; 
 for several cases are generally remarked to occur much about the 
 same time ; and it has been further remarked, that when rose, 
 scarlet fever, and bad sore throat prevail, instances of diffuse inflam- 
 mation are not unfrequent. 
 
 With regard to agents wliich appear to possess exciting power, 
 it may occur spontaneously : but has been observed to succeed the 
 following circumstances ; venesection and punctured wounds in 
 general, application of a ligature to a vein, puncture by a cutting 
 
€4 
 
 GENERAL AND PATHOLOGICAL ANATOOT. 
 
 instrument during dissection, inoculation by morbid secretions 
 from living animals, the bite of a venomous serpent, acrid or poi- 
 sonous substances of the acrid family applied directly to the skin 
 or adipose membrane, sprains or injuries of the fibrous tissues, and 
 contused or lacerated wounds. 
 
 Though this disease may arise both spontaneously, and also in 
 consequence of lacerated or punctured wounds, or even mere 
 scratches or abrasions, and in consequence of various poisonous 
 substances applied to the skin or the adipose membrane, it appears 
 further, in certain circumstances, to ensue on the application to 
 the skin of various acrid and irritant poisons. Thus, in the expe- 
 riments of Orfila upon the mode of operation of these poisons, it 
 was a frequent occurrence, to observe diffuse inflammation in the 
 adipose tissue ensue on the application of such substances as bry- 
 ony-root, elaterium, colocynth, gamboge, spurge-flax, euphorbium, 
 &c. to the skin or the adipose membrane exposed by wound. Dr 
 Duncan relates a case communicated by Dr Spens, in which it 
 followed the application of an ammoniacal plaster for the removal 
 of rheumatic pains. It has been observed to follow or attend ma- 
 lignant pustule. (Practice of Medicine, Vol. i. p. 656.) 
 
 The account of the necroscopic appearances, however, above 
 given, is applicable principally to the disease as it takes place in 
 the subcutaneous adipose tissue ; and perhaps, as it spreads to the 
 intermuscular filamentous tissue. These appearances, though in 
 all general characters similar in other tissues, are varied according 
 to the portion of adipose membrane attacked. 
 
 The disease may either, when originally commencing in the sub- 
 cutaneous adipose tissue, spread to the periangial, or it may com- 
 mence in the latter at once, and produce destructive ravages in the 
 periangial sheath, and most pernicious effects on the blood-vessels. 
 Thus, I have elsewhere recorded the principal circumstances of a 
 case in which the disease attacked the periangial adipose tissue of 
 the right carotid artery and jugular vein, destroyed the sheath for 
 the space of eight inches, denuded and exposed both vessels, pro- 
 duced gangrene and erosion of the artery and inflammation of the 
 jugular vein, with obliteration of its canal, and denudation of the 
 trunk of the pneumogastric nerve. (Edin. Med. and Surgical 
 Journal, Vol. xlviii. p. 396.) 
 
 The adipose tissue connected with the internal organs is also 
 liable to be attacked by inflammation. That enclosing the kidneys 
 
ADIPOSE TISSUE. 
 
 65 
 
 in particular has been found affected with, and destroyed by, the 
 true disjunctive inflammation. One of the most characteristic ex- 
 amples of this disease on record is given by Dr Thomas Turner, 
 in the fourth volume of the Medical Transactions of the Royal 
 College of Physicians. In this case the disease commenced with 
 sickness, vomiting, and pain in the bowels, followed by pain in the 
 back and loins ; and at the end of about thirty-eight hours with 
 great restlessness, anxiety, laborious, panting respiration, and loss 
 of pulse at the wrist. Death took place at the end of forty-eight 
 hours. The whole adipose tissue enclosing the kidneys was in a 
 gangrenous state, exhibiting a large mass of black pulpy matter. 
 The capsules of both kidneys were inflamed, that of the right kid- 
 ney mortified, and slight traces of inflammation were observed in 
 the internal structure of both kidneys. In the winter of 1816-17, 
 I examined the body of a man in whom I found the whole of the 
 adipose cushion surrounding the left kidney, converted into an ash- 
 coloured fetid, semifluid pulp, similar to a mixture of train oil and 
 jelly, mingled with shreddy filaments, and in which this suppura- 
 tive sloughing process had opened a passage from the fat of the 
 left kidney into the interior of the transverse arch of the colon. In 
 this case, though the patient did not complain of much pain, and 
 presented chiefly the general languor, oppression, and stupor ob- 
 served in typhoid fever, the pulse was quick and small, the tongue 
 brown and dry, the thirst intense, afterwards not felt, the counte- 
 nance dingy and lurid, and the eyes heavy, the bowels difficult to 
 be affected by medicine, the urine scanty and high-coloured, and 
 at length suppressed ; and the patient, after muttering delirium and 
 typhomania on the second day of the attack, with subsultus tendinum, 
 passed into a comatose state, which terminated on the fourth day 
 in death. 
 
 The endosteal or intra-osseous adipose tissue, in other words, the 
 medullary membrane, is liable in like manner to both forms of in- 
 flammation, but especially the suppurative and disjunctive ; and 
 the invariable eflrect of this is to kill the compact tissue of the bone, 
 and produce atomical death or caries of the cancellated tissue. Ne- 
 crosis is the result of the former, and spina ventosa and caries of 
 the latter. The full consideration of this variety of the disease, 
 however, belongs to another subject. 
 
 I have now described the usual characters of this disease in its 
 
 E 
 
66 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 most acute, intense, and rapid form. But it sometimes happens 
 that it is slower in progress and less intense in severity ; and in 
 this case it may be said to be subacute or chronic. Thus I have 
 seen an instance in which the disease attacked the adipose tissue of 
 the arm, and though attended with well-marked fever, yet without 
 the overpowering symptoms of prostration so often observed, — 
 and advancing so slowly as to admit of the employment of local 
 depletion by leeches, and the effect of antimonials and purgatives, 
 so as eventually to terminate in resolution. 
 
 The foregoing account may communicate some idea of the seat 
 of this disease, of its effects, and of its dangerous tendency. I have 
 yet to offer a few remarks on its nature, its pathological peculiari- 
 ties, and the causes on which its developement may seem to depend. 
 Some of these points I have indeed anticipated. But others are 
 entitled to more systematic examination. 
 
 The most remarkable circumstance in tbe pathological history of 
 Pimelitis, is the extreme rapidity with which it generally proceeds 
 to sero-purulent infiltration and disjunctive destruction. In several 
 cases this has been known to take place within thirty -six hours 
 from the appearance of the first symptoms of uneasiness. In 
 others it occurs in the course of about seventy-two hours; and 
 in very few cases is this event protracted beyond the fourth 
 day. 
 
 Very nearly at the same rate may be estimated the fatality of 
 the disease. Wherever the inflammation is very extensive, and es- 
 pecially if it occur in middle-aged or elderly corpulent persons, 
 death is very likely to ensue in the course of the third, or at most, 
 the fourth day. In young and robust persons, on the contrary, 
 and in whom the adipose tissue is not much loaded, the disease is 
 slower in progress, and less frequently fatal in termination. The 
 most rapidly fatal case which I think I have yet witnessed occurred 
 in a male patient in the Boyal Infirmary this season. He had been 
 under treatment for slight diarrhoea, which disappeared under the 
 use of chalk mixture and opiates, alternated with gentle eccopro- 
 tics, and the use of nutritious diet, and for several days expressed 
 himself well. He was in his usual health at the visit preceding the 
 last day of his life ; but in the afternoon, about four, he was at- 
 tacked with pain of the left thigh and iliac region, which speedily 
 became swelled, hot, red, and livid, and presented a large detach- 
 ment of the cuticle, containing livid serum {phhjctana.y^.^Q's.t 
 
ADIPOSE TISSUE. 
 
 67 
 
 day the features were decomposed, the face pale, the counte- 
 nance Hippocratic; and death took place the same evening, with- 
 in twenty-six hours from the first appearance of symptoms. Upon 
 inspection, the whole adipose membrane was found extensively 
 infiltrated with dirty oily-like serum. The arteries were not dis- 
 eased. 
 
 Anatomico-Pathological Causes of Disjunctive Inflam- 
 mation. — Though I do not deny that this disease is occasionally 
 to be seen in the filamentous tissue, yet I think this is a much 
 rarer occurrence than in the adipose membrane ; and several cir- 
 cumstances appear to prove, that it is, if not the only, at least by 
 far the most common, form of inflammation in that tissue. This 
 conclusion is founded not only on the anatomical fact of the adipose 
 membrane being found most usually the seat of the disease, and of 
 its affecting parts where this texture is most abundant, as already 
 -stated, but also in another circumstance, viz. that the disease is 
 most frequent in corpulent persons, in whom the adipose tissue is 
 abundant. This circumstance again seems to be referable to the 
 low vital energy of that tissue, as already in some degree ex- 
 plained. 
 
 In the corpulent, either by habit or age, in whom this disease 
 assumes its most exquisite, intense, and unmanageable forms, — 
 who are generally not only plethoric, but bloated, and liable to im- 
 perfect circulation, and disorders of tbe circulation and secretion 
 generally, — and in whom slight causes are often followed by serious 
 disorders, the adipose tissue appears to lose a great proportion of 
 the small degree of vital energy which it possesses, and the more 
 abundant the secreted product is, the less active are its vessels 
 and the inherent properties of the membrane. In consequence of this 
 greatly impaired energy, slight causes, as cold, scratches, or abrasions, 
 punctures, contusions, &c. are suddenly followed by a more or less 
 complete loss of circulation and action in tbe tissue ; for the disease 
 consists not in increased, but diminished action ; and this impaired 
 energy continues, until the natural functions of the tissue become 
 extinct. In these circumstances, with few and inert blood-vessels, 
 the secreted or inorganic matter of the adipose tissue becomes, as 
 it were, a cause of strangulation of tbe tissue itself, or at least tends 
 so directly to suppress the energies of its organic part, that it is 
 incapable of resisting the influence of morbific agents of ordinary 
 power ; and hence, the organic portion either may be smitten with 
 
68 
 
 GENERAL ANB rATHOLOGICAL ANATOMY. 
 
 immediate death, or is easily made to assume a very low, languid, 
 and imperfect form of morbid action, which speedily terminates in 
 death. 
 
 This low degree of vital energy seems the principal if not the 
 sole cause of the disjunctive, and, as it may be termed, the disor- 
 ganizing character of the inflammation, of which the adipose mem- 
 brane becomes the seat. If we compare the different elementary 
 tissues of the animal body, we find that the nature of the inffamma- 
 tory process, of which each becomes the seat, bears a relation more 
 or less intimate and direct to the nature of its organization. All 
 parts well provided with blood-vessels, and, therefore, highly orga- 
 nized, seem to have high vital energies, and great powers of resist- 
 ing disorganization. Parts, on the other hand, less highly orga- 
 nized, and which have few or small- sized blood-vessels, may be 
 said to have inferior degrees of organization, and to be less capable 
 of resisting the vascular perversion in which inflammation consists. 
 Thus the skin, the serous membranes, and the mucous membranes, 
 all of which are highly vascular, possess also great powers of resist- 
 ing the disorganizing effects of inflammation ; and, when these take 
 place, either counteract this by some supplementary process, which 
 inflicts no serious injury on the structure of the inflamed membrane, 
 and does not permanently injure its functions, or, if actual destruc- 
 tion ensue, it is not by direct death of the part, but by the minute 
 atomical absorption named ulceration ; and at the same time the 
 vessels make attempts, though sometimes abortive, to repair this 
 species of destruction. 
 
 My limits do not allow me to consider at length the apparent 
 exceptions to this principle, otherwise it would appear distinctly 
 that these were only confirmations of the fact now stated, — that 
 the protecting faculty of any tissue against the ravages of inflam- 
 mation depends very much upon, if it be not directly proportioned 
 to, its organization, or the size and number of its nutrient vessels. 
 This principle is also very clearly illustrated in the inflammation of 
 the adipose membrane, in which an imperfect, and, indeed, an in- 
 ferior degree of organization seems to be the main cause of the 
 destructive effects of that process. In that tissue inflammation is 
 no sooner established than it proceeds rapidly to death, chiefly be- 
 cause the texture has not powerful vital energies, and is less capa- 
 ble than others of resisting the tendency to destruction. It pos- 
 sesses less of the independent form of vitality which the vascular 
 
ADIPOSE TISSUE. 
 
 system communicates to all the elementary tissues of the frame, 
 and hence sinks more easily and promptly under the influence of 
 the perverted or impaired vascular disorder in which inflammation 
 consists. 
 
 It is not unlikely that this is also one of the principal causes of 
 the peculiar irritative characters of the febrile disorder with which 
 the inflammation of the adipose tissue is attended. We know that 
 in the case of inflammation of highly organized tissues, as the se- 
 rous membranes, the character of the concomitant fever is often 
 distinct and acutely inflammatory, — much perverted action of the 
 vascular system, but little of the nervous system, and much less of 
 the overpowering prostration and oppression of all the vital powers 
 which attend inflammation of the adipose membrane. In the one 
 case, the actions of life seem to be simply increased, and are cer- 
 tainly perverted, and in one respect augmented in intensity. In 
 the other, they are oppressed and overpowered ; and the full vi- 
 gom’ of reaction, as it has been named in the mechanical lan- 
 guage of the iatro-matheraatical schools, is not permitted to deve- 
 lope itself. 
 
 But it is not only in its constitutional effects that inflammation 
 of the adipose tissue is a malady so important. From its intimate 
 union with the parts which it incloses, its destruction entails their 
 destruction ; and, if it do not prove fatal by the severity of the fe- 
 brile disorder which it induces, it may do so by the ravages which 
 it causes among muscles, nerves, and blood-vessels. I mentioned 
 its tendency to expose and denude the blood-vessels ; because in 
 almost all the dissections which I have seen and performed of this 
 disease, I have found the vascular sheath more or less diseased, 
 sometimes destroyed, and the vessels exposed, the veins thickened 
 and inflamed, and the arteries brittle, softened, and sloughy. In 
 all these cases, however, the disease proves fatal, either by the in- 
 tensity of the febrile disorder, or by causing inflammation of the 
 veins, or passing to some internal organ, as for instance when it 
 affects the adipose membrane of the chest, and thence passes, as I 
 have seen it, to the pleura and lungs. It cannot be doubted, how- 
 ever, that, were life not terminated in either of these modes now 
 mentioned, the destruction of the adipose tissue, forming the sheath 
 of the vessels, would have the effect of producing death in the ar- 
 terial tunics, and rupture of these vessels. We know, that when 
 the sheath is by any means detached from the arterial tunics, either 
 
70 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 by disease, oi’ aceident, or in consequence of operation, a result al- 
 most inevitable is death of these tunics, chiefly in consequence of 
 the destruction, which the nutrient vessels, the vasa vasorum^ ne- 
 cessarily sustain by the inflammation of the adipose sheath, by which 
 these vessels are supported. That this has not been more frequently 
 observed in cases of spontaneous inflammation of the adipose 
 cushion, is to be ascribed to the fact, that the disease in general 
 proves fatal by the severity of the constitutional disorder, or by the 
 induction of inflammation of the veins, passing from their exter- 
 nal to their internal coat. 
 
 It is proper to remark, that in an abstract of the case of inflam- 
 mation of the periangial adipose tissue above referred to, in the 
 Archives Generales, (iii. New Series, Dec. 1837,) M. Godin, the 
 author of that notice, has attempted to oppose the view that the 
 disease consists in inflammation of the adipose membrane, by re- 
 presenting it to be diffuse phlegmon. I have only to remark, that 
 this is a contradiction in terms, which, instead of conveying a cor- 
 rect view of the disease, tends to confuse still more than formerly. 
 The view given by me rests on the accuracy of the anatomical 
 observations ; and unless these are shown to be erroneous, 1 see 
 no mode of denying the fact, that in most of the cases of diffuse 
 inflammation the adipose membrane is the chief seat of the dis- 
 ease. 
 
 2. Hemorrhage. EflPusion of blood into the adipose tissue is 
 not very common. It is observed in the same circumstances 
 nearly in which it occurs in the filamentous tissue. Thus it has 
 been seen in land and sea scurvy. Huxham observed it in fevers 
 with petechial eruptions. And Cleghorn states that one of the ap- 
 pearances after death in the continuous and malignant tertians of 
 Minorca was extravasation of blood in the form of black patches 
 in the adipose layer of the mesentery, omentum, and colon. 
 
 3. Excessive Deposition. In certain subjects, and in peculiar 
 circumstances, the quantity deposited is enormous. The average 
 weight of the human subject at a medium size is about 160 pounds, 
 or between eleven and twelve stones. Yet instances are on record 
 of its attaining by deposition of fat in the adipose membrane the 
 extraordinary weight of 510, and 600 pounds, or from thirty-five 
 to forty stones. Cheyne mentions a case in which the weight was 
 448 pounds, equal to thirty-two stones. In the Philosophical 
 
 Transactions are recorded two cases of persons so corpulent, that 
 
 4 
 
ADIPOSE TISSUE. 
 
 71 
 
 one weighed 480 pounds, and another 500 pounds. And the Bres- 
 lau Collections contain cases in which the human body weighed 
 580 and 600 pounds. 
 
 In females and in eunuchs it is more abundant than in males ; 
 in females deprived of the ovaries it is more abundant than in those 
 possessed of these organs ; and it is well known that sterility is fre- 
 quent among the corpulent of both sexes. In some circumstances 
 this accumulation may be so great as to constitute disease, {Poly- 
 sarcia adiposa^ Cyrilli, Sauvages, Cullen, and Good;) and in other 
 circumstances the deposition of fat is a means which the secret- 
 ing system seems to employ to relieve fulness and tension of the 
 vessels, and if not to cure, at least to obviate morbid states of the 
 circulation. (Parry.) Accumulations of fat are said to take place 
 in some animals in a few hours in certain states of the atmosphere. 
 During a fog of twenty-four hours’ continuance, thrushes, wheat- 
 ears, ortolans, and red-breasts are reported to become so fat that 
 they are unable to fly from the sportsman. (Bichat.) 
 
 4. Local Hypertrophy. The adipose membrane is liable to a form 
 of hypertrophy, local in situation, and of a peculiar character. The 
 surface of the person and extremities presents many small tumours, 
 varying in size from a garden pea to that of a filbert, soft, com- 
 pressible, movable under the skin, and indolent. In some the sur- 
 face acquires a bluish tint, apparently from compression of the ves- 
 sels of the skin. In the most marked case of this which I have 
 seen, the number was very considerable, probably not less than 
 eighty or ninety of different sizes. On inspection after death, which 
 was the consequence of another disease, these bodies were found to 
 consist of globular or spheroidal masses of fat, not different from 
 that of the ordinary fat, contained within membranous capsules, 
 with walls a little firm. The individual was corpulent ; but the 
 presence of these bodies seemed, from the account of his medical 
 attendants, to exert no appreciable influence on the state of his 
 health. 
 
 These bodies appear to be merely the result of hypertrophy af- 
 fecting many separate points of the adipose membrane. 
 
 5. Extreme Diminution. The diminution or disappearance of 
 fat is much more frequent than its extraordinary abundance. This 
 diminution is said to depend on one or other of the following 
 causes. Is^, Long abstinence, as in fasting, and the periodical 
 sleep of dormant and hybernating animals ; 2r/, Organic diseases, 
 
72 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 as consumption, cancer, disease of the liver, especially cirrhosis, 
 disease of the heart, granular degeneration of the kidneys, ulcera- 
 tion of the intestines, &c. ; 3c?, Purulent collections or secretions ; 
 Ath, Leucophlegmatic and dropsical states ; 5tli, Gloomy and me- 
 lancholy thoughts or passions ; Qth, Long and uninterrupted effort 
 of the intellectual powers ; 1th, Preternatural increase of the na- 
 tural evacuations, as in cholera, diarrhoea, diabetes, &c. mucous 
 discharges, especially from the pulmonary and intestinal mem- 
 branes, as in chronic catarrh, inflammation of the intestines and 
 dysentery ; 8?/<, Long and intense heat, whether natural, as during 
 hot summers, or artificial, as in furnaces, hot-houses, &c. ; 9th, 
 Running, riding, and every species of fatiguing exercise long con- 
 tinued, as is exemplified in the case of grooms at Newmarket, 
 Doncaster, &c. ; 10?7«, States of long disease not organic; Wth, 
 Night- watching and want of sleep in general ; \2th. Immoderate 
 use of spirituous liquors ; 1 Zth, Habit of eating bitter and spiced 
 or acid aliments. 
 
 Yet even in these states the fat of the animal body is seldom en- 
 tirely wasted. In several organic diseases, in which great ema- 
 ciation takes place, a considerable quantity of fat is always found 
 in the orbits behind the eyeball, round the substance of the heart, 
 around the kidneys, in the colon, and in the mesentery and omen- 
 tum.* According to the observation of William Hunter, anasar- 
 cous dropsy is the only disease in which the fat of the adipose mem- 
 brane is entirely consumed. “ This disorder, when inveterate, has 
 that effect in such a degree, that we find the heart or mesentery of 
 such subjects as free from fat as in the youngest childi’en.” This, 
 however, is in some degree denied by Bichat, who contends that it 
 is not uncommon to find much subcutaneous fat in subjects greatly 
 infiltrated, (Vol. I. p. 57.) It is obvious that much will depend on 
 the stage of the disease. It cannot be expected, that the moment 
 serous infiltration appears in the filamentous tissue, all the fat 
 should be at once removed from the adipose. The process of ab- 
 
 ■* An instance of this, which occurred within the last few days, may be now men- 
 tioned. I had occasion to examine the body of a young gentleman, (3d October 
 1827,) who had laboured under symptoms of pulmonary disease during the three 
 months previous to his death. Though the left lung was completely occupied with 
 small whitish amorphous masses of tubercular' matter of different degrees of consist- 
 ence, and the right lung in addition to this was in the second stage of pulmonic in- 
 flammation, yet a considerable layer of fat was found between the skin and muscles on 
 the chest and belly. 
 
ADIPOSE TISSUE. 
 
 73 
 
 sorption is gradual as that of deposition ; and the inference of Hun- 
 ter may be regarded as nearly exact in reference to long continued, 
 or what he terms inveterate dropsy. It is certain, that, while it is 
 very difficult to deprive the bones of ordinary subjects of oil, those 
 of dropscal subjects are the only ones which it is possible to obtain 
 free from this substance. 
 
 Lastly, I have to observe, that the remark of Dr Hunter is appli- 
 cable chiefly to granular disease of the kidney, which, whether ac- 
 companied with anasarca or not, has a remarkable effect in re- 
 moving: the fat and various other animal substances. 
 
 The removal of the fat from its containing membrane is effected 
 by the process of absorption, the agents of which are supposed by 
 William Hunter, Portal, Bichat, and Mascagni, to be the lym- 
 phatics. According to the results of the experiments of Magendie, 
 Mayer, Tiedemann and Gmehn, Segalas, &c. it must, in some 
 measure at least, be ascribed to the influence of minute veins. It 
 is a point of some interest to know in what form it is absorbed, 
 whether as oily matter, or after undergoing a process of decompo- 
 sition. The observation of Hewson, of Dr Traill, and Dr Christison, 
 above quoted, would lead to the former view ; but it is not easy to 
 conceive that this should be uniform. W'e want, in short, correct 
 facts on the point at issue. 
 
 5. Adipose Sarcoma. This consists in an unusual deposition of 
 firm fatty matter in cells, the component fibres of which are suffi- 
 ciently firm to give its consistence. The tumour, which is gene- 
 rally globular, is always surrounded by a thin capsule formed by 
 the condensation of the contiguous filamentous tissue. The tumour 
 is supplied by a few blood-vessels, which proceed from the capsule, 
 but which form so slender an attachment that they are readily 
 broken, and the tumour is easily scooped from its seat. This sort 
 of tumour occurs almost invariably in the adipose membrane, and 
 seems to consist in a local hypertrophy of the part in which it is 
 found. It may have a broad basis, but is often pendulous, or at- 
 tached by a narrow neck or stalk. It is the most common form of 
 sarcomatous tumour, and may occur in any part of the body in 
 which there is adipose membrane, but is chiefly found on the front 
 and back of the trunk, and not unfrequently on two places at the 
 same time. 
 
 6. Steatomu. In adipose sarcoma the adipose matter is deposit- 
 ed in cells, and the tumour derives a degree of firmness from the 
 
74 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 fibres with which it is thus traversed in every direction. In other 
 instances, however, the adipose matter is deposited in a mass in the 
 cavity of a spherical or spheroidal cyst, formed in the filamentous 
 or the adipose tissue ; and the tumour is soft and compressible, and 
 seems to contain fluid or semifluid matter. When cut open it is 
 found to contain a soft semifluid matter of the consistence of honey, 
 but of oily or adipose properties. In such circumstances the inner 
 surface of the cyst, or at least the vessels of this surface, are the 
 agents which secrete the fatty matter. This tumour may occur 
 either in the filamentous or the adipose tissue ; but is to be re- 
 garded as an example of local deposition of adipose matter. It 
 may appear in any region of the filamentous tissue, but is most 
 frequent about that of the head and face. Small steatoms are not 
 unfrequent in the eyelids and in the scalp. Larger ones are more 
 frequent about the neck. 
 
 The other forms of encysted tumours, distinguished hy the names 
 of atheroma, pulticula ah ada^a, pultis genus), and meliceris 
 
 (iOE. 2 X/K>)g/? mel and cera, honey ; wax), are to be viewed ratber as va- 
 rieties of the steatom than as generically different. The substance 
 contained may differ in consistence, but is nearly the same in es- 
 sential qualities. 
 
 7. Melanosis. I have already spoken of the melanotic deposi- 
 tion taking place in the filamentous tissue. The adipose mem- 
 brane is also a frequent seat of this singular change. The black 
 or melanose matter is found in the subcutaneous adipose membrane 
 and the subjacent cellular tissue of the chest and belly ; it is not 
 uncommon in the fat of the orbit ; it is very commonly seen in the 
 adipose cushion on the fore-part of the vertebral column, that sur- 
 rounding the kidneys, and in the fat of the anus and rectum ; it is 
 found in the anterior and posterior mediastinum ; and it is found 
 between the folds of the mesentery, of the mesocolon, and of the 
 omentum. It is also found in the substance of the marrow of 
 bones ; and perhaps in most cases in which the osseous system ap- 
 pears to be stained with the melanose deposite, the dark matter may 
 be traced to the medullary particles, the situation of which it is 
 found accurately to occupy. 
 
 In all these situations it appears in various degrees of perfection, 
 and in different forms. It may be disseminated in black or inky 
 spots through the adipose membrane ; it may be accumulated in 
 spherical or spheroidal masses of various size and shape ; or it may 
 
ARTERY, ARTERIAL TISSUE. 
 
 75 
 
 be found in the form of brown or ebon-coloured fluid or semifluid, 
 enclosed in a cyst formed of the contiguous tissue more or less 
 condensed. 
 
 The melanose matter is entirely destitute of organization, and is 
 to be regarded as the result of a peculiar secretion. No vessels 
 have been traced into it ; and when bodies afiected with this de- 
 posite are minutely injected, the vessels can be traced no farther 
 than the enveloping cyst. (Breschet.) It is also to be noticed that 
 it is never deposited exactly in the site of organic flbres, but always 
 between them, and very generally in the precise situation of the 
 adipose particles. These several circumstances show that the me- 
 lanose disease consists not in a degeneration or conversion into 
 another substance, but in the deposition of a new form of matter 
 in the manner of a secretion. 
 
 In what form the melanose substance is first deposited we have 
 few accurate facts to enable us to form a judgment. Laennec is 
 of opinion that it is first deposited in a solid form, and afterwards 
 becomes fluid. The former he considers the stage of crudity, the 
 latter that of softening, {ramoUissemenL') Several facts, however, 
 would lead to the conclusion, that when first deposited it was fluid, 
 and afterwards acquired consistency. Thus, in several dissections 
 performed by Dr Cullen and Mr Carsewell, the matter of the small 
 tumours, which are supposed to be of short duration, were found 
 to be softest, and sometimes as fluid as cream.* In like manner, 
 in a case recorded by M. Chomel, in which the disease was found 
 in the liver in the shape of large cysts, the melanose matter was 
 more fluid in the centre than in the circumference of the cysts.f 
 Upon the whole, if the melanose deposite be, as is supposed, an in- 
 organic secretion, the idea of its being poured forth from the ves- 
 sels at first in a fluid or semifluid state is most probable, and most 
 consistent with the usual phenomena and laws of animal pro- 
 cesses. 
 
 8. Acephalo-cysts. This form of hydatid is occasionally found si- 
 tuate beneath the skin, partly in the adipose tissue, partly in the 
 cellular membrane. When present in numbers, they form an ex- 
 tensive superficial tumour over the person, most commonly the 
 back, and in rare cases in the extremities. They present the usual 
 characters of acephalo-cysts in other regions ; that is, they are glo- 
 
 * Transactions of the Medico-Chirurgical Society of Edinburgh, Vol. I. p. 264. 
 
 ■f Nouveau Journal de Medecine, Tome III. p. 41. 
 
76 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 bular cysts, sometimes solitary, more frequently associated or con- 
 gregated with membranous coverings, thin, opaque, and almost 
 translucent. In some instances they give rise to suppuration, and 
 by this means come to the surface. If they do not, they seem to 
 cause inconvenience by their size, number, and situation. One 
 incision made through the skin often allows the escape of a great 
 number, leaving an extensive cavity in the adipose and cellular 
 membrane. 
 
 9. Induration. I think it probable that the peculiar affection which 
 takes place in the bodies of infants described at p. 43 in chapter iii. 
 should be referred to this tissue. But after this mention of the sub- 
 ject, I think it unnecessary to alter the arrangement. 
 
 CHAPTER V. 
 
 ARTERY, ARTERIAL TISSUE, {Artcvia , — Tissu arterid.) 
 
 Section I. 
 
 The structure of the arteries has been so much the subject of 
 examination at all periods of the history of anatomy, that to men- 
 tion the authors by whom it has been described would be much the 
 same^ as to enumerate all the anatomists who have ever written. 
 To omit Galen, and some of those who wrote shortly after the re- 
 vival of literature, descriptions of the structure of arteries have 
 been given with different degrees of minuteness and accuracy by 
 Willis, Vieussens, Verheyen, Lancisi, Bldloo, the first Monro, 
 Morgagni, Ludwig, Haller, De La Sone, Bichat, Gordon, Magen- 
 die, and by Mondini. Yet the descriptions given by these observ- 
 ers are so discordant, that Ludwig complains of the difficulty of re- 
 conciling them, and Haller evidently felt it ; and with the excep- 
 tion of those given by the four last authors, they do not accord with 
 the characters which this substance actually presents. 
 
 The following account is derived principally from repeated ex- 
 amination of the arteries of the human subject, occasionally com- 
 pared with those of the more familiar domestic animals. 
 
 Every arterial tube greater than one line in diameter is visibly 
 composed of one adventitious and two essential substances. The 
 
ARTERY, ARTERIAL TISSUE. 
 
 77 
 
 first, the sheath, reputed to consist of condensed filamentous tissue : 
 the two last, the proper arterial and internal tissues. ( Tunica pro- 
 pria et membrana intima.') 
 
 1. The inner surface of the arterial tube is formed by a very 
 thin semitransparent polished membrane, which is said to extend 
 not only in the one direction over the inner surface of the left ven- 
 tricle, auricle, and pulmonary veins, but in the other to form the 
 minute vascular terminations which are distributed through the 
 substance of the different organs. This membrane is particularly 
 described by Bichat under the name of common membrane of the 
 system of red blood, because he believed it to exist wherever red 
 blood was moving, — in the pulmonary veins, in the left side of the 
 heart, and over the entire arterial system. 
 
 The inner membrane may be demonstrated by cutting open or 
 inverting any artery of moderate size, when it may be peeled oflf in 
 the form of thin slips by the forceps. Or, if the tube be fitted on 
 a glass rod, by removing the layers of the proper membrane in suc- 
 cessive portions, the inner one at length comes into view in the 
 form of a thin translucent pellicle, of uniform, homogeneous aspect, 
 without fibres or other obvious traces of organization. This mem- 
 brane is supposed to be prolonged to form those minute vessels in 
 which the proper coat cannot be traced. It is very brittle, and is 
 distinguished during life by a remarkable activity in forming the 
 morbid states to which arteries are liable. In other respects it is 
 deemed by Bichat peculiar, and, though similar to the proper mem- 
 brane, is to he considered as unlike any other tissue. Its chemical 
 composition is not known. 
 
 2. Exterior to this common or inner membrane is placed a dense 
 strong tissue of considerable thickness, of a dun yellowish colour, 
 which is found to consist of fibres disposed in concentric circles 
 placed contiguous to each other round the axis of the artery. If 
 this substance be examined either from without or in the opposite 
 direction, it will be found that, by proper use of forceps, its fibres 
 can be separated to an indefinite degree of minuteness, even to that 
 of a hair, and that they uniformly separate in the same direction. 
 Longitudinal fibres are visible neither in this nor in any other tis- 
 sue of the arterial tube. This is the proper arterial tissue, {tunica 
 propria.) Its uniform dun yellow colour is perceived through the 
 semitransparent inner membrane, and is most conspicuous either 
 when this is removed, or when the outer cellular envelope is de- 
 
78 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 tached and the component threads separated from each other ; and 
 if it be less distinct in the smaller branches, it is because the tissue 
 on which the colour depends is here considerably thinner. In this 
 respect it varies in different regions. Though in general less dense 
 and abundant as the arteries recede from the heart, it is thicker, 
 cateris paribus^ in those of the lower than in those of the upper ex- 
 tremities. In the vertebral and internal carotid arteries, and in 
 those distributed in the substance of the liver, spleen, &c. it is 
 thinner than in vessels of the same size in the muscular interstices. 
 
 The nature of this tissue has been the subject of much contro- 
 versy. It was long believed to be muscular, and to possess the pro- 
 perties of muscular fibre. Bichat showed that the arguments by 
 which this opinion was supported are inconclusive, and that the ar- 
 terial tissue has very few qualities in common with the muscular. 
 The circumstances from which he derived his proofs were its phy- 
 sical and physiological properties. 
 
 The arguments derived from the physical properties of this tis- 
 sue are chiefly the following. The arterial tissue is close, elastic, 
 fi’agile, and easily divided by ligature ; muscular fibre is more loose 
 in structure, by no means elastic, and, instead of being divided or 
 cut by ligature as artery is, undergoes a sort of strangulation. 
 The action of alcohol, diluted acids, and caloric, by means of hot 
 fluids, which are not corrosive, affords a proof of the chemical dif- 
 ference of these animal substances. All of them produce, in the 
 arterial tunic, a species of shrivelling or crispation, which seems to 
 depend on more complete coagulation of one of the chemical prin- 
 ciples ; but no similar effect takes place in muscular fibres. Ac- 
 cording to Berzelius the proper arterial tunic contains no fibrine.* 
 Bedard, however, asserts, that he has ascertained that it contains 
 a portion of this principle ; but nevertheless hesitates to consider it 
 as a muscular or fibrinous tissue, and expresses his opinion, that it 
 would be with greater propriety referred to that order of substan- 
 ces which he has named yellow or tawny fibrous system. 
 
 The consideration of the physiological or organic properties leads 
 to similar results. Neither mechanical or chemical agents applied 
 as stimulants produce any change or motion in tlie living arterial 
 membrane. 1. The arteries of an amputated limb, exposed the 
 moment after amputation, while the muscles are in active motion, 
 
 * A View of the Progress of Animal Chemistry. By J. J. Berzelius, M. D. &c. &c. 
 London, 1813. Pp. 24, 25. 
 
ARTERY, ARTERIAL TISSUE. 
 
 79 
 
 do not contract or move when punctured by the scalpel. 2. The 
 experiments of Bikker and Van-den-Bos with the electric spark, 
 and those of Vassalli-Eandi, Griulio, and Rossi with the galvanic 
 pile, may be considered as disproved by the experiments of Nysten,* 
 who found no contraction in the human aorta after violent death, 
 while the heart and other muscles could still be excited. In per- 
 forming the same experiment with the artery of the living dog this 
 physiologist was equally disappointed. 3. The circular contraction 
 of the calibre of an artery, either partially or wholly divided, de- 
 pends not on irritability, but either on its elasticity, or on that pro- 
 perty which it possesses of contracting strongly, the instant the dis- 
 tending agent is removed. This power, which was rather happily 
 named by Bichat contractUite par defaut extension, is qiute differ- 
 ent from muscular contraction or irritability, and must not be con- 
 founded with them ; but it depends in a degree not much less on 
 the living state of the body and the individual arterial tube. 4. 
 The contraction said to take place in living arteries after the appli- 
 cation of alcohol, acids, or alkalis, is to be ascribed to the chemical 
 crispation, and not to stimulant power. It does not relax. 5. 
 These inferences are not inconsistent with the experiments of Thom- 
 son, Philips, Hastings, and Kaltenbrunner, on minute arterial tubes, 
 which may be admitted to possess something like irritability, or ra- 
 ther susceptibility of contraction, without the necessity of supposing 
 the same property in the large branches and trunks. 6. This is so 
 much more probable, as in these minute arteries the proper arte- 
 rial tunic is either wanting, or is so much thinner and so modified, 
 that it is impossible to conceive its presence capable of affecting the 
 result of experiments made to deterraime the degree or kind of ar- 
 terial contraction. 
 
 3. The outer surface of the proper arterial tissue is enveloped, 
 as above noticed, in a layer of dense filamentous or cellular mem- 
 brane, which is very firmly attached to it, and which was formerly 
 considered as part of the arterial tissue. It is adventitious ; a mo- 
 dification of filamentous or cellular texture which establishes a com- 
 munication between the artery and the contiguous parts, and is ne- 
 cessary to the nutrition and healthy state of the vessel. It incloses 
 and transmits the minute vessels anciently denominated vasa vaso- 
 rum, {arteriolce arteriarum, Haller ;) and if detached even through 
 
 * Nouvelles Experiences Galvaniques, &c. Par P. H. Nysten, &c. A Paris, An. 
 XL pp, 235 and 236. 
 
80 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 a trifling extent, the arterial portion thus isolated is sure to become 
 dead ; to be affected with inflammatory and sloughing action ; and 
 ultimately to give way and discharge the contents of the vessel. M. 
 Bedard considers it a fibro-cellular membrane, which may in the 
 larger arteries be divided into two layers, one exterior, similar to 
 the general filamentous tissue ; the other inside between the outer 
 layer and the proper tissue, yellowish and firm, but still sufficiently 
 distinct from the proper tunic. In the cerebral arteries it is want- 
 ing, and in most parts of the chest and belly its absence is supplied 
 by a portion of pericardium, pleura, or peritonaeum. Yet even 
 there a thin layer of fine cellular tissue appears to connect these 
 membranes to the proper tunic. In the extremities the cellular 
 sheath is removed in dissecting arterial preparations. 
 
 At different periods several anatomists have maintained the ex- 
 istence of longitudinal fibres in arterial tissue ; and even at the pre- 
 sent day this notion is not entirely abandoned. Morgagni was the 
 first who, trusting to mere observation, the only sure guide in ana- 
 tomical science, doubted the existence of these fibres, and was not 
 ashamed to say he was unable to perceive them.* Upon the same 
 ground Haller would not admit their existence ;f and Bichat and 
 Meckel positively deny them. I have repeatedly examined almost 
 every considerable artery of the human body, and I have never 
 been able to recognize any longitudinal fibres either in the middle 
 or proper coat, or in the thin internal membrane, as taught by 
 Willis, Douglas, and De La Sone. 
 
 Though arterial tissue does not appear to be very vascular, it is 
 furnished with arteries and veins {yasa vasormn ; arterioles arteria- 
 rum,) which do not come from the artery or vein itself, hut from the 
 neighbouring vessels.^ Thus the aorta at its origin is supplied with 
 minute arteries from the right and left coronary, and in some in- 
 stances with a proper vessel adjoining to the orifice of the right co- 
 ronary artery, which Haller regards as a third coronary. The rest 
 of the thoracic aorta derives its vessels from the upper bronchials, 
 from twigs of the internal mammary arteries, from the bronchials, 
 from the oesophageals, and from the phrenics. The abdominal por- 
 
 * Adversaria Anatomica, II. 23- 78. 
 
 t “ Verum anatome et microscopium omnino fibres longitudinem seqiientes num- 
 quam demonstravit, aut mihi, aut aliis, ante me, scriptoribus, quorum auctoritate 
 meam tueor.” — Elementa, Lib. ii. sect. 1, sect. 7. 
 
 + Hunter, IV. p. 131. 
 
 3 
 
AliTERY, ARTERIAL TISSUE. 
 
 81 
 
 tion is supplied from the spermatics, the lumbar, and in some in- 
 stances the mesocolic artery. The same arrangement nearly is 
 observed with regard to the veins. 
 
 Few textures are more liberally supplied with nerves than arte- 
 ries are. Almost every considerable trunk or vessel is surrounded 
 with numerous plexiform filaments of nerves, many of which may 
 be traced into the tissue of the artery. The anterior part of the 
 arch of the aorta is abundantly supplied with branches from the 
 superficial cardiac nerves, which Haller was unable to trace beyond 
 the artery. The coeliac, the mesenteric, and the mesocolic arteries 
 are invested with numerous plexiform nervous filaments derived 
 from the large semilunar ganglion of the splanchnic nerve. The 
 renal arteries in like manner are surrounded with numerous twigs 
 of the renal plexus. And each of the intercostal arteries at its 
 origin receives nervous threads from the intercostal nerves. In the 
 face the branches of the fifth pair may often be traced enveloping 
 the arteries. This arrangement, which is observed chiefly in the 
 blood-vessels going to the internal organs, led Bichat to announce 
 it as a general fact, that the arteries derived their nerves almost 
 exclusively from the ganglions, and the gangliar nerves.* The 
 inference does not rest upon strict observation, and evidently owes 
 its birth to the hypothetical opinions of this ingenious physiologist. 
 All the arteries going to the extremities, the axillary, and iliac, and 
 their branches, receive nerves from the neighbouring nervous 
 trunks, which are formed chiefly from cerebral or spinal nerves, 
 and have no immediate connection with the system of the ganglions. 
 In the internal carotid and the vertebral arteries, and their branches, 
 nerves cannot be distinctly traced.f 
 
 Organized in the manner now described, it is requisite to take a 
 short view of the anatomical connections of the arterial system, or 
 to consider it in its origin, its course, and its termination. 
 
 The arterial system of the animal body may be viewed as one 
 large trunk divided into several branches, which again are subdi- 
 vided and ramified to a degree of minuteness which exceeds all 
 calculation. It is requisite, therefore, to consider the origin, Is^, Of 
 the aorta, the large trunk ; 2d, Of the branches wliich arise from 
 it ; and, Zdly, Of the small vessels into which these are divided. 
 
 * “ Le grand arbre a sang rouge ou I’arteriel, est presque exclusivement embrasse 
 par la premiere classe des nerves.” — Anatomie General, Tom. I. p. 302. 
 
 ■f H. A. WrisbergDe Nervis Arterias Venasque comitantibus, Tome III. 
 
 F 
 
82 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Every one knows that the aorta is connected at its origin with 
 the upper and anterior part of the left ventricle. The manner of 
 this connection has been well examined by Lancisi, by Ludwig, and 
 particularly by Bichat. It may be demonstrated by dissection, but 
 is much more distinctly shown by boiling the heart with the blood- 
 vessels attached. In a heart so treated the thin internal membrane 
 may he traced passing from the interior of the ventricle along the 
 margin of its orifice to the inside of the arterial tube. Exactly at 
 the point of union it is doubled into three semicircular folds, form- 
 ing semilunar valves, and thence is continued along the whole 
 course of the artery. This membrane is entirely distinct from the 
 proper or fibrous coat. Of the latter, the cardiac extremity or be- 
 ginning is notched into three semicircular sections, each of which 
 corresponds to the base or attached margin of a semilunar valve. 
 These sections are attached to the aortic orifice of the ventricle by 
 delicate filamentous tissue, but are not connected with the fleshy 
 fibres of the heart ; and at the angle or point of attachment, the 
 thin inner membrane is folded in so as to fill up a space or interval 
 which is left between the margin of the orifice and the circumfe- 
 rence of the proper arterial tissue, where it is notched or trisected. 
 
 The aorta is soon divided into branches, which again are subdi- 
 vided into small vessels. With the mathematical physiologists, it 
 was a favourite problem to ascertain the number of branches into 
 which any vessel might be subdivided. Keill made them from 
 forty to fifty. Haller states, that, counting the minutest ramifica- 
 tions, he has found scarcely twenty. The inquiry is vain and use- 
 less, and cannot be subjected to accurate calculation. In no two 
 subjects is the same artery found to be subdivided the same number 
 of times, and in no two subjects are the very same branches found 
 to arise from the same trunk. 
 
 A branch issuing from a trunk generally forms with it a particu- 
 lar angle. Most generally, perhaps, these angles are acute ; but 
 in particular situations they approach nearly to a right angle. 
 Thus the innominata, left carotid, and left subclavian, issue from 
 the arch of the aorta nearly at a right angle, at least to the tangent 
 of the arch. The intercostals form a right angle with the thoracic 
 aorta ; the renal and lumbar arteries form a large acute angle, 
 approaching to right with the abdominal ; and the coeliac comes 
 off nearly in the same manner from the anterior part of the vessel. 
 The internal and external carotids, again, the external and inter- 
 
AETEKY, ARTERIAL TISSUE. 
 
 83 
 
 nal iliacs, the branches of the humeral, and those of the femoral, 
 form angles more or less acute with each other. The angle which 
 the spermatics make is, generally speaking, the most acute in the 
 arterial system. 
 
 It is convenient to distinguish the branches and divisions of the 
 arterial system into different classes or orders, according to their 
 size and their proximity to, or distance from, the heart. Though 
 the arterial system may be considered as one single artery divided 
 and subdivided into a multiplicity of branches and twigs, yet in re- 
 ference to the communications between the latter, they may be dis- 
 tinguished into the following orders. 
 
 First order, the aorta and innominata ; the second order, the 
 common carotid arteries, the subclavian arteries, and the common 
 iliac arteries ; the third order, the external and internal carotid 
 arteries, the axillary arteries, the external and internal iliac arte- 
 ries ; the fourth order, the brachial arteries, the femoral arteries, 
 and the sacromedian arteries ; the branches of the subclavian and ax- 
 illary trunks, as the vertebrals, transverse cervicals, scapular arte- 
 ries, the pelvic and other branches of the posterior and anterior 
 iliac arteries ; the fifth order, the superficial and deep brachial ar- 
 teries, the radial and ulnar, the superficial and deep femoral arte- 
 ries, the popliteal, the anterior tibial, and posterior tibial, and the 
 peroneal arteries ; and the sixth order, all other small vessels be- 
 neath the size and capacity of those already specified. 
 
 This division is useful in reference to the phenomena of obstruc- 
 tion of arteries, and the means and channels by which the incon- 
 veniences of obstruction are compensated. It will be seen after- 
 wards that obliteration or contraction of vessels of the fourth, fifth, 
 and sixth orders, and obstruction of their canals, are evils much less 
 serious and important than contraction or obliteration of vessels of 
 the first, second, and third orders. In short, the functions of ar- 
 teries in the first, second, and third orders of vessels are in this re- 
 spect more necessary and indispensable than in the three last or- 
 ders of vessels. Hemorrhage, also, from the first two or three or- 
 ders of vessels is much more dangerous than from the fourth, and 
 from the fourth than from the fifth or sixth. 
 
 I have already alluded to the structure of the arterial tissue at 
 the divarications. These changes relate both to the inner and to 
 the proper membrane. In the inside of the vessel, the inner mem- 
 
84 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 brane is folded somewhat so as to form a prominent or elevated 
 point, the disposition of which varies according to the angle of di- 
 varication. Is#, When this is rectangular, the prominence of the 
 inner membrane is circular, and is equally distinct all round. 2d, 
 When the angle is obtuse, as in the mesenteric artery, the promi- 
 nence is distinct, and resembles a semicircular ridge, between the 
 continuation of the trunk and the branch given off, but indistinct 
 on the opposite side where the angle is obtuse. 3c?, If the angle 
 is acute, and that formed by the branch with the continuation of 
 the trunk is obtuse, the beginning of the artery presents an oblique 
 circle, the elevated half of which is near the heart, the other more 
 remote. 
 
 The arrangement of the fibres of the jjroper tissue is described 
 by Ludwig from the divarication of the iliac arteries, and may be 
 seen in any part of the arterial system where the vessels are large. 
 The circular fibres separating form on each side a half ring, from 
 which is produced a complete ring which incloses the smaller rings 
 formed by the circular fibres of the vessel given off. These cir- 
 cular fibres proceed to the prominence of the internal membrane 
 already described, and are arranged round it much in the same 
 manner, in which those of the large vessels surround its inner mem- 
 brane. In this, however, no continuity between the rings of the 
 large vessel and those of the small one can be recognized. The 
 latter are inserted as it were into the former, and they are con- 
 nected by the continuity of the inner membrane only. 
 
 In observing the course or transit of arterial tubes, the principal 
 point deserving notice is the sheltered situation which they gene- 
 rally occupy, their tortuous course, and their mutual communica- 
 tions. In the extremities they are always found towards the inte- 
 rior or least exposed part of the limb, generally deep between 
 muscles, and sometimes lying along bones. When they are mi- 
 nutely subdivided, they enter into the interior of organs, without, 
 however, sinking at once into their intimate substance. In the 
 muscles, they are lodged between the fibres ; in the brain, in the 
 convolutions ; in glands, between their component lobes. In such 
 situations they are generally observed to be more or less tortuous 
 in the course which they follow. On the reasons of this, much dif- 
 ference of opinion still prevails. (Bichat and Magendie.) 
 
 In the course of the arteries, no circumstance is of greater mo- 
 
 4 
 
AETERY, ARTERIAL TISSUE. 
 
 85 
 
 ment than their mutual communications or inosculations, (anasto- 
 moses.) Of this there may be two forms ; the first when two equal 
 trunks unite, the second when a large vessel unites with a smaller 
 one. Of the first, three varieties have been mentioned. Is^, Two 
 equal trunks may unite at an acute angle to form one vessel. 
 Thus, in the foetus, the ductus arteriosus and the aorta are con- 
 joined; and tbe two vertebral arteries unite to form the basilar 
 trunk. 2d, Two trunks may communicate by a transverse branch, 
 as the two anterior cerebral arteries do in forming the anterior 
 segment of the circle of Willis. 3d, Two trunks may, by mutual 
 union, form an arcb, from the convexity of which the minute ves- 
 sels arise, as is seen in the branches of the mesenteric arteries. 
 
 The second mode of inosculation is frequent in the extremities, 
 especially round the joints. The multiplied communications of the 
 arterial system in these regions, though well known to anatomists, 
 and enumerated by Haller, were first clearly and systematically 
 explained by Scarpa, and afterwards by Cooper and Hodgson. 
 The importance of this arrangement in facilitating the motions of 
 the circulation, in obviating the eflfects of local impediment in any 
 vessel or set of vessels, and in enabling the surgeon to tie an arte- 
 rial trunk when wounded, affected with aneurism or any other dis- 
 ease, has been clearly established by these authors. Their re- 
 searches have shown that there is not a single vessel which may 
 not be tied with full confidence in the powers of the collateral circu- 
 lation. Even the aorta has been found contracted or obliterated, 
 and its channel obstructed in the human subject in twelve instances, 
 (Paris,* * * § ) (Graham,t)(Winstone,J)(Otto,§) (Meckel,||) (Reynaud,^) 
 
 * Retrecissement considerable de I’Aorte Pectorale, observe a I’Hotel Dieu de Pa- 
 ris. Journal de Chirurgie. Par Desault. Tome II. p. 107. Paris, 1791. 
 
 •f- Case of Obstructed Aorta. By Robert Graham, M. D., Medico-Chirurgical Trans- 
 actions, Vol. V. p. 287. London, 1814. 
 
 X Surgical Essays. By Astley Cooper, F. R. S., and Benjamin Travers, F. R. S. 
 Part 1. p. 115. Third Edition. London, 1818. 
 
 § Neue Seltene Beobachtungen zur Anatomie, Physiologie und Pathologic gehorig. 
 Von Adolph Wilhelm Otto. Berlin, 1824. 4to. Dritter Abshnitt, C. XXIX. Seite 66. 
 
 II Verschhessung der Aorta am Viertel Brustwirbel. Von A. Meckel zu Bern. Ar- 
 chiv fiir Anatomie und Physiologie. Herausgegeben Von Johan Friederich Meckel, 
 
 1827. Leipzig. Seite 345. 
 
 ^ Observation dUne Obliteration presque complete de PAorte, &c. Par M. Rey- 
 naud. Journal Hebdomadaire de Medecine, Tome Premier, 1828. P. 161. Paris 
 
 1828. 
 
86 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 (Jordan,* * * § ) (Le Grand, f) (Nixon, J) (Craigie,§) (Eichler and Ro- 
 mer, || ) (Tiedemann,^) ; and a ligature has been put on its abdominal 
 portion, (Cooper.) 
 
 To ascertain the several modes in which arteries terminate has 
 been a problem of much interest to the physiologist, and of no 
 small difficulty to the anatomist. The alleged terminations as be- 
 lieved to be established, are minutely and elaborately enumerated 
 by Haller, who, however, multiplied them too much according to 
 the modern acceptation of the term. 
 
 1. The first undoubted termination of arteries is immediately in 
 veins. It is unnecessary to adduce in support of this fact the long 
 list of observers enumerated by Haller. It is sufficient to say that 
 it was clearly established by the microscopical observations of Leu- 
 wenhoeck, Cowper, and Baker, by Haller himself, and by Spal- 
 lanzani in his beautiful experiments on the circulation of the blood. 
 
 2. The second termination which may he mentioned here is that 
 into the colourless artery, {arteria non rubra.) This is sufficiently 
 well established by the phenomena of injections. 
 
 3. A third termination which is supposed to exist, but of which 
 no sensible proofs can be given, is that into colourless vessels sup- 
 posed to open by minute orifices on various membranous surfaces, 
 and therefore termed exhalants. The nature of these vessels shall 
 he considered afterwards. 
 
 Haller admits a termination in, or communication with lympha- 
 tic vessels, hut allows that it is highly problematical. Partial com- 
 munications have been traced between arteries and lymphatics by 
 several anatomists ; but the point requires to be again submitted 
 to accurate researches. 
 
 * A Case of Obliteration of the Aorta. By Joseph Jordan, Esq., Surgeon to the 
 Lock Hospital, Manchester. The North of England Medical and Surgical Journal, 
 Vol. I. London, 1830-31. P. 101. 
 
 t Du Retrecissement de 1’ Aorta : Du Diagnostic et du Traitement de cette Ma- 
 ladie, &c. Par le Docteur a Le Grand. Paris, 1832. 8vo. Pp. 58. 
 
 $ Case of Constriction of the Aorta, with Disease of its Valves, &c. By R. L. 
 Nixon, Surgeon. Dublin Medical Journal, Vol. V. p. 386. Dublin, 1834. 
 
 § Instance of Obliteration of the Aorta beyond the Arch, illustrated by similar 
 Cases and Observations. By David Craigie, M. D., Physician to the Royal Infirmaiy. 
 Edinburgh Medical and Surgical Journal, Vol. LVl. p. 427. 
 
 II Eichler und Romer in Medicinische lahrbucher des Osterreichischen Staats, 1830. 
 B. XXIX. N. 2, S. 200. 
 
 ^ Friedrich Tiedemann, Von der Verengung und Schliessung der Pulsadern in 
 Krankheiten. Heidelberg, und Leipzig, 1843. Fall 9. 
 
 3 
 
AETERY, .ARTERIAL TISSUE. 
 
 87 
 
 Another mode of termination, that, namely, into excreting ducts, 
 admitted by Haller, scarcely requires particular mention. So far 
 as an artery can be said to terminate in such a manner, it would 
 come under the head of that into exhalant vessels. Many of the 
 proofs mentioned by Haller, however, may he shown to be exam- 
 ples of a morbid state of the mucous membranes of these ducts, in 
 which their capillai'y vessels are disorganized. 
 
 In considering the several terminations of arteries, it is not un- 
 important to advert to the distribution of these vessels. Injections 
 show that they penetrate into every texture and organ of the ani- 
 mal body, excepting one or two substances in which they have 
 never yet been traced. But in different textures they are found 
 in different degrees ; and they may vary in extent even in the same 
 texture in two different conditions. The parts which receive the 
 largest and most numerous vascular ramifications are the brain and 
 spinal chord, the glandular organs, the muscles, voluntary and in- 
 voluntary, the mucous membranes, and the skin. In the fibrous 
 membranes, and their modifications, tendons, and ligaments, and 
 in the serous membranes few arteries are seen to penetrate ; and 
 these are generally minute, sometimes only colourless capillaries. 
 Bones hold in this respect an intermediate position, being well sup- 
 plied with blood-vessels, especially in early life, though to less ex- 
 tent than the muscles, and in greater proportion than the fibrous 
 tissues. In some textm-es arteries cannot be traced, though their 
 properties indicate that they must receive vessels of some kind. 
 Such are cartilage and the arachnoid membrane. (Ruysch and 
 Haller.) Lastly, arteries are not found in the scarf-skin, in nails, 
 the enamel of the teeth, the hair, nor in the membranes of the um- 
 bilical chord. In early life bones are much more vascular than in 
 adult age; and in the bones of young subjects arteries maybe 
 traced going out through the epiphyses into the cartilages, in which 
 they cannot at a later period of life be demonstrated.* 
 
 Section II. 
 
 The morbid states of arteries belong either to the inner mem- 
 brane, or to the proper arterial tissue, or to both. 
 
 1. Adhesive Inflammation, Arteritis. Acute, limited. The 
 inner membrane is liable to inflammation, terminating generally in 
 effusion of lymph, adhesion of the sides, and obliteration of the 
 
 * Huuter in Philosophical Transactions, No. 470. 
 
88 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 canal of the tube. This process takes place in all circumstances in 
 which the corresponding surfaces of the vessel are mutually applied, 
 while the current of blood through the vessel is interrupted. The 
 pressure of a tourniquet, or any mechanical object moderately firm ; 
 the pressure of a tumour, or of an aneurism in some instances ; the 
 application of a ligature not so tight as to divide the coats ; and in 
 the case of small vessels, the spontaneous retraction and collapse 
 of its sides after complete division by a cutting instrument, are 
 conditions which have been followed by adhesion and obliteration 
 of the canal. On the knovdedge of this property depends the 
 practice of tying arterial tubes in wounds, and in the cure of aneu- 
 rism. 
 
 Inflammation of the internal arterial membrane may also take 
 place spontaneously, or independent of mechanical causes. Thus 
 the inner membrane of the aorta may be inflamed in persons labour- 
 ing under general or severe inflammation of the thoracic viscera. 
 (Portal, Hodgson.) The anatomical characters are deep red colour 
 of the membrane, and more or less effusion of lymph within the 
 cavity of the vessel. 
 
 If the individual survives such a disease, the lymph thus effused 
 becomes penetrated with blood-vessels, and forms a new body ad- 
 hering to the inner surface of the vessel. This is the origin of 
 several of the granulated bodies, fungous growths, or vegetations, 
 which have been described by Senac, Morgagni, Portal, Baillie, 
 Corvisart, Burns, and Bertin, as often found at the origin of the 
 aorta, attached to the semilunar valves, or even on the mitral valve, 
 the structure of which is not dissimilar. 
 
 A red or crimson staining of the inner membrane, especially in 
 the aorta, has been mentioned by Corvisart, Frank, Hodgson, and 
 Laennec, and may be often seen in persons who have died without 
 symptoms of pectoral or arterial disorder. Its nature is not well 
 known. It seems to be the effect of a dyeing or tinging property 
 of the blood, either during the last moments of life, or after the 
 heart has ceased to heat. It must not be confounded with inflam- 
 mation or its effects. 
 
 2. Arteritis Diffusa. It has been believed that an extended or 
 diffuse attack of inflammation might take place over several divisions 
 of the arterial system simultaneously and successively ; and the ex- 
 istence of such a disease has been maintained by Beil, and the two 
 Franks. The only unequivocal facts in proof of such a disease, 
 however, have been given by Tliomson and Meli. In the case oh- 
 
ARTERY, ARTERIAL TISSUE. 
 
 89 
 
 served by the former, the inflammatory attack which appeared suc- 
 cessively in the femoral and humeral arteries appears to have been 
 the consequence of previous chronic inflammation of these vessels ; 
 and consequently the case is not a pure example of idiopathic acute 
 arteritis. In the case given by Meli, there is no reason to believe 
 that the acute attack was preceded by chronic disease of the arteries ; 
 and that probably is the least objectionable example of the disease. 
 The symptoms during life were pain along the course of the large 
 vessels ; violent throbbing and beating in all the arteries of the ex- 
 tremities which were felt like tense chords ; much heat ; great and 
 intense fever, thirst, restlessness ; and finally delirium and death. 
 The arteries were found covered with lymph outside, thickened, 
 and containing internally clots of blood and lymph ; and the tunics 
 were roughened.* 
 
 Inflammation less extensive but not less intense takes place in 
 arteries about to be, or already affected wdth aneurism. In almost 
 all cases of aneurism the arterial tunics are previously in a state of 
 inflammation. The tunics are reddened and softened, though la- 
 cerable ; sometimes ulceration takes place in various points ; clots 
 of blood and lymph are deposited ; and pain is felt in the site and 
 along the course of the artery. When aneurismal enlargement 
 has actually taken place, it is attended with manifest tokens of the 
 presence of inflammation. Pain, generally severe and lasting, is 
 felt along the course of the vessel and on the seat of the aneurismal 
 dilatation. In cases of aneurism of the aorta or innominata, pain 
 is felt proceeding upwards to the neck and head on the left side ; 
 and though much of this is caused by pressure of the tumour on 
 nerves, yet much also is caused by inflammation in the aneurismal 
 tumour, and in the vessel or vessels proceeding from. They are 
 found red, softened, thickened, lined with lymph and clots of blood, 
 and presenting points of ulceration and steatomatous and osseous 
 deposit, the efiects of the chronic inflammation. 
 
 3. Chrordc Inflammation. In persons who have long laboured 
 under the constitutional effects of the syphilitic poison, or who have 
 been repeatedly and permanently under the influence of mercury, 
 especially in cold and variable climates, the arterial tissue is not 
 unfrequently affected by a slow insidious process of inflammation. 
 It is not easy to determine to what extent this may affect the inner 
 membrane exclusively ; for probably both suffer at the same time, 
 and from the same causes : but the effects of the process differ in 
 
 * On Acute Aortitis. By Norman Chevers, M. D. Guy’s Hospital Reports, VoL 
 VI. p. 304. 
 
90 
 
 GENERiVL AND PATHOLOGICAL ANATOMY. 
 
 tlie two tissues. In the inner membrane chronic inflammation may 
 cause partial effusion of lymph, which becoming organized gives 
 rise, as already mentioned, to the production of fungous growths 
 and vegetations. It may render the membrane opaque and thick, 
 and give it a shrivelled puckered appearance. It may cause a tu- 
 bercular thickening either of the membrane or of the semilunar 
 valves. It may induce gristly induration especially in these and in 
 the mitral valve. Or, lastly, there is reason to believe it is often 
 the agent of the processes next to be considered, — calcareous de- 
 position, steatomatous deposition, and atheromatous deposition. 
 
 When it causes tubercular thickening, the inner surface of the 
 aoi’ta from the semilunar valves upwards along the whole course 
 of the arch is covered with small irregular-shaped orbicular emi- 
 nences, placed at irregular intervals along the course of the cylinder 
 of the artery. From this they extend into the innominata, the left 
 carotid and left subclavian, and often they are found beyond the 
 arch at the origin of the intercostal arteries. 
 
 These bodies, for which their shape and appearance has procured 
 the name of tubercles and warts, I think are merely lymph of a 
 particular kind deposited either by the inner coat, or, as sometimes 
 seems to be the case, by the middle coat, in a state of chronic in- 
 flammation, and assuming the tubercular or verrucose shape, ap- 
 pearance, and disposition. 
 
 The opinion that cartilaginous and osseous induration of the se- 
 milunar and mitral valves depends on chronic inflammation, derives 
 great probability from several circumstances observed in the origin 
 and progress of these changes. In the first place, in the serous 
 membranes the formation of cartilaginous and osseous patches is 
 often preceded by distinct marks of inflammation. Though we 
 cannot prove absolute identity between these textures and the inner 
 cardiac and arterial membrane, yet, as in many of their properties 
 they are very similar, there is reason to believe that in this also 
 they resemble each other. In the second place, after or along 
 with rheumatic attacks, it is not uncommon to observe symptoms of 
 a morbid state in one or both sets of valves ; symptoms of rigidity 
 and immobility ; and symptoms of more or less contraction of the 
 orifices which they form. Thirdly, the presence of more or less 
 disease in the semilunar aortic valves is usually associated with in- 
 dications of the effects of chronic inflammation of the aortic lining 
 membrane ; roughness of its interior caused by tubercular, steato- 
 matous, or atheromatous growths. 
 
ARTERY, ARTERIAL TISSUE. 
 
 91 
 
 It is doubtless true that these chauges in the valves may be re- 
 garded as eflFects and examples of misnutrition, {paratrophiaJ) 
 This, however, would not alter much the essential merits of the 
 question ; for most instances of misnutrition are accompanied with 
 marks of chronic inflammation, and one of the leading characters 
 of chronic inflammation may be said to be the derangement in 
 the nutrition of the parts which it attacks. It must be allowed also 
 that often the changes take place insidiously and in an impercep- 
 tible manner. The most decided evidence, however, as to the 
 cause of these changes being inflammation or not is found in the 
 examination of the changes themselves. 
 
 In the semilunar aortic valves they are as follow. 
 
 1. The valves may be mutually adherent by their edges; that is, 
 two valves may adhere ; or the whole three may be mutually adhe- 
 rent. In other instances two valves only may adhere ; and the 
 coalescence may be so perfect that there shall appear to be only 
 two semilunar valves instead of three. When all the three adhere 
 they produce very great occlusion of the orifice of the aorta. In 
 one case which I knew well, the aperture scarcely admitted a silver 
 catheter of calibre No. 10. 
 
 2. The semilunar valves may be, without mutual accretion, ri- 
 gid, firm, and immovable, or at least not readily movable. This 
 state is manifestly caused partly by deposition on their upper and 
 under surface, partly by thickening of their substance. In general 
 this deposit and thickening is greatest at the attached margin of 
 the valves. They are at the same time shrivelled or drawn irre- 
 gularly fi’om the free margin to the attached. In this state the 
 blood regurgitates from the aorta into the left ventricle. 
 
 3. The whole surface and margins of the valves may be covered 
 by small tubercular bodies, varying in size, like pin-heads, or split 
 vetches, and sometimes irregular on the apices like warts. The 
 valves are thickened and rendered rigid and shrivelled. If these 
 be not the effects of chronic inflammation, they are products of mis- 
 nutrition. They are deposited at first as lymph. 
 
 4. I have seen the following state of the semilunar valves. The 
 whole three valves were thickened, stiffened, and indurated ; and 
 their surfaces were covered with a series or crop of hair -like or 
 bristly processes, growing from tbe attached margin and both sur- 
 faces of the valves, and projecting into the area of the artery, not 
 unlike a hair-like fringe. It seems difficult to understand the for- 
 
92 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 mation of these bodies unless they were from chronic inflammation 
 affecting the valves. The person in whom they were observed died 
 within three hours after his admission to the hospital. He was a 
 stout agricultural labourer, about 47 or 50 years of age. But of 
 his previous state his friends gave no information, except that he 
 had been attacked with difficult breathing and uneasiness in the 
 chest about ten days before he applied for assistance. His pulse 
 was feeble and the surface cold when he was admitted. 
 
 5. The surface or margins of the valves may present globular 
 or spheroidal softish dark-red coloured bodies like the granules of 
 cauliflower adhering to them. These are aggregated in masses, so 
 as to form something like fungous or cauliflower growths. They 
 are friable and easily broken off, and most commonly in handling 
 them, many are removed. These bodies seem to be originally 
 masses either of lymph or fibrin, which thus are either effused by, 
 or adhere to the valves in a state of inflammation. 
 
 4. Ossification, Earthy Degeneration of Scarpa ; Calcareous De- 
 position. It has been long known that arteries are liable to depo- 
 sition of calcareous matter. By De La Sone it was first remarked 
 that this process takes place in the inner membrane only;* and 
 Bichat afterwards referred it to the outer or attached surface of 
 the membrane, an opinion in which he is supported by the testi- 
 mony of Meckel, Scarpa, Hodgson, and others. Scarpa only ad- 
 mits as a possible alternative its deposition in the interval between 
 the inner and proper coat in the delicate tissue termed second cellu- 
 lar by Haller.f By Jourdan and Breschet, however, the transla- 
 tors of the work of Meckel, who contend that the internal mem- 
 brane is never ossified, it is positively stated that the calcareous 
 matter is accumulated in the cellular tissue connecting the inner 
 to the proper coat. It is perhaps of no great moment to dispute 
 this point ; but I shall mention three facts, which show that the 
 statement of MM. Jourdan and Breschet must be admitted with 
 caution. 1st, There is no cellular tissue between the two mem- 
 branes,^ and the inner adheres simply to the proper coat. This 
 is established, notwithstanding the authority of Haller, by dissec- 
 tion, and by observing the effects of maceration and boiling. 
 Calcareous deposition is observed to take place at the semilunar 
 
 * Memoires de I’Academie Royale, 1756, p. 199, 12mo. 
 
 .f* Suir Aneurisma, Capitolo v. § 29. 
 
 “ La surface externe, foiblement unie a I’autre membrane, comme nous I’avons 
 vu, n’a point un intermediare cellulaire.” — Bichat, Tome I. p. 291. 
 
AETERY, ARTERIAL TISSUE. 
 
 93 
 
 valves, which consist of two folds of inner membrane, when it is 
 found in no other part of the aorta. Mly, Admitting, for the sake 
 of argument, that cellular tissue is placed between the inner coat 
 and the proper arterial tissue, if calcareous matter be deposited in 
 it, it is not analogous to what is observed in this tissue elsewhere. 
 Without relying much, however, on these facts, I shall state the 
 ordinary mode in which the deposition appears, independent of any 
 opinion as to its precise source. 
 
 The calcareous incrustation commences invariably at the outer 
 surface of the inner membrane in the form of minute gritty points, 
 or of small isolated patches. In the former state they appear to 
 be hard and crystalline, and render the inside of the vessel rough ; 
 in the latter they are simply firm, and are less earthy or gritty, and 
 without forming asperities in the inside of the vessel, may make it 
 merely firm and unyielding, and deprive it of its elasticity. In 
 either case, these calcareous deposits, confined more or less to one 
 side, may spread along the tube for a considerable extent. They 
 seldom affect the whole circumference of an artery unless in the 
 lower extremities, in which they have been observed to form dis- 
 tinct rings, connected by intermediate portions of sound artery. 
 (Hodgson.) 
 
 When the deposition is partial and limited, and of short duration, 
 it is still covered by the inner membrane ; and the inside of the 
 vessel, though irregular, is comparatively smooth. When the 
 patches multiply and enlarge so as to coalesce, the inner membrane 
 gives way at one or more points of the margin of the calcareous 
 deposite, which now adheres only to the surface of the proper mem- 
 brane ; and an irregular ragged circumference is exposed. If the 
 artery contains many patches, its entire inner surface presents a 
 series of asperities resulting from the rupture of the thin pellicle of 
 inner membrane with which they were at first covered. Yet these 
 calcareous patches are not known to be detached entirely. 
 
 Scarpa represents this morbid change as taking place something 
 difierently. But 1 shall afterwards show that this arises from con- 
 founding the calcareous with the steatomatous deposition, a change 
 different in several respects. 
 
 In many instances of aged persons, the calcareous deposit ap- 
 pears in the form of rings of bony matter, into which the circular 
 fibres of the middle coat are transformed. It often happens that 
 the arteries of the extremities are thus converted into bony tubes. 
 
 This deposition may take place in any part of the arterial sys- 
 
94 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 tem ; and it is said to be equally common in branches as in trunks. 
 It may occur in the radial artery, in the temporal, or in the tibial. 
 By Cowper and Naish it was found in the arteries of the leg in 
 the course of amputation.* I have seen it in the radial and ulnar 
 in tying the vessels of an amputated fore- arm ; and in the femoral 
 and several of the perforating branches of the thigh under the same 
 circumstances. It is, however, most commonly found in the arch of 
 the aorta, or in some of the branches which issue from it. Many 
 cases of its occurrence in the coronary arteries have been recorded. 
 (Crell, Erdmann, Frank, and Parry.) Nor is it confined to the arterial 
 tubes only ; for it is seen in that part of the pellucid arterial membrane 
 which forms the valves, and lines the inside of the left ventricle, and 
 is frequently found to take place in the semilunar and mitral valves. 
 
 The nature of this deposition has given rise to various specula- 
 tions. But this variance has partly arisen from the practice of 
 confounding it with the steatomatous deposition. It is said to dif- 
 fer from osseous matter in two circumstances. First, The deposi- 
 tion is earthy from the first, without any previous matrix of animal 
 matter. Secondly, It is destitute of the usual fibrous structure, 
 and presents an irregular but homogeneous crust without any ob- 
 vious arrangement. It consists, however, of the usual combina- 
 tion of animal matter and bone earth. A specimen analyzed by 
 Mr Brande gave 65’5 parts of phosphate of lime, and 34‘5 of ani- 
 mal matter in the 100 parts. The latter was chiefly albumen, with 
 traces of gelatine. 
 
 Calcareous deposition may take place at any period of life, but 
 is supposed to be most common in advanced age. Portal, Scarpa, 
 and Hodgson, mention instances of its occurrence in young sub- 
 jects. According to Stevens, it is more common to find the arte- 
 ries ossified than healthy after the 30th year.f But this statement 
 is probably delivered in too general terms, and from too limited a 
 collection of cases, Baillie restricts its occurrence as a general 
 pbenomenon to the period after the 60th year and this corre- 
 sponds with the inference of Bichat, who states, that in ten subjects 
 seven at least present these incrustations after the 60th year.§ Its 
 influence on the circulation varies at different periods of life, and 
 according to its extent and situation. In the aged it is said to 
 
 * Philosophical Transactions, No. 285, p. 1391, and No. 369, p. 226. 
 
 t Medico-Chirurgical Transactions, Vol. V. p. 433. 
 
 t Transactions of a Society for the Improvement, &c., Vol. I. jr. 133. 
 
 § Anatomic Generale, Vol. II. p. 292. 
 
ARTERY, ARTERIAL TISSUE. 
 
 95 
 
 produce much less inconvenience than in the young and adult. 
 (Bichat.) It is certain that in the latter it almost invariably causes 
 fatal disease of the heart or arteries, or of both. 
 
 The most ordinary effect of calcareous incrustation, when exten- 
 sive, is to induce chronic inflammation and ulceration of the arterial 
 tissue. The earthy matter operates as a foreign body, and by con- 
 stant irritation destroys the vitality of the inner membrane, which 
 exfoliates, and inflames the proper tissue, which is then eroded. In 
 this state the occasional application of a slight force may be followed 
 by more or less laceration of the proper coat. In arteries covered 
 by a filamentous sheath, the blood thus discharged is injected into 
 the sheath, which is then distended into a spherical sac situate more 
 or less on one side of the vessel. This forms the disease described 
 as true aneurism by Scarpa. In arteries not supplied with fila- 
 mentous sheath, as in the brain, the blood escapes freely, and may 
 by its quantity induce fatal compression of that organ. (Blane, 
 Hodgson, Bouillaud, and Serres.) 
 
 The calcareous deposition renders the arterial tube so brittle, 
 that the application of a ligature invariably cracks it, prevents the 
 usual process of adhesion, and is generally succeeded by ulceration 
 and hemorrhage. In persons advanced in life calcareous deposi- 
 tion in the arteries of the lower extremities is a cause not unfre- 
 quent of mortification of the toes, feet, and legs, generally termi- 
 nating fatally. (Cowper, Naish, and Pott.) 
 
 5. Atheromatous Deposition. This term has been applied to a 
 semifluid or cheesy opaque substance, which is not unfrequently 
 found hetw'een the inner and proper tunics of arteries. Its consis- 
 tence may vary from that of purulent matter to the tenacity of 
 curd, or the granular firmness of cheese. Observed by the first 
 Monro, by Haller, and others, it appears to he considered by Scarpa 
 as a variety of the same change which I am afterwards to mention 
 as steatomatous deposition. From this certain circumstances show 
 that it ought to be distinguished. Is?, Atheromatous deposition 
 appears to arise from a sort of suppuration; for, in genei’al, it is 
 possible to trace the transition from purulent fluid to the concrete 
 matter of atheroma. 2cf, This account of its origin derives strong 
 confirmation from the fact, that it almost always contains a patch 
 or patches of calcareous matter in its centre. Mly, It is associated 
 much more frequently with the calcareous than with the steatoma- 
 tous deposite. It is for these reasons not unlikely that the athero- 
 
96 
 
 GENERAL AND PATHOLOGICAL ANATOMY, 
 
 matous deposition is to be viewed as one of the effects of chronic 
 inflammation, either in the inner or the proper tunic, or in both. 
 
 6. Steatomatous Deposition^ either alone, or with calcareous patch- 
 es, is often found between the inner surface of the proper membrane, 
 and the outer surface of the internal one. Whether these depo- 
 sits invariably derive their origin from the former or from the lat- 
 ter of these tissues, is not easy to say. In many instances they ap- 
 pear to be produced rather by the proper arterial tunic. They 
 occur in various forms ; but two may be particularly mentioned. 
 
 In the first, small irregular patches of yellowish or fawn-coloured 
 matter like wax appear on the inner surface of the proper coat. As 
 the process of deposition advances, these become thicker and broad- 
 er. They coalesce, and sensibly raise the outer filamentous coat; 
 while, by their prominence interiorly, they diminish the capacity of 
 the arterial tube. At the same time the inner membrane becomes 
 irregular, opaque, and shrivelled ; and the connection with the pro- 
 per tunic being destroyed, it is detached with great facility.* 
 
 This deposition constitutes the steatomatous degeneration of Pro- 
 fessor Scarpa and other authors. The name is not well chosen, 
 for the substance dejjosited is not adipose, but rather like crude 
 bees-wax. It was applied, however, by Stentzel,| the original wri- 
 ter on this subject, and it is unnecessary to change it, when its ex- 
 act import is understood. Though it may occur probably in any 
 part of the arterial tubes, it takes place most frequently at the bi- 
 furcations of the arteries. It invariably commences in this parti- 
 cular spot of the vessel ; and when it occupies any extent of the 
 tube, it will be found to have begun at the bifurcation, and spread 
 thence along the vessel. Thus I have seen this deposition confined 
 to the point common to the common carotid, and its external and 
 internal branches, and this in both sides in the same subject. I 
 have seen it in another person at the same part of the carotids, and 
 at the point common to the internal carotid and the sylvian artery. 
 Lastly, in another instance I have found it affecting at once in the 
 same subject the arch of the aorta, where it gives off the innorninata 
 and left subclavian artery ; the descending aorta, where it gives off 
 the coeliac and superior mesenteric, including the beginning of these 
 vessels ; and the coeliac, when it divides into its gastric, hepatic, 
 and splenic branches. 
 
 * Morgagni Epist. XXIII. Ai-t. iv. vi. XLV. Art. xxiii. &c. 
 
 + Christiani God. Stentzel de Steatomatibus Aortee. Haller Disput. ad Morborum 
 Historiam, &c. Tomo II. p. 527. Art. Lxv. 
 
ARTERY, ARTERIAL TISSUE. 
 
 97 
 
 In describing this morbid state of arteries, Professor Scarpa, T 
 conceive, confounds it with ossification. After noticing the loss of 
 fine polish (Tintima tonaca delV arteria perde per certo tratto siio bel 
 liscio,) which the inner arterial membrane sustains, he represents it 
 as becoming irregular and wrinkled, and successively occupied 
 with yellow spots, which are converted into so many earthy grains 
 or scales, or into steatomatous and caseous concretions. I think 
 they may be justly distinguished, because the calcareous deposite 
 very often exists without the steatomatous; and conversely, the 
 steatomatous may be found without the calcareous deposition. I 
 must not omit to mention, nevertheless, that the circumstance which 
 seems to have led Scarpa to consider these depositions as the same, 
 is, that sometimes in the centre of a steatomatous patch is found a 
 broad scale of hard substance, not so firm as bone, and not so crys- 
 talline or gritty as the genuine calcareous deposition. It is gene- 
 rally so soft as to be flexible, and resembles rather a firm piece of 
 cartilage than true bone. It may be designated as the steatomatous 
 and osteo-steatomatous deposition. 
 
 Scarpa represents the steatomatous state as proceeding invaria- 
 bly to ulceration. This, however, is not a uniform result. A large 
 portion of an artery may be affected with it without suffering the 
 smallest breach of continuity or destruction of tissue. It simply 
 distends the vessel mechanically ; and if unaccompanied with cal- 
 careous deposition, this distension may be considerable without any 
 ulceration or laceration. In this manner probably are produced 
 those simple dilatations of arteries which by many of the French 
 authors are regarded as aneurism. In other instances, more espe- 
 cially when the steatomatous is combined with the calcareous de- 
 position, or when the arterial tunics have been long and much dis- 
 tended, ulceration may take place and terminate in partial or en- 
 tire destruction and rupture of the arterial tunics. In genei’al, 
 this destruction takes place in the transverse direction, (Hodgson,) 
 and the laceration or fissure is therefore across the tube. 
 
 In such circumstances, if the aperture is not large enough to 
 cause fatal hemorrhage, aneurism first by dilatation, and ultimately 
 by rupture, is the consequence. 
 
 Of all these changes or deposits, tubercular, atheromatous, steato- 
 matous, or calcareous, the invariable effect is to render the arterial 
 tunics brittle, to impair their elasticity and contractile power, and to 
 render them less pliant and more easily ruptured. Hence in arteries 
 
 G 
 
98 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 diseased in these modes, as the tunics do not easily become distended, 
 they are liable to give way and burst on any occasion when the blood 
 is either accumulated or delayed within their canals, or when the 
 vessels themselves are exposed to any extraordinary stretching or 
 twisting motion. Sudden or violent motion of any kind, indeed, 
 is liable to produce rupture of arteries diseased and rendered 
 brittle in the manner now specified. 
 
 In short, arteries in this state are liable to inflammation, ulcera- 
 tion, and rupture. 
 
 7. Aneurism. On the nature of the aneurismal tumour some 
 difference of opinion has prevailed. Since it has been the custom 
 to settle points of pathology by reference to dissection, three opi- 
 nions have been successively entertained. First.^ It w’as maintain- 
 ed by Elsnei’, Severinus, Hildanus, Sennert, and others, that 
 aneurism was produced by rupture of the proper coats of the ar- 
 tery. The second opinion, which is that of Fernel, Forestus, 
 Diemerbroek, &c. is, that it consists in uniform dilatation of the 
 arterial tunics. Thirdly, From the cases recorded by I^ancisi, 
 Friend, Guattani, Morgagni, and especially those described by 
 Donald Monro,* it results that aneurism may arise either from 
 rupture or from dilatation of the arterial tissues, or from both causes 
 jointly. 
 
 The first doctrine has been revived and strenuously and ingeni- 
 ously defended by Scarpa, who infers that aneurism never consists 
 in dilatation, but invariably arises from erosion and laceration of 
 the proper coats, and injection of arterial blood into the filamentous 
 or membranous sheath with which the vessel is invested. By Hodg- 
 son, again, this docti’ine has been successfully combated, and the 
 third opinion shown to be most consonant with the process of aneuris- 
 mal disease. The result of his inquiries may be stated in the follow- 
 ing manner. In many aneurisms the first step is destruction 
 
 and partial laceration of the internal and proper coats of the artery ; 
 and when the blood escapes from its cavity it distends the filamen- 
 tous or membranous sheath into a cyst or sac, between which and 
 the tunics it is found in successive layers. 2c?Zy, In several aneu- 
 risms the first step of the process is mere dilatation of the arterial 
 tunics, either partial or general. When this has proceeded to a 
 certain extent, varying in different cases, the arterial tissues give 
 way, and the same process of hemorrhage and coagulation in suc- 
 cessive layers results. 
 
 * Essays and Observations, Phys. and Lit, Vol. III. Art. xii. 
 
ARTERY, ARTERIAL TISSUE. 
 
 99 
 
 It appears, therefore, that in every case of aneurism there is 
 eventually laceration. The only difference is in the mode of ori- 
 gin, which in some is rupture, and in others mere dilatation.* This 
 question M. Breschet investigated anatomico-pathologically in 1832, 
 and drew the following conclusions. 1st, That there exist true 
 aneurisms, that is, aneurisms consisting in dilatation of the ar- 
 terial walls without any apparent lesion, and without any solution 
 of continuity in the membranes of these vessels. 2d, That arteries 
 of all calibres, from the largest to the most capillary, may undergo 
 this dilatation. ?>d, That the arteries of bone are liable to this expan- 
 sion. ‘^th. That these true dilatations may be distinguished as to ex- 
 ternal form, into a. sacciform, b. fusiform, or spindle-shaped, c. 
 cylindroid, and d. cirsoid, or arterial varix ; that there are also 
 mixed aneurisms in which the middle arterial tunic is torn, and 
 in which the inner is proti’uded through it in the form of a hernial 
 tumour, while the external or cellular coat is dilated and forms the 
 exterior covering of the aneurism ; and that this mixed aneurism 
 depends on lesion of the arterial tunics, and may be multiplied, that 
 is, more than one occurring in the same individual.f 
 
 This accords generally with the results obtained by Mr Hodg- 
 son. But it must be observed, that, whatever be the amount of ex- 
 perience in France as to the comparative frequency of trire aneu- 
 rism and mixed aneurism, it is certain that the latter is the form of 
 disease most common in England. It may be said that we see fifty 
 cases of mixed aneurism for one of true aneurism. In short, aneu- 
 rism in England is a disease dependent on previous lesion of the 
 arterial tunics. 
 
 In its final result an aneurismal sac bursts in one of two modes. 
 l.s^, When it bursts into the cavity of any of the serous membranes, 
 as the pleura, pericardium, or peritonaeum, the breach is formed by 
 laceration. 2d, When it bursts through the skin or into cavities 
 lined by a mucous membrane, the breach is the effect of sloughing 
 and ulceration. 
 
 Certain divisions of the arterial system are evidently more liable 
 than others to aneurism ; and in general the comparative liability 
 may be traced to the greater or less susceptibility of disease of the 
 tunics, and the situation of the vessel in being exposed to frequent 
 motion. Hence aneurisms are calms paribus more frequently 
 
 * Hodgson on the Diseases of Arteries and Veins, p. 74. 
 
 f Memoire sur les Aneurismes. Par M. Gilbert Breschet. Memoires de I’Aca- 
 demie Royale de Medecine, Tome troisieme. Paris, 1833. 4to, p. 101. 
 
100 
 
 GENERAL AND PATHOLOGICAL ANATOBIY. 
 
 observed at the flexures of joints than elsewhere. Aneurisms are 
 also more frequent in men than in women. The following table 
 by Mr Hodgson exhibits the comparative frequency of true aneu- 
 risms in different arteries, and in the two sexes, in sixty-three cases 
 in which that gentleman either saw the patients during life, or ex- 
 
 amined the parts after death. 
 
 Males. 
 
 Females. 
 
 Total. 
 
 Of the ascending aorta, the arteria innominata, and the 
 
 
 
 
 arch of the aorta, 
 
 16 
 
 .5 
 
 21 
 
 descending aorta. 
 
 7 
 
 1 
 
 8 
 
 carotid artery .... 
 
 2 
 
 
 2 
 
 subclavian and axillary arteries. 
 
 5 
 
 
 5 
 
 inguinal artery, .... 
 
 12 
 
 
 12 
 
 femoral and popliteal artery, . 
 
 14 
 
 1 
 
 15 
 
 66 
 
 7 
 
 63 
 
 Aneurism in this country is most commonly seen in the arch of 
 the aorta or innominata, or both. In the course of eight years 1 
 have observed nine cases, and dissected eight of these. Only one 
 was in the abdominal aorta, 
 
 8. Cirsoid Aneurism of M. Breschet. Aneurysma Cirsus. An- 
 eurysma Cirsoideum. Varix Arterialis of M. Dupuytren. Arterial 
 Varix. 
 
 The name Cirsoid Aneurism is applied by Breschet to a tumour 
 of an arterial tube or tubes, called by Dupuytren Arterial Varix, 
 because arteries affected by it may be compared to varicose veins. 
 It consists in dilatation of the vessel in a greater or less extent of its 
 course, often through the whole length of the trunk and its princi- 
 pal branches. The vessel at the same time becomes elongated and 
 tortuous, and describes circuits more or less numerous and consi- 
 derable. Sometimes, besides these sudden dilatations of the tube, in 
 some parts are seen nodosities or little circumscribed aneurismal tu- 
 mours, which are true sacciform aneurisms, and occasionally mixed 
 aneurisms. 
 
 Most frequently the parietes of the vessel are thin, soft, and flaccid ; 
 and when divided, they collapse like those of varicose veins ; while in 
 true cylindroid aneurism the parietes are thickened ; and if divided 
 perpendicularly to their axis, the diameter (calibre) of the vessel re- 
 mains open. The artery affected with varix resembles much a varicose 
 vein, and for such it might easily be mistaken if injection or dissec- 
 tion to the principal trunk did not demonstrate the nature of the 
 organ. 
 
 This kind of aneurism has been observed in the arteries of me- 
 
AUTERY, ARTERIAL TISSUE. 
 
 101 
 
 diiim calibre, or those of the fourth and fifth orders, as the iliac, the 
 carotids, the brachial, the femoral, the tibial ; and in vessels still 
 smaller, or those of the sixth order, as the occipital, auricular, radial, 
 ulnar ; in the palmar and plantar arches ; and in the ophthalmic 
 artery. 
 
 Sometimes in arterial varix, amidst a very dilated flexuosity of 
 the artery, we observe a sudden contraction, and for some inches 
 of its length, the vessel preserves its natural volume. 
 
 Arterial varix is distinguished from aneurism by anastomosis, 
 by the irregularity of the dilatations which it presents. 
 
 It is distinguished from venous varix in the living body by the 
 pulsations of the dilated vessels. 
 
 A state quite similar to that of cirsoid aneurism is observed in 
 old varicose aneurism, or aneurism resulting from the simultane- 
 ous lesion of an artery and of a vein in the same point by the same 
 instrument, from the interchange of the blood of the two vessels, 
 but especially from the passage of the venous blood into tlie artery. 
 
 Next to the retardation in the artery of the blood below the 
 wound, the dilatation of the whole of that part of the external sys- 
 tem, the weakening of the pulsations, the diminution of tempera- 
 ture in the parts below the opening of communication between the 
 two orders of vessels, the violet hue of the same parts ; lastly, the 
 less brilliant colour of the blood in the lower end of the artery 
 when it is examined before the application of ligatures, and the 
 entrance of the venous blood into the artery during the diastole of 
 this vessel, are the circumstances which, according to Breschet, 
 leave no doubt on the nature of the disease and its causes, viz. in- 
 terchange of the two kinds of blood. 
 
 This analogical circumstance under the relation of the organic 
 change in the arterial varix and old varicose aneurism, leads na- 
 turally to the idea, that in arterial varix there may be a communi- 
 cation between the two orders of vessels and the passage of a cer- 
 tain quantity of the venous blood into the dilated and varicose ar- 
 tery. A case by Pearson would lead to the same inference. 
 
 9. Wounds and their consequences. An artery may be punctured, 
 perforated, cut longitudinally, divided partially or entirely across, 
 or torn completely asunder. 
 
 In the first three cases the blood which escapes is injected into 
 the filamentous sheath, and coagulating, prevents further effusion 
 from the vessel. In a few hours the edges of the wound inflame, 
 and, pouring out lymph, are united by adhesion. In the case of 
 
102 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 small wounds, especially longitudinal, this union may be effected 
 without obliteration of the canal. But when the wound is large or 
 oblique, if the inflammation is sufficient to effect union and prevent 
 further hemorrhage, so much lymph is effused, that in general, 
 with the pressure and rest requisite, the opposite sides of the vessel 
 adhere, and its canal is for some space obliterated. (Jones, Hodg- 
 son.) 
 
 In most cases, however, of longitudinal or oblique wounds, and 
 in all cases of partial transverse wounds, the process is different. 
 Supposing the external opening to be closed, which it sooner or 
 later is, the blood from the wounded artery is extensively injected 
 into the sheath, where its coagulation prevents as before further 
 effusion. Though inflammation takes place, however, and lymph 
 is effused, it is insufficient to unite permanently the divided edges. 
 Either the wound is never thoroughly united, or at a period after 
 its infliction, varying according to its extent and direction, and ac- 
 cording to the size of the artery and its distance from the heart, its 
 edges are rent asunder by the incessant impulse. (Jones, Hodg- 
 son, Guthrie.) Blood continues from time to time to escape into 
 the sheath, which it distends into a sac, and in which it is deposited 
 in successive layers. In this manner is formed a pulsating tumour, 
 which has been termed false, spurious, or bastard aneurism. (Monro 
 Pi imus.) If the injection is extensive, so as to cause a diffuse 
 swelling, spreading to some distance along the limb, the disease is 
 termed diffuse aneurism. If it is more limited, distends the sheath 
 into a globular sac, and assumes the appearance of the usual aneu- 
 rismal tumour, then it is termed circumscribed aneurism. This is 
 the sort of aneurism which takes place when the brachial artery is 
 opened, instead of the vein at the bend of the arm ; (William Cow- 
 per, Macgill, Monro Primus^ &c.) and it is not uncommon in the 
 temporal artery, when, that vessel has been opened to discharge 
 blood for affections of the head. It may, however, succeed punc- 
 tured wounds, especially sword-thrusts in any part of the body. In 
 short, every cause which partially wounds or injures the side of an 
 artery, as a sharp spicula of bone, may be followed by false aneu- 
 rism. At the bend of the arm it is to be distinguished from aneu- 
 rismal varix and varicose aneurism. 
 
 When an artery is entirely divided across, the result varies ac- 
 cording to the size of the vessel. The moment the division is com- 
 pleted, a copious gush of blood issues from the vessel, the divided 
 
.yjTEKY, AETEEIAL TISSUE. 
 
 103 
 
 portions mutually recede with more or less force, and the walls of 
 the vessel collapse so as to contract its area uniformly from the 
 circumference to the centre. Of the two latter actions the former 
 is limited by the attachment of the proper arterial tissue to the fila- 
 mentous sheath. But notwithstanding this limitation, so forcible is 
 the retraction, as it is termed, that the connecting fibres of the fila- 
 mentous sheath are always rent for some small space from the cut 
 ends of the tube. The annular contraction, or centi’al diminution 
 of the area, is also counteracted by the longitudinal impulse of the 
 blood ; and in large vessels this resistance to the central contrac- 
 tion is so great, that the latter has little or no sensible influence in 
 suppressing hemorrhage. In such circumstances the chief agents 
 of this process are the pressure of coagulated blood etfused into the 
 sheath, {coagulum externum^) and a conical or cylindrical plug of 
 the same material {coagulum internuvi,) within the mouth of the 
 divided vessel.* When by the formation of this double clot a tem- 
 porary check to the transit of blood is given, inflammation and 
 lymphy exudation from the divided edges tend to supply the means 
 of permanent suppression. When this fails false aneurism is the 
 consequence. 
 
 In the case of small vessels the annular contraction bears a larger 
 proportion, cocteris paribus^ to the size of the vessel ; and it exercises 
 a greater influence in arresting the current of blood through the 
 divided orifice. With the pressure of the external and internal 
 clots, and the recession of the divided portions, this annular con- 
 traction is in general amply sufficient to stop permanently the ef- 
 fusion of blood from small vessels. Hence in partial wounds of 
 such vessels as the radial, the ulnar, and the temporal arteries, the 
 entire division of the vessel is often the most effectual means of 
 checking the flow of blood from them. In amputation also, in 
 which the arteries are divided transversely, the smaller vessels may 
 be left untied without danger. 
 
 The principle now laid down Dr L. Koch of Munich has at- 
 tempted to carry to a much greater length. Denying that hemor- 
 rhage, from arteries entirely divided, is suppressed in the manner 
 now mentioned, denying especially the formation of the double clot 
 
 * “ The mouth of the artery being no longer pervious, nor a coUateral branch very 
 near it, the blood just within it is at rest, coagulates, and forms in general a slender 
 conical coagulum, which neither fills up the canal of the artery, nor adheres to its 
 sides, except by a small portion of the circumference of its base, which lies near the 
 extremity of the vessel.”- — Jones on Hemorrhage, Chap. I. sect. iii. p. S3. 
 
104 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 as a uniform result of transverse division, he has recourse to the 
 supposition of a peculiar force and action to account for the cessa- 
 tion of hemorrhage. He denies the necessity of ligature in any 
 case, and proposes to leave large as well as small vessels untied. 
 His arguments are manifestly derived from the phenomena of the 
 division of small arteries only, and cannot therefore be justly ap- 
 plied to large ones. I have already shown, that in the case of the 
 former the annular contraction is the main agent of the cessation 
 of hemorrhage ; and to this, I conceive, corresponds the peculiar 
 force to which Dr Koch ascribes that process.* 
 
 When an artery is lacerated or forcibly rent asunder, the same 
 process of injection, coagulation, retraction, and annular constric- 
 tion take place, but more powerfully and more speedily than in the 
 case of the same artery divided transversely by a cutting instru- 
 ment. The external clot especially is formed very rapidly ; the 
 internal one is large and extensive ; and the annular contraction 
 of the lacerated vessel is much more considerable. (Guthrie and 
 others.) These circumstances afford an explanation of the well- 
 established fact, that any artery, when forcibly rent asunder, bleeds 
 infinitely less than the same vessel completely divided by a trans- 
 verse incision. So uniform is this fact, that arteries of moderate 
 size have been torn by a transverse laceration without effusing 
 more than a few drops of blood. 
 
 10. Aneurismal Varix. It sometimes happens that an artery sub- 
 jacent to, and in immediate contact with a vein, is punctured by the 
 same instrument with which the vein has been perforated, and the 
 wound thus inflicted establishes between the two vessels a commu- 
 nication, tlu’ough which the blood passes from the one to the other. 
 Thus, from want of caution on the part of the operator, it may 
 happen that in venesection at the bend of the arm, the lancet may 
 not only transfix the vein, but wound the subjacent artery. The 
 blood flows from the latter into the former with a peculiar hissing 
 noise, and dilates it into a sack which disappears on pressure, but 
 returns when the pressure is removed. The tumour thus formed, 
 which depends on the wound of the arterial and venous tunic re- 
 maining open while their sides are in contact, was first distinguish- 
 ed as a peculiar affection by William Hunter,| and is known un- 
 der the name of aneurismal varix. It may occur in any part of 
 
 ■* Journal fiir Chinirgie und Augenheilkunde von Graefe und M^altlier, p. 9, t. 560. 
 
 t Aledical Observations and Inquiries, Vol. II. p. 396, 400. 
 
 4 
 
ARTERY, ARTERIAL TISSUE. 
 
 105 
 
 the vascular system in which a vein lies immediately over an arte* 
 rial trunk. In most of the cases hitherto recorded it has continued 
 for years (five. Hunter, Cleghorn ; fourteen, Hunter, Scarpa, 
 Bell ; twenty-five, thirty-five. Bell, Hunter ;) without serious in- 
 convenience. 
 
 1 1 . Varicose aneurism. In the case of an artery lying beneath, but 
 not in immediate contact with a vein, or in the case of the wound 
 being oblique and the puncture of the vein not corresponding to 
 that of the artery, the same accident is followed with another va- 
 riety of tumour. The blood from the arterial tube flows partly into 
 the sheath, which is distended into a sac, and partly into the vein, 
 which is morbidly dilated. The tumour thus resulting, the anato- 
 mical characters of which are a circumscribed aneurism between 
 the artery and vein, and a varicose state of the latter, has been dis- 
 tinguished as varicose aneurism.* 
 
 The filamentous sheath, though not proper to the arterial tissue, 
 performs, nevertheless, an important part in the morbid states of 
 arteries, whether spontaneous or resulting from injuries. It has 
 been already shown what is its influence in the production of ge- 
 nuine aneurism, in the suppression of hemorrhage, and in the for- 
 mation of the several varieties of false or spurious aneurisraal tu- 
 mours. It is liable further to the same forms of inflammatory ac- 
 tion as attack this tissue in other parts of the animal frame. But 
 inflammation here is often attended with the bad efiect of produc- 
 ing ulceration of the middle coat, and laceration succeeded by he- 
 morrhage more or less violent, according to the size of the vessel. 
 This process, which depends on the destruction of the nutrient ves- 
 sels {vasa vasorum) transmitted in the filamentous coat, may suc- 
 ceed any injury inflicted on the neighbouring parts, as contused 
 wounds, burns, phagedenic sores, especially those in lymphatic 
 glands, the application of improper ligatures, especially broad tapes, 
 and the use of foreign bodies as pads, presse-arferes and serre-ar- 
 teres in the neighbourhood of an artery. Removal of the filamen- 
 tous sheath, partly or entirely, is not unfrequently followed with the 
 same effect. This, however, must be understood to apply chiefly 
 to the human subject. In the lower animals the filamentous sheath 
 may be removed without injuring the proper and inner membrane. 
 
 * Paik in Bledical Facts and Observations, Vol. IV. p. Hi. Phvsick in Medical 
 Museum, Philadelphia, Vol. I. p. 65. 
 
106 
 
 GENEKAL AND PATHOLOGICAL ANATOMY. 
 
 (Hunter and Home.)* This shows that in these circumstances its 
 inflammation is not attended with the bad efiects which result in 
 the human subject. 
 
 1 2. Obstruction in the cavity of arteries. Occlusio arteriarum; op- 
 pilatio arteriarum. The deposits and growths already mentioned, 
 whether tubercular or wart-like, or atheromatous, steatomatous, or 
 calcareous, all tend to diminish more or less the calibre of the ar- 
 tery, and to cause more or less obstruction to the motion of the 
 blood. It is true that soon after deposits of any of these growths 
 have taken place, there appears at their site to be a sort of bulging 
 of the arterial tube, or a dilatation general or partial ; and, in point 
 of fact, this often takes place with at the same time a certain degree 
 or dilatation internally. This appears to be the result of the im- 
 pediment which the blood encounters in passing over diseased por- 
 tions of an arterial tube ; for as tbe blood meets greater resistance, 
 it is, especially in the aorta, propelled with greater force ; and in 
 almost the whole of these cases in which the interior of the aorta 
 is thus diseased, the left ventricle of the heart is more or less hy- 
 pertrophied. 
 
 It also happens, however, that these new growths may by their 
 number and size diminish in a greater or less degree the calibre of 
 the arterial cylinder. Thus in the case recorded by Stentzel, the 
 atheromatous or steatomatous tumour had greatly contracted the 
 dimensions of the canal of the aorta. | In a case given by the elder 
 IMeckel, the diameter of the aorta in an aged female was not more 
 than eight lines, from a similar cause.J Sandifort mentions the 
 case of a man in whom a similar deposition in the interior of the 
 aorta had contracted much the calibre of the artery. Stoerck states 
 that in inspecting the body of a female, aged 64, who had long la- 
 boured under diflicult breathing and palpitation of the heart on 
 making any exertion, and who died in syncope, he found the arch 
 of the aorta completely bony, and the tunics thickened, and the 
 canal of the artery so small that it would not admit the little finger. 
 This form of obstruction is generally partial. 
 
 In the progress of those changes which take place in aneurism, 
 the calibre of an artery may be so much contracted, and its interior 
 
 * Transactions of a Society for improving Medical and Chirurgical Knowledge, Vol. 
 I. p. 144. 
 
 t Chris. Gottff. Stentzel de Steatomatibus Aortae. Wittembergse, 1732. 
 
 X Haller, Dissert. Medico-Practice, Tom. ii. 
 
 3 
 
AETERY, ARTERIAL TISSUE. 
 
 107 
 
 so much obstructed, as to impede much the motion of the blood 
 through it. The obstruction is caused not only by atheromatous 
 and steatomatous growths adhering to the artery, but by deposits 
 of blood and lymph or fibrin adhering to the internal surface of the 
 vessel previously diseased, most commonly in a state of ulceration. 
 
 The obstruction may be partial, and confined to one side of the 
 vessel ; or it may be general, extending nearly all round, but not 
 thoroughly closing the canal of the vessel ; or it may be complete, 
 closing altogether the tube and preventing the blood from flowing 
 along it. 
 
 Partial obstruction is mostly seen in large vessels, as the aorta, 
 the innorainata, the thoracic and abdominal aorta, or in the com- 
 mon iliacs, or the common carotid, or the subclavian artery. 
 General obstruction also occurs in these'vessels though more rarely ; 
 and is usually in vessels belonging to the third class, which are of 
 smaller size. Partial and general obstruction mostly takes place 
 either in consequence of steatomatous deposits in the interior of the 
 artery, or the deposition of blood and lymph in the progressive 
 changes which occur in aneurismal tumours, which pressing more 
 or less completely on the part of the artery on which they take 
 place, retard or interrupt the flow of blood through, cause thus the 
 formation of clots, and thereby tend to diminish much the calibre 
 of the arterial cylinder. 
 
 Complete obstruction to the interior of an artery may take place 
 under the same circumstances as partial and general obstruction. 
 That is, the blood and lymph deposited in an aneurismal tumour 
 and within the arterial canal above it, may be so arranged as to 
 compress the vessel and interrupt or obstruct entirely the course of 
 the blood through the artery. Such was the case in the instance 
 recorded by Larcheus, which I have elsewhere described ;* in that 
 published by Dr Crampton, and that by Dr Monro. In cases of 
 this nature, one of two eflects may ensue. First, the artery dis- 
 tended with blood, which is allowed neither to flow through the 
 trunk nor to escape by collateral branches, may burst, and the ac- 
 cident may prove fatal. This is by far the most common termina- 
 tion when the arterial canal is so much obstructed. Thus I have 
 seen the abdominal aorta burst above an aneurismal tumour, and 
 
 * Instance of Obliteration of the Aorta beyond the Arch. Illustrated by similar 
 Cases and Observations. By Dawd Craigie, M. D., &c. Edin. Medical and Surgical 
 Journal, Vol. LVI. p. A27. 
 
108 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the blood escaping tear and dissect away the whole peritoneum 
 from the subjacent muscles. The same appears to have taken place 
 in the case given by Fantoni. Secondly, in consequence of the 
 blood not passing through the arterial tube, the parts to which it 
 is distributed are deprived of their nutrient fluid, and become at 
 first cold, numb, and slightly paralytic ; afterwards they become 
 unusually hot; and gangrenous inflammation is rapidly developed 
 and terminates in mortification. 
 
 A species of complete obstruction liable to take place in arteries 
 previously diseased, especially in the extremities, is that which 
 takes place in cases of gangrene of the toes in the aged, {gancjrcKna 
 senilis,) and which has been described as a form of inflammation of 
 the arteries (^arteritis) by Dupuytren. The interior of the artery 
 is filled with clots of blood, generally Arm and solid, and often ex- 
 tending through the greater part or the whole of the arterial trunk. 
 Thus it may extend through the femoral artery from the ligament 
 of Poupart to the loin, and sometimes the tibial and femoral arte- 
 ries are filled with solid clots of blood of the same kind. The ar- 
 terial tube is generally firm, indurated, penetrated or lined by 
 atheromatous or steatomatous specks or osseous matter, indicating 
 that it has been in a state of chronic inflammation. This disease, 
 therefore, is to be considered rather as an effect of chronic inflamma- 
 tion than acute inflammation. In general the first indications of the 
 formation of coagula, are pains in the limb, numbness, and then the 
 artery is observed to have ceased to beat. This is followed by the 
 usual symptoms of gangrenous inflammation ; — pain, heat, redness, 
 lividity, phlyctaenae or vesications, and death of the limb, followed 
 by general death. In milder cases, one or two toes only, or the 
 foot may be affected, and the limb vt'ith life is saved. 
 
 A species of obstruction apparently complete, though in several 
 instances temporary in duration, I have seen take place in the ar- 
 teries of the extremities. A female, between 20 and 25, labour- 
 ing under rheumatism of the ankles and wrists, with slight indica- 
 tions of affection of the pericardium or endocardium, was suddenly 
 attacked with numbness and loss of power and sensation in the left 
 arm ; and when it was examined no pulsation w’as recognised either 
 in the radial artery or the liumeral, to within two inches of the 
 axilla, or in the ulnar artery. These sensations were attended with 
 weight of the arm and occasional pains, pricking and lancinating. 
 Warmth was applied externally. The symptoms, however, con- 
 
ARTERY, ARTERIAL TISSUE. 
 
 109 
 
 tinued for about eight days, and after that time gradually subsided. 
 Pulsation returned feebly to the radial artery, but not to the hu- 
 meral. The patient after some time recovered, and remained well 
 for years, though with some feebleness and numbness in the left 
 arm. Though I have not the evidence of dissection, therefore, yet 
 I infer that this was obstruction in the humeral artery, probably 
 by slight inflammation taking place in its coats and causing effusion 
 of lymph, and the formation of an obstructing clot of blood. A 
 case very similar, illustrated by inspection of the parts, is given by 
 Dr Graves in the Dublin Hospital Reports, Vol. V. p. 1 ; (case of 
 Patrick Magrath), and one without inspection by Dr Gairdner in 
 the Edinburgh Medico-Chirurgical Transactions, Vol. III. 
 
 Obstruction of arteries may also ensue as the effect of external 
 pressure, as the effect of tumours increasing in size and encroach- 
 ing on the space occupied by the artery. Thus when a small ar- 
 tery, as the temporal, is opened and afterwards subjected to com- 
 pression, in general its interior is obstructed, sometimes adhering 
 and obliterated. Encephaloid tumours of the chest or abdomen 
 compress and obstruct the abdominal aorta ; exostosis of the ver- 
 tebrse compress the thoracic and abdominal aorta and obstruct the 
 interior ; exostoses of the cranium and tumours within the brain 
 have been observed to compress and obstruct the branches of the 
 internal carotid and vertebral arteries ; and I have seen in tumours 
 of the uterus and cancerous swellings the posterior iliac artery and 
 its branches closed and its interior obstructed. 
 
 13. Obliteration. From complete obstruction the transition to 
 obliteration of arteries is easy. The result is the same; but the mode 
 in which it is accomplished is different In obstruction tbe closure 
 or impediment is caused by the presence either of new growths or 
 blood and lymph within the artery and the arterial tunics. In ob- 
 literation the impediment or arctation of the canal is caused not so 
 much by internal growths as by the approximation of the arterial 
 walls, in consequence of external pressure, or some similar agent. 
 Hence the cases of obstruction which I mentioned at the close of the 
 preceding paragraph may be regarded as examples of obliteration. 
 
 Of obliteration of arteries there are several forms and sorts ; 
 and the accident may take place in any artery almost, of any class. 
 It is nevertheless more frequent in vessels of the second, third, and 
 fourth class, for very obvious reasons, than in those of the first class. 
 Arteries become obliterated in consequence of pressure of any kind, 
 the presence of coagula in their interior either in consequence of 
 
110 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 inflammation or similar causes, and in consequence of the applica- 
 tion of ligatures, all arterial canals being obliterated a little above 
 and a little below, sometimes a good space from the point at which 
 the ligature has been applied. 
 
 14. Arctation or Obliteration of the Aorta at the definite point 
 The species of obliteration, or sometimes only of obstruction, 
 which here deserves notice, is one which takes place always at a 
 definite or fixed point in the aorta. This consists in a peculiar 
 arctation or contraction of the aorta, in the arch at its farther end, 
 or rather at that point of the arch which is beyond the origin of 
 the left carotid and left subclavian arteries. Of this species of ob- 
 literation I met with one case in my own sphere of observation : and 
 I have collected from various sources other nine cases ; and since 
 that time three or four more cases have been published, so that 
 thirteen cases altogether have now been recorded and described. 
 In the whole of these cases the arctation or contraction was observed 
 at the point specified, viz. where the ductus arteriosus^ converted 
 into a ligament, joins the aorta. It appears in the form of a deep 
 annular indentation surrounding the entire cylinder of the artery, 
 though sometimes more deep at one side than at another ; and in 
 almost all the cases this indentation is greatest towards the convex 
 side of the vessel, and least towards the concave and the attachment 
 of the ductus arteriosus. In general the arch of the aorta becomes 
 small immediately after giving off the left carotid and left subclavian, 
 and diminishes greatly, though progressively, to the point of oblite- 
 ration. In some cases the aorta at the point of obliteration and for 
 some space around it, is lined or penetrated with osteo-steatoma- 
 tous matter, and is much indurated. (Otto’s Case, Craigie’s Case.) 
 
 When I published the first edition of this work, and when the 
 only known cases were those by M. Paris, Dr Graham, Mr Win- 
 stone, M. Otto, and A. Meckel of Bern, though the phenomena 
 of these cases satisfied me of the peculiar nature of the arctation of 
 the aorta, yet it would have been premature to have drawn from so 
 small a number of facts the conclusions which I have since been 
 enabled to deduce. From comparing the whole ten cases, and 
 considering what I observed in the case dissected by myself, I in- 
 fer that the contraction and obliteration when it takes place, de- 
 pends on the same action which closes the ductus arteriosus being 
 extended into the aorta. It must be remembered that in the foetus 
 the pulmonary artery, consists, as it were, of three branches, one 
 going to the right lung, one to the left, both small, and one to the 
 
ARTERY, ARTERIAL TISSUE. 
 
 Ill 
 
 aorta, the largest and most capacious of the three. Through 
 the two former little or no blood flows ; through the latter a large 
 quantity flows, almost directly from the right ventricle into the ab- 
 dominal aorta, or that portion, of the aorta below the entrance of 
 the ductus arteriosus. At birth and after that event, in consequence 
 of the lungs being developed and subjected to the action of respi- 
 ration, the blood from the right ventricle proceeds along the pul- 
 monary artery and its two divisions, which are now enlarged and 
 daily enlarging, while the third branch, or ductus arteriosus, under- 
 goes rapid contraction. The point at which the duct joins the aorta is 
 fixed, and keeps the aorta there as it were immovable. Meanwhile 
 the walls of the duct, in consequence of little or no blood passing 
 through them, mutually approximate, and at length adhere, produc- 
 ing obliteration. The same action may extend into the aorta, the 
 more liable to undergo contraction, that at the very time at which 
 the large current of blood is diverted into the two branches of the 
 pulmonary artery, little passing along the ductus arteriosus,Yiit\Q also 
 must flow through this part of the aorta. This action once begun 
 has only to continue. It does not require to be increased. If it 
 continue, while the other parts of the aorta and the arterial system 
 are enlarging, this remains stationary, or in the foetal condition and 
 dimensions. If this only continue, obliteration at that point is the 
 inevitable result. 
 
 Meanwhile the blood is maintaining its old channels which it pre- 
 served previous to birth, and rendering them larger and more 
 suited to the exigencies of extra-uterine life. The superior and in- 
 ferior intercostal arteries, the transverse cervicals, the mammary 
 above ; and below, the epigastric and circumflex arteries of the 
 ilium, with the lumbar arteries, are found very much enlarged, and 
 to have constituted the means of conveying blood from the heart to 
 the inferior portion of the trunk and to the lower extremities. 
 These changes are evidently effected in early life, in short, in in- 
 fancy, and increase with the growth of the individual. 
 
 The facts now detailed contain a remarkable example of a defect 
 or impediment in the arterial system, which might be inferred, from 
 om’ knowledge of that system, to be incompatible with the continu- 
 ance of life and the enjoyment of good health. They also show 
 the remarkable provision by which the pernicious effects of so great 
 a lesion are very nearly, if not completely, obviated and counter- 
 acted. It appears that the lesion has little tendency to abridge the 
 duration of human life; for two persons attained the age of 50 years. 
 
112 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 one of 57, one that of 60, and one the extraordinary length of 90 years. 
 It appears, nevertheless, that all of the subjects of this lesion had been 
 either exposed to cold, or were labouring under the effects of ca- 
 tarrh, attended with symptoms of dyspnoea, constriction in the chest, 
 sometimes pain and anxiety, with palpitation of unusual violence 
 and severity; and amidst attacks of this nature almost all of them ex- 
 pired. This shows what might a priori be expected, that in persons 
 ■with such a defect or lesion, life is held by a precarious and uncer- 
 tain tenure. Among the ten cases recorded by me, in four the 
 immediate cause of death was laceration of the heart or aorta ; an 
 event attributable to the impediment encountered by the blood in 
 passing out of the left ventricle into the aortic arch. 
 
 It is further singular that with so great an impediment to the 
 transit of the circulating fluid, the lower extremities were well 
 nourished : and in several of the cases the persons were strong and 
 robust. 
 
 Arteries may be involved in the diseases of muscles, bones, and 
 other parts, and in the progressive invasion of foreign or new pro- 
 ductions. 
 
 CHAPTER VI. 
 
 VEIN, VENOUS TISSUE, (PAs-vj/. ( Vena — Tissu veneux.) 
 
 Section I. 
 
 The structure of the tubular canals, termed veins, has been 
 much less examined by anatomists than that of the arteries. Some 
 incidental observations in the writings of Willis, Glass, and Clifton 
 Wintringham, comprise all that was published regarding them pre- 
 vious to the short account of Haller. Since that time they have 
 been described with various degrees of minuteness and accuracy by 
 John Hunter, Bichat, Magendie, Gordon, Marx,* and Meckel. 
 In the following account the facts collected by these observers have 
 been compared with the appearance and visible organization pre- 
 sented by veins in different parts of the human body. 
 
 The veins are membranous tubes extending between the right 
 
 * Diatribe Anatomico-pliysiologico de structura atque vita venarum. Carolii-ulias 
 1819. 
 
VEIN, VENOUS TISSUE. 
 
 113 
 
 side or pulmonary division of the heart and the different organs in 
 which their minute branches are ramified. 
 
 Every venous tube greater than one line in diameter consists of 
 three kinds of distinct substance. The outermost is a modification 
 of the filamentous tissue, (membrana cellulosa,^ and though less 
 compact, and less thick than the arterial filamentous envelope, is 
 in every other respect quite similar, and is in general intimately 
 connected with it. The innermost {membrana intima) is a smooth, 
 very thin membrane. Between these is found a tunic somewhat 
 thicker, which is termed the proper venous tissue, {tunica propria 
 vena.') The structure and aspect of this proper membrane shall 
 be first considered. 
 
 1st, When the loose filamentous tissue in which the blood-ves- 
 sels are inclosed, and the more delicate and firm layer immediately 
 contiguous to the veins, are removed, the observer recognises a red 
 or brown- coloured membrane, not thick or strong, but somewhat 
 tough, which is the outer surface of the proper venous tunic. If 
 dissected clean, it is tolerably smooth ; but however much so it can 
 be made, a glass of moderate powers, or even a good eye, will per- 
 ceive numerous filaments adhering to it, which appear to be the 
 residue of the cellular envelope. 
 
 According to Bichat parallel longitudinal fibres, forming a very 
 thin layer, may be distinguished in the larger veins; but he ad- 
 mits, although they are quite real, that they are always difficult to 
 be seen at tbe first glance. In the trunk of the inferior great vein, 
 {vena cava inferior,) they are always seen, he observes, more dis- 
 tinctly than in that of the superior ; and they are always more ob- 
 vious in the divisions of the former than in those of the latter ves- 
 sel, and also in the superficial than in the deep-seated veins. These 
 longitudinal fibres, he asserts, are more distinct in the saphena than 
 in the crural vein, which accompanies the artery. Lastly, he re- 
 marks, these fibres are proportionally more conspicuous in branches 
 than in trunks.* 
 
 Notwithstanding the apparent correctness of this description, 
 Magendie informs us, he has sought in vain for the fibres of the 
 proper venous membrane ; and he remarks, that, though he has 
 observed very numerous filaments interlacing in all directions, yet 
 these assume the longitudinal and parallel appearance only when 
 
 * Anatomie Generale, Tom. I. p. 399. 
 
 H 
 
114 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the tube is folded longitudinally, — a disposition often seen in the 
 larger veins. 
 
 By Meckel, on the contrary, the accuracy of the observation of 
 Bichat is maintained. This anatomist states that he has, by the 
 most minute dissections, assured himself that these fibres are longi- 
 tudinal ; but he admits that they are not uniformly present in all 
 parts of the venous system, and that in degree and abundance they 
 are liable to great variation. He follows Bichat also in represent- 
 ing these fibres as thicker and more distinct in the system of the 
 inferior than in that of the superior cava^ and in the superficial 
 than in the deep veins. 
 
 In the inferior cava of the human subject, certainly filaments or 
 fibres may be recognised. But, instead of being longitudinal, they 
 may be made to assume any direction, according to the manner in 
 which the filamentous tissue is removed. For this reason probably 
 these fibres are to be viewed as part of the filamentous sheath. In 
 the saphena vein of the leg oblique fibres may be seen decussating 
 each other ; but it is doubtful whether these belong to tbe proper 
 venous tissue, or to the filamentous covering. 
 
 I have repeatedly seen and demonstrated the following facts. 
 
 If the vena cava descendens be cut open by a longitudinal inci- 
 sion and washed in pure water, there is seen first the inner mem- 
 brane perfectly smooth, very thin, and semitransparent, so much so, 
 that it cannot be detached from the middle coat, without the risk 
 of bringing some of the latter away. Secondly, longitudinal fibres 
 or lines running along the middle coat in its substance parallel to 
 the axis of the vein. Thirdly, when the cellular coat is detached 
 carefully by the forceps, there is seen a moderately thick membra- 
 nous layer of fawn-colour, presenting longitudinal threads, lines, 
 or fibres. 
 
 The same can be seen, though much less distinctly, in several of 
 the large venous trunks, for instance the iliac and common femo- 
 ral veins. 
 
 The nature of this proper membrane or venous fibre, as it is 
 sometimes named, (Bichat,) is not at all known. Its great exten- 
 sibility, its softness, its want of elasticity in the circular direction, 
 or fragility, its colour and general aspect, distinguish it from the 
 arterial tunic. It possesses some elasticity in the longitudinal di- 
 rection, and is retracted vigorously when stretched. It possesses 
 considerable resistance, or in common language is tough. The 
 
VEIN, VENOUS TISSUE. 
 
 115 
 
 experiments of Clifton Wintringham show that it sustains a con- 
 siderable weight without breaking, and that this toughness is greater 
 in early life, or in the veins of the young subject, than at a later 
 period.* In short, it may be stated as a general fact, that venous 
 tissue, though thinner, possesses greater elasticity and tenacity than 
 arterial tissue. According to the experiments of the same inquirer 
 this property depends on that of the superior density of the venous 
 tissue, the specific gravity of the matter of the vena cava being in- 
 variably greater than that of the aorta in the same subject, both in 
 man and in brute animals. 
 
 From some experiments Magendie is disposed to consider it of a 
 Jibrinous character. But it exhibits in the living body no proof of 
 muscular structure or irritable power. When punctured by a 
 sharp instrument, or exposed to the electric or galvanic action, it 
 undergoes no change or sensible motion. 
 
 This tunic is wanting in those divisions of the venous system 
 termed sinuses, in which its place is supplied by portions of the 
 hard membrane ; (dura meninx.) 
 
 2d, The inner surface of any vein which has been laid open and 
 well washed is found to be smooth, highly polished, and of a bluish 
 or blue-white colour. This is the inner or free surface of the in- 
 ner venous membrane, (membrana intima.) It is exceedingly thin, 
 much more so than the corresponding arterial membrane, much 
 more distensible and less fragile. It bears a very tight ligature 
 without giving way as the arterial does ; but it also sustains con- 
 siderable weight, which shows that it is tough and resisting. This 
 is the membrane termed by Bichat common membrane of dark or 
 nnodena blood. According to the views of this anatomist it forms 
 the inner or free surface not only of all the venous twigs, branches, 
 and trunks composing this system of vessels, but it is extended from 
 the superior and inferior great veins over the inner surface of the 
 right auricle and ventricle, and thence over that of the pulmonary 
 artery and its divisions ; and through this whole tract it is the same 
 in structure and properties. 
 
 This doctrine has not yet been controverted. But perhaps it 
 may be doubted, both with regard to the inner arterial membrane, 
 that the inner tunic of the aorta and of the pulmonary veins is quite 
 the same ; and in regard to this inner venous membrane, whether 
 that of the veins in general is quite the same with that of the pul- 
 
 * Experimental Inquiry on some parts of the Animal Structure. London, 1140, 
 
116 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 raonary artery. The subject demands further research. Mean- 
 while strong confirmation is found in the interesting remark of 
 Bichat, that the osseous or calcareous depositions which are com- 
 mon in various spots of the inner arterial membrane, and especially 
 at the mitral and aortic valves, are never found in the inner venous 
 membrane, or at the tricuspid valve, or in the semilunar valves of 
 the pulmonary artery. Have these depositions been found inside 
 the pulmonary veins, and not inside the pulmonary artery ? This 
 fact is still wanting to complete even their pathological similarity. 
 
 The inner or common venous membrane is, however, the most 
 extensive and the most uniform of all the venous tissues. It is the 
 onl)^ one which is found in the substance of organs, and is present 
 where the cellular and proper membrane are wanting. This is the 
 case not only with venous branches and minute canals as they issue 
 from the substance of muscles, bones, and such organs as the liver, 
 kidneys, spleen, &c. but is also very remarkably observed with re- 
 gard to the venous canals of the brain. I have already noticed 
 the absence of the cellular and proper tissues in these tubes ; and 
 I have now to remark, that the cerebral veins consist solely of the 
 inner membrane, while in the brain or membranes, and when in 
 the sinuses of this inner membrane, placed between folds of the 
 dura mater. When the jugular vein reaches the temporo-occipital 
 sinuosity, it loses its proper membrane, while its common or inner 
 membrane passes into the hollow of the dura mater.^ called 
 and thus forms the venous canal. This fact is readily demonstrat- 
 ed by slitting open either the lateral or the superior longitudinal 
 sinus, when a thin delicate membrane, quite distinct from the fib- 
 rous appearance of the dura mater will be found to line the inte- , 
 rior of these canals. 
 
 The inner surface of many veins presents membranous folds pro- 
 jecting obliquely into the cavity of the vessel. These folds, which, 
 from their mechanical office, have been named valves., (yalvulce^) 
 are parabolic in shape, have two margins, — an attached and free, 
 and two surfaces, a concave turned to the cardiac end of the vein, 
 and a convex turned in the opposite direction. The attached mar- 
 gin is not straight, as may be imagined, but circular, and adheres 
 to the inner surface of the vessel. The free margin resembles in 
 shape an oblong parabola ; and the direction of the valve is such, 
 that a force applied to its convex surface would urge it more closely 
 to the vein, whereas a force applied to the concave surface would 
 
VEIN, VENOUS TISSUE. 
 
 117 
 
 either obliterate the circular area of the vessel, tear the valve from 
 the vein, or otherwise meet with resistance. 
 
 The size of the valves is variable. In some instances they are 
 sufficiently large to fill the canal of the vessel, and in others they 
 are too small to produce this effect. The obliteration of the cir- 
 cular area of the vessel is most perfect when there are two or three 
 at the same point. Bichat ascribed the variable state of this qua- 
 lity to the dilated or contracted condition of the veins at the mo- 
 ment of death. This, however, is denied by Magendie. 
 
 In structure these valvular or parabolic folds are said to consist 
 of a doubling, or two-fold layer of the inner membrane; and with 
 this statement no fact of which we are aware is at variance. A 
 hard prominent line, which generally marks their attachment of 
 the fixed margin to the vein, is asserted by Bichat to consist of the 
 proper venous tissue, the fibres of which, he says, alter their direc- 
 tion for this purpose ; and when the common or inner membrane 
 reaches this line, it doubles or folds itself {elle se replie) to form the 
 valve, which thus consists of two layers of the inner or common 
 membrane. This, however, is denied by Hunter,* who considers 
 them of a tendinous nature, and by Gordon, who made several un- 
 successful attempts to split these two layers.f 
 
 Valves are not uniformly present in all veins. They are found. 
 Is?, In the following branches of the superior great vein ; — the in- 
 ternal jugular, the azygos, the facial veins, those of the arms, &c. 
 2d, In the following branches of the inferior great vein ; the divi- 
 sions of the posterior iliac, of the femoral, tibial, internal and ex- 
 ternal saphena, and in the spermatic veins of the male. 
 
 They are wanting in the trunk of the inferior great vein (cava 
 inferior,) in the renal, mesenteric, and other abdominal veins, in 
 the portal vein, in the cerebral sinuses, in the veins of the brain 
 and spinal chord, in the veins of the heart, of the womb generally, 
 and of the ovaries, and perhaps in all other veins less than a line 
 in diameter.j; In the cerebral sinuses the transverse chords are 
 supposed to supply their place. 
 
 In situation the valves vary considerably. In general they are 
 found in those parts of venous canals at which a small vein opens into 
 a larger. But even from this arrangement there are deviations. 
 The only valve which is definite and invariable in its situation is 
 
 * X. Of Veins, p. 182. 
 
 + Haller, Lib. ii. sect. ii. 
 
 t Anatomy, pp. 66, 67. 
 
118 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the Eustachian, {valvula Eustachiana^ valvula nobilis^') which is al- 
 ways placed at the cardiac end or beginning of the inferior cavuy 
 where that vessel is attached to the sinus of the right auricle. 
 Shaped in general like a crescent, the attached margin of which is 
 the arch of a large circle, and the free that of a small one, it pro- 
 ceeds from the left extremity of the sinus downwards, forwards, 
 and towards the left side, where it is insensibly lost on the mem- 
 brane of the auricular septum. At its lower end it generally 
 covers the orifice of the large coronary vein. This membranous 
 production is always larger, more perfect, and more distinct in the 
 foetus, and in the infant, than in the adult. In the latter it is al- 
 most always reticulated ; and sometimes the only vestige of its ex- 
 istence is a thin chord or two representing its anterior margin. I 
 have seen it reticulated even at the age of sixteen or seventeen, 
 and almost destroyed beyond thirty. Haller was much perplexed 
 to account for the use of this membranous fold.* The conjecture 
 of Bichat, that it is connected with some purpose in the foetal cir- 
 culation, is entitled to regard. 
 
 Dr Gordon has mentioned a third partial substance, which is 
 occasionally found in local patches at various parts of veins. This, 
 which I believe to be accidental, or not connected with healthy 
 structure, is, I suppose, the following. Where the veins unite 
 to form a single trunk at the point of union, there is often seen 
 extending from it into the trunk a reddish coloured matter of 
 a triangular shape with the apex turned toward and into the 
 
 trunk. This seems void 
 j of organization, and it 
 appears to me a deposit 
 from the blood exactly at the point where the current is least forci- 
 ble, upon the same principle as that on which we observe banks of 
 silt, gravel, and sand accumulated under the sterlings of a bridge. 
 
 Besides the cellular or filamentous envelope, veins receive ca- 
 pillary arteries, to which there are corresponding veins. The ar- 
 teries rise from the nearest small ramifying arteries ; and the cor- 
 responding veins do not terminate in the cavity of the vein to 
 which they belong, but pass off from its body, and join some others 
 from different parts; and at last terminate in the common trunk 
 some way higher.f Nervous branches, or rather filaments, are 
 
 * Haller de Valvula Eustacliii. Extat in Disput. Anatomic. Selee. Vol. II. p. 189. 
 + Hunter, X. Of Veins, p. 181. 
 
VEIN, VENOUS TISSUE. 
 
 119 
 
 observed in the pulmonary artery and great veins only. Are they 
 derived from the great sympathetic, as is generally said ? 
 
 In the veins, as in the arteries, the anatomist recognises two 
 extremities, the cardiac or collected, and the organic or the rami- 
 fied. Examined physiologically, however, the terms origin and 
 termination are not of the same import as when applied to the 
 arteries. In reference to the veins, they become convertible terms ; 
 and it is the usage even of writers on anatomy to represent the veins 
 as arising where the arteries terminate, and terminating at the 
 organ from which the latter arise. Tliis distinction must be kept 
 in view in the following observations. 
 
 The cardiac extremity or termination of the veins is so well known 
 as to render any minute explanation unnecessary. 
 
 The organic extremity or origin of the venous system is more 
 obscure and difficult to be understood. It is indeed impossible to 
 trace the origin of the small venous vessels, unless in the manner 
 in which Leuenhoek,* William Cowper,f Henry Baker,! Haller and 
 Spallanzani,§ did in their observations on the transparent parts of 
 animals in general cold-blooded. Erom the experiments of these 
 observers, we know that a very small vessel, evidently tending and 
 conveying blood toioards a larger, connected with a venous branch, 
 may be seen passing directly from a similar small vessel, as evi- 
 dently conveying blood from a larger, which is connected with the 
 arterial system. All that we know from this, however, is, that a 
 vein containing red blood may rise from an artery conveying red 
 blood. This is matter of pure observation, and all beyond is little 
 more than conjectural. 
 
 Haller, indeed, admits origins of veins as manifold as the termi- 
 nations of the arterial system, a view in which he has been followed 
 by almost all subsequent authors ; and Bichat states it as a leading 
 proposition, that the veins arise from the general capillary system. 
 Neither conclusion is founded on strict observation ; and while that 
 of the former physiologist is derived chiefly from uncertain facts 
 
 * Arcana Naturae Detect. Opera Omnia, Tom. II. p. 160, 168. 
 
 ! Philosophical Transactions, No. 280, p. 1179. Cowper saw this communication 
 of arteries and veins not only in cold-blooded animals, as the lizard, tadpole, and fishes, 
 but in the omentum of a young cat and a dog. 
 
 J On Microscopes, and the discoveries made thereby. Two vols. 8vo. London, 
 1785. 
 
 § Experiments on the Circulation of the Blood. By Lazaro Spallanzani. Trans- 
 lated by W. Hall. London, 1801. 
 
120 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 and loose analogies, the statement of the latter is too hypothetical 
 and general to be either entirely true or wholly false. 
 
 Of one fact only are we certain. ■ The blood which is conveyed 
 into the small vessels, and the substance of the tissues and organs, 
 is brought back by the veins. We have seen that the only origin, 
 which is strictly susceptible of demonstration, is that of the red vein 
 from the red artery. The point, then, to be ascertained is, whether 
 colourless veins and absorbent veins arise from the several textures, 
 as colourless and exhalant arteries terminate in them ? The pro- 
 per place for the further examination of this question is the subse- 
 quent chapter. 
 
 I must not omit to mention, nevertheless, that the veins have 
 been shown to be connected at their ramified extremities with the 
 lymphatics. 
 
 When the veins become distinct vessels, branches, and trunks, 
 they become once more objects of sensible examination. In their 
 course or transit from their organic to their cardiac extremities, 
 they present various circumstances which merit attention. 
 
 1. In general, every artery is accompanied by a venous tube, 
 which is divided in the same manner, and furnishes or receives an 
 equal number of branches. Thus the descending aorta is accom- 
 panied by the vena cava inferior ; the common iliac arteries by 
 common iliac veins ; the anterior iliac, femoral, and popliteal, by 
 anterior iliac, femoral, and popliteal veins. These veins are deep- 
 seated, and are generally named the concomitant veins, {pence co- 
 mites vel venae satellites.) In some situations, an artery may be ac- 
 companied, either in its trunk or in its branches, by two veins of 
 equal size. Thus, in general, the brachial artery, and its branches 
 the radial and ulnar, are each accompanied by two veins. The 
 only situations in which the number of veins can be said to be ex- 
 actly equal to that of the arteries, are in the stomach, in the intes- 
 tinal canal, in the spleen, in the kidneys, in the testicles, and in 
 the ovaries. 
 
 2. In the extremities and in the external regions of the trunk 
 we find, in addition to the concomitant veins, an external layer of 
 venous tubes immediately beneath the skin, {vence suiter cutem dis- 
 persce., VYmy.) These subcutaneous or superficial veins do not cor- 
 respond to any artery ; but, as they are chiefly destined to convey 
 the blood from the skin and other superficial parts, they open into 
 
 the deep-seated veins. Thus in the case of the basilic and cepha- 
 
 3 
 
VEIN, VENOUS TISSUE. 
 
 121 
 
 lie, two superficial veins of the arm, the former, after passing the 
 bicipital fascia, forms in the sheath the brachial vein, and becoming 
 the axillary in the axilla, receives the latter vessel. In the same 
 manner, the saphena, (pXs'4/ /scccpaimg, vena manifesta,) the super- 
 ficial vein of the leg, passes through the falciform process of the 
 fascia lata to join the femoral vein. 
 
 From this it results that the venous canals are on the whole 
 more numerous than the arterial. In a few situations only, a single 
 vein corresponds to two arteries, as in the penis, the clitoris, the 
 gall-bladder, and the umbilical chord. Often also in the renal 
 capsules and the kidneys, two or more arteries have only one cor- 
 responding vein. In such circumstances the vein is always large 
 and capacious. 
 
 It has been generally stated that the calibre and area of the ve- 
 nous tubes are much larger than those of the corresponding arte- 
 ries, and, consequently, that the capacity of the venous system is 
 much greater than that of the arterial. I acknowledge that I know 
 not on what exact evidence the former of these propositions, the 
 only one with which the anatomist is concerned, is made to rest. 
 If it be mere inspection in the dead subject, or the efiects of injec- 
 tion, little doubt can be entertained that the alleged greater calibre 
 depends chiefly on the laxity and distensible nature of the venous 
 fibre. The arterial tubes appear small in consequence of the ten- 
 dency which they have to collapse, or annular contraction, when 
 the distending force has ceased to operate. The venous canals ap- 
 pear large by reason of their distension and distensibility during 
 life, from the tendency to accumulation in their branches in most 
 kinds of death, except that by hemorrhage, and from a smaller de- 
 gree of the physical property of shrinking and annular contraction 
 when empty. 
 
 When a vascular sheath is exposed in the human subject, as in 
 the operation for aneurism, or in the lower animals in the way of 
 experiment, the vein, it must be admitted, generally appears larger 
 than the corresponding artery. This, however, is never so consi- 
 derable as it is represented by most authors, and certainly could 
 by no means afibrd grounds for the high estimates which Keill, 
 Turin, and other mathematical physiologists have assigned to the 
 relative capacity of the arteries and veins. It is also to be observed 
 that something of this greater size depends on the increase of dila- 
 tation resulting from removing the pressure of superincumbent 
 
122 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 parts. In young animals, also, the difference between the size of 
 the veins and their corresponding arteries is so trifling as to be 
 scarcely discernible. This would show that something is to be as- 
 cribed to the incessant operation of a dilating force increasing uni- 
 formly with the duration of life. 
 
 Upon the whole, it is chiefly on the ground* of their larger nu- 
 merical arrangement that the veins collectively can be said to be 
 more capacious than the arteries. On this subject some observa- 
 tions of Bichat are entitled to attention.^ 
 
 3. The veins _in general accompany the arteries. The venous 
 trunk placed contiguous to the arterial in the same sheath is di- 
 vided into branches at the same points, and is distributed into the 
 substance of organs much in the same manner. From this ar- 
 rangement, however, certain deviations are observed in particular 
 regions. Thus, in the brain, neither the internal carotid, nor the 
 basilar artery, nor their large branches, are accompanied with 
 veins.] ^The small branches only have corresponding veins, which, 
 as they unite to form large ones, pour their blood into the venous 
 canals termed sinuses, the arrangement of which is unlike any 
 other part of the venous system. In the chest also a different dis- 
 position of the venous from the arterial tubes is observed. The 
 vencB cava, though conveying the blood to the pulmonic division of 
 the heart, as the aorta conveys it from it, do not, however, corre- 
 spond with the latter either in situation or in dependent branches. 
 The azygos and the demiazygos veins in like manner, which re- 
 ceive the intercostal veins, have no concomitant artery, but open 
 into the superior cava, to which it may be viewed as an appendage. 
 Lastly, The portal vein, which is formed of the united trunks of 
 the splenic, superior mesenteric and inferior mesenteric veins, cor- 
 responds to no individual arterial trunk, and forms of itself a pe- 
 culiar arrangement in the venous system. 
 
 Some anatomists have dwelt much on the more superficial and 
 less sheltered situation of the veins than of the arteries. Upon 
 this point no very positive inferences can be established. In the 
 extremities the former are in general most superficial ; but in the 
 interior of the body, especially in the chest, the venous trunks are 
 quite as deep-seated as the arterial. 
 
 The course of the venous canals is in general more rectilineal 
 and less tortuous than that of the arteries. In no part of the ve- 
 * Aiiatomie Generate, Tome I. p. 378. 
 
VEIN, VENOUS TISSUE. 
 
 123 
 
 nous system is such an inflection presented as that which the inter- 
 nal carotid makes in the carotic canal. The general result of this 
 is, that a set of venous tubes is shorter than a corresponding set of 
 arterial ones. The trunks also are less inflected than the branches. 
 
 4. The mutual communications of the venous system, (anasto- 
 moses^ inosculationes,) are more numerous and frequent than those 
 of the arterial. 1. The minute veins communicate so freely as to 
 form a perfect net-work. 2. In the twigs, though more rare, 
 these communications are still frequent. 3. In the branches, 
 though less numerous, they are nevertheless observed ; and in this 
 respect alone the venous must he greatly more numerous than the 
 arterial inosculations, which are confined chiefly to the smaller and 
 more remote parts of the system. These inosculations, indeed, 
 between the venous branches, constitnte one of the most peculiar 
 and important characters of their arrangement, in so far as by their 
 means the communication is maintained between the superficial and 
 deep-seated vessels of the system. Thus the emissary veins are 
 the channel of communication between the cerebral sinuses and 
 the temporal, occipital, and other external veins. The external 
 and internal jugulars communicate by one or two considerable ves- 
 sels. And the free communication between the basilic and cepha- 
 lic by the median veins, that between them and the deep brachial 
 vessel, and that between the saphena and its branches and the fe- 
 moral vein, are sufficiently well known. The application of these 
 anatomical facts to the ready motion of the venous blood is obvious. 
 
 But of all the communications between the branches or large 
 vessels of the venous system, the most important, both anatomical- 
 ly and physiologically, is that maintained by means of the vena 
 azygos between the superior and inferior cava. The azygos itself 
 is connected at its upper or bronchial extremity with the superior 
 caufl, and at its lower extremity it is in some subjects connected 
 directly with the inferior cava., in others by means of thfe right re- 
 nal vein, and in most by the first lumbar veins. By means of the 
 demiazygos., again, it is connected with the left renal vein, or the 
 lumbars of the same side, and in some instances directly with the 
 inferior cava. To the azygos and demiazygos, therefore, belong 
 the remarkable property of connecting not only the venous canals 
 of the upper and lower divisions, hut those of the right and left 
 halves of the body. 
 
124 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Section II. 
 
 Venous tissue is liable to inflammation, adhesive or circum- 
 scribed, and spreading, — generally suppurative, to varix, to osse- 
 ous deposition, and to the formation of concretions. 
 
 1. Inflammation. {^Phlehitis.^ Of circumscribed or adhesive in~ 
 jiammation of veins, a good example is found in the ordinary union 
 after incised wounds, as in venesection. In this case the lips of the 
 wound, if accurately applied to each other, adhere sometimes di- 
 rectly by inosculation, in other instances by eflfusion of lymph, 
 which becomes organized. 
 
 2. Spreading injiammation of venous tissue is a much more se- 
 rious disorder, and appears to belong essentially to the inner ve- 
 nous membrane. Rarely spontaneous, it takes place only after 
 some violence offered to the vein ; but the degrees of this may he 
 so various, and even the kinds so different, that it is impossible to 
 trace much analogy of action between them. Thus it may occur 
 after a simple clean incision, as in blood-letting ; after the appli- 
 cation of a ligature, as occasionally happens in amputation, in the 
 operation for varix, or in the umbilical chord after birth ; or in 
 consequence of pressure, as sometimes happens after the use of a 
 tourniquet. In either case, the inflammatory action originating in 
 one spot of the inner membrane, spreads along its surface, generally 
 towards the heart, more or less rapidly, and with much violence. 
 
 The pathological effects of this process vary according to its se- 
 verity and extent. In general the tissue of the affected vein or 
 veins is swelled, thickened, and indurated to such a degree as make 
 the vessel resemble an artery. Much pain is felt along the course 
 of the inflamed vessel. The whole limb is diffusely swelled ; and 
 the skin is tense, with tenderness of the surface. Upon examina- 
 tion of the parts, it is found that the whole subcutaneous cellular 
 and adipose tissue are filled with serous fluid. The vein is found 
 firm and hard, sometimes filled with bloody clots. When laid open, 
 clots of blood or lymph or both are found adhering to the inner 
 tunic, which is rough and irregular, and thicker than usual. In 
 these clots are contained specks of purulent matter. In other in- 
 stances, the interior is filled with purulent matter, or presents a 
 series of abscesses along the tract of the canal ; and the inner tu- 
 nic is generally removed, the middle one not unfrequently injured 
 by ulceration. This process is always attended with great commo- 
 
VEIN, VENOUS TISSUE. 
 
 125 
 
 tion in the organs of circulation, much general fever, a brownish 
 tint of the complexion, glaring, injected, suffused, or turbid eyes, 
 and more or less affection of the intellectual functions, and if con- 
 siderable, generally proves fatal. 
 
 Inflammation of the inner venous membrane I have represented 
 generally to succeed violence offered to the vessel ; but what sort 
 of violence is requisite is not well known. I have in two or three 
 instances thought I could trace it to wound, laceration, or pressure 
 in the site of a valve ; but in others this could not be established. 
 
 I have seen the disease so often take place after application of 
 the finger to the wound in the vein at the bend of the arm, in the 
 common operation of venesection, that I cannot doubt that it is 
 often produced in this manner. The perspiration on the finger 
 acts like an irritant poison to the cut edges of the vein, and there- 
 by causes inflammation. It was also a very common accident after 
 injecting saline solutions during the epidemic cholera in 1832. In 
 the veins of the womb, after parturition, it may follow the forcible 
 revulsion of the placenta ; or the sinuses being left open and patent, 
 air from the atmosphere, or from the decomposition of the blood, 
 or the uterus, may enter these canals and irritate or inflame their 
 coats. In this organ it is most common along the lateral regions 
 of the womb. 
 
 The circumstances under which phlebitis may take place may be 
 enumerated in the following order. 
 
 Is^, After venesection, especially when the finger is applied to 
 the wound so as to touch the divided edges of the vein ; 2cf, After 
 amputation, especially when there is much fingering, or when a 
 ligature is put on a vein; Zd, After laceration of a vein, as in 
 certain lacerated wounds ; Ath, After any venous tube has been 
 laid open by ulceration or erosion, as in cancer or ulceration of the 
 womb ; 5th, After laying open the uterine veins, as in child-bear- 
 ing ; Qth, After deligation of a vein, as in the operation for varix, 
 the old operation for castration, in which all the vessels were tied 
 in one mass, and after operations on the hemorrhoidal veins. 
 
 This process is known to take place spontaneously in the veins 
 of the brain and in those of the womb. The latter Dr Clarke* and 
 Mr Wilsonf found filled with purulent matter or lymph in the per- 
 sons of females cut off by puerperal fever ; and in a number of fatal 
 cases of the same disease, I saw these veins containing purulent 
 
 * Practical Essays on the Management of Pregnancy, p. 63, 72. 
 
 t Transactions of a Society, Vol. III. p. 63 and p. 80. 
 
126 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 fluid. Tonelle found among 222 cases suppuration of the uterine 
 veins in 90 cases. Dr Lee among 45 cases inspected found traces 
 of inflammation of the uterine veins in 24. Taking both together, 
 we have among 267 cases 114 instances of phlebitis. This 
 
 is not quite one-half; but it is as near as may be three-sevenths. 
 
 The venous tubes of the brain have been found presenting marks 
 of inflammation by Dr Abercromby* and M. Gendrin.f I have 
 found inflammatory products, as lymph and purulent matter with 
 clots of blood, within the sinuses of the brain, in tbe following cir- 
 cumstances. 
 
 1. In certain cases of inflammation of the internal ear and the 
 petrous portion of the temporal bone, when inflammatory action 
 had spread to the internal jugular vein in the temporal ybssa. 
 
 2. In certain cases of gangrenous inflammation of the lungs, 
 when suppuration takes place in the brain ; and when the agents 
 of this process appear to be the venous canals of the lungs opening 
 into the gangrenous or suppurating portion. Thus, in a child of 
 two years, in whom this affection of the lungs had taken place, I 
 found the convolutions of the brain flattened, the longitudinal sinus 
 filled with lymph and purulent particles and clots of blood, and a 
 similar state of the lateral sinuses, and several of the small sinuses. 
 
 3. In cases of hypertrophy of the spleen. This shall be noticed 
 under its proper head. 
 
 It appears, therefore, that inflammation of the inner venous coat 
 rarely terminates in albuminous exudation and adhesion ; and it 
 may be stated as a peculiar character of this tissue, as distinct from 
 the inner arterial membrane, that, while the latter is almost sure to 
 assume the adhesive, the former is exceedingly prone to the suppu- 
 rative form of inflammation. 
 
 3. Instances, nevertheless, have occurred in which inflammation 
 of this membrane was followed by deposition of lymph and union of 
 its free surfaces, producing obliteration of tbe canal of the vessel. 
 Dr Baillie mentions an instance of obliteration of the lower cava, 
 from the emulgent veins to the entrance of the venae cavae hepaticce, 
 which he ascribes to effusion of lymph and consequent adhesion \\ 
 and Mr Wilson records a similar case in which about four ounces 
 of well-formed purulent fluid were found in the vena cava imme- 
 
 * Medical and Surgical Journal, Vol. XVIII. 
 
 •f- Revue Medicale, Avril 1826. 
 
 J Transactions of a Society for the Improvement of Medical and Chirurgical Know- 
 ledge, Vol. I. Art. viii. p. 133. 
 
VEIN, VENOUS TISSUE. 
 
 127 
 
 diately below the liver, and a considerable quantity of coagulated 
 lymph below the entrance of the three large hepatic veins, (vencB 
 cavcB hepaticcB,) which at once united the opposite sides of the ves- 
 sel, and prevented this fluid from proceeding to the heart.* Simi- 
 lar examples of obliteration are recorded by Haller, Morgagni, and 
 by Hodgson,! and Breschet. In the College Museum collection 
 there is a preparation of a case in which the right vena innominnta 
 was filled with a solid plug of fibrin or albuminous matter, in con- 
 sequence of a tyromatous tumour compressing the vessel below, at 
 its junction with the left vena innominata and vena cava, and in 
 which the left innominata was very much contracted at its lower 
 end. The pressure of the tumour in this case had interrupted the 
 current of blood to the heart, and contracted the channel of the 
 vein ; and in consequence blood had been coagulated and attached 
 to the walls of the vessel, and so obstructed the interior of the vein. 
 
 In 1841, a man under my care in the hospital, with obstinate 
 ascites and indications of liver disease, had undergone the operation 
 of paracentesis twice with relief, when no benefit was produced by in- 
 ternal medicines. 
 
 About twelve days after the performance of the second opera- 
 tion, the water was again accumulating, and he died. Upon in- 
 specting the body after death, I found the vena porta in the liver 
 completely obstructed, being contracted and filled with lymph, and 
 the lymph extending into the splenic and mesenteric veins. The 
 lymph was small in quantity, and the trunks of the vessels were 
 evidently diminished in size. The liver was reduced to about one- 
 fourth of its usual size, the whole right lobe almost had become 
 shrunk into a small portion, while the organ was represented by a 
 small left lobe. 
 
 A case of obliteration of the vena cava is recorded by M. Gely 
 in Gazette Medicale, 7th November 1840. 
 
 In other instances, when inflammation in the vein of an extremity 
 takes place, causing permanent obstruction, it produces not only 
 swelling of that extremity, but deposits of lymph in the veins, in 
 the pulmonary artery, and in the vessels of the lungs. Thus I 
 have seen inflammation of the femoral vein with lymphy deposit 
 within the vessel, followed after some time by the deposit of similar 
 lymph and blood in clots in the branches of the pulmonary artery 
 and in various parts of the lungs. 
 
 ■* Transactions, &c. Vol. III. Art. vi. p. 63. 
 
 i" Treatise, p. 10. sect. 3. 
 
128 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 All these phenomena, which may be called the secondary etFects 
 of phlebitis^ arise from the inflammatory deposits, viz. lymph and 
 purulent matter, being taken into the veins and circulated along 
 these vessels ; and sometimes from purulent matter being carried 
 by the veins directly to the pleura, the veins of the lungs, or the 
 synovial membrane, or the cellular membrane. 
 
 4. Purulent matter and lymph may be found within the veins, 
 and prove a cause of death. Thus in a case of hypertrophy of the 
 spleen I found purulent matter and lymph in the sinuses of the 
 brain, and the veins of the chest and abdomen.* In such cases the 
 deposit is not preceded by inflammation. 
 
 It is easy to perceive how the pressure of tumours may cause 
 obliteration of these vessels. When any venous tube, under such 
 circumstances, becomes impervious, the collateral communications 
 afford channels for continuing the motion of the blood. 
 
 5. Secondary effects of Phlebitis. Inflammation of veins, though 
 usually and ordinarily a fatal disease, is neither necessarily so, nor 
 always. But when it has terminated, as it commonly does, in 
 the formation of purulent matter, it occasionally gives rise to 
 a train of very remarkable and dangerous phenomena. This I 
 shall describe in two forms, as it most usually presents itself. 
 
 In the ordinary case of inflammation of the vein taking place 
 after venesection, when the patient survives the immediate eflfects, 
 lymph having been eflfused, and caused obliteration of part of the 
 vessel, purulent matter is effused at the same time ; or rather the 
 effusion is a sort of sero-albuminous matter, the thicker portion of 
 which is the medium of partial and local adhesion, while the more 
 liquid forms purulent fluid. The latter is taken into the circula- 
 tion ; and the original febrile symptoms assume the characters of 
 hectic. Soon after the patient has difficult and laborious breath- 
 ing, with pain in some part of the chest or side, and purulent 
 matter is formed within the pleura. Or another result may ensue. 
 With the symptoms of great disorder in the organs of respiration, 
 as rapid laborious breathing and cough, without expectoration, the 
 symptoms of hectic fever continue ; and after two or three weeks, 
 the patient being much emaciated and feeble, dies. On inspection 
 of the body, the lungs, when divided, present numerous abscesses, 
 
 * Case of Disease of the Spleen, in which death took place in consequence of the 
 presence of purulent matter in the blood. By David Craigie, M. D. &c. Edinburgh 
 Medical and Surgical Journal, Vol. LXIV. p. 400. 
 
VEIN, VENOUS TISSUE. 
 
 129 
 
 not larger than peas. When these are examined, they are found 
 to be not abscesses, but the veins of the lungs filled with purulent 
 matter. The veins of the arm are at the same time thickened in 
 their walls, and contain lymph and purulent matter. These ap- 
 pearances I observed in the body of a young man, on whom vene- 
 section had been performed three weeks previously for the removal 
 of symptoms of peritonitis. Similar phenomena were seen by Vel- 
 peau in a case of amputation. 
 
 In other instances the intermuscular cellular tissue, either of an 
 arm or a leg is attacked ; and purulent collections more or less ex- 
 tensive are deposited in them. At the same time one or more of 
 the joints, as the shoulder -joint or the knee-joint, may be attacked 
 with acute pain, aggravated by motion and pressure, swelling and 
 heat ; and in no long time it is observed that fluid has been form- 
 ed within the joint. This is most commonly purulent, from in- 
 flammation of the synovial membrane. After it has taken place, 
 the synovial membrane is removed by ulceration ; the cai'tilages 
 are partially or entirely destroyed in the same manner ; and either 
 the joint becomes ankylosed by the adhesion of the lymphy effusion, 
 or the patient is destroyed by the long-continued severe irritation 
 on the constitution. 
 
 When the veins of the womb have been the seat of inflammation, 
 if the morbid action do not terminate fatally, it is occasionally fol- 
 lowed by the same train of phenomena as have been now enume- 
 rated ; — purulent deposits within the pleura, purulent deposits in the 
 intermuscular cellular tissue of the extremities, and purulent de- 
 posits within the joints, most usually the knee-joint. The most fa- 
 vourable case is that of purulent deposits among the muscles of the 
 extremities, especially the leg. Yet here, often in the process of 
 healing, adhesions between the muscles take place, and lameness is 
 the result. 
 
 6. Varix. This consists in permanent dilatation of the venous 
 coats beyond their natural capacity. It is in general, if excessive, 
 confined to one spot ; but sometimes a whole vein becomes more 
 or less dilated through its entire course. At the same time it be- 
 comes so tortuous, that this may be received as one of the physical 
 characters of varicose veins. W e possess no very precise facts on 
 the exact change which takes place in the venous tunics, whether 
 it be mere dilatation or injury of some kind, and rupture of the 
 proper venous coats. By Meckel it is regarded as simple dilatation 
 
 I 
 
130 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 without injury of texture. When one part of a vein is dilated into 
 a distinct sac, I believe the inner coat is generally rent. In some 
 cases of varix one or more valves are lacerated, or detached from 
 the inner membrane. In others varix has followed a rent or lace- 
 rated w'ound of the outer venous tunic, or a cutaneous ulcer affect- 
 ing that tunic. 
 
 Varix occurs especially in the veins of the lower extremities, for 
 instance in the trunk or branches of the saphena. It is common in 
 those of the spermatic chord, in which it is distinguished by the 
 name of varico-cele^ and not unfrequent in the veins of the rectum, 
 where it causes one variety of hemorrhoidal tumours. In the up- 
 per extremities it is rare, one case only by Petit being recorded. 
 I have seen, nevertheless, a varicose tumour of the posterior ulnar 
 vein on the back of the hand, which disappeared under the use of 
 pressure, continued for six or seven months. 
 
 Of the internal veins the vena azygos and subclavian have been 
 found varicose. (Morgagni, Portal, Baillie.) When a cluster of 
 subcutaneous veins becomes varicose, they generally give rise to 
 much pain, swelling and redness of the skin, and if not opposed by 
 suitable treatment, may produce cutaneous inflammation terminating 
 in a bad ulcer. ( Ulcus varicosum.) The same process nearly may 
 result from the inflammation round a single varicose trunk. Varix 
 sometimes terminates in laceration or rupture ; and if the vein be 
 large and not covered by the skin, the hemorrhage may be fatal. 
 (Laurentius, Nebel, Bonet.) Varix of the vena azygos terminating 
 in rupture and fatal hemorrhage was seen by Manfredi.* 
 
 Ossification. Calcareous or osseous matter is very rarely depo- 
 sited in venous tissue. Instances of this, however, are recorded, 
 (Morgagni, Baillie, Hodgson. )f 
 
 Loose stony concretions have been found in the cavity of veins, 
 which in such circumstances are generally dilated. These concre- 
 tions do not appear to be formed and deposited in the venous tissue, 
 but, according to Hodgson, are more likely to have been produced 
 outside by some contiguous tissue, and to liave found their way in- 
 to the venous tube by progressive absorption. Is it not possible 
 that they are the result of temporary retardation or stagnation of 
 a portion of blood around which, as a nucleus, calcareous matter 
 had been deposited ? They have not been chemically examined ; 
 but it is said that they have no appearance of any thing osseous. 
 
 * Morgagni, xxvi. 29. -f- Treatise, Part iv. sect. 2. 
 
SYSTEM OF CAPILLARY VESSELS, &C. 
 
 131 
 
 These concretions, which in other respects are very imperfectly 
 known, have been termed veinstones. (Phlebolites.) 
 
 CHAPTER VIL 
 
 SYSTEM OF CAPILLARY VESSELS, — TERMINATIONS OF ARTERIES, — 
 ORIGINS OF VEINS. 
 
 Section I. 
 
 Though we can scarcely, with propriety, speak of the capillary 
 tissue.! tissue of capillary vessels, we find it requisite to intro- 
 
 duce in this place the general facts of the anatomical peculiarities 
 of this important part of the human body. 
 
 The term capillary system, though much spoken of in physiolo- 
 gical and pathological writings, is perhaps not always precisely de- 
 fined or distinctly understood. According to Bichat it is not only 
 the common intermediate system between the arteries and veins, 
 but the origin of all the exhalant and excreting vessels.* If we 
 consider the modes in which arteries have been said to terminate, 
 and veins to take their origin, we shall find, that in this view of the 
 capillary system there are some things which are doubtful, and 
 some which are inconsistent with the rest, 
 
 Haller, and most of the physiological authorities since his time, 
 concluded, chiefly from the phenomena of injections, sometimes 
 from microscopical observation, and where these failed, from the 
 obscure and uncertain evidence of analogy, that an artery traced 
 to its last or minute divisions will be found to terminate in one or 
 other of the following modes. Is^, Either directly in a red vein or 
 veins ; 2d, in excreting ducts, as in the lacrymal and salivary glands, 
 the kidney, liver, and pancreas, the female breast, and the testicle 
 of the male ; 3d, in exhalants, as in the skin, in the membranes of 
 cavities, (serous membranes,) the cavities of the brain, the cham- 
 bers of the eye, the filamentous tissue, the adipose cells, the pulmo- 
 nary vesicles, and mucous surfaces and their follicular glands ; 4?/«, 
 in smaller vessels, for instance lymphatics ; and, 5th, in the colour- 
 less artery ; (arteria non rubra.)] 
 
 * Anat, Gen. Vol. I. p. 471. Systeme Capillaire, Article 1. 
 
 -j- Elementa Physiologise, Lib. i. sect. 1. p. 22-29. 
 
132 
 
 GENEHAL AND PATHOLOGICAL ANATOMY. 
 
 A similar application of the same facts has assigned to the veins 
 a mode of origin not unlike. If, therefore, we admit the definition 
 given by Bichat, it follows that the capillary system consists, Is^, 
 of minute arteries communicating with veins ; 2d, of excreting 
 ducts ; 3(Z, of exhalants ; and, Ath, of minute arteries or veins con- 
 taining a colourless portion of the blood. It is obvious, however, 
 that it is absurd to say that the system of capillary vessels at once 
 comprehends and gives origin to the excretories and exhalants. In 
 other respects the whole of this theory, for little of it is matter of 
 strict observation, rests on very hypothetical grounds. 
 
 Of the different kinds of terminations assigned to arteries, and of 
 origins assigned to veins, one only admits of sensible and satisfac- 
 tory demonstration. Arteries, when they have so much diminished 
 as to become capillary, are seen by the microscope, in some instan- 
 ces by the naked eye, to pass directly into corresponding capillary 
 veins, or to end abruptly in some organ or membrane unconnected 
 with any other vessel.* It is likewise certain that the microscope 
 shows every capillary vein to arise from a capillary artery ; and if 
 there be any other mode of origin, it has not yet been demonstra- 
 ted or established.! Only one other circumstance requires to be 
 taken into account in this inquiry. This is, that the capillary ar- 
 tery and vein may contain either red or colourless blood ; for, ac- 
 cording to the size of the vessels, and the nature of the organs or 
 tissues in which they are distributed, the blood which flows through 
 them will be coloured or colourless. This view of the communi- 
 cation of minute arteries and veins, which is perfectly consistent 
 with the known facts, will afford the only explanation which it is 
 possible to give, of the singular division of the capillary system 
 which Bichat has chosen. 
 
 This author has considered the capillary system under three ge- 
 neral heads. Is^, In organs in which it contains blood only ; for 
 instance, in the muscles, the spleen, some parts of the mucous mem- 
 branes. 2d, In organs in which it contains blood and other fluids ; 
 for example, in bone, cellular tissue, serous membrane, part of the 
 fibrous system, the skin, the vascular parietes, glands, &c. And, 
 Zd, In organs in which it contains no blood, the instances of which 
 are, tendon, cartilage, ligament, hair, &c. 
 
 Now, it is of little consequence to say that the tissues of the two 
 last divisions contain other fluids thaa blood, when we are also told 
 
 t Ib. p. 62. 
 
 Gordon, p. 56. 
 
SYSTEM OF CAPILLARY VESSELS, &C. 
 
 133 
 
 that the phenomena of injections, which prove that their capillaries 
 communicate directly with arteries conveying red blood, the effect 
 of irritating applications mechanical or chemical, and the phenomena 
 of acute or chronic inflammation, show that they may convey or 
 receive red blood. The conclusion of this in common language is, 
 that the capillary arteries and veins of the second order of tissues 
 do not all contain red blood, but that many of them contain a co- 
 lourless part of that fluid ; and that all the capillary arteries and 
 veins of the third order of tissues convey in the natural state co- 
 lourless blood only. What, then, is the precise idea which ought 
 to be formed of the intermediate system which Bichat conceived to 
 exist between the minute arteries and veins, or what have been 
 termed the venous radicula? 
 
 It appears that the present state of facts will admit of nothing 
 more to constitute this capillary system than those minute vessels, 
 whether conveying coloured or colourless blood, in which inspec- 
 tion, microscopic observation, and injections show that arterial 
 branches at once terminate, and minute veins {i-adicul(B venose) 
 have their origin. It is clear that, physiologically speaking, these 
 vessels can neither be regarded as arteries nor as veins strictly ; 
 for the characters on which this distinction is founded are neces- 
 sarily lost or obliterated in this system of vessels. There is no pre- 
 cise point at which the arterial tissue or structure can be said to 
 terminate, and none at which the venous structure can be said to 
 commence. Microscopic observation shows merely a minute and 
 endless network of interlacing and communicating vessels, in 
 which the blood moves with great velocity. And the vessels are 
 too small to allow their structure to be correctly examined. If, 
 however, we adopt the doctrines of Bichat with regard to the 
 inner arterial and venous tunics forming the ultimate tube of 
 small arteries and small veins, we must conclude that the arte- 
 rial membrane is lost in the venous, and that the common mem- 
 brane of red blood is identified with the common membrane of 
 dark or modena blood. In this conclusion there is nothing either 
 absurd or improbable, and, though not founded on actual obser- 
 vation, it is greatly more natural than many similar ideas which 
 have been formed on the nature of this system of vessels. It 
 may be added that it is not at variance with w'hat is observed in 
 these vessels in the living body. It is found that the blood in a 
 
134 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 minute artery is not of the bright red colour which it possesses in 
 the trunk and large branch from which the minute artery derives 
 its blood, but is gradually acquiring the dark hue which belongs 
 to the blood of the venous branches and trunks. 
 
 By some, again, this direct communication of minute arteries 
 and veins is denied. Thus, according to Doellinger, the arteries 
 at their last ramifications are devoid of proper membranous walls ; 
 the blood moves in immediate contact with the solid matter of the 
 body, which is in truth the fundamental or penetrating filamentous 
 tissue ; and from this it passes into the venous tubes and lym- 
 phatics, which also arise from this substance. 
 
 According to Wilbrand, again, who equally denies this direct 
 communication of arteries and veins, all the blood is converted 
 into organic fibres and secretions ; and these organic fibres becom- 
 ing gradually fluid are converted into blood and lymph, which con- 
 tinue the circulation. 
 
 These notions are too fanciful and too incapable of demonstra- 
 tion to become the object of serious attention to the anatomist. It 
 is of little moment whether the vessels in the ultimate ramifications 
 possess tunics or not. When they cease to possess tunics they 
 cease to be vessels ; and to carry observation beyond this point is 
 either impracticable or useless. In other respects the investigation 
 of this point belongs to the subject of the exhalant vessels. 
 
 This idea is, however, adopted by Wedemeyer, who founds it 
 chiefly on the fact, that he could not detect by the microscope any 
 membrane interposed between the parenchyma of the tissues and 
 the blood moving in the minuter capillaries, or rather furrows in 
 which it is seen. It must be allowed that this idea receives some 
 confirmation from a fact to be afterwards noticed, that during in- 
 flammation, new vessels are observed by the microscope to be formed 
 in inflamed parts. 
 
 Bichat has described two great capillary systems in the human 
 body. Is^, The general one, or that which consists of the minute 
 terminations of the aortic divisions, and the origins of the superior 
 and inferior great veins; and, 2d, The pulmonary capillary system, 
 or that which consists of the minute terminations of the pulmonary 
 artery, and the origins of the pulmonary veins. It is evident, that 
 the manner in which the first of these systems is here repre- 
 sented, communicates a very incorrect idea of its true character; 
 
SYSTEM OF CAPILLARY VESSELS, &C. 
 
 135 
 
 and that there is actually an individual capillary system, not only 
 for every organ, but in some instances for every tissue. The brain 
 possesses an individual capillary system ; and that of the mem- 
 branes is evidently distinct from that belonging to the organ itself. 
 The heart and the kidneys possess each an individual capillaiy 
 system; and the liver may be said to have two, — one formed by the 
 communication of the hepatic artery and veins, and another con- 
 sisting of the divisions of the portal vein, with the branches of the 
 hepatic hollow vein, (Vena cava hepatica.) 
 
 The organic properties of the capillary vessels are as little known 
 as their structure. Many physiological and pathological writers, 
 especially experimentalists, have ascribed to them a power which 
 has at different times been called muscular, tonic, irritable, con- 
 tractile; and have asserted that, because the larger arteries are 
 provided with a fibrous membrane, which they have called muscu- 
 lar, and to which they have ascribed irritability, or the power of 
 contraction when stimulated, their minute or capillary termina 
 tions must have the same property. This conclusion is completely 
 unfounded for two reasons. Is^, I have already shown that the 
 proper arterial tunic is not muscular in structure, and, according 
 to the best experiments, possesses no property of contraction when 
 stimulated, 2d, Although it be admitted that the proper arterial 
 tissue is muscular and irritable, it is quite certain that observation 
 has not hitherto shown that this tunic can be recoo'nised in arteries 
 
 O 
 
 smaller than a line in diameter ; and it is certain that in the capil- 
 laries, properly so called, that is, in vessels which partake of the 
 nature of artery and vein, no such structure has yet been observed. 
 
 It is not impi’obable, however, that the capillaries possess certain 
 organic or vital properties ; but all that has been taught on this 
 subject is either hypothetical, or derived from an insufficient and 
 imperfect collection of facts. It is certain that the blood which 
 moves through them is beyond the direct influence of the action of 
 the heart, and can be affected by this only so far as it keeps the 
 larger vessels constantly distended with a column of blood which 
 cannot retrograde, and must therefore move forward in the only 
 direction left to it. It has been therefore argued that the capil- 
 laries must have an inherent powder of contraction by which this 
 motion is favoured. Is it not sufficient to say that they act merely 
 as resisting canals, to prevent their contents from escaping, and to 
 minister to the various tissues and organs those supplies of blood 
 which the several processes of nutrition, secretion, &c, require ? 
 
136 
 
 GENERAL AND PATHOLOGICAL ANATOIIY. 
 
 The experiments of Wedemeyer and Dutrochet show that the 
 capillary vessels are the seat of an action of intro-pulsion and ex- 
 tro-pulsion of fluids, (endosrnosis and exosmosis,') or a force by which 
 fluids may be impelled inwardly into them, or in the opposite di- 
 rection without them. 
 
 The effects which the application of mechanical Irritants, or 
 chemical substances, as alcohol, acids, and alkalis, produced in 
 the experiments of Hunter, Wilson Philip, Thomson, and Has- 
 tings, have been supposed to demonstrate the irritable 'nature of 
 the capillary vessels. The conclusion is illegitimate, in so far as 
 the results of these experiments are open to several sources of 
 fallacy. In some instances these effects are to be ascribed to In- 
 cipient inflammation, in others to shrivelling of the capillary struc- 
 ture, or crispation by chemical action, in others to actual coagula- 
 tion of the blood of the capillaries ; but none of them prove satis- 
 factorily or precisely any peculiar properties in the vessels of which 
 the capillary system is composed. 
 
 Section H. 
 
 The morbid deviations incident to the system of capillary vessels 
 are of the utmost importance. As they are the main agents of 
 most of the healthy processes of the animal body, so there are few 
 morbid states, in which their operation is not primary, or in which 
 they do not more or less partake. To enumerate these would form 
 a long nosological list, since the diseases of every tissue depend 
 chiefly, if not entirely, on its eapillary system. It will be sufficient 
 to consider the influence of the capillary vessels as an individual or 
 isolated organic system in the production of morbid action. 
 
 1. Inflammation. The capillary vessels are believed to be the 
 exclusive seat of the morbid process termed injlammatmi. No tis- 
 sue, or no substance, rather, destitute of capillaries, is believed sus- 
 ceptible of this process; and its frequency and violence are justly 
 estimated in proportion to the number of capillaries with which the 
 tissue is supplied. Hair, nail, enamel of the tooth, and cuticle, do 
 not undergo inflammation ; and their morbid states are to be as- 
 cribed to disorder of the textures on which their existence and nu- 
 trition depend. Filamentous tissue, on the other hand, mucous 
 and serous membrane, and the substance of such organs as the 
 lung, liver, &c. are very liable to various forms of inflammatory ac- 
 tion, which is generally proportional to the predominance of red 
 
SYSTEM OF CAPILLAEY VESSELS, &C. 
 
 137 
 
 capillaries in the substance of each. Bichat has justly observed 
 that inflammation is very frequent in the cutaneous, mucous, se- 
 rous, and filamentous tissues, which injection and microscopic ob- 
 servation show to abound in capillary vessels, but rare in bone, 
 cartilage, and the fibrous tissues in vvhich there are few capillaries, 
 or where the irritable or inflammatory susceptibility, (la sensibilite 
 organique,) is more moderate. It is difficult to explain the infre- 
 quency of inflammation in muscular tissue without having recourse 
 to this last property, which this author ascribes to the capillary 
 vessels. Its sensibility to the operation of a stimulus is great. Its 
 susceptibility of inflammatory action is very small. 
 
 The change which takes place in the capillary vessels in the state 
 of inflammation has given rise to much speculation, research, and 
 experiment. 
 
 But it may be doubted whether the questions which have been 
 agitated on this subject can yet be regarded as decided. On one 
 point only is there any thing like agreement in the various opinions 
 delivered. It appears to be now the general belief, that during 
 the process of inflammation the capillary vessels of the part are 
 dilated, and contain more blood than in the healthy state. (Cul- 
 len, Hunter, Vacca, and many other authors.) On the cause of 
 this dilatation, however, the sentiments of pathologists are as much 
 at variance as ever ; and not only are the results of experiments 
 made to determine the circumstances on which this distended state 
 of the capillaries depends, variable and sometimes contradictory, 
 but the conclusions to which they have led are very opposite. 
 One opinion is, that the dilatation depends on increased action ; 
 according to the other, it is the effect of a weakened state of the 
 capillaries. 
 
 The first of these docti’ines, which in some form or other has 
 been adopted from Stahl, and De Gorter, by Dr Cullen, appears to 
 have been suggested by the increased number of the arterial pulse 
 in a given space, the hardness and tension of its beat, the throb- 
 bing of inflamed parts, and the violent and sometimes rapid changes 
 of structure which attend inflammation. This has led to the con- 
 clusion that the blood moves in the capillaries of such parts more 
 rapidly, and with greater force, (momentum^ than in the healthy 
 state. (Parry. ) With superficial observers this opinion has pass- 
 ed current, as generally consonant with the phenomena and effects 
 of the inflammatory process ; and the pathologist has studied to 
 
138 
 
 GENERAL AND I'ATHOLOGICAL ANATOMY. 
 
 render his notions palpable, by supposing, in the language of tlie 
 mathematical physicians, an inoi'dinate flow, morbid affiux^ or in- 
 creased determination of blood to the inflamed parts. Had this 
 opinion ever been subjected to rigid scrutiny, its fallacy must have 
 been manifest. 
 
 Is#, The fact of increased determination is not established. In 
 its present state it is a mere assumption, 2<f, Increased determi- 
 nation is not necessary to the production of the effect. When the 
 capillaries of any part are unusually loaded, this may take place 
 from the blood not being removed with the same regularity, and in 
 the same proportion in which it is conveyed, with the same facility 
 as by supposing an increased current, 3c#, Even admitting the 
 current to be increased through any set of capillaries, it is impossi- 
 ble to discover the agents of such a process. It is cleai' it cannot 
 be the heart. And to suppose the capillaries capable of this, is 
 to ascribe to them a power which they have not been proved, in 
 ordinary circumstances, to possess. 
 
 Against the hypothesis of increased force and increased velocity 
 of circulation, various arguments may be urged ; and several of 
 these depend on the circumstance, that this hypothesis also has 
 been assumed on very insufficient grounds. Is#, The increased 
 number of the arterial pulse does not demonstrate that the blood is 
 moving more rapidly than in the ordinary circumstances of health. 
 It merely shows that the heart contracts more frequently in a given 
 time than usual. 2f/, The increased number, or strength, or ten- 
 sion of the arterial pulse does not indicate that the blood is moving 
 with greater force, or that the arteries through which it is moving 
 are acting with greater power, but rather that the heart is contract- 
 ing much more frequently in order to overcome some obstacle. 
 3fZ, It does not appear that the increased number or force of the 
 pulse, as manifested by the contractions of the heart, depends on 
 any other cause, than the vital irritation occasioned by a local sti- 
 mulus of a morbid nature. 4#/i, The throbbing of inflamed parts 
 proves nothing more, than that the shock communicated from the 
 lieart along the arterial tubes is rendered more sensible, first, by 
 their dilated and distended condition ; and, secondly, by the greater 
 quantity of matter deposited in and around these vessels. (Parry.) 
 
 On the other hand, it appears to me certain that, from what we 
 see by the microscope in the vessels of cold-blooded animals, as 
 the frog, fish, &c. the blood moves most rapidly in the healthy 
 
SYSTEM OF CAPILLAEY VESSELS, &C. 
 
 139 
 
 state ; and when it moves slowly, or is retarded, and stops or re- 
 trogrades, as is occasionally seen, this is unnatural, and if continu- 
 ed for any time constitutes a morbid state. This is further con- 
 firmed by the results of the experiments made by Kaltenbrunner, 
 who ascertained that in inflammation and similar morbid states, the 
 blood not only moved more slowly, but formed what he called 
 stases, or points of immobility and stagnation. 
 
 The second doctrine, that the distended or dilated state of the 
 capillaries is to he ascribed to weakness or debility in their coats, 
 appears to be more consonant with the usual phenomena of the 
 process, and with the effects which it produces iu the different tis- 
 sues. But although much has beeu lately done by IVilson Philip, 
 Hastings, and others, to determine this point, it is still beset with 
 some difficulties and objections, and would perhaps require some 
 variation in the experiments, in order to place the subject in the 
 clearest light. This hypothesis first originated with Vacca Ber- 
 linghieri, and was supported in this country by Lubbock, Allen, 
 Reeve, Thomson, Wilson Philip, and subsequently by Hastings 
 and Black, and receives some confirmation from the experiments of 
 Kaltenbrunner, who has given the most complete set of observations 
 on this subject. This author regards congestion as a preliminary 
 stage of inflammation, and he therefore considers in connection the 
 phenomena presented by both. 
 
 Congestion he considers as a process increasing from an initial 
 point ; proceeding to a certain degree of development ; and abat- 
 ing and disappearing. In the first stage the following is the state. 
 The congestion accumulated to one point is thence extended to the 
 circumference. Thither the blood flows ; its motion is quickened ; 
 the walls of the vessels are tense ; the globules of arterial blood 
 are no longer changed into venous ; they are altered ; the paren- 
 chyma is swelled. 
 
 This state of the vessels takes place at the same time in all points 
 of the organ which is the seat of congestion. Not only is the cir- 
 culation of the blood altered. The blood itself, the parenchyma, 
 and the arterial walls partake in the common afiection. The nor- 
 mal functions of the organ are impeded ; the formation and absorp- 
 tion of lymph are in general interrupted. 
 
 The affection advances to different degrees of intensity accord- 
 ing to the nature and severity of the lesion by which it is produced. 
 The afflux of blood is more or less abundant ; its motion more or 
 
140 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 less accelerated ; the vascular walls, especially the arterial, are more 
 or less tense ; the blood is variously altered ; the^extent of the pro- 
 cess varies ; in certain cases it is directly proportional to its inten- 
 sity, and in others it is not. 
 
 The extent of congestions is usually limited ; and their develop- 
 ment is completed within a short time. 
 
 When congestion has attained a certain point, it remains station- 
 ary. It then attains the second stage. 
 
 This is not distinguished by any new phenomenon. The pheno- 
 mena of congestion are already established ; and those that are 
 essential are, afflux of blood to one point; acceleration in the move- 
 ment of the blood ; extension of the process little beyond its initial 
 point ; tbe functions of tbe organ embarrassed ; swelling of the 
 ■parenchyma ; and alteration in the globules. 
 
 This condition must not be confounded with certain derange- 
 ments in the circulation which imitate some of the phenomena of 
 congestion. These derangements are irregular and proceed from 
 the local action of any irritant, the effect of which is slight and 
 temporary. Sometimes, however, these derangements are follow- 
 ed by congestion ; and this is when these irritant agents act more 
 intensely and for a longer time. 
 
 The development of true congestion is a successive process, and 
 takes place only when the immediate action of the irritant cause 
 has ceased to act on the organ. 
 
 When congestion has lasted some time it decreases and termi- 
 nates in the following manner. 
 
 The amount of blood and the velocity of its movement begin to 
 diminisb at the circumference ; the blood seeming to flow from this 
 region towards this centre. The blood during the course furnishes 
 an exhalation of fluid, which takes place in jets through the capil- 
 lary vessels, and in general at the surface of the organ. The mo- 
 ment of the exhalation of the liquid is transitory ; but it is often 
 repeated at different points until the congestion disappears. It is 
 critical, because the congestion subsides in proportion as it is re- 
 peated and proceeds. The quality of the secreted matter varies 
 according to the nature of the affection. It is often bloody, espe- 
 cially in the lower animals. The products of critical exhalation 
 may always be easily seen. They consist of small red patches dis- 
 persed through the parenchyma. In some instances serous fluid is 
 discharged through the blood-vessels ; and in this case the liquid 
 being transparent is not so easily observed. 
 
SYSTEM OF CAPILLARY VESSELS, &C. 
 
 141 
 
 It is evident, that, in the phenomena now ascribed to congestion, 
 many would be disposed to see the early stage of inflammation. 
 This, howevei*, Kaltenbrunner distinguishes as a process of greater 
 intensity, with more varied phenomena, and more complex, and pre- 
 senting greater modifications. The difference, nevertheless, seems 
 more in degree and stage than in any other circumstance, and in / 
 the effects which it is liable to produce on the tissues which it af- 
 fects. 
 
 Inflammation like congestion has a period of increase, of esta- 
 blishment, and one of decline, often with destructive effects. 
 
 In the period of increase, the phenomena agree in general with 
 those of congestion. The movement of the blood is quickened ; the 
 vessels are distended ; the blood is altered. After this, however, 
 other changes are observed. The blood begins to move less quickly 
 in some capillary vessels, and at length stops completely. Thus 
 are formed in the system of disease^ vesse ls sta ses, statical or stag-y^/^ 
 nating points, which increasing occupy a large space round the 
 paid where the cause of inflammation is seated. (An eschar pro- 
 duced by the hot iron.) At the circumference of these statical 
 points the circulation proceeds rapidly. Thus inflammation is es- 
 tablished. The same phenomena appear on the application of 
 muriate of soda, alcohol, sal-ammoniac, or corrosive sublimate. 
 
 The stases are formed in the following manner. At the com- 
 mencement of inflammation the blood traverses all the vessels with 
 great velocity. Soon, however, its movement becomes slower at 
 first in certain capillaries, situate on the central point of inflamma- 
 tory action. Then the circulation is disturbed ; its motion becomes 
 unsteady ; the blood seems to oscillate irregularly in the canals ; 
 lastly, its movement is entirely stopped ; and the blood stagnates in 
 different points. These stagnating points progressively increase, 
 and affect even the smaller veins ; but they rarely take place in the 
 arteries. 
 
 The blood never stagnates in the canals so as to fill them entirely. 
 
 It is accumulated in certain points so as to leave void part of the 
 canals. Those in which the blood stagnates are relaxed. 
 
 The stagnating points are so much more diffused and dispersed, 
 and occupy a space more extensive, as the inflammation is more 
 severe and has been of longer duration. Their presence is evinced 
 by the redness of the part on which they are situate, which is more 
 intense on the initial point than on the circumference. The in- 
 
142 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 flammatory I’edness is livid when the inflammation is intense, and 
 the statical points are dispersed and diflFused. 
 
 The first change which the hlood undergoes in an inflamed 
 part is, that it is not converted into venous blood. Next to this 
 the coagulability is increased, so that the globules coalescing form 
 minute clots. Then the globules forming these clots are decom- 
 posed; for they are surrounded by serous liquid which exudes 
 fi’om them. 
 
 The colour of the blood is in like manner altered. When mu- 
 riate of soda is used, it gives the blood a purple tint ; the use of 
 alcohol imparts a clear colour ; that of corrosive sublimate a dull 
 brown colour. 
 
 Kaltenbrunner further maintains, that often in the course of the 
 phenomena of inflammation has he observed the formation of new 
 vessels or canals in an inflamed organ. The globules of blood are 
 observed to spring all at once from some capillary canal, to fall 
 into the surrounding parenchyma, pave a path for themselves, and 
 by this reach another canal.* This seems to confirm the idea of 
 Doellinger and Wedemeyer, already mentioned, (p. 134.) 
 
 These form the principal phenomena of inflammation in its in- 
 creasing and to its established periods. After that the phenomena 
 observed relate to an advanced stage, which has been usually con- 
 sidered as that of effects. To these, therefore, I shall revert subse- 
 quently. 
 
 Upon the whole, two facts may be considered to be established 
 regarding the state of the capillary vessels of an inflamed part. 
 The first is, that these vessels are unnaturally and unusually 
 distended, and really contain more blood than in the state of 
 health. This is proved not only by incisions into inflamed parts, 
 but by dissections of every part and organ of the body. The se- 
 cond is, that the blood moves more slowly in these vessels than in 
 the healthy state, and even after some time may remain entirely 
 motionless. This is also established by observing the effects of in- 
 flammation in the human body, but especially by the phenomena of 
 inflammation excited artificially in the bodies of the lower animals. 
 
 It is still a point to he ascertained, whether these two conditions 
 
 * Experimenta circa statum sanguinis et vasorum in Inflammatione. Auctore Doc- 
 tore Georgio Kaltenbrunner Monacliii, 1826. 
 
 Recherches Experimen tales sur I’lnflammation, par M. G. Kaltenbrunner, Docteur 
 en Medecine. Breschet Repertoire General d’Anatomie, et de Physiologie Patholo- 
 giques, &c. Tome ivtrieme, p. 201. Paris, 1827. 
 
SYSTEM OF CAPILLARY VESSELS, &C. 
 
 143 
 
 constitute what may be termed the essence of inflammation ; and 
 it is still undetermined by what agency these states are induced in 
 the capillary system of any tissue or organ. On this head it may 
 be remarked, that, if by any means the natural velocity with which 
 the blood moves through any set of capillaries be diminished, and 
 continue so, the quantity of blood in these vessels must be gradu- 
 ally and steadily increased, until it becomes very considerable. 
 This appears to be one cause of the accumulation of blood in any 
 part which is in the state of inflammation. 
 
 2. Temporary dilatation of the capillaries not inflammatory. 
 The capillary vessels undergo a temporary dilatation during the 
 progress of aneurism, whether allowed to go on naturally, or after 
 the application of the ligature to the arterial trunk. When the 
 collateral circulation has been fully established by the enlargement 
 of the anastomosing branches, the capillary system shrinks to its 
 ordinary size. 
 
 3. Extravasation. When the capillary vessels of any part have 
 been injured, so as to burst or give way, the blood which they con- 
 tained is eflFused round them, and into the cellular or other structure 
 of the part, occasioning sometimes considerable swelling, and, if 
 near the surface, a red, blue, or yellowish colour. In such cir- 
 cumstances the blood is said to be extravasated . and the change of 
 colour is termed ecchymosis. 
 
 4. Mode of repair ; union hy adhesion and granulation. When 
 they are divided by simple incision, they pour out first blood, then 
 serous or colourless fluids, lastly, a semifluid, which undergoes co- 
 agulation, and which forms the uniting medium of the divided sur- 
 faces, {liquor sanguinis, or blood-plasma.) This is the radical 
 moisture of the older physiologists ; (Taliacotius, Ambrose Pare, 
 Phioravant, &c.); the balsam of Nature, or agglutinative balsam 
 of Wiseman,* the gluten of Sauvages, Gaubius, and Cullen, the 
 
 ■* “ But in regard there is a certain medium which answers in proportion to a glue, 
 required in this work, Natirre taketh what is next in hand, even the nouiishment of 
 the part which is hurt to make it of. Uhi morbus ibi remedium is here as an oracle ; 
 where the disease is, there is the remedy. No sooner is the wound made but the bal- 
 sam is discovered. Blood, at least the serous part of it, is the glue, which she useth 
 both in curing by the first and second intention. The first being performed per sym- 
 physin, i. e. a reunion of the parts without any medium, by which word I here mean any 
 callus or flesh, or other body interposed ; for in another sense the balsam of Nature is 
 the medium, the instrument of unity, and puts the parts together ; the second per cys- 
 sarcosin, i. e. with a medium or interposition of some flesh or callous substance, that 
 
144 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 coagulating or organizahle Igmph of Hunter, and the glutinous or 
 albuminous exudation of the F rench pathologists. 
 
 According to the observations of Hunter, Baillie, and Home, 
 this lymph is afterwards penetrated with minute arteries and veins, 
 or acquires a capillai'y system of its own ; and in this state it is 
 properly organized lymph. This process of formation of new ca- 
 pillaries occurs in every situation in which lymph is deposited ; 
 
 In the exudation of inflamed serous membranes, which afterwards 
 forms the membrane of adhesions ; 2<^, In wounds of skin, cellular 
 membrane, mucous membrane, muscle, &c. ; 3tZ, In inflammation 
 of these tissues, whether occurring spontaneously, in consequence 
 of bruise or laceration, or the introduction of foreign bodies. In 
 each of these cases, though suppuration should also take place, 
 still there is lymph effused, and this lymph is penetrated by newly 
 formed capillaries. This formation of new capillaries is termed by 
 the French pathologists, accidental development of the capillary sys- 
 tem. Is it lymph of a peculiar kind that is effused from the ca- 
 pillaries of fractured bones in the first stage of the process of re- 
 union ? The substance named callus is not cartilage, as was an- 
 ciently supposed, and possesses qualities not unlike those of the 
 •lymph of soft tissues. Is lymph effused from the fragments of a 
 broken cartilage, or a ruptured tendon ? In each of these cases 
 of injury, a soft homogeneous fluid, pale red or bluish, is effused 
 immediately or soon after the injury ; and in each it seems to pos- 
 sess the same qualities, and only in the course of the process of re- 
 union to be afterwards penetrated by the peculiar matter of the 
 tissue injured. A preliminary step to this penetration of proper 
 substance is uniformly the formation of new capillary arteries and 
 veins. 
 
 In those examples of spontaneous disease or injury in which sup- 
 jH puration takes place, the capillaries in depositing lymph are con- 
 cerned in another process, the formation of red eminences, hemi- 
 spherical or hemispheroidal, of various size, and varying in firm- 
 ness or consistence. This process has been termed granulation.^ a 
 name which has been also improperly given the individual bodies. 
 The simplest, and perhaps the most correct view of this process, 
 shows that it consists of three distinct stages, which it is important 
 for the pathologist to know. 
 
 fills up the space between the lips of the wound.” — Chirurgical Treatises by Richard 
 Wiseman, Sergeant-Surgeon, Book v. Chap. 1. Of Wounds. 
 
SYSTEM OF CAPILLARY VESSELS, &C. 
 
 145 
 
 a. The first of these consists in eflTusion of lymph, or rather sero- 
 albuminous fluid or liquor sanguinis, from capillary arteries in the li- 
 quid form, and which speedily undergoing coagulation as it exudes, 
 is converted into irregular globules or masses. The extent to which 
 this exudation takes place will depend on the extent of the surface 
 and the degree of inflammation ; and the same principles will regu- 
 late the appearance of the globules or masses of lymph in the diflre- 
 rent points of the granulating surface. 
 
 b. After these globules have been effused and coagulated, they 
 are soon penetrated with vessels which, according to Hunter, may 
 be justly esteemed mere prolongations of the capillaries which ori- 
 ginally secreted the lymph. This penetration of vessels constitutes 
 what may be considered the second stage of granulation. This 
 process, which must have been observed by many practical sur- 
 geons, has been clearly and correctly described by Hunter. ‘‘ I 
 have often,” says he, ‘‘ been able to trace tbe growth and vascula- 
 rity of this new substance. I have seen on a sore a white substance 
 exactly similar to coagulating lymph. I have not attempted to 
 wipe it off, and the next day of dressing I have found this very 
 substance vascular ; for by wiping or touching it with a probe it 
 has bled freely.” And, again, “ The vessels of granulations pass 
 from the original parts, whatever these are, to the basis of the gra- 
 nulations, from thence toward their external surface, in pretty re- 
 gular parallel lines, and would almost appear to terminate there.”* 
 At the same time the formation or secretion of purulent fluid goes 
 on ; and the surfaces of these bodies themselves acquire the same 
 power of preparing this fluid which the surface fi-om which the gra- 
 nulations were produced, possessed. In this instance we have an 
 example of capillary vessels performing at the same time the effu- 
 sion of lymph and the secretion of purulent fluid. 
 
 In this stage of the process of granulation, Mr Hunter has 
 remarked the disposition to union, ohesion, or adhesion, which 
 granulating eminences possess, and described the mechanism by 
 which this is accomplished. By many it might be deemed a 
 distinct process. But in so far as the capillaries are concerned, the 
 chief object of consideration at present, it is to be viewed as a part 
 of the second stage. The vessels of the granulating eminences 
 continue to secrete lymph, which unites the corresponding surfaces 
 of their new bodies till their capillaries pass into each other, so as 
 to inosculate, and the union is completed. 
 
 * II. p. 477. 
 
 K 
 
146 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 c. The third stage in the process of granulation consists in what 
 he has termed contraction. In describing this important part, I fear 
 he has committed two errors — one in looking at the whole granu- 
 lating surface and contiguous parts, rather than at the individual 
 bodies ; the other in ascribing contraction to the elasticity and mus- 
 cular action of the contiguous parts rather than to a change in the 
 state of the granulations. These circumstances are certainly use- 
 ful accessory means ; but they must not be regarded as the primary 
 and essential cause. Perhaps also some slight differences take 
 place in the time in which contraction occurs, and the extent to 
 which it proceeds, according to the nature of the granulating sur- 
 face, and the relation which the production of the granulating emi- 
 nences bears to the part to be restored. The general phenomena 
 of the process appear to be the following. 
 
 After the granulating eminence or eminences have been form- 
 ed, and have united with the contiguous ones, the uninterrupted 
 action of their new capillaries continues to effuse lympli as a basis 
 for fresh granulations, and to give out vascular or capillary pro- 
 longations, in order to organize them. Meanwhile the vessels of 
 the granulating eminences near the edges of the surface begin to 
 diminish in size ; and as they diminish the eminences themselves 
 become less red and smaller, but more firm. At length, as the 
 eminences become covered with the membrane of cicatrization, they 
 appear to have diminished so much, that little inequality can be re- 
 cognised, the redness is sensibly diminished, and the whole appears 
 as if it were becoming quite as solid or firm as the contiguous 
 parts. If in this part of the process a granulating surface be inject- 
 ed, the vessels which go to the outer granulating eminences will be 
 found to be, Is^, much less numerous ; and, 2J, to be mucb dimi- 
 nished in size ; and this change will be observed to be most re- 
 markable at the edge, and less at the centre of the sore. It is this 
 diminution in the number and size of the granulating capillaries 
 which is the main agent of the process of contraction. As these 
 vessels become less numerous and smaller, the bodies to which they 
 are distributed diminish and become firmer ; and if a wound or 
 part wbich has been healed by granulation be injected some weeks 
 or months after being healed, the vessels will be actually found 
 less numerous and smaller than in the contiguous parts of the same 
 tissue. 
 
 When union by granulation is accompanied with the formation 
 
SYSTEM OF CAPILLARY VESSELS, &C. 
 
 147 
 
 of a thin membrane, which afterwards assumes the appearance and 
 properties of skin, the last part of the process is called shinning or 
 cicatrization ^ — the formation of a scar. The nature and mechanism 
 of this process will be considered in its proper place. 
 
 Granulation may be viewed as the means which the several tis- 
 sues of the human body possess of reproducing themselves, or re- 
 pairing those losses of substance which result from direct injury, or 
 take place in consequence of disease. Of this process the capilla- 
 ries of the texture are the agents. But it is uncertain to what ex- 
 tent they possess the power of reproducing the same sort of sub- 
 stance as that of the texture destroyed. The kind of matter v/hich 
 is most generally reproduced is filamentous or cellular tissue. It 
 is certain also that bone is reproduced. But it is uncertain whe- 
 ther skin, that is true skin, muscle, teudon, or ligament, is repro- 
 duced, and almost certain that cartilage is not. 
 
 5. Different effects of inflammation. I have said that granula- 
 tion is in general accompanied with the formation of more or less 
 purulent matter. This process, which is termed suppuration, ge- 
 nerally precedes that of granulation. It has been viewed at one 
 time as a consequence or effect of inflammation, at another as a 
 character of it, and at a third as a cause. The circumstances 
 which justify these distinctions should be understood. 
 
 Inflammation is a progressive process, which tends through cer- 
 tain stages to a certain termination. Of the intermediate steps not 
 much is known with certainty ; and pathological writers have dis- 
 tinguished chiefly the different modes in which it may terminate. 
 These are resolution, effusion, adhesion, suppuration, granulation, 
 ulceration, cicatrization, induration, and gangrene. This division 
 is more scholastic than natural. The first only can be justly de- 
 nominated a termination. All the others are to be regarded as 
 effects either immediate or remote of the process. 
 
 a.. Resolution is that action in which the redness, pain, heat, and 
 swelling of an inflamed part gradually disappear, either spontane- 
 ously or under the use of means, with or without sensible evacua- 
 tion, and in which the part, which had been inflamed, resumes by 
 degrees its natural state, without suffering derangement of structure 
 or properties. This is exceedingly rare. The minute veins are 
 doubtless the great agents of cure in such circumstances. 
 
 (3. In most cases of inflammation more or less fluid is early effus- 
 ed or extravasated from the capillaries or the exhalants of the part. 
 
148 
 
 GENERAL' AND PATHOLOGICAL ANATOMY. 
 
 No sooner do the vessels become overloaded with blood than part 
 of it either entire, or in the form of serous fluid, is separated from 
 the vessels. Thus in inflammation of filamentous tissue blood or 
 serum may be poured into its interstitial spaces ; and the effusion 
 of the latter is one cause of oedematous and anasarcous infiltration. 
 In inflammation of the serous membranes also we shall find that 
 effusion of serous fluid is an eaidy and frequent result. 
 
 When this effusion is moderate it may be removed under suit- 
 able management by the action of the veins and lymphatics ; and 
 in siich circumstances this termination would still come under the 
 head of resolution. 
 
 7. In general, however, the fluid effused is of a more compli- 
 cated nature. The natural tendency of the process of inflamma- 
 tion is to cause the vessels to secrete or exhale, or effuse a fluid 
 which at once contains coagulable lymph and a thinner serum, 
 which, at a later period, at least in the filamentous tissue, corre- 
 sponds to sero-purulent or purulent fluid. The serum is not con- 
 verted, as Cullen imagined, into purulent matter. But the same 
 vessels which, at an early stage of the process, secrete serous fluid 
 containing lymph, at a more advanced period secrete purulent mat- 
 ter. This is easily proved by tracing the progressive changes in a 
 large wound ; for instance an amputated stump, an incision made 
 into an inflamed swelling, or an Incision made on purpose into the 
 soft parts of an animal. The same general conclusion results also 
 from observing the progressive steps in the human body after a 
 seton has been inserted, or an issue established. In the case of part 
 of the surface being destroyed by caustic, actual or potential, the 
 process may be less distinctly observed ; but it is still nearly the 
 same. 
 
 Upon the whole, the natural course of phenomena in inflamma- 
 tion may be stated in the following order. First, vessels dilated 
 and distended with blood, which moves more slowly than natural. 
 Secondly, the secretion or effusion from these vessels, or their ex- 
 halant terminations, of a fluid consisting of serum and coagulable 
 matter, sometimes with extravasation of blood. Thirdly, the se- 
 cretion of purulent fluid from the same vessels. 
 
 The intimate nature of the process by which purulent matter is 
 formed is by no means well known. The notion of Grashuys, * 
 that it arose from a liquefaction or melting of the adipose tissue, 
 
 * De Suppuratione. 
 
149 
 
 SYSTEM OF C-VPILLARY VESSELS, '^C. 
 
 though adopted by Haller,* is too ridiculous to merit the slightest 
 attention. It is sufBcient to remark, that purulent matter is pre- 
 pared by many other tissues which contain no adipose matter ; for 
 instance the mucous and serous membranes, and several of the 
 glandular organs, internal and external. The fallacy of the opi- 
 nion of Cullen, which was derived from the experiments of Pringle 
 and of Gaber, has been already noticed. 
 
 The view of Hunter is, on the whole, more correct. In inflam- 
 mation of the filamentous tissue, where the parts, or more accu- 
 rately, the vessels lose the power of resolution, they begin to “ alter 
 their mode of action, and continue changing till they gradually 
 form themselves to that state which fits them” to prepare purulent 
 matter. This applies, however, only to the case in which lymph is 
 exuded and purulent matter is secreted, simultaneously or succes- 
 sively, or, in other words, to the transition from the adhesive to the 
 suppurative stage. In certain circumstances this transition does 
 not take place, and purulent fluid may be secreted without the pre- 
 vious effusion of coagulable lymph. The first action of the vessels 
 is then to pour forth serous fluid, and the next is the secretion of 
 purulent matter in a more or less perfect form. This is well ex- 
 emplified in diffuse inflammation of the filamentous tissue. 
 
 No doubt can be entertained, from the experiments of Brug- 
 mann, f Hunter, | and Home, § and from the daily phenomena of 
 purulent collections, that suppuration is a process analogous to, if 
 not the same as secretion. || 
 
 This is demonstrated in the case of mucous and serous mem- 
 branes, in which purulent matter is formed without breach of sur- 
 face, and in which, therefore, its formation must be ascribed to a 
 new action of the vessels. It does not, however, follow from this 
 that these vessels perform, as Hunter imagined, the office of a gland. 
 This notion appears to be adopted merely to render the conception 
 of suppuration more distinct than it would be if simply ascribed to 
 the action of vessels. 
 
 Suppuration is the direct and exclusive, or the concurrent effect 
 of inflammation. It is generally the direct eflfect in inflammation 
 of the mucous membranes, often in that of the serous membranes, 
 
 * Elementa, Lib. i. sect. 4. f De Puogenia. 8vo. Groningte, 1781. 
 
 J Treatise on the Blood, Inflammation, &c. Chap. v. 
 
 § On the Properties of Pus. 4to. London, 1788. 
 
 II “ This new structure or disposition of vessels I shall call glandular, and the effect 
 or pus a secretion.” Chap. v. 
 
150 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 and it is so in diffuse inflammation of the filamentous tissue. In 
 circumscribed inflammation in the filamentous tissue, in inflamma- 
 tion of the skin, and occasionally in inflammation of the serous mem- 
 branes, it is preceded by exudation of coagulable lympb, and is 
 either concurrent or successive to it. 
 
 Suppuration is represented by Hunter as always preparatory to 
 granulation. This, however, must be understood to apply to sup- 
 puration of cellular tissue, and those textures of which it makes 
 part. In mucous and serous membranes suppuration may, and al- 
 most invariably does, take place without granulation. I shall af- 
 terwards have occasion to mention another sort of purulent collec- 
 tions, in which granulation never occurs. 
 
 Suppuration varies according to the nature of the inflammatory 
 process which it succeeds, and according to the texture in which it 
 takes place. 
 
 As inflammation varies according to the nature of the texture in 
 which it takes place, so its effects are different in the different or- 
 ganic textures. The purulent matter formed on the skin differs 
 from that which flows from an abscess of the cellular tissue. That 
 secreted by mucous membranes is different from either ; and even 
 the purulent fluid of serous membranes possesses certain charac- 
 ters by which a careful observer may distinguish it from the same 
 fluid in other situations. 
 
 The suppurating process may be varied according to the nature 
 of the inflammation by which it is preceded. A sound principle 
 laid down by John Hunter was to regard every form of suppura- 
 tion as the result of inflammation. From this, however, he depart- 
 ed in his views of the nature of suppurations of lymphatic glands, 
 of diseased joints, of lumbar abscesses, and of the cold or chronic 
 abscess in general. * It is easy to show, that, with the single ex- 
 
 • Many indolent tumours, slow swellings in the joints, swellings of the lymphatic 
 glands, tubercles in the lungs, and swellings in many parts of the body, are diseased 
 thichenings, wthout visible inflammation. And the contents of some kinds of encyst- 
 ed tumour ; the matter of many scrofulous suppurations, as in lymphatic glands ; the 
 suppuration of many joints, viz. those scrofulous suppurations in the joints of the foot 
 and hand, in the knee, called white swellings ; in the joint of the thigh, commonly 
 called hip-cases ; in the loins, called lumbar abscesses ; the discharge of the above- 
 mentioned tubercles in the lungs, as well as in many other parts of the body, are all 
 matter formed without any previous visible inflammation, and are therefore in this 
 one respect all very similar to one another. They come on insensibly, the first symp- 
 tom being commonly the swellings, in consequence of the thickening, which is not the 
 case with inflammation ; for there the sensation is the first symptom,” — Treatise, Chap, 
 iv. IV. p. 391. 
 
151 
 
 SYSTEM OF CAPILLAEY VESSELS, &G. 
 
 ception of pulmonary tubercles, in every one of the instances which 
 he has adduced the formation of fluid matter, is invariably preceded 
 by inflammation, that is, by morbid enlargement of the capillaries / 
 of the aflPected texture. 
 
 In the case of lymphatic glands suppurating, these bodies inva- 
 riably enlarge previously, and are always the seat of dull heavy 
 pain. This enlargement depends either on the vessels undergoing 
 a slow process of dilatation and distension, or on the formation of 
 tubercles in the substance of the gland. 
 
 The affections of the knee-joint, hip-joint, and other articulations, 
 have been satisfactorily traced to inflammation either of the synovial 
 apparatus, or of the cartilages, or of both, passing on the one hand 
 to the capsule, and on the other to^the bones. During life they 
 are painful, generally swelled or enlarged, and invai’iably hotter 
 than natru’al. Dissection shows these parts to be more or less, 
 sometimes highly, vascular. 
 
 The collections denominated lumbar abscess depend either on 
 disease of the vertebrm, generally of an inflammatory nature, or 
 on slow inflammation of the lumbar cellular tissue and lymphatic 
 glands. 
 
 The circumstance in which Mr Hunter trusted, in considering these 
 collections to be independent of inflammation, was the absence of 
 pain as the first symptom. In this, however, I believe that accu- 
 rate observer was mistaken. In every one of the cases of disease 
 to which he refers as examples, more or less pain is invariably felt 
 in the course, if not from the first date of the complaints. Two 
 circumstances, indeed, distinguish this sort of pain. It is neither 
 severe nor uninterrupted, and may be so moderate as not to attract 
 the attention of the patient, or form a serious subject of complaint. 
 But even admitting the statement of Mr Huntei’, that the sensation 
 of pain is not the first, it is doubtless too limited a view of the in- 
 flammatory process to imagine, that this can never exist unless 
 when the sensation of pain is the first symptom. In some of the 
 textures, especially mucous membrane, we know that inflammation 
 may be established for some time without much attendant pain. 
 
 In others, especially the serous membranes, inflammation approaches 
 so slowly and imperceptibly, that both lymph and purulent matter 
 may be effused before the existence of the disease is suspected. 
 
 For these and similar reasons it has become requisite to admit 
 the existence of a slow insidious form of inflammation termed chronic. 
 
152 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 corresponding to the inflammation hy congestion of Pare, Hildanus, 
 Wiseman, and the older surgeons, and causing the cold abscess to 
 whieh I had occasion formerly to allude. But, with the exception 
 of its being attended with little or no pain, and proceeding much 
 more slowly than acute inflammation, little is known regarding the 
 anatomical and pathological characters of this form of the process. 
 From several circumstances it might be inferred that the capillaries 
 begin to assume the suppurative action, at least in fllamentous tis- 
 sue, more readily than in the case of acute inflammation. In other 
 parts chronic inflammation may exist without terminating in the 
 suppurative process. 
 
 In cases in which the acute seems to be combined with the chronic, 
 so as to form an intermediate or mixed variety of disease, it has 
 been distinguished by the name of subacute inflammation. 
 
 Under certain circumstanees chronic inflammation may terminate 
 in the acute. Thus an abscess in the cavity of a joint, either by 
 distension or by propagation of action, may induce inflammation in 
 the subcutaneous cellular tissue and in the skin. When a chronic 
 abscess is opened, its whole interior surface is attacked with acute 
 inflammation ; and when a lumbar abscess is opened, or is allowed 
 to burst, the same effect results. By carefully excluding the air, 
 indeed, and healing up the wound according to the manner of Mr 
 Abernethy, the severity of this inflammation may be much mitigat- 
 ed ; but it always takes place, and sooner or later becomes gene- 
 ral and severe. In this sense only can suppuration be said to cause 
 inflammation. But the proper view of the relation of these two 
 processes is, that chronic inflammation may cause the acute form 
 by the capillaries assuming a new mode of action, or by propagat- 
 ing the irritation to those of a new texture. In circumstances of 
 this description, suppuration is in general without granulation or 
 attempt at repair. 
 
 h. Suppuration may be either without attempt at repair, or with 
 absolute destruction of texture ; and it is then distinguished as ul- 
 ceration, or the formation of an ulcer. Since the time of Hunter, 
 who gave the first clear idea of this process, ulceration has been 
 generally understood to consist in absorption with suppuration. 
 This notion is perhaps more hypothetical than the old one of breach 
 of surface or loss of substance, which simply expressed the fact 
 without reference to its supposed cause. But as loss of substance 
 implies the absorption or resumption of part of the animal texture. 
 
SYSTEM OF CAPILLAEY VESSELS, &C. 
 
 153 
 
 and as this must be understood to be effected by the vessels of the 
 part, the chief objection with which this opinion can be charged, is, 
 that not only the lymphatics, but the minute veins must be con- 
 cerned in the process of resumption. 
 
 I do not propose here to consider all the various forms of ulce- 
 ration, or the circumstances under which it may take place. But 
 I shall mention a few by way of example. 
 
 Ulceration occurs in the skin in consequence of inflammation 
 from injury, as wound, tear, burn, &c., death of a part occasioned 
 either by mortification, or by the cautery, actual or potential, or the 
 application of a morbid poison. 
 
 Ulceration occurs in the mucous membranes under the same 
 circumstances as in the skin, and also after spontaneous inflamma- 
 tion, that is, inflammation coming on without manifest cause. 
 
 Ulceration occurs in the cellular tissue in consequence of the 
 pressure and progressive advancement of a large abscess, in conse- 
 quence of the presence of foreign bodies, as bullets, sword-points, 
 pins, &c. ; or the sharp end of a bone. 
 
 Ulceration is not common in serous membranes. In these, how- 
 ever, it takes place in consequence of the continued pressure of 
 large collections of matter. This is seen in empyema and collec- 
 tions of purulent matter in the peritonaeum. 
 
 Ulceration occurs in bone either spontaneously, or in conse- 
 quence of the death of part of it. The former is seen in caries, 
 the latter in necrosis and exfoliation. 
 
 Ulceration occurs in cartilage in consequence of inflammation. 
 This is seen in diseases of the knee-joint and hip-joint. 
 
 In all cases of ulceration, the capillaries of the parts are larger 
 and more numerous than natural, and certainly contain more blood 
 than in the state of health. This is seen very well in the case of 
 ulcers of the cornea, which are invariably surrounded by an annu- 
 lar net-work of small vessels, which in the sound state of that tex- 
 ture are invisible. In the skin it is very well established by inci- 
 sions made in the treatment of boil and carbuncle. In both cases, 
 if the incision be carried through either tumour, much more blood 
 is discharged from the point where ulceration is established than at 
 any other part. The same fact is demonstrated by the appearance 
 of ulcerated patches of the intestinal mucous membrane. 
 
 In the process of ulceration it is generally possible to trace a 
 final intention or definite purpose, after the accomplishment of 
 
154 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 which it ceases spontaneously. It takes place under circumstances 
 in which it is requisite to remove some part of a texture which is 
 either unsound, or has become foreign to the system, as in the case 
 of dead bones, mortified sloughs, or to procure an outlet for some 
 morbid fluid, as is seen in deep purulent collections, or to expel a 
 foreign body from a situation in which its presence is injurious. 
 Hence it has been justly remarked by Hunter, that every process 
 of ulceration is preceded by adhesive inflammation at one or more 
 points, sometimes round the whole line along which the ulcerating 
 process takes place. The object of this is to prevent hemorrhage 
 by the closure of vessels, and to prevent the diffusion of purulent 
 fluid in situations where its presence would be injurious. In se- 
 veral situations, however, it fails to accomplish this purpose. 
 
 When the ulcerative process has effected the object for which it 
 was commenced, a new mode of action takes place. The vessels 
 begin to deposit lymph in rounded masses, which become vascular, 
 and all the phenomena of granulation succeed. In such circum- 
 stances, are we to suppose that the absorbing process has given way 
 to that of deposition, — the action of veins and lymphatics to that 
 of minute arteries ? 
 
 In certain situations, this process of deposition may be observed 
 going on in one part of a sore, while that of removal, destruction, 
 or absorption is proceeding in another. Thus in an eschar occa- 
 sioned by a burn, or by cautery, actual or potential, while the pro- 
 cess of ulceration is detaching the margin of the slough, a crop of 
 granulations may be observed rising with equal rapidity and stea- 
 diness, and pushing off, as it were, the dead substance. The phe- 
 nomena of these and similar processes present objections to the 
 theory of Hunter. 
 
 E. Softening (^Malacismus ; JEnallaxis ; Sphacelismus ;) or pre- 
 ternatural diminution of consistence, is an effect of inflammation, 
 which in different tissues is liable to ensue. The tissues in which 
 it is most frequent are the brain, spinal chord or nerves, the lungs, 
 the uterus, and the bones. It consists in the more or less com- 
 plete separation of the component atoms of these tissues, whether 
 fibrous, globular, or amorphous, by the destruction or dissolution 
 of their filamentous tissue, and occasionally, if not constantly, with 
 the substitution of serous, sero-albuminous, sero-sanguine, or sero- 
 purulent fluid. The characteristic organization of the tissue is, in- 
 deed, more or less completely destroyed. Its elasticity and te- 
 
SYSTEM OF CAPILLAEY 'VTISSELS, &C. 
 
 155 
 
 nacity are destroyed; and it is rendered lacerable. In certain 
 tissues, especially that of the lungs, and perhaps that of the hrain 
 occasionally, softening is analogous to mortification of other tissues. 
 In the hrain, however, it is most usually analogous to suppuration. 
 
 One variety of softening is often observed in parts or new struc- 
 tures, originally hard, and consists not so much in the process now 
 mentioned, as in the slow solution or liquefaction of the tissue or 
 substance, partly by disruption of its particles, partly by death of 
 their individual atoms, with the admixture of blood, serous or sero- 
 purulent fluid. This softening, which takes place in encysted tu- 
 mours, tyromatous or scirrhous tubercles, and in most of the ad- 
 ventitious tissues, is a spurious variety of suppuration. 
 
 Induration (iS'cZero? 72 a, Verb art ung), or preternatural firm- 
 ness, is a usual concomitant and effect of the process of inflamma- 
 tion, The process rarely, indeed, exists for a few hours or days 
 in any tissue without rendering it considerably harder and more 
 resisting than natural. In the external parts of the body this is 
 seen in inflammation of the skin and filamentous tissue, in which 
 the inflamed parts are much harder and firmer than natural ; and 
 every inflammation of the filamentous tissue is accompanied with 
 hardness more or less extensive. This hai’dness, which is also ac- 
 companied with swelling and enlargement, depends partly on the 
 excessive distension of vessels by blood, and partly on the effusion 
 of sero-albuminous fluid. 
 
 The latter circumstance explains the presence of induration as 
 a consequence of the inflammatory process. The sero-albuminous 
 fluid, though first, when eflPused, liquid, and homogeneous, is 
 speedily separated by virtue of its property of spontaneous coagu- 
 lation into two parts, — the serous, liquid, or non-coagulable, 
 and the albuminous, consistent, or coagulable. The former is the 
 cause of the oedematous swelling already mentioned as often ac- 
 companying inflammation, and, after remaining for some time in 
 the interstices of the filamentous tissue of the part, may be removed 
 by the absorbent property of the capillaries and minute veins. 
 The latter, in the form of minute amorphous masses, disposed be- 
 tween the filamentous fibres, or the component atoms of the tissue, 
 augments its volume, and the space which it occupies, agglutinates 
 contiguous parts, and, eventually contracting and becoming con- 
 solidated, increases much the natural consistence and density of the 
 tissue in which it has been deposited. In this manner induration 
 
156 
 
 GENERAL AND RATHOLOGICAL ANATOMY. 
 
 takes place in the subcutaneous and intermuscular cellular tissue 
 after an abscess, in the female breast or male testis, and the liver 
 of both sexes, after inflammation, and in the pulmonic tissue after 
 an attack of peripneumony. In the glands now mentioned, and 
 even in the prostate gland, inflammatoi’y induration has been re- 
 peatedly mistaken for scirrhous induration. This error the accu- 
 rate pathologist will avoid. Inflammatory induration occasionally 
 disappears, and is never attended with acute pain. Scirrhous in- 
 duration never disappears, but proceeds to disorganizing softening, 
 and atomical mortification, and is always attended with stinging 
 darting pain, and flushes of burning heat. 
 
 Along with the state of induration, the textures are often ren- 
 dered brittle and lacerable. This is seen in the arteries, the ten- 
 dons, and the bones. 
 
 Yj. Gangrene or Mortification. This is much less frequent than 
 has been supposed. It may occur in the skin, in raucous mem- 
 branes, in fibrous structures, especially tendons, in bone, in carti- 
 lage, and in the substance of the lungs. In dry gangrene, {necro- 
 sis, ustilago, mal des ardens,) which is the most perfect specimen of 
 the death of parts. It affects skin, cellular membrane, muscle, 
 tendon, ligament, artery, vein, periosteum, bone, and cartilage in- 
 discriminately and generally. Its anatomical character consists in 
 coagulation of the blood in the vessels, always the capillary, some- 
 times the larger branches. But whether tlfis be the cause or the 
 effect of the death of the parts is uncertain. A fact formerly men- 
 tioned regarding the influence of ossification of the arteries in pro- 
 ducing gangrene of the toes, feet, and legs in old persons would 
 seem to show that it is the cause. The phenomena of the dry gan- . 
 grene, or that produced by spurred rye and bad food, on the other 
 hand, might favour the notion, that coagulation of blood is the ef- 
 fect. The gangrene produced by tight ligature, and in the case of 
 tumours, may be referred to either head. 
 
 6. Fever. In this disease, whatever be its form, intermittent, 
 remittent, or continued, the capillary vessels are the principal seat 
 of disorder. Nor is the affection confined to the capillaries of one 
 region, of one organ, or of one tissue. The seat of fever is to be 
 sought neither in the capillaries of the brain and spinal chord, nor 
 in those of the lungs, nor in those of the alimentary canal, but it 
 
 is diffused over the minute ramifying communications of the aortic 
 
 4 
 
SYSTEIM OF CAPILLARY VESSELS, &C. 
 
 157 
 
 and venous branches in whatever part of the body these communi- 
 cations are found. To establish the truth of this statement, it is 
 requisite merely to consider the phenomena of fever in the living 
 body, and its traces and effects in the dead. 
 
 a. I presume that the affection of the capillary system of the 
 brain, both cranial and vertebral, is too generally admitted to re- 
 quire being formally demonstrated. In point of fact, the pain of 
 the head in the beginning of all fevers, the derangement of thought 
 during their progress, and the tendency to stupor, and absolute 
 coma towards the conclusion, are sufficient alone to prove disorder 
 of the cerebral capillaries. But when blood or serous fluid is found 
 effused into the ventricles, when the vessels of the brain are found 
 turgid, distended with blood, and more numerous than natural, it 
 is impossible to resist the inference as to the overloaded state of the 
 cerebral capillaries during life. I am aware that cases of fever are 
 sometimes adduced, in which neither pain of the head nor deranged 
 thought are observed. I can only say, that, among a very great 
 number of cases which I have observed, though in a few the pa- 
 tient did not complain of headach, it was always possible to recog- 
 nize more or less derangement of thought. 
 
 In all cases, pain is felt when the patient coughs or stoops, or 
 when the head is slightly shaken, and when no pain is said to be 
 felt, it indicates that the stage of natural sensation is passed, and 
 that he complains not, because be does not feel. 
 
 In ague, the oppression of the cerebral capillaries may be so 
 great as to constitute inflammation (Siriasis j^gyptiaca,') or phre- 
 nitic ague, or in various degrees the sleepy quotidian, the sleepy, 
 lethargic, hemiplegic, carotic, and apoplectic tertian, and the co- 
 matose quartan of practical authors, (Werlhof, Torti, Lautter, 
 Morton, Sydenham, &c. ;) the same disease which has been named 
 by Lancisi, Baglivi, and IMorgagni, epidemic apoplexy. (Apo- 
 plexia febricosa, Cams febricosus.) 
 
 Tbe disorder of tbe capillaries of the spinal chord is indicated 
 by pain and weight in various parts of the column, by the derange- 
 ment in the muscular motions, especially local palsy, e. g. of the 
 arms, legs, &c. by the tetanic spasms and convulsions taking place 
 in many fevers. After death, much serous fluid flows from the 
 theca ; the vessels of the chord are distended and numerous ; in 
 all instances, serous fluid is effused, and sometimes pure blood is- 
 sues from its capillaries. 
 
158 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 / 3 . That the capillary system of the lungs is overloaded and op- 
 pressed in all fevers, is one of the most certain points in pathology. 
 During the ague fit, the respiration is invariably quicker than na- 
 tural, sometimes to the amount of thirty or thirty-six in the minute; 
 the patient complains of a sense of weight in the breast, cannot 
 breathe fully, pants, and has frequent cough. In continued fever, 
 the respiration is invariably quicker and more laborious than na- 
 tural, a deep breath cannot be drawn easily, and more or less sense 
 of oppression and weight is felt. I have found the respiration in 
 continued fever so quick as thirty-six in the minute, while, in or- 
 dinary cases, the application of the stethoscope indicates an embar- 
 rassed state of the circulation in the pulmonary capillaries. In 
 persons predisposed, expectoration streaked with blood, (Jicemoptoe,) 
 is not unfrequent during continued fever. 
 
 The same conclusion is clearly established by examination of the 
 lungs of persons cut off either by intermittent or by continued fe- 
 ver. In many instances of the former it induces bronchial inflam- 
 mation, or proceeds to actual peripneumony or pleurisy, constitut- 
 ing the catarrhal, pneumonic, or pleuritic tertian respectively. 
 (Werlhof, Torti, Lancisi, &c.) In the latter, the bronchial mu- 
 cous membrane is always more or less red, sometimes crimson or 
 purple, or of a deep brown colour, rough, and much thickened ; 
 the submucous tissue is brown and loaded with serous fluid ; and 
 the minute vessels are much distended with dark-coloured blood. 
 The bronchial tubes are very commonly, in fatal cases, perfectly 
 filled with thick viscid mucus, which adheres to the inner surface 
 of the bronchial membrane. The serous surface of the organ is 
 generally livid or marbled from this cause ; but the pleura itself 
 is not much changed, save from bloody serum discharged into its 
 cavity. The lungs in totality are generally dense, and firmer than 
 in the natural state. 
 
 These changes arise from the minute ramifying vessels at the 
 termination of the pulmonary artery, and the origins of the pulmo- 
 nary veins being unusually loaded with blood. As they are more 
 so than can be readily affected by the ordinary quantity of air ad- 
 missible in such a state, imperfect respiration and undue change of 
 venous blood contributes powerfully to the bad symptoms and the 
 unfavourable termination of the disease. In such a state of the 
 organs of respiration the bronchial arteries are less able to coun- 
 teract the bad effects of imperfectly respired blood, in so fiir as they 
 
SYSTEM OF CAPILLAKY VESSELS, &C. 159 
 
 receive from the aorta, blood which has not been suflBciently arte- 
 rialized. 
 
 y. In the capillary system of the chylopoietic and assistant chylo- 
 poietic viscera traces of the same condition may be recognized, both 
 from the symptoms during life and the appearances after death. 
 In these organs two capillary systems may be distinguished, a pri- 
 mary and a secondary one. The primary is that which consists of 
 the ultimate divisions of the splenic, gastric, and duodenal arteries, 
 and of the superior and inferior mesenteric arteries, and their cor- 
 responding veins, which afterwards terminate in the splenic and 
 superior and inferior mesenteric veins. The secondary capillary 
 system is that which results from the union of the minute extremi- 
 ties of the portal vein, and of the hepatic artery with those of the 
 vencB cavcB hepaticce. 
 
 It is unnecessary to dwell on the proofs of the loaded state of 
 the capillary system of the alimentary canal. It is sufficient to 
 remind the student that the furred or brown tongue, the thirst, the 
 sense of internal heat, the loathing, squeamishness, and sometimes 
 sickness, with weight, oppression, and tenderness of the epigastric 
 region, sufficiently demonstrate the morbid state of the capillaries 
 of the oesophagus, stomach, and duodenum ; while the constipa- 
 tion of the bowels at the commencement, insensibility to cathartic 
 medicine throughout, and occasional looseness at the conclusion, 
 indicate the deranged condition of those of the intestines. After 
 death the minute vessels of the whole of these parts are found much 
 distended with blood, generally dark-coloured. (Hamilton, Mills, 
 Bateman, Percival, &c.) 
 
 In one form of fever, the abdominal or intestinal typhus, the ileum 
 and its mucous follicles, are very much affected. The follicles be- 
 come enlarged, elevated, and prominent, and swelled in consequence 
 of their proper tissue being attacked, and perhaps their secreting 
 pores being obstructed. The apices become dead, and are thrown off 
 in the form of sloughs ; and in their place are left small ulcers, which 
 in no long time enlarge, spread, and increase in depth. These 
 changes may take place either in the isolated follicles or in the ag- 
 gregated patches, or in both orders of glands. They shall be con- 
 sidered more fully under the proper head. 
 
 In certain forms of fever there are pain, distension, and uneasy 
 sensations in the right iliac region ; and when percussion is em- 
 ployed, the sound emitted is dull, while a peculiar croaking noise 
 
160 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 is heard, and a gm’gling movement is felt beneath the fingers, as if 
 produced by air and liquid moving within the intestine. These symp- 
 toms continue the greater part of the duration of the fever ; and 
 though they are abated by local depletion, by means of leeches and 
 the use of laxative medicines, they do not disappear until the fever 
 itself either abates or altogether retires. 
 
 The portal vein constitutes, among the vessels of the digestive 
 organs, a secondary capillary system, in which the blood is not less 
 accumulated than in the primary one. It may be thought, that, as 
 the blood is accumulated in the first, it ought not so readily to find 
 its way into the trunk, branches, and ramifications of the second. 
 But this objection will vanish, when it is remembered that at the 
 same time both the primary and the secondary system of capillaries 
 become overloaded. This state of the capillaries of the portal and 
 hepatic system is established by the appearance of the liver in per- 
 sons cut off by fever. 
 
 The spleen may suffer so much from this capillary distension as 
 to resemble a mass of clotted blood without trace of organization. 
 
 This morbid and extraordinary distension of the primary and 
 secondary capillary systems of the chylopoietic organs, though dis- 
 tinct enough in the fevers of temperate countries, is most conspicu- 
 ously demonstrated in the agues and remittents of warm climates, 
 and especially in the severe and exquisite form termed yelloro fever. 
 In the former great sickness and epigastric tenderness, with more 
 or less vomiting, are frequent, and in the latter constant symptoms. 
 The vomiting, nevertheless, is not bilious, as has been too generally 
 imagined. It is at the commencement always a watery fluid, evi- 
 dently derived from the capillaries of the gastric, and perhaps the 
 duodenal mucous membrane. (Dr John Hunter, Jackson, &c.) 
 After some time it begins to be mixed with bile, expressed in all 
 probability from the gall-bladder by the pressure of the stomach in 
 the act of vomiting. A much more uniform occurrence, however, 
 if the disease does not subside spontaneously, or is checked by art, 
 is the gradual admixture of blood somewhat darkened with the wa- 
 tery fluid. This blood issues from the capillaries of the gastric and 
 intestinal tissues by a process analogous to exhalation in the sound 
 state, but differing in so far as in the capillaries, from which it pro- 
 ceeds, a degree of disorganization has taken place. As the blood 
 escapes into the cavity of the canal originally not highly scarlet, it 
 is rapidly blackened by the action of the carbonic acid and sulphu- 
 
SYSTEM OF CAPILLAEY YESSELS, &C. 
 
 161 
 
 retted hydrogen gases, at all times present in greater or less quan- 
 tity. This bloody exudation is at first scanty, but gradually in- 
 creases as the disease goes on, until it constitutes the greater part 
 of what is discharged both by vomiting and by stool. In the for- 
 mer case it forms the black vomit, (vomito prieto,) or coffee-ground 
 matter, so frequent in fatal cases of remittent or yellow fever. In 
 the latter it forms the dark, tarry, or treacle-like stools mentioned 
 by practical authors in the same disease. (Jackson, Hunter, Phy- 
 sic, Cathrall, Bancroft, &c.) 
 
 The description now given is general, and applies to this capil- 
 lary disorganization, as it takes place both in bad agues and remit- 
 tents, and in yellow fever. In the former it is less frequent, but 
 nevertheless takes place sufficiently often. In the latter it is seen 
 in its most exquisite form, and is almost invariable in fatal cases. 
 Its origin and formation have been traced in the most satisfactory 
 manner by repeated dissections. 
 
 The idea of black vomit being morbid or vitiated bile deserves 
 no attention. In some instances of severe yellow fever a dark-co- 
 loured fluid of the same physical characters as those found in the 
 intestinal tube, may be traced coming down the biliary and hepatic 
 duct from the pori hiliarii. This, however, instead of being bile, is 
 blood which has oozed from the hepatic capillaries in the same 
 manner as that from the intestinal ones. 
 
 h. The capillaries of the urinary system are much affected dim- 
 ing fever. Both in intermittents and in continued fevers bloody 
 urine has been discharged. 
 
 £. In the same manner the capillaries of the muscles, of the fila- 
 mentous tissue, and of the skin are morbidly distended. One of 
 the most common symptoms of fever is pain, soreness, and a sense 
 of bruising in the muscular parts and limbs in general. In fatal 
 cases, when these parts are examined by incision, unusual vascular 
 distension and extravasation of blood are frequently seen. The 
 livid spots and patches, {molopes ; vibices ; ecchymomata) are proofs 
 of the same state of the capillaries of the filamentous tissue, as pe- 
 techial eruptions denote this in the skin. 
 
 In short, there is scarcely a texture or organ of the animal body, 
 the capillaries of which are not disordered in the different forms of 
 fever ; and this disorder, instead of being confined to the capilla- 
 ries of a single organ, is extended throughout the capillary system 
 at large. 
 
 n 
 
162 
 
 GENEKAL AND PATHOLOGICAL ANATOMY. 
 
 It is doubtless true that in individual cases this disorder may be 
 greater and more distinct in one set of capillaries than in another. 
 In one set of patients the capillaries of the brain may appear to be 
 most disordered ; in another those of the lungs ; in a third those 
 of the intestinal canal ; and in a fourth those of the urinary organs. 
 It is always found, however, in such cases, that the affection of one 
 organ does not entirely exclude that of another ; and while the ca- 
 pillaries of the one are very much affected, though those of the 
 others are less so, they are by no means in the healthy state. In 
 all cases of severe and exquisite fever, whether intermittent, re- 
 mittent, or continued, the capillaries of the brain, of the lungs and 
 heart, of the chylopoietic organs, of the urinary organs, of the 
 muscles, of the cellular tissue, and of the skin, are affected nearly 
 in the same degree. (Macartney, Cooke, &c.) 
 
 An important question is to ascertain the precise nature of this 
 affection. The dissections of Pringle, Ilome, Ploucquet, Mills, 
 &c. as to the brain, those of Schenck, Morgagni, Lieutaud, Sar- 
 coni, and others, as to the thoracic organs, and those of Lieutaud, 
 Petit and Serres, Broussais, Lerminier and Andral, Louis, Cho- 
 mel, and Bright, as to the intestinal canal, might favour the 
 supposition that the morbid process of fever consists in inflam- 
 mation. Against this conclusion, however, various facts and 
 arguments may be adduced. Isit, In fatal cases of fever unequi- 
 vocal traces of inflammation are not uniformly or invariably found. 
 The proportion in which these marks, as albuminous effusion, sup- 
 puration, ulceration, &c. are observed, is small compared with the 
 number in which accumulation of blood in the capillaries, and more 
 or less disorganization of these vessels are observed. 2d, In cases 
 of pure, genuine, and unmixed inflammation of the internal or- 
 gans, whether spontaneous or from injury, the concomitant symp- 
 toms, though febrile, are totally different from those which distin- 
 guish either intermittent or continued fever. 2>d, The marks or 
 effects of inflammation which are found in the bodies of persons 
 cut off by fever are accidental complications, and may almost in- 
 variably be traced to inflammatory reaction supervening on the fe- 
 brile process, in consequence either of the physical peculiarities of 
 the individual, the local weakness of the parts, or the influence of 
 external morbific causes. 4<7i, Inflammation is a local action con- 
 fined to the capillaries of one tissue, or at most of one organ and 
 contiguous tissues ; and while the structure and functions of the 
 
 3 
 
SYSTEM OF CAPILLAEY VESSELS, &C. 
 
 163 
 
 organ may be completely impaired, those of others remain un- 
 altered. In fever, on the contrary, the capillaries of all the tissues 
 and of every organ are affected ; and while no individual organ is 
 much affected at the commencement, every organ suffers a little in 
 the general disorder of the capillary system. 5th, Inflammation 
 gives rise to albuminous exudation, suppuration, ulceration, and in 
 certain parts to serous or sero-purulent effusion. In fever the 
 morbid state of the capillaries terminates in complete destruction 
 or disorganization of their organic extremities, and the consequent 
 oozing of blood from the surface of the several membranes and or- 
 gans. 
 
 In conclusion, though it may be regarded as established, that 
 during the morbid process of fever the w’hole capillary system is 
 unduly distended and loaded with an inordinate quantity of blood, 
 which really moves more slowly and imperfectly than during health, 
 we have no facts which enable us to determine wbat induces this 
 peculiar and excessive accumulation. Much has been lately said 
 of congestion, and especially venous congestion. The state of the 
 capillary system which I have attempted to describe is that of con- 
 gestion or accumulation ; and so far the hypothesis of congestion 
 is intelligible. Of the existence of venous congestion, however, 
 unless as an effect of that in the capillary vessels, there is neither 
 proof nor probability. It is not a primary but a secondary, or 
 rather remote consequence. (Marsh.) 
 
 ■n. Changes in the blood in Fever. {Hcematopathia.) An- 
 other question belonging to a different head, nevertheless, in this 
 place may deserve some consideration in explaining this uni- 
 versal affection of the vascular system. This is the state of the 
 blood itself, and to what extent and in what manner it influences 
 the formation of these phenomena of deranged action in the vascu- 
 lar system. Though this has been already in part noticed under 
 the head of the blood, yet it may render the pathological views 
 on fever more complete and more intelligible to advert shortly to 
 certain facts on the subject in this place, and the necessary infe- 
 rences from these facts. 
 
 All observers agree in representing the blood to be more or less 
 changed in its properties and constitution in tbe different varieties of 
 fever, whether intermittent, remittent, or continued. To the princi- 
 pal views of the old pathologists it is unnecessary to advert. But by 
 all observers during the 18th century, when it was supposed import- 
 
164 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 ant to attend much to the state of the blood and its appearances, it 
 is commonly described as dissolved, and deficient in crasis. 
 
 What this dissolved state consists in we are not informed ; neither 
 do we at present possess means of knowing. In many of the con- 
 tinental schools, however, the term dyscrasia of the blood has been 
 and is now employed to express a morbid state of that fluid. 
 
 The following facts, which I have repeatedly observed in conti- 
 nued fever, appear to me deserving attention. 
 
 If a person attacked with fever (synochus or typhus,) be blooded 
 at the commencement of the attack or within three or four days there- 
 from, The blood coagulates very much in the usual time, and, with 
 a moderately firm coagulum, shows an average proportion of serum. 
 If in a person labouring under fever blood be drawn about six or 
 seven days after the commencement of the symptoms, it coagulates 
 more slowly, and less perfectly. The coagulum is loose and soft, 
 and the quantity of serum small. If blood be drawn at a period 
 still later in the disease, the coagulum is yet more loose and soft, 
 and the serum still smaller in quantity. In the majority of cases 
 of fever at this stage, the serum sometimes does not exceed one 
 drachm, or at most two, and in some cases no serum at all is sepa- 
 rated. At the same time, the coagulum is soft, flaccid, tremulous, 
 and when divided, evidently consists of the coagulum, properly so 
 called, and the serum involved and retained within the clot. This 
 I have seen so often, and after trials made with attentive observa- 
 tion of the fact, that I cannot doubt its accuracy as a general fact. 
 
 The conclusion which I conceive naturally flows from the facts 
 now stated, is, that in fever the coagulating power of the blood is 
 progressively impaired in the course of the disease, and it may in 
 extreme cases he altogether gone. The quantity of serum produc- 
 ed is in general in the direct ratio of the coagulating power. If 
 the blood coagulates vigorously and energetically, the serum is ex- 
 pressed from it in large quantity. If the serum is separated in 
 small quantity, it shows not that little serum is in the blood, but 
 that the coagulating power being impaired and weakened, it does 
 not force the serum out of the fibrin in due quantity. When no 
 serum appears at all, it shows that the coagulating power is so far 
 destroyed, that it is unable to separate the blood into clot and 
 serum. 
 
 That this loss of coagulating power in the blood takes place in 
 fever, and increases gradually as the disease advances, is rendered 
 
 4 
 
SYSTEM OF CAPILLARY VESSELS, &C. 
 
 165 
 
 certain, not only by the facts now stated, but by tbe condition of 
 the blood found in the vessels after death. That fluid is then 
 found filling the arteries, as well as the veins, not scarlet, but 
 of a dark-brown colour, and viscid, grumous, and very imperfectly 
 coagulated. 
 
 There appear, therefore, here, two remarkable circumstances ; 
 one, the diminution or loss of coagulating power ; the other the di- 
 minution or loss of arterialization. 
 
 What is the cause of these changes ? It is reasonable to think 
 that for this cause we ought to look chiefly in the lungs. The 
 lungs, I have already observed, are in all cases of fever more or 
 less disordered, their vessels are congested and oppressed ; their ac- 
 tion is impaired ; and there is proof of great derangement in the 
 action of the bronchial membrane, imperfect admission of air to 
 the bronchial tubes and their membrane, and, accordingly, inade- 
 quate arterialization, or it may be the lowest possible degree of 
 that function. These may be regarded as matters of fact, capable 
 of demonstration. Does this morbid state of the blood, then, begin 
 in the lungs, or in some other part, or set of vessels ? When we 
 consider the large extent of the bronchial membrane, the fact that 
 upon it are ramified the capillary divisions of the pulmonary ar- 
 tery and veins ; the fact that through these vessels passes the whole 
 blood of the body, and the further fact of the manifest disorder of 
 the whole blood of the system in fever, it is impossible to resist the 
 conclusion, that it must be chiefly, perhaps solely, on the blood of 
 the lungs, that the cause of fever begins to display its primary and 
 initial operation. 
 
 On the nature of tliis cause it is not possible to speak with con- 
 fidence or certainty. But if the general opinion, that it is a poi- 
 son difiused through the air, be well founded, it is not difficult to 
 perceive at least some traces of its mode of operation. YVhether 
 that poison be extricated in the form of a vapour or exhalation 
 from the surface of the earth, and is telluric in origin ; or is elimi- 
 nated from vegetable matters in certain circumstances of decay or 
 change; or from vegetable and animal matters conjoined; or is 
 given oflP as a subtile effluvium from the bodies of living human 
 beings, in circumstances unfavourable to ventilation and the healthy 
 performance of the functions ; or is the result of some unknown and 
 unappreciable state of the atmosphere ;— it must equally be inhaled 
 with the air in inspiration, and thus thoroughly mixed with the 
 
166 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 blood of the lungs in successive acts of the function of respiration. 
 
 If it be so mixed, it must be circulated with the circulating blood, 
 and in this manner distributed through the whole vascular system 
 to every organ of the body. In doing so, however, this poisonous 
 material must have so altered the blood in the lungs, as to produce 
 in that blood and in these organs a more decided effect than else- 
 where. The shock first inflicted on the blood in these organs ap- 
 pears, it is natural to think, the great cause of the loss of coagu- 
 lating power and the impaired arterial ization. We know that one 
 of the great uses of the lung next to, or along with the arteriali- 
 zation of the blood, is to maintain the coagulating power, and to 
 restore it when impaired. It is, therefore, natural to infer, that 
 when the coagulating power is diminished, it depends on some im- 
 pediment to the function of respiration, and that when the function 
 of respiration is imperfectly performed, that should evince its effects 
 in a diminished proportion of coagulating power. 
 
 If these views be well founded, it follows, that, when the blood 
 thus altered is circulated, however imperfectly, it must operate 
 hurtfully on the organs to which it is transmitted. It must act, in 
 truth, as a poison ; and many of the phenomena of fever are similar, 
 certainly, to the effects of poison, especially a poison at first irritant, 
 and then sedative and narcotic. This appears to be the mode in 
 which, towards the latter stage of fever, its cause acts on the brain 
 and spinal marrow. 
 
 7. Hemorrhage. In all cases of Hemorrhage, whether by rup- 
 ture or by exhalation, the capillaries are unusually loaded with 
 blood. This is established by the appearance of the brain in apo- 
 plexy, of the lung in hemoptysis.! (pulmonary apoplexy of Laennec,) 
 pneumonorrhagia of Frank and Latour, of the prostate gland in 
 chronic enlargement, (Home,) and the state of the mucous surfaces 
 in general. In the two first cases, especially in that of the lungs, 
 the pulmonic capillaries are large, numerous, and distended with 
 blood, the pulmonic tissue more or less injected and firm, and blood 
 is found oozing from the surface of the bronchial membrane. ( Stark 
 and Laennec.) With this, however, is conjoined a friable or la- 
 cerable and imbrowned state of the bronchial membrane and pul- 
 monic tissue. 
 
 8. Excess of Nutrition. {Hypertrophia.') Hypertrophic aug- 
 mentation. That every unusual increase in the size of parts is to 
 be ascribed to the agency of the capillaries is well established by 
 
SYSTEM OF CAPILLAEY VESSELS, &C. 
 
 ' 167 
 
 the phenomena of morbid enlargements and preternatural growths. 
 Every instance of unusual or anormal size is of three kinds. 
 
 a. A texture or organ becomes enlarged in consequence of a 
 uniform increase of its proper organic substance. Thus the heart 
 becomes thicker, firmer, and larger in all its dimensions. Its mus- 
 cular substance, and perhaps the intermuscular filamentous tissue, 
 are actually augmented. They are redder, firmer, and contain 
 more blood than natural ; and their blood-vessels are increased in 
 size and number. The bladder in like manner undergoes the same 
 change ; and in its thickened and indurated tissue also dissection 
 shows a more copious supply of blood, and a more abundant distri- 
 bution of vessels than in the natural state. 
 
 Of this preternatural increase of bulk and density the capillaries 
 of the organs are the sole agents. In some instances this hyper- 
 trophy appears to be of the nature of a chronic process of inflam- 
 mation. This is exemplified in the case of the liver, the testicle, 
 the prostate gland, the female breast, and even the heart. 
 
 /3. Any individual texture may undergo a preternatural or anor- 
 mal enlargement by local deposition of matter similar to itself. 
 Thus a bone may become enlarged, as in exostosis ; a gland may 
 become enlarged, as in various instances the testicle and the female 
 breast do. That the skin is liable to a particular species of hyper- 
 trophic augmentation is well ascertained from cases given by many 
 authors, but especially from one recorded by Mr John Bell.* In 
 mucous membrane, lymphatic gland, and secreting glands, similar 
 local augmentations take place. 
 
 y. In any tissue or organ a deposition of new matter altogether 
 foreign to that tissue may take place. This new matter may be 
 either similar to that of some natural tissue of the animal body ; 
 for example, it may be serous membrane, or bone, or cartilage ; 
 or of a nature entirely dissimilar, and never seen unless in the mor- 
 bid state ; for instance, the several varieties of tubercular deposi- 
 tion of scirrhous deposition, of fungoid deposition, and several of 
 the forms of sarcoma enumerated by Mr Abernethy. 
 
 In whatever mode these new productions vary in intimate struc- 
 ture, all agree in being connected with more or less augmented 
 development of the capillary system. In many the growth, if not 
 the origin, can be traced to the increased number, or at least en- 
 larged size, of the capillary arteries. In most of these tumours 
 * Principles of Surgery, Vol. III. Discourse ii. Case of Eleanor Fitzgerald. 
 
168 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the vessels are large, numerous, and well filled with blood ; and if 
 divided in the living body they are the source of abundant hemor- 
 rhage. In some instances these vessels penetrate from the adjoin- 
 ing tissue all round the tumour in the form of numerous minute 
 arteries, which afterwards are ramified in the tumour. In others, 
 which are perhaps more numerous, they enter at one point in the 
 shape of three or four large trunks, which are afterwards divided 
 in the substance of the growth. 
 
 As these new or foreign growths, therefore, are known to abound 
 in capillaries, it is inferred, that, if this abundance of vessels be not 
 the direct cause, they furnish the materials of growth. The diffi- 
 culty in the theory of their formation is to ascertain the circum- 
 stances which first determine this local development of the capillary 
 system. In some instances it can be distinctly traced to mechani- 
 cal injury, (John Bell and Abernethy.) After a bruise, for exam- 
 ple, blood and lymph being poured forth, instead of being absorbed, 
 become penetrated with vessels, which conversely are stimulated 
 by the presence of this substance to convey more blood, and thus 
 enlarge in size. In others this local capillary development com- 
 mences without obvious cause. Upon the whole, the growth of 
 tumours is to be viewed as the result of an aberration or anorraal 
 action of the usual nutritive process to which the capillary vessels 
 are subservient.* 
 
 The theory of tumours or morbid growths depending on inor- 
 dinate local development of the capillary system was understood 
 by Valsalva, Morgagni, Pohl, and others, but was first fully illus- 
 trated by John Bell and Mr Abernethy, f and afterwards by Sir 
 Everard Home and Mr Macilwain. 
 
 * “ As wounded parts are healed by adhesion, so are dilated or strained parts by in- 
 creased nutrition.” — “ Tumour and various modifications of disease follow fi-om the 
 same law of vascular action and nutrition which maintained health. If each indivi- 
 dual vessel, whether artery or vein, have its coats thickened by dilatation or partial 
 laceration, the same must be presumed of each minuter vessel in the distended womb, 
 of each lesser vein and petty artery in a piece of distended skin, or in a diseased gland. 
 The enlargement, then, of each blood-vessel by deposition of nutritious matter along 
 its sides makes not a mere distension of vessels, but a solid and permanent bulk. The 
 more vessels are enlarged consistently with their healthy action, the more particles are 
 they able to secrete ; whence the increment of tumours is perpetually accelerating 
 unless when opposed by peculiar causes.” — The Principles of Surgery, by John Bell, 
 Surgeon. Vol. III. Discourse ii. 
 
 -f- An Attempt to form a Classification of Tumours according to their Anatomical 
 Structure, by John Abernethy. London, 1811, 
 
ERECTILE TISSUE. 
 
 169 
 
 CHAPTER VIII. 
 
 ERECTILE TISSUE, — ( Vasa Erigentia , — Vascula Erectiha , — 
 Tissu Erectile. 
 
 Section I. 
 
 The peculiar arrangement of vessels constituting the erectile 
 tissue was very early anticipated by our countryman William 
 Cowper, who states, that he demonstrated the direct communication 
 of arterial and venous canals, not only in the lungs, but in the 
 spleen and penis, “ in which,” says he, ‘‘ I have found these com- 
 munications more open than in other parts.”* 
 
 The system of capillary arteries and veins does not present the 
 same arrangement in all situations or in all the tissues of the human 
 body. Among the terminations of arteries enumerated by Haller, 
 one which he referred to the head of exhalants was that of a red 
 artery or arteries pouring their blood into the spongy or cellular 
 structure of the cavernous bodies of the nipple, the clitoris, and 
 the penis, that of the wattles of the turkey, and the comb of the 
 cock.f His detailed examination of these parts shows, that, with a 
 correct knowledge of their anatomical structure, he had not a very 
 distinct conception of the manner in which their vesels are dis- 
 posed. 
 
 Bichat remarked that the spleen and the cavernous body of the 
 penis, instead of presenting, as the serous surfaces, a vascular or 
 capillary net-work, (i-eseaii vasctdaire,) in which the blood oscillates 
 in different directions according to the impulse which it receives, 
 exhibit only spongy or lamellar tissues, still little known in their 
 structure, in which the blood appears often to stagnate instead of 
 moving. As this peculiar structure was known in the cavernous 
 body to be the seat of a motion long known by tbe name of erec- 
 tion., MM. Dupuytren and Richerand distinguished this arrange- 
 ment of arteries and veins as a peculiar tissue, under the name of 
 erectile, — a distinction which, though partly understood before, 
 nas only now been admitted as well-founded in the writings of 
 anatomical authors. According to the arrangements of M. Bec- 
 lard, this tissue comprehends not only the structure of the ca- 
 
 * Philosophical Transactions, Vol. XXIII. No. 285, p. 1386. 1703. 
 
 -}• Elementa, Lib. ii. sect. I. sect. 24. III. p. 102. 
 
170 
 
 GENERAL AND rATHOLOGICAL ANATOMY. 
 
 vernous body, but that of the spongy substance, {corpus spongio- 
 sum,') which encloses tbe urethra, and forms its two extremities, 
 the bulb and gland, the clitoris, the nymplice, and the nipple of the 
 female, the structure of the spleen in both sexes, and even that 
 of the lips.* * * § Some are disposed to add the structui’e of the iris, 
 and the peculiar plexiform network of vessels in the vagina of the 
 female. 
 
 It is somewhat unfortunate that the researches of anatomists on 
 this erectile tissue have been restricted chiefly to the spongy body 
 of the urethra and the cavernous body of tbe penis ; and it is ra- 
 ther by analogy than very direct proof, that similarity of structure 
 between them and the other parts referred to the same head is 
 maintained. I shall state here what is most satisfactorily known 
 on the subject. 
 
 The cavernous body of the urethra, or what is now termed its 
 spongy hody,\ is represented by Haller to consist of fibres and 
 plates issuing from the inner surface of the containing membrane, 
 and mutually interlacing, so as to form a series of communicating 
 cells,! into which the proper urethral arteries pour their blood di- 
 rectly during the state of erection. § 
 
 The cavernous body of the penis is in like manner represented 
 to be a part of a spongy nature, or to consist of innumerable sacs 
 or cells separated by plates and fibres, which, at the moment of 
 erection, are distended with blood poured from the arteries, and 
 which was afterwards removed by some absorbing power of the 
 veins. 
 
 This opinion, which was that of many subsequent anatomists, 
 even Bicbat himself, || was derived apparently from the facility with 
 which the blood so deposited escapes, not, as it was believed, from 
 divided vessels, but from areola, or interlaminar spaces. It ap- 
 pears, however, to have been at variance with what had been an- 
 ciently taught by Vesalius, Ingrassias, and Malpighi, and more 
 positively stated regarding these vessels by Hunter ; and modern 
 
 * Additions a I’Anatomie Generate de Xav. Bichat, par P. A. Bedard, p. 118. 
 
 t Haller applies the name of cavernous tody not only to the structure of the penis, 
 but to that of the urethra. — Elem. Lib. xxvii. Sect. 1 . 
 
 J Elementa Physiologise, Lib. xxvii. sect. 1, § 33. 
 
 § “ Sed et in pene, et in chtoride, et in papilla mammse, et in collo galli indici, 
 nimis manifestum est, vemm sanguinem effundi, neque unquam ejus color totus de iis 
 partibus evanescit, quae ab effuso sanguine turgere solent.” — Elementa, Lib. xxvii. sect: 
 3, § 10. 
 
 II Systeme Absorbant, § 3, p. S98. 
 
ERECTILE TISSUE. 
 
 171 
 
 researches have shown it to be completely erroneous. Cuvier and 
 Ribes in France, Mascagni, Paul Farnese, Moreschi in Italy, and 
 Tiedemann in Germany, have shown that there are no cells or 
 spongiform structure in the erectile tissue of the cavernous body. 
 
 The first correct view of the structure of parts of this description 
 in the human subject was given by Mascagni in his account of the 
 arterial and venous communications in the Spongy Body of the 
 Urethra. In 1787 he announced in his work on the Lymphatics, 
 that the parts called cavernous bodies, both in the penis and in the 
 clitoris, were simply fasciculi, or accumulations of arterial and ve- 
 nous vessels without interruption of canal ; but that between the 
 arteries and veins of the spongy bodies a dilated cavity or minute 
 cell was interposed. In 1795 repeated minute injections led him 
 to doubt the existence of this sort of cell ; and about the close of 
 1805 he publicly demonstrated the fact, that many veins of consi- 
 derable calibre collected in the manner of a plexus, with corre- 
 sponding arteries, hut small and less numerous, really form the 
 outer and inner membranes of the urethra, the whole of the glans 
 penis, and the whole substance of the spongy body. In each of 
 these parts, and also in the spongy structure inclosing the orifice 
 of the vagina, he ascertained by repeated injections that there are 
 no cells, as was imagined, and that the arteries, reflected, as it 
 were, give origin to numerous veins,* which, forming an intimate 
 plexiform net-work, constitute the whole glans, and the entire vascu- 
 lar body which surrounds the urethra and the entrance of the vagina. 
 
 In the cavernous bodies of the penis and clitoris he had not suf- 
 ficient facts to ascertain the existence of the same structure, as he 
 had never succeeded in injecting these parts so completely as the 
 glans and the spongy part of the urethra. Eventually, however, he 
 succeeded, especially in children, in injecting fully these cavernous 
 bodies of the penis and clitoris. He found in their interior nothing but 
 fasciculi of veins, with corresponding arteries, though rather smaller. 
 He inferred, therefore, that these vessels, collected and ramified in 
 various directions, constitute a vascular texture capable of expand- 
 ing and shrinking, according to the quantity of blood conveyed to it.f 
 
 * “ Le arterie vi si ritorcono, et danno origine alle vene, e queste formano in seg>iito 
 alcuni plessi, i quali accumulati in varia maniera, instituiscono tutto il glande, e tutta 
 quella massa vascolare, che trovasi intorno al’ canale deil’ uretra, e all’ ingresso deUa 
 vagina.” Prodromo della Grande Anotomia di Paolo Mascagni. Folio, Firenze, 1819, 
 Capitolo, II. p. 61. 
 
 t Prodromo del Paolo Mascagni, loco citato, p. 61. 
 
172 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 The general accuracy of this description has been since confirmed 
 by the researches of Paul Farnese and Moreschi. The latter espe- 
 cially has shown, Is^, That the glans consists of arteries and a very 
 great number of minute veins, which pour their blood into the cu- 
 taneous dorsal vein ; 2d, That the urethra, and especially its poste- 
 rior part, may in like manner be shown to consist of numerous 
 minute veins, which terminate in a posterior branch of the dorsal 
 vein, and communicate with the veins of the bulbous portion of the 
 urethra ; and 3c?, That in the cavernous bodies, though also re- 
 ceiving blood-vessels, these are much less numerous, and are chiefly 
 derived from the urethral vessels.* 
 
 The same arrangement was recognized by Cuvier in the penis of 
 the elephant, and by Tiedemann in that of the horse. 
 
 Upon the whole, the fiicts collected by different anatomists on 
 this subject furnish the following results. 
 
 If the arteries, on the one hand, be injected, they are found to 
 terminate in very fine ramifications, the disposition of which is ex- 
 actly the same as in other parts. If, on the other, the veins be 
 injected, it is easy to perceive the two following circumstances. 
 l5^. That they are much dilated at their origin, that is, that the 
 venous radiculoE are really more dilated than might be anticipated 
 from the other characters of these vessels. 2d, That the tubular 
 dilatations to which they are accessory, form very numerous inos- 
 culations or anastomoses, precisely as the capillary system of which 
 they constitute a part. The effect of this arrangement is to give 
 these vessels the appearance of being penetrated with sieve-like 
 openings, which makes them resemble areola, or interlaminar spaces 
 mutually communicating. As the whole difference, therefore, be- 
 tween the capillary vessels of this and other parts of the human 
 frame, consists in the minute veins {I’adicula venosa^ being dilated 
 or distended in a peculiar manner, M. Bedard concludes, that the 
 erectile tissue of the cavernous body consists simply of minute ar- 
 teries and dilatable veins interwoven in the manner of capillary 
 nets. These distended venous cavities are indeed so remote from 
 being cells, that they are truly continuous with veins, the inner 
 membrane of which may be easily recognised among thern.f 
 
 * Commentarium de Urethrse Corporis Glandisque Structura 6to Tdus Decembris 
 1810 detecta Alexandri Moreschi, Eq. Coron. Ferreee in Ticinensi primum, turn Bo- 
 noniensi Archigymnasio, Anatomes Professoris. Mediolani, 1817. 
 t Additions, p. 119. 
 
ERECTILE TISSUE. 
 
 173 
 
 During erection the blood accumulates in this tissue ; but the 
 cause and mechanism of this accumulation are completely unknown. 
 
 Since these observations were made, M. Muller of Berlin has, 
 by injecting the arteries of the penis, been enabled to give a more 
 detailed and satisfactory account still of the peculiar arrangement 
 of the erectile vessels. 
 
 By injecting the principal artery of the penis before its subdivi- 
 sion, and dividing longitudinally one of the corpora cavernosa^ the 
 ramifications of the nutrient arteries are then seen upon the inner 
 side of the venous spaces, the arteries becoming smaller and smaller, 
 until they pass into the capillary network, where their divisions can- 
 not be seen by the naked eye. Besides these nutrient ramified 
 arteries, there is seen on careful inspection another set of arterial 
 branches of diflferent size, form, and disposition, which are given 
 oflF nearly at right angles from both the larger and smaller trunks. 
 These arterial processes are about one-hundreth of an inch in dia- 
 meter, and one-twelfth long, and are easily seen by the naked eye. 
 They project into the cavities of the spongy substance, and termi- 
 nate either bluntly or by dilated extremities, without undergoing 
 any ramification. These short arterial processes are turned round 
 at their extremities into a semicircle or more, and present a spiral 
 appearance like the extremity of a screw. This disposition sug- 
 gested to M. Muller the name of Helicine, or spiral or screw-like 
 arteries; {ArtericE Helicine.)* 
 
 The helicine arteries of the penis are more easily seen in man 
 than in any other animal which Professor Muller has examined. 
 He has found them in all the animals in which he has sought for 
 them ; they are to be seen at the posterior part only of the penis 
 in the stallion, but in the dog exist throughout the whole organ. 
 
 In man, the helicine twigs of the penal arteries sometimes come 
 oflp singly, and at other times they form tufts or bunches, consisting 
 of from three to ten branches, and having in general a very short 
 common stem. The swelling at the extremity, when it occurs, is 
 gradual, and is greatest a little way from the end. The helicine 
 branches given off from large arteries are not of a greater size than 
 those coming from smaller ones, and even the smallest capillary 
 arteries of the profunda penis^ which can be seen with the help of 
 a glass only, give off helicine twigs of a much greater size than 
 themselves. 
 
 * Ueber die Arteri® Helicin®. Von Johann Dr MiiUer, Archive fur Anatomie 
 und Physiologic, Heft II. 1835. 
 
174 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Each helicine branch projecting into a venous cavity is covered 
 by a thin membrane, which Professor Muller regards as the inner 
 coat of the dilated vein, and when there is a tuft of helicine twigs, 
 the whole tuft is covered with one envelope of a gauze-like mem- 
 brane. This covering is considerably thicker on the helicine arte- 
 ries in the posterior part of the corpus spongiosum urethrae than in 
 the corpus cavernosum ; but it is probable that this is in some 
 measure connected with the state of repletion of the arteries ; for 
 when the injection has run well, it becomes difficult to distinguish 
 the external covering. 
 
 Professor Muller could not discover any apertures either in the 
 sides or in the ends of the helicine arteries ; but he seems to regard 
 it as probable that there are minute apertures, which may be of a 
 nature to allow the passage of blood in some states and not in others. 
 
 The helicine arteries are not, as some may suppose, loops of ves- 
 sels which have been incompletely filled, and which, after making 
 a coil, pass into venous spaces, as E. H. Weber discovered to be the 
 case with the arteries of the maternal portion of the placenta. 
 They are merely branches projecting from the arterial trunks con- 
 taining blood. 
 
 The helicine arteries are more numerous towards the root than near 
 the point of the penis. They are observed in the corpus spongiosum 
 urethrae, especially towards its bulb, but they are not so easily seen 
 there as in the corpora cavernosa. They have not yet been observed 
 in the glans. Their structure is nearly the same in all the animals 
 in which they have been observed ; those of the ape bear the near- 
 est resemblance to those of man, and in most animals they are less 
 obvious than in the human subject. In the horse and dog they 
 give off small nutrient twigs from their sides, which render them 
 more difficult to be seen in these animals than in man. 
 
 It seems not doubtful that the accumulation of blood in these 
 helicine arteries is the physiological cause of the phenomena of 
 erection. 
 
 The spleen, M. Bedard thinks, may be said to resemble the ca- 
 vernous body both in structure and phenomena ; and he considers 
 it as at once consisting of erectile tissue, and to be the seat of a 
 species of erection more or less similar to that of the cavernous 
 body. This organ, he argues, becomes the occasional seat of a 
 motion of expansion and contraction ; and he adduces the three 
 following conditions in which it takes place. \st, In experiments ; 
 when in a living animal the course of the blood in the splenic veins 
 
ERECTILE TISSUE. 
 
 175 
 
 is arrested, the spleen swells, but returns to its former dimensions 
 as soon as the circulation is restored, 2<7, In diseases ; the parox- 
 ysms of intermittent fever are accompanied with obvious enlarge- 
 ment of this organ, which subsides at the conclusion of the parox- 
 ysm. It appears that the same phenomenon takes place during 
 digestion. 
 
 Sir Everard Home, with the assistance of the microscopic in- 
 spection of M. Bauer, has made many observations on the struc- 
 ture of this organ. But his purpose appears to have been more 
 particularly directed to ascertain the phenomena of its function and 
 uses ; and 1 cannot discover that his ideas on its intimate struc- 
 ture, and the arrangement of its capillary system, are very precise 
 or distinct. 
 
 The most distinct examples, in short, of erectile tissue are to be 
 found, according to Bedard, in the spongy texture which surrounds 
 the urethra^ in the cavernous body of the clitoris, the vascular 
 structure of the nymphos, and in the nipple of the female. The 
 structure of the lips in both sexes is not unlike. The veins of 
 these parts may be shown to be well-marked and largely dilated 
 at their origin, so as to give the appearance of cellular net-work. 
 The same disposition is observed in the pulp of the fingers. It has 
 been attempted to explain the motions of the iris by supposing it 
 to be formed of this erectile tissue ; but the justice of this conjec- 
 ture seems doubtful. 
 
 In the tissue now described it is manifest that the physiologist 
 ought to place the phenomena of the process distinguished by the 
 name of vital turgescence {turgor vitalis) by Hebenstreit,* * * § Reil,f 
 Ackermann,! and Schlosser.§ Though these authors suppose vital 
 turgescence in different degrees in almost all the textures of the 
 animal body, their most distinct examples are taken from those 
 parts which consist of erectile vessels. After the explanation of 
 the anatomical structure above given, it is superfluous to seek for 
 any other cause except the arrangement of the minute vessels, their 
 helicine termination, and the disposition of the veins. 
 
 * Brevis Expositio Doctrinse Physiologicae de Turgore Vitali. 1795. Ab Ernesto 
 Benjamino Gottlieb Hebenstreit, M. D., &c., extat in Brera Sylloge Opusculorum Se- 
 lect. Vol. II. Opusc. vi. 
 
 f Archiv. fiir die Physiologic, I. Band, 2. Heft, S. 172. 
 
 $ Ackermann Physische Darstellung der Lebenscraft, 1797. 1. Band, S. 11. 
 
 § Georgii Eduardi Schlosser Dissertatio de Turgore Vitali ext. in Brera Sylloge, Vol. 
 VII. Opusc. ii. 
 
176 
 
 GENERAL AND PATHOLOGICAL AJ^JATOMY. 
 
 Section IL 
 
 Little is known regarding the peculiar pathological states of this 
 tissue. 
 
 1. Rupture of its vessels occasionally occurs, but is not attended 
 with peculiar phenomena, unless there is an external communica- 
 tion, when hemorrhage takes place. 
 
 2. It is liable to a peculiar species of enlargement or swelling, 
 in which the parts are very tense, and resemble a swollen bladder. 
 They have an oedematous appearance, yet it is not oedema. This 
 is often seen in phimosis and paraphimosis, in enlargement of the 
 mjmplKB and lahia in females, and in a swelling incident to the 
 eyelids after the application of leeches in both sexes. 
 
 This swelling, I think, is most usually connected with some mor- 
 bid state of the surface of the parts ; either inflammation, as in go- 
 norrhoea and leucorrhoea, or an abrasion, an ulcer, or laceration, or 
 some similar lesion. 
 
 3. Priapism is a morbid state of the erectile tissue of the caver- 
 nous body. The painful and anomalous mode of erection termed 
 chordee appears to depend on the erectile tissue of the corpus spon- 
 giosum being unduly irritated by the presence of the inflamma- 
 tory stimulus in the urethral membrane and its submucous tissue. 
 There is at the same time, however, a spasm of the erector muscle, 
 (ischio-cavernosus,) which, Haller justly remarks, instead of erect- 
 ing the penis, ought to depress it. 
 
 4. Is the erectile tissue more prone to hemorrhage than others ? 
 Is this hemorrhage more frequently venous than arterial ? These 
 are points on which we have almost no certain information. Urethral 
 hemorrhage, when violent and copious, may depend on rupture of 
 the erectile tissue of the spongy body, or those vessels of the ure- 
 thra which have been well delineated by Mr Shaw.* When it is 
 so copious as to be restrained with difficulty, there is reason to be- 
 lieve that a communication is opened between the urethra and the 
 communicating veins of the spongy body. 
 
 It may here be mentioned that hemorrhage from the vagina, 
 whether intentionally or accidentally inflicted, is always most pro- 
 fuse and copious, and difficult to be restrained. From this cause 
 various females in this country have died, before adequate means 
 
 * Medico-Chirurgical Transactions, Vol. X. p. 342 and 357. 
 
ERECTILE TISSUE. 
 
 177 
 
 to suppress the hemorrhage could be adopted. This is manifestly 
 dependent on the plexiform arrangement of the multiplied venous 
 vessels by which the vaginal mucous membrane is surrounded. 
 
 5. The disease described by John Bell and Mr Freer* under the 
 name of aneurism by anastomosis^ {aneurysma per anastomosin')^ 
 termed by Meckel angiectasia, (Ayysiov ixraaig, vasorum dilataiio,) 
 and by some of the German pathologists, telangiectasis, (vasorum 
 ultimorum distensio,) appears to be an accessory or morbid form of 
 erectile tissue occurring in parts naturally provided with simple 
 capillary tissue. In some circumstances it is a congenital disease, 
 and appears at birth like a ncevus maternus. In its early stage the 
 tumour is a mere pimple, and appears to consist of a congeries of 
 arteries and veins.| In this state it is firm, and the throbbing is 
 indistinct ; but as the cellular net-work, which ultimately forms the 
 bulk of the swelling, is developed, it becomes more compressible, 
 and the pulsation becomes more evident. At last it appears to 
 consist of a cluster of sacs of a purple or livid colour, which burst 
 from time to time, and bleed profusely. Anastomotic aneurism 
 may occur in any part of the body in which the capillary vessels 
 are numerous. Mr Bell saw it in the face, near the angle of the 
 eye. Mr Freer saw it within the mouth, between the gums and 
 the cheek. I have seen it on the skin of the nose and on the gum. 
 
 In two instances in which I saw it on the skin of the nose, the 
 body resembled a small reddish mark on the skin, about the size 
 
 * Observations on Aneurism and some Diseases of the Arterial System. By George 
 Freer, Fellow of the Royal College of Surgeons, London, &c. Birmingham, 1807, p. 
 34. 
 
 t The Principles of Surgery, in Two Volumes, &c. by John Bell, Surgeon, Discourse 
 XT. p. 4S6, Vol. I. 4to Edition. 1801. 
 
 J “ The tumour is a congeries of active vessels ; and the cellular substance through 
 which these vessels are expanded resembles the cellular part of the penis, the gills of 
 a turkey cock, or the substances of the placenta, spleen, or womb. It is apparently a 
 very simple structure that enables those parts, (the womb, the penis, the spleen,) to 
 perform their functions ; and it is a very slight change of organization that forms this 
 disease. The tumour is a congeries of small and active arteries, absorbing veins, and 
 intermediate cells. The irritated and incessant action of the arteries fills the cells with 
 blood ; from these cells it is reabsorbed by the veins ; the extremities of the veins 
 themselves perhaps dilate into this cellular form. There seems to be a perpetual 
 circulation of blood ; for there is incessant pulsation. The tumour is permanent, but 
 its occasional variation of bulk is singular. It swells like the penis in erection, or the 
 gills of a turkey-cock in a passion. It is puffed up by exercise, di-inking, or emotions 
 of the mind. It is filled and distended with blood upon any occasion which quickens 
 the circulation, as by venery, menstruation, the pleasures of the table, heated rooms, 
 or the warmth of the bed.” — Principles of Surgery, p. 457. 
 
 M 
 
178 
 
 GENERAL AND PATHOLOGICAL ANATOBIY. 
 
 of a split pea, without elevation, but presenting, when closely ex- 
 amined, a cluster of minute vessels proceeding from a circumfe- 
 rence to a point, in the asteroid form. In both cases they were 
 liable to become red and uneasy on exposure to external heat, 
 during blushing, and on any excited state of the circulation. When 
 pressed, the vessels seemed to be for one moment emptied and then 
 to be immediately filled, giving the part a deeper red colour than 
 before. In the instance, in which I saw the tumour on the gum, 
 {parulis aneurysmatica,') the form of the disease was greatly more 
 distinct. It appeared in the form of a tumour of the size of a 
 large pea, situated in the gum of the upper jaw. It pulsated 
 strongly and distinctly, and was the seat of a disagreeable sensa- 
 tion of heat and throbbing. When situate on the mucous surfaces, 
 these tumours are liable to attacks of hemorrhage ; and occasion- 
 ally this accident takes place in those of the skin. 
 
 When it occurs on the surface of the body, its covering is so 
 thin as to appear destitute of the usual corion. The pulsation in 
 the tumour is increased by all those causes which accelerate the 
 action of the heart.* 
 
 The arterial disease found often affecting the branches of the 
 temporal, posterior aural, and occipital arteries, as described by 
 Mr Maclure, Mr Maclachlan, Mr Syme, and M. Lallemand, is 
 manifestly the same affection as that already noticed under the 
 head of arterial varix and cirsoid aneurism. The arteries are 
 dilated, tortuous, and serpentine ; the tunics of the vessels are thin, 
 flaccid and feeble, and pulsate strongly ; while occasionally after 
 death these vessels are observed, like veins, to have undergone the 
 suppurative inflammation.! 
 
 6, Osteo-aneurism. Not dissimilar to the anastomotic aneui’ism 
 is a species of throbbing tumour observed by Pearson,! and fully 
 described by Scarpa.§ In the latter instance a pulsating tumour, 
 which had gradually attained the size of the fist, was formed in the 
 substance of the anterior part of the tibia, beneath the periosteum, 
 which had become thick and fleshy, and formed a sort of contain- 
 ing membrane. Its inner surface was villous and irregularly 
 
 * For further details on this subject the reader may consult Warren on Tumours, 
 section viii. Boston, 1837. 
 
 t Breschet, Memoires de I’Academie, Tome III. p. 161. 
 
 J Medical Communications, Vol. II. p. 95 and 100. 
 
 § A Treatise on the Anatomy, Pathology, and Surgical Treatment of Aneurism. 
 By Antonio Scarpa. Edinburgh, 1808, Case x. p. 439. 
 
ERECTILE TISSUE. 
 
 179 
 
 spongy, like the utei’ine surface of the placenta ; and wax injected 
 into the popliteal artery escaped from it, and was deposited be- 
 tween layers of coagulated blood, which must have proceeded from 
 vessels opening on this surface. The substance of the tibia at the 
 bottom of the cavity was rough, corroded, and partly destroyed. 
 
 After the limb was removed the patient remained well for five 
 years, when the stump, and eventually the whole thigh, was attack- 
 ed with painful pulsation. At death, which soon took place, the 
 substance of the thigh-bone was found to be removed by absorption 
 from the cut end to near the neck ; and the periosteum, which was 
 much thickened, was interspersed with largely dilated vessels, and 
 formed a sort of capsule or inclosing membrane to the diseased parts. 
 
 This disease differs from anastomotic aneurism in its pulsation 
 and distension being at all times the same, and in not presenting 
 the phenomena of erection. Though it is mentioned in this place 
 from its general resemblance to that disease, it may be more justly 
 regarded as genuine aneurism of the capillaries, or rather aneurism 
 of the arteries of bone. 
 
 Morbid States of the Spleen as an erectile organ. 
 
 1. Softening. The most common morbid state of the splenic tissue 
 is that of softening. This may be various in degree. In the least 
 severe the texture of the spleen is lacerable ; and when torn, the 
 surfaces present a good deal of the natural structure of the organ 
 in the form of fibres and vessels, and filaments of some firmness. 
 In the next stage, the softening is more complete and the organ 
 may be crushed between the fingers. "When a stream of water is 
 directed on the surface, it washes away much wine-red-colour- 
 ed fluid, leaving shreds and filaments. In the third and most com- 
 plete degree of this lesion, the spleen is converted into a soft semi- 
 fluid pulpy mass, of a dark-red or deep pink colour, like thick wine- 
 lees, with nothing but a few shreds and filaments left. 
 
 This change of consistence takes place in ague, remittent fever, 
 yellow fever, typhus, occasionally in puerperal fever, and sometimes 
 in diseases of the stomach and alimentary canal. 
 
 The nature and origin of softening of the spleen is not perfect- 
 ly known. If not an effect of inflammation, it must he regarded 
 as one of excessive vascular distension. It is associated with that 
 state in which the internal vascular system in general, and that of 
 the abdomen in particular, is for a long time inordinately distended. 
 Inflammation, it must be remembered, has the effect of destroying 
 
180 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the cohesion of tissues, and thereby causing softening. It seems to 
 be in fever a mortal lesion. 
 
 2. Splenia ; Splenitis ; Lienia. The spleen appears to be liable to 
 four forms of inflammatory action; proper inflammation, ter- 
 minating in resolution or suppuration ; 2d, suppurative inflamma- 
 tion ; 3r/, simple enlargement from vascular distension ; and, Ath, 
 enlargement, with induration of its tissue. 
 
 Simple inflammation, though not common, does take place. In 
 two cases of inflamed spleen examined by Dr William blunter, 
 where the inflammation had advanced to suppuration, the patients 
 could not define accurately the seat of the pain, which seemed to 
 travel over the general cavity of the abdomen. In another case, 
 in which Anthony de Haen found the spleen distended with a large 
 quantity of thick white purulent matter, the symptoms had, during 
 the inflammatory stage, been ascribed to pleurisy. 
 
 Both Schmidt, Heusinger, and Grottanelli record, in like man- 
 ner, instances in which suppuration had taken place in the spleen 
 without the production of any manifest symptom or local uneasi- 
 ness, sufficient to lead the circumstance to be suspected, except ge- 
 neral bad health and wasting. A remarkable case of this kind is 
 recorded by Dr Abercrombie, in which the patient, after slight ca- 
 tarrhal symptoms, pined away without distinct local uneasiness for 
 six months, and died wasted and weakened, latterly with diarrhoea 
 of two days’ standing ; and upon inspection the spleen contained se- 
 veral ounces of purulent matter. Similar instances of purulent 
 collections in the spleen, where no indication of previous disorder 
 was afforded, have come under my notice in the course of inspect- 
 ing bodies at the Royal Infirmary. 
 
 These facts show clearly that suppuration of the spleen may take 
 place without being attended with evident or urgent external symp- 
 toms. In this case it may become a question whether the suppu- 
 ration is the effect of acute inflammation, or rather of a peculiar 
 chronic suppurative action, — connected probably with that conve- 
 nient and ill-defined abstraction, the strumous diathesis. It must 
 not be imagined, nevertheless, that no symptoms are produced by 
 this disorder. There are always wasting or pining, considerable 
 weakness, sometimes a thin unhealthy look, sometimes slight dys- 
 peptic symptoms, and sometimes, though more rarely, a sense of 
 uneasy fulness deep in the left hypochondriac region. The most 
 perplexing part of the semiography and symptomatology is this, that 
 
EEECTILE TISSUE. 
 
 181 
 
 these purulent collections cause almost no uneasy feelings, till by 
 their size they induce distension or painful stretching of the organ, 
 or pressure or tension of some of the surrounding parts. 
 
 In such circumstances, it is chiefly by negative signs that the 
 practitioner can infer the existence of disease, in the shape of in- 
 flammation or abscess of the spleen ; and, if he meets with a case 
 in which the patient pines away, without cough, expectoration, ca- 
 vernous respiration in the chest, or the signs of empyema in the 
 side, or indications of enlarged liver, or ulceration of the intestinal 
 mucous membrane, he may then infer the probable existence of 
 suppurative or other disorder of the spleen. 
 
 This disease is rare, and therefore not well known ; but the prac- 
 titioner must not expect, like Pemberton, never to meet with it. 
 Abscess of the spleen is sometimes found to be the only morbid 
 appearance in sundry cases of long ill health, with waiting and 
 hectic fever. 
 
 3. It is not perfectly ascertained whether the form of simple 
 enlargement of the spleen, or the enlargement with induration 
 ever proceeds to suppuration, or whether suppuration and abscess 
 of the spleen is in certain circumstances the result of one peculiar 
 form of inflammation. P rom the testimony of Grottanelli suppu- 
 ration of the spleen seems a lesion not unfrequent in Tuscany and 
 other aguish districts in Italy. * M. Raikem of Vol terra records in 
 a young book-keeper of 21, a case of splenitis ending in an exten- 
 sive collection of fetid purulent matter, in which, from the pro- 
 gress of the symptoms, there is reason to believe that the organ had 
 been affected at first with simple enlargement from vascular dis- 
 tension. The whole duration of the disease appears to have been 
 rather more than three months ; the acute symptoms for which the 
 patient was under the care of M. Raikem, two months ; and the 
 tumour of the left hypochondre, which was at first hard and re- 
 sisting, and extended to the linea alba and navel, became about 
 the sixth week soft, increasing in size, and afterwards diminishing 
 remarkably. 
 
 Inspection of the body disclosed the following facts. The left 
 pleura contained more than two pounds of citron-yellow serous 
 fluid, with albuminous flakes floating in it. The pleura of that side 
 was covered by a thin coating of concrete puriform matter, and was 
 
 * Ad Acutae et Chronicae Splenitidis in huniilibus praesertim Italiae locis conside- 
 ratae eidemque succedentinm Morbomm Historias Animadversiones. Auctore Stanis. 
 lao Grottanelli, Philosoph, Med. et Chir. Doctore. Florentiae, 1821. 8vo. 
 
182 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 reddish, and had the appearance of being slightly thickened. The 
 corresponding lung was crepitant and void of tubercles. Its pleura 
 adhered to the costal pleura by means of soft recent albuminous 
 bridles ; and the lobes were connected in the same manner. 
 
 The upper portion of the descending colon and the large end of 
 the stomach adhered closely to the spleen. This organ was twice 
 its ordinary size, and was of a crimson red colour at the margins. 
 The portion of the abdominal peritoneum, corresponding to the 
 posterior splenic surface, was raised by a white, thick, purulent, 
 very fetid liquid, proceeding from the interior substance of the 
 spleen, which was hollowed into a large abscess with purulent-lined 
 walls. The contents had been effused between this serous mem- 
 brane and the adjoining muscular layer, the vertebral column, and 
 left kidney, and had extended to the crural arch. * 
 
 It seems probable that this is an example of suppurative inflam- 
 mation from the commencement. 
 
 In some instances of suppuration or abscess of the spleen, instead 
 of one large abscess, several small ones are observed. These are 
 probably of a more chronic character, and perhaps are indications 
 of the strumous diathesis. A case, in which, in a young woman of 
 20, the spleen contained two circumscribed abscesses, is given by 
 Dr Tweedie in his Illustrations of Fever. In this case there were 
 ulcers in the intestinal mucous membrane. 
 
 Do these collections ever find their way to the surface by means 
 of progressive absorption ? Fantoni gives an instance of one which 
 had opened at the navel in a female, and who recovered her health 
 and afterwards bore a child. Five years afterwards she died, and 
 upon inspecting the body after death no trace of spleen was found. 
 
 The following case is given by Grottanelli. A Franciscan 
 monk, aged sixty-seven, a sufferer from ague, was attacked, in the 
 autumn of 1812, with pain in the region of the spleen, where was 
 a hard painful swelling. At the end of eighteen days the pain was 
 abated ; but there appeared in the abdomen, near the Iznea alba^ a 
 considerable convex swelling with fluctuation. Three days after, 
 under the use of anodyne plasters, an opening spontaneously took 
 place ; and there was discharged a fluid partaking of the character 
 of steatomatous and albuminous matter. Of this forty-eight ounces 
 were discharged the first day, and as much on each of the three fol- 
 lowing days. At the end of thirty days the patient was well ; the 
 spleen v'as a little lai’ger than natural, but without pain and un- 
 
 * Breschet, Repertoire General cl’Anatomie et de Physiologie, Tome vii. p. 115. 
 
 4 
 
ERECTILE TISSUE. 
 
 183 
 
 easiness. This person lived about two years afterwards. He was 
 again attacked with ague, oedema of the feet, and died.* 
 
 The external opening is doubtless the most favourable. That 
 into the stomach or colon, when it is followed by purulent vomiting 
 or diarrhoea, is next favourable. That through the diaphragm into 
 the pleura or lungs is much less favourable, and must he considered 
 as peculiarly dangerous. And when the outlet is made within the 
 peritoneum, or without that membrane, it is necessarily and very 
 speedily fatal. 
 
 It is necessary to mention, nevertheless, that Grottanelli gives 
 two cases, (IX. § 53, § 56,) in which he states that, notwithstand- 
 ing this kind of outlet witliin the peritoneum, recovery took place. 
 In the first, in consequence of a kick on the abdomen, an abscess 
 of the spleen had burst into its cavity ; and though the immediate 
 effects bore all the characters of speedily approaching death, yet, 
 after twenty hours, the patient began to rally, and after voiding 
 a large quantity of urine-like faeces for the space of three weeks, 
 finally recovered, and was seen perfectly well seven years after. 
 In the second, the person received a kick from a horse in the re- 
 gion of the organ ; yet, after diarrhoea and bloody hypostatic urine 
 lasting for many days, he eventually recovered. 
 
 4. Simple or indolent enlargement from vascidar distension. — 
 Almost all authors have noticed enlargement of the spleen, super- 
 vening either spontaneously or after ague and other bad fevers. 
 Morgagni relates an instance in which the spleen of a slender wo- 
 man of twenty-eight, who had undergone chronic fever, occupied 
 the whole of the left side of the belly, and weighed eight pounds 
 and a-half, without change of its interior structure, but apparent 
 dilatation of the vessels and development of its lymphatics ; and 
 Pemberton mentions one weighing three pounds two ounces, yet 
 with perfectly natural structure. Mr Elliot describes one weighing 
 eleven pounds thirteen ounces, with natm’al structure,! and Bree 
 states it to vary from one to twenty or thirty pounds after ague 
 and chronic diseases of the viscera. The natural weight of the 
 spleen is from nine to fourteen ounces. Baillie remarks, that this 
 simple enlargement with structure perfectly healthy, happens to the 
 spleen more commonly than to any other organ, and regards it 
 rather as a monstrous growth than as actual disease. It appears to 
 me that this is correct only to a certain extent ; and that simple 
 
 * Ad Acutse et Chronic® Splenitidis, &c. Art. V. Hist. XI., quoted by Raikcm, 
 but carelessly. 
 
 •f Med. Com. Vol. XVII. p. 497. Stoll, Ratio Med. i. 163, 251. 
 
184 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 enlargement is an incipient morbid state, which will progressively 
 terminate in another morbid state, which is distinguished hy less 
 equivocal organic characters. Pemberton formed a just notion of 
 this enlargement or swelling of the splenic substance, when he said 
 it might perhaps arise from a larger quantity of blood being con- 
 veyed to it by the arteries, without, however, these arteries taking 
 on that action, which is the essence of inflammation. In short, 
 whatever be the remote cause or the material agent, the disease 
 consists in unusual accumulation of blood in the organ, whether 
 conveyed by arteries or not removed by veins ; and if this accumu- 
 lation continues long, it .will, under certain circumstances, render 
 the organ unusually soft. When the capsule, which in such cir- 
 cumstances is very tender, is broken, the substance of the spleen 
 seems to consist of little else than a very soft brownish red mucus, 
 intermixed with a spongy fibrous texture. This softening, as it 
 may be named, appears to be caused by the immense quantity of 
 blood in the vessels, producing a slow but severe disorganization or 
 breaking down of the proper splenic tissue. (See Dr Bree’s paper.) 
 Baillie thinks it is hardly to be considered as a disease ; but this 
 opinion, I fear, rests on no good foundation. In some circumstan- 
 ces, to be afterwards specified, the structure of the spleen not en- 
 larged is unusually soft, apparently from some cadaverous change ; 
 but the true softening of the enlarged organ is efiected in the man- 
 ner represented,* 
 
 The symptoms of simply enlarged spleen are not well known. 
 The patient usually complains of a sense of fulness rather than pain 
 in the left side ; in some instances pain is felt when the left side is 
 examined or pressed ; in others the pain is not perceived in the seat 
 of the spleen, but at the lower part of the left side, inclining to- 
 . wards the back ;f and in others, the swelling may proceed to a 
 very large size without causing any uneasiness whatever. In most 
 cases the left hypochondi'iac region bulges out, and in some the 
 enlargement may be distinctly felt by the hand. The patient can 
 only lie on the left side ; the countenance is sallow, but not jaun- 
 diced ; hemorrhages from the nose take place ; and if it continues 
 long, it may cause watery effusion within the peritoneum ; {ascites.) 
 
 Indolent enlargement of the spleen may terminate in resolution, 
 by subsiding spontaneously or under medical treatment, in soften- 
 ing with emaciation or death, or in induration and incurable dropsy 
 of the belly. 
 
 * See note on Cooke’s Morgagni, Vol. II. p. 176. The spleen, a mass of gore. 
 
 f Morgagni, l.w. 10. 
 
ERECTILE TISSUE. 
 
 185 
 
 The causes of indolent enlargement are little known. A long 
 residence in districts infested by intermittent fevers, especially quar- 
 tans, and repeated attacks, or the prolonged continuance of these 
 disorders, give the spleen a tendency to swell ; and the disease is 
 common in fenny and aguish districts, both in this island and on 
 the continent. Thus in Lincolnshire, Essex, Kent, Cambridge- 
 shire, &c. it is not uncommon ; it assumes its most formidable ap- 
 pearance in the department of the lower maritime Alps in France ; 
 in Hungary it is endemial ; and in the Carolinas and other south- 
 ern states of the American Union, it is rare to find persons who 
 have attained thirty or five and thirty years, without more or less 
 enlargement of the spleen. In some instances the disease succeeds 
 a blow on the hypochondre. 
 
 5. Indurated enlargement of the Spleen. This is perhaps more 
 common than enlargement with softening ; for every enlarged 
 spleen may in process of time become hardened. In this state the 
 organ may be five or six times its natural size, yet, when divided, 
 presenting its natural structure, only much more dense and com- 
 pact than natural. This is sometimes considered as scirrhus, but 
 it is unlike to this in other parts of the body, and its real nature is 
 not well understood. It is not improbable that it is the effect of 
 chronic inflammation. It is generally attended with dropsical effu- 
 sion within the peritoneum. It can seldom be recognised till the 
 disease has made such progress that the enlarged organ is felt ex- 
 ternally, when it protrudes the false ribs, and the anterior edge or 
 top of the organ can be felt by the hand appbed to the belly under 
 the margin of the ribs. It is sometimes notched. Even in this 
 state the only symptoms are an unhealthy sallow look, wasting of 
 the fleshy parts, and swelling of the belly, dry skin, and at length 
 the usual signs of dropsy of the belly. 
 
 The disease is a common effect of residence in aguish districts. 
 According to Grottanelli it is endemial in the territory of Pitigliano 
 and other low districts in Italy. 
 
 The size and weight of the spleen, when affected with hypertro- 
 phy and induration, are seldom so considerable as when the disease 
 is simple induration. The spleen weighs, then, in this country, 
 from three to seven pounds. In one remarkable case which I have 
 published for other reasons, the indurated spleen weighed seven 
 pounds three ounces and a-half ; and in another case which had 
 also been under my care, and in which death took place in the 
 same manner, the spleen weighed seven pounds twelve ounces. 
 
186 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Hypertrophy of the spleen with induration presents occasionally 
 a singular mode of termination. When the swelling has attained 
 a great size, the patient is attacked rather suddenly with symptoms 
 of inflammatory fever of considerable intensity, accompanied with 
 marked disorder in the circulation of the brain. The skin is hot, the 
 pulse quick, from 100 to 110; the face is of a deep-red or brown 
 colour ; the eyes are suflPused and injected ; and the patient com- 
 plains of thirst and pain in some part of the head. The breathing 
 is also a little hurried and oppressed. The symptoms, in short, 
 are very similar to those of phlebitis. After this has proceeded for 
 one or two days, delirium comes on, the breathing is more oppressed, 
 and the patient expires. 
 
 Upon inspection all the large veins of the chest and abdomen, 
 and the sinuses and veins of the brain are found filled with masses 
 of clotted blood mixed with lymph and purulent matter. The tu- 
 nics of the veins, however, are not thickened, nor are the lining 
 membranes roughened. 
 
 This result I have seen take place in two cases, both of which 
 were so carefully observed, that no error appears to me to have 
 been committed. The occurrence it is not easy to explain. All 
 that we can do is to note the fact, that in such cases of splenic dis- 
 ease, a severe lesion is liable to take place with lymphy and pur- 
 ulent deposits in the venous blood of the chest, abdomen, and brain.* 
 
 6. Tubercles of the spleen or tyromatous bodies are occasionally 
 met with. The organ is generally enlarged ; and its interior pre- 
 sents disseminated through it a number of whitish-gray or cream- 
 coloured bodies, globular or spheroidal, varying from the size of 
 small peas to that of moderate sized beans. Their substance is 
 very much like that of tyromatous matter in other parts of the 
 body, that is, a sort of albuminous or caseous matter without orga- 
 nization. The splenic tissue is at the same time in general a little 
 more consistent than usual. 
 
 An important circumstance to be observed is the early period at 
 which tubercles of the spleen may be generated. I have seen them 
 in infancy before the termination of the first year of life. This I 
 observed in the body of an infant in 1832, who had been cut off by 
 intestinal disorder. Tubercular deposits were found also in the 
 lungs. 
 
 * Case of Disease of the Spleen, in which death took place in consequence of the 
 presence of purulent matter in the blood. By David Craigie, M. D., &c., Edin. Med. 
 and Surgical Joiunal, Vol. LXIV. p. 400. 
 
SYSTEM OF EXHAEANTS. 
 
 187 
 
 CHAPTER IX. 
 
 SYSTEM OF EXHALANTSy ( Vasa exhalantia .) — exhalant system, — 
 (^Si/steme exhalant.) 
 
 Section I, 
 
 Are there such vessels as the exhalants described by physiolo* 
 gical authors ? Is their existence proved by observation or inspec- 
 tion ? If not, what are the proofs fi’om which their existence has 
 been inferred ? 
 
 The existence of minute arteries, the open extremities of which 
 are believed to pour out various fluids in different tissues of the 
 human body, has long been a favourite speculation with physiolo- 
 gical anatomists. The decreasing vessels, {vasculorum continuo 
 decrescentium multi sibique succedentes oi'dines,)* and exhalant ori- 
 fices of Boerhaave, are, or should be known to almost all. Haller 
 ascribes to the skin, membranes of cavities, {serous membranes^ 
 ventricles of the brain, the chambers of the eye, the cells of the 
 adipose membrane, the vesicles of the lung, the cavity of the sto- 
 mach and intestines, an abundant supply of these exhalant arteries 
 or canals, which, according to him, pour out a thin, aqueous, jelly- 
 like fluid, which, in disease, or after death, is converted into a wa- 
 tery fluid susceptible of coagulation. The existence of these ves- 
 sels, he conceives, is established by the watery exudation which 
 appears in these several parts after a good injection of the ar- 
 teries.! 
 
 As these minute canals, however, through which this injected 
 fluid is believed to percolate, have never been seen, or rendered 
 capable of actual inspection, their existence was denied by Mas- 
 cagni, who ascribed the phenomena of exhalation to the presence 
 of inorganic porosities in the arterial parietes, through which he 
 imagined the fluids transuded to the membranes or organs, in which 
 
 * Haller, Elementa, Lib. ii. sect. i. and his Notes on Boerhaave, Praelectiones, 
 Tome II. p. 245. 
 
 t “ Aqueum humorem de arteriis perinde exhalare, olei terebinthin®, ahorumve 
 pigmentorum et vivi ai-genti iter persuadet, quod anatomica manu impulsum, ant om- 
 nino vivo in homine a consuetis natm-se viribus eo deductum, in ejus humoris, qiiam 
 vocant cameram, depluit.” — Elementa, Lib. vii. sectio 2, § 1. 
 
188 
 
 GENERAL AND PATUOLOGICAL ANATOMY. 
 
 they were found. This mechanism, which was equally invisible 
 with the Hallerian, was, for obvious reasons, denied by Bichat, who 
 resolved to reject every opinion not founded on anatomical obser- 
 vation, and to determine the existence of the exhalants by this evi- 
 dence alone. Obliged, however, to avow the difficulty of forming 
 a distinct idea of a system of vessels, the extreme tenuity of which 
 prevented them from being seen, he undertook to attain his object 
 by what he terms a rigorous train of reasoning. 
 
 This consists in nothing more than the effects observed to result 
 from fine and successful injections of watery fluids, or of spirit of 
 turpentine containing some finely levigated colouring matter, from 
 the phenomena of active hemorrhage, which Bichat considers 
 merely as exhalation of blood instead of serous fluid, and from a 
 multitude of considerations which are to be unfolded in the course 
 of further examination of the subject. In this manner he believes 
 himself warranted to conclude, that the only things rigorously as- 
 certained are, Is^, The existence of exhalants; 2d, Their origin in 
 the capillary system of the part in which they are distributed ; and, 
 3(/, Their termination on the surfaces of serous and mucous mem- 
 branes, and the outer surface of the corion or true skin. 
 
 The exhalant vessels, the existence, origin, and termination of 
 which he thus proved, he distinguished into three classes. The 
 first contains those exhalants which are concerned in the production 
 of the fluids, which are immediately removed from the body, — the 
 cutaneous and the mucous exhalants. The second contain those 
 exhalants which are employed in the formation of fluids, which, 
 continuing a given time on various membranous surfaces, are be- 
 lieved to be finally taken again into the circulation by means of 
 absorption. And the third class consists of the exhalants con- 
 cerned in the process of depositing nutritious matter in the differ- 
 ent tissues and organs of the human frame. This arrangement is 
 more distinctly seen in the following table. 
 
 1. Exterior, opening on natural surfaces or canals, 
 
 . 2. Interior, opening on membranes, or within cellular 
 textures. 
 
 ^3. Nutritious. 
 
 I Cutaneous, 
 j Mucous. 
 
 ! Serous. 
 Synovial. 
 Cellular. 
 Medullary. 
 
 Each organic tissue is in this system supposed to have its appro- 
 priate exhalant arteries, from which it derives the material requi- 
 site for its nutrition. 
 
SYSTEM OF EXHALANTS. 
 
 189 
 
 It is undeniable that this arrangement is at once clear, and "pos- 
 sesses a sort of interesting regularity, which would prompt the wish, 
 that the existence of these vessels was actually demonstrated with 
 certainty. It is evident, however, that the regularity of arrange- 
 ment is the only advantage which it possesses over the views of 
 those authors, whose method and opinions Bichat professed not to 
 follow. The existence of exhalants is as little proved in the ri- 
 gorous reasoning of Bichat, as in the fanciful theories of Boerhaave, 
 the generalizing conclusions of Haller, or the bold supposition of 
 lateral porosities by Mascagni. This defect in his system has 
 therefore been recognised by Magendie and Bedard, the first 
 of whom, though he admits the existence of exhalation as a pro- 
 cess of the living body, allows that no explanation of its mecha- 
 nism or material cause has been given, and asserts that Bichat has 
 created the system of vessels termed exhalants ; — while the second 
 thinks that anatomical observation furnishes no evidence of their 
 existence. 
 
 The colourless capillaries, he observes, which are admitted by 
 all, and the existence of which is satisfactorily established by the 
 well-known experiment of Bleuland, proves nothing whatever con- 
 cerning the existence of exhalant vessels ; for these colourless ar- 
 teries are observed to terminate in colourless veins, and there is no 
 proof hitherto adduced of their proceeding further, or terminating 
 by open mouths. He admits that the fact of exhalation in the 
 living body, of nutrition, of transudation by arterial extremities, 
 shows that these extremities possess openings through which the 
 fluids of exhalation, the materials of nutrition, and the matter of 
 injection escape. But whether these openings are found at the 
 point, at which the capillary arteries are continuous with veins, or 
 belong to a distinct order of vessels continued beyond these arte- 
 ries, is a question which observation has not yet determined, and 
 which it perhaps is unable to determine. Meanwhile, that the ex- 
 istence of a process such as exhalation is believed to be, is carried 
 on in the animal body, appears to be proved by the phenomena 
 of endosmosis and exosmosis. Such is the present state of know- 
 ledge in relation to the existence of exhalant arteries. While 
 the process of exhalation is admitted and believed, we must avow, 
 as Cruikshank did long ago, that we are unable to prove satisfac- 
 torily the existence of any set of vessels, or any mechanism by which 
 it might be accomplished. 
 
190 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 This difficulty, however, need not prevent us from observing, 
 that this is the proper place for noticing those morbid changes, 
 which are referred to the process of exhalation. 
 
 Section II. 
 
 The exhalations, properly so called, may be morbidly augment- 
 ed or diminished, or quite changed. 
 
 1. The best examples of morbid increase of exhalation is con- 
 ceived to be found in those of the serous membranes, giving rise 
 to the disease termed dropsy, {Hydrops.) It is most frequent in 
 the peritoneum and in the general cellular membrane ; less so in 
 the pleura and pericardium, and in the arachnoid membrane or its 
 divisions. In a local form it is very frequent in the vaginal coat 
 of the testicle. Recent observations on this morbid change, and on 
 the state of the system when under its influence, lead to the con- 
 clusion, that it is rarely a primary process, but is generally to be 
 considered as the effect of another, — as the symptom of a peculiar 
 condition of the system of capillary arteries going to the tissue 
 which is the immediate seat of exhalation. 
 
 The conditions of the capillary system in which exhalation is 
 preternaturally augmented are referable to two general heads. 
 The first of these is the state of distension which takes place during 
 inflammation, fever, &c. The second is the distension w'hich re- 
 sults from any mechanical impediment to the free motion of the 
 blood in a venous trunk or trunks, or in the arteries. 
 
 a. That the distended or overloaded state of the capillaries which 
 occurs during inflammation may cause a great and disproportionate 
 increase in the fluid exhaled, is established by the phenomena of 
 inflammation of the filamentous tissue, and especially of the serous 
 membranes. In the former, oedema and anasarca are results by no 
 means unfrequent. In the latter, one of the first effects of inflam- 
 mation, under certain circumstances, is effusion of fluid more or 
 less copious, and containing various proportions of coagulable mat- 
 ter. If the proportion of the latter be great, its coagulation forms 
 organizable lymph, which is the medium of adhesion, while the se- 
 rous part disappears, apparently by absorption. If it be small, its 
 coagulation gives rise to mere loose flakes, which, with the con- 
 stant increase of the quantity of fluid effused, are unable to main- 
 tain their attachment to any part of the membrane ; while the thin 
 
SYSTEM OF EXHALAJ^TS. 
 
 191 
 
 serous part is so copious, that as it is not removed by the veins and 
 lymphatics, it remains in the form of a serous, a sero-sanguine, or 
 a sero-purulent fluid, constituting genuine dropsy. The detailed 
 examination of this morbid accumulation belongs to the chapter on 
 the serous membranes. 
 
 That the capillary distension which takes place in fever is a fre- 
 quent cause of anormal exhalation, is shown by the collections of 
 limpid serum often found in the brain and spinal chord, by that 
 sometimes seen in the pericardium, and by the brownish watery 
 fluid often found in the pleura in the bodies of persons cut off by 
 any of the varieties of that disease. 
 
 /3. The influence of impediment to the return of the venous blood 
 in the production of extraordinary effusion has been known from 
 the earliest periods of medicine. In proof of this I shall not ad- 
 duce the experiment of Lower, who by tying the vena cava in a dog, 
 produced dropsy in a few hours ; for the injury in such a case may 
 produce inflammation of the peritoneum, and consequent effusion ; 
 and Hewson has justly objected to its competency, that the ligature 
 might have included lymphatics along with the venous trunk.* 
 Nor is it requisite to notice the experiments of Peyer, Bontekoe, 
 and others. It is sufficient to say, that the fact is established by 
 the eflfects of deranged circulation, as they take place, in veins ; 
 secondly^ in arteries ; and, thirdly, in both sets of vessels jointly, or 
 in the capillary system. 
 
 To the first head are to be referred tumour’s in the vicinity, or 
 affecting the substance of veins ; various diseases of the right au- 
 ricle and right ventricle of the heart ; hard disorganization or tu- 
 bercles of the liver ; cirrhosis of the liver ; hepatization or tuber- 
 cular disorganization of the lungs ; hard disorganization or scirrhus 
 of the pancreas ; induration and hj-pertrophy or tubercles of the 
 spleen ; and compression of the ascending cava by the gravid 
 womb during the latter stage of pregnancy. Of a more local cha- 
 racter are the oedematous swellings which appear in the neighbour- 
 hood of tumours and abscesses. Thus in abscess, aneurism, or tu- 
 mom’ of the arm-pit, and in scirrhus or cancer of the female breast, 
 the whole arm becomes oedematous from the top of the shoidder to 
 the tip of the fingers. One of the earliest symptoms of lumbar ab- 
 scess is in some instances an oedematous enlargement of the leg of 
 the side on which the abscess takes place ; and almost all deep- 
 
 * Experimental Inquiries, Part ii. by William Hewson, F.R.S. London, 177-1. p. 142. 
 
192 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 seated collections of matter give rise to considerable oedema of the 
 superior cellular membrane and skin. 
 
 The operation of the several circumstances now mentioned, 
 though well understood by many pathologists, has been happily 
 illustrated by M. Bouillaud, who has shown that in many instances 
 tumours in the neighbourhood of venous trunks compress them so 
 much, as to produce obliteration of their canal. The interior of the 
 vessel is then occupied with a clot of blood, solid, fibrinous, and 
 more or less friable, manifestly produced by the blood being stop- 
 ped in its course along the vein.* To obstruction of this descrip- 
 tion M. Bouillaud traced several instances of partial dropsy. 
 
 Of the influence of the second cause in producing dropsical ef- 
 fusion, we have examples in that which results from enlargement of 
 the right side of the heart, ossification and contraction of the mitral 
 or semilunar valves, ossification of the coronary arteries, aneurism 
 of the aorta or innominata, or even of the coeliac artery, all of which 
 give rise to more or less serous effusion in the pleura, or a symp- 
 tomatic dropsy of the chest. 
 
 The third condition is perhaps the most common origin of the 
 symptomatic or secondary dropsies. Whatever retards the free 
 circulation of blood through the minute arteries and veins of any 
 organ or texture will produce one or other of the following efiects ; 
 viz. inflammation, injection with effusion of red blood, or efiPusion 
 of serous fluid from the exhalants, according to circumstances. In 
 subjects where the structure of the parts is somewhat lax and yield- 
 ing, the last will be the most likely result ; and it may be regard- 
 ed as tbe mere consequence of tbe mechanical obstruction which 
 the blood encounters in its transit from the capillary vessels to the 
 larger trunks. “ The compression of a vein,” it is judiciously re- 
 marked by Hewson, “ may, by stopping tbe return of the blood, 
 not only distend the small veins, but the small arteries ; and the 
 exhalants may be so dilated, or so stimulated as to secrete more 
 fluid than they did naturally.”f It is in general, however, a re- 
 mote consequence, and is observed to take place only after the 
 cause of deranged circulation has subsisted for some time. Thus 
 tumours, tubercles, and other foreign growths of the brain give 
 rise to watery effusion within its ventricles. Hepatization and tu- 
 
 ■* De I’obliteration des veines et de son influence sur la formation des hydropisies 
 partielles, &c. Par M. Bouillaud. Interne des hopitaux civils de Paris. — Archives Ge- 
 nerates de Medecine, Tome II. p. 188. 
 
 •f- Experimental Inquiries, Part ii. &c. p. 142. 
 
SYSTEM OF EXHALANTS. 
 
 193 
 
 bercles of the lungs, chronic inflammation of the bronchial mem- 
 brane, ossification, cancer, tubercles, and other morbid changes in 
 the pleura, produce a symptomatic water within the chest. And in 
 dysentery, tubercular disease of the peritoneum, and enlargement 
 of the mesenteric glands, {tabes mesenterica), sy^mptomatic ascites is 
 a very frequent occurrence. 
 
 2. Unusual increase of exhalation may take place in the syno- 
 vial membranes, either articular or tendinous. In the former case 
 it constitutes one form of disease of the joints, to which perhaps the 
 name of hydrarthrus ought to be restricted. To this head also be- 
 longs the efliision which takes place in articular rheumatism and in 
 synovial rheumatism. In the latter, inordinate exhalation produ- 
 cing effusion forms the elastic hemispheroidal tumour known under 
 the denomination of ganglion. 
 
 3. Diminution of exhalation is rare, unless in consequence of an 
 unnatural augmentation of it elsewhere. 
 
 4. Hemorrhage. The only example of complete change of ex- 
 halation is that termed by Bichat preternatural exhalations., and 
 the most common of these is when the matter exhaled consists not 
 of the usual watery fluid, but of pure blood, constituting several 
 forms of the disease termed hemorrhage. This bloody exhalation 
 may take place either in the exhalations termed excrementitial, 
 or in those termed recrementitial, 
 
 «, To the first head are to be referred those hemorrhages from 
 the skin which are sometimes observed, and those from mucous 
 membranes, which are very frequent, during congestion of their ca- 
 pillary system. In the lungs for example, nothing is more com- 
 mon than exudation of blood from the bronchial membrane during 
 catarrh or bronchial inflammation. In such circumstances it is ge- 
 nerally small in quantity, {heemoptoe,) and unlike the copious and 
 irresistible discharge of pulmonary apoplexy. 
 
 It is still more distinct in haemoptysis, in which considerable quan- 
 tities of blood issue from, the surface of the bronchial membrane 
 without breach or laceration, and consequently from the orifices of 
 vessels by a process analogous to exhalation. (Bichat.) Is it also 
 by exhalation that the copious discharge of pulmonary apoplexy 
 takes place ? On this point facts are wanting. 
 
 In hemorrhage from any point of the gastro-intestinal membrane 
 the blood is exhaled in the same manner. The researches of Por- 
 
 N 
 
194 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 tal,* and Abernetliyf especially, as well as those of Bichat, esta- 
 blish the point as to the stomach and small intestines in li(Bmate- 
 mesis and rnelcBna. In dysentery the blood, however copious it 
 may appear, oozes from a large extent of the surface of the lower 
 end of the ileum, and from that of the colon, without ulceration or 
 gangrene, and evidently from the vessels of the villous membrane, 
 which during health secrete mucous and intestinal fluid. The same 
 is to be understood of hemorrhages from the rectum, indiscrimi- 
 nately known under the name of Immorrhois and hemorrhoidal dis- 
 charges, and erroneously supposed to proceed, in all cases, from the 
 hemorrhoidal veins. The true source of many of those bloody 
 discharges is the vessels of the villous membrane of the bowel, 
 which is usually observed to be reddened or embrowned, thicken- 
 ed, softened, and covered with blood- coloured mucus. 
 
 In the exhalants of the genito -urinary mucous system the same 
 condition takes place. Hemorrhage from the kidney, unless caused 
 by calculus, is the result of exhalation. Menstruation, both in the 
 sound state and when excessive, is equally so. (William Hunter 
 apud Cruikshank, I Bichat.) 
 
 In all these cases of hemorrhage two conditions of the capillary 
 and exhalant system may be remarked. First, In the capillaries 
 an unusual proportion of blood is accumulated, so that the small 
 ones conveying red blood become large and distended, and those 
 conveying the colourless part are injected with red blood. Second- 
 ly/, After this state has continued for some time, red blood is ob- 
 served to ooze in minute drops from the surface of the membrane, 
 and progressively to increase in quantity and superficial extent. 
 
 * Memoires sur la Nature et la Traitement cle plusieurs Maladies. Par M. Antoine 
 Portal. Tome II. Paris, 1800, p. 108. 
 
 f On the Constitutional Origin and Treatment of Local Diseases. By John Aber- 
 nethy. London, 1811. 
 
 ^ “ It happened that a woman died when her menses were flowing. Dr Hunter 
 examined the internal surface of the uterus, found it exceedingly red and loaded mth 
 Ijlood ; that the principal redness was from the distended and convoluting arteries. 
 He pressed forward the blood, wliich was fluid, and which, he asserted, never coagu- 
 lated, and saw it appear on the surface near the extremities of these arteries. As this 
 discharge happened instantly, and from the gentlest pressure of the finger, it could not 
 be transudation, which always requires time ; it could not be rupture of vessel. I 
 have had several opportunities of repeating this experiment, which always succeeded 
 in the same manner.” — The Anatomy of the Absorbing Vessels of the Human Body, 
 by William Cruikshank. London, 1786 and 1790, Chapter xi. p. 55; The same fact 
 has been satisfactorily established by observation in cases of prolapsed or retroverted 
 uterus, when the blood is seen oozing from the villous surface of the organ. 
 
 i 
 
SYSTEM OF EXHALANTS. 
 
 195 
 
 The cause of this accumulation and consequent exudation is not 
 known. To assert, as Bichat has done, that a change in the or- 
 ganic sensibility of the exhalants opens a passge through them to 
 are unchanged blood, is to describe the fact in a different mode 
 without explaining its reason. The hemorrhagic effort of Stahl, 
 and the error loci of Boerhaave, are equally true and not less in- 
 telligible. 
 
 /3. In the recrementitial exhalants, and first in those of transpa- 
 rent or serous membranes, though less frequently, the same anor- 
 mal condition may be often recognised. In the pleura or the pe- 
 ricardium, and in the peritoneum, it is not unusual to find bloody 
 fluids of various tints, evidently the result of exhalation. The fluid 
 effused may be simply bloody serum if little blood is exhaled, very 
 red if more is poured forth, or even, as I shall show afterwards, it 
 may be pure blood. In several of the cases in which blood is found 
 in the ventricles of the brain, it cannot be traced to any other source 
 save the exhalants of the choroid plexus ; and blood may be showm 
 to be effused occasionally from the outer division of the arachnoid 
 membrane, and also fi’om that which covers the spinal chord. 
 
 In each of these cases, whether the fluid is merely sanguinolent 
 or is pure blood, it issues from the same vessels which, in the 
 healthy state of the membrane, prepare its proper secretions. No 
 rupture or breach can be recognised by the most accurate scrutiny. 
 Bichat is disposed to view the sanguinolent effusions as the effect 
 of inflammation, acute or chronic, or like dropsy, as the consequence 
 of organic diseasa The few cases hitherto acciu'ately recorded 
 show, that, whatever be the remote cause, the state of the capilla- 
 ries of the serous membranes is much the same as those of mucous 
 surfaces under similar circumstances. 
 
 I formerly spoke of hemorrhage occurring in cellular membrane. 
 The blood is in this case derived from the exhalants of that tissue 
 exactly as it issues from those of the serous membranes. As an 
 active hemorrhage, it is not unfrequent in severe ■phlegmon, and in 
 the bloody abscess, as it is named, with which the practical surgeon 
 is familiar. As a passive hemorrhage, it occurs in land-scurvy 
 and in sea-scurvy. 
 
 In some instances the synovial membranes, both in joints and in 
 the tendinous sheaths, are found to contain blood or bloody fluid, 
 which must have issued from their exhalant arteries. 
 
 5. Elephantia. Another example still of disease to be referred 
 to the head of anormal exhalation, is presented in the unshapely 
 
196 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 enlargement of a member, which has been termed elephant-leg, 
 (^Elephantiasis,) the glandular disease of Barbadoes by Hendy, and 
 which is known in the East under the name of the Cochin-leg. 
 Though most frequently seen in the lower extremity, it is not pe- 
 culiar to this part ; and authentic instances of its occurrence in the 
 upper extremity are not wanting. Thus, Fabricius Hildanus re- 
 lates a case of enlargement of the arm, {brachium monstrosum,) in 
 a poor woman of Champs d’Or.* * * § Henseler records and delineates 
 an example of the same in the arm of a woman at Ulm and 
 mentions an instance in the arm and leg at once in a woman at 
 Dresden. And an instance not dissimilar in the person of a Hin- 
 doo was given not long ago by Mr Kennedy of Madras.^ Ac- 
 cording to Dr Graves, it is most frequent in the upper extremity 
 in Ireland.§ Cases of the same kind from Caithness, Ross-shire, 
 and, if I remember right, from the Shetland Islands, are occa- 
 sionally seen here. The instances in the lower extremity are doubt- 
 less most common in tropical countries. 
 
 Though it has been the general pi’actice since the time of Hendy 
 to regard this disease as resulting from obstruction of the lympha- 
 tic vessels and glands, the phenomena of its formation and progress, 
 with those of its morbid anatomy, show clearly, I think, that the 
 inordinate enlargement arises from a quantity of albuminous or 
 sero-albuminous fluid, being effused from the exhalants into the 
 cellular tissue of the limb, and which is not removed by adequate 
 absorption. That the enlargement is effected in this manner, and 
 that the effusion is the result of some form of the process of inflam- 
 mation recurring periodically, may be inferred from the following- 
 considerations : — 
 
 Is^, In all the cases of the disease which have been accurately 
 observed, the first attack of enlargement is preceded by general in- 
 flammatory action affecting the whole limb, described as similar to 
 rose {erysipelas^ and distinguished by heat, pain, general swelling, 
 and more or less redness. Of these symptoms the effusion and 
 enlargement are a sort of natural crisis. 
 
 2d, In most, if not all the cases, this inflammatory attack recurs 
 
 * Joaniiis Henseler, Historia Bvachii Prcetumicli. Extat in Haller Disputat. Chi- 
 rurgicis, Vol. V. p. 445. 
 
 -f- Centuria IV. Observ. 69, with a good wooden cut. 
 
 :j; Case of diseased arm, by Alexander Kennedy, Esq. Edinburgh Medical and Sur- 
 gical Journal, Vol. XIII. p. 54. 
 
 § Dublin Hospital Reports, Vol. IV. Clinical Observations, by Robert Graves, 
 
 M. D. 
 
SYSTEM OF EXHALAOTS. 
 
 197 
 
 after certain intervals, which are progressively shorter, and always 
 with the effect of increasing the enlargement. 
 
 M, In all the cases in which the enlarged limb has been ex- 
 amined by dissection, the subcutaneous and intermuscular filamen- 
 tous tissue is hardened, thickened, and condensed, and contains a 
 quantity of granular matter, viscid and gelatinous in consistence, 
 but like fat in appearance. This has not been analyzed ; but little 
 doubt can be entertained that it contains a good proportion of al- 
 buminous matter. That this is the essential change, is established 
 by the testimony of many observers. (Jaegerschmidt, Henseler, 
 Kennedy, Graves, Hull.) The distension of the skin, the enlarge- 
 ment of its papillae, the slender blanched appearance of the muscles, 
 and the enlargement of the inguinal glands, are effects only of the 
 state of the subcutaneous and intermuscular cellular tissue. In 
 short, until new facts he adduced, the description given by Dr 
 Graves, and the case of Mr Hull, establish the inference, that the 
 elephantine enlargement of the extremities is the result of gelati- 
 nous or albuminous exudation from the arteries of the subcutane- 
 ous filamentous tissue. Dr Musgrave considers it as migratory in- 
 flammation. 
 
 6. Accidental Development or Morbid Formation of the Exha~ 
 lant Si/stem. In several instances a process of exhalation takes 
 place in certain textures in which it did not originally exist, at 
 least under the same form ; or a process of exhalation may go on 
 without a corresponding one of removal by absorption. Of this 
 abnormal development of the exhalant system, which constitutes 
 the tumours called encysted, (tumores cystici, tunicati, Salzmann, 
 Heister,) several varieties have been noticed by practical authors, 
 as Ingrassias, Severinus, Tagault, Pare, Schelhammer, Astruc, 
 Meek’ren, Heister, &c. ; and^the division of Celsus into meliceris^ 
 atheroma^ and steatoma, has been repeated by the generality of 
 writers, from Hildanus to Monteggia, Abernethy, and Boyer. 
 This division, to which I have already adverted in speaking of en- 
 cysted tumours in the cellular tissue, is nevertheless imperfect; and 
 indeed no distinct and connected arrangement of all the varieties 
 of encysted tumour has yet been given, unless the seventh genus 
 of the system of Plenck be entitled to this charactei’.* Without 
 attempting to specify the individual defects of the classification of 
 
 * Joseph! Jac. Plenck, Novum Systema Tumomm, quo hi morbi in sua genera et 
 species rediguntur. ViennEc, 1707. 
 
198 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 this surgeon, I conceive I am justified in asserting, that one more 
 strictly pathological may be given. 
 
 Considered as examples of inordinate exhalation without corre- 
 sponding absorption, the species of encysted tumour may be enu- 
 merated in the following order. 
 
 a. Acephalo-cysts or Hydatids are cysts secreting limpid watery 
 fluid. They have been commonly believed to be living animals. And 
 since the full account of their origin and nature by Laennec, this 
 opinion has been almost universally received. They therefore do not 
 properly belong to the present head, and should be arranged with 
 that of parasitical productions. By Plenck the hydatid is regarded 
 as a variety of the next species — the liyyroma. Combined with 
 atheromatous or steatoraatous matter, hydatid-cysts are occasionally 
 found in the subcutaneous cellular tissue. (Heunden apud Tyson, 
 sixty hydatids in a cyst in the neck.) 
 
 /3. Hygroma. The serous cyst. Cysts secreting sero-puruient, 
 or even a sero-sanguine fluid. This epithet Plenck applies to a 
 spherical tumour containing coagulable lymph, evidently meaning 
 fluid ; and regards it as differing from the hydatid in size only, 
 and from lymphatic (serous) tumours, by the possession of a mem- 
 branous covering, or proper cyst. It is more expedient to apply 
 it to all encysted tumours not manifestly hydatoid, which contain 
 serous, sero-purulent, or viscid glairy fluid, or even reddish serum, 
 in whatever situation they are found. The best example of this 
 tumour is the cyst or cysts often found in the female ovary, in 
 which they vary in size, and in the colour and consistence of their 
 contents, from mere serum, with more or less albumen, to reddish, 
 bloody, or even tar-like fluid. They occur in the brain, e. g. its hemi- 
 sphere,* and in the pineal gland. The cases delineated by Hooper 
 as vesicles and encysted tumour, are evidently of this description. 
 Plenck admits the serous hygroma in the cellular membrane. 
 
 y. Hcematoma. A cyst secreting, or containing a bloody fluid. 
 Severinus, Ingrassias, and moi’e recently Monteggia, John Peter. 
 Frank, Scarpa, and Montini, mention examples of globular or 
 spheroidal tumours containing blood more or less fluid within a 
 membranous sac or covering. Under the name of bloody abscess., 
 indeed, Severinusf assembles aneurisms, as well as the blood-cyst. 
 
 * The Morbid Anatomy of the Human Brain. By Robert Hooper, M.D. Plate 
 XIII. XII. Fig. 8. and XIV. 
 
 -f- Miirci Aurelii Severini apud Neapolitanos Medici ac Philosopliii Regii, de Ab- 
 scessnum Recondita Natura, Libri viii. Lugduni Batavorum, 1724. Lib. iv. cap. vii. 
 
SYSTEM OF EXHALAXTS. 
 
 199 
 
 Frank, I believe, first (1786) distinguished one of these tumours 
 on the chin of a girl of nine, of the size and shape of a goose-egg, 
 as of the encysted kind, and first applied to it the denomination of 
 hcsmatoma* About the same time (1789) Monteggia described 
 the hloody tumour similar to that of Severinus, as occurring in the 
 arm-pit, and attaining a great size, and, when opened, speedily prov- 
 ing fatal.! An example of the disease was afterwards seen hy Scarpa 
 in the same situation in the person of a priest about fifty, in the thy- 
 roid gland and neck of other subjects, and in the breast of a lady 
 and Montini saw it in the thigh of a woman in childbed at Lodi.§ 
 
 An example of this species of tumour was in 1843 given by 
 the late Dr Hannay of Glasgow. It occurred in the lateral and 
 posterior region of the neck of a child of fourteen months, in other 
 respects healthy. It appeared first on the left side of the neck, 
 half-way between the jaw and collar-bone, in the form of a small 
 hard body about the size of a gooseberry. It remained stationary 
 for months. When seen by Dr Hannay, it had attained the size 
 of a goose’s egg, consisted of two or more lobules, was smooth, 
 something glistening, and of a very indistinct shade of blue or ve- 
 nous blood colour. The lonw diameter was horizontal. It was 
 
 O 
 
 elastic, and gave a sense of fluctuation ; and touching or handling 
 seemed to cause pain. It was punctured by the lancet, and three 
 ounces of grumous but fluid blood were discharged. After this the 
 cyst seems to have contracted. 
 
 Dr Hannay adds, that previous to this he had seen four cases. 
 Of these, one was presented by Mr Brookes to his pupils as a case 
 of abscess; and some alarm was caused, when the punctm’e by the 
 lancet was followed by blood apparently pure. Against mistakes of 
 this kind, if not to be obviated, surgeons would be prepared, by in- 
 forming themselves of the nature of the hcEmatoma or blood-cyst. 
 Of the other three cases. Dr Hannay had seen two within six 
 months ; one in an infant, the other in a woman between forty and 
 fifty years of age.|| 
 
 * Joannis Petri Frank, Med. Clinic, in Ticinensi Academia, Prof. Discursus Aca- 
 demic. mense Junii 1786, habitus, Observationem de Haematomate, &c. exhibens- 
 Delectus, Vol. III. Ticini, 1787. 
 
 t Monteggia, Fasciculi Pathol, p. 88. Mediolani, 1789. 
 
 X Treatise on the Anatomy, &c. Appendix, p. 456. See also Richter de mro iu- 
 more mammm. Works of Else, and J. E. Pohl de Varice, § XI. 
 
 § Montini, Saggio di Osservazioni et Riflessioni Chirurgico-pratiche. Lodi, 1803. 
 
 II Pathological Gleanings ; or Cases in Dispensary Practice. By A. J. Hannay, M. D. 
 &c. Edinburgh Medical and Surgical Journal, Vol. LX. p. 319, October 1843. 
 
200 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 From tlie united testimony of these observers, it appears that 
 the blood-cyst (Jicematoma,) is a tumour consisting of a membi’a- 
 nous sac, the inner surface of which is liberally supplied with blood- 
 vessels, from which blood, or a bloody fluid, is incessantly oozing 
 or distilling by exhalation. In some instances this fluid contains 
 a proportion of flbrin sufficient to effect coagulation ; and the in- 
 terior of the cyst then resembles the spleen or a mass of clotted 
 blood. From aneurism it may be distinguished by the following 
 marks ; that it does not throb ; that it contains a fluid ; that it is 
 surrounded by bluish tortuous veins ; and that it is dark or purple- 
 coloured, while the investing skin is transparent. When seated in 
 the neck, however, near the carotid artery, it may derive from it, 
 or from the subclavian, a pulsating motion, which may give it the 
 appearance of aneurism. 
 
 There is no reason to believe that these tumours are in any way 
 malignant, or of the character of heterologous growths. They 
 seem to be cysts, the inner surface of which secretes either blood 
 or a bloody liquid for some time, until by their size and position 
 they cause inconvenience. When the fluid has been evacuated, 
 the cyst contracts, its opposite walls adhere, and the action ceases. 
 The ordinary locality of Immatoma is easily understood from 
 what has been already said. It occurs most usually in the filamen- 
 tous tissue of the arm-pit and neck, in the substance of the thyroid 
 gland, and at the knee. (Monteggia.) Zeller describes it as it 
 appears in the brain of infants, under the name of cephalcematoma. 
 Dr Hooper has represented an example of what he refers to this 
 head in his tenth engraving. But from the description, the justice 
 of this appears questionable.* It is also mentioned by Dr Monro.f 
 h. Meliceris. An indolent tumour, generally small, with smooth 
 uniform surface, communicating a sense of fluctuation, and con- 
 taining viscid matter of the aspect and consistence of honey. 
 Seated always in the skin or its attached surface, meliceris consists 
 in the enlargement of one of the subcutaneous glands or follicles, 
 arising from obstruction of its excretory duct. The mechanism of 
 its formation from this source was understood by PlenckJ and 
 Monteggia,§ and was, in 1819, brought under notice by Sir Astley 
 
 * Morbid Anatomy of the Human Brain, p. 27. 
 
 •t Morbid Anatomy of the Brain, p. 56. 
 
 Josephi Jacobi Plenck, NoTOin Systema, Classis vii. 
 
 § “ Alcuni cisti si formano per la chiusura del orificio escretore dei follicoli sebacei 
 e mucosi.” Instituzioni Chirurgiche di G. B. Monteggia, edizione seconda. Milano, 
 1613. Vol. II. capo xiii. 
 
SYSTEM OF EXHALANTS. 
 
 201 
 
 Cooper.* It must not be forgotten, however, that it is to this va- 
 riety only of encysted tumour, that this mode of explanation is ap- 
 plicable. Meliceris is in short the only example of the folliculated 
 tumour. 
 
 Meliceris may occur in any part of the person where sebaceous 
 follicles exist. When on the scalp, they are distinguished among 
 the older surgeons by peculiar epithets (talpa et testudo ;) and 
 natta when on the face. In such situations they often contain hair. 
 Those which Severinus mentions at the wrist appear to have been 
 panglia I a mistake which enables us to understand why he doubted 
 whether the meliceris was an encysted tumour. 
 
 Atheroma. A wen or cyst, indolent, uniform on the surface, 
 firmer than the meliceris., of the same colour with the skin, and 
 containing granular semifluid matter like boiled meat or saw-dust. 
 It is always confined to the cellular tissue. The mechanism of its 
 formation is unknown, unless that proposed by Monteggia he ad- 
 mitted. According to this pathologist, the tumour may originate 
 in slight adhesive inflammation of any definite portion of cellular 
 tissue, in consequence of which one cell, being obstructed and pre- 
 vented from communicating with others, is progressively distended 
 by deposition of matter, which, pressing on the surrounding tissue, 
 gradually condenses it into a membrane as it extends. To this 
 idea objections have been already stated from Bichat ; and it must 
 be admitted that facts are still wanting to explain this otherwise 
 than by saying, that the cyst is formed, and secretes its proper 
 contents. 
 
 <^. Steatoma. A wen or cyst, containing adipose matter like lard, 
 or fat void of its natural yellow colour, and become white, firm, 
 and granular like suet, (Boyer,) with more or less albumen, ap- 
 proaching to the nature of adipocu’e. In the first case it is soft, 
 compressible, and generally small, and is not unfrequent in the 
 eyelids and on the scalp. In the second case it is more common 
 on other parts of the body ; and the size which it then attains is 
 enormous. In all surgical works almost instances are given of the 
 extraordinary size of steatomatous tumours.| In some instances 
 
 * Surgical Essays, by Astley Cooper, F. R. S., and Benjamin Travers, F. R. S. 
 Part II. London, 1819. Essay iii. On Encysted Tumom-s, p. 220. 
 
 f Vide Joannes Philip. Ingrassias de Tumoribus. Severini, de Abscessum Natiu-a 
 Recondita, Lib. iii. Cap. xxii. Gulielmi Fabricii Hildani, Opera omnia. Francof, 
 1646. Gabrielis FalIo 2 m. Op. Lib. de Tumoribus, p. n. c. 24. Fabricii ab Aquapen- 
 dente. Lib. i. Ambrose Pare, Book vi. c. xix. one of twenty-six pounds. J. Langius ; 
 
202 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 osseous matter is deposited either in the cyst, or with the sebaceous 
 matter ; a circumstance which has procured it from Plenck a se- 
 parate place with the title of osteosteatoma* (Scheuzer, Hund- 
 termarc, and Haller.) It is merely a variety of the steatom. The 
 appearance of steatomatous cysts in bones and bony tumours, as 
 seen by Kulm and Weidmann,| belongs to another place. 
 
 Tj. Lipoma. This name was first applied by Littre to a wen or 
 cyst filled with soft matter possessing the usual properties of ani- 
 mal fat.§ The matter of steatom, according to this surgeon, is 
 either not, or imperfectly inflammable, by reason of its degenera- 
 tion or commixture with some other animal secretion. The pro- 
 priety of this distinction has been denied by Louis and others, who 
 maintain that these tumours differ in nothing, unless perhaps in 
 degree. It has been favoured, nevertheless, by Morgagni, and 
 adopted by Plenck, Desault, Bichat, and various foreign surgeons, 
 and is defended by Boyer, who represents the steatom as differing 
 from lipoma, in the matter being white, firm, and changed from 
 its original character, and in possessing the tendency to degenerate 
 into cancer.;}; Plenck had previously distinguished the lipoma, by 
 being destitute of cyst, a circumstance not required by Littre. 
 
 Though thus admitted to differ, the anatomical character, as 
 given by Morgagni, || and confirmed by Boyer, is in both nearly 
 the same. A cyst containing unchanged fat, or granular adipose 
 matter, in cells formed by the original fibres of the adipose mem- 
 brane, according to Morgagni, or those of the filamentous tissue, 
 according to Boyer. At the base or stalk in the case of pendulous 
 steatoms, the cells are compressed, but loose in the body of the 
 tumour. 
 
 — one said to weigh sixty pounds. Papers in Haller’s Disputationes Chirurgicae, Vol. 
 V. by Elsholz, Kell, and Friesse. Fred. Ruysch, Epist. ad Boerhaave. J. Palfyn. 
 Anatomie du Corps Humain, B. ii. chap. ii. Two of great weight, one by Schroeck, 
 from Morgagni in the Ephem. Nat. Curios. Cent. 5. Ob. 27, and others in the same 
 work. In the Phil. Transactions, Memoires de I’Academie Royale de Chiiairgie, &c. 
 Edinburgh Medical Essays, Vol. III. Medical Com. I. 190. Ed. Aled. and Surg. 
 Journal, Vol. IX. J. P. Weidmann de Steatomatibus, 4to, Moguntise, 1817. 
 
 * Breslau Sammlungen, 1722, p. 319. Tittmani Dissert. Osteo-steatomatis, cas. rar. 
 Ilalleri Opuscula Pathologica, Obs. 6. 
 
 t Joan. Adami Kulm, Disputatio Medico-Chirurgica de Exostosi Steatomatode, 
 &c. Haller, Vol. V. p. 653. Weidmann, p. 6, and Fig. 5. 
 
 J Histoire de I’Academie Royale des Sciences, Anno 1709. Observat. Anatom. 3. 
 
 § Traite des Maladies Chirurgicales, Tome II. Chap. i. Art. 12. 
 
 II De Sedibus et Causis Alorborum, Lib. ix. Epist. I. Art. 24 and 25, and Lib. v. 
 Epist. Ixviii. Art. 6 and 8. 
 
SYSTEM OF EXHALANTS. 
 
 203 
 
 This description, with the alleged cancerous tendency, accords 
 more with the characters of the adipose sarcoma than those of the 
 genuine wen. Personal examination enables me to say, that, in 
 the ease of small steatoms of the scalp, eyelids, face, &c. no fibres 
 of this kind are recognised; and to such if any distinction be 
 adopted, the name of lipoma should be confined. In the case of 
 such large steatoms as I have seen in other regions of the body, 
 though the contents are firmly connected together, and some fila- 
 mentous threads may be seen here and there, or the tumour may 
 be even separable into masses, I have not been able to trace the 
 distinct arrangement of cells mentioned by Morgagni and Boyer. 
 Wiedmann mentions, that in one case the matter of steatom was a 
 sort of liquefied fat, and in another firm and dense, and not divid- 
 ed into lobes or cells. 
 
 The chemical history of steatomatous and lipomatous tumours 
 is imperfectly known. Many years ago Dr Bostock analysed a 
 stearoid tumour without obtaining any precise result. The effects 
 of the agents employed indicated the presence of neither fat, jelly, 
 nor adipocire ; nor was any change accomplished by potass. From 
 its general intractability, however, and the effects produced by 
 sulphuric acid, he infers that it is composed chiefly of carbonaceous 
 matter.* 
 
 I attempted some years ago to examine the chemical nature of 
 the matter contained in a steatomatous cyst removed from the eye- 
 lids. This matter was of a lemon yellow colour, not absolutely 
 opaque, yet not translucent, and like a mixture of fat and wax. 
 It communicated a stain to paper, and liquefied on exposure to 
 heat. Though it was perfectly soluble in oil of turpentine, I found 
 that no method which I could devise could make it unite with po- 
 tassa. It was also soluble in ether. From the experiments of 
 Chevreul, it is not improbable that they contain stearine, cetine, 
 or adipocire. But it must be admitted, that precise information is 
 still wanting. 
 
 &. Lupia. This term, which has been often applied generally to 
 wens, {loupes,) is used in a more limited sense by Plenck, to desig- 
 nate a cyst containing a spongy substance in the cellular tissue, of 
 which it is conceived to be a degenerate form. It is convenient 
 as a head to which certain rare and anomalous cystic tumours may 
 be referred. 
 
 * Edin. Mecl. Journal, Vol. II. p. 14 and 17. 
 
204 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 I. Melanoma. In many instances the melanotic matter, already 
 mentioned, is deposited in a cyst. In such circumstances, there- 
 fore, it is referable to this head. 
 
 CHAPTER X. 
 
 LYMPHATIC SYSTEM, Vasa Lymphatica , — Vasa Lymphifera , — 
 Lijmphce-Ductus of glisson and jolyffe. — systems absor- 
 BANT. Die Saugadern. 
 
 Section I. 
 
 In most situations of the human body, and especially in the vi- 
 cinity of arterial and venous trunks, there are found long, slender, 
 hollow tubes, pellucid or reddish, which present numerous knots, 
 joints, or swellings in their course, and to which the name of lym- 
 phatics or absorbents has been given. It is most expedient to em- 
 ploy the former appellation only, as the latter implies the perform- 
 ance of a function, the reality of which has been much questioned 
 of late years. 
 
 Though Eustachius had seen the thoracic duct in the horse, and 
 some slight traces of a knowledge of vascular tubes, different either 
 from arteries or veins, are found in the writings of Nicolaus Massa, 
 Falloppius, and Veslingius, the merit of establishing their existence 
 is generally ascribed to Caspar Asellius, a physician of Pavia. 
 This anatomist, who had, in 1622, seen the white-coloured tubes, 
 then first named lacteals. issuing from the intestines of the dog, 
 observed also a cluster of vessels less opaque near the portal emi- 
 nences of the liver, — an observation which he afterwards repeated 
 in the horse and other quadrupeds. The same vessels were also 
 described and delineated by Highmore. 
 
 Passing over the uncertain and obscure hints given by Walaeus 
 and Van Horne, the first exact information after Asellius is that 
 which relates to Olaus Rudbeck, who, in 1650, is said to have seen 
 them in a calf, and to have demonstrated the thoracic duct, and the 
 dilated sac, afterwards termed receptaculum ckyli. 
 
 i 
 
LY3IPHATIC SYSTEM, &C. 
 
 205 
 
 Glisson informs us that JolyfFe had, in 1652, imparted to him 
 the knowledge of a set of vessels diflFerent from arteries and veins ; 
 and it appears from the testimony of Wharton, that JolyfFe had de- 
 monstrated these vessels in 1650.* * * § In short, the discovery of lym- 
 phatics, and the correction of some errors of Asellius, is ascribed 
 to the English anatomist, not only hy Wharton and Glisson, hut 
 by Charleton, Plott, Wotton, and Boyle. 
 
 The existence of these vessels, thus partially demonstrated, was 
 afterwards more fully established by the researches of Bartholin, 
 Pecquet, Bilsius, Nuck, the second Monro and Haller. It is 
 chiefly to the exertions of William Hunter and his pupils, Hew- 
 son,| Sheldon, J and Cruikshank§ in this country, and to those of 
 Mascagni II in Italy, that the anatomical world are indebted for the- 
 complete examination and history of this system of vessels. 
 
 The lymphatic vessels consist, in the members, of two layers, a 
 superficial and a deep-seated one. The first is situate in the sub- 
 cutaneous cellular tissue, between the skin and the aponeurotic 
 sheaths, and accompanies the subcutaneous veins, or creeps in the 
 intervals between them. A successful injection of these superficial 
 lymphatics will show an extensive network of mercurial tubes sur- 
 rounding the whole limb. 
 
 The deep-seated layer of lymphatics is found chiefly in the in- 
 terspaces between the muscles, and along the course of the arterial 
 and venous trunks. In tracing both layers of lymphatics to the 
 upper, fixed, or attached end of the members, we find they increase 
 in volume, and diminish in number. At the connection of the 
 members with the trunk, they are observed to pass through certain 
 spheroidal or spherical bodies, termed lymphatic glands or gangli- 
 ons. The lymphatics of the upper extremity, after passing through 
 the glands of the arm-pit, terminate in trunks, which open into the 
 subclavio-jugular veins, one on each side of the neck. Those of 
 
 * Francisci Glissonii Anatomia Hepatis, Cap. xxxi. Thomse MTiarton, Adenographia, 
 Cap. ii. p. 98. 
 
 + Experimental Inquiries, Part the Second. By ‘William Hewson, F. R. S. Lon- 
 don, 1774, 8vo. Also the Works of William Hewson, F. R. S. Edited by George 
 Gulliver, F. R. S. By Sydenham Society'. London, 1846. 
 
 J The History of the Absorbent System, &c. by John Sheldon, Surgeon, F.R.S., &c. 
 London, 1784. Folio. 
 
 § The Anatomy of the Absorbing 'Vessels of the Human Body. By William Cruik- 
 shank, London, 1786, 4to. The Second Edition, London, 1790. 
 
 II Pauli Mascagni Vasomm Ly mphaticorum Corporis Humani Historia et Ichno- 
 graphia, foUo, Paris, 1787. See also Prodrome, &c. Capitolo, i. 
 
206 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the lower extremity, after passing through the glands of the groin, 
 proceed with the common iliac vein into the abdomen, where they 
 unite with other lymphatics. 
 
 The lymphatics of the trunk consist in like manner of two layers, 
 a subcutaneous and deeper seated one, distributed in the chest be- 
 tween the muscles and pleura, and in the abdomen between the 
 muscles and peritoneum. In the chest and belly, each organ pos- 
 sesses a superficial layer of lymphatics distributed over its surface, 
 and pertaining to its membranous envelope ; the other ramifying 
 through its substance, and pertaining to the peculiar tissue of the 
 organ. This twofold arrangement is most easily seen in the lungs, 
 the heart, the liver, spleen, and kidneys. 
 
 In a similar manner are arranged the lymphatics in the exter- 
 nal parts of the scull, on the face, where they are very numerous, 
 in the spaces between the muscles, and on the neck, in which they 
 pass through numerous glands. No lymphatics, however, have 
 been found in the brain, the spinal chord, their membranous en- 
 velopes, the eye, or the ear. 
 
 All the lymphatics hitherto known terminate in two principal 
 trunks. One of these, termed from its site thoracic duct, {Ductus 
 thoracicus ; die Milch-brustrbhre ; ie canal thoracique) is situate on 
 the left side of the dorsal vertebrm. It receives the lymphatics of 
 the lower extremities, of the belly, and the parts contained in it ; 
 those of great part of the chest, and those of the left side of the 
 head, neck, and trunk, and left upper extremity. The other lym- 
 phatic trunk, which is situate on the right side of the upper dorsal 
 vertebrae, is formed by the union of the lymphatics of the right side 
 of the head, neck, right upper extremity, and some of those of the 
 chest. Both of these trunks, it is well known, open into the sub- 
 clavio-jugular vein of each side. 
 
 That lymphatics terminate in branches of the venous system has 
 been asserted on the authority of various observers. Steno, for 
 instance, states that he traced the lymphatics from the right side of 
 the head, the chest, and pectoral extremity in animals into the right 
 axillary vein ; and he gives delineations of anastomotic connections 
 of several lymphatics with the axillary and jugular veins. Similar 
 facts have been reported by Nuck, Richard Hale, Bartholin, and 
 Hartmann. Ruysch traced the lymphatics of the lung into the 
 subclavian and axillary veins ; Hrelincourt those of the thymus 
 gland in animals into the subclavians ; and Hebenstreit saw those 
 of the loins pass into the vena azygos. 
 
LYMPHATIC SYSTEM, 8cC. 
 
 207 
 
 Haller, though unwilling to deny the testimony of these ob- 
 servers, regards it liable to various sources of fallacy, and doubts 
 the direct communication of the lymphatic and venous systems. John 
 F. Meckel, the grandfather, maintained in 1771 the communication, 
 from the circumstance, that he injected the lymphatics from the 
 veins.* Hewson, though not doubting the fact, regards it as an 
 exception to the general rule. Cruikshank, again, states that he 
 never saw a lymphatic vessel inserted into any other red veins than 
 the subclavians and jugulars. The termination remarked by Steno 
 and his successors constitutes in truth the common trunk or lympha- 
 tic vein admitted by Cruikshank, — a thoracic duct of the right side. 
 
 This mode of termination was afterwards in 1821 revived by 
 Tiedemann and Fohman,-f* who, in the seal, state that the lactiferous 
 vessels communicate with veins arising from the mesenteric glands, 
 and pass thence into the venous trunks without proceeding through 
 the thoracic duct. This, however, was shown by Dr Knox to be 
 a mistake, resulting from the decomposed state of the animals 
 examined by the German anatomists. J M. Lauth J unior of Stras- 
 bourg, again, conceives that he has demonstrated, that lymphatics 
 communicate with veins within the substance of organs, and in 
 the interior of the lymphatic glands ;§ an inference which at pre- 
 sent requires further verification. The statements of Lippi of 
 Florence, that every lymphatic almost communicates freely with 
 venous tubes, is still more improbable, and has been rendered ex- 
 ceedingly doubtful by the researches of Rossi ;|| and Panizza shows 
 that there is no communication between the minute arteries and the 
 lymphatics. 
 
 The connections of the ends of lymphatics with the organs and 
 tissues from which they arise, termed their origins^ are completely 
 unknown. In some favourable instances the lymphatics of the in- 
 testinal canal are so filled with a reddish or whitish fluid after the 
 process of digestion has continued for some time, that not only are 
 their larger branches easily seen, but by the aid of the miscroscope 
 
 * Jo. Fr. Meckel, Nova Experimenta et Observationes de finibus Venarum ac Va- 
 sorum lymphaticorum, &c. § I. p. 4. Lugduni Bat. 1772. 8vo. 
 
 -j- Anatomische Untersucbungen uber die Verbinduug der Saugadern mit den Venen. 
 Heidelberg, 1821. 
 
 J On the Anatomy of the Lacteal System in the Seal. Edin. Med. and Surgical 
 Journal, Vol. XXII. p. 26, &c. 
 
 § Essai sur les Vaisseaux Lymphatiques. Strasbourg, 1824. 
 
 II Cenni sulla comunicazione dei vasi linfatici colle vene ; di Giovanni Rossi Doc- 
 tore, &c. Annali UniversaLi di Medecina, Anno 1826. Vol. XXXVII. p. 52. 
 
208 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 some of the smaller may be traced to their commencement. This, 
 which was ascertained by Cruikshank, (p. 55 and 58,) and con- 
 firmed by Hewson, ' Bleuland, and Hedwig, has been contradicted 
 by the observations of Rudolphi and Albert Meckel. In all other 
 parts, however, though a successful injection may show the course 
 and distribution of many of the smallest lymphatics, yet no orifices 
 are perceptible at the point at which they seem to stop, and we are 
 uncertain whether these points are their origins. (Cruikshank.) 
 Mere observation is here as unavailing as in regard to the termi- 
 nation of exhalants. The continuation of lymphatics with arteries, 
 unless in the case of those which arise from the interior of arterial 
 tubes, (Lauth,) is not satisfactorily established. It has been con- 
 jectured, however, that their ends or imperceptible origins are con- 
 nected to the tissues to which they are traced, and that the lym- 
 phatics arise in this manner from these tissues. 
 
 The lymphatics are distinguished by being in general cylindri- 
 cal in figure, and by varying in calibre at short spaces. In this 
 respect they differ from the arteries and veins. It has been further 
 justly remarked by Gordon, that the middle-sized lymphatics are 
 remarkably distinguished from the corresponding parts of the ar- 
 terial and venous system by three peculiarities. When two 
 lymphatics unite to form a third, the trunk thus formed is seldom 
 or never larger than either of them separately ; 2rf, their anasto- 
 moses with each other are continual ; and, 3J, they seldom go a 
 great space without first dividing into branches, and then reuniting 
 into trunks.* 
 
 The outer surface of a lymphatic is filamentous and rough, the 
 inner smooth and polished, like that of small veins. It is impossi- 
 ble to observe the structure of these tubes in the middle-sized, or 
 even in the large lymphatics ; and anatomists have generally been 
 satisfied with supposing that the structure of all of them is similar 
 to that of the thoracic duct, or some other large vessels equally 
 susceptible of examination. According to the observations of 
 Cruikshank, (Chap, xii.) which have been verified by Bichat, the 
 thoracic duct presents, a layer of dense firm filamentous or 
 cellular tissue, exactly similar to that found inclosing arterial and 
 venous tubes, which the latter regards as foreign to the vessel, but 
 giving it a great degree of support and protection ; 2d, a proper 
 membrane, delicate, transparent, and moistened inside by an unctu- 
 
 * System, p. 71. 
 
LYMPHATIC SYSTEM, &C. 
 
 209 
 
 ous fluid, which he seems inclined to ascribe to transudation. Mus- 
 cular fibres, of which Sheldon speaks positively, Cruikshank re- 
 presents, though seen in some instances, (Chap, xii.) yet to be more 
 generally not demonstrable. Their existence, though admitted by 
 Schreger and Soemmering, is denied by Mascagni, Rudolphi, 
 and J. F. Meckel, and I, may add, by Bichat and Bedard. This 
 account difibrs not much from that of Dr Gordon, who could not 
 recognize distinctly more than one coat, similar to the inner coat 
 of veins. The filamentous layer noticed by Bichat, and considered 
 by Mascagni as an external coat, is of course excluded. 
 
 The knotted or jointed appearance of lymphatics is occasioned 
 chiefly by short membranous folds in their cavity called valves. 
 These folds are thinner than the venous valves; but they are 
 equally strong, and have the same shape and mode of attachment 
 to the inside of the vessel. They are generally found in pairs, but 
 never three at the same point. A single valve is sometimes found 
 at the junction of a large branch with a trunk, or of a trunk with 
 a vein. According to Cruikshank there is considerable variety in 
 the distribution of valves; but in general a pair of valves will be 
 found at every one-twentieth of an inch in lymphatics of middling 
 size. In the larger lymphatics they are less numerous than in the 
 small. The structure of these valvular folds is as little known as 
 that of the inner membrane, of which they appear to be prolonga- 
 tions. According to Mascagni they sometimes contain a small 
 portion of fine adipose substance. 
 
 The tissue which forms the lymphatic tubes is strong, dense, 
 and resisting ; and, from the weight of mercury which they bear 
 without rupture, it has been generally concluded, that they are 
 stronger in proportion to their size than veins. This tissue also 
 possesses considerable elasticity. 
 
 The opposite states of lymphatics dm'ing digestion and after long 
 fasting, and the phenomena of mercurial injections, prove that the 
 tissue of which they consist is distensible and contractile. Though 
 it does not exhibit appearances of muscular structure, it has been 
 long supposed to be endowed with a property analogous to irrita- 
 bility. Such is the inference which Hunter, Hewson, Cruik- 
 shank, and others have derived from various phenomena in the 
 living and recently dead tissue. 
 
 Though Bichat doubted svhat he termed organic sensible con- 
 tractility, yet he admitted the insensible contractility as necessary 
 to the functions ascribed to lymphatics. Previous to his time 
 
 o 
 
210 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Sclireger, in different experiments, observed the first of these qua- 
 lities in consequence of the application not only of acids, butter of 
 antimony, and alcohol, but even of hot water and cold air. Simi- 
 lar contractions and relaxations have been induced by mechanical 
 irritation.* Such phenomena are observed not only during life, 
 but even after death ; and if we add to this, that the thoracic duct 
 is often after death large and flaccid, though empty, but in the liv- 
 ing body is almost always contracted and scarcely visible, and that 
 a portion of it included between two ligatures and punctured, 
 quickly expels its contents, it may be inferred, according to Tiede- 
 mann and Bedard, that the lymphatic tissue possesses a considerable 
 degree of this vital or organic property. 
 
 Section II. 
 
 The lymphatic vessels have been supposed to perform an import- 
 ant part in the formation of the diseases incident to the animal 
 body. In addition to the ordinary causes of disease which affect 
 all organic substances, the several derangements of property or 
 function to which they are liable have been supposed to exert a 
 powerful influence on other tissues and organs, and on their func- 
 tions. On this principle Hewson, Cruikshank, Thomas White, 
 Nudow, Isenflamm, Johnstone, and Maanen, have ascribed to dif- 
 ferent forms and degrees of disorder of the lymphatic system a very 
 large proportion of the diseases incident to the human body. All 
 of these authors, nevertheless, have been exceeded by Soemmering, 
 and more recently by Alard, both of whom represent the lym- 
 phatics as mainly concerned in every morbid state of tbe human 
 body. The former has delineated an extensive picture of diseases, 
 in the production of which the lymphatics are believed to be more 
 or less concerned. Besides immediate morbid states of the lym- 
 phatics themselves, he enumerates upwards of sixty diseases and 
 morbid states of the human body, in which, according to one or 
 another pathologist, the lymphatics have an influence, direct or 
 indirect, immediate or remote.f The latter reasons most strenu- 
 ously for the universal influence of the lymphatic system in every 
 disease almost of the animal frame. 
 
 * Schreger de Irritabilitate Vas. Lymph. Lips. 1789. 
 
 t S. Thomas Soemmering de Morbis Vasorum Absorbentium Corporis Humani sive 
 Dissertationis quae prcemium retulit Societatis Rheno-Trajectinae, anno 1794, Pars 
 Pathologica. Trajecti ad Moenum, 1795. 8vo. 
 
LYMPHATIC SYSTEM, &C. 
 
 211 
 
 Little doubt can be entertained, that by these authors the in- 
 fluence of the lymphatic vessels has been very much overrated. 
 Notwithstanding the authority of their names, it is certain that 
 neither anatomical inspection, nor the observation of the pheno- 
 mena and efiects of disease, justify the views advanced by these 
 authors. It further requires little argument to show, that this 
 mode of explaining the formation and nature of diseases does not 
 tend to the advancement of accurate pathological knowledge. 
 
 All the diseases to be referred to this head come naturally under 
 two divisions. The first consists of disordered states occurring in 
 the lymphatic vessels themselves. In the second are included mor- 
 bid states of other textures or systems, arising immediately from, 
 disease of the lymphatics. 
 
 1. Inflammation^ — i^Angioleucitis.') The first morbid state to 
 be mentioned as incident to the lymphatics is inflammation. As a 
 spontaneous occurrence it is little known, and perhaps is exceed- 
 ingly rare. Hendy, indeed, undertook to show, that inflammation 
 of the lymphatics was the pathological cause of Barbadoes leg ;* 
 and this view, wLich has been almost implicitly adopted by every 
 subsequent observer, has been strenuously maintained and illus- 
 trated by M. Alard.f I have already adduced such facts and ar- 
 guments as I conceive are sufficient to show that this disease de- 
 pends on a peculiar inflammation of the filamentous tissue of the 
 limb, recurring periodically, and terminating in albuminous exu- 
 dation ; and that the affection of the lymphatic glands, vessels, &c. 
 on which the hypothesis of Dr Hendy is founded, is an effect of this 
 diseased state. It is unnecessary, therefore, to give the subject 
 more consideration. 
 
 Not less objectionable is tbe notion advanced by Charles White, $ 
 that inflammation or obstruction of the lymphatics is the cause of 
 the swelled leg, (j)hlegmasia dolensf) of puerperal women. Obser- 
 vation and dissection concur'in showing that this malady arises from 
 inflammation of the uterine and pelvic veins terminating in albu- 
 minous or sero-albuminous exudation, and causing obstruction to 
 the venous circulation. 
 
 Angioleucitis Uterina puerperarum. Inflammation has been 
 
 ■* Treatise on the Glandular Disease of Barbadoes, proving it to be seated in the 
 Lymphatic System. By John Hendy. London, 1784. 
 
 -f- Histoire d’une Maladie particuliere an Systeme Lymphatique, &c. 1806 ; et 
 Nouvelles Observations sur I’Elephantiasis des Arabes. Par M. Alard, 1811. 
 
 X Inquiry into the Nature and Cause of that Swelling in one or both of the Lower 
 Extremities in Lying-jn- Women. By Charles White, Surgeon. Warrington, 1784. 
 
212 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 observed to attack the lymphatic vessels of the womb in puerperal 
 fever, and then it too often proceeds to suppuration. The uterine 
 lymphatics are then seen extending over the surface of the organ 
 jointed and knotted, and distinctly presenting purulent matter in 
 their interior, and sometimes along their exterior. Tonelle found 
 among 222 fatal cases of puerperal fever, that in 32 purulent mat- 
 ter was contained in the lymphatics.* This shows tliat in about 
 one-seventh of the cases of puerperal fever, inflammation and sup- 
 puration of the lymphatics may take place. This doctrine has been 
 forcibly illustrated by Cruveilhier.j 
 
 Inflammation of lymphatic vessels may almost invariably be traced 
 to irritation, or an irritating cause at their organic extremities. 
 Thus a sore in the finger or hand, whitloe, or other inflamed states 
 of the fingers, are often attended with painful red streaks or lines, 
 extending up the arm to the arm-pit. These red streaks indicate 
 inflammation of the subcutaneous lymphatics. In like manner I 
 have seen a blister applied to the surface of the belly cause inflam- 
 mation of the lymphatics leading to the inguinal glands. 
 
 The inflammation when not violent terminates in resolution. In 
 more severe cases it may cause effusion of lymph into the cavity of 
 the vessel, so as to effect adhesion and obliterate its canal. This 
 was probably the cause of the obstruction which Mascagni states 
 he found in the lymphatics of several subjects after the use of blis- 
 ters. Suppuration, as a consequence of inflammation of lympha- 
 tics, is little known. 
 
 2. Wounds of lymphatics must occur frequently. In truth, 
 scarcely an incision dividing the skin and cellular membrane can 
 fail to involve several lymphatics, and every deep incision divides 
 many of them, j; They appear to unite easily. Is the cavity obli- 
 terated ? The frequent anastomoses render this event of no con- 
 sequence. Hewson observed that in several instances lymphy coa- 
 gulable fluid continued to ooze from the wounded vessel for days. 
 
 3. Cirsus (K/gffoj) or Varicose Dilatation. This name is applied 
 by Meckel to denote a dilated state of lymphatics similar to varix 
 in veins. Schreger and Tilesius delineate what they conceive to 
 be varix in the lymphatics of the conjunctiva ; Mascagni repre- 
 
 * Des Fievres Puerperales observees a la Maternite de Paris pendant I’annee 1829. 
 Par M. Tonelld, Archives Generales, XXII. p. 345. 
 
 T Anatomie Pathologique. 
 
 J Monro in Edin. Medical Essays, Vol. V. Art. xxvii. 
 
LYMPHATIC SYSTEM, &C. 
 
 213 
 
 sents the same condition in those of the lungs ; and Soemmering 
 describes those of the intestines as varicose in hernia. The same 
 condition was observed by Bichat in the lymphatics of serous mem- 
 branes. In dropsical subjects they are always much distended 
 with fluid ; and hence the anatomist finds their demonstration much 
 more easy in such circumstances. 
 
 4. Rupture of the lymphatics has been assumed as a probable 
 cause of consumption by Morton, of scrofula in general by Acker- 
 man, of Barbadoes leg by Hendy, of puerperal swelled leg by 
 White, of dropsy by Van Swieten, Haase,* * * § Assalini,! Metzler,j; 
 and Soemmering, § and of white swelling of the joints by Bram- 
 billa. II Yet in neither of these diseases has the existence of rup- 
 ture of the lymphatics been demonstrated ; nor has the accident 
 been shown to be one of ordinary frequency. Baillie admits that 
 the thoracic duct may have been ruptured. But Guifiart is the 
 only person who is said to have seen this accident in the person of 
 a boy of fourteen. IT 
 
 5. Dilatation loitli Obstruction. Soemmering repeatedly found 
 the lacteals of the small intestines near the duodenum filled and 
 distended with a thick curdy matter like soft cheese. Of the same 
 deposition in the lacteals of the jejunum with much induration, 
 Walter delineates an example in a man of about thirty. Edward 
 Sandifort represents the lacteals in an infant of a few weeks much 
 thickened, approaching to varicose, with swelled mesenteric glands.** 
 And Ludwig saw them in a similar state in a girl of seven, with 
 induration of these glands. 
 
 6. Osseous Deposition. Callous hardness, with osseous matter, 
 was seen in the coats of the lymphatics in the pelvis by Mascagni, 
 Cruikshank, and Walter found them ossified, and of stony hard- 
 ness. The thoracic duct was found filled with caseous or tyroma- 
 tous matter by Poncy, all the neighbouring glands, both thoracic 
 and mesenteric, being enlar-ged and tyromatous ;ft and with earthy 
 
 * J. Gotti. Haasius de Vasis Cutis, &c. Absorbentibus. Leip. 1786. 
 
 t Essai Medical sur les Vaisse.aux Lymphatiques, &c. p. 56. 
 
 + Dissertatio de Hydrope, &c. p. 23. 
 
 § De Morbis Vasomm Absorbentium, p. 132. 
 
 II Acta Acad. Medico-Chirurg. Militaris Viennensis, Tome I. p. 16. 
 
 ^ Apiid Barth olini Opuscula nova de vasis Lymphaticis, &c. Hafiiise, 1670. 
 
 ** Observation. Anatom. Pathologic. Lib. ii. cap. 8. 
 
 tt Nouveau Recueil D’Observations Chirurgicales Faites par M. Saviard. A. Maitve- 
 Chirurgien de I’Hotel Dieu et Jeure a Paris. Paris, 1702. Obs. CXI. p. 500. 
 
214 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 or osseous matter by Assalini.* Cheston found it obstructed with 
 a solid substance resembling calcareous matter ;f Bayford found it 
 much obstructed by the pressure of an aneurismal tumour and 
 Scherb is said to have met with an actual concretion.§ All these 
 phenomena, excepting that of the aneurismal tumour, are the ef- 
 fects of strumous disorder. 
 
 The lymphatics have been long supposed to be the agents con- 
 cerned in the formation of king’s evil, (^struma, scrofula^') and in 
 the development of the disease when latent. What are the proofs 
 of this opinion ? Have the lymphatics been actually found disor- 
 ganized in cases of strumous disease, and does scrofula never take 
 place without traces of this disorganization ? Do they act as the cause, 
 or do they partake in the effects of another morbific agent more 
 general in operation ? In answering these questions much will de- 
 pend upon the meaning attached to the term scrofula. If this be a 
 disease appearing in the lymphatic glands only, there may be some 
 ground for the opinion. But to assemble the numerous disorders 
 termed strumous, under the head of the lymphatics, implies conclu- 
 sions which are not supported by anatomical facts. 
 
 It seems more natural and more consistent with the known phe- 
 nomena of diseased action, to place the genesis of struma, whatever 
 that may be, in the process of digestion, in the lacteal vessels that 
 arise from the jejunum^ and in the blood of the small capillary 
 vessels generally. From what is most generally observed, the pro- 
 cess of arterialization in the lungs appears to be defective. 
 
 Since the arguments which have been adduced against the ab- 
 sorbent power of the lymphatic vessels by Mayer, Magendie, and 
 others, their influence either in the production of dropsy, or in re- 
 moving it, seems to be very doubtful. 
 
 How far can they be admitted to explain the process of ulcerative 
 absorption so ingeniously contrived and ably maintained by J ohn Hun- 
 ter? and what share can they be supposed to possess in the removal of 
 other matters, either proper or foreign to the system, as that patholo- 
 gist believed ? Upon these questions accurate facts are still wanting. 
 
 * Essai Medical sur les Vaisseaux Lymphatiques, &c. Par Paolo Assalini. Tu- 
 rin, 1787-8. 
 
 + Philosophical Transactions, Vol. LXX. 1780. And Pathological Inquiries ; and 
 Observations on Surgery, from the Dissections of Morbid Bodies ; with an Appendix 
 containing three Cases on different subjects. By Richard Browne Cheston, Surgeon 
 to the Gloucester Infirmary. 4to. Gloucester, 1766. 
 
 J Medical Observations and Inquiries, Vol. III. p. 18. 
 
 § Apud Haller, Dissertation. Patholog. 
 
LYMPHATIC GLAND Oil GANGLION. 
 
 215 
 
 CHAPTER XL 
 
 LYMPHATIC GLAND OR GANGLION, KERNEL. {GlandulcE Lym 
 
 phaticcB, — Glandulce Conglobntai. — Die Saugader-Dreusen.) 
 
 Section I. 
 
 This is the proper place to consider the structure of those bodies 
 which are in common language termed kernels, to which anatomists 
 have applied the name of lymphatic glands, and the French ana- 
 tomists have more recently given that of lymphatic ganglions. The 
 general appearance, figure, and usual situation of these bodies, are 
 well known and described in the common treatises on anatomy. In 
 general they are spheroidal, seldom quite globular, and most com- 
 monly their shape is that of a flattened spheroid. In different sub- 
 jects, and in subjects at different ages, they vary from two or three 
 lines to an inch in diameter. The medium rate is about half an 
 inch. Their surface is smooth ; their colour grayish-pink, some- 
 times pale red, bluish, or of a peach- blossom tinge, — varieties which 
 seem to depend on degrees of bloody transudation ; for when wash- 
 ed and slightly macerated, they assume the gray or whitish-blue 
 colour. In a few instances they are jet black, — a peculiarity 
 which seems to depend on a degree of black infiltration, or on the 
 incipient stage of that change which has been termed melanosis, or 
 melanotic deposition. The idea that it may be derived from the 
 carbonaceous matter suspended in the atmosphere of great cities, 
 has been shown by Cruikshank to be absurd. Its anatomical pos- 
 sibility may be justly questioned. 
 
 They are always situate in the celluloso-adipose tissue found in 
 the flexures of the joints. They are found in small number at the 
 bend of the ham, and that of the elbow ; they are more numerous 
 in the arm-pit and groin ; in considerable number in the cellular 
 tissue of the lumbar region, before the psoas and iliacus muscles; 
 and they are most abundant round the neck. The posterior me- 
 diastinum, and the cellular tissue between the mesentery and ver- 
 tebral column, abounds with lymphatic glands mutually connected 
 in clusters. 
 
 Each gland may be said to consist of a peculiar substance, in j 
 
216 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 closed in a thin membrane like a capsule. The capsule is a thin 
 pellucid colourless suostance, which is resolved by maceration into 
 fine whitish fibres. It is very vascular ; and Mascagni appears to 
 have detected absorbents in it. It is connected to the proper sub« 
 stance by fine filamentous or cellular tissue. The capsule is con- 
 sidered by Beclard as a fibro-cellular membrane. The proper sub- 
 stance of lymphatic glands consists of a homogeneous pulp, in 
 which injections have shown numerous ramifications of minute ves- 
 sels. As these vessels are injected from the lymphatics which are 
 seen to enter the body of the gland, they are believed to be conti- 
 nuous with them, and to be lymphatics arranged in a peculiar man- 
 ner. These vessels are of two kinds, one entering the gland called 
 vasa afferentia or inferential entrant lymphatics ; the other quitting 
 is called vasa efferentia, egredient lymphatics. This distinction is 
 founded on the direction of the valves. In the vasa inferentia the 
 fi’ee margins of the valves are turned toward the gland ; in the vasa 
 efferentia they are turned from it. 
 
 The number of entrant lymphatics varies from one to thirty, and, 
 what is more remarkable, almost never corresponds with that of the 
 egredient lymphatics, which are in general much fewer. Cruik- 
 shank says he has injected fourteen entrant lymphatics to one gland, 
 to which only one egredient vessel corresponded. When the en- 
 trant lymphatic reaches the gland it splits into many radiated 
 branches, which immediately sink into its substance. The egredi- 
 ent lymphatics are generally larger than the entrants. 
 
 The arrangement of these vessels in the interior of the glands is 
 best described by Mascagni, whose observations are confirmed by 
 Gordon. To see this well, it is requisite to inject the entrant lym- 
 phatics of two glands in two different modes ; one with mercury, 
 the other with wax, glue, or gypsum. After a successful mercu- 
 rial injection, the entrants are seen, before sinking in the gland, to 
 divide into two orders of branches. One of them, which belongs 
 chiefly to the surface or circumference of the gland, consists of 
 large vessels, bent, convoluted, and interwoven in every direction, 
 communicating with each other, and swelling out into dilated cells 
 at certain parts, and of smaller vessels, which form a minute net- 
 work on the surface, and which seem to terminate in the cells or 
 distended parts of the larger vessels. 
 
 From these distended parts or cells, again, arise many minute 
 vessels, which, after winding about on the surface of the gland, 
 unite gradually, and form the egredient vessels of the gland. 
 
LYMPHATIC GLAND OR GANGLION. 
 
 217 
 
 The wax, glue, or gypsum injection is employed to show the 
 deep-seated or central vessels of the gland. The distribution of 
 these is found to be quite the same as that of the superficial vessels. 
 
 The cells delineated by Cruikshank, I am disposed to regard 
 as mere dilated parts of the lymphatic vessels which constitute the 
 intimate structure of the gland. 
 
 These minute tubes are connected by delicate filamentous tissue, 
 which is more abundant in early life than afterwards. 
 
 Injections show the existence of blood-vessels, which accompany 
 the convolutions of the lymphatics in the glands. But no nerves 
 have been found either in the glands or their capsules. 
 
 The white matter described by Haller and Bichat is not con- 
 tained in the cellular substance, but in the cells of the lymphatic 
 vessels themselves. 
 
 Section II. 
 
 1. a. The lymphatic glands as organized bodies, may be sup- 
 posed to be liable to ordinary inflammation. Yet on this subject 
 no very precise facts are given. The swelling called bubo, (/SouCwif, 
 Hippocrates) appears to be in most cases inflammation of the cap- 
 sule and surrounding cellular substance. 
 
 /3. Adenosis. Strumous Inflammation. The glands, however, ap- 
 pear to be liable to a slow chronic inflammation, which does not 
 readily suppurate, and which, when it does suppurate, always forms 
 a bad and tedious disease. They ai’e believed to be often affected 
 in scrofulous subjects; and the definition of the evil (struma, scro- 
 fula, les ecrouelles,') has been directly taken from this pnenomenon. 
 In such affections these bodies undoubtedly become the seat of a 
 slow inflammatory action, which is attended with gradual enlarge- 
 ment, without much pain or change of colour in the integuments. 
 At length, the gland is found to become softer than it had been, 
 and an opening takes place in the skin, through which a fluid is 
 discharged, not homogeneous, but in general consisting of a thin 
 serous water, in which thicker pieces like curd are mixed. This 
 fluid, which is generally most completely formed in suppuration of 
 the lymphatic glands, is what has been termed scrofulous, or stru- 
 mous matter. Simple strumous enlargement in these glands may 
 proceed to such an extent as to interfere with, and even impede the 
 functions of important organs. In those of the neck they have, by 
 
218 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 compressing the windpipe, caused fatal suffocation. (Soemmering 
 and others.) Bleuland saw them in an infant impede deglutition 
 hy pressing the oesophagus,* 
 
 7. Adenitis. Irritative Enlargement. The lymphatic glands are 
 liable to become painful and enlarged, in consequence of causes not 
 originally resident in themselves. A sore or wound, especially if 
 punctured or lacerated, on the hand or foot, may be succeeded in 
 a few days by an enlarged painful swelling of one or more glands 
 in the arm-pit or groin. A wound of the scalp may be followed 
 by a glandular swelling of the neck ; and a spoilt tooth, or a sore 
 of the mouth, will often give rise to a painful enlargement of the 
 glands under the jaw. 1 have repeatedly seen a whole chain of 
 them enlarge, and continue so for months, in consequence of the 
 use of mercury carried to salivation, and especially after enlarge- 
 ment and ulceration of the muciparous follicles of the ileum, whe- 
 ther isolated or aggregated. It is particularly to be observed, that 
 when these follicles of the aggregated glands become prominent 
 and swelled, or atfected by ulceration, which usually takes place 
 towards the lower end of the ileum, then the mesenteric glands op- 
 posite and corresponding to these intestinal follicles become en- 
 larged and swelled often to a great degree. The enlargement and 
 swelling seem at first to be simple enlargement of the glandular 
 parenchyma ; but after some time this appears to contain a new 
 deposit, which appears to be what I have called tyromatous matter. 
 The tracheo-bronchial glands become enlarged in inflammation 
 of the bronchial membrane of the pulmonic tissue, and other dis- 
 eases of the lungs ; and those of the mesentery increase in conse- 
 quence of disease of the intestinal canal. In such instances it is ob- 
 vious that irritation at the organic end of the lymphatics is the 
 cause of morbid action in the glands, at the glandular end of these 
 vessels. 
 
 In other instances, for example, when a sore on the penis is fol- 
 lowed by enlargement of the inguinal glands, or a cancerous breast 
 is attended with swelling and pain of the axillary glands, it has 
 been concluded, that, as the primary diseases depend on a peculiar 
 or specific action, as it was termed, peculiar matter is absorbed, and 
 conveyed to the gland, in which it gives rise to the morbid changes. 
 We now know that it is unnecessary, in the majority of cases, to 
 suppose absorption, which indeed is rendered very doubtful ; and 
 
 * Obaervationes de sano et morbosa (Esophagi Structura. Lugdun. Bat. 1785. 
 
LYMPHATIC GLAND OR GANGLION. 
 
 219 
 
 it is sufficient to ascribe the glandular enlargement in such instances 
 to mere irritation at the organic ends of the lymphatics. 
 
 2. Enlargement from the Operation of Poisonous Matter, Pes- 
 tilential Bubo. In plague the glands of the arm-pit and of the 
 groin generally become enlarged as the disease advances. The 
 period at which this takes place is uncertain, but seems to vary 
 from the first twenty-four hours to the seventh or eighth day. 
 (Russel, de Mertens, Orraeus, &c.) This enlargement, which soon 
 proceeds to a bad open sore, accompanied with sloughing and the 
 discharge of foul, dirty-coloured fluid, has been generally ascribed 
 to the absorption of the pestilential poison, and its direct operation 
 on the glandular system. This is probably in general the true ac- 
 count of the pestilential bubo. As, however, they are almost in- 
 variably accompanied with carbuncles, it is not unlikely that in 
 some instances the bubo may be the result of irritation from the 
 presence of a carbuncle. 
 
 3. Enlargement with Death of the Glandular Tissue, a. Stru- 
 mous Mortified Bubo. Of strumous bubo there are many varieties 
 well known to the practical surgeon. To this head, however, I 
 refer a peculiar disease which I have seen in the glands at the bend 
 of the arm. The glands become enlarged, painful, and hard; and, 
 notwithstanding all efforts to procure resolution, the skin first gives 
 way, chiefly by sloughing, and matter with some membranous 
 shreds is discharged. A sore of a peculiar character is formed^ 
 Its edges consist of skin cut very sharp, and notched or serrated, 
 as it were, into angular slips. From these margins the sore de- 
 scends deep and rather foul to an ash -coloured, solid, convexly- 
 rounded body, which is evidently a diseased gland. Round this the 
 process of suppuration and ulceration proceeds, with the occasional 
 discharge of sloughs, till the gland is expelled either in fragments 
 or in a mass. After which the hollow is filled with granulations, 
 and cicatrization is easily effected. 
 
 This process is attended with pain at first in the skin chiefly, but 
 afterwards it seems to cause no more uneasiness than an ordinary 
 abscess. Its duration varies according to the size and number of 
 the glands to be ejected. In the most distinct cases which I have 
 seen, it occupied between three and four months. This disorder I 
 regard as arising from a gland being suddenly smitten, as it were, 
 with death in its intimate structure, from previous disease of its 
 membranous capsule and proper vessels. I have seen it only in 
 
220 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 those at the bend of the arm ; and to Cruikshank it appears to 
 have occurred in the same situation.* It may occur, however, and 
 probably has been seen by others elsewhere. 
 
 3. Phagedenic Buho. Seen principally in the inguinal glands 
 in persons labouring under the operation of the syphilitic poison, 
 or who have been subjected to repeated courses of mercurial medi- 
 cines. The skin first becomes hard, painful, hot, and dull red, 
 with circumscribed edge, but dififusely swelled. The transition to 
 a dirty grayish-brown indicates that the skin has become dead ; 
 and the process of ulceration, alternating with sloughing, is esta- 
 blished. As the skin, and successively the cellular tissue, are 
 thrown off in this manner, one, two, or more glands come into 
 view, somewhat swelled, and of a brownish-red colour, but equally 
 distinct as if they had been carefully dissected. The surface of the 
 sore is generally a deep-red brown, covered with a foul blood-co- 
 loured serous fluid, without appearance of granulations, and with 
 the sensation of burning or searing pain. The process of sloughing 
 proceeds in the cellular tissue, while the gland or glands remain 
 as so many brownish masses, with small marks of vitality, until 
 they are detached entirely from the cellular substance, in which 
 they are imbedded, and are thrown off dead. In effecting this 
 object, the process of sloughing may proceed to such extremity as 
 to affect first the superincumbent cellular coat, and next the sheath 
 of the femoral artery, which, in such circumstances, inevitably 
 gives way ; and the patient is suddeidy destroyed by hemorrhage. 
 An instance of this accident in a soldier of the guards used to be 
 mentioned by Dr Hunter.f In a case which occurred some years 
 ago in the military hospital of the Castle, it was deemed requisite 
 to avert the impending danger by tying tbe femoral artery. Sub 
 sequent gangrene of the foot and leg, however, rendered amputa- 
 tion indispensable ; and recovery at length took place. 
 
 In more favourable circumstances, after great destruction of 
 parts, and the expulsion of one, two, or more mortified glands, the 
 phagedenic action stops spontaneously, granulation takes place, 
 and the sore is gradually healed. 
 
 I have described the progress and phenomena of this disease, as 
 I have witnessed them in several instances which have fallen under 
 
 * “ I have known the last mentioned glands (the bracliial) die, and slough out in 
 scrofula without any great inconvenience.” — The Anatomy of the Absorbing Vessels, 
 p. 132. 
 
 -f- The Anatomy of the Absorbing Vessels, p. 122, p. 134, second edition. 
 
LYMPHATIC GLAND OR GANGLION. 
 
 221 
 
 my observation. It appears that the active symptoms manifest 
 themselves first in the skin and cellular membrane ; and it may 
 therefore he thought that the disease belongs properly to these tis- 
 sues. Their affection, nevertheless, is so far as can be determined, 
 the result of the previous state of the glands, which appear to he 
 directly killed either by the syphilitic poison, or the mercurial ac- 
 tion, and thus to give rise to the violent process of disorganization, 
 which then takes place in the skin and cellular membrane. 
 
 Enlargement of the mesenteric glands has been supposed by 
 most authors to be the anatomical characters of the disease term- 
 ed mesenteric wasting — {Tales mesenterica. Tabes glandularis. 
 Wharton, Baglivi, Richard Russell.) Without absolutely deny- 
 ing this, I shall afterwards show, that, in most instances of that dis- 
 ease, the enlargement of the glands is secondary to some morbid 
 state either of the intestinal villous membrane, the muciparous fol- 
 licles, or of some of the intestinal tissues. 
 
 4. Enlargement and Induration. ( Vascular Sarcoma.) Either 
 after repeated attacks of inflammation, alternating with resolution, 
 or with a slow and indistinct form of the disease, a gland, or a 
 cluster of glands gradually enlarges, and, resisting all means of 
 resolution, becomes unusually hard. This continues, or is liable 
 to slight occasional aggravations, with dull pain in the substance, 
 or in the neighbourhood of the gland. Though such enlargement 
 may be termed strumous.^ and may have originated in what is termed 
 strumous action, the structure of the gland or glands is so much 
 changed as not to be distinguished from vascular sarcoma. A 
 tumour of this kind, when divided, presents a firm homogeneous 
 substance of a bluish-gray colour, somewhat elastic and compres- 
 sible, traversed with more or fewer vessels which may be injected 
 from the neighbouring arteries, and consisting in its intimate 
 structure of amorphous granular masses united by dense filamen- 
 tous tissue. The great hardness, and the malignant tendency of 
 this growth, have procured for it from most authors the ominous 
 names of scirrhus and cancer. Though correct enough for all 
 practical purposes, these epithets are not justified by the anatomi- 
 cal characters. 
 
 Sarcomatous enlargement may occur in any of the lymphatic 
 glands. It is frequent in those of the neck, and may often be trac- 
 ed to strumous inflammation, or to the irritation of spoiled teeth. 
 Cruikshank mentions an instance in which the tracheo-bronchial 
 
222 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 lymphatic glands were atFected with this morbid change to such ex- 
 tent as to cause fatal suffocation.* In the internal iliac glands it 
 is not uncommon, so as to form large indurated masses ; and in the 
 female may operate as a cause of difficult parturition equally fatal 
 to the mother and the infant. (Hunter apud Cruikshank.)f The 
 same disease occurs in the mesentery either primarily, or in con- 
 sequence of ulceration of the intestines. 
 
 5. Tyroma glandularum. Tyromatous deposition. Tubercular 
 deposition. The lymphatic glands are liable to become the seat of 
 a deposit of matter different in all appearances from their own tis- 
 sue. The gland or glands so affected may either be enlarged or 
 not ; but in almost all cases they are eventually enlarged, sometimes 
 to three, four, or even six times their natural size. Their shape 
 they sometimes retain, sometimes not, becoming irregular on the 
 surface, lobulated, and generally projecting considerably in the 
 free or unattached direction. When divided by incision, the sec- 
 tion presents not the usual bluish or pale-red tint of the healthy 
 lymphatic gland ; but a colour cream-yellow, gray, or whitish gray. 
 Nor is this colour always uniform ; for in one lymphatic gland in 
 a cluster it is cream-yellow, or grayish, and in another it is of 
 white colour, and sometimes this difference is seen in different parts 
 of the same gland. In this material few or no vessels are recog- 
 nised. The whole is more or less a homogeneous matter of gray 
 or cream-yellow colour, like soft cheese, pretty firm and resisting ; 
 and it presents to the glass no arrangement of cells or vessels, but 
 a confused mass of substance with no trace or mark of organiza- 
 tion. This has been called cheesy or caseous substance ; and in 
 those cases in which it is deposited in the form of small spherical 
 or spheroidal globules, it has been named tubercle, and tubercular. 
 I think that the term Tyroma (Tu^og, caseus,) is most suited to ex- 
 press its nature and most obvious characters. 
 
 This tyromatous substance is effused in the fluid or semifluid 
 form, and then gradually acquires the consistent character. It ap- 
 pears in several instances to be effused at different points of the 
 gland ; and hence the consistence and colour is different at different 
 points. In the most fluid form it is like thickish cream, or a mix- 
 ture of chalk and water. In others more consistent the matter 
 contained is like soft putty, or consists of consistent granules diffus- 
 ed in a whey like or milk like fluid. This is what is often called 
 
 * Anatomy of the Absorbing Vessels, p. 129. -f Ibid. p. 123. 
 
LYJIPHATIC GLAND OR GANGLION. 
 
 223 
 
 pultaceous matter and atlieromatous matter. In some of these ty- 
 romatous deposits are observed portions much firmer, sometimes as 
 hard as cartilage, and in some as solid as earthy or stony matter. 
 
 This deposit of earthy or bony matter also takes place in the li- 
 quid or semifluid form, and gradually becomes thick and consis- 
 tent by the absorption of the serous or most fluid part ; and the 
 earthy or gypseous portion shows its true nature by becoming solid 
 and its particles coalescing. 
 
 This deposit is liable to take place in any of the glands. It is, 
 however, most common in the bronchial lymphatic glands and in the 
 mesenteric lymphatic glands, and in the lymphatic glands of the 
 neck. In the bronchial lymphatic glands it is mostly a disease of 
 infancy, certainly of early life. I have not seen it much in adults; 
 but I have repeatedly met with it in dissecting the bodies of infants 
 and children ; and many of the thoracic and tracheal affections to 
 which children are liable may either he traced to or are associated 
 with the presence of enlarged and tyromatous bronchial glands. 
 This may be caused by the fact, that most children, in whom the 
 bronchial glands are tyromatous, die in childhood. 
 
 Enlargement of the bronchial and tracheal glands gives rise to 
 great dyspnoea, and sometimes to symptoms of crowing inspiration. 
 
 In the glands of the neck it is less hurtful, not being a cause of 
 disease in the lungs or trachea ; and hence it continues longer with- 
 out influencing much the duration of life. 
 
 In the abdomen, on the other hand, it is different. For there it 
 evidently compresses the lacteals proceeding from the intestinal tube. 
 At the same time it is there seldom alone, but is preceded by more 
 or less disease, often enlargement and ulceration of the intestinal fol- 
 licles, as was mentioned when speaking of common glandular en- 
 largement. 
 
 This species of deposit takes place chiefly in those in whom the 
 habit called strumous predominates. It is supposed, indeed, to be 
 the effect and an indication of the strumous disposition; and such pro- 
 bably it generally is. Though not a heterologous deposit, and con- 
 sisting entirely of crude albumen insusceptible of organization, yet it 
 is in its consequences suflBciently hurtful. When large tyromatous 
 glands compress the bronchial tubes and lungs, and cause cough 
 and difficult and laborious breathing, they may also by their size 
 and position compress important blood-vessels and seriously de- 
 range the circulation. 
 
 Tyromatous glands, after becoming consistent, are liable to under- 
 
224 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 go an ulterior stage of softening, and apparently almost ulcerative 
 sloughing. Thus we find them soften and suppurate iu the'neck and 
 groin ; and after a tedious process of suppuration subside and dis- 
 appear, leaving bad and indelible scars with much irregular con- 
 traction of the skin. In the bronchial glands, when tyromatous, I 
 have seen them in like manner softened and converted into a sort of 
 cream-like sero-purulent matter ; and others presenting deep ragged 
 ulcerated cavities. Lastly, in the mesentery, where they are often 
 allowed to pass through all their stages before the death of the pa- 
 tient, it is not uncommon to find the glands in different stages of 
 softening. One or two are firm and consistent; others present 
 softening, taking place at different points ; others present portions 
 of cream-like or soft caseous purulent matter ; and others are re- 
 presented by bags of puriform atheromatous semifluid substance, 
 which is the tyromatous matter dissolved or liquefied, contained 
 within the capsule or tunic of the gland, the only persistent por- 
 tion of the whole structure. 
 
 The tubercular disorganization is represented by Laennec, 
 Dupuy, and others, as exceedingly frequent in lymphatic glands. 
 By some authors these bodies are regarded as constituting the ana- 
 tomical character of the strumous or scrofulous gland. In many 
 instances of scrofulous enlargement and induration, the glands are 
 indeed found to be occupied with minute bodies, somewhat firm, 
 which undergo a slow liquefaction or mollescence. But it is per- 
 haps too limited a view to restrict to this only the characters of 
 scrofula. In some instances these tubercles appear to consist of 
 the original cells of the gland, filled with albuminous or albumino- 
 calcareous matter. 
 
 6. Ossification, Calcareous Deposition. The lymphatic glands 
 are liable to become ossified, or to be penetrated with deposition of 
 calcareous matter. The diseased action commences at one or more 
 points, and is progressively extended, till the gland is converted 
 into a bony mass.*' This change was observed by Cruikshank in 
 the tracheo-bronchial glands, which he represents as in that state 
 producing ulceration through the trachea, and being coughed up 
 as osseous concretions. Baillie, adopting the same view, regards 
 the calcareous deposition as more common in these bodies than in 
 any other of the same texture.J Lastly, Bayer has observed this 
 
 * A Practical Essay on the Diseases of the Vessels and Glands of the Absorbent 
 System, &c. By William Goodlad, Surgeon, &c. p. 74. London. 1814. 
 
 ■f Anatomy, &c. p. 129. Morbid Anatomy. 
 
ORGANIZATION AND STRUCTURE. 
 
 225 
 
 change not only in the tracheo-bronehial glands in subjects which 
 he terras phthisical, but in the cervical glands in laryngeal con- 
 sumption, and occasionally in persons cut off by mesenteric scro- 
 fula, {carreau^) and in tbe inguinal glands in persons who have 
 had buboes. This change he considers the effect of inflammation.* 
 To the same head are to be referred the earthy or calcareous de- 
 positions (rnatiere platreuse, gypseuse) observed by Dupuy in these 
 glands. 
 
 7. Melanotic deposition is common in the tracheo-bronchial lym- 
 phatic glands, and in those of the groin. Of the former, an ex- 
 ample is at the present moment before me in the lungs of a woman 
 much occupied by tubercular masses. 
 
 CHAPTER XII. 
 
 The three orders of tubes or canals, the anatomical characters, 
 and pathological relations of which have now' been completed, con- 
 stitute what has been termed tbe Vascular System, ( Vasa ; Sys- 
 tema Vasorum, Das Gefass System. Le Systems Vasculaire.) 
 The great extent of its distribution, and the part which it performs 
 in all the processes of the living body, both in health, and during 
 disease, must be easily understood. In every texture and organ 
 arteries and veins are found ; and in all, except a few, the art of 
 the anatomist has demonstrated those colourless valvular tubes de- 
 nominated lymphatics. The arrangement of the former, especially 
 in the substance of the several textures, essentially constitutes what 
 is termed the organization of these textures. IMany anatomists 
 have imagined that each texture has a proper matter, or paren- 
 chyma^ by which it was supposed to be particularly distinguished, 
 and which was conceived to consist of minute inorganic solid atoms. 
 "Whether this opinion be w'ell founded or not, it is perhaps of little 
 moment to inquire. At present it is certain that it is not suscep- 
 tible of demonstration. 
 
 The phenomena of injections, in which he was eminently suc- 
 cessful, led Ruysch to entertain the opinion, that every substance 
 
 * Memoire sur I’ossification morbide, consideree comme une terrainaison dc®. phleg- 
 niasies. Par P. Raver. Archives Generales, Tome I. p. 439, 
 
 P 
 
226 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 of the animal frame consisted of nothing but vessels. This idea, 
 though opposed by Albinus,* on the same grounds on which it was 
 advanced, was nevertheless revived by William Hunter, who be- 
 lieved that the inorganic parts of animal bodies are too minute for 
 sensible, or even microscopical examination. In every part, how- 
 ever minute, always excepting nails, hair, tooth enamel, &c., ves- 
 sels could be traced ; and even a cicatrix he demonstrated is vas- 
 cular to its centre, f 
 
 By the aid of the microscope the researches of Lieberkuhn tend- 
 ed still more powerfully to favour this opinion.^ But repeated 
 observation of the effects of injection in every part and texture al- 
 most of the body by Barth and Prochaska has led the latter to con- 
 clude, that this opinion, understood in the ordinary mode, is not 
 tenable. Prochaska, who has investigated this subject with much 
 attention, thinks he is justified in dividing all the substances of the 
 animal frame into two, — those which may be injected and those 
 which cannot. In this manner he regards skin, especially its outer 
 surface, muscle, various parts of the mucous membranes, the pia 
 mater^ the lungs, the muscular part of the heart, the spleen, the 
 liver, kidneys, and other glands as very injectible ; but tendon, li- 
 gament, cartilage, &c. as not injectible.§ Without entering mi- 
 nutely into the merits of this distinction, or the inferences which 
 Prochaska makes to flow from it, it is sufficient, so far as all useful 
 knowledge is concerned, to infer, that blood-vessels are an essential 
 constituent of every organic texture, however different; and, if 
 there be any other matter inherent in such textures, it must be 
 derived from these as a secretion. Muscle, brain, nerve, osseous 
 matter, and cartilage are depositions or the product of nutritious 
 secretion from the respective arteries of these organized substances. 
 
 To apply these distinctions to pathological anatomy, therefore, 
 two leading facts are presented as principles. The first of these is 
 the arrangement of the vessels in the substance of the organic tex- 
 tures ; — their organization. The second is the great result of or- 
 ganization, the principal duty performed by the vessels in each tis- 
 sue ; — the formation of each organic substance, or the process of 
 
 * Annotationum Academicarum, Lib. iii. 
 
 t Medical Observations and Inquiries, Vol. II. 
 
 :}: De Villis Intestinorum. 
 
 § Georgii Prochaska Disquisitio Anatomica-Physiologica Organismi Corporis Hu- 
 mani ejusque Processus Vitalis, 4to. Vienna, 1812. 
 
 4 
 
OEGANIZATION AND STRUCTURE. 
 
 227 
 
 nutrition. To changes in one or other of these two circumstances 
 almost all morbid actions which become the subject of pathological 
 anatomy may be referred; under the two general divisions, of 
 changes in organization ; and, 2d, changes in nutritious deposition, 
 or intimate structure. 
 
 It is unnecessary to render this division more complex, by ad- 
 mitting, as has been done by several pathological writers, a third 
 head in the changes which take place in the process of secretion. 
 That process is to be viewed in general, nay, in almost all circum- 
 stances, as a complementary effect of nutrition ; and the morbid 
 changes which it occasionally undergoes may, without violence, be 
 referred to one or other of the two foregoing heads. 
 
 It is different, however, with a third form or source of disease. 
 I allude to those errors in the formation and relative situation of 
 parts, especially the integrant parts of organs, which have been 
 termed malformations, (Missbildungen.) These have been shown 
 by Oken, Meckel, and others, to depend on the accidental inter- 
 ruption of the process of development, and misapplication of the 
 component parts of organs during the early stage of that process. 
 
 In the subsequent chapters of this work, though it is unnecessary 
 to abandon the simple arrangement hitherto observed, the morbid 
 changes incident to the several textures shall be enumerated in re- 
 ference to the two first distinctions, — those in minute organization 
 and its products, and those in nutrition and intimate structure. 
 The various forms of malformation constitute a distinct family by 
 themselves. 
 
BOOK II. 
 
 THE NERVOUS SYSTEM. 
 
 The nervous systena of the animal body ineludes, according to 
 the most rational views, two general divisions. The first of these 
 is collected in a single and indivisible mass, and contained in a pe- 
 culiar cavity, formed by part of the osseous system of the animal. 
 In the less perfect tribes this is limited to the vertebral column, or 
 sometbing analogous to it ; but in man, and the more perfect ani- 
 mals, we find a lai'ge cavity at the superior extremity of this column 
 superadded. The second division of the nervous system is found 
 in the form of long chords or threads mutually connected, and 
 running in various directions through the body in the mode of ra- 
 mification, To these the name of nervous trunks or chords, or 
 simply nerves, has been long applied. 
 
 CHAPTER I. 
 
 A. The Central Part of the Nervous System. 
 
 Section I. 
 
 BRAIN, CEREBRAL SUBSTANCE, Cerebrum^ — BRAIN, cranial and 
 SPINAL. MviXov ey/.i(puXo\/ nai fjjViXov vunam ; — Marrow of the 
 Head and Marroio of the Bach, Galen. 
 
 Of all the works which have been composed on the anatomy of 
 the brain, the subjects may be referred to two general heads ; — 
 those which treat of the configuration of the organ, and those which 
 undertake to investigate its minute structure. The authors them- 
 selves, however, do not always distinguish accurately between these 
 two departments of anatomical science. As it is chiefly the latter 
 which is to occupy attention at present, I may mention, that after 
 the epistle of Varoli on the base of the brain and the origin of the 
 optic nerves, the writings of Willis, Malpighi, and Vieussens, are 
 
BRAIN, 
 
 229 
 
 the first which claim much notice. The works of Ridley,* * * § and of 
 Glaserus,t contain some good observations ; and that of Santorini^ 
 deserves to be mentioned for the first good description of the optic 
 thalarni and the corpora geniculata. Father Della Torre, § Pro- 
 chaskaj and Monro, are the first after Lewenhoeck who treat of 
 the structure of the brain after microscopical observation. The 
 essay of Vicq-D’Azyr, and his elaborate engravings are sufficiently 
 well known.^ About the same time, 1780, Vincenzo Malacarne 
 described the component parts of the organ with more accuracy 
 than had hitherto been attempted.** * * §§ Red followed, and communi- 
 cated much new information on the minute structure of several 
 parts of the organ.jf The work of Rolaudo, which appeared in 
 1809,J+ has been little known till of late. Better fortune awaited 
 the elaborate treatise of John and Charles \Venzel,§§ which is 
 highly appreciated by every anatomical inquirer in Europe. 
 Lastly, the description of Gordon, 1||| the microscopical observations 
 of Sir Everard Home,W who has confirmed many of the facts ob- 
 served by Della Torre, and the microscopical observations of 
 Ehrenberg, who has examined every part of the brain with much 
 care, and those of Treviranus, Valentin, and Weber, are entitled 
 to attention. 
 
 The brain may be considered as a continuous organ consisting 
 of three divisions; — the convoluted, the laminated, and the smooth 
 or uniform portions. Of these divisions, which are framed accord- 
 ing to the peculiar external configuration of each, the first part 
 
 * Anatomy of the Brain. By Henry Ridley. Lend. 1695. 
 
 •f- J. H. Glaserus de Cerebro. Basil, 1680. 
 
 + Jo. Dom. Santorini Observationes Anatomicse. Lugdvm. Bat. 1739. 
 
 § D. Giovanni Maria Della Torre, Nuove Osservazione Microscopicbe. Napoli, 
 1776. 
 
 II Georgii Prochaska, De Structura Nervorum Tractatus Anatom. Viennae, 1779, 
 et apud Op. Min. 1800. 
 
 ^ Recherches sur la Structure du Cerveau. Memoires de I’Academie des Sciences. 
 Paris, 1781-83. 
 
 ** Encefalotomia Nuova Universale di Vincenzo Malacarne Saluzzese. Torino, 
 1780. 
 
 ■It Fragmente Ueber die Bildung des Gehbns im Menschen. Vom Professor Reil. 
 Archiv. fur die Physiogie. 8ter Band, &c. et various papers in 9ter Band.^ 
 
 Saggio sulla vera Structura del cervello dell’ uomo. Sassari, 1809. 
 
 §§ J. et C. Wenzel, De Penitiore Structura Cerebri Hominis et Brutorum. Tubin- 
 gs, 1812. 
 
 III! Observations, &c. and Outlines of Human Anatomy. By John Gordon, M. D. 
 &c. Edinburgh. 
 
 in Phil. Trans. 1821, p. 25, 1824, p. 1, and 1825, p. 436. 
 
230 
 
 GENERAL AND PRTHOLOGICAL ANATOMY. 
 
 corresponds to what is called the brain proper, {cerebrum ;) the se- 
 cond to the small brain, {cerebellum ;) and the third to the oblong 
 cylindrical body contained within the vertebral column, and known 
 under the name of spinal chord. 
 
 The convoluted portion presents two surfaces, an outer or con- 
 voluted, and an inner or figurate. The laminated portion in like 
 manner presents two surfaces, an outer or laminated, and an inner 
 or central. The third has only one exterior surface. 
 
 The exterior surface of the convoluted division of the organ is 
 formed into eminences longitudinal and rounded, but directed in 
 various ways, and separated from each other by deep hollows. 
 These eminences have been named convolutions or circumvolutions, 
 {gyri, Soemmering, Wenzel,) and the depressions swfe’ or furrows. 
 This surface of the organ is most properly termed the convoluted 
 surface. To see it distinctly, the vascular membrane termed pia 
 mater., {meninx tenuis,) (Das Gefasshaut,) must be cautiously re- 
 moved by dissection. 
 
 The convoluted surface communicates with another interior sur- 
 face at two parts ; 1st, on the middle plane, under the posterior 
 end of the middle band or meso-lobe, {corpus callosum ;) 2d, on 
 each side of the middle plane, at the outer margin of the fluted 
 masses termed limbs of the brain, {crura cerebri) ; (Die Hirnschen- 
 kel) ; between these limbs and the posterior end of the optic cham- 
 ber or couch, {thalamus opticus)', (Der Sehhugel.) This surface of 
 the organ may be termed the central or figurate. 
 
 The exterior surface of the cerebellum is differently disposed. 
 Instead of presenting convoluted eminences, it consists of thin por- 
 tions of cerebral substance, placed contiguously, and either paral- 
 lel or concentric. These portions, which have been named plates 
 {lamiruB,) or leaves {folia,) are separated from each other by fur- 
 rows of various depth. This surface, which may be named the 
 laminar or foliated surface of the small brain, communicates also 
 with the figurate surface; Isf, at its superior part on the middle 
 plane, between the semilunar notch (Der halbmondformige Aus- 
 schnitt; Reil); behind, and the white cerebral plate termed Vieus- 
 senian valve, before. 2d, At its inferior surface between the parts 
 termed almonds by Malacarne, or spinal lobules by Gordon above ; 
 and the upper end {medulla oblongata) of the spinal chord, below. 
 
 The convoluted surface of each hemisphere may be convenient- 
 ly divided into the following five regions; 1. The commutual or 
 
BRAIN. 
 
 231 
 
 dichotomous ; 2. The lateral-superior, or convex ; 3. The antero- 
 inferior, or frontal ; 4. The medio-inferior, or spheno-temporal ; 
 5. The posterior or cerebellic region of the convoluted surface. 
 
 The first of these regions of the convoluted surface is easily un- 
 derstood. Plane in its surface, of a shape nearly semicircular, it 
 forms the central boundary of each hemisphere, corresponds to the 
 falciform or dichotomous portion of the hard membrane, 
 
 meninx dura,) by which it is separated from the similar sur- 
 face of the opposite hemisphere. Before and behind it extends 
 from the superior to the inferior surface of the brain ; but a consi- 
 derable portion of its middle is terminated by the upper surface of 
 the object named middle band, (mesolobe, corpus callosum,) which 
 lies between the two hemispheres. It is contained between the se- 
 micircular and the rectilineal margins. 
 
 The second region of the convoluted surface is extensive, and 
 occupies the whole of the anterior, upper, lateral, and posterior 
 parts of the hemisphere, from their anterior to their posterior ex- 
 tremity, and from the semicircular m.argin to a line which extends 
 between these extremities along the lateral borders of the organ. 
 
 The antero-inferior, or frontal, is that region of the convoluted 
 surface which rests on the horizontal part of the frontal and eth- 
 moid bones, and commencing before with a curved outline, — the 
 anterior end of the hemisphere is bounded behind by the curvili- 
 near hollow, which has been named the pit or fissure of Sylvius. 
 It is slightly uneven, and is bounded at its inner or mesial margin 
 by the great fissure which separates the hemispheres. This inner 
 margin always presents one convolution, which is quite uniform in 
 direction, extent, and configuration. It consists of a longitudinal 
 eminence, which extends in the adult brain about 1^ inch from the 
 beginning or posterior end of the notch, towards its anterior ex- 
 tremity. The inner margin of the eminence, which is about four 
 lines broad, forms the side of the fissure ; and its outer margin or 
 border is separated from the contiguous part of the convoluted sur- 
 face, by a furrow or hollow equally uniform in direction and figure 
 with the eminence, — about the same average length (1 inch 5 lines.) 
 This furrow contains the cerebral portion of the first pair or olfa- 
 cient nerves. 
 
 The medio-inferior, or spheno-temporal, is sitnate immediately 
 beliind this region, from which it is separated by the curvilinear 
 hollow. {Fossa Sylvii.) In the ordinary descriptions, this forms 
 what has been named the middle lobe of the brain ; while the pos- 
 
232 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 terior part of the convoluted surface, or that which corresponds to 
 the cerebellum, though distinguished by no evident mark or limit, 
 has been with equal impropriety named the posterior lobe. If 
 the whole region be examined from the curvilinear hollow to 
 the posterior tip of the hemisphere, it affords no mark, line, or 
 boundary on which to establish this popular and much used di- 
 vision ; and the whole presents one uniform region of convolu- 
 tions, which resemble in every respect those found on other paits 
 of this surface. The whole region, therefore, ought to be viewed 
 as a single division of the convoluted surface ; but as its posterior 
 part rests not on the cranium, but on tbe horizontal portion of the 
 hard membrane which covers the small brain, while the division of 
 lobes must be discarded as artificial, it may be expedient to subdivide 
 the surface into two, the medio-inferior and postero-inferior regions 
 of tlie convoluted surface, according as they correspond to different 
 containing parts. 
 
 The first, which near the curvilinear hollow, is slightly convex or 
 rounded, is lodged in a considerable cavity of tbe cranium, formed 
 by the sphenoid and temporal bones, bounded before by the spheno- 
 frontal arch, and behind by the pyramid or petrous portion of the 
 temporal bone. This part of the convoluted surface, which may be 
 named the spheno-temporal., is one of considerable importance, and 
 should be accurately known by the anatomical student. 
 
 The posterior division of this region, which is plane, corresponds 
 to the horizontal or cerebellic part of the hard membrane, and, 
 though not to be distinguished by any innate or organic limit, 
 may, however, for the sake of more precision, be marked by this 
 adventitious character.* It may be named the cerebellic region of 
 the convoluted surface. 
 
 The ordinary appearance of the convoluted surface is well known. 
 It is formed of cerebral matter, of a gray or dirty wax colour, the 
 surface of which is smooth and polished, where it has not been rent 
 by the removal of the membranes and their attachments. The con- 
 volutions consist of longitudinal eminences, rounded transversely, 
 running in various directions, and separated from each other by 
 deep furrows. If these be examined when the membranous cover- 
 
 * Lest the use of these terms be objectionable by their obscurity, I may observe 
 that, in describing parts of the human body, it is not unfi-equently requisite to have 
 recourse not only to marks on the organ described, but also to certain characters be- 
 longing to the contiguous parts. The first of these may be named the orr/anic or inr 
 note, as they belong to the organ ; the second, which do not belong to it, should be 
 named adventitious or esoteric. Tliis is indispensable in relative anatomy. 
 
BRAIN. 
 
 233 
 
 ings are removed, they are observed to present many minute orifi- 
 ces, into which the soft membrane (Xstt-j] meninx tenuis^ -pia 
 
 mater,) transmits filamentous bodies, most of them minute blood- 
 vessels. They are neither arteries nor veins exclusively, but seem 
 to consist of both. 
 
 Neither the eminences, nor the hollows or depressions, are uni- 
 form in number or distribution ; and in no two brains is it possible 
 to trace any similarity in the figure, presence, or direction of these 
 objects. This must he understood of the whole upper, lateral, and 
 posterior part of the convoluted surface, and, in short, all its divi- 
 sions, unless where it approaches the central or figurate suriace. 
 In the latter situation, this want of uniformity disappears; and a 
 number of important objects are presented to the attention of the 
 observer. The points at which this approach of the two surfaces 
 takes place, are. Is#, Along the rectilinear margin of the coramu- 
 tual region, where it is contiguous with the upper surface and the 
 posterior end of the middle or central band ; 2d, From the last of 
 these situations, on each side over the protuberance and cerebral 
 limbs ; 3(f, From this again by the outer margin of the cerebral 
 limbs, to the curvilinear hollow and along its course. In the last 
 of these situations chiefly the convoluted surface becomes important, 
 and exhibits objects which distinguish these regions fi'om the others. 
 
 The outer surface of the cerebellum, or small brain, differs from 
 that of the brain proper. It cannot be said to be convoluted ; for 
 it does not present the tortuous eminences and furrows which con- 
 stitute the convolutions of this part of the organ. But the cere- 
 bral matter of which it consists, is disposed in the manner of plates 
 {laminoe) or leaves {folia), parallel to each other, or at least con- 
 centric, and separated by parallel or concentric furrows. It is 
 scarcely requisite to say, that this definition is not meant to imply, 
 that the direction of all these objects is the same throughout the 
 whole organ, — but merely that the cerebellic plates, of which cer- 
 tain groups consist, observe the same direction ; — and that any 
 one or two plates or leaves have several of the contiguous ones pa- 
 rallel or concentric with them, while those of the next group, though 
 disposed differently, observe the same direction in relation to each 
 other. By this peculiarity the various regions of the laminated or 
 foliated surface of the small brain may be distinguished. The 
 plates of the hemispheres are curvilinear and concentric, and pur- 
 sue in various regions of the organ certain definite directions ; 
 
234 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 those in the middle between the hemispheres are straight, trans- 
 verse, and parallel ; and at one spot they are oblique and parallel. 
 By means of these invariable characters of the cerehellic plates, the 
 surface of the organ may be conveniently distributed into several 
 divisions. 
 
 To the cerehellic plates or their peculiarities, little attention was 
 given before the time of Vincenzio Malacarne, professor of surgery 
 in the city of Acqui, in the duchy of Montferrat. This learned 
 person, the most diligent descriptive anatomist of his time, pub- 
 lished in the year 1780 three treatises on the Anatomy of the 
 Brain ;* in the third of which he describes with much precision and 
 minuteness, the anatomical characters of the outer or laminated 
 surface of the cerebellum. Some knowledge of his distinctions, 
 which were adopted by Beil, is requisite to comprehend distinctly 
 the configuration and structure of this part of the organ. 
 
 Commencing with the well-known division of the whole organ in- 
 to two hemispheres, Malacarne remarks, that, if the whole upper 
 surface of the organ be presented to the eye, the outline of each he- 
 mispherical surface is found to describe three-fourths of a circle ; 
 and as these circular segments mutually meet towards the mesial 
 plane, where they are respectively adapted to different parts, the 
 mode of union varies according to the figure of these adjoining ob- 
 jects. Is^, As the hemispherical border approaches the anterior 
 part of the organ, it is found to be suddenly interrupted, where the 
 cerehellic branches or peduncles {crura cerebelli) are connected with 
 the protuberance, and, pursuing a retrograde direction on each side 
 towards the mesial plane, forms a species of re-entrant curvature. 
 The hollow thus formed, which corresponds to the lower of the four 
 eminences on the upper surface of the protuberance {corpora quad- 
 ricjemina. Die Vierhugel,) is named by Malacarne the semilunar 
 curvature, — (der halbmondfbrraide Ausschnitt; Reil.) 2c7, Again, 
 as the hemispherical borders approach the posterior part of the 
 small brain, advancing nearer to the mesial plane, they proceed, by 
 an acute circular turn, almost straight backwards, so as to form, at 
 the posterior edge of the organ, a deep rectangular notch, )__( not 
 unlike the figure of the ancient lyre. This posterior hollow, in 
 which is lodged the cerehellic vertical portion of the hard mem- 
 brane {falx cerebelli^) is named by Malcarne the common perpendi- 
 
 * Encefalotomia Nuova Universale di Vincenzo Malacarne, Saluzzesc. Torino, 
 1780. 
 
BRAIN. 
 
 235 
 
 cular fissure (incui'vatura^ and by Reil, to whose fancy this epithet 
 seems to have been deficient in expression, the purse~lihe fissure 
 (Der beutelfcirmige Ausschnitt.) Between these two well-marked 
 boundaries the cerebellic plates, of which the hemispheres consist, 
 are united in the middle by a confused interlacing junction, {un in- 
 treccio confuso ed irregolare di sostanza,') to which the Italian ana- 
 tomist gives the name of suture {ruffe, raphe) of the cerebellum. 
 I find that the careful removal of the soft membrane, {pia mater ^ 
 renders this more distinct, and shows the mesial termination of the 
 hemispherical plates. On the surface, a large hollow between the 
 hemispheres, and extending backwards fi’om the semilunar to the 
 purse-like fissure, previously called by Haller {vallecula,) the little 
 valley, received from Malacarne the corresponding term {Valletta) 
 in his own language. 
 
 The divisions of the cerebellic surface made by IMalacarne, and 
 adopted by Reil, are founded entirely on the groups of plates, and 
 the comparative depth of the furrows by which these groups are 
 separated. Groups of plates, separated by the deepest furrows, 
 are named lobes, (Zo5z, M. Lappen, R.); and those separated by 
 furrows of less depth are named lobules, {lobetti, I\I. Lappchen, 
 R.) In some situations the lobules present divisions formed by 
 furrows of less depth, between which the groups of plates are of 
 greater or less size. To such clusters IMalacarne gives the name 
 of laminar leaflets, {foglietti laminosi.)* 
 
 Each hemispherical surface consists of five lobes. 1. The ante- 
 rior-upper. 2. The posterior-upper. 3. The posterior-lower. 4. 
 The slender, rarely exceeding three lines in breadth. 5. The two- 
 bellied or biventral. The two first belong to the upper or flat 
 hemispherical surface ; the three latter to the lower or convex he- 
 mispherical surface. Besides these, a sixth lobe may be mentioned 
 as common to the two hemispheres. It is situate on the mesial 
 plane of the upper surface, between the anterior end of the middle 
 line {raffe,) and the middle or apex of the semilunar fissure. This 
 situation is not an improper reason for the name by which IMala- 
 carne has distinguished it, — the central lobe. 
 
 In the bottom of the purse-like notch are many bundles or 
 clusters of plates, which unite the posterior lobes of the upper and 
 lower surfaces to those of the opposite hemispheres. These IMa- 
 lacarne names transverse laminar chords {cordoni laminosi traver- 
 sali,) or commissures of the cerebellum. 
 
 * Encefalotomia, nuova, &c. Parte iii. Articolo i. No. 13. 
 
236 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 The anterior-upper lobe, with four sides and four angles, named 
 therefore by Malacarne the quadrilateral or four-sided lobe, (vier- 
 seitige^ Reil,) approaches somewhat to the figure of the trapezoid. 
 It is bounded by three curved margins and one straight one. Of 
 the former, the most anterior forms one-half of the semilunar fis- 
 sure ; while the posterior, which is also the longest, and parallel to 
 this, is a curvilinear or circular tract (the great furrow,) extending 
 from the bottom of the purse-like fissure behind to the anterior 
 outline of the hemisphere before, where it terminates about one 
 inch from the end of the semilunar fissure. This last space be- 
 tween the anterior end of the great furrow forms the third curved 
 margin of the four-sided lobe ; while its straight margin is made 
 by the middle line, which here is common to the two lobes. Ma- 
 lacarne further divides this lobe into five lobules, and describes the 
 limits of each with minuteness and accuracy. For the details of 
 these distinctions 1 refer to the original. 
 
 The posterior-upper lobe — the second division of the upper he- 
 mispherical surface — may be defined in the following manner. 
 The circular tract or great furrow, which I have already said forms 
 the posterior margin of the four-sided lobe, is its anterior boun- 
 dary. The hemispherical outline of the upper surface, if traced 
 from before backwards, will be found to coincide about 1^ inch, 
 sometimes more, from the purse-like notch, with a considerable 
 furrow (the hoi’izontal,) which turns round at the purse-like notch 
 to meet the great furrow already mentioned. The curved outline 
 thus continued is the outer boundary of the posterior lobe ; and it 
 is easy to perceive, that, in consequence of the direction which this 
 line observes, and its meeting with the great furrow, the lobe 
 is contained between the horizontal and great furrow, or between 
 two curved lines. This lobe is subdivided by Malacarne more mi- 
 nutely than the former. It is found, however, that the number of 
 lobules is not the same in both, — those of the left being most 
 uniformly about eight, while those of the right are more numerous, 
 but in general less distinctly marked. 
 
 These with the central lobe, the general situation of which has 
 been already noticed, form the several divisions of the uj)per region 
 of the cerebellic laminated surface. The inferior region presents 
 divisions more numerous, more complicated, and more interesting. 
 
 The first of these, the posterior-lower, is contiguous, at its outer 
 or greater boundary, with the posterior-upper lobe, where a small 
 
BRAIN. 
 
 237 
 
 segment of it is seen, when the cerebellum is examined from above. 
 Its anterior or inner boundary is marked by a curvilinear furrow 
 of moderate depth, by which it is separated from the slender lobe, 
 and the posterior end of which terminates, not in the purse-shaped 
 notch, but, after a sigmoid turn towards the laminar pyramid,* is 
 insensibly lost among a cluster of transverse plates, which shall 
 be afterwards noticed. 
 
 Immediately anterior to this is found the slender lobe, {il lobo 
 sottile, Malacarne ; l)er zarte Lappen, Reil ;) which is not above 
 three lines broad, and being contained between two concentric fur- 
 rows, is not unlike the segment intercepted by the truncated arcs of 
 two small circles of a sphere. 
 
 The space of the hemispheric surface within the slender lobe, or 
 between this and the peduncle or arm, is inclosed by three circular 
 lines, two of which, the exterior and interior, correspond to so many 
 furrows ; while the third, which is anterior, is formed by the hori- 
 zontal or marginal furrow. The space thus inclosed is similar to 
 a spherical triangle, and is occupied by a group of plates which 
 Malacarne denominates the biventral lobe, (der Zwey-bauchige Lap- 
 pen, Reil.) Its contiguity with the cerebral end of the pneumo- 
 gastric nerve led Vicq-D’Azyr to give it the name of the lobule of 
 the eighth pair, (lobule du nerf vague ,-) and its situation at the pos- 
 terior corner of the peduncle, and under that body, is the reason 
 why it was called sub-peduncular lobule by Dr Gordon. Of these 
 plates the arrangement is peculiar, since they are neither so ex- 
 actly concentric as in the other lobes ; nor yet is their direction 
 different from each other. The plates at its outer margin are the 
 largest, as they extend the whole length from the marginal furrow 
 to the end of the slender lobe, at which, however, they are con- 
 tracted to a narrow point. The next set are shorter, and are more 
 contracted or acuminated at their posterior end, where they are 
 contiguous to the almonds or tonsils. The third and last set are 
 the shortest, and are more twisted down, as it were, next the al- 
 monds. These contracted or acuminated ends of the cerebellic 
 plates are named (code,) tails by Malacarne. 
 
 The disposition now described renders the posterior corner of 
 the biventral lobe very pointed, and its margin very concave ; and 
 between this margin and the parts which occupy the valley is placed 
 a group of plates somewhat convex, rounded, and disposed also in 
 
 * Encefalotomia, &c., Articolo i. No. 20, ed Articolo ix. No. 77. See p. 318. 
 
238 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 a peculiar manner. This group Malacarne names the tonsil, or 
 tonsils, {tonsille.,)* a terra which Reil, regarding it synonymous with 
 amygdalcE^ renders literally almonds, (Die Mandeln) ; the spinal lo- 
 bule of Dr Gordon. If the cerebellum be examined before the 
 head of the spinal chord is cut from the protuberance, the inner 
 margin of the almond will be found contiguous to the oval emi- 
 nence {corpus olivare,') and even pressed by it. It is best, however, 
 to examine the almonds after the chord {medulla oblongata') has 
 been removed. It will then be perceived that each almond is 
 bounded on the outside by a well-marked circular furrow, which 
 separates it from the biventral lobe on the inside by a free surface 
 directed to the corresponding surface of the opposite almond ; and 
 before, by a continuation of this directed outwards toward the bi- 
 ventral lobe. I have already said that the direction of the consti- 
 tuent plates of this body is peculiar. In general they observe a 
 direction opposite to that of the biventral plates ; so that, if pro- 
 duced, they would cross. Its apex or most pointed corner is con- 
 tiguous to that of the biventral lobe ; and altogether, each almond 
 presents the appearance, on a cursory glance, of two similar bodies 
 directed inversely to each other. 
 
 The last body which I shall notice here is the Flock or Flocks. 
 The description of its situation, as given by Malacarne, is by no 
 means clear ; but perusal of the context, with examination of the 
 parts described, can leave no doubt on the certainty of the object 
 which he has in view. The flock {il fioccho, il Jiocchi, Die Flocken,) 
 is a minute body, of a shape not easily defined, situate in the an- 
 gular hollow between the biventral lobe and the branch or peduncle 
 {crus ; gamba ; braccia ; Die Arme) of the small brain. The lower 
 or free surface of the latter object (tbe branch) possesses an ante- 
 rior and posterior margin or corner. The latter is contiguous to 
 the biventral lobe, from which it is separated by a small furrow, 
 out of which the flock seems to issue. Each flock consists of six 
 or seven plates {laminee) starting directly, as it were, from the be- 
 ginning of the peduncle, and with the concave margins directed 
 towards the protuberance. 
 
 Ruysch has represented in their site objects to which he applies 
 the name of vermiform prominences ; a circumstance which is in 
 some measure to be ascribed to the vague manner in which this 
 term has been used. 
 
 Encefalotomia, Articolo ix. 
 
BRAIN. 
 
 239 
 
 The valley, (vallecula, Valletta, das Thai) or hollow between the 
 two hemispheres, is occupied by a numerous series of plates, which 
 lie transversely, are parallel to each other, and which form a sort 
 of uniting medium of the cerebellic plates of each side. The ap- 
 pearance of this region in the brain of the dog and monkey, the 
 animals which the ancient anatomists chiefly dissected, might fur- 
 nish them with some reason for applying to it the name of worm, 
 or worm-shaped body ; (<rxwX'/)g, exoAn^osidyis.) But the mo- 
 
 dern anatomists are not bound to apply it to the corresponding 
 part of the human cerebellum, which certainly by no means jus- 
 tifies the appellation. The confusion which has arisen from this 
 practice of imitating the ancients is a sufficient reason to abandon 
 the term for ever ; since scarcely two anatomists agree in giving 
 the name of vermiform process to the same part of the organ. 
 
 With a view to obviate all misconception on this point, Mala- 
 carne has recourse to distinctions completely new. Beginning with 
 the back end of the valley at the purse-shaped notch, where are 
 seen the plates afterwards named by Reil the short exposed cross- 
 bands^ (Die kurzen und sichtbaren-Querbander ;) and the long co- 
 vered cross-bands, (Die langen verdeckten Querbander ;) and pro- 
 ceeding forward, he distinguishes a group of parallel plates, or la- 
 minated leaves, to which he applies the name of pyramid. This 
 body, which is bounded behind by the purse-shaped notch, and be- 
 fore by another cluster of plates called by Malacarne the uvula, 
 consists of twenty parallel plates, of which six, he observes, are very 
 short ; and a triangular termination in the longer, forms the sum- 
 mit of the body. The uvula (ugola) (Der Zapfen,* Beil,) which 
 is anterior, he found to consist of twelve laminated leaves, to have 
 six lines of longitudinal extent, and four of breadth. It is smaller 
 than the pyramid, and conical, with its base turned to that body, 
 (Reil). Lastly, anterior to the uvula, and separated from it by a 
 furrow, is the laminar tubercle,f (tuberculo laminoso,) consisting of 
 about ten thin leaves or transverse plates. This body, which is the 
 smallest in the row, is the nodule or knot, (Das Knotchen) of Reil. 
 
 The second surface of the brain is very different from the first. 
 In situation it is interior or central ; and its configuration is such, 
 
 * Mr Mavo, by translating this term spigot, makes it appear to be a different part 
 from that meant by Malacarne, and understood by Reil. Though the word der Zapfen 
 signifies spigot, it is also used to denote the uvula, and in this sense it is employed by 
 Reil. 
 
 t Encefalotomia Nuova, &c. Parte iii. Articolo x. p. 61. 
 
240 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 that it may be named the jigurate or symmetrical surface of the 
 brain. Instead of presenting the uniform eminences and hollows 
 which distinguish the convoluted sirrface, it is disposed or moulded 
 into definite shapes, which correspond with each other, as they are 
 situate on opposite sides of the middle plane, — or the parts of which, 
 when situate on this plane, are exactly symmetrical. The surface 
 formed by these variously figured objects, bounds what are termed 
 in the common descriptions the ventricles or cavities of the brain. 
 They cannot justly be termed cavities any more than the hollows 
 between the convolutions, but ought to be viewed as continuations 
 of the exterior or convoluted surface. As the several objects of 
 the figurate surface are well known, I shall at present, avoiding 
 minute description, notice those circumstances only which have not 
 been sufficiently studied, or correctly represented, or which are 
 necessary to establish the general principle, — that the convoluted 
 surface of the brain and the laminated surfaee of the cerebellum 
 communicate directly with the inner, central, or figurate surface of 
 these organs. 
 
 The commutual or dichotomous region of the convoluted surface 
 is terminated below by a sinuosity, which is formed chiefly by a 
 part of the brain, remarkable in appearance and organization. This, 
 which was named by the ancient anatomists the smooth or polished 
 body (<rw,t(.a nXXosIdi:, corpus lcBve)f to distinguish it from those sur- 
 faces which were formed by a cutting instrument, appears in the 
 form of white fibrous matter, passing transversely between the he- 
 mispheres ; but is also marked by certain longitudinal lines, fii’st 
 correctly represented by Vicq-DAzyr. The most conspicuous of 
 these is that which lies exactly in the middle plane, and which is 
 formed by the meeting of the transverse fibres, of which this body, 
 termed middle or central hand^ {rnesolobe of Chaussier, the beam 
 (der Balken) of Reil,)t consists. These fibres, which issue like 
 
 * This is the literal translation and the true meaning of the term used by the Alex- 
 andrian school. The name corpus callosum, which is adopted by modern anatomists, 
 is a bad ti'anslation made at the revival of literatoe. In defence of the error, Vicq- 
 D’Azyr contradicts nature by the assertion, that this is somewhat harder or firmer than 
 the other parts of the brain. “ Cette production a plus de co7isistence que le reste du 
 cerveau. — Ce corps un peu plus dur que le reste de la substance blanche du cerv'eau. ” 
 Of many brains examined, with a different object, certainly, from that of proving the 
 learning or ignorance of the translators of the Greek physicians, I never could perceive 
 any difference in the consistence of this and other parts of the brain. 
 
 f Archiv. fiir die Pliysiologie. Neunter Band, Erstes Heft. 3. b. p. 172. 
 
BRAIN. 
 
 241 
 
 white parallel lines, exceedingly minute, from the substance of the 
 hemispheres, either stop suddenly, or change their direction at this 
 point. Their sudden termination gives rise to an appearance, to 
 which the expressive but erring epithet of suture (raphe) has been 
 given. On each side of this other lines are remarked following 
 the same direction. In general, they are situate about three or 
 four lines from the median plane ; but are in a few instances ob- 
 served to be very regular in their disposition at the anterior end of 
 the middle band. About its middle, however, a very distinct ap- 
 pearance of lines collected into a considerable bundle, may be 
 observed proceeding backwards to its posterior end. As they ad- 
 vance they become more distinct, are about 1^ line broad, and of 
 a grayish colour ; at the posterior end of the middle band, they 
 diverge somewhat, and, passing over this, proceed in a lateral di- 
 rection downwards, till they are lost about the spot where the limbs 
 of the brain (crura cerebri^ Die Hirnschenkel) issue from the optic 
 eminences. This forms the inner, central, or gray portion of the 
 cylindroid eminence. 
 
 The posterior extremity of this body is rounded ; and when the 
 membranes have been removed, the surface which forms this round- 
 ed end is found to communicate directly with the chamber named 
 third or middle ventricle. This surface is in truth continued for- 
 ward, and forms the vault or ceiling, (fornix, Die Zwillingsbinde, 
 the twain band, Reil,) a point which, though sufficiently obvious, is 
 never noticed in description, or perspicuously demonstrated. The 
 names of callous body and vault are applied in the ordinary works, 
 as if they were denominations of different objects, or rather of dif- 
 ferent bodies. If they are still to be retained, it ought to be stated 
 that they are names applied to opposite surfaces only of the same 
 object. 
 
 The relations of the round or posterior end of the middle band 
 are w'orthy of examination. The handle of a scalpel inserted be- 
 neath it will be found to be in the middle ventricle, with the vault 
 above, the conarium or pineal body, and four eminences of the up- 
 per surface of the protuberance (corpora quadrigemina) below, and 
 a part of each optic chamber on each side. I find it convenient to 
 remove the posterior part of the hemispheres by a transverse sec- 
 tion following the plane or level of the hinder end of the central 
 band. A distinct view is thus given of this communication of the 
 convoluted with the figurate surface ; and it may be observed, not 
 
 Q 
 
242 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 only in the middle, but on each side. The middle one is bounded 
 above by the posterior end of the middle band and the back part 
 of the vault ; below, by the pineal body and the four eminences ; 
 before, it is continuous with the middle ventricle ; behind, it looks 
 to that space between the convoluted surface of the brain and the 
 laminated surface of the cerebellum, which is occupied by the hori- 
 zontal part, (tentorium cerebelli), of the hard membrane. 
 
 On the sides, — that is beyond the margin of the body with the 
 four eminences, a different arrangement is observed. The poste- 
 rior end of the middle hand penetrates into the substance of the 
 hemispheres ; but the gray chords which have been already noticed, 
 in pursuing their lateral course, are immediately enveloped in white 
 plates, derived, as we shall see, from the sides of the vault, assum- 
 ing thus a cylindrical appearance. Thus is formed exactly oppo- 
 site to the cerebral limbs, a body with a free rounded surface, which 
 bends in a curvilinear direction laterally and downwards, and is 
 found to be the great hippocampus or cylindroid process. (Chaus- 
 sier.) In observing this curvilinear course, it rests on and corre- 
 sponds to, the upper margin of the cerebral limb, as it issues from 
 the optic chamber. It must not, however, be imagined that it ad- 
 heres to this body. The surfaces both of the beginning or upper 
 end of hippocampus, and of the cerebral limb, are free and uncon- 
 nected. They are indeed covered wdth vascular membrane, (pia 
 mater,) which keeps them in apposition ; but if this be removed, as 
 it ought alw'ays to be, the two surfaces will he found quite distinct, 
 and in no manner connected, unless in corresponding wdth each 
 other. The whole of this communication may be seen, and is best 
 examined by keeping the organ in its natural position, and view- 
 ing it from behind, after the posterior parts of the cerebral hemi- 
 spheres have been removed. It forms what was described by Bichat 
 under the name of the great cerebral fissure* This denomination 
 does not accurately express the idea intended ; nor does the idea 
 itself, it may be remarked, present a correct view of the natural 
 arrangement. The conformation which I have attempted to de- 
 scribe does not form a fissure, but a regular symmetrical opening, 
 by which the convoluted surface communicates distinctly and di- 
 rectly with that which is figurate. 
 
 The next step of the process in the further exposition of this 
 opening or communication, requires the inversion of the brain, and 
 
 * Anat. Descriptive, Tom. III. 
 
BRAIN. 
 
 243 
 
 the exposition of the inferior regions of the convoluted surface, — the 
 base of the brain. We have seen the manner in which the convo- 
 luted passes into the figurate surface, above and behind the middle 
 band. At the inferior regions this transition is effected in a mode 
 somewhat different; — and the channel or means by which it is 
 made, is the curvilinear hollow. To understand clearly the rela- 
 tions by which this is established, the demonstrator should remove 
 in small portions the membrane which covers the optic commissure 
 and tracts, the pituitary peduncle, the pisiform eminences, and 
 which binds together the adjoining convolutions, and especially 
 those which are connected by it to the limbs of the brain.* When 
 the convolutions are thus exposed, the furrows on each side of the 
 hollow will be found to be very deep, and the eminences propor- 
 tionally high from the more solid part of the encephalic organ ; 
 and the hollow itself will appear almost like the furrow of a con- 
 volution on a large scale. Its peculiarity indeed is, that the bot- 
 tom of the hollow is not convoluted, but presents an extensive uni- 
 form space of grayish cerebral matter, on each side of wliich, but 
 especially behind, the convolutions are very large and distinct. 
 This convoluted part begins insensibly at the outer or lateral edge 
 of the hemisphere, where it is narrow ; becomes broader as it ad- 
 vances forwards and inwards ; and about one inch from the mesial 
 plane, is particularly distinct, broader, and more spacious than at 
 any other part of its course. 
 
 It here presents an infinity of holes or orifices of various size in 
 the cerebral substance, not arranged in any regular order, but uni- 
 formly found in this situation. Some of these orifices are suffi- 
 ciently large to admit the point of a small silver probe ; but the 
 greater number are more minute, and do not exceed the calibre of 
 a common-sized bristle. The space over which they extend is va- 
 rious, and its figure cannot be accurately denned ; it is generally 
 equivalent to the half of a square inch. In numerous dissections, 
 I have found it uniformly at this part, and of this size, as nearly 
 as it is possible to estimate, in measurement of objects so variable 
 as those of the organs of the animal body. I have not been able 
 to recognize any difference in the colour of this and other parts of 
 the convoluted surface. I suspect, therefore, that Vicq-D’Azyr, 
 
 * This process is best performed by the scissors and forceps, ^rith the occasional 
 use only of the scalpel, and with the aid of an assistant with delicate fingers and for- 
 ceps. 
 
244 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 who in noticing this part has called it the white perforated substance, 
 {substance blanche perforce), applied the term of colour without ex- 
 amining the contiguous parts, when denuded of their membranous 
 investments. The same name nearly, {lamina perforata), has been 
 given it by Reil. The orifices which characterize this part of the 
 brain admit, from the Sylvian or middle artery, an infinity of blood- 
 vessels, which here penetrate the part denominated the hook-shaped 
 cerebral band (Der Haaken-fbrinige Mark-bundcl) delineated by 
 Reil. This circumstance renders the adjoining part the most vas- 
 cular of the whole organ, — a fact which will be shown to be im- 
 portant in the pathology of the brain. 
 
 Anterior to the perforated spot at the extreme verge of the un- 
 convoluted substance, is situate a small pointed eminence, of gray 
 colour, shaped like a triangular pyramid, most conspicuous when 
 cleared of the membrane which covers it. Proceeding backward 
 from this, we remark two slender white lines of different lengths, 
 and following different directions. The inner of these is short ; 
 and after a course seldom exceeding four or five lines in the adult 
 brain suddenly ceases to be visible. The outer one is much longer, 
 follows a curved direction, with the concave part of its course di- 
 rected anteriorly, and is of a more vivid white colour. These two 
 lines are the generating or initial filaments of the first pair of nerves. 
 
 Within the perforated spot the curvilinear hollow is generally 
 conceived to be terminated. The unconvoluted space, however, in 
 which it consists, is here directly continuous with the figurate sur- 
 face of the brain. This space indeed makes here a sharp turn 
 backwards ; and having on the inside the long cerebral band 
 termed the optic tract, may be conceived to be bounded by the 
 limb of the brain. This body, with that of the opposite side, will 
 be imperfectly seen at first ; and though the end which unites each 
 with the bridge or protuberance is sufficiently conspicuous, the op- 
 posite extremity cannot be distinctly perceived. It is indeed co- 
 vered by a portion of the convoluted surface, the inner and promi- 
 nent surface of the medio-inferior or spheno-temporal region. This 
 must therefore be gently moved outwards or laterally, and also 
 raised ; and with the aid of the handle of a scalpel and the fingers 
 of a dexterous assistant, the cerebral limb may be shown to be here 
 crossed or surrounded by the optic tract of the side. The purpose 
 of this part of the exposition is to show the geniculate bodies, or 
 
 posterior eminences of the optic chambers. 
 
 4 
 
BRAIN. 
 
 245 
 
 But the attention of the demonstrator is to be directed to that 
 part of the convoluted surface which covers the anterior end and 
 outer margin of the cerebral limb, and which has been raised on 
 the scalpel-handle. When gently everted, it is found to present 
 the thin white body named the tape or fringe {tcBuia') of the hippo- 
 campus ; and if the portion of convoluted brain most anterior or 
 next to the curvilinear hollow be raised and everted in the same 
 manner, the anterior end of this object termed the foot {pes hippo- 
 campi) will come into view. If this operation be properly per- 
 formed, no part will be torn, broken, or displaced ; the objects ex- 
 hibited are free surfaces, not adhering to each other but only in 
 apposition. The white plate or tape of the hippocampus forms, in 
 the natural position of the organ, the outer and lower border of the 
 opening, while the limb of the brain, and after that the outer and 
 lower surface of the optic chamber, forms its inner border. 
 
 To obtain an idea yet more clear and distinct of this communi- 
 cation between the convoluted and figurate surfaces of the brain, it 
 is convenient to follow the direction of the opening with the scalpel 
 handle backwards and upwards, until it reach the upper margin of 
 the brain-limb, where it is shown to be merely a continuation of 
 the lateral part of the posterior opening. This step of the exposi- 
 tion requires cautious and gentle management ; and the peculiar 
 curvature which the parts forming the outer border of the commu- 
 nication follow, renders it difficult to avoid laceration or displace- 
 ment. In general, it is best accomplished on a single hemisphere, 
 from which the cerebellum has been previously removed ; but it is 
 desirable to preserve also the whole of the central band, which shows 
 not only the relative connection of the several parts, but serves also 
 to demonstrate a curious fact in the configuration of the parts form- 
 ing the outer border of the communication. This is the hippo- 
 campus through its entire course, or the body which its figure has 
 led Professor Chaussier to name the cylindroid process. 
 
 This body consists essentially of two parts. The first is an inner 
 or central portion, gray in colour, notched or indented in appear- 
 ance, and though free at the indented edge, adhering to the cere- 
 bral substance by its opposite margin. This is the gray indented 
 band; (Gordon ;) — le corps godronnee, Vicq-D’Azyr.) It is as 
 thick as a large crow-quill. This is covered by the outer or second 
 part, which is a broad thin plate of white cerebral matter rolled or 
 folded over the gray indented band, precisely as a map is rolled 
 
246 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 rover a cylinder of wood, and covering it unless removed by art. 
 This last part of the cylindroid process is what is well known, and 
 always described under the name of the tape or fillet of the hippo- 
 campus. Its ari-angement with regard to the gray indented band 
 is less generally understood, and is indeed never noticed in the or- 
 dinary descriptions. A correct idea of it may be formed in the 
 following manner. 
 
 Divide, by successive transverse sections, the hippocampus from 
 the part named the foot upwards, as far as it can be traced. It will 
 be found that each section presents a central portion of gray matter, 
 enveloped in a thin curled plate of white matter, which is free at 
 one edge, — the concave one, — and hangs over the gray band like 
 a veil, but adheres, by its opposite, to the cerebral substance. It 
 will be perceived, also, that the white plate does not adhere to the 
 gray band, unless at its fixed margin, and that a probe or scalpel 
 handle may be introduced into the angular furrow between them.* 
 As the sections approach the upper end of the cylindroid process a 
 new arrangement is observed. The white plate becomes unusually 
 broad, and is less bent or rolled over the gray band ; while the 
 latter, thus less completely covered, instead of following the same 
 direction with the white plate which it does below, is much sepa- 
 rated from it, and leaves a considerable angle between the plate and 
 itself. This arrangement is most conspicuous where the process 
 corresponds to the upper part of the optic chamber and the cere- 
 bral limb. The white plate of the hippocampus traced further is 
 found to coalesce with the margins of the vault, and tapering as it 
 approaches the anterior end of that body, is finally identified with 
 its substance. The upper termination or connection of the gray 
 band is different. When it begins to recede from the white plate, 
 which it does nearly opposite to the optic eminence, it proceeds di- 
 rectly to the rounded posterior end of the central band, (corpus 
 callosum,) over which, and along the upper surface about one inch, 
 it may be traced ; and beyond this it is seldom capable of being 
 distinguished from the white matter of which the central band con- 
 sists.f The gray indented hand, therefore, which forms the inner 
 
 * This last fact may also be demonstrated without transverse sections, by simple 
 elevation of the white plate by the handle of the instrument. 
 
 -I The importance of this object in forming the outer border of the great commu- 
 nication, will rerrder it not im2:iroper to glance at the history of its discovery. Vicq- 
 D’Azyr is supiJosed to have been the first anatomist who observed and described its 
 site and appearance with accuracy ; and we find him, in a Memoir of the Royal Aca- 
 
BRAIjS'. 
 
 247 
 
 or central part of the cylindroid process, is continuous, or connect- 
 ed with the upper surface of the central band of the organ ; and 
 if the terms of origin or derivation be admitted, may be said to be 
 derived from it ; while the thin white plate which is rolled over the 
 gray band, and gives the hippocampus its cylindrical figure, is con- 
 nected with the under surface of the same central band, or that 
 part which the usual nomenclature styles the vault {fornix) of the 
 brain. 
 
 Such, as nearly as language can represent, is the configuration 
 of the cylindroid process, — an object which it is impossible to know 
 too accurately, if we reflect, that it forms the entire outer border 
 of the great communication between the convoluted and figurate 
 surfaces of the brain. If, by the method now described, a clear 
 idea of this disposition is not communicated, it is expedient to use 
 another contrivance, which I have rarely found to fail in demon- 
 strating the facts which I wish to impress. Let a brain, divested 
 of its membranes, be inverted ; and when the opening behind the 
 outer margin of the cerebral limbs has been exposed, let a deep 
 transverse incision between the feet of the hippocampus of each side 
 be made. This incision must not touch the cylindroid process, but 
 going deep into the substance of the organ, will detach the whole 
 of that part which contains the several objects of the figurate sur- 
 face from the anterior part of the hemispheres. The portion thus 
 separated will, however, still adhere by the sides to the substance 
 of the hemispheres ; and other incisions must be made, following 
 the direction of the outer or lateral margin of the striated bodies 
 
 demy of Sciences in 1787, detailing its peculiarities with some minuteness, under the 
 name of “ Bord externe et dentele de la Come d’Ammon.” He subsequently repre- 
 sented it in his great work in the year 1786, imder the name of gray, cortical, external 
 notched portion of the Horn of Ammon, and speaks of it familiarly enough by the 
 term of corps godromiee. Bichat, however, whose descriptive anatomy was pubhshed 
 in 1802, though his accurate manner prevented him from overlooking it, and 
 led him to give a sufficiently minute acco\mt of it, boldly asserted, that it had 
 been entirely neglected by authors. Dr Gordon of this place, who was quite aware of 
 this oversight in Bichat, took special care, in demonstrating it, to notice the merit of 
 Vicq-D’Az}T ; and this fact he mentions shortly in a note, in his description of 
 the gray band. None of these eminent anatomists have been altogether right in this 
 matter ; and the truth is, that Vicq-D’Az}’r is not the first who dehneated this bodv. 
 The gray indented band is distinctly represented by Pierre Tarin, in the second en- 
 graving of his Adversaria ; and although this had been pubhshed in 1750, tliirty years 
 before the engravings of Vicq-D’Azyr, yet it was requisite for the latter writer to make 
 it the subject of a particular memoir, and Bichat to wite a description of it, before it 
 seems to have been known as part of the organ. 
 
248 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 (corpora striata') and the optic chambers (thalami optici,) until the 
 whole be completely insulated. If these incisions be properly ma- 
 naged, the whole of the middle band, the vault, the cylindroid pro- 
 cess, and the white tape, will be left uninjured, and will present a 
 large hollow surrounded by an extensive border, the posterior part 
 of which is made by the posterior end of the central band, while la- 
 teral divisions are formed by the cylindroid process of either side. 
 The observer will likewise form a very just idea of the situation 
 and connections of the middle band, and will perceive that its infe- 
 rior surface is the same as that named vault or ceiling. He will 
 further remark, that the thin white plates (tcBnice) which are attach- 
 ed to the margins of this object, and between which is the space 
 improperly named the extend in a circular and revolute di- 
 rection outwards and downwards, so as to cover, in the mode de- 
 scribed, the gray hand of the cylinder, and give this object its cy- 
 lindrical aspect. 
 
 The correct understanding of the outer border of this commu- 
 nication should be followed by an equally just idea of those parts 
 which form what we must name its inner border. These are more 
 numerous and rather more complicated ; but frequent examination, 
 with a little attention, will enable the student to overcome all the 
 difficnlties with which they may be attended. The parts contained 
 in the mass of brain removed, as we described in the last section, 
 will contribute also very much to render the knowledge of this 
 border easy and intelligible. I have already said, that at the 
 posterior end of the middle hand the inner or lower border is 
 formed by the four eminences (c. quadrigemina) situate on the 
 upper surface of the thick mass named protuberance. On each 
 side of these the inner border is formed by successive portions of 
 the optic chamber, until it has reached the inferior region of this 
 body, where the outer and lower margin of the limb of the brain 
 becomes the border of the opening. To render this arrangement 
 more intelligible, I shall here state some circumstances of the fi- 
 gurate surface, which are either omitted or indistinctly mentioned 
 in the ordinary descriptions. 
 
 Its principal objects are familiarly known ; and none can be igno- 
 rant of the situation of the striated bodies, the optic chamber, the 
 semicircular chord between them, and other similar objects. 
 
 The posterior eminences, or the optic chambers, hold the most 
 
BRAIN. 
 
 249 
 
 important place ; and their connection and relative situation render 
 them much more interesting, than they are usually made in works 
 of descriptive anatomy. Connected before and on the outside to 
 the striated body by means of the double semicircular chord {cen- 
 trum semidrculare geminum, Vieussens,) each optic eminence pre- 
 sents four free surfaces, — the upper, the inner, the posterior, and 
 the lower. The upper, the first, is gently rounded and of white 
 colour. Its figure and limits are not easily defined. The outer 
 margin is bounded by the circular band, which even passes on an- 
 terior to it, so as to form its boundary in that direction also. Be- 
 hind, it is less distinctly limited, unless by the appearance of a con- 
 siderable prominence, which has been generally named the posterior 
 tubercle of the optic couch. The inner margin of the upper sur- 
 face is most distinctly marked by a small sharp gray line, which, 
 beginning insensibly at the anterior part of the body, becomes more 
 distinct as it extends backwards, and is ultimately found to bend 
 gently toward the median plane. There it unites with a similar 
 elevated line of the opposite optic eminence : and to the point of 
 union is attached a small conical body with a minute point, of a 
 gray colour, and of a shape like that of the pine-apple. This is 
 the object improperly termed pineal gland ; {glandula pinealis, eon- 
 arium\ Die Zirbel-driise ; Beil); and the minute linear emi- 
 nences or tracts, which form the inner edge of the upper optic sur- 
 face, have been named peduncles of the pineal gland. The inner 
 surface of the optic couch or chamber presents nothing important, 
 save the small portion of soft cerebral matter, which unites it to the 
 similar surface of the opposite body. Its posterior edge, however, 
 is terminated by the cerebral limb of that side ; and the lower edge 
 meets that of the opposite one, and is connected to it by a portion 
 of brain, which, examined in this manner, has received no name, 
 but forms the lower part of the middle ventricle. The portion of 
 brain which corresponds to it on the outside (base of the brain) has 
 been named the bridge of Turin. {Pons Taririi.') This is the tri- 
 angular space between the limbs of the brain which has been called 
 by Vicq-D’Azyr the pit of the oculo-muscular nerves. It may be 
 named the triangular intercrural hollow. 
 
 The posterior surface of the optic eminence is the most impor- 
 tant, but the least understood. It is so intimately connected with 
 the inferior, that in description they cannot be easily distinguished. 
 Santorini, I believe, was the first who observed that the posterior 
 
250 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 part of the optic couch was terminated by a projection or process, 
 wliich he named the jointed or geniculate body, and which, he had 
 likewise the merit of observing, gives rise to the optic nerve.* * * § 
 More recently Malacarne remarked that this region is rendered 
 unequal by a tubercle, from which the nerves seem partly to rise.| 
 About the same time it was noticed by Vicq-D’Azyr, that on the 
 side, a little behind and below, there are three superficial tuber- 
 cles of a rounded figure, and disposed in a triangle ; and that one 
 of them must have been the body mentioned by Gunz and Bon- 
 homme, and of which Hallei^ avowed his ignorance. J He after- 
 wards mentions a slight prominence near the upper of the four 
 eminences, of a white colour, but gray exteriorly, communicating 
 with the optic tract ;§ while the external-lateral region of the optic 
 couch presents several similar eminences, but less considerable. 
 The notice given by Bicbat is still more brief and less satisfactory 
 “ Tout a fait en arriere cette parti inferieure ofFre une ou deux 
 saillies, et se continue avec les tubercules quadrijumeaux.” 
 
 The inaccurate manner in which these authors seem to have exa- 
 mined this part of the organ, the vague and imprecise terras in 
 which they speak of it, as if its existence were apocryphal, — show 
 the necessity of more correct researches. Soemmering and Gor- 
 don describe in this situation two eminences, termed the outer and 
 inner geniculate bodies. The description of the former author is 
 brief and precise, but not quite so satisfactory as could be wished. 
 That of the latter is more minute ; but in some respects it is either 
 not clear, or it does not apply generally. 
 
 * “ Quod tamen per repetitas diligenterquo institutas disquisitiones ab eadem potius 
 membi-ana eos non proficisci, seepius vidisse vissus sum ; vemm turn ab eorum Thala- 
 morum interiori parte, turn a quodam vdut gcnicvilato corpora circa corundem Thala- 
 morum posteriora locato adjimctoque, cujus eorticalis sen cinerea interior substantia 
 est, medullaris et Candida exterior facies luculentius prodire, sum assecutus : Ad ho- 
 rum tamen exortus locum a latere prominentiarum quod natiformes nuncupantur, 
 conspicuus medullaris tractus transversim sic Thalamis conjungitur, ut vel in eorum 
 substantia disjiciatur, vel inflexus caeterisqiie fibrillis involutus ad Nervorum ojrticorum 
 exortum accedat, conjicere quidem, decernere autem minime valui.” Observat. Ana- 
 tomic. Joan. Dorn. Santorini, cap. iii. § 14. See also a more minute description in his 
 posthumous Tabulae Anatomicce, Tabula iii. fig. 1. p. 32. Parm£e, 1775. 
 
 f “ La stessa faccia superiore — e coperta d’una lamina midollare tenuissima ed ha 
 disuguale la posteriore estremita per un hernacolo irregola/i'c, da cui sembra che in 
 parte usscono i nervi ottici.” Articolo, vii. 63. 
 
 Elementa Physiologies, Tom. IV. lib. x. sect. 1. § 24. 
 
 § Recherches sur la Structure du Cerveau, &c. ix. Memoires de I’Academie 
 Roy ale des Sciences, Annee 1731. 
 
BRAIN. 
 
 251 
 
 The confusion and uncertainty which prevails on this part of ce- 
 rebral anatomy, induced me to adopt a method which I find to be 
 more certain in unfolding the objects in question, and which may 
 be safely recommended to the practical anatomist. Let the brain 
 be examined from below, and let the examination commence with 
 the optic tracts. That the acceptation of this term may he definite, 
 I observe that the optic nerves should be in accuracy counted from 
 the commissure only. The cerebral extremity or origin, as it is 
 named, of a nerve, should be reckoned from that point only at 
 which it is quite free in its whole circumference from the organ. 
 This happens to the optic nerves at the anterior part of the com- 
 missure only ; for behind this body the longitudinal hands called 
 tracts adhere by one side (the outer) to the cerebral substance. A 
 narrow angular sinuosity, admitting the point of a small probe, is 
 found at the inner or mesial edge of the tracts ; hut beyond this 
 they adhere indissolubly. As they pursue their course backward 
 and outward, they reach the limbs of the brain, the inferior sur- 
 face of which they cross, still adhering by their outer edge, brtf 
 more extensively. Here likewise they ar£ sensibly broader than 
 at their anterior end. 
 
 When they have passed completely the limbs of the brain, at 
 which they are about the breadth of three lines, they begin to pre- 
 sent a linear furrow or depression, which extends in their long di- 
 rection about one-half or three-fourths of an inch, and thus divides 
 the tract into an outer and an inner limb. This depression, how- 
 ever, does not divide the tract equally, but leaves the outer broader 
 than the inner limb. It is insensibly terminated at the upper sur- 
 face of the optic eminence or chamber ; and its last part, (about 
 three or four lines,) contemplated with care, will he found to sepa- 
 rate two spheroidal eminences which are respective terminations of 
 the outer and inner limbs of the tract. The outer of these emi- 
 nences is the largest and most prominent, and is the body mention- 
 ed by authors as the posterior tubercle of the optic chamber. It is 
 the body which Santorini named the geniculate, (corpus quiddam 
 geniculatum ;) — an epithet for which it is not easy to account, un- 
 less we suppose that his fancy had likened it to the appearance of 
 a bent joint, especially that of the knee, to which, if viewed lateral- 
 ly in connection with the tract, it bears some remote resemblance. 
 It is broader, larger, and more convex than the inner eminence, 
 and is evidently the chief origin of the optic tract. The eminence 
 
252 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 on the inside of the linear furrow is much smaller, and often less 
 distinctly marked than the outer. In ordinary circumstances it 
 may be described as an eminence of cerebral matter contained be- 
 tween two circular segments, in such manner that its longitudinal 
 extent, which is nearly vertical, is greater than its transverse. It 
 is obviously connected with the smaller limb of the optic tract. 
 Whether this body actually takes its origin from the four eminen- 
 ces {corpora quadrigeminal depends on evidence of a different de- 
 scription. 
 
 The inner or mesial side of the geniculate bodies is contiguous 
 to the four eminences, and is separated from them by a linear fur- 
 row. These eminences occupy the upper surface of the protube- 
 rance, and partly that of the limbs of tbe brain, and the linear fur- 
 row marks the point at which the limbs issue from the substance of 
 the optic couches. The lower surface, indeed, of these bodies pre- 
 sents tbe long thick cylinder of the limbs ; and while they occupy 
 this conspicuous situation, and a considerable proportion of the 
 lower surface, it is impossible to assign them more cerebral space 
 above, than that occupied by the upper two of the four eminences 
 (nates^) and the adjoining part of the optic couch. 
 
 This view of the objects occurring in this region of the figurate 
 surface, will show the formation and arrangement of the inner 
 border of the communication. It will be seen that it consists of 
 successive portions of that figurate surface, proceeding from the 
 mesial line, on each side to the lower and outer margin of the cere- 
 bral limbs. It will be seen, that, if we begin at the longitudinal 
 furrow of the four eminences, we find first the upper eminence of 
 one side ; then the contiguous part of the optic couch ; then the 
 greater geniculate eminence ; after this, as the cylindroid process 
 pursues its winding and revolute course, the outer part of the cere- 
 bral limb ; and, lastly, the outer and lower angle of that limb. 
 
 Not only, however, does the convoluted surface of the brain 
 communicate with the figurate one, but the laminated surface of 
 the cerebellum communicates with the analogous surface of that 
 organ, and thus with the great figurate surface. This communi- 
 cation takes place on the middle plane, below the transverse or 
 middle plates which form the pyramid, uvula, and nodule, and be- 
 tween these bodies and tbe restiform processes. This is the fourth 
 ventricle of anatomical writers ; and as it has never been denied 
 that it communicates with the outer surface of the cerebellum, it is 
 
BRAIN. 
 
 253 
 
 noticed here merely as an integrant part of those views which I 
 apply to the organ at large. 
 
 The central or figurate surface exposed in the manner now ex- 
 plained is smooth, polished, and possesses a degree of firmness and 
 closeness of texture which prevents it from being readily broken 
 or abraded. These qualities are ascribed by Reil to a thin mem- 
 branous pellicle, which he terms Epithelion^ and with which he 
 conceives the proper matter of the brain is covered.* Trusting to 
 ordinary inspection, aided by a good glass, I do not think there is 
 any sensible proof of the existence of this covering. It is moi’e 
 natural to regard it as cerebral matter modified for its situation. 
 In point of fact, the deep cerebral matter may be rendered equally 
 firm with this by immersion in alcohol or dilute acids. But no- 
 thing can give the smooth, polished, close-grained surface which 
 belongs to every spot of this part of the brain. After this expla- 
 nation, I shall not scruple to use the term Epithelion, not in the 
 sense given by Reil, but merely as a name to the firm smooth sub- 
 stance which forms the figurate surface of the brain. 
 
 In certain situations this surface is unusually firm, for instance 
 in the narrow winding hollow between the striated bodies and the 
 optic eminences. ( Centrum semicirculare geminum^ Vieussens ; 
 tania semicircularis, Haller.) Of the central surface, not only 
 docs every division mutually communicate, but the whole central 
 surface of the convoluted brain communicates with the central sur- 
 face of the laminated part of the organ. Thus the lateral divisions, 
 called ventricles, communicate freely and directly with each other 
 below the vault or twain-band ; (^fornix. Die Zwillingshinde ;) the 
 surface of which lies free over the top of the thalami. These again 
 communicate with the intermediate space called the third ventricle, 
 from which it is well known there is a passage to the space between 
 the medulla oblongata and the cerebellum. The communication 
 with the posterior and infeidor divisions, {cornua), is well known. 
 
 The whole of this surface is covered by a vascular membrane, 
 which is a continuation of that {pia mater) of the convoluted sur- 
 face. One part of this which lies over the objects in the lateral 
 ventricles has been long known under the name of choroid plexus ; 
 and an intermediate portion by which those of the two sides are 
 united, has been distinguished by the term velum interpositum. 
 Not only are each of these parts of the same membrane, and con- 
 
 • Archiv. fiir die Physiologie, 9ter Band, 3. Untersuchungen, &c. p. 143. 
 
254 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 nected with the pia mater ; but individual portions of vascular 
 membrane or choroid plexus, all continuous, are found in every 
 division of the figurate surface of the brain. This membrane sus- 
 tains the vessels going to and issuing from the cerebral substance. 
 
 Between the two surfaces now described is placed the proper 
 matter of the brain, which in different regions of the organ is ar- 
 ranged differently. The intimate arrangement peculiar to indivi- 
 dual parts, and the manner in which the arrangement of each is 
 mutually connected, are now to become the object of examination. 
 
 The convoluted surface first claims attention. The colour of 
 this is well known to be of an ash-gray, passing in certain parts 
 to pale brown. In whatever part the substance of the convolutions 
 be examined, they never present any appearance of linear or fibrous 
 arrangement. I have often examined the convoluted substance of 
 the human brain after induration in alcohol and dilute nitric acid ; 
 and I never could recognize the distinct fibrous disposition ob- 
 served in other parts of the organ. A portion of brain, hardened 
 in the manner now mentioned, breaks with a small conchoidal frac- 
 ture, and an uneven granular subordinate surface. The surface 
 thus exposed presents, however, a very determinate aspect, which 
 it is easy to recognize after repeated trials. It is ash-gray and 
 without lustre. It is rough, and consists, when minutely examined, 
 of roundish grains aggregated togetlier. The direction of the frac- 
 ture is more at right angles to the convoluted surface than obliquely 
 or parallel to it. In some instances even it is possible to recognize 
 depressed marks perpendicular to the surface, sending off angu- 
 larly like branches smaller depressed marks, meeting similar rami- 
 fications from other perpendicular depressions. 
 
 I have often attempted to determine, by breaking portions of 
 brain in every direction, whether this appearance is uniform ; but 
 I cannot say that I have obtained satisfactory proof of the point. 
 I am not unaware that Reil represents the intimate structure of the 
 convolutions to be distinctly fibrous. So far as I understand his 
 description, I admit the fact of the conchoidal fracture which I 
 have often verified ; but I am not prepared to allow that this arises, 
 as he imagines, from the fibrous matter being arranged in plates 
 or^^leaves, which are folded and rolled together.* Upon the whole, 
 the convoluted substance I regard as chiefly granular, but so ar- 
 ranged as to be more frangible in the direction perpendicular to 
 ’ Archiv. fiir die Physiologie neunter Band, p. 145. 
 
BRAIN. 
 
 255 
 
 its surface than otherwise. It is said to he more abundantly sup- 
 plied with vessels than the white matter ; (Ruysch, Albinus, Pro- 
 chaska, Soemmering, and Ehrenberg;) and indeed a great number of 
 large vessels enters it all over, and especially at certain parts, e. g. 
 the perforated space of the Sylvian fissure. It is not, however, abso- 
 lutely and at all points more vascular than the white matter. The 
 transition from the gray convoluted matter to the white inclosed, 
 is in all parts of the hemispheres sudden and distinct. It is more 
 distinct, however, after induration by immersion in alcohol or di- 
 lute acid than in the recent brain. 
 
 The only part of the convoluted surface which presents a distinct 
 fibrous arrangement is that part of the Sylvian fissure which has 
 been named by Reil the unciform bundle; (der haakenfdrmigeMark- 
 biindel). This, however, can scarcely be said to belong to the 
 convoluted surface. It is situate on the outside of the perforated 
 spot, and corresponds with a short smooth convolution, which passes 
 between the middle and the anterior lobes. The unciform bundle, 
 in short, unites these lobes, and is intimately connected* with the 
 internal arrangement of the nucleus and its capsule, parts immedi- 
 ately to be noticed. 
 
 The white cerebral matter is arranged in various parts of the 
 organ, in the form of inconceivably minute parallel lines, lying in 
 juxtaposition. It is unnecessary to enumerate all the parts in which 
 this arrangement may be observed; and greater advantage will 
 result from a short view of the mutual relation and connection of 
 the fibrous parts of the organ, so far as they are well ascertained. 
 
 In tracing this part of the intimate structure of the brain, several 
 anatomists have imbibed the notion that one part of the brain gives 
 rise to or generates another. From this assumption even Reil is 
 not wholly exempt. Without entering on the subject of organo- 
 genesy, or the question of, which part of the brain in the foetal ex- 
 istence is first, and which subsequently formed, — which will be con- 
 sidered in its own place — I begin wdth stating, that in the adult 
 every part of the organ is supposed to be coeval ; that the idea of 
 one part generating or reinforcing another is an effort of fancy 
 which must not be admitted in strict science ; that when a bundle 
 of fibres, or a fibrous arrangement, is seen proceeding from one 
 part to another, it is imagination only which suggests that the for- 
 mer produces the latter, or conversely ; and that from this nothing 
 Archiv. fiir die Physiologie, 9ter Band, pp. 184, 197, and 201. 
 
256 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 more can be inferred than that the parts so arranged are mutually 
 and generally connected. 
 
 The inner fibrous part of the brain proper is divided by Reil into 
 the system of the brain-limbs {crura Das Hirnschenkel-system ;) 
 the system of the beam or mesolobe, (Das-Balken system ;) and the 
 striated ganglion (das gestreifte Hirnganglion ;), and to one or 
 other of these he refers the arrangement of all the other parts of 
 which the organ is composed. I do not adopt all his views, nor is 
 it requisite to follow his distinctions minutely. But I shall attempt 
 to trace briefly what I conceive admits of demonstrable proof. 
 
 The beam or mesolobe, {corpus callosum^ Der Balken} consists 
 of white cerebral matter disposed in transverse fibres, which meet 
 on the mesial plane, and thus give rise to the longitudinal lines 
 seen on its upper surface {Raphe externa et iaterria, Reil). They 
 appear to change direction, and bend down at right angles, parallel 
 with those of the opposite half. At the distance of from four to 
 five lines on each side, these transverse fibres undergo a similar 
 interruption or change of direction, so as to form the covered bands 
 (die bedeckten Bander), which appear also in the form of long, firm, 
 fibrous lines, extending longitudinally along the upper surface of 
 the beam. Between these bands and the inner margin of the olfa- 
 cient groove a connection may be traced over the knee (das Knie), 
 or anterior end of the heam. 
 
 Beyond the covered bands the transverse fibres pass directly into 
 the white matter of the hemispheres, where they are connected in 
 diflPerent modes with different parts. The general direction is that 
 of expansion, like the rods of a fan, or radiation, like the rays of a 
 luminous body. The fibres which compose the knee or anterior 
 end, sinking into the hemisphere near the anterior cornu, meet 
 those forming the first and anterior staff" of the brain- limb, which 
 lie in the anterior knotty end of the striated body, and wind round 
 the adjoining edge of the staff-wreath ; (der Stabkranz). In the 
 intermediate substance, which is knotty before, and spreads into a 
 brush-shaped expansion behind, the middle rods of the staff-wreath 
 unite with their anterior extremities, and with the fibres of the 
 beam. This forms the first or anterior junction of the heam with 
 the limbs. 
 
 The middle fibres, passing immediately into the hemisphere, 
 meet more abruptly with those of the limbs Suddenly contract- 
 ing, as it were, they coalesce with those of the taenia, and are co- 
 
BRAIN. 
 
 257 
 
 vered by the gray matter of the brush-like termination above-men- 
 tioned, and epithelion, which is here very thick. The radiating 
 fibres of both systems are here shortest. The deep layers form in 
 some parts immediate mutual communications, especially in the 
 posterior cornu ; and at this point alone the inner layer of the beam 
 descends directly on the fibres of the limb. In expansion, these 
 radiating fibres receive between them white matter from the hemi- 
 spherical circumference ; and in this manner form connections, as 
 remarked by Reil, with the peripheral or convoluted part of the 
 hemispheres, and especially with those which form the Sylvian fis-- 
 sure.* This may be considered the second connection of the beam 
 with the brain limbs. 
 
 The hinder part of the beam is something firmer than the fore 
 part reckoned towards the centre ; a circumstance which depends 
 on the closeness with which its fibres are here compacted in mass. 
 After forming the elevated ridge which constitutes the hinder cross- 
 bar of the vault, they plunge into the hemispheres in the form of 
 thick bundles, which, running horizontally backwards over the 
 posterior cornu, are expanded in the posterior parts of the hemi- 
 spheres. The inner layer of these fibres, which falling on the outer 
 wall of the cornu over the radiation of the limbs, covers it and part 
 of the outer wall, is named by Reil the tapestry, or hanging. (Die 
 Tapete. ) This may be viewed as a third point of junction between 
 the beam and the brain limbs. 
 
 I am now to trace the direction of the component fibres of the 
 latter parts. These are connected below, above, and behind, with 
 so many important parts, that it is requisite to comprehend several 
 parts under the general denomination of System of the limbs. After 
 the example of Reil, we begin from the head of the spinal chord ; 
 (medulla oblongata.) 
 
 This part consists in the human adult of six eminences, three on 
 each side of the mesial plane ; the pyramidal or pyriform eminences 
 before and below, the restiform bodies behind and above, and the 
 olivary eminences on each side. Of these the olivary eminences are 
 to be viewed as the most important, since by each containing a ci- 
 liary or moriform nucleus, (corpus ciliare, c. dentatum, c. moriforme, 
 c. rhomboideum,) they make an approach in structure to the cha- 
 racter of the cerebellum. 
 
 The pyriform or pyramidal bodies are important in another light 
 
 * Archiv. f Ur die Physiologie, Neunter Band, p. 179. 
 
 K 
 
258 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Varoli, who has the merit of first examining with attention what 
 is termed tlie base of the brain, traced in these bodies longitudinal 
 fibres passing upwards through the body, named after him Pons 
 VaroUi, the annular protuberance^ {jnoiuberantia annularis ; Wil- 
 lis ; nodus cerebri; Rau;) towards the limbs and substance of the 
 brain. By Vieussens and Morgagni the fact of this arrangement 
 was afterwards verified ; and it has been confirmed by the obser- 
 vations of Reil on the adult brain, and by those of Tiedemann in the 
 foetal organ. 
 
 The pyramidal bodies, situate on the anterior -part of the medulla 
 oblongata, and mutually separated by the median furrow, consist 
 entirely of bands or rods of whitish fibres, (Die Mark Stabchen,) 
 extending longitudinally through them. Becoming thicker, but 
 not less compact at the upper end, where they are connected with 
 the part named bridge, {pons Varolii ; die Brucke ;) or annular 
 protuberance ; {nodus cerebri ;) these longitudinal fibres undergo a 
 new arrangement. First, They are covered with a firm layer of 
 transverse fibres, which proceed, as it were, from the middle line 
 on each side circularly round. These fibres are white, firm trans- 
 versely, and abundantly distinct. ^ When peeled off to the depth 
 of about 1^ line or two, the longitudinal fibres of the pyramids be- 
 gin to appear ; but no longer collected in mass as below. Nume- 
 rous transverse or circular- transverse fibres are interposed between 
 them, so as to separate them into layers. Hence results the com- 
 plex structure of the bridge, which externally appears to consist of 
 circular-transverse matter, but internally presents many longitudi- 
 nal bands. It is worthy of notice, that in transverse and longitu- 
 dinal sections the part which appears gray on the transverse section, 
 is white on the longitudinal, and conversely. The closeness with 
 which the circular fibres are compacted render the bridge decidedly 
 the firmest part of the whole brain. 
 
 Proceeding from the lower to the upper surface of the bridge, 
 this combination of long and cross bands is less distinct. Part, if 
 not the whole of the transverse fibres, sink into the peduncles or 
 cru7-a of the cerebellum ; and they evidently predominate here over 
 the longitudinal. 
 
 The posterior-upper part of the medulla oblongata consists of two 
 longitudinal bodies separated on the median line by a deep furrow. 
 These, which are the restiform or rope-like processes, chordal pro~ 
 cesses of Ridley, {corpora restiforrhia) {processus restiformes, Mor- 
 
 3 
 
BRAIiV. 
 
 259 
 
 gagni,) are described in most works as the pyramidal eminences. 
 (Haller, Malacarne, Red.) As there is no doubt that this part of 
 the spinal chord presents six eminences, three on each side, as above 
 stated, with the view of avoiding the confusion with which anato- 
 mists speak on these bodies, I adhere to the plan originally adopted 
 by Willis, Ridley, Ruysch, and Morgagni, of distinguishing the 
 anterior eminences as ■pyramidal^ and the posterior as the restiform 
 ■processes* 
 
 Stretching in the form of thick strong bands between the pe- 
 duncles of the cerebellum above, and the spinal chord below, the 
 restiform processes are mutually parted by a deep furrow, (calamus 
 scriptorius,) in the bottom of which, when slightly separated, white 
 chords proceeding from the process of one side are observed to be 
 plaited or crossed with those of the other. This arrangement was 
 first observed by Dominico Mistichelli,t a physician at Rome, in 
 1709, and shortly after by Pourfour dePetitJ at Namur. Though 
 subsequently verified by the observation of Santorini,§ Win- 
 
 * “ The third descends from this part (the cerebellum) backwards upon the upper 
 .side of the medulla oblongata, like two longish thick chords on each side, making the 
 medulla look somewhat thicker and broader in that place, and not unfitl}' styled the 
 chordal process." The Anatomy of the Brain, &c. By H. Ridley, Coll. IMed. Bond. 
 Soc. London, 1695, chap. xiv. j). 136. Of this the term processus restiformis is a 
 literal translation, given by his Latin translator, and in the collection of Mangetus. 
 It is remarkable, that, though thus earR noticed by Ridley, and afterwards distin- 
 giushed as posterior pyramidal eminences by Ruysch, the restiform processes have 
 been completely neglected, and are scarcely known even bj' name. It is not uncom- 
 mon both in books and in demonstration to see them pointed out as the corpora py- 
 ramidalia. By those who wish to avoid the confusion resulting from this oversight, 
 they are termed posterior pyramidal bodies ; and in support of this, the authority of 
 Ruysch, Prochaska, and Soemmering'* may be adduced. 
 
 T Trattato dell’ Apoplessia. Roma, 1709. Lib. i. Cap. vi. ix. 
 
 t Lettre d’un Medecin des Hospices du Roi. Namur, 1710. 
 
 § “ Nos autem sic earn luculenter conspeximus, sic eHdenter, ubi apta incidere ca- 
 davera demonstravimus, ut nulla amplius nobis de hac re supersit dubitandi ratio. Id 
 autem triplici potissimum in loco animadvertere potuimus ; in utraque scilicet priore 
 posterioreque annularis protuberantiae crepidine, atque maxime in imo medullaris cau- 
 dicis, qua in spinalem abit. In priore itaque annularis protuberantire parte, qua supe- 
 rius reflexa pro comprehendendis oblongatre medullas cruribus in anguli formam in- 
 terius producta tenuatur, sic ex concurrentibus fibris, strictiorique agmine coeuntibus, 
 altera alteram scandit, ut praeter mirum implexum, decussatio luculentissime appareat. 
 Id ipsum ferme in postica ipsius crepidine occurrit. Eo iterum in loco, qui quarto ven- 
 triculo subjicitur, (the space between the restiform processes,) praeter varios fibrarum 
 
 * Frederic! Ruyschii Responsio ad M. E. Ettmuller de Corticali Cerebri Substantia, &c. p. 25. Am- 
 stel. 172li Georgii Prochaska De Structura Nervorum Tractatus, &c. Sectio 3. tabula i. fig. 1. S. T. 
 Soemmering De Basi Encepha'i, &c. Tab. U. sect. 3. § 18. Apud Ludwig, Tom. II. 
 
260 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 slow,* Lieutaud, and Soemmering,-}- it had escaped the notice of Hal- 
 ler, Vicq-D’Azyr, Monro, and others, and was, therefore, doubted 
 till revived by M. Gall. Independent of the testimony of the above 
 authors, it is easy to demonstrate by slight separation of the resti- 
 form bodies the fact, that whitish chords are seen lying obliquely 
 across the linear depression, and that those connected with the right 
 process cross to the left, while conversely those of the left cross to 
 the right. 
 
 It is to the inner or mesial fibres of the restiform processes only 
 that this cross plaiting is confined. Neither the pyramidal, nor the 
 olivary, nor even the whole of the restiform bodies partake of it. 
 It is sufficient, however, to establish a communication between the 
 right and left halves of this part of the spinal chord. It was seen 
 by Tiedemann in the fourth and fifth weeks of uterine life. 
 
 The interior fibres of these bodies are longitudinal, and proceed 
 partly to the cerebellum, partly to the protuberance. The deep- 
 seated layer is partly interwoven with the transverse circular fibres 
 of this body, in the same manner in which those of the pyramidal 
 eminences are, partly bends up to the peduncles of the cerebellum, 
 with the bands of which they are then combined. The superficial 
 layer is connected chiefly with the substance of the corpora quadri- 
 gemina, (Die Vierhugel,) which constitute the upper surface of the 
 protuberance. 
 
 The structure of the olivary body is more complex. Though its 
 surface consists of longitudinal fibres, which, like those of the other 
 eminences, are lost in the protuberance, these form a sort of super- 
 ficial covering to a capsule of gray matter arranged in a serrated 
 form, inclosing a nucleus of white. This arrangement constitutes 
 a ciliary or moriform body, (corpus ciliare, c. dentatum^ c. rliom- 
 boideum^) precisely similar to that in the white trunks of the cere- 
 
 ordines et colores, in adversum latus productas, et decussatas fibras cximmode specta- 
 vimus. Si ea tamen evidenter uspiam conspicitur, profecto quam evidentissime duas 
 vix lineas infi'a pyramidalia, atque adeo olivaria corpora conspici potest. Qua enim 
 in longitiidinem producta linea, seu rimula pyramidalia corpora (the restiform pro- 
 cesses) discernuntur, si leniter diducantur, probe prius eo potissimum loco artissime 
 hserente tenui meninge nudata, non tenues decussari fibrillas sed validos earundem fas- 
 cicvlos in adversa contendere, quam apertissime demonstravimus.” Observ. Anatom. 
 J. D. Santorini. Lug. Bat. 1739. Cap. 3, § 12. p. 61. Also Tab. II. apud Girardi, 
 p. 28, 29. 
 
 * Exposition Anatomique, &c. Par J. B. Winslow. Paris, 1732. Traite de la 
 Teste, 110, p. 626. 
 
 t S. T. Soemmering de Basi Encephali, lib. ii. sect. 3. § 18. 
 
BRAIN. 
 
 261 
 
 helium, to which, therefore, the olivary eminence approaches in or- 
 ganization. 
 
 All these parts may be viewed as external markings on the bulb 
 of the spinal marrow, {medulla oblongata.) It is to be observed, 
 that in the foetus, the infant, and in young subjects in general, 
 they are more distinct, than in the brains of adults and especially 
 of the aged. In the brains of infants and the young, all the mark- 
 ings both separating furrows and elevations are most distinct ; 
 and the restiform bodies or posterior pyramidal bodies present each 
 a longitudinal furrow, parting them in two portions, one lying 
 close on the median line and furrow, the other lying between their 
 median and most posterior portions and the olivary bodies. To 
 these sometimes the name of posterior pyramidal bodies is applied, 
 and the name appears sometimes to be applied to the restiform 
 bodies, while that of restiform bodies is given to these anterior 
 portions of the posterior masses, still regarded as posterior pyra- 
 mids. 
 
 As life advances this longitudinal furrow becomes less distinct, 
 and at length is so small as to be imperceptible in many adult and 
 aged persons. This is the reason of the discordance in the state- 
 ments of different anatomists. 
 
 In the infant brain, therefore, and in that of the young, the 
 medulla oblongata is marked or distinguished externally into eight 
 bodies, or four on each side of the mesial plane. At this period of 
 life also, each of the four lateral bodies is more strongly figured, 
 and appears in more distinct relief than in the brain examined at a 
 subsequent period. 
 
 In the brain of the young, also, the internal structure is if pos- 
 sible more strongly marked than in that of the aged. It is then 
 seen, that the longitudinal fibres of the bulb are interlaced or in- 
 terwoven with numerous transverse fibres ; that the corpora resti- 
 forma are closely connected with the peduncles of the cerebellum ; 
 that the anterior pyramids are connected or continuous with the crura 
 of the brain ; and that the olivary bodies, by presenting a corpus 
 dentatum., form a repetition of the cerebellum in the spinal marrow. 
 
 The longitudinal fibres of these several parts passing through 
 the protuberance are observed beyond this body to be in direct 
 continuation with those of the cerebral limbs. ( Crura, Die Hirn- 
 schenkel.) These are cylindrical masses, stretching obliquely be- 
 tween the protuberance behind and the optic chambers or eminences 
 
262 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 before. The longitudinal bands of which they consist give their 
 lower surface a fluted appearance, at least to the inner margin of 
 the optic tracts, by which they are obliquely crossed. Connected 
 before with the posterior-inferior region of the tlialami, they may 
 be traced into the substance of these parts, where they undergo an 
 arrangement new and peculiar. 
 
 Though the name couch or thalamus be still applied to these 
 bodies, it conveys an erroneous idea of their anatomical relations. 
 With the striated bodies, they form the central portion and most 
 perfectly organized nucleus of the organ. 
 
 Each optic thalamus may be said to be united behind with its 
 fellow by means of the quadrigeminous eminences. These con- 
 sist superficially of epithelion or capsular cerebral matter, below 
 of a semilunar stratum of fibres derived from the cerebral limbs, 
 while a similar production forms the deep layer of the corpus geni- 
 culaturn internum. 
 
 In each optic thalamus may be distinguished, according to Reil, 
 four layers, each consisting of gray and white matter. The up- 
 permost is merely the epithelion or condensed matter which forms 
 the covering. The second is connected with the inner corpus ge- 
 niculatum.^ from which fibres appear to spread or expand in the 
 manner of rays, over the outer edge of the limb, and embracing 
 the part to he mentioned as the nucleus of the brain. The third 
 layer consists of a set of fibres which, issuing from the upper layer 
 of the brain-limb at their entrance into the thalamus, are firmly 
 tied as it were into a loop or knot, (die Schleife,) and are then 
 expanded like a brush into the substance of the thalamus. The 
 lower is formed chiefly by the cerebral limb. It is partly in the 
 former, partly in the latter, that the dark-coloured matter consti- 
 tuting the locus niger is placed. 
 
 The thalamus is so intimately connected with the limbs, that they 
 must be viewed as essential parts of the same organized whole. 
 The component rods or fibrous bands (seine Markstabchen) of the 
 latter, partly combining with the former, but chiefly receiving them, 
 spread out near the outer edge of the thalamus circularly, and con- 
 stitute the radiated expansion called by Reil the StafFwreath. 
 (Der Stab-Kranz.) These rods, at first obliquely horizontal, gra- 
 dually, as they expand, assume a more vertical direction. Inwards, 
 or towards the mesial plane from the first band or rod ascends the 
 anterior pillar of the Twainband { fornix) to the knobs of the beam. 
 
BRAIN. 
 
 263 
 
 Then follow the first band or spoke of the wreath,' and the rest in 
 succession. The anterior rods are long, slender, numerous, and 
 thickly crowded on each other. The middle or lateral are short, 
 thick, roll-like, and form a sort of crest or comb. The posterior 
 are long and of fibrous structure. As they expand they form 
 nearly a complete circle, which radiates through all the lobes. 
 The radii of this circle are connected in the anterior lobes with the 
 knee of the beam, cross thejTos-sa Si/lvii near the anterior and pos- 
 terior cornua to the outer edge of the thalamus, and terminate in 
 the lateral coi'nu in the apex of the middle lobe, at the beginning 
 of the Sylvian furrow. In this course the anterior rays of the 
 StafFwreath are longer than the middle and lateral rays, the inter- 
 ruption of which forms the comb or crest. (Der Kamm.) The pos- 
 terior, which go to the border of the outer wall of the capsule, are 
 the longest ; and shorter ones are again seen below in the region 
 of the lateral cornu. 
 
 The last part, the organization of which can be here made the 
 subject of short consideration, is the striated body. When ob- 
 served, this part presents a singular arrangement of white and gray 
 matter in the form of alternate streaks. This arrangement, though 
 constant, it is unnecessary to describe minutely, unless so far as it 
 is connected with the appearances already mentioned. The parts 
 which chiefly claim attention on this head are the cerebral nucleus^ 
 its capsule, and the loalls of the capsule. 
 
 The striated part of the brain may be regarded as a nucleus, 
 (Der Kern) or organized central mass,^ which is contained within 
 a capsule consisting of three walls or enclosing plates of white mat- 
 ter ; a lower, an outer, and an inner wall. 
 
 The lower wall of the capsule, which is accidental, consists chiefly 
 of the tractus innominatus, (Die ungenannte Marksubstanz,) the 
 perforated spot, and that part of the convoluted space from which 
 the olfacient nerve issues. 
 
 The outer wall is the most remarkable. It rests on the unciform 
 band (Der haakenformige Markbiindel) at the entrance of the Syl- 
 vian fossa, which connects the convolutions of the anterior lobes by 
 the perforated spot with the middle lobe. F rom this unciform band 
 as a centre, the fibres of the whole outer wall radiate ; and as the 
 
 ReiJ considers it a ganglion, (Das Gestreifte grosse Himganglium.) But this idea 
 is hypothetical ; and while I use the term nucleus, I vdsh to convey no idea but that 
 of one part contained within another. 
 
264 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 deep ones are beneath the level of the cerebral limb, Reil regards 
 them as connected neither with this nor with the beam or raesolobe. 
 He represents, nevertheless, the radiation of the outer wall as too 
 much detached from the unciform band. Frequent examination 
 of this part leads me to represent the outer wall and the unciform 
 band as parts of the same system of fibres. The unciform band is 
 situate not on the same vertical plane with the rest of the outer 
 wall, which not only radiates in every direction forward, upward, 
 and backward, but swells out laterally, or towards the convoluted 
 region of the hemispheres. The result of this arrangement is, that 
 the section which shows the unciform band most distinctly shows 
 only the peripheral or marginal fibres of the outer wall. A sec- 
 tion more external or lateral, however, shows the radiating fibres 
 of the part between the centre, (the unciform process,) and the cir- 
 cumference ; and in order to see them distinctly all at once, and 
 to have a correct conception of their assembled disposition, it is re- 
 quisite to pare off from its outer surface the exterior white matter, 
 or to excavate externally, so as to form a spherical segment. 
 
 The outer wall of the capsule is, in short, a spherical shell, con- 
 sisting of fibres radiating from a point above the fossa Sylvii. So 
 far as 1 have been able to observe, it has no connection with the 
 limbs of the brain. 
 
 The inner wall of the capsule is composed, on the contrary, of 
 the stem of the limb, and the fore-part of the staffwreath, which 
 sends fibres under the round part of the inner portion of the nu- 
 cleus. Joining the outer wall above by means of an arched mar- 
 gin, and at acute angles, it gives the capsule the shape of an in- 
 verted boat. 
 
 In this capsule is lodged the outer part of the large striated nu- 
 cleus of the brain; the inner, usually named corpus striatum, being 
 covered only by epithelion within the ventricle. Both are parts of 
 one organ which should not be separated. 
 
 Of the cerebellum, the internal arrangement is nearly the fol- 
 lowing. 
 
 The restiforra processes I have already mentioned as connected 
 partly with the protuberance, partly with the four eminences, {cor- 
 pora quadrigemina), situate on its upper surface. The circular 
 transverse fibres of the protuberance, which enclose the longitudinal 
 ones produced in a lateral-posterior direction, plunge into the ce- 
 rebellic hemispheres in the form of thick, strong, white chords, 
 
 4 
 
BEAIN. 
 
 265 
 
 named stalks or peduncles of the cerebellum. At the point at which 
 they take this direction, they further receive a considerable accession 
 from the restiforra processes, the fibres of which are here seen to 
 make a slight bend upwards, in order to follow the direction of the 
 peduncles. Thus is composed a thick strong trunk of white matter, 
 which on each side forms a sort of central pillar, (Die Marksaule, 
 Der Pfeiler,) to each cerebellic hemisphere. The interior arrange- 
 ment of this pillar or trunk is distinctly fibrous longitudinally, at 
 its origin, or parting from the protuberance, and for a considerable 
 distance from this point through the hemisphere. Unless I am 
 misled by optical deception, the part derived from the restiforra 
 processes is also fibrous, and changes direction, to accord with that 
 of the peduncular bands. 
 
 In the centre of the white fibrous pillar thus formed is contained 
 a body consisting of a capsule of fibrous matter enclosing a nucleus 
 of white. The serrated or indented form in which both the nucleus 
 and its capsule are arranged gives it the name of ciliary or mori- 
 form body ; {corpus ciliare v. dentatum^ c. moriforme or rhomboi- 
 deum.) The capsule is incomplete at one end, that turned towards 
 the base or root of the trunk. Each trunk or stem (Stamm) divides 
 into a certain number of branches, (Aeste) ; each branch into a 
 number of twigs (Zweige ;) and to each twig is attached a number 
 of leaves. (AbZ/a ; Blattchen.) 
 
 Of these plates or leaves the structure is uniformly the same, 
 
 white matter internally, covered with a thicker layer of gray. 
 Whether the white is really fibrous or not, as Reil describes, is not 
 easy to say, in consequence of its extreme tenuity and small quan- 
 tity. It is certainly fibrous in the stems and branches, in which 
 the linear appearance can be seen almost by the eye, and always 
 by a glass. I cannot say that it is so evident in the twigs, in which 
 it is in very small quantity ; and in the leaves the intimate dispo- 
 sition is still more difficult to recognize. In the gray matter it is 
 impossible to trace any thing like fibrous structure. 
 
 The ramification (die verzweigung, die zerastelung,) in the cere- 
 bellic hemispheres is connected with the circular-transverse fibres 
 of the protuberance and the restiforra processes exclusively. Some 
 would say that from this, this ramification is derived, — the precise 
 meaning of which I have already endeavoured to determine. In 
 the middle of this organ, however, or on its mesial plane, is found 
 a ramification which appears to be connected with a different source. 
 
266 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Tills is the structure of the upper and lower worm. Between the 
 lower of the quadrigeminous eminences and the cerebellum is a 
 thick semicylindrical hand on each side, known under the name of 
 pillars of the valve^ and processus a cerehello ad testes. These a 
 little below the lower margin of the valve seem to sink directly into 
 the cerebellic substance, mutually join, and form a whitish stem, 
 which is ramified in the middle of the cerebellum. About four 
 lines or half an inch from their first entrance into the organ, a 
 branch set off almost straight upwards is the vertical branch, (Der 
 Stehende Ast,) which, after giving off its first twig (der erste zweig) 
 to the central lobe, divides into other seven, which are distributed 
 to the anterior or mesial lobules of the quadrilateral lobes, as they 
 meet on the mesial plane. The white stem of this vertical branch 
 is thick and large. 
 
 A more slender stem, the continuation of the original white 
 band, proceeding horizontally backwards towards the purse-shaped 
 notch, is the horizontal stem (Der Liegende Ast,) which constitutes 
 by ramification a number of important parts on the mesial plane of 
 the cerebellum. After giving three or four twigs generally small, 
 and also vertical, to the last leaves of the quadrilateral lobes, the 
 branches are parted in the following order : — 1 st, A twig under 
 the cross commissures of the posterior-upper lobes, forming the 
 short exposed ci'oss-hands (die Kurzen und sichfbaren Querbander,) 
 and the long covered cross-bands ; (die verdeckten und langen 
 Querbander;) — 2d, A branch dividing into three strong twigs, 
 forming the leaves of the pyramid ; — ‘del, A long branch dividing 
 into three twigs, forming the leaves of the uvula (der Zapfen ;) — 
 Ath, The last generally a single twig, constituting the laminar tu- 
 bercle or nodule (das Knotchen.) 
 
 The spinal chord is the last part of the central class of organs 
 coming under the head of brain. It may be viewed as two longi- 
 tudinal bands united by the middle. Both are fibrous internally 
 throughout their entire length ; and in the lumbar region of the 
 canal these fibres are separated and expanded into a true brush-like 
 arrangement, named cauda equina. Some anatomists have ima- 
 gined they could recognize cross fibres in the chord ; but, with the 
 exception of what has been stated regarding the connection of the 
 restiforra processes, nothing of this nature can be regarded as esta- 
 blished. 
 
 Some anatomists have also thought it possible to demonstrate 
 
BRAIN. 
 
 267 
 
 the existence of a longitudinal cavity or canal in the spinal chord. 
 In the adult this never exists in the normal state. The canal of 
 the chord is part of the foetal structure only ; and in this respect it 
 is to he viewed as one of many peculiarities of formation belonging 
 to the lower animals, through which the human foetus passes in 
 the early stage of development. A longitudinal canal is found in the 
 spinal chord, during the whole course of existence, in reptiles, fishes, 
 and birds. In mammiferous animals in general it is always found 
 in the foetus, and continues in several for some time after birth. 
 (Sewel, F. Meckel, and Tiedemann.) As the animal grows, how- 
 ever, it ceases to be found ; and the only trace of its previous ex- 
 istence is a longitudinal depression on the anterior part of the 
 chord. In the young of the human subject it has been found after 
 birth by Charles Stephen, by Columbo, Piccolhomini, Bauhin, 
 Malphighi, I^yser, Golles, Morgagni, Haller, and Portal. No 
 doubt can be entertained, however, that in such cases it was part 
 of the foetal structure continued to an unusual period by the slow 
 progress of growth, or in consequence of some interruption to th« 
 usual process of development. The chord, in short, is formed in 
 two portions; and when these are incomplete, the longitudinal 
 cavity exists between them. As by progressive enlargement they 
 mutually approximate on the mesial plane, this canal necessarily 
 diminishes until it entirely disappears. 
 
 I am now to consider shortly the minute anatomical structure 
 of cerebral matter in the several parts of the organ. The three di- 
 visions of brain, small brain, and vertebral prolongation, and their 
 constituent parts, do not present every where the same aspect or 
 obvious qualities, but appear to consist of substances which are dis- 
 tinguished chiefly by their colour. 
 
 The outer convoluted part of the first division {cerebrum) con- 
 sists of peculiar substance of a gray or ashen colour. Its convo- 
 luted surface, which is covered by the adherent surface of the soft 
 or vascular membrane, {meninx tenuis^ pia muter), is smooth and 
 uniformly gray, without spots or streaks. At various situations it 
 presents minute holes or orifices, which correspond to arterial or 
 venous branches. It is not easy to apply accurate terms to denote 
 the kind of colour ; but, according to Gordon, this surface is of the 
 wood-brown or lead-gray tinge;* and the substance so coloured 
 
 Same’s Nomenclature of Colours. 
 
268 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 extends only one-eighth or one-tenth of one inch in depth, and is 
 then succeeded hy a tinge of orange-white substance. Of the cor- 
 rectness of this ohservation, I am not assured. If sections of the 
 convoluted part he made, no difference can be observed in the re- 
 cent brain ; and the cut surface appears to consist of homogeneous 
 and uniform gray matter, from the outer or free margin to that 
 which adheres distinctly to the white substance. 
 
 The consistence of the convoluted cerebral substance is consi- 
 derable ; but it is less than that of the white matter. 
 
 If we trust to the observations of Father Della Torre, the gray 
 and the white substance of the brain, cerebellum and spinal chord, 
 consist of an accumulation of transparent globules, floating in a 
 transparent crystalline^ but somewhat viscid fluid.* These globules, 
 he imagined, are largest in the brain, smaller in the cerebellum, 
 and still smaller in the spinal chord. 
 
 According to the observations of Prochaska, however different 
 in colour the gray cerebral substance be from the white, no differ- 
 wce in minute structure can be recognized by the most powerful 
 lens. Each appears to consist of an infinite multitude of globules, 
 connected by a peculiar, elastic band ; and he observes that this 
 cerebral globule does not float in a fluid, as Della Torre imagined, 
 but is connected to the contiguous ones by a thin and transparent 
 cellular web, (tela cellulosa suhtilissima et pellucidissima^) which is 
 a series of membranous partitions derived from the soft membrane 
 and minute vessels. This last conclusion is not quite certain, and 
 would require to be made the subject of further researches. f 
 
 On the structure of these globules nothing is known with cer- 
 tainty. They are not exactly spherical, but are said to be irregu- 
 larly round. The observation of Della Torre, that they are largest 
 in the convoluted brain, (cerebrum,) smaXXev in the laminated, (cere- 
 bellum,) and most minute in the vertebral portion, is fanciful, and 
 perhaps unfounded. Prochaska, however, admits that the globules 
 are not all of the same size, but that it is impossible to ascribe their 
 variable magnitude to a regular principle, unless the proximity or 
 remoteness of the lens.J 
 
 The accuracy of these observations is confirmed in general by 
 
 * Nuove Observazione Microscopicbe. Napoli, 1776. Osserv. 16, 17, 18, 19, &o. 
 t Georgii Prochaska De Structura Nervorum, &c. VienuEe, 1779. Sectio 2, ca- 
 put iv. 
 t Ibid. 
 
BRAIN. 
 
 269 
 
 the testimony of Soemmering, whose inferences, derived from the 
 observations of Lewenhoek, Della Torre, Malacarne, Metzger, and 
 Prochaska himself, are found in the conclusion of his description 
 of this organ.* 
 
 From thirty-one experimental observations on the cerebral mat- 
 ter of the human subject, in various mammiferous animals, fowls, 
 and fishes, Joseph and Charles Wenzel of Tubingen have drawn 
 the conclusion ; — that the gray and white (cortical and medullary) 
 matter of the human brain, the substance of the colliculi, (optic 
 chambers and striated bodies,) that of the conarium, spinal chord, 
 and nerves ; in short, the mass of brain in mammiferous animals, 
 birds, and fishes, consists of the same small roundish bodies, mu- 
 tually cohering, of which the substance of muscle, liver, spleen, 
 and kidney is composed ; that as these minute bodies derive their 
 shape from the cells of the cellular tissue, the substance of brain, 
 spinal chord, and nervous matter, appears to consist of the same 
 roundish minute bodies ; but that the relative size of these cells 
 cannot be determined. 
 
 These conclusions throw little light on the point at issue, — the 
 minute structure of the cerebral matter in general ; and it must 
 be said that the microscopical observations and chemical experi- 
 ments of these anatomists do not communicate information propor- 
 tioned either to their number, or to the elaborate assiduity with 
 which they appear to have been conducted. Subsequently the atomic 
 constitution of different parts of the brain and cerebellum was in- 
 vestigated by Sir Everard Home, aided by the powerful microscopes 
 of ]\I. Bauer. 
 
 According to this observer, white cerebral matter consists of in- 
 numerable globules, aggregated or connected in rows, so as to con- 
 stitute fibres, by means of a transparent, colourless, jelly-like mat- 
 ter, somewhat viscid, elastic, and readily soluble in water. The 
 globules are whitish, semitransparent, and vary from 24^0 to 
 of an inch in diameter, the average being 
 
 Upon different proportions of these two constituent elements, and 
 partly upon differences in size of the component globules, the chief 
 peculiarities of structure in the several sorts of cerebral substance 
 depend. Thus the gray matter of the convoluted surface of the 
 brain, and the laminated simface of the cerebellum, consists chiefly 
 of globules from gg^gg to jgigg of uo iuch in diameter, the smaller 
 
 * Samuelis Thomae Soemmering De Corporis Humani Fabrica, Tom. III. Tra- 
 jecti ad Moenum, 1800. 
 
270 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 globules being most numerous, of a large proportion of the gela- 
 tinous, elastic, viscid substance, and a yellowish fluid resembling 
 the serum of the blood, probably albuminous. In the white mat- 
 ter, on the contrary, the large globules (4550 of inch) predomi- 
 nate ; the connecting jelly is more tenacious, but less abundant in 
 proportion to the globules ; and the latter are more distinctly ar- 
 ranged in rows, so as to constitute fibres. 
 
 The mesolobe contains the greatest quantity of the small glo- 
 bules (34^55 of an inch ;) and the viscid jelly is said to be at least 
 equal to the globules in quantity. In the limbs of the brain and 
 peduncles of tlie cerebellum, the jelly is said to be in greater pro- 
 portion than the globules. The annular protuberance is chiefly 
 composed of globules of the average size (53505) with abundant vis- 
 cid matter. In the restiform processes, the pyramidal bodies, and 
 the olivary eminences, the fibrous structure consists chiefly of the 
 large globules, with abundant viscid jelly, which is rapidly soluble 
 in water.* 
 
 When the brain by immersion in alcohol is hardened, the elastic 
 jelly is coagulated and rendered opaque, and the appearance of 
 globules is lost.*j* 
 
 These observations partly verify those of Della Torre, partly ex- 
 plain those of Prochaska. They show, that, so far as the micro- 
 scope can be trusted, the globules of which cerebral matter consists 
 vary in size and proportion in different parts ; and that the white 
 cerebral matter generally consists of larger globules, or at least 
 contains a larger proportion of these globules than the gray. 
 
 The observations by Ehrenberg in 1833J on this subject next 
 deserve attention. * 
 
 This observer, by using the compound microscope, found the fol- 
 lowing forms of organic structure in the brain and nerves : — 
 
 1. A substance consisting partly of very minute fine grains, with 
 some coarser grained matter, disseminated, as is said in the lan- 
 guage of mineralogy, through the fine-grained matter. The latter 
 is entirely confined to the gray matter of the convoluted surface of 
 the brain, and the laminated surface of the cerebellum. 
 
 ■* The Croonian Lecture. Microscopical Observations on the Brain, &c. By Sir 
 Everard Home, Bart. V. P. R. S. Philosoiihical Transactions, JR21, Part i. v. p. 25. 
 
 i- The Croonian Lecture. On the Internal Structure of the Human Brain, &c. By 
 Sir Everard Home, Bart., V. P. Philosoirhical Transactions, 1824, p. 3. 
 
 + Ehrenberg employed a microscope manufactured by Chevalier of Paris, and aug- 
 mented in Power by Pistor and Schiek of Berlin ; and the powers varied from 260' to 
 360 diameters. 
 
BRAIN. 
 
 271 
 
 2. A set of tubes presenting at definite intervals globular or 
 spheroidal expansions, so as to resemble a string of beads, which do 
 not touch each other, but have a short communicating space inter- 
 posed between each bead. To these tubes he gives the name of 
 varicose^ from their resemblance to the varices of a vein, and jointed 
 or articulated tubes, because of the slight resemblance to a set of 
 joints. These tubes, which present to the microscope the appear- 
 ance of parallel fibres, he shows by various proofs to have an in- 
 ternal cavity or canal, and to contain a peculiar matter, to which 
 he assigns the name and qualities of nervous fluid. These are con- 
 fined chiefly to the white matter of the brain. They may be termed 
 moniliform tubes. 
 
 3. A set of tubes straight and uniform, without the alternate 
 spheroidal enlargements, also hollow, and to which he applies the 
 name of simple cylindrical tubes. These are found chiefly in the 
 nervous chords and trunks. They are generally lai’ger and coarser 
 than the articulated tubes. But at certain points the latter pass 
 into the former by gradually losing their bead-like enlargements. 
 These tubes Ehrenberg represents to be distinguished from the ce- 
 rebral jointed tubes, by containing in their interior a viscid, white, 
 but less transparent matter, to which he applies the name of me- 
 dullary. 
 
 The substance of the circumference or the convoluted part of 
 the brain consists of a thick, very delicate, vascular network, con- 
 veying often numerous blood-globules, and traversed by serpen- 
 tine tendinous fibres. Besides the thick delicate vascular net of the 
 first substance, Ehrenberg saw in the same, near its utmost edge 
 and its remotest circumference, a very fine-grained soft substance, 
 in which here and there are imbedded larger grains or nuclei. These 
 large grains are free, and consist of granules or nucleoli which are 
 connected in rows by means of slender threads to the fine small 
 grains of the substance singly. In the neighbourhood of the me- 
 dullary substance, the fibrous character of the cortical matter al- 
 ways appears more distinctly ; and in the same substance the blood- 
 vessels are larger and less numerous. 
 
 The white or medullary matter of the brain shows more distinct- 
 ly the arrangement of fibres, which proceed in the form of direct 
 and enlarging continuations of the delicate cortical fibres, from 
 certain eminences, that is, the linear or band-like origins of the 
 convoluted surface, in a radiated manner, towards the hrain. These 
 
272 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 are not simple cylindrical fibres ; but resemble bollow strings of 
 pearls, the component parts of winch are not in contact, but are 
 connected by a canal for a small space ; or they resemble tubes or 
 cylindrical canals dilated at intervals into minute bladders. These 
 bladders or ampullulcB of the tubes were known to Leeuwenhoek, 
 who regarded them as globules of fat, which constituted the greatest 
 part of the brain. The connecting canals also he has obscurely 
 indicated. These tubes, uniformly straight, are generally parallel 
 in direction, sometimes, however, crossing each other. Four times 
 Ehrenberg recognised ramification in such individual canals ; but 
 anastomoses he never observed. These tubes vary in diameter 
 from to of one line. 
 
 In the neighbourhood of the base of the brain and in the matter 
 surrounding the ventricles, there are always seen between these 
 bundles of nodulated or jointed tubes, individual tubes much thicker 
 than the rest. In these thick tubes it is often possible to recognise 
 in their walls an external and internal boundary ; or they present, 
 besides their two external boundary lines, other two inner lines, 
 which enable the observer to distinguish the width of the area of 
 the internal cavity of the tubes. These nodulated linear parts of 
 the brain are varicose articulated tubes or canals. 
 
 The large cerebral tubules of the cerebral matter converge to- 
 wards and pass into those parts of the base of the brain, where the 
 peripheral nerves arise. Some of the large jointed-tube-matter 
 appears to terminate in or be connected with the cerebral cavities, 
 in the walls of which it is well developed. Many jointed or vari- 
 cose tubes pass into tbe spinal marrow, and tbence immediately 
 proceed to the spinal nerves. 
 
 In the spinal marrow the arrangement now described is in some 
 respects reversed. In the brain the most vascular and delicate 
 structure is placed at the exterior ; while the least vascular, but 
 perhaps more organised, viz. the varicose tubular structure, is placed 
 at the interior. In the spinal chord the most vascular and delicate 
 part lies in the centre ; while it is covered externally by the coarse 
 medullary matter. 
 
 Both substances are quite like those in the brain. From the ex- 
 ternal medullary matter, consisting of large varicose or monilifonn 
 tubes, the spinal nerves immediately proceed ; and these varicose 
 or jointed tubes, as they emerge from the investing dura mater, 
 assume suddenly the form of nerve-tubes, becoming thicker and 
 
BRAIN. 
 
 273 
 
 passing into the pure cylindrical form. These transitions are easily 
 recognised in the posterior part of the spinal marrow. 
 
 The optic, the auditory, and the olfactory nerves are immediate 
 continuations of, or productions from, the varicose medullary tubes 
 of the brain. All the other nerves, excepting the sympathetic in 
 the middle of its course, differ from the cerebral matter. 
 
 All these other nerves also consist only of cylindrical parallel- 
 lying tubes, about t igth part of a line in diameter, normally never 
 anastomosing. These are the elementary nerve-tubes, which, united 
 in fasciculi or bundles, again form larger bundles, which constitute 
 the nerve-chords. 
 
 These are the chief facts ascertained by Ehrenberg regarding 
 the minute structure of the brain and spinal chord. These have 
 been mostly confirmed by Berres and Muller. By others again 
 the accuracy of these results has been called in question. Thus 
 the observations of Treviranus, Valentin, and Weber tend to show 
 that all the primitive cerebral fibres or tubes are cylindrical, and 
 that the varicose or raoniliform appearance is an efiect of compres- 
 sion; or the violence employed in subjecting them to microscopic 
 observation. Muller, nevertheless, admits that the primitive cerebral 
 tubes have great proneness to become varicose or beaded. 
 
 The only points which, amidst the discordance of the results of 
 different microscopical observers, from Leewenhoek and Fontana 
 to Ehrenberg, Berres, Treviranus, and Muller, can be regarded 
 as established, are the following ; that the convoluted portion of the 
 brain consists of very minute granules or nucleoli arranged in rows 
 so as to form fibres, which radiate from the periphery to the inner 
 boundary of the convoluted portion ; that near the inner boundary, 
 and as they approach the white cerebral matter, this fibrous ar- 
 rangement becomes more distinct; and that the white cerebral 
 matter forming the walls of the ventricles and the base of the brain 
 is composed of tubular cylinders, mostly of large size, and having 
 a cylindrical cavity ; but whether these are varicose or not seems 
 undetermined.* 
 
 * C. G. Ehrenberg in PoggendorfF’s Annalen der Physik und Chemie, Jahrg. 1833. 
 Band XXVIIL § 449-65, und 1834. Band XXXIV. § 76, 80. Also Beobachtung 
 einer bisher unbekannten auffallenden structur des Seelenorgan bei Menschen und 
 Thieren. Von C. G. Ehrenberg. Gelesen in der Akademie der Wissenschaften am 
 24 October 1833. Gedruckt im, Feb. 1836. Abhandlungen ; seite 665. Translated, 
 with Additions and Notes. By Baud Craigie, M. D. Edinburgh Medical and Surgical 
 Journal, Vol. XLVIII. p. 257. October 1837. 
 
 G. Valentin uber die Dicke der varicosen Faden in dem Gehim und dem Rucken- 
 mark des Menschen. In Muller’s Archiv. 1834. §401-410. 
 
 S 
 
274 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 The sources from which the brain derives its blood are well 
 known. It is highly vascular throughout. These vessels, first 
 divided in the productions of the jna mater^ are afterwards subdi- 
 vided to an incredible degree of minuteness, in the substance of 
 the organ. They never anastomose. (Home.) They are accom- 
 panied with very minute veins, provided, it is said, with valves. 
 Of these the most delicate branches are found, according to Sir 
 Everard Home, in the gray convoluted matter, contrary to the 
 statements of Ruysch, Albinus, and others ; and conversely in the 
 white matter they are much larger.* 
 
 The substance of brain has been examined by several chemists ; 
 but the analysis most to be trusted, is perhaps that of Vauquelin, 
 who found that 100 parts of cerebral substance consist of 80 of 
 water, 7 of albumen, 4.43 of a white adipose matter, 0.70 of a red 
 adipose matter, 1.12 of osmazome, 1.5 of phosphorus, and 5.15 of 
 acids, salts, and sulphur. Upon the presence of the albuminous 
 matter depends the solidification which the brain undergoes when 
 immersed in alcohol, acids, or solutions of the metallic salts, which 
 coagulate that substance. Upon the presence of the white adipose 
 matter depends the formation of those brilliant white crystalline 
 plates, resembling cholesterine, observed by M. Gmelin in the brains 
 preserved in the anatomical cabinet of Heidelberg.f The opinion 
 of this physician, that it pre-exists in the brain, in the form of the 
 adipocerous or cholesterine matter (waxy brain-fat,) is improbable, 
 and requires more decisive experiments than those on which he has 
 founded it. 
 
 The development and growth of this organ was, in 1816, in- 
 vestigated with much care by Tiedemann, who has ascertained the 
 following points. In the embryo of six weeks, the spinal chord is 
 represented by a flat long substance, the upper end of which is 
 slightly enlarged. In the second month, when the brain is little 
 developed compared with the spinal chord, it may be said to con- 
 sist, 1st, of a cerebellum, with considerable transverse extent ; 2J, 
 of brain proper, exceedingly small ; 3rf, of a third portion placed 
 
 G. R. Treviranus Beitrage zur Aufkiarung der Erscheinungen und Gesetze der Or- 
 ganischen Lebens Band I. Heft. II. 183(>- 8, § 24. H. und Heft. IV. 1836. 
 
 E. II. Weber in Schmidt’s Jahrbuchern der in-und-auslandischen Medicin. Bd. XX. 
 § 5. und Henle ebendaselbst. § 339. 
 
 * Philosophical Transactions, Lond. 1821, pp. 29 and 30. 
 
 t Zeitscrift fiir Physiologie, Von Tiedemann, Treviranus, und L. C. Treviranus, 
 Band I. 1 Heft, 1824. 
 
 3 
 
BRAIN. 
 
 275 
 
 between these two, and the size of which exceeds that of the brain. 
 This third portion corresponds to the protuberance, or rather to 
 that part of the organ, the upper surface of which is formed by the 
 four eminences, (^corpora quadrigeminal and the lower surface by 
 the annular protuberance.* According to ]\I. Serres, it is formed 
 in man and animals before the brain and cerebellum, and imme- 
 diately after the spinal chord. In the fifth month the brain covers 
 a part of the protuberance ; it advances to the cerebellum, and in 
 the seventh exceeds it. At the same time, the other parts, and 
 especially that, which we have mentioned, as the third or central 
 portion, do not grow at the same rate. 
 
 At the beginning, that is about the seventh week, the brain is 
 found to be divided in two portions by a longitudinal fissure. Each 
 half mutually approaches as growth continues, and are at length 
 united, so that at the third month the only parts found separate are 
 the middle ventricle, the aqueduct or canal, which is at this time a 
 large cavity continuous with it, and the fourth ventricle. The de- 
 velopment of the cavities called lateral ventricles is closely connect- 
 ed with that of the contiguous parts of the organ. These appear 
 nearly in the following order. 
 
 The lateral lobes appear first about three months after concep- 
 tion ; and about the same time the mesolobe, {corpus callosum,) is 
 formed by union of the hemispheres; and the cylindroid processes, 
 {cornua ammonis,) Ywli, {fornix,) mammillary eminences, posterior 
 commissure, and cerebral limbs or peduncles, may be recognized. 
 Shortly after may be seen the ergot, or small hippocampus, and the 
 anfractuosity from which it issues, and the conarium and its pe- 
 duncles ; then the anterior commissure, the thin partition {septum 
 lucidum) and its cavity, which at this time communicates with the 
 middle ventricle ; lastly, the semicircular fillet, {taenia semicircula- 
 ris,) and the infundibulum, which correspond to the seventh month ; 
 and about the same time the outer surface of the brain begins to 
 present the eminences denominated convolutions, and the cerebel- 
 lum its laminated or foliated appearance. 
 
 In the early weeks of existence the brain is fluid, soft, and homo- 
 geneous. The white matter and its fibrous structure is first seen ; 
 and the cross structure of the fibres of the pyramids are observable 
 about the eighth week, according to I^I. Serres. About the sixth 
 month the cerebral substance appears, when microscopically exa- 
 
 * Anatomie und Bildungs-Geschichte des Gehinis im Foetus des Menschen u. 3 . f. 
 Von Dr Fredrich Tiedemann, Professor der Anatomie, u. s. f. Nurnberg, 1816, 4to. 
 
276 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 mined, to consist of globules immediately beneath the pia mater, 
 and of fibres at a greater depth. In the seventh month a section 
 of the ventricles shows very distinct layers of radiating fibres. Af- 
 ter these are seen new ones, which form convolutions, and which 
 are termed converging fibres. At the ninth month the organiza- 
 tion is complete. 
 
 The gray substance appears a long time after the white. At 
 the end of the sixth or seventh month this substance is formed in 
 the olivary eminences, which then assume their proper appearance ; 
 about the end of gestation the spinal chord is also filled with gray 
 matter, and about the ninth month this substance is distinctly seen 
 in the convolutions, the plates of the cerebellum, &c. These re- 
 sults are much like those of Serres, unless as to what regards the 
 brain proper, in which, according to this anatomist, the optic cham- 
 bers and striated bodies consist originally of gray substance entirely, 
 to which white cerebral matter is afterwards added. 
 
 Of the process of growth, the principal, indeed the sole agent is 
 the vascular membrane ; (meninx tenuis, pia mater et plexus cho- 
 roides: das Geffasshaut. ) The two divisions of this, viz. the ex- 
 ternal, or that belonging to the convoluted surface, and the inter- 
 nal, or that pertaining to the figurate, may be distinguished pre- 
 vious to the formation of any part of the brain, and when the two 
 portions, which are afterwards destined to be separate, are the 
 same, and indistinguishable from each other. The formation of 
 the organ appears to commence at once upon two orders of vessels 
 mutually looking towards each other; that which is to be the cen- 
 tral (^plexus choroides) being merely a mesh of vessels looking to 
 that which is to be peripheral, {pia mater.) The first portions of 
 newly deposited cerebral matter form the barrier between these 
 extremities, which continue to be more widely parted, as the process 
 of development advances. This membrane is then more vascular 
 than at any subsequent period. The cerebral matter is first depo- 
 sited soft, and firmly adherent to these vessels, which are ramified 
 in every direction through its substance. It becomes firmer after- 
 wards and less vascular the longer the period from deposition. 
 Hence the two surfaces, the outer and inner, are much softer and 
 more pulpy, and more firmly attached to the vessels, than the in- 
 termediate deep matter. Tiedemann appears to regard the process 
 of development as proceeding from the centre to the circumference. 
 This is correct, but not in the exact sense in which he understands 
 it. The centre is not in this case the figurate surface of the 
 
BRAIN. 
 
 277 
 
 brain, but tbe centre of the optic and striated bodies which is first 
 deposited, and from which the process of deposition advances 
 to both surfaces at the same time, and nearly at equal rates. 
 These inferences are established by the phenomena observed in the 
 development of the organ in the young of mammiferous animals in 
 general. 
 
 Section II. 
 
 Cerebral substance is liable to inflammation, acute and chronic, 
 to hemorrhage, to eflPusions of serous fluid, to alterations in its na- 
 tural consistence, and to tumours. 
 
 Encephalia Acuta ; Encephalitis. (Frank, Costantin.) Acute 
 inflammation of the brain is a rare disease, and, perhaps, if always 
 carefully investigated, would be found never to take place sponta- 
 neously or primarily. As the effect of accidental violence, and the 
 result of morbid poisons, it is much more frequent ; and it is chief- 
 ly under such circumstances that its phenomena and effects are 
 known. (Pott, Dease, Hill, Malacarne, Desault, J. Bell, M. A. 
 Petit, O’Halloran, Aberuethy.) As the effect of mechanical in- 
 jury, the disease is found to be generally circumscribed. Part of 
 the brain becomes very vascular, acquires a red colour of various 
 shades of intensity, and eventually becomes brownish or green, and 
 much softer than natural. The formation of matter in a distinct 
 cavity appears not so common in this form of the disease as in 
 another, which I am soon to mention. An abscess is not very fre- 
 quently remarked under such circumstances, unless when a foreign 
 body, as a bullet, a stone, or a piece of bone has been di’iven into 
 the brain. This process gives rise to intense headach, delirium, 
 and intolerance of light, quickly succeeded by convulsions, coma, 
 and death. 
 
 Of the effect of morbid poisons in inducing cerebral inflam- 
 mation more or less acute, an example is found in the severe 
 form of fever prevalent in jails and camps. In several examples 
 of this disease abscesses of the brain have been found, (Pringle) ; 
 and it is often possible to trace the process from the flrst marks of 
 injection to the complete formation of purulent matter. 
 
 2. Encephalia Suhacuta. (Pulpy destruction ; ramollissement, 
 Rostan, Lallemand, &c.) Subacute or chronic inflammation of the 
 brain is greatly more common. Its anatomical characters are much 
 the same as those of the acute form ; but the longer duration of the 
 process gives rise to modifications which the pathologist should dis- 
 
GENERAL AND PATHOLOGICAL ANATOMY. 
 
 tinguisli. At first a part of the brain becomes more or less red 
 and vascular. As this goes on, it passes successively into crimson, 
 violet or purple, brown, or claret colour, while the consistence of 
 the part is much diminished. A shade of green announces the 
 formation of purulent fluid ; and in proportion as this process con- 
 tinues before life is extinct, the part becomes yellow, or gray, or 
 grayish brown, (suhfusca) very soft and pulpy, or even semifluid. 
 It is perhaps equally rare in this as in the former case, to find per- 
 fect purulent matter in a distinct cavity. This change, which is 
 often mentioned by Morgagni,* is one form of the disease describ- 
 ed by Rostan f and Lallemand,:j: under the name of softening (ra- 
 mollissement) of the brain, and since that time by Bouillaud, 
 Bright, Durand-Fardel, and other authors. The softening is a 
 mere effect of the process of inflammation, subacute or chronic. In 
 some instances the softening is attended with effusion of serous 
 fluid, without much discoloration of the part. 
 
 Subacute or chronic inflammation, terminating in softening of 
 the brain, may take place either on the convoluted surface of the 
 organ, wdien it generally occupies an extent of two or three square 
 inches ; or at the figurate surface, when it is most common on the 
 middle portion, (^septum lucidum^ and extending along the twain- 
 band ; or in the substance of the organ, when it affects most fre- 
 quently the striated bodies, the optie thalami, the central part of 
 the hemispheres, the cerebellum, and the cerebral prolongations, 
 (crura cerebri^ in the order now enumerated. Its occurrence in 
 the spinal chord, in which the same series, of changes takes place, 
 has been described by M. Pinel the younger, § M. Olivier, || and 
 M. Velpeau.^ 
 
 What is the intimate nature of this disease, and wherein does it 
 
 ■* Epistola, V. 6, 7. IX. 16, 18, 19. In the brain of Marchetti, the anatomist, 
 who, after two epileptic attacks, died apoplectic, the gray matter was so tender, that 
 on the slightest touch it was converted into a fluid substance, as if it never had co. 
 hered. — L. vii. 14, 15. 
 
 -|- Recherches sur une maladie encore peu connue, qui a refu le nom de ramollisse- 
 ment du Cerveau. Par L. N. Rostan, Medecin de la Salpetriere, &c. A. Paris, 1820. 
 
 J Recherches Anatomico-Pathologiques sur I’Encephale, et ses dependances. Par 
 F. Lallemand, Prof, de Clinique, &c. Paris, 1820-1821. 
 
 § Sur ITnflammation de la Moelle Epiniere. By AI. Pinel, Fils. Journal de Phy- 
 siologie Experimentale, Vol. li. p. 54. 
 
 II De la Moelle Epiniere et de ses Maladies. Par C. P. Ollivier. Paris, 1824. 
 
 ^ Memoire sur une Alteration de la Moelle Allong^e, &c. Par M. A. I'’elpeau. 
 Archives Generales, Tome VII. p. 52 and 329. Paris, 1825. 
 
BRAIN. 
 
 279 
 
 differ from suppuration of tfie organ ? This question must be de- 
 termined by considering the anatomical characters of the lesion, 
 and the circumstances under which it takes place. In the part af- 
 fected, the portion of brain is never entirely removed. The- cere- 
 bral substance is separated, broken down, and mixed either with 
 serous, with bloody, or with purulent fluid. 
 
 It may succeed at least four morbid states of the organ. 1. It 
 may be the consequence of the blood-stroke, {coup de sang,) or in- 
 jection of the vessels of a given region of the organ. The softened 
 part is then reddish, rose-coloured, amaranth, crimson, or brown. 
 2. It may follow the effusion of x’ed blood, which nearly in the 
 same manner separates and breaks down the delicate substance of 
 the organ in which it is effused. The softened portion is then ge- 
 nerally brown, or a wine-lee colour ; but if a considerable time has 
 elapsed after effusion, it may be of a dirty or ashy colour, tending 
 to green, and not unlike softened bread. 3. It may either accom- 
 pany or follow the process which terminates in hydrocephalic effu- 
 sion. It is then of a milk-white colour. (Rostan, Lallemand.) 
 4. It may take place in the cerebral substance surrounding tu- 
 mours, (Meckel, Blane, Powell, &c.) when its colour varies from 
 pale-red to green, yellow, and brown. 
 
 From these facts it may be inferred, that softening, or pidpg 
 disorganization of the brain is not so much a proper disease as the 
 effect of a morbid process, which takes place in different conditions 
 of the brain. 
 
 When it occurs in the first manner, it is the result of a species 
 of diffuse inflammation, in which there is no tendency to limit the 
 action of the disease by the effusion of lymph, or the formation of 
 a vascular cyst. This is well illustrated in those cases recorded by 
 Morgagni, in which parts of the brain had become yellowish or 
 greenish, with much diminution of consistence, (Epist. lii. 2. ix. 20. 
 XXV. 10. lii. 23) ; and in the eighth delineation of Dr Hooper, 
 (p. 23.) In cases of this description, a sero-albuminous or semi- 
 purulent fluid is infiltrated into the cerebral substance, portions of 
 which are thus separated and detached from each other. The pro- 
 cess is allied to inflammation ; but it is an abortive form, in so far 
 as it fails to concentrate the action to a definite spot. 
 
 That it takes place in the inflammatory or disorganizing process 
 which succeeds mechanical injury is established by the necrological 
 appearances found in the brain in such circumstances. (Fantoni, 
 
280 
 
 GENERAL AND PATHOLOGICAL ANATOMY, 
 
 Morgagni, Louis, Le Dran, Schmucker, O’Halloran, Lease, Aber- 
 nethy, Thomson, Hennen, &c.) 
 
 When softening takes place in connection with serous effusion, 
 it is partly the concurrent effect of inflammation, partly of the ef- 
 fused fluid. This is well illustrated in those cases in which the 
 septum lucidum is attenuated, reticular, and perforated, or at length 
 ruptured. This form of destruction, accompanied with more or less 
 softening of the twain-band, (fornix ), is repeatedly mentioned by 
 Morgagni, and has been noticed by most authors who have described 
 cases of watery effusion within the cerebral cavities. I have seen it 
 in three sorts of cases ; first, in the true hydrocephalic effusion ; 
 secondly, in that which takes place in continued fever; and, thirdly, 
 in the course of chronic meningeal inflammation, with thickening 
 of the dura mater ^ after injury. 
 
 Not only does pulpy disorganization occur in this part of the 
 organ in continued fever, but it takes place in the substance of the 
 hemispheres. Of this pathological fact good instances are given by 
 Jemina, as they occurred in an epidemic at Montreal, in the terri- 
 tory of Turin, in 1783-84. In one the white matter of the hemi- 
 sphere {centrum ovale) was soft, pulpy, (fracidum,) of an ash-colour, 
 passing into yellow, and pasty ; in another it was soft and tawny- 
 coloured, like spoilt fruit ; and in a third the cerebellum was simi- 
 larly cbanged.* The same change was observed by Dr Black of 
 Newry in the cerebral hemisphere. (Transactions, Vol. II.) 
 
 When pulpy disorganization is connected with effusion of blood, 
 it has been supposed by M. Rostan to be the cause of that effusion. 
 That this supposition is inadmissible, I infer from the following 
 facts, which I have witnessed more than once. Lf, That the por- 
 tion of brain inclosing the clot is soft and pulpy all round, but 
 sound in proportion to the distance from the clot. 2fZ, That in 
 some instances in which partial recovery takes place, part of the 
 red clot has disappeared, and its place is supplied by serous fluid. 
 3rf, That in cases in which death takes place early, the pulpy dis- 
 organization is less complete than those in which it takes place at 
 a later period. In short, the extent of the disorganization is pro- 
 portionate to the interval which elapses between the effusion of the 
 blood and the period of death. 
 
 When pulpy disorganization accompanies tumours of the brain, 
 
 * De Febre, Anno 1783-84, Monteregali Epidemica, auctore Marco Antonio Jemina, 
 M. D. &c. Extat in Brera Sylloge, Vol. X. p. 218, 247. 
 
 4 
 
BKAIN. 
 
 281 
 
 that it is the effect of the presence of these tumours, and the chronic 
 congestion which they cause, is sufficiently obvious to render super- 
 fluous any minute induction. It is enough to say, that, though not 
 constant, it is a very general effect. (Morgagni, Meckel, Sandi- 
 fort, Powell, Yellowly, Plane, &c.) 
 
 The morbid change now described was supposed by Morgagni 
 and Lieutaud, to the former of whom it was well known, to be of 
 the nature of gangrene in other parts. This idea, which is also 
 that of Jemina* and of Baillie, has been revived by Dr Abercrom- 
 bie.f Though unwilling to dissent from the opinion of a pathologist 
 distinguished for accurate induction, it appears to me exceedingly 
 doubtful, for the reasons above stated, how far this analogy can be 
 demonstrated. 
 
 A part of the brain changed as above described is indeed disor- 
 ganized, may be said to be dead, and in this sense the change may 
 be termed gangrene of the brain. But when it is found in different 
 degrees, and in so many different morbid states of the brain, some 
 of them of long continuance, it is difficult to be satisfied that every 
 one of them must be viewed equally as gangrene. In the present 
 work I avoid as much as possible whatever is hypothetical or doubt- 
 ful. Upon this principle I conceive it improper to offer, on the 
 nature of this change, any further opinion than can be collected 
 from the circumstances above stated of its history and connections. 
 
 One form of softening, nevertheless, there is, which is more justly 
 entitled to the character of gangrene than the others. In a certain 
 proportion of cases the arteries of the brain become steatomatous 
 and opaque and inelastic, or osteo-steatomatous and more or less 
 rigid. Thus the Sylvian artery or its branches, the basilar artery 
 or its branches, the posterior and middle cerebral, and the cerehellic, 
 may all be affected with this transformation. In such circumstances, 
 it is observed that softening comes on very suddenly, and, apparently 
 without any preliminary inflammatory or hemorrhagic stage, pro- 
 ceeds instantly or speedily to complete brown or green-coloured 
 disorganization of a portion of the brain. The entire duration of 
 this form of softening seldom exceeds three or four days. It is 
 
 * “ Aliud etiam ex hoc morbo defuncti caput aperui ; et memini inter ceetera ob- 
 servata substantiae cerebri pulposae portionem magnitudine nucis’ avellanae, colore, et 
 consistentia vitiatam, ita ut esset coloris tane et mollior, non secus ac poma vel pyra 
 cum intus marcescere incipiunt. Annon gangraena hujus visceris ? De Febre, anriis 
 1783-84. MonteregaU Epidemica, auctore Marco Antonio Jemina, M. D. &c. Apud 
 Brera Syllogen, Tom. X. p. 247. 
 
 t Pathological and Practical Researches, p. ‘25. 
 
282 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 most common in the corpus striatum, or that and the optic thala- 
 mus^ and in the crura of the brain, 
 
 Tliis aifection resembles in some respects gangrene of a member 
 from disease and obstruction of its arteries. 
 
 Pulpy softening presents different characters in different regions 
 of the brain. On the convoluted surface in many brains there are 
 seen depressed orange-coloured spots about the size of a split pea, 
 and sometimes larger. These spots, which are slightly depressed 
 or hollow, are the remains of previous attacks of softening affecting 
 the convoluted surface. In some instances, especially where they 
 have succeeded injury or violence inflicted on the skull, they are 
 more extensive and deeper ; and, while the depressed surface is of 
 the orange-colour, it is also softened, pulpy, not presenting the 
 usual structure ; and there has been a manifest loss of substance. 
 
 Persons, in whose brains these appearances are observed, are 
 unsteady or tottering in gait, paralytic, and speak inarticulately and 
 thick. Their memory is feeble, sometimes greatly impaired ; their in- 
 tellect is sometimes disordered ; and in certain cases they are fatuous. 
 
 When softening affects the central portions of the brain, it con- 
 verts them into a soft, white, cream-like substance. The fornix is 
 either much softened or destroyed ; its posterior and lateral limbs 
 are softened ; the septum lucidum is perforated by many holes, or 
 completely broken down, and converted into one large aperture. 
 
 When softening affects either of the corpora striata or ojdic tha- 
 lami., it usually assumes the reddish-brown colour, showing that 
 there had been effusion of blood ; and sometimes the reddish-brown 
 is mixed with yellow, or greenish-yellow softening, or the wine-lee 
 softening passes into the greenish-coloured softening, showing that 
 blood had been effused, and that suppuration was proceeding. 
 
 Lastly, in either of the crura, softening is commonly what is 
 called hortensia-red, that is, of the deep crimson imitating the co- 
 lour of the flower of the hortensia ; in short, it is blood recently 
 effused, breaking down and mixed with the cerebral matter. The 
 reason of this is, that hemorrhagic softening in the crura is in ge- 
 neral speedily fatal, that is, it is followed by death within three or 
 four days, and the life of the individual is rarely prolonged to the 
 sixth day. 
 
 Hemorrhage within the substance of the protuberance is still 
 more rapidly fatal ; and in that body accordingly softening, pro- 
 perly so called, is almost never seen. 
 
 Lastly, it is proper to observe, that, in a large proportion of 
 
BRAIN. 
 
 283 
 
 cases, softening of the brain is preceded by the steatomatons or 
 osteo-steatomatous degeneration of the cerebral arteries, which are 
 either specked, or opaque, or rigid and brittle, and by an unsound 
 and irregular state of the circulation within these vessels. 
 
 The effects of this disease on the system are not very well dis- 
 tinguished. They may be divided into common and proper. The 
 common eflFects are dull pain, or sense of weight in the head, dull- 
 ness, impaired memory, frequent drowsiness, and occasional peevish- 
 ness at trifles, and paralytic affections of the face, head, and mem- 
 bers. The proper efiects are sense of formication, numbness, and 
 rigidity, or occasional involuntary contractions of the muscles of the 
 upper extremities, followed by delirium or fatuity, and a peculiar 
 odour about the head, not dissimilar to that of the mouse. In the 
 spinal chord it gives rise to numbness and rigid contraction of the 
 muscles of the lower extremities, and eventually palsy more or less 
 complete. 
 
 These symptoms, which are chiefly those given by the French 
 authors already mentioned, apply to the acute form of the disease.* * * * 
 In more chronic states it seems not to affect the muscular motions 
 considerably, but rather to induce fatuity and other forms of im- 
 paired intellect. This inference at least results from some of the 
 observations of Morgagni,* and those of Dr John Hunter.f This 
 is the state of brain which tabes place in cases of fatuity succeeding 
 coup-de-soleil. 
 
 3. Suppurative Inflammation, Apostema Cerebri. Collections of 
 purulent matter have been often found in the substance of the brain. 
 That these collections may take place spontaneously, as a conse- 
 quence of previous inflammation, is established by the testimony of 
 Morgagni,^ Lieutaud,§ Baader,|| Baillie,^' Powell,** * * §§ Brodie,ft Hoo- 
 per,JJ and Abercrombie. §§ Of the observations of these authors 
 the result is, that, though a collection of purulent fluid to a greater 
 
 * Epist. viii. .|- Apud Baillie, Morbid Anatomy. 
 
 + Epistola V. § Historia Anatomico-Medica. 
 
 11 Joseph! Baader, Observat. Med. Obs. 22. Extat apud Sandifort Thesaurum 
 Vol. III. p. 28. 
 
 ^ Engi-avings to illustrate the Morbid Anatomy, &c. X. Fasciculus, Plate vi. p. 221 
 
 ** Some Cases illustrative of the Pathology of the Brain. By Richard Powell, M. d! 
 Transactions of the College of Physicians, Vol. V. p. 198, Case 6 and 8. 
 
 tt Case of Abscess in the Brain. By B. C. Brodie, Esq., F. R. S., &c. Transactions 
 of a Society, Vol. III. p. 106. 
 
 it The hlorbid Anatomy of the Human Brain. Bv Robert Hooper, M. D. London 
 1826. Plate ix. p. 25. ' ’ 
 
 §§ Abercrombie, Cases 31, 32, 33, and 34. 
 
284 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 or less extent may take place in either of the hemispheres, and in 
 almost any part of these hemispheres, its situation is influenced 
 much by the kind of abscess. The ordinary abscess, consisting of 
 an irregular cavity containing purulent matter, sometimes mixed 
 with flakes of lymph, and rendering it curdly, may take place either 
 in the anterior lobe (J. Earle,* * * § Hooper,) or in the centre of the 
 hemisphere (Chizeau,f Baillie). An abscess, consisting of several 
 small communicating cavities, takes place in the anterior lobe, and 
 occasionally in the substance or in the vicinity of the striated nu- 
 cleus of Reil. The abscess consisting of a firm cyst, containing 
 purulent matter, is generally found in the centre of the hemispheres. 
 (Powell, case 8 ; Hooper, PI. 9, Fig. 3 ; Abercrombie, cases 16, 
 17.) 
 
 Collections of purulent matter have been found in the lobes of 
 the cerebellum by Bianchi,J (often Latinized Janus Plancus,) 
 Stoll,§ Weikard,|| and Abercrombie. IF In general they are con- 
 tained in a cyst more or less distinct, the walls of which are mem- 
 4)ranous and vascular. In the case of Weikard he represents the 
 whole white matter almost of the left lobe to be converted into a 
 millet-like, something foul, purulent matter, by which I understand 
 it to have been flocculent and lymphy. Suppuration, less distinctly 
 defined, and deposited generally in small irregular cavities, takes 
 place in the medulla oblongata^ especially in that part of the olivary 
 body which contains the corpus dentatum. Abercrombie mentions 
 a case at the junction of the protuberance (39.) In the chord itself, 
 though more rare, and generally confined to the surface, yet it has 
 been seen in the form of infiltration by Brera ;** and in a distinct 
 cavity in the cervical portion by Velpeau.ft 
 
 The origin of these collections is not well known. That they 
 are the result of a form of inflammation cannot be denied ; but that 
 it is not ordinary inflammation, is to be inferred from the 
 slow progress which they generally observe, and from the vari- 
 
 * Med. and Phys. Journal, Vol. XXTIl. p. 89. 
 
 -]- Recueil Periodique, No. xxxiv. 
 
 if Giovan. Bianchi Storia d’un Apostema nel lobo destro del Cerebello. Rimini, 
 1751. And Jani Planci Storia, d’un Apostema nel Cerebello. Rimini, 1752. 
 
 § Maximil. Stoll Rationis Medendi, Pars i. 178, et iii. 159. 
 
 II Vermischte Scbriften von M. A. Weikard fiirstl. Fuldisch Leibartz. Frankfort 
 am Main, 1782. Viertes St. p. 74. 
 
 K Pathological and Practical Researches, case iii. and xl. 
 
 ** Cenni sulla Rachitide. 
 
 TT Revue Medical, 1826. 
 
BRALV. 
 
 285 
 
 able effects to which they give rise. They are said in general to 
 be connected with the strumous diathesis ; and they are most com- 
 monly found in subjects who present the usual marks of this dia- 
 thesis. This, however, is only expressing, in different terms, an 
 obscure fact, the real cause of which is quite unknown. The en- 
 cysted abscess, especially that such as is delineated by Dr Hooper, 
 is of the kind called by old pathologists abscess by congestion^ or 
 cold abscess. 
 
 One form of suppuration of the brain I think there is strong rea- 
 son to believe depends on the presence of previous disease, inflamma- 
 tory, suppurative, or gangrenous, in the lungs, and probably in other 
 organs. This is when suppuration takes place in the brain, either 
 in one abscess, or diffusely, or in the sinuses of the brain after sup- 
 puration or gangrene of the lungs. This connection was observed 
 in the two following cases. 
 
 In the summer of 1836, I was requested to see a child of about 
 two years, labouring under apparent affection of the brain. Symp- 
 toms of this I indeed observed in the heat of the head, the restless- 
 ness, the spasmodic movements of the eyes, a little enlargement of 
 the head, constant tossing backwards and to each side, the uneasi- 
 ness of the stomach, and the insensible state of the intestinal tube. 
 But besides these symptoms, the child was greatly emaciated, 
 coughed much, and occasionally expectorated. There was much 
 general feverishness. On examining the chest, I found consider- 
 able cavernous destruction of the upper lobe of the right lung, with 
 some flattening and depression of the ribs. Two days afterwards, 
 death took place, I found the upper lobe and part of the middle 
 lobe of the right lung hollowed into a rugged cavernous abscess, 
 with irregular cavities, and walls covered with a little purulent 
 matter, emitting an offensive odour. In the brain the convolutions 
 were much flattened, indeed their eminences were almost effaced ; a 
 little turbid sero-purulent fluid was contained within the ventricles ; 
 the longitudinal sinus, the torcular, the lateral sinuses, and the small 
 sinuses at the base were filled with blood half-coagulated, and con- 
 taining lymph and purulent matter ; and even the large veins of 
 the pia mater opening into these sinuses contained half-clotted 
 blood and purulent matter. 
 
 It appears to me nearly certain, that the lymph and purulent 
 matter were conveyed by the veins of the lungs into the circulation, 
 and thence into the venous canals of the brain. 
 
286 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 I have elsewhere published in detail the circumstances of a case 
 of abscess in the right hemisphere of the brain, immediately on the 
 outsiile of the ventricles, in which this lesjon accompanied or fol- 
 lowed an attack of gangrene of the right lung. The matter was 
 here contained within a distinct cavity ; was opaque, consistent, 
 greenish-yellow, like well-formed purulent matter ; and the progress 
 of the symptoms had been carefully watched. The abscess was 
 about two inches and a-half long antero-posteriorly, and one inch 
 broad transversely,* and about one inch at its greatest vertical depth. 
 
 I am aware that in both cases it may be argued there was merely 
 coincidence in the two circumstances. And by some it may be even 
 said, that the evidence is as strong for the affection of the lungs 
 having followed that of the brain, as the affection of the brain fol- 
 lowing that of the lungs. All this may be correct. The main 
 point is to remark the fact of coincidence or simultaneous existence, 
 and the anatomico-pathological fact, that in other instances the 
 veins appear to act as the channels for conveying, through various 
 parts of the human body, lymph, purulent matter, and other sub- 
 stances presented to their orifices. 
 
 One variety of cerebral abscess, that connected with discharge 
 from the ear, originates in a more obvious manner. Purulent dis- 
 charge from the ear-hole is indeed generally connected with in- 
 flammation, subacute or chrouic, of the dura mater, or vascular 
 membrane, or both ; and in some instances the disease takes an 
 unfavourable turn in this manner, and speedily proceeds to a fatal 
 termination. (Morgagni, Powell, case 5 ; Itard, Duncan Junior, 
 Abercrombie.) In other circumstances, however, either with or 
 without this meningeal inflammation, a similar affection strikes sud- 
 denly a part of the cerebral substance, and, proceeding rapidly to 
 the suppurative stage, forms a distinct cerebral abscess. Cases of 
 this description were early noticed by Ballonius, Gontard, and 
 more recently by an anonymous writer ,f Mr Brodie,J Dr 0’Brien,§ 
 Mr Parkinson, |] and Dr Duncan Junior.^ 
 
 ’ Cases and Observations illustrative of the Nature of Gangrene of the Lungs. By 
 David Craigie, M. D., F. R. S. E., &c. Edin. Med. and Surgical Journal, Vol. LVl. 
 p. 1, case 1. 
 
 t Medical Commentaries, II. 180. The History of a Suppuration of the Brain, &c. 
 
 X Transactions of a Society, &c. Vol. III. p. 106. 
 
 § Trans, of King and Queen’s Coll. Dublin, Vol. II. p. 309. 
 
 II Medical Repository. London, 1817. 
 
 ^ Edinburgh Medical and Surgical Journal. Contributions to Morbid Anatomy, 
 No. ii. Vol. XVII. p. 331. By A. Duncan, Jun. M. D., &c. Cases 4th, 5th, and 6th. 
 
BRAIN. 
 
 287 
 
 By Bonetus this atFection of the cerebral substance was believed 
 to precede and to cause the discharge from the ear. Although this 
 idea was refuted by Morgagni, who regards the cerebral abscess 
 as consecutive to the ear-discharge, especially its suppression, it has 
 been revived by Mr Brodie, who seems to think the affection of the 
 brain coeval with that of the ear. I shall afterwards show that the 
 internal affection, to which Bonetus and Mr Brodie ascribe this 
 character, and which they think causes the ear-discharge, is disease 
 either of the tympanal cavity, or of the dura mater investing the 
 temporal bone. The inflammation which terminates in abscess of 
 the cerebral substance is the effect of inflammation of the mem- 
 branes, and in some instances of the discharge being suddenly 
 checked, and the chronic external inflammation being suddenly con- 
 verted into an acute internal disease. Is^, It is generally remarked 
 to succeed quickly the suppression or the disappearance of the ex- 
 ternal discharge. This, which was the opinion of Morgagni, is 
 proved by the cases of Mr Brodie, Mr Parkinson, Dr O’Brien, and 
 Dr Duncan. 2fZ, That it does not exist from the origin of the 
 discharge may be inferred when the patient is suddenly attacked 
 with acute deep pain in the head, intolerance of sound, and deli- 
 rium, quickly followed by insensibility and coma. Zd, It is impro- 
 bable that a disease, commencing with the acute symptoms to 
 which the formation of this abscess can generally be traced, should 
 be going on for years without deranging more considerably the 
 faculties of sensation, thought, and motion. 
 
 This disease is generally observed in young subjects of the habit 
 named strumous. So far as I have observed or read, though it 
 takes place in one of two modes, either as an extension of the ori- 
 ginal disease of the ear and cerebral membranes, or an alternating 
 and vicarious result, the latter is most frequently its genuine cha- 
 racter. The abscess is contained in an irregular cavity, surround- 
 ed by lymph and cerebral matter, which is very vascular. It is in 
 all cases attended with inflammation, thickening, and suppuration 
 of the membranes. The pia mater is highly vascular, and more 
 or less covered with lymph. The dura viater is thick, opaque, 
 dark-coloured, and detached from the bone. 
 
 The variety of abscess now mentioned is understood to depend 
 upon the operation of internal causes only. At least no external 
 cause can be recognized ; and if it were, it would be such as in 
 other subjects would perhaps be inadequate to the effect. There 
 
288 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 is, however, a class of purulent collections in the brain which in 
 general it is possible to trace to noechanical violence inflicted on 
 the head ; and it is remarkable bow long a period may elapse be- 
 tween tbe date of the injury, and that destruction of the organ 
 which renders the continuance of life impossible. 
 
 Pigray gives a case in which an abscess, the size of a nut, proved 
 fatal at the end of six months ;* * * § and Morand mentions one in which 
 a soldier, who had received a shot in Italy, after slight treatment 
 of the wound, proceeded thence to Paris ; and nine months elapsed 
 before suppuration and total destruction of the right lobe terminat- 
 ed life.f 
 
 In a case mentioned by Prochaska, the first foundation of the 
 disease appears to have been frequent beating on the head for years, 
 finally carried to intensity by a blow on the forehead, five months 
 after which death took place. | In a case by Sir E. Home, nearly 
 nineteen months elapsed between tbe receipt of tbe injury and the 
 fatal termination. § In one by Dr Denmark, the interval between 
 the supposed injury and the period of death was twelve months. || 
 Many similar cases are found in the writings of surgeons. IF The 
 result is, that a portion of brain more or less extensive is convert- 
 ed into purulent matter, contained in general in a membranous 
 cyst, more or less thick and vascular, according to the interval be- 
 tween tbe infliction of the injury and the time of examination. 
 
 Between suppuration of the brain, from internal and external 
 causes, a distinction has been drawn by Baillie, in the circum- 
 stance, that in the former it is generally in the substance, and in 
 the latter on the surface of the organ. This distinction does not 
 hold good in several respects, and requires modification. Is^, 
 Where a long interval elapses after the infliction of the injury, the 
 collection of purulent matter is almost invariably deep seated. 2c?, 
 In like manner, when the injury operates in the manner of counter- 
 stroke, the collection is also often within the substance of the or- 
 
 * Libre IV. chap. ix. 
 
 t Opuscules de Chirurgie, 1. c. p. 159. 
 
 $ Obs. Patholog. Section iv. apud Opera Minora, p. 304. 
 
 § Transactions of a Society, Vol. III. p. 94. 
 
 II Medico- Chirurgical Transactions, Vol. V. p. 24. 
 
 H See especially several cases of this kind in the writings of Loms, Le Dran, Rava- 
 ton ; and by Volaire, Journal de Med. Vol. XX. p. 503. Thilenius, Med. und Chir. 
 Bemerkungen. Walther, Obs. 33. Thulstrup Physicalks BibUothek. fiir Danmark 1 
 Band. April. Bailey in Med. and Phys. Journal, Vol. XXIII. p. 376. 
 
BRAIN. 
 
 289 
 
 gan. (Pigray, Quesnay, Petit, Chopart.*) For example, several 
 weeks or months after a blow on the upper or fore part of the head, 
 from which the patient never perfectly recovers, but is more or 
 less paralytic, perhaps occasionally lethargic, deaf, blind, or fatu- 
 ous, death takes place, and an abscess is found in the substance of 
 the hemispheres, in the corpus striatum, or even in one of the lobes 
 of the cerebellum. 3c?, In some instances of suppuration after in- 
 jury, the collection does not take place at the part at which the 
 blow struck the skull, but either in the line of the force passing 
 through the brain, or in some of the lines into which this force 
 may be resolved. 4?7 j, It is chiefly when the force has been direct- 
 ly expended on the part, i. e. when the hone has been immediately 
 broken, and its membranes injured, that suppuration takes place 
 on the surface of the brain. This suppuration is then the result 
 rather of the affection of the membranes, especially of the pia 
 mater, than of the cerebral substance itself.f 
 
 Suppuration may take place in any part of the brain ; but it is 
 most frequent in the hemispheres. The effects which it produces 
 vary according to the situation and the extent of the purulent col- 
 lection. They are much the same as from the presence of blood, 
 tumours, or other unusual substances. 
 
 In the circumstances now mentioned, purulent collections are 
 the result of primary inflammation, spontaneous or traumatic. I 
 must further repeat explicitly what has been already said, that they 
 take place in a secondary manner in fever. Collections of purulent 
 matter within the brain after fever were first distinctly found by 
 Pringle, afterwards by Borsieri and Eisfeld,| and more recently 
 by Jackson and Mills. These are doubtless the effects of inflam- 
 mation, which, however, is, in this case, a secondary and adventitious 
 circumstance in the progress of the disease. 
 
 These, nevertheless, and similar phenomena, have been conceived 
 to afford evidence that fever consists in inflammation of the brain. 
 It is unnecessary to examine the origin of this theory ; the first 
 traces of which may be found in the writings of Willis, Werlhof, 
 
 * Memoire sur les centre coups dans les lesions de la tete. Par M. Chopart. Me- 
 moires pour le Prix. de la Academie Royale de Chirurgie, Tom. XI. 12mo. 
 
 Traite des Plaies de Tete, et de I’Encejshalite, principalement de ceUe qui leur est 
 consecutive, &c. Par J. P. Gama, OfRcier de la Legion d’Honneur, Chirurgien en 
 Chef, &c. Paris. 1830. 8vo. 
 
 $ J. F. A. Eisfeld Meletemata, Qufedam ad Historiam Naturalem Typhi Acuti 
 Lipsiae aestivo tempore, anni 1799, grassantes pertinentia. § xviii. p. 72, &c. apud 
 Brera, Vol. VI. p. 1. 
 
 T 
 
290 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Torti, Donald Monro, and a paper of M. Marteau de Grand villiers.* 
 Riel appears to have entertained the idea, that cerebral inflamma- 
 tion, though not the cause of the symptoms, takes place in fever. 
 The first attempt, however, to connect the phenomena of fever with 
 those of inflammation, was made by Ploucquet of Tubingen in 
 1800,t and this was more expressly undertaken by Costantin of 
 Leipzic in the same year, in consequence of an epidemic typhus 
 which had prevailed at Leipzic in 1799. According to the latter 
 author. Encephalitis^ by which he understands that form of fever 
 which happens to the cerebral and cerebellic vessels and membranes, 
 comprehends three genera, Synocha, Typhus, and Paralysis ; — the 
 first distinguished by increased irritability, with normal or increas- 
 ed reaction ; the second by increased irritability, but impaired reac- 
 tion ; and the third by irritability and reaction being equally im- 
 paired, inert, and more or less abolished. f 
 
 These ideas, though carried to an extreme, derive some support 
 from the phenomena of fever, and the morbid changes left in the 
 brain. They were afterwards more fully developed by Clutterbuck § 
 and Mills| in this country, and by MarcusIF and others in Germany. 
 
 The merits of this theory I have already attempted partially to 
 appreciate. Though autoptic examinations prove that the capilla- 
 ries of the brain, in common with those of other organs, are much 
 overloaded with slowly moving blood, this state differs from inflam- 
 mation in several respects. Suppuration, especially, is not a con- 
 stant, or is rather an exceedingly rare occurrence, and is to be re- 
 garded as adventitious, or depending upon accidental peculiarities 
 and idiosyncrasies, and not essential. The overloaded state of the 
 capillaries, though taking place in those of the organ itself, is never- 
 theless more remarkable, according to my observation, in those of 
 the proper cerebral membrane. The principal character of that 
 blood is, as I have above shown, that it is non-arterialized, and 
 consequently poisonous. 
 
 * Description des Fievres Malignes avec une Inflammation sourde du Cerveau, &c. 
 &c. Par AI Marteau de Grandvilliers, Medecin de I’Hopital a Aumale, Journal de 
 Medecine, Tome VIII. 1758. p. 275. 
 
 t G. F. Ploucquet Expositio Nosologica Typhi. Tubingen, 1800. Tubing. Anz. 
 1800. 
 
 J Caroli Fred. Costantin, M. D. Dissertatio de Encephalitide. Lips. 1800. Ext. in 
 Brera Sylloge, Vol. VI. p. 72. 
 
 § An Inquiry into the Seat and Nature of Fever, &c. By Henry Clutterbuck, M.D. 
 &c. Lond. 1807, and second edition, London, 1825. 
 
 II On the Utility of Blood-letting in Fever. By Thomas Mills. Dublin, 1819. 
 
 11 Ephemeriden der Heilkunde. Band I. Heft. 1. 
 
BRAIN. 
 
 ^291 
 
 5. Ulceration I Erosion. From the various forms of pulpy de- 
 struction and abscess, the transition to ulceration is easy. By this is 
 understood destruction of part of either of the surfaces of the brain, 
 so as to present a hollow or depressed surface, rough, irregular, and 
 covered partially either with bloody or albuminous exudation. In 
 the former case its claim to the character of a genuine ulcer may 
 be doubtful, since it may be view'ed as the residue of a partial effu- 
 sion of blood. It is possible that this may have been the origin of 
 the case of erosion of the corpus striatum described by IMorgagni, 
 in which that body is said to have been entirely detached from the 
 brain ; * and I think it is next to certain this was the cause of the 
 ulcerous cavity, f which he shortly after states was found in the base 
 of the left ventricle of another case. This is almost admitted by 
 Morgagni himself, who regards these ulcers as ruptured cavities or 
 cells, originally formed by effused serum. (Ibid, art 8.) 
 
 So far as accurate observation hitherto goes, the genuine ulcer 
 is found chiefly at the convoluted surface of the brain ; (Ridley, p. 
 212; Powell, case 6;) or the foliated surface of the cerebellum 
 (Haller, Vol. iv. p. 351,) and is always connected with an unsound 
 state of the proper or vascular membrane. Of this sort of ulcer, 
 Stoll found an instance on the cerebellum of a young man of twen- 
 ty-six, accompanied with redness, thickening, and erosion of the 
 pia mater. | Two cases of the same nature are recorded by Scou- 
 tetten. In one, the lower part of the right anterior lobe presented 
 a hard, dry, irregular surface, thirteen lines long and seven broad, 
 with irregular indented edges, with the contiguous cerebral sub- 
 stance sound. In the other, the extremity of the posterior lobe pre- 
 sented two small ulcerated patches, one oval, six lines long, and 
 covered with deep gray pulpy matter; the other a linear depres- 
 sion, — both with wine-lee colour of the adjacent brain. In both 
 cases, the investing proper membrane was red, injected, and some- 
 what eroded. § From these facts, it results that ulceration of the 
 brain is an effect of circumscribed inflammation of the pia mater. 
 
 The instances of erosion, or ulceration from the penetration of 
 foreign bodies, mentioned by Morgagni and various surgical authors, 
 are rather examples of suppurative destruction. 
 
 6. Encephalamia. Hemorrhayia Cerebri, Hoffmann. Hemor- 
 rhage. Apoplexia Sanguinea, Sauvages, Cullen, &c. Apoplexie Ce- 
 
 * Epist. xi. 2. -f Ibid. 4. 
 
 i Ratio Medendi, pars tertia, p. 1 22. 
 
 § Memoire sur quelques cas rares d’Anatomie Pathologique du Cerveau &c. Par 
 Scoutetten, D. M. P. &c. Archives Generates, Tome VII. 31. 
 
292 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 rehrale of Serres. One of the great uses of the proper or vascular 
 membrane {pia mater) is to sustain and convey, as it were, the minute 
 arteries into the substance of the brain. No artery, however mi- 
 nute, enters this organ without previously passing through the pia 
 mater ; and if the carotid and vertebral arteries he injected, the ce- 
 rebral matter may be washed away entirely ; while all the vessels, 
 by which it was traversed, are seen issuing from the attached surface 
 and numerous processes of this membrane. The vessels thus de- 
 monstrated consist of minute arteries and veins, through which, in 
 the sound or normal state, the blood moves uniformly and easily 
 without undergoing any permanent retardation. Dissection, how- 
 ever, shows, that from various causes, either the whole of these ves- 
 sels, or a certain cluster or set of them, may become inordinately 
 distended with blood ; while others, which, in consequence of con- 
 veying colourless fluid previously, eluded observation, now becom- 
 ing injected with red blood, are rendered visible. The existence 
 of this state is proved by cutting into thin slices the brains of per- 
 sons cut off in this condition, when numerous blood-drops follow 
 each incision, and each part is penetrated by a much greater number 
 of vessels than natural.* The exquisite or most perfect degree of 
 this state is when the blood-drops enlarge immediately after inci- 
 sion, — a circumstance from which a very inordinate quantity of fluid 
 blood in the cerebral vessels is indicated, f 
 
 This state of the cerebral vessels is similar to that of inflamma- 
 tion. The patient is highly sensible to transitions of heat and cold ; 
 the skin is hot and dry ; the tongue foul ; the stomach disordered, 
 and the urine high-coloured and sedimentous. The pulse is full 
 and strong, sometimes hard, but not frequent. The local complaints 
 are dull pain and weight of the head, occasional giddiness, indis- 
 tinctness of vision, or dazzling of the eyes, and more or less aboli- 
 tion of memory. When blood is drawn, I have found it present a 
 thick, tough, huffy coat ; an observation in which I And I am anti- 
 cipated by Stoll j; and Sir Gilbert Blane. 
 
 When the above phenomena have continued for a few hours, 
 sometimes a day or two, according to circumstances, the individual 
 falls down destitute of sense and motion, and continues so for a 
 short time. After a little, recollection gradually returns, and with 
 it sensation and the power of moving the limbs, though not with 
 such freedom as before. A sense of tingling and numbness may 
 
 * Morgagni passim, especially iii. and iv. 
 
 ■f Morgagni epist. x. 17 and 18. 
 
 $ Ratio Med. Pars v. p. 31. Vienna, 1789. 
 
BRAIN. 
 
 293 
 
 remain in an arm or leg for some time. This is the simplest and 
 mildest form of the apoplectic seizure. {Cataphora.) 
 
 It has been thought that this could not happen unless blood is ef- 
 fused ; but various instances have occurred to competent observers 
 in which the cerebral vessels are loaded only, and in which effusion 
 had not yet taken place. It may further be inferred, that the in- 
 stances in which persons recover from complete apoplectic seizure 
 without suffering palsy depend upon vascular injection only. That 
 fatal cases even may result from mere accumulation, is admitted 
 by Morgagni,* afterwards by Baillie,f without being aware that the 
 observation had been made, and by Rochoux, who thinks, however, 
 that it is notuniform.J I observe, nevertheless, that M. Rochoux 
 forgets that the cases in which it occurs being less frequently fatal, 
 are more rarely the subject of inspection. 
 
 According to M. Serres, indeed, cases of apoplectic seizure 
 without palsy depend on injection of the membranes exclusively. § 
 This point shall be afterwards considered when speaking of the 
 cerebral membranes. In other respects, however, the researches of 
 this physician tend to establish the general inference, that extrava- 
 sation is not necessary to apoplexy. \st. From experiments made 
 on living animals,! from the phenomena of effusions of blood either 
 spontaneously, or from wounds and injuries of the head, it appears 
 that a considerable quantity of blood or other fluid may be effused 
 in various parts of the brain without causing apoplectic symptoms. 
 (Wepfer, Valsalva, and Serres). 2c?, From various cases it ap- 
 pears that the apoplectic symptoms connected with extravasation 
 disappear, while the extra vasa ted blood remains. (Serres’s cases, 
 7, 8, 7, 10, 11, 12, and others.) 3<?, It results from cases record- 
 ed not only by Morgagni, Baillie, and Rochoux, as above mention- 
 ed, but by the physicians of Breslau,1[ by Quarin, by Stark,** and 
 
 * Epist. iii. 25 and 26. 
 
 + “ The milder forms of apoplexy depend upon a distension of some of the vessels 
 of the brain from undue accumulation of blood in them. I have known, however, one 
 instance of fatal apoplexy, where many of the blood-vessels were found, upon exami- 
 nation after death, to be much distended with blood ; but no blood had been extrava- 
 sated in any part of the brain.” — Lectures and Observations on Medicine. London, 
 1825, p. 167. 
 
 J Recherches sur TApoplexie. Par J. A. Rochoux. Paris, 1814. 
 
 § Nouvelle Division des Apoplexies ; par M. Serres ; Chevalier, &c. Annuaire 
 Medico-Chirurgicale des Hopitaux et Hospices Civiles de Paris. A Paris, 1817. 4to, 
 p. 246, 277. 
 
 II Annuaire Medico-Chirurgicale, 260, 261. 
 
 11 Historia Morborum Vratislaviensium. 
 
 ** Clinical and Anatomical Observations, Part iv. § 4, p. 73. This appears, how- 
 
294 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 more recently, I may add, by Dr Abercrombie, that complete 
 symptoms of apoplexy may result from mere general injection of 
 the cerebral vessels. The satne phenomenon appears to have been 
 witnessed by Cheselden. (Book iii. chap. 14, p. 224.) If, on this 
 point, my own observation be entitled to any weight, I may add, 
 that in 1817 I had occasion to examine the body of a young wo- 
 man who died with all the symptoms of well-marked apoplexy ; and 
 though every part of the brain was cut into minute portions with 
 the iitraost care, no effusion of red blood could be recognized. The 
 only abnormal appearance was some injection of the vessels going 
 to the annular protuberance and medulla oblongata.* Though 
 
 in several cases of persons cut off with well-marked apoplectic 
 symptoms, I have found extravasated blood, it bore no proportion 
 to the severity of the disease. Instead of being in the shape of 
 clots in distinct cavities, it consisted simply of long linear streaks 
 of blood stretching through parts of the brain, sometimes in the 
 neighbourhood of blood-vessels. In sucb cases, however, the blood- 
 vessels were much injected, especially in the vicinity of the mem- 
 branes. In other instances capillary injection is observed in the 
 corpora striata or substance of the hemispheres. This is the capil- 
 lary apoplexy of M. Cruveilhier. 
 
 Upon the whole, I conceive it legitimate to infer, that the essen- 
 tial anatomical character of apoplexy is injection of the vessels of 
 the brain more or less general. This may terminate in one of two 
 modes, both of which are accidental and accessory. The first is ef- 
 fusion of serous fluid ; the second is effusion of red blood. 
 
 Serous fluid exhaled from the capillaries has been supposed to 
 constitute a peculiar form of apoplexy entirely distinct from that 
 termed sanguine, and depending on extravasation of blood. In. the 
 writings of raorgagni and others are cases in which the effusion of 
 serous fluid was associated with distinct and general- vascular injec- 
 tion. Cases of this description are referred by Stoll to the head of 
 sanguine apoplexy, in which the pathological character is injection 
 or accumulation, which is at once the cause of the serous effusion 
 and of the apoplectic symptoras.f It was afterwards demonstrated 
 
 ever, to have been a case depending on vascular injection of the medulla oblongata axii 
 spinal chord. 
 
 * Case of Ann Dinwiddle. Clinical Ward. 
 
 -|- “ In apoplecticorum secto cerebro frequenter leguntur vasa cerebri sanguine tur- 
 gida, et serum multum effusum. Hujus generis apoplexi® plerumque serosm audiunt. 
 Verius sanguinece appellarentur ; accumulatus enim intra caput sanguis, et seri effusi, 
 et apoplexia; causa est ; serum ipsum effrisum ad concatisas pevtinet scrim accedentes. 
 
BRAIN. 
 
 295 
 
 by Portal, that serous infiltration and eflFusion invariably arise from 
 the same state of the vessels as hemorrhage;* and this inference 
 has since been confirmed by the observations of Dr Cheyne, Dr 
 Abercrombie, of M. Serres, and others. In short, if from any 
 cause the circulation within the head becomes unusually slow, and 
 the vessels of the brain become inordinately distended, either red 
 blood or serous fluid is poured out from the extremities of the ar- 
 teries. The latter process, if we admit the testimony of Chesel- 
 den,| Morgagni,! and Willan,§ takes place in the slow and gra- 
 dual drowsiness and stupefaction which distinguish the form of the 
 disease termed lethargy ; {veterniis.y^ The cause of the symptoms, 
 however, is not the effusion, as Willan imagined, but the general 
 vascular distension and injection from which the effusion arises. 
 
 Hemorrhage, nevertheless, takes place in a considerable propor- 
 tion of cases. Howship says in nine of ten ; but this is evidently a 
 general assertion founded on no accurate elements. From the dis- 
 tended vessels blood escapes, though whether by exhalation or by 
 actual rupture is not agreed ; and, forcing its way through the 
 cerebral substance, breaks it down, and forms a sort of hollow or 
 cavern, in which it coagulates. If the quantity be considerable ; 
 if it be effused suddenly, and in certain parts of the brain ; (optic 
 thalamus, annular protuberance, brain-limbs, and medulla oblon- 
 gata ,-) if the cerebral injection continues, notwithstanding the dis- 
 charge and the use of remedies, complete coma very soon termi- 
 nates in death ; and on dissection more or less blood is found in 
 some part of the substance of the brain, and the vessels are much, 
 sometimes exceedingly injected with fluid blood. 
 
 When the effusion is not copious, or dependent upon very ge- 
 neral injection of the cerebral vessels, nor take place suddenly, or 
 in a vital part of the brain ; or if the injection is thereby, or bv 
 other means moderated ; then further changes^ take place, and con- 
 tinue until the natural structure of the organ is so much altered 
 that life can no longer be continued. The effused blood, both 
 
 qumve morbiim, ipmm non produxere, attamen productum augcnV' Rationis Medendi, 
 Pars i. p. 138. Lugduni Bat. 1780. 
 
 * Sur la Nature et le Traitement de Plusieurs Maladies, &c. Tome I. p. 280 ; et 
 Sur I’Apoplexie, et Sur les Moyens de la prevenir. Paris, 1811. Tome II. p. 216. 
 
 •]- The Anatomy of the Human Body. Book iii. chap. 14. 
 
 J Epist. vi. 
 
 § Reports on the Diseases in London. By Robert Willan, M. D. &c. 1799, p. 338, 
 8vo edit. 1821. 
 
 11 Thom« Willis, De Anima Brutorum, Pars Pathol. Cap. 14. 
 
296 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 when fluid, and especially after coagulation, acts as a foreign body, 
 — breaks down, softens, and disorganizes the part with which it is 
 in contact. After some time the clot begins to change, assumes a 
 brown or brownish-black colour, and is separated into fragments 
 floating in a wine-lee fluid. The further dissolution of these forms 
 a homogeneous chocolate -coloured matter, which is eventually re- 
 moved more or less perfectly ;* while the part, which the extrava- 
 sation converted into a hollow, is filled with serous fluid, and sof- 
 tened or pulpy cerebral matter. In some cases of complete re- 
 covery this is gradually converted, by a slow process of adhesive 
 inflammation, into a membranous substance, harder than the sur- 
 rounding brain, which, however, is generally softer than sound ce- 
 rebral matter. (Lerminier, cases 1, 2.) In this manner are formed 
 the cavernous sacs described by Wepferand Morgagni, (Epist. hi. 
 7, 8, 9, lx. 2, 6,) and the cavities described by Baillie, (450, 455,) 
 Wilson, Abernethy,t and others. 
 
 The contiguous enclosing cerebral matter also undergoes pecu- 
 liar changes, which vary with the interval between extravasation 
 and death. The portion in immediate contact with the clot is ge- 
 nerally dark red, wine-lee colour, or, at later periods, of a choco- 
 late brown, and rather pulpy. The portion exterior to this is 
 paler, and of an orange colour, but generally much penetrated by 
 distended vessels. Exterior to this again may be in general dis- 
 tinguished a layer of bluish-white or bluish-yellow matter, gradu- 
 ally terminating in sound brain, but all more or less traversed by 
 blood-vessels. In other cases, in which a longer period elapses 
 between extravasation and death, the portion of brain enclosing the 
 clot is pulpy, of a dun-red or orange-colour, passing to yellow, and 
 terminating gradually in brain of natural colour and consistence. 
 In both cases minute shreds of cerebral matter and filamentous 
 threads may he traced in the pulpy matter and in the bloody clot, 
 either recent or dissolved into the chocolate-coloured fluid. By 
 some these filamentous threads are supposed to be the fine cellular 
 tissue of the brain ; but I think it impossible to doubt that they are 
 
 * “ The appearance of the effused blood differs according to the duration of its ef- 
 fusion. Wlien death ensues quickly, at the end of three or four days, for example, it 
 is in the form of soft blackish clots. After a month or six weeks it becomes firmer, 
 assumes a deep brown colour, and resembles the blood of aneurismal tumo'ii's. At a 
 more remote period it becomes still more compact and of a pale red colour, bordering 
 on ochreous yellow. Lastly, it is entirely absorbed.” — Rochoux, p. 86. 
 
 Surgical Works, Vol. II. On Injuries of the Head, pp. 18, 19, and 20. London, 
 
 1811. 
 
BRAIN. 
 
 297 
 
 minute capillary vessels. This general description I have derived 
 partly from the description of Rochoux,* but especially from those 
 ofLerminier and Serres,f and partly from personal observation. 
 
 The change in the structnre and consistence of the brain sur- 
 rounding the clot forms one variety of softening {I'amollissement,') 
 or pulpy disorganization ; and notwithstanding the opinion expressed 
 by Pariset, Recamier, Rochoux, J and others, that it is the cause of 
 the effusion, it is invariably the effect either of this or of the preli- 
 minary injection. This is established not only by the facts already 
 mentioned, but by the cases of Morgagni, of M. Dan de la V au- 
 terie,§ and especially by those ofLerminier and Serres.|| 
 
 Vascular injection, with or without bloody effusion, may take 
 place in any part of the brain ; but certain parts are much more 
 commonly the seat of this discharge than others. Thus Morgagni, 
 treading in the steps of Bonetus, justly remarked, that either bloody 
 effusion, or the caverns formed by it, are found almost always in 
 the striated bodies, or in the optic thalami^ or in both, while the 
 anterior part of the hemisphere was very rarely, and the posterior 
 part almost never affected.lf The general accuracy of this conclu- 
 sion is in some degree confirmed by modern observation, which, in 
 a majority of cases, has found the striated and optic bodies diseased. 
 Rochoux particularly shows, that of forty-one cases of bloody effu- 
 sion terminating fatally, twenty-four were found in the corpus stria- 
 tum, two in the optic thalamus, one in the corpus striatum and optic 
 thalamus, and one beneath the corpus striatum; while only thirteen, 
 not more than one-half, were found in other parts of the brain. 
 The reason of this is to be found in the anatomical relations of this 
 part of the brain. Near the beginning of the fissure of Sylvius is 
 situate the white perforated spot of Vicq-d’Azyr (“substance blanche 
 que j’appelle perforee”) Through these orifices the Sylvian or 
 middle artery of the brain, w'hich lies in the fissure, transmits a 
 great number of arteries of various sizes into the substance of the 
 brain, and through the cerebral nucleus {corpus striatum,') which 
 lies immediately over this perforated spot. This arrangement ren- 
 ders the striated body, or rather the striated nucleus, the most 
 vascular part of the whole organ, and the most liable, when the 
 cerebral vascular system is overloaded, to effusion of blood. 
 
 * Recherches. Cases, passim. Article pp. 87, 88. Section ii. art. 2. 
 
 t Annuaire JMedico-Chirurgicale. Lerminier, Cases 4, .5, 7, 8. Serres, various cases 
 in § 12. Apoplexie Cerehrale. 
 
 i Recherches, &c. pp. 88 and 89. § These soutenue, &c. 
 
 II Annuaire, loco citato. ^ Epistola iii. 18. 
 
298 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 This doctrine is not, however, altogether free from objection. 
 By M. Serres especially it has been said that hemorrhagic cavities 
 are formed in the fore part, the middle, or the posterior part, of the 
 hemispheres, without affecting the thalami or striated bodies, much 
 more frequently than is represented by Bonetus, Morgagni, and 
 Rochoux. I find from examining the cases of Howship, Lerminier, 
 Serres, Tacheron, and others, that this is not entirely without foun- 
 dation. Of 6 cases of cerebral hemorrhage given by Lerminier, 
 3 are in the hemispheres, 1 in the right optic thalamus, one in the 
 left optic thalamus, and 1 in the left corpus striatum* Of 7 cases 
 of cerebral hemorrhage given by Serres, two are in the centre or 
 posterior part of the left hemisphere, 1 in both hemispheres, 1 in 
 the left hemisphere and in the mesolobe, and 3 in the annular pro- 
 tuberance.! Among 19 cases of cerebral hemorrhage or its effects, 
 recorded by Tacheron, 5 were in the right hemisphere, and 4 in 
 the left, 2 were in the posterior part of the right hemisphere, 2 in 
 the substance of the optic eminences, 2 in that of the striated bo- 
 dies, 1 in the mesolobe and adjoining part of the left ventricle, I in 
 the annular protuberance, 1 in the optic eminence and striated body 
 at once ; and in one, in which the last extravasation took place in 
 the right optic thalamus, one cyst was found in the neighbourhood 
 of the cylindroid eminence, another in the centre of the left optic 
 thalamus, and a third in the annular protuberance.! 
 
 Upon the whole, we are in possession of few very accurate ele- 
 ments to determine this question. From the authentic cases, how- 
 ever, which I have perused, for it is in vain to di’aw conclusions 
 from individual observation only, I think there are grounds to infer, 
 that, next to the striated nucleus, the hemispheres are the most 
 frequent seat of cerebral injection and hemorrhage. It is worthy 
 of remark, that the extravasation, when it takes place, does so 
 chiefly on the outer side of the lateral ventricle, generally towards 
 its posterior end, and in that portion of brain which forms the ex- 
 ternal-lateral boundary of the optic thalamus, separated from the 
 ventricle by a thin plate. Into the ventricle it rarely takes place 
 primarily ; and when blood is found there, it is the result either of 
 bloody extravasation in the hemisphere breaking down the floor,§ 
 
 ■* Annuaire Medico-Chimrgicale, p. 213, et ensuite. 
 
 t Ibid. p. 324, §. xi. et ensuite. 
 
 ^ Recherches Anatomico-Pathologiques, &c. par C. F. Tacheron, Doct. a Medecine, 
 &c. Tome Illme. Paris, 1823. Ordre 4trieme, 2ieme genre. Case 31st. 
 
 § Howship, Case 15, 19. 
 
BRAIN. 
 
 299 
 
 the wall, or the ceiling of the ventricle, or, as shall be afterwards 
 shown, it issues from the choroid plexus. The same remark applies 
 to blood on the surface of the brain. 
 
 In this process the hemorrhage produces extensive laceration of 
 the substance of the hemisphere attacked ; and if the hlood effused 
 be copious, and the laceration of the hemisphere great, the lesion 
 proves speedily fatal. This fact I have verified by several cases 
 carefully observed and examined after death ; and, in order to il- 
 lustrate more clearly the nature of the lesion and its attendant 
 effects, I shall mention shortly the condition of the brain in one 
 extreme case. A quantity of dark-coloured blood, spread over the 
 surface of the brain, was found on the anterior, superior, and lateral 
 regions of the right hemisphere. This was thin at the posterior and 
 superior part of the hemisphere, that is, about the thickness of a 
 half-crown piece, diminishing to that of a shilling. At the anterior 
 lohes it became much thicker, and at their lower surface and the 
 anterior end of the mesolobe {corpus callosum), it was at least one- 
 fourth of an inch thick. It was spread, much to the same extent 
 and of the same dimensions, over the olfactory nerves and inferior 
 surface of the anterior lohes, over the optic chiasma, pisiform emi- 
 nences, and most of the whole lower surface of the middle lobe. A 
 lacerated opening had taken place at the inner margin of the right 
 hemisphere where it is joined to the mesolobe, and by this, which 
 had forcibly torn up the mesolobe from its connections with the 
 hemisphere, the blood had escaped, and gradually spread itself over 
 the lower, anterior, and superior surfaces of the hemisphere. 
 
 It was then found that a large lacerated cavity had been formed 
 in the substance of the right hemisphere, about three inches long, 
 tapering at each end, but about two inches or one inch and a half in 
 diameter at middle ; that from this the blood had escaped by one la- 
 cerated opening anteriorly to the surface of the brain ; and by a 
 lateral one into the ventricle, which was also filled with blood. 
 
 Cases of the kind now specified are of extreme violence, and not 
 only fatal, but very speedily fatal. It has been said that apoplexy, 
 that is, cerebral hemorrhage, is not a speedily fatal disease ; and, 
 under certain restrictions, this is correct. It is indeed not instanta- 
 neously fatal, like the bursting of an aortic aneurism, or the sudden 
 death following on disease of the valves of the aorta or the heart. 
 According to Rochoux, the shortest time that, in the most rapid 
 cases, elapses between the first appearance of the symptoms and the 
 
300 
 
 GENEEAL AND PATHOLOGICAL ANATOMY. 
 
 occurrence of the fatal termination, is sixteen hours. I am satisfied, 
 nevertheless, from several facts, as well authenticated as these can, 
 under the circumstances, be, that, in the cases now adverted to, 
 the interval between the first attack and the cessation of life is 
 much shorter. In one case, in which my attention was particu- 
 larly directed to this point, the interval between the first symptoms 
 and the extinction of life might be six hours, but did not exceed 
 eight hours. In other cases there is good reason to believe that 
 the interval was not more than five hours. 
 
 The cause of this speedy extinction of life, compared with other 
 cases, is to be found in two circumstances ; the large quantity 
 of blood effused, and consequently compressing a large extent of 
 the brain and suspending its functions ; and, 2ff, the great injury 
 inflicted on the brain by laceration of its substance, disorganization 
 of its structure, and consequent disorder and suspension of its func- 
 tions. The amount of effused blood, in short, and the great extent 
 of brain injured, place this lesion as to fatality and speedy influence 
 on the same footing with effusion of blood into the substance of the 
 annular protuberance. 
 
 Next to the hemispheres in hemorrhagic tendency may be placed 
 the protuberance, the limbs of the brain, the medulla oblongata, and 
 the cerebellum, in the order now enumerated. 
 
 When hemorrhage takes place into the annular protuberance, 
 the blood is generally deposited in layers in the interstices between 
 the transverse fibres. In one fatal case I observed this so distinctly, 
 that the blood and cerebral matter formed alternating layers. 
 When it is very abundant, however, the transverse fibres are broken 
 through, and the effused blood is contained in irregular cavities. 
 (Cheyne, case 9, Serres, Tacheron.) The proximity of the protu- 
 berance to the large transverse branches of the basilar artery affords 
 some reason for the readiness with which it may be affected with 
 vascular injection and hemorrhage. 
 
 Of effusion into the cerebellum little is accurately known. Mor- 
 gagni records two cases, one in both hemispheres, most in the left ; 
 and it is interesting to remark, that he lays particular stress on the 
 pulpy state of the surrounding substance of the cerebellic hemi- 
 sphere.* In the other, it appears to have been more recent. In 
 a case by Dr Abercrombie a clot was found in the right hemisphere. 
 
 ■* “ Ea autem portio cerebelli quse corpus ejusmodi circumstabat, fradda erat.” 
 Epistola ii. 22. Epist. lx. 6. 
 
BRAIN. 
 
 301 
 
 Howship furnishes a curious case of extravasation into the medulla 
 oblongata^ in which parallel layers of blood were deposited trans- 
 versely in the substance of the part.* (Case 20.) 
 
 Genuine hemorrhage of the brain, as now described, though is- 
 suing from the capillaries, is thought not to take place by exhala- 
 tion.! It is never possible to trace it to a single vessel ; and he- 
 morrhage from rupture of an arterial trunk, though producing the 
 same symptoms, belongs anatomically to a different head. Cheyne,| 
 and more recently Lerminier and Serres, appear to have found al- 
 ways many minute capillaries opening into the hemorrhagic cavity. 
 
 On the greater frequency of affection of the right side of the 
 brain nothing very satisfactory has been ascertained. Morgagni 
 believing it, ascribes it to the greater frequency with which the 
 muscles of the right side are used than those of the left. In 41 
 cases, however, given by Rochoiix, the number in the left was 18, 
 that in the right 17, and that in both sides 6, which proves that 
 this cannot be established with any precision. 
 
 It is important to ascertain the influence which bloody effusion 
 in different parts of the brain, exerts on the functions of sensation, 
 voluntary motion, and the muscles of respiration. For there is 
 reason to believe, that, according as congestion or hemorrhage takes 
 place in the hemispheres, in the striated bodies, in the annular pro- 
 tuberance, in the cerebellum, or in the medulla oblongata, the effects 
 produced will be palsy, or apoplexy more or less violent, and with 
 different degrees of lethargic or comatose affection. The inquiry 
 is beset by this difficulty, that not the extravasation, hut the injec- 
 tion, is the essential cause of death. Scarcely a part of the brain 
 has been found unaffected in fatal cases. Itis certain thateffusion into 
 the white matter of the hemispheres, and into the striated nucleus, is 
 not essentially and invariably fatal, unless from the size of the rent 
 in the brain and the amount of blood effused. For from cases of 
 this kind temporary recovery has taken place. Neither is the in- 
 ference of Bichat, that effusion into the protuberance is invariably 
 fatal, well-founded. Tacheron records a case in which temporary 
 recovery was effected. It must be admitted, nevertheless, that ef- 
 fusion into this part is more likely to be fatal than into any other. 
 The cases of Serres afford the explanation of this fact, by showing, 
 that injury done to the protuberance causes a severe and permanent 
 
 * Practical Observations on Surgery and Morbid Anatomy, &c. By John Howship. 
 London, 1816. 
 
 + Bichat, Anatomie Generale, Tome II. article iii. p. 279. 
 
 X Cases of Apoplexy and Lethargy. 8vo, London, 1812. 
 
302 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 lesion of the function of the lungs, the vessels of which become dis- 
 tended with unrespired blood, while the air-vesicles are ruptured, 
 and death is effected by asphyxia. 
 
 The state of the cerebral vessels which terminates in hemorrhage 
 may occur, perhaps, at any period of adult life. But these blood- 
 vessels are liable to a peculiar state which predisposes to impeded 
 motion, accumulation, and extravasation. This consists in deposi- 
 tion of earthy matter between the coats of the internal carotid arte- 
 ries, and of the basilar artery and their branches. In consequence 
 of this deposition, they lose much of their contractile and distensile 
 powers, and some of their tenacity ; become rigid, brittle, and less 
 able to perform their functions as transmissile tubes ; and whenever 
 blood is accumulated in unusual quantity, as they do not so readily 
 admit of distension, rupture is the consequence. (Baillie, 454.) 
 Hodgson also shows how generally this my)rbid state of the cere- 
 bral arteries is connected with extravasation,* 
 
 This cause, however, is predisponent only. A fit of apoplexy 
 may occur and prove fatal in persons in whom neither ossification 
 of the arteries of the brain, nor any other state, except mere vascu- 
 lar injection, is found. And, on the other hand, the cerebral ar- 
 teries may be ossified or steatoraatous, in many persons who have 
 never had a single fit of apoplexy. The general result of the cases 
 observed by Vater, Morgagni, Cheyne, Howship, Rochoux, Serres, 
 and Tacheron, is, that disease of the arterial coats is connected with 
 vascular injection, which may terminate, according to circumstances, 
 in serous effusion, pulpy destruction, or bloody extravasation. It 
 is a well established fact, however, that the extravasation does not 
 take place from the diseased arterial trunks, but from the minute 
 capillaries in which these arteries terminate. 
 
 Old age has generally been regarded as a predisponent cause of 
 apoplexy ; and it is attended with two circumstances, which are 
 perhaps not altogether without reason regarded as of some moment. 
 The first of these is the venous plethora, so ingeniously maintained 
 by Cullen. The second is the tendency which the arterial system 
 more especially betrays to become diseased after the meridian of 
 life. The proofs of the existence of venous plethora, and the theory 
 of its operation, may be found in Cullen, who, perhaps, overrated 
 its influence. There is little doubt that the circulation in the veins, 
 either in consequence of diminished pressure and tension of the 
 skin and other coverings, does not go on with the same perfection and 
 
 * A Treatise on the Diseases of Arteries and Veins, pp. 25 and 26. 
 
BRAIN. 
 
 303 
 
 facility with which it does in early life. But whether there is a 
 greater venous plethora in the head at that period than before or 
 not seems doubtful. There is reason to believe, that the fulness 
 resides as much in the arteries as in the veins. It is manifest also 
 that the main cause of this venous plethora in advanced life, viz. 
 the frequency of disease of the heart, especially its mitral valve, 
 and of the aortic valves, Cullen altogether overlooked. Of the 
 effect and reality of arterial disease I have already spoken. 
 
 In point of fact, cases of apoplexy occur at all ages, but are most 
 frequent between the 50th and the 65th, or 70th year. Willan in- 
 forms us he has seen young persons from 12 to 18 years of age 
 affected with apoplexy and hemiplegia. In Bonetus and Morgagni, 
 instances of apoplexy are found occurring in persons below the 
 age of 30 ; but in general they were induced by external violence 
 or organic diseases. I have seen an instance of cerebral hemorrhage 
 terminating in hemiplegy in a young man of 19, labouring under 
 disease of the left auriculo-ventricular orifice. The young woman 
 to whose case I have already alluded, was, I think, about 22 ; and 
 in general when the disease takes place between 18 and 30, it is in 
 consequence of disease of the heart or its valves, or of the aorta. Of 
 eighteen cases described by Bonetus, five occurred in persons above 
 60, and six in persons below 40. Morgagni relates the cases of 
 thirty apoplectic persons, seventeen of whom were above the age of 
 60, and five below that of 40. Of thirty-one cases of bloody ex- 
 travasation in the ventricles or the substance of the brain, recorded 
 by Lieutaud, one was at the age of 25, eight between the ages of 
 30 and 41, eleven between 41 and 51, six betw'een 51 and 61, two 
 between 61 and 71, twm between 71 and 81, and one only above 
 100. Of twenty-nine cases seen or dissected by Portal, two were 
 between 19 and 23, four betw'een 30 and 41, seven between 41 
 and 51, eight between 51 and 61, four between 61 and 71, and the 
 same number between 71 and 81. Of 6 cases of cerebral hemor- 
 rhage given by Cheyne, three were between 30 and 35, two at 50, 
 and one at 63. Rochoux, however, has given the fullest and most 
 accurate results on this point. Among sixty-three cases of apo- 
 plexy, two occurred betw'een the age of 20 and 30, eight between 
 that of 30 and 60, seven between that of 40 and 50, ten between 
 that of 50 and 50, twenty-three between that of 60 and 70, twelve 
 between that of 70 and 80, and only one between that of 80 and 
 90. According to this view apoplexy is extremely rare before the 
 30th year ; from that period to the 50th it is not common but may 
 
304 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 occur ; after 50 it becomes more common ; between 60 and 70 is 
 more frequent ; becomes of the same rate of frequency after 70 as 
 before 60, and is very rare after the 80th year. Of the cases given 
 by Lerminier and Serres, though two are between 30 and 35, the 
 great part are between 60 and 75. 
 
 The state of the cerebral circulation now described is understood 
 to depend exclusively on the vessels of that organ, and to consti- 
 tute, therefore, primary apoplexy. . The same state, or a near ap- 
 proach to it, may take place secondarily in at least two different 
 states of the system ; first, as a consequence of injuries of the head ; 
 and, secondly, in the course of fever intermittent, remittent, or con- 
 tinuous. The first shall be considered afterwards. The second, 
 or the febrile apoplexy, belongs to this place. 
 
 a. Apoplexia Febricosa. The best example of this occurs in 
 certain forms of ague, accompanied with marks of great accumu- 
 lation in the head. It takes place chiefly at the termination of 
 the cold stage, and the commencement, or in the course of the 
 hot. In a slight degree the paroxysm is attended with drowsi- 
 ness or lethargy, from which the patient may still be roused. 
 When this recurs once or twice, the insensibility.is more complete, 
 till the phenomena of perfect apoplexy are induced. In other 
 instances after dull heavy pain of the head, dizziness, impaired 
 vision, and some affection of the urinary secretion, the individual 
 falls down suddenly with the mouth open, the eyelids fluttering, 
 and other marks of relaxed muscles; and continues during the 
 rest of the paroxysm in a stertorous sleep. This may cease spon- 
 taneously, or terminate in death, unless the paroxysm, which is 
 generally protracted to twenty-four hours, and follows the tertian 
 type, is finished. Though this is most frequent in the tertian, it is 
 not uncommon in the quartan and quotidian. 
 
 The cases examined necroscopically show the cerebral vessels to 
 be much distended with blood, sometimes bloody extravasation. 
 In other instances which belong to a different head, the distended 
 vessels are accompanied with serous effusion between the membranes, 
 or within the cavities. The anatomical character of soporose ague 
 is therefore inordinate injection of the cerebral and cerebro-menin- 
 geal capillaries. 
 
 This constitutes in various degrees the sleepy quotidian (C. Piso, 
 Obs. 178,) the sleepy^ lethargic^ hemiplegic, carotic, and apoplectic 
 tertian, (Werlhof, Torti, Lautter, Morton,) and the comatose quar- 
 tan (Piso, Werlhof;) and is the disease which has been named by 
 
BRAIN. 
 
 305 
 
 Baglivi* and Lancisi f epidemic apoplexy {apoplexia febricosa, c&rus 
 febricosus), and which Morgagni J and Casimir Medicus§ represent 
 as periodical and intermitting. When it is known that the apo- 
 plectic symptoms are regulated by the motions of the ague, which 
 alone is epidemic, or rather endemial, the nature of the periodical 
 and epidemic apoplexy is easily understood. 
 
 These soporose agues may be sporadic or general ; prevail mostly 
 in the summer or autumnal months in warm countries ; and after 
 a few paroxysms, sometimes the second or third, are generally fatal. 
 Their mortality is so uniform that they have been named death-fe- 
 vers (Todten-fieber) in Germany and Hungary, where they used 
 to be very common. They were observed at Rhodes by Praxago- 
 ras, the master of Herophilus; afterwards at London in 1678 by 
 Sydenham ; at Rome and in various parts of Italy by Baglivi in 
 1694 and 1695, and by Lancisi the same year, and at Bagnareain 
 1707 ; at Hanover by Werlhof; and by Cleghorn in Minorca. 
 
 The extravasations into the cavities of the brain, observed by 
 Jackson in yellowfever, belong to the head of meningeal hemorrhage. 
 
 In continued fevers of this and other countries, apoplectic death 
 is so common, that I need only refer to the works of Stoll, Mills, 
 Bateman, Cheyne, Barker, and Harty. It appears to be at once 
 cerebral and meningeal. 
 
 In purpura and sea-scurvy death not unfrequently takes place 
 from hemorrhage within the brain, or on its surfaces. The latter 
 is most common, and as such belongs to the head of meningeal he- 
 morrhage. 
 
 Apoplexia Traumatica. Traumatic Apoplexy. Apoplexy from 
 violence. Hemorrhage from the Cerebral Membranes. Traumatic 
 Apoplexy. Meningeal apoplexy of Serres. The effects of injury on 
 the skull, especially in the form of repeated blows, are very peculiar. 
 One blow, of course, or a fall, in which the skull lights on a stone or 
 other hard body, may, as it often does, fracture the skull, and prove 
 fatal either by tbe concussion, cr by blood effused afterwards. But 
 there is another class of cases in which a series of blows has been in- 
 flicted on the head, proving fatal, yet without fracturing the skull. In 
 the class of cases, also, to which I now refer, the patient falls into a 
 
 * G. Baglivi Dissertatio, 8vo. De Observationibus, &c. Appendix de Apoplexiis 
 fere epidemicis proximo elapso biennio in Urbe et per Italiam Observatis. Op. Om. 
 Antwerpice, 1715, p. 683, 
 
 t D.e Noxiis Paludum Effluviis. + Epist. iii. iv. and v. 
 
 fcj Geschichte Periode-haltender Krankheiten. Erstes Buch ; Erstes Capitel, g ii. 
 
 Peode-haltender Schlagfluss, p. 5. Frankfurt und Leipzig, 1794. 
 
 U 
 
306 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 state of insensibility from which he never recovers ; and this, after 
 lasting from 40 or 50 minutes to two, three, or more hours, termi- 
 nates in death. 
 
 The state of the brain is in such cases the following. 
 
 The whole surface of the brain under the site of the blows, and 
 not unfrequently all over, is covered with a layer of what appears 
 to be blood of considerable thickness. At first sight this appears 
 to be outside the membranes. But on examination it is found that 
 the blood is effused or infiltrated into the subarachnoid or inter- 
 membranous tissue, and that it has escaped from the lacerated ves- 
 sels of the pia mater. The thickness of this layer varies. Some- 
 times it is pretty uniformly spread as thick as a crown piece all over 
 the upper and lateral parts of the hemispheres. It generally in- 
 creases in amount and thickness at the lateral and inferior regions 
 of the brain. The whole posterior lobes and the cerebellum may 
 be covered by it. Most usually, however, it is thickest over the 
 crura., the i liter cruralybssa, the annular protuberance and the me- 
 dulla oblongata. Over these parts, in two fatal cases in which death 
 followed almost immediately repeated blows on the head, I found 
 the blood effused into the intermembranous tissue over the base of 
 the brain, to the thickness of half an inch. 
 
 This, therefore, is a meningeal hemorrhage. 
 
 In the same class of cases blood is effused within the ventricles 
 often to a great amount. It is coagulated, and the clot is surround- 
 ed by bloody coloured serum. This escapes in like manner from 
 the vessels of the choroid plexus and the internal pia mater. These 
 appearances are so uniformly the result of violence, that the cir- 
 cumstance of their situation and appearance may, along with other 
 circumstances, be justly inferred, in doubtful cases, to prove that 
 death is the result of violence. The fact, therefore, forms a valu- 
 able piece of evidence in medico-legal inquiries, to prove that such 
 hemorrhage and such death could not have taken place from inter- 
 nal causes. Attempts are often made either by ignorant or designing 
 persons, or by counsel, to prove that this intermembranous or menin- 
 geal hemorrhage is sanguineous apoplexy. The answer is very sim- 
 ple but decisive. In sanguineous apoplexy the hemorrhage always 
 takes place in the substance of the brain and lacerates the brain. In 
 traumatic apoplexy, or that from violence, it takes place on the sur- 
 face from the vessels of the membranes, and compresses the organ. 
 
 By M. Serres, indeed, a species of meningeal apoplexy has been 
 recognised as taking place spontaneously. It is a very rare oc- 
 
BRAIN. 
 
 307 
 
 currence, and the hemorrhage is in general on the free surface of 
 the arachnoid membrane ; in other words, within the arachnoid 
 membrane. Collateral circumstances will here be available. 
 
 7. Apoplexia Neonatorum. Among the cases of infants expelled 
 from the womb lifeless, or in such a state that they soon cease to 
 live, in a considerable number the appearances are the following. 
 A layer of blood, mostly coagulated, but with some bloody serum 
 oozing from it, is spread uniformly over the whole of the superior, 
 anterior, posterior, and lateral surfaces of the hemispheres. A si- 
 milar layer of blood is found extending over the laminated surface 
 of the cerebellum.^ and less frequently, perhaps, over the base of the 
 brain. Within each lateral ventricle, and sometimes within the 
 third and fourth, are found clots of blood with bloody serum. At 
 first sight, it might be thought that these infants had been born 
 alive, and had died in consequence of violence inflicted on the head. 
 This inference is not quite correct. Violence has been in some de- 
 gree inflicted ; but it is the violence resulting from the efforts of the 
 uterus in forcing a large head, or a wrong presentation through the 
 pelvic outlet ; and the infants were either not born alive, or vital ac- 
 tion speedily ceased. Life was extinct before the head was expelled, 
 in consequence of blood effused from the meningeal vessels into the 
 subarachnoid tissue, all over the brain, and from the choroid ’plexus 
 within the ventricles. The cause is most commonly protracted and 
 tedious labour, during which the head is forcibly compressed against 
 the pelvic bones ; and the hemorrhage from the membranes takes place. 
 
 This is the apoplexia neonatorum., or apoplexy of new-born in- 
 fants, a lesion almost necessarily and invariably mortal. To me 
 it appears to be the most frequent cause of still-births, as they are 
 termed ; for at least 17 instances in 20 that I have inspected, in the 
 course of a long series of yeai’s, presented the appearances now spe- 
 cified. To understand the true nature of this lesion is important 
 in a medico-legal point of view ; for rash and ignorant persons have 
 often inferred, that it was the effect of violence intentionally inflict- 
 ed on the head of an infant born alive. Cruveilhier gives good il- 
 lustrations of the lesion, and the history of several cases in proof of 
 its true nature and origin.* He shows that all infants with this 
 lesion are not still-born, but may die soon after birth; that it is 
 impossible, in all cases, to determine the cause of death ; that is, 
 the cause of the hemorrhage ; but that cases take place after pre- 
 sentation of the vertex, of the hips, of the chord ; and after long 
 
 * Anatomie Pathologique, Livraison xv. 
 
308 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 and repeated attempts at turning. In general the head has been 
 too slowly born, or the presentation has been unfavourable. 
 
 d. On a form of apoplexy termed nervous much has been said by 
 Zuliani of Brescia,* * * § Kortum of Dortmund in Westphalia, -f- and 
 Kirkland of Ashby de la Zouche and the subject has been re- 
 vived by Mr Abernethy,§ and Dr W. Philip. In this, apoplectic 
 symptoms are said to take place without any abnormal state of the 
 brain or its vessels, and from some disorder in the chylopoietic or- 
 gans, which is supposed to induce a torpid condition of the brain, 
 or suspension of its proper energy. It may he doubted whether 
 satisfactory proof of such a state has yet been adduced. Is^, A 
 fallacy results from the doctrine that hemorrhage is in all instances 
 requisite to give rise to apoplectic symptoms. I have shown that 
 congestion, injection, or distension of the cerebral vessels is adequate 
 to produce this effect ; and whether this state is to disappear, re- 
 main unchanged, or produce serous effusion, or bloody extravasa- 
 tion, so as to remain after death, will depend much on the consti- 
 tution of the individual and the treatment employed. No satisfac- 
 tory conclusion can be drawn from the absence of hemorrhage or 
 serous fluid. 2c?, Disorder of the chylopoietic organs is an acces- 
 sory remote cause, which may operate on the meningeal and cere- 
 bral circulation. 3c?, The instances adduced as examples of this 
 disease are at least ambiguous. The fourth case of Kirkland can- 
 not be admitted. The case of Stark (§ iv. p. 73,) I have already 
 mentioned as one of injection either of the spinal chord or its mem- 
 branes. The first case of Dr Powell might have been similar, for 
 the spinal chord was not examined, y In other instances, as in that 
 recorded by Morgagni, (Epist v. 17 and 19,) one in the meningeal 
 vessels, and in the vascular system in general, might have been the 
 cause of death. It has been shown by M. Serres, that many 
 of the cases of supposed nervous apoplexy must have been examples 
 of what he terms meningeal apoplexy, i. e, injection of the menin- 
 geal vessels with or without effusion or extravasation. 5?A, In other 
 instances a very slight and incipient degree of the state which is 
 
 * F. Zuliani De Apoplexia presertim Nervea. Lipsiae, 1780. 
 
 + C. G. Theod. Kortum Tremoni® Westphali dissertatio de Apoplexia Nervofsa. 
 Goettingae, 1785. Ext. in Frank. Dilectu, Vol. IV. p. 1 ; et Ludwig Scrip.-Neur, 
 Tom. IV. p. 379. 
 
 + A Commentary on Apoplectic and Paralytic Affections, &c. By Thomas Kirk- 
 land, M. D. 1792. 
 
 § On the Constitutional Origin of Local Diseases. 
 
 II Medico-Chirurgical Transactions, Vol. 111. By Thomas Chevalier. 
 
BRAJN. 
 
 309 
 
 to proceed to pulpy destruction may cause death. When it affects 
 a whole hemisphere, which it may sometimes do, (Morgagni, Epist. 
 V. 15, 16 ; li. 7, 1 1,) it may alter the appearance so little as readily to 
 escape observation. Qth, The first and fourth cases of Dr Abercrom- 
 bie I am unable to explain ; but I think they may have taken place 
 in persons with granular disease of the kidney, which not unfre- 
 quently causes apoplectic death, yet without leaving any traces of 
 vascular injection or hemorrhage. 
 
 For the reasons now assigned, it may be justly questioned whe- 
 ther there is ground for admitting such a state of the brain as the 
 nervous apoplexy of Zuliani, Kortum, Kirkland, and Abernethy. 
 According to the present state of evidence, it is wisest to adopt the 
 side which does not recognize this form of apoplectic disease. 
 
 7. In the foregoing account of the state of the brain giving rise to 
 apoplectic symptoms, I have said nothing of that loss of voluntary 
 muscular power known under the name of (^paralysis; paresis; 
 resolutio because I suppose it to depend on the same state 
 
 of the cerebral capillaries which causes the general apoplectic af- 
 fection, which it either precedes, accompanies, or follows ; or on 
 that state of the brain or spinal chord which I have already de- 
 scribed as terminating in pulpy destruction. In attempting to es- 
 tablish clearly the anatomical characters of palsy, two circumstances 
 merit particular attention. 
 
 First, several cases of apoplectic death are preceded by paraly- 
 tic affection of one side, more or less extensive, in the successive 
 forms of distortion of one side of the face, loss of speech, loss of 
 power in an arm, a leg, or the entire side. When these phenome- 
 na are followed by coma and death, necroscopic inspection shows, as 
 in apoplexy, capillary injection with or without extravasation, and 
 generally more or less destruction of brain. The commencement of 
 the morbid process in this instance is doubtless the same capillary 
 injection of part of the organ, which in a more exquisite degree 
 produces the comatose state. Secondly, Though there are not a 
 few instances in which an attack of loss of consciousness, sensation, 
 and motion, is not followed by loss of voluntary motion, these, I 
 have already attempted to show, depend on that capillary injection 
 which is removable by the use of remedies. When the capillary 
 injection proceeds to destruction either by hemorrhage, by soften- 
 ing, or by ulceration, i. e. by superficial pulpy destruction of cere- 
 bral substance, consequent on hemorrhage, It almost invariably 
 leaves after it more or less loss of voluntary motion, generally on 
 
310 
 
 GENERAL AND RATIIULOGICAL ANATOMY. 
 
 the side of the body opposite to that of the brain wliich lias sus- 
 tained the lesion. One of the most frequent effects of cerebral he- 
 morrhage and its consequences, indeed, is palsy of the hemiplegic 
 form ; and in the brains of such persons as have laboured under 
 this disease, either a broken down and softened spot, or one or 
 more hemorrhagic cavities or cysts are found after death, (Wepfer, 
 Willis, Morgagni, John Hunter, Baillie, Wilson, Abernethy, Ro- 
 choux, Serres, Lerminier, Tacheron, Abercrombie.) The general 
 accuracy of these conclusions is confirmed not only by the necrosco- 
 pic appearances of the brains of those who die of coma succeeding 
 to palsy, but of those who die of the effects of injuries of the head, of 
 abscess of the brain and cerebellum, and of tumours and other or- 
 ganic changes taking place either in the brain or in its membranes. 
 
 I have said that palsy occurs generally in the side opposite to 
 that in which the lesion of the brain is found, because in some cases 
 it has been observed in the same side. 
 
 Though this singular phenomenon early attracted the attention 
 of pathologists, it cannot be said that the circumstances, under 
 which it takes place or does not take place, are determined. The 
 fact was early demonstrated by Molinelli ; and, in order to obtain a 
 satisfactory explanation of it, much inquiry and experiment was un- 
 dertaken by Pourfour de Petit, Saucerotte, and others, members of 
 the Academy of Sui’gery; and the phenomenon has since been the 
 subject of occasional inquiry to several from Morgagni, Haller, and 
 Prochaska, to Dr Anderson and Dr Yellowly. The mutual inter- 
 lacement of the cerebral chords between the restiform bodies has 
 been supposed at various times, from Mistichelli and Pourfour de 
 Petit, adequate to explain it. To this the principal objection is the 
 fact, that palsy of the opposite side, though frequent, is not an in- 
 variable result of injury of the brain. 
 
 The situation of these destroyed spots and hemorrhagic cavities, 
 when inducing palsy, corresponds much with that of the cerebral in- 
 jection or hemorrhage from which they arise. The region most ge- 
 nerally affected is that already described as the striated nwc/ewsof Reil. 
 Willis, for example, states, that in several dissections of persons 
 dead after long-continued and obstinate palsy, he invariably found 
 the corpora striata unusually soft, discoloured like wine-lees, and 
 with the usual alternation of white and gray streaks much oblite- 
 rated.* The accuracy of this inference regarding the part of the 
 
 * Thoma; Willis, Cerebri Anatome, cap. xiii. p. 43, et De Anima Brutorum, 
 cap. ix. p. 144 et 145. 
 
BRAIN. 
 
 311 
 
 organ most frequently affected is confirmed by cases given by 
 Petit ; by several of those given in the Essay of ]\I. de la Peyro- 
 nie* * * § by Antonio Caldani ; by Morgagni in repeated observations 
 both of paralytic cases terminating in coma, and of those originally 
 apoplectic, accompanied with distinct palsy ; (Epist. xl. 2, 4, 6, 
 11 ; li. 12 ; Ixii. 7, 9;) by three cases given by Prochaska by 
 Cheyne, by Rochoux, by Lallemand, by Tacheron, (26, 27, 28, 29, 
 30,) and by Abercrombie, (p. 252, cases 112, 113, 114, 115.) 
 
 On this point, however, the remarks already made on the seat 
 of cerebral hemorrhage are applicable. Though the striated nu- 
 cleus and the contiguous part of the hemisphere forming the outer 
 and upper walls of the capsule, are the most frequent seat of he- 
 morrhagic cavities and pulpy destruction, other parts of the brain 
 are not exempt. In the work of Dr Abercrombie are given cases 
 in which the diseased spot was nearer the surface of the organ. 
 (Ill, 116, 117, 118.) I met with one instance in which hemiple- 
 gia was connected with pulpy disorganization of the posterior part 
 of the hemisphere, so near the convoluted surface, that the lesion 
 could be immediately recognized after removing the dura mater, 
 by the unusual change of colour and consistence. Dr Duncan 
 Junior records two excellent examples in which pulpy destruction 
 of the anterior and middle lobes of the brain caused hemiplegy, 
 and that of the cerebellum gave rise to palsy of the paraplegic form, 
 without disorder of intellect.^ It appears also from the testimony 
 of Dr Cheyne, that the form of disease which he terms creeping 
 palsy depends on the progressive softening of the substance of the 
 hemispheres. In the only example of this lesion recorded by the 
 author, the morbid change was vascular injection, and pulpy de- 
 struction of the white matter of both cerebral hemispheres, which 
 was of the consistence of thick cream. § 
 
 The circumstances of cases, in which this change takes place, 
 show that it is not so much the destruction of the cerebral sub- 
 stance as the capillary injection or inflammation, with which it is 
 attended, that produces the loss of power in the muscles of volun- 
 
 * Observations par lesquelles on tache de decouvrir la partie dii Cerveau ou Tame 
 exerce ses Fonctions. Chez Memoires de I’Academie Royale des Sciences, 1741. 
 
 Georgii Prochaska Op. Minorum, partem ii. Viemice, 1800. Observat. Patholog 
 sect. iv. Casus tres co7nplectens, die. 
 
 f Contributions to Morbid Anatomy, Nq. II. By A. Duncan Jun. M. D., &c. 
 Ed. Med. and Surgical Journal, Vol. XVII. 328, 329. 
 
 § Dublin Hospital Reports, Vol. IV. p. 270. 
 
312 
 
 GENERAL AND PAI’HOLOGICAL ANATOMY. 
 
 tary motion. Tn some instances of paralytic disorder lasting for a 
 considerable time, instead of finding hemorrhagic cavities or de- 
 stroyed spots in the bi-ain, it is impossible to recognize any thing 
 but some vascular injection and effusion of serous fluid, which 
 doubtless proceeded from the overloaded vessels. This injection 
 is not confined to one spot, but is diffused in different degrees 
 through the brain, and is in some instances strongly marked in the 
 cerebellum, annular protuberance, and tbe meningeal vessels to- 
 wards the base of the organ. The effects which this state of the 
 brain produces vai’y somewhat from genuine apoplectic palsy. 
 They constitute a double but unequal bemiplegy approaching very 
 gradually, and very often simulating paraplegia. From this, how- 
 ever, they differ, in the lower extremities being seldom affected in 
 the same degree and at an equal rate. It is often attended with 
 some loss of memory, or sensation, and some slight degree of men- 
 tal imbecility. The anatomical character of the disease may be 
 represented as a chronic congested state of the cerebral capillaries. 
 It may terminate either in serous effusion from the meningeal ves- 
 sels, in softening of the cerebral substance, or in induration. In 
 the first instance, it belongs to the head of meningeal injection, to 
 be afterw'ards noticed. In the second case, it will often correspond 
 with the creeping palsy of Dr Cheyne ; or it may give rise to epi- 
 leptic attacks. (Morgagni, ix. 16, 18, 20, 23; Greding, No. 49, 
 p. 494 ; No. 42, p. 524 ; Wenzel, Portal.) In the third, it is one 
 of the morbid states of the brain causing insanity. 
 
 8. The spinal chord is liable to the same species of vascular in- 
 jection and hemorrhage which takes place in the brain. The ca- 
 pillaries, which, in the sound or normal state, are small, and convey 
 almost colourless fluid, become enlarged and penetrated with red 
 blood. In a stage of the process, which is to be regcirded as fur- 
 ther advanced, drops of blood, and occasionally clots of some mag- 
 nitude, are found deposited in the substance of the chord. These 
 undergo and give rise to the same changes which have been al- 
 ready described as taking place in the brain, and are a cause by 
 no means unfrequent of pulpy disorganization of the chord. In 
 the case given hy Gaultier de Claubry, which is the most distinct 
 on record, the chord opposite the seventh cervical vertebra was of 
 a deep red colour from vascular injection, but still unbroken in 
 structure.; from the seventh cervical vertebra to the third dorsal it 
 was not only deep red on the surface, but on the substance, and 
 
BRAIN. 
 
 313 
 
 so soft as to sink under the knife or finger ; and from the third dor- 
 sal vertebra to the lower part of the sacrum, it was a red blood- 
 coloured pulp destitute of organization.* The cases of Chevalier, 
 which belong rather to the head of meningeal hemorrhage, shall 
 be noticed afterwards. 
 
 Pulpy softening of the spinal chord may arise either spontaneously 
 or as a consequence of injury, more especially if that injury causes 
 fracture or even concussion of the vertebras. When it takes place 
 spontaneously, often the arteries of the chord are previously dis- 
 eased. Most commonly the appearance of the chord is that of a 
 pulpy softened mass, falling entirely down on the membranes being 
 divided. In extreme cases, the chord is converted into a soft se- 
 mifluid diffluent mass, not unlike cream. Sometimes in recent 
 cases, considerable vascularity and injection are observed. But in 
 chronic cases, the vessels are in general scanty. When the disease 
 arises spontaneously, it may affect a large portion of the chord. 
 
 When softening is the result of injury, as contusion, concussion, 
 or fracture of the vertebrae, it is in general limited to the spot where 
 the injured bones are situate. The anatomical and physical cha- 
 racters are the same. 
 
 The effects produced by capillary injection and bemorrhage in 
 the spinal chord vary according to the stage of the process and the 
 region of the chord in which it occurs. In the stage of injection it 
 produces irregular involuntary twitches of the muscles of the trunk 
 and extremities, numbness and coldness of the skin about the back, 
 and occasionally of the limbs, and more or less of muscular power. 
 In the advanced stage, whether that of hemorrhage or of pulpy de- 
 struction, numbness and palsy of the paraplegic form are com- 
 plete. 
 
 In some instances the state of capillary injection appears to 
 give rise to tetanic symptoms. This fact, which was observed by 
 Dr Robert Reid in Ireland,! Duchatelet,! Martinet, and Oilivier,§ 
 
 * Journal General de Medecinede Chirurgie et de Pharmacie, &c. 12ieme annee. 
 Tome XXXII. A Paris, 1808. P. 129. 
 
 f On the Nature and Treatment of Tetanus and Hydrophobia. By Robert Reid, 
 M. D. Dublin, 1817. 
 
 J Recberches sur ITnflammation de TArachnoide cerebrale et Spinale, &c. Par 
 M.M. Parent-Duchatelet et L. IMartinet. Paris, 1821. 
 
 § De la Moelle Epiniere et de ces Maladies, <ftc. Par C. P. OUivier d’Angers. A 
 Paris, 182-1. Pp. 307, 308, 317, 349. 
 
314 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 in France, and by Dr Duncan Junior, in the stage of suppuration,* 
 has led to the recent revival of an opinion originally proposed by 
 Galen, and reproduced in modern times by Fernel, Willis, and Hoff- 
 mann, — that tetanus depends on a morbid state of the spinal chord 
 or its membranous coverings. This inference, nevertheless, is not 
 in its present state susceptible of that degree of accuracy which en- 
 titles it to a place among the established principles of pathology. 
 Though in some instances capillary injection of the chord, and the 
 origins of the spinal nerves is attended with tonic spasms of the 
 muscular system, in a great number, perhaps a larger proportion, 
 no contractions of this kind take place, notwithstanding every mor- 
 bid change from vascular injection to pulpy destruction or suppu- 
 ration. Tetanic spasms, Ollivier infers, are connected with the 
 advanced and intense forms of the disease; but the cases collected, 
 not only by this author himself, but by Pinel, Velpeau, and Aber- 
 crombie, show, that in some of the most aggravated forms of the 
 disease no spasms had taken place till the last few hours of exis- 
 tence. In short, the circumstances under which tonic spasms occur 
 in connection with vascular injection and inflammation of the chord, 
 have not yet been distinctly indicated. From the cases observed 
 by Reid, Duchatelet, and Martinet, Jones, Ollivier, and Duncan 
 Junior, tetanic spasms appear to be more frequently connected with 
 injection of the membranes than of the substance of the chord. 
 
 The variation of effects according to the region of the chord 
 affected may be distinguished into three heads as the morbid 
 process affects the longitudinal extent, the transverse breadth, or 
 the antero-posterior thickness of the chord. 
 
 a. When it is seated in the upper or cranial portion of the chord, 
 {meclullu oblongata,) the effects are more or less disorder of the 
 senses, locked-jaw, gnashing of the teeth, impaired articulation and 
 deglutition, respiration oppressed, disordered, and panting, palsy, 
 and death by asphyxia. 
 
 When it is seated in the cervical portion it gives rise to tetanic 
 rigidity, convulsion, or palsy of the muscles of the neck, more or 
 less palsy of the intercostals, and muscles of the trunk and extre- 
 mities in general, paralytic weakness of the diaphragm, and even- 
 tually, as this advances, death by suspension of the mechanical 
 agents of respiration. 
 
 ■* Contributions to Morbid Anatomy, Case 5th. Medical and Surgical Journal, 
 Vol. XVII. p. 332. 
 
BRAIN. 
 
 315 
 
 . In the dorsal region it induces convulsive throes of the trunk, 
 palsy of the intercostal muscles, with short, languid, diaphragmatic, 
 respiration, palpita,tion, and irregular throbbing of the heart, 
 hiccup, squeamishness, vomiting, and eventually death, partly by 
 impaired respiration, partly by failure of the action of the heart. 
 
 In the lumbar region, palsy of the lower extremities is always a 
 prominent symptom ; but to this are added paralytic retention of 
 urine at first, afterwards incontinence and involuntary voiding of 
 the contents of the rectum. 
 
 0 . The transverse diameter of the chord is so small, that in ge- 
 neral the capillary injection and its consequences are not confined 
 to one side only. When this happens, however, which is rare, it 
 produces hemiparaplegia, or palsy of the lower extremity of one 
 side. Though this has been so frequently observed to occur on 
 the same side with the lesion of the chord, that it may be stated as 
 a general result, it is nevertheless requisite to mention, that to 
 Portal we are indebted for a singular case, in which capillary in- 
 jection and pulpy destruction of the right side of the lumbar divi- 
 sion of the chord, gave rise to palsy of the left inferior extremity.* 
 
 7 . To the antero-posterior diameter of the chord the same ob- 
 servations nearly apply ; and it is rare to find the anterior part 
 diseased without affection of the posterior, and conversely. In- 
 stances of this, nevertheless, have been observed ; and it is inte- 
 resting to remark, that the effects which respectively result from 
 lesion of either singly, tended to confirm those inferences which 
 Charles Bell and Magendie have drawn regarding the anterior 
 and posterior roots of the spinal nerves. Thus when the anterior 
 part of the chord is affected without the posterior, the effect is loss 
 of muscular power more or less complete, while sensation remains. 
 Conversely, when the posterior part of the chord is injured without 
 the anterior, sensation is more or less obliterated, while voluntary 
 motion is little affected. Thus in a case recorded by Dr Jones, 
 vascular injection of the posterior surface of the chord impaired 
 sensation remarkably, but left motion little affected. | In like 
 manner, in a case communicated by Royer-Collard to Ollivier, 
 (Ohs. 47, p. 334,) pulpy destruction of the anterior part of the 
 chord, from the restiform and olivary eminences, down to the lum- 
 
 * Anatomie Medical, Tome IV. p. 116. 
 
 t Medical and Surgical Journal, Vol. XXI. p. 81, 83. 
 
316 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 bar portion without affection of the posterior, caused palsy of the 
 . trunk and lower extremities without impairing sensation. 
 
 9. State of the Brain in Fever. A singular state of the brain is 
 observed in fever, whether typhus or ordinary synochus, which usu- 
 ally ends in typhus. The whole of the convoluted portion of the 
 brain, and the laminated portion of the cerebellum^ indeed the whole 
 gray matter of the organ acquires a peculiar deep colour, as if the 
 gray matter had been tinged of a reddish-brown, or slight pink- 
 colour. The white matter is also redder than usual, and presents 
 when divided numerous dark-red points effusing semifluid dark- 
 coloured blood. The white matter of the crura of the brain, of 
 the protuberance, and the bulb of the spinal marrow (medulla ob- 
 longata), acquires a peculiar pink-colour, totally different from that 
 observed in death by other diseases, and similar only to the state 
 of the brain in persons destroyed by acute or chronic asphyxia. 
 The membranes are generally loaded with serous fluid, which is 
 also found in the cerebral substance and within the ventricle. 
 Brains in this state are not easily preserved. They are soft, and 
 lacerable, and generally undergo decomposition early and speedily. 
 
 This state is manifestly the result of the brain being supplied 
 only with dark-coloured or non-oxygenated blood. With this its 
 arteries are filled during life and after death. The organ is indeed 
 })oisoned with unrespired blood, much as if the individual had 
 breathed carbonic oxide gas. These appearances, which depend 
 on the quality, not the amount of blood, in the cerebral vessels, 
 have been ascribed to turgescence, to inflammation, to venous con- 
 gestion, and everything but the true cause, which is the state of 
 the lungs and blood, already noticed in Chapter VII. Section II, p. 
 
 1 64. Unarterialized blood is sent to the brain, and by poisoning sus- 
 pends and annihilates its functions. Death is in such cases pi’e- 
 ceded by stupor and coma, more or less deep, and on some occasions 
 by fits of convulsions. 
 
 10. Malahencephalon. Diminished consistence of the brain. The 
 change above described in the consistence of the brain is always 
 accompanied with more or less destruction of its texture. Under 
 certain circumstances, nevertheless, its consistence may be dimi- 
 nished without change of texture. 
 
 The natural consistence of the recent adult brain, though well 
 known, it is difficult to describe in exact terms. In general it pos- 
 sesses a degree of toughness which prevents it from being easily 
 
BRAIN. 
 
 317 
 
 divided, unless by a very keen instrument ; and after incision mi- 
 nute fragments are left on the sides or edge of the knife. A very 
 thin slice of white cerebral matter is sufficiently tenacious and con- 
 sistent to sustain its own weight, and to admit of considerable 
 stretching without being broken or lacerated. If put into pure 
 water it continues unchanged for at least eight, ten, or sometimes 
 twelve hours, and without any portion of it being either dissolved, 
 or rendering the water in any degree turhid. A newly cut surface 
 of brain communicates to the finger a peculiar clammy or viscid 
 sensation, in consequence of which it moves with less facility over 
 the skin of any opposite surface. 
 
 These qualities, the existence of which may he easily demonstrated, 
 pertain especially to the white substance of the adult brain, when 
 death takes place either accidentally or by an acute disease, without 
 direct lesion of the organ. The consistence of the gray matter of 
 the convoluted surface is inferior to that of the white. The -white 
 matter of the twain-band {corpus callosum) is firm and tough in the 
 direction of its cross fibres, and may be pulled to a considerable 
 degree without giving way. The cylindrical fluted masses forming 
 the limbs of the brain, (crura,) wbicb consist chiefly of white matter, 
 are much firmer than the substance of the striated nucleus, which is 
 mostly gray ; and the annular protuberance, which is chiefly white 
 matter, is the firmest and most tenacious part of the organ. The cere- 
 bellum, which consists chiefly of gray matter, is invariably less firm 
 than the brain ; and tbe firmest part of tbe former is the substance 
 of the peduncles and the white matter of the cerebellic hemispheres. 
 Of the spinal chord, the cranial part, especially the olivary emi- 
 nences, are the firmest ; and the consistence, though less than that 
 of the brain, is tolerably uniform to the lumbar region, in which it 
 undergoes a distinct diminution, and finally becomes very loose in 
 the caudiform expansion. 
 
 The degree of consistence now attempted to be defined, varies at 
 different periods of life, and under different circumstances of health 
 and disease. 
 
 In early life the substance of the brain is very different in con- 
 sistence and tenacity. In the foetus and at birth its softness ap- 
 proaches to semifluidity. Some weeks after it passes from a soft 
 pulpy substance to a state of greater flrmness and tenacity ; but at 
 the distance even of many months after birth, it is still much in- 
 ferior in these qualities to the brain of an individual, who has at- 
 
318 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 tainecl the fourteenth or fifteenth year. In three cases of infants 
 cut off by different acute diseases, between the ages of 20 months 
 and years, I found the brain soft, compressible, elastic, but not 
 tough; of the consistence of custard-pudding; but not quite so firm 
 as to bear much handling or stretching without being broken or 
 torn. In several cases of children dead between the 7th and the 
 11th year of scarlet- fever or measles, the brain was firmer, and had 
 acquired greater tenacity, but was still considerably softer and less 
 tough than the brains of adults who had attained the 18th, 20th, 
 or 22d year. Between 12 and 15 the brain in general acquires a 
 decided degree of firmness and tenacity ; for, though still highly 
 elastic, it is much less compressible, and much more distensible 
 without lacei’ation than before. This increase of firmness and te- 
 nacity is particularly conspicuous in the twainband and mesolobe, in 
 the limbs, in the optic thalamus^ in the annular protuberance, and 
 in the olivary eminences. It is impossible to say when the organ 
 may be said to attain its maximum of firmness. But after the 22d 
 year I have not been able, in a very considerable number of human 
 brains, to recognize much variation of consistence not connected 
 with some morbid state, either of the system at large, or of the or- 
 gan itself. 
 
 In extreme old age, it has been said the brain generally becomes 
 firmer, harder-, and dr'ier than in the meridian of life. This, I be- 
 lieve, is not altogether without foundation ; though it is doubtful 
 how far this is to be r-egarded as a uniform change, independent of 
 disease or morbid effects. It is further exceedingly difficult to de- 
 fine the time at which this change in the consistence of the brain 
 commences or is accomplished. In persons between 50 and 60, I 
 have seen the brain as firm as in others between 70 and 80, or 
 above that age. Conversely, the brain is found sometimes soft, 
 even in persons much advanced in life. 
 
 The brain of the adult is liable to lose its normal consistence, 
 and become preternatural ly soft in chronic diseases of emaciation, 
 as dropsy, pulmonary consumption, and other pulmonary disorders, 
 mesenteric wasting, marasmus, diabetes, and organic diseases in 
 general. The diminished consistence now remarked is most fre- 
 quently observed in dropsy, diabetes, and pulmonary disorders. 
 
 In the first the brain is almost invariably soft and flaccid through- 
 out. It cannot sustain itself, but falls down much more quickly 
 than in the natural state. It is not easily cut, but rather gives 
 
BEAIN. 
 
 319 
 
 way before the knife ; and a portion of such a brain is easily lace- 
 rated, and falls down quickly in water. This diminished consist- 
 ence, which, though greatest at the centre, extends through the 
 whole organ, depends partly on the deposition of the proper cere- 
 bral matter being interrupted, and partly on the admixture of se- 
 rous fluid with its minute atoms. The texture or atomic constitu- 
 tion of the organ is not altered. 
 
 In diabetes a similar change takes place, chiefly from the former 
 cause. 
 
 In pulmonary consumption, whether depending on chronic bron- 
 chial inflammation, chronic pleurisy, or on tubercular disorganiza- 
 tion, the brain is invariably found softer than natural. When the 
 disease which induces death has continued long, this softness is very 
 considerable, and amounts almost to semifluidity. It may then 
 constitute a true cause of adventitious disease. This state of the 
 brain, combined with a languid and retarded motion of the blood 
 through the cerebral capillaries, may be the pathological cause of 
 the delirium, which, either alone or alternating with coma, not un- 
 frequently precedes the death of phthisical patients. The cerebral 
 capillaries in such subjects I have found large and numerous. Is 
 the density of the brain diminished ? Meckel states that he found 
 a cube of six lines of the brain of a man of 24, cut off by phthisis, 
 to be Ij grain lighter than the same bulk of sound brain. 
 
 Confinement, with inactivity and low diet, tend to impair the 
 firmness of the brain. Thus in condemned felons and others, who 
 have been imprisoned for some time previous to death, either vio- 
 lent or natural, the brain is found unusually soft. Dr Monro, 
 tertius, formerly Professor of Anatomy in the University of 
 Edinburgh, who has had numerous opportunities of examining the 
 brains of persons cut otf under these circumstances, states that in 
 criminals in general he found the brain unusually soft ; and in a 
 young man otherwise healthy, who was put to death for piracy, the 
 brain was so soft that it gave way at the corpus callosum. The 
 softness appears, from the account of Dr Monro, to be greater in- 
 ternally than externally, so that it was impossible to demonstrate 
 the deep-seated parts of the organ.* In opposition to this, how- 
 ever, I must not omit to mention that Littre found the substance 
 of the brain, cerebellum, and medulla oblongata, unusually compact 
 
 * The Morbid Anatomy of the Brain. By Alexander Monro, M.D., &c. &c. Vol. I. 
 Edinburgh, 1827, p. 35 and 160. 
 
320 
 
 GENERAL AND PATHOLOGICAL ANATOBIY. 
 
 and dense in a felon, who, to avoid public punishment, killed him- 
 self by dashing his head against the wall of his cell. * * * § 
 
 To the same head probably is to be referred a form of diminish- [ 
 ed consistence, without change of texture, which is occasionally oh- j 
 served in the brains of persons in whom chronic encephalo-menin- 
 sreal congestion caused mental derangement. The brain in fatu- 
 ous persons appears to have been early observed by Tulpius, Ker- ij 
 kringius. King, and Scheide, to be soft and flaccid. This fact, 
 which was repeated by Morgagni, was afterwards verified by John 
 Ernest Greding of Waldheim, who, in 1771, in an elaborate de- I 
 scription of the abnormal changes found in the brains of epileptic 
 maniacs, states, that in more than one-half (fifty-one cases) the 
 brain was either universally or very generally, especially in its jj 
 
 central parts, unusually soft and flaccid ; and that though this may i 
 
 not be a uniform cause of deranged intellect, it is a frequent ac- 
 companiment of the state of the brain on which this depends.f In 
 twelve cases the vault and septum were so soft, that spontaneously 
 or by a sliglit touch they were reduced to thin pulp. 
 
 Among thirty-seven cases of this form of cerebral disorder in- 
 spected by Haslam, in seven the substance of the brain was soft, |: 
 
 very soft, or doughy with abundance of red points, the usual i 
 
 indications of capillary injection, and effusion of serous fluid, the 
 effect of meningeal injection, j Among the dissections of Dr Mar- 
 shall, not more than one belongs to this head,§ (case, 6th p. 202.) 'i 
 This change depends on chronic injection of those capillaries of the ; 
 vascular membrane {pia meninx) which are distributed through the j 
 brain. 
 
 11. Sclerenheplialia. Induration of the brain. — That the brain 
 may acquire an unnatural degree of firmness, and perhaps of den- 
 sity, is well established from the observations of Morgagni, Meckel, 
 Greding, Haslam, Marshall, Serres, Lallemand, Lerminier, Pinel 
 Jun., Bouillaud and Gaudet. Instead of the usual compressible 
 elastic character which it presents in the sound state, it may be- 
 
 * Histoire de I’Acad. Royale des Sciences, An. 1705. 
 
 -j- MelanchoUco-Maniacorum et Epilepticorum in Ptochotropheo Waldheimensi 
 demortuorum sectiones tradit Joannes Emestus Greding. Cent. 2da, Apud Ludwig 
 Adversaria, &c. Vol. ii. partem 3tiam, p. 533. 
 
 J Observations on Madness and Melancholy, &c. By John Haslam, 2d edition, i[ 
 London, 1809. Cases 4, 10, 18, 25, 28, 30, 37. 
 
 § The Morbid Anatomy of the Brain, &c. London, 1815. 
 
ERAIN. 
 
 321 
 
 come like coagulated or boiled albumen, or may approach in 
 consistence to that of the brain which has been immersed in strong 
 alcohol or dilute acid. From the facts hitherto collected, this in- 
 duration appears to be of two kinds, according as it takes place in 
 a shorter or longer period. 
 
 a. According to the facts collected by Bouillaud, a general in- 
 duration of the brain may take place within ten or fifteen days be- 
 fore death, with more or less redness and injection of the cerebral 
 substance. By M. Gaudet this change is conceived to be one of 
 the material causes of ataxic, (typhoid) fever This is not very 
 widely different from the view of Bouillaud, who, like M. Brous- 
 sais, regards it as the result of meningo-encephalic inflammation, f 
 
 Notwithstanding the authority of these observers, I think it 
 doubtful whether this change can be supposed to take place in the 
 short period assigned for it Is it not more reasonable to think 
 that this change hatl pre-existed for some time, and that it ter- 
 minated in a more acute disorder of the organ or its membranes, 
 which proved fatal ? 
 
 13. The chronic induration of the brain has been long known. 
 Originally observed by Littre, Geoffrey, Boerhaave, LancisI, and 
 Santorini, it was recognized by Morgagni as a morbid change 
 which occasionally caused more or less mental derangement. J J. 
 F. Meckel afterwards undertook to establish this doctrine more 
 fully, and to show that the organ is harder and more elastic than 
 natural. With this change, however, he rather paradoxically con- 
 nects another, diminution of specific gravity, and finds that a cube 
 of six lines of indurated brain is from 1-| to 2 grains lighter than a 
 cube of the same size of sound brain. In six among fifteen cases 
 given by this author, the brain was much firmer than natural ; in 
 some as hard as indurated white of egg, and always elastic. § 
 
 This result, though not entirely, is partly verified by the re- 
 
 * Recherches sur rendurcissement general de I’encephale, consideree comme une 
 des causes materielles des fievres dites ataxiques, par M. Le Docteur Gaudet. Paris, 
 1825. 
 
 t Observations et Reflexions sur I’induration generale de la substance du Cerveau, 
 consideree comme un efiet de I’encephalite generale aigue, par M. Bouillaud. Ar- 
 chives Generales, Tome \dii. p. 477. 
 
 J Epistola Anatomico-Med. viii. 4 — 18. 
 
 § Recherches Anatomico-Physiologiques sur les causes de la Folie qui viennent du 
 vice des parties internes du corps humain, par M. Meckel. Mem. de TAcademie 
 Royale de Berlin, Tome vii. p. 306, art. 92. Avignon, 1768. 
 
 X 
 
322 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 searches of subsequent inquirers. Greding, whom I have already 
 mentioned as having found the brain in a large proportion of cases 
 softer than natural, found it in thirty-nine cases natural in consis- 
 tence, firm, or even exceeding the natural firmness.* * * § He thinks, 
 however, that this difference is more in word than reality. Of the 
 thirty-seven cases inspected by Haslam, in nine the brain was un- 
 usually firm, in one (24) remai’kably so, and in one (29) elastic.f 
 In all the cases given by Dr Marshall, except two, again, amount- 
 ing to fifteen, the brain was unusually firm and generally elastic.^ 
 The cause of this change, and the means by which it is effected 
 are entirely unknown. It is conjectured that it is a result of in- 
 flammation ; and it may be admitted as a proof of this, that the 
 brain is almost invariably penetrated with numerous loaded capil- 
 laries, and that more or less effusion of serous fluid is found be- 
 neath the arachnoid membrane and in the cavities. These, how- 
 ever, might be effects of the induration, or at least of the concomi- 
 tant capillary injection. M. Serres has seen cases of cerebral in- 
 jection and hemorrhage causing apoplectic symptoms terminate in 
 induration ;§ and Lallemand,|| Bouillaud,^ and Pinel,** have found 
 portions of the brain indurated in connection with chronic inflam- 
 mation. But whether this is to be viewed as the result of capillary 
 injection or of some derangement in the process of nutrition, it is 
 at present impossible to determine. It would be desirable to as- 
 certain chemically the exact nature of the change which takes place, 
 and in what respect the indurated cerebral matter differs from that 
 of the normal state. It is possible that the albuminous substance 
 may be either changed, or in greater proportion ; but on this point 
 no accurate observations have hitherto been made. 
 
 Whatever be the agent or means of this change, nevertheless, 
 enough is known to show that when it exists, it is in general ac- 
 companied with an injected state of the cerebral capillaries, and 
 
 * Adversaria Medico-Practica. Lud\vigf, Tom. ii. p. 3ti», p. 533. 
 
 t Observations on Madness and Melancholy, &c. Lond. 1809. 
 
 + The Morbid Anatomy of the Brain, &c. Lond. 1815. 
 
 § Annuaire Medico-Chirurgicale. 
 
 II Recherches Anatomico-Pathologiques, &c. Lettre 2xieme, cases 30, 31, p. 3U.j 
 and 313. 
 
 U Traite Clinique et Physiologique de PEncephalite, Obs. 40, p. 198. 
 
 ** Recherches d’Anatomie et de Physiologie Pathologiques sur les Alterations do 
 TEncephale. Bulletins, &c. chez Revue Medicale, Tome vi. Paris, 1821, p. ,298 and 
 31.5. 
 
BRAIN. 
 
 323 
 
 1 
 
 that it gives rise to loss of memory, confusion of thought, and de- 
 rangement of the mental faculties. It appears, indeed, to be a fre- 
 quent cause of insanity, especially when permanent, without lucid 
 interval ; and if long continued, it may cause that complete obli- 
 teration of the intellect which constitutes fatuity ; {dementia.) The 
 cerebral arteries are generally found opaque, and affected with 
 steatomatous deposition. (Marshall.) 
 
 From slight induration of a great part or the whole of the cere- 
 bral mass, to considerable induration of particular regions, the 
 transition is easy. According to the researches of INI. Pinel the 
 younger, who has examined the subject with particular attention, 
 in the change from sound brain of natural consistence to that of 
 final, compact, and apparently inorganic induration, two distinct 
 stages may be recognized. 
 
 a. From the observations of MM. Foville and Pinel-Grand- 
 Champ, it results that in certain persons the exterior or peripheral 
 part of the brain is liable to a state of capillary injection or chronic 
 inflammation ; in other words, that the meningeal and encephalo- 
 meningeal capillaries may become the seat of a process of injection 
 partly chronic, partly intermittent, or variable, according to the 
 state of the vascular system in general, and the operation of va- 
 rious exciting causes. One of the effects of this encephalo-menin- 
 geal injection is to tinge of a red colour more or less deep, the gray 
 colour of the convoluted surface ; and while the injection produces 
 more or less mental derangement, this red tint is connected almost 
 invariably with furious and maniacal paroxysms. When it pro- 
 ceeds to fatuity, albuminous deposits take place on the surface, or 
 on the membranes of the brain ; and the gray substance becomes 
 very pale, and softer or firmer than natural.* 
 
 I have above said that the subacute or chronic cerebral inflam- 
 mation which terminates in pulpy destruction is a frequent patho- 
 logical cause of mental derangement. In general the disease is 
 then of shorter duration, and terminates sooner either in convales- 
 cence or in death. A more chronic form, however, is connected 
 with this encephalo-meningeal congestion, the duration of which 
 may vary from twelve or fifteen months to as many years. At the 
 termination of these periods the cerebral substance is compact, re- 
 markably white, appears void of blood-vessels and capillaries, is 
 
 , • Recherches sur les Causes Physiques de PAlienation mentale. Par M. Pinel 
 
 1 Fils, D. M. P. Journal de Physiologie, Tom. vi. p. 44. A Paris, 1826. 
 
 I 
 
324 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 diminished in volume, no longer falls under the fingers, but is torn 
 with difficulty, and recoils with elasticity when stretched. It as- 
 sumes a horny hardness under the action of fire or nitrous acid. 
 These circumstances show that it contains altered albuminous mat- 
 ter. The gray matter also is thinner and paler than natural, and 
 seems to be confounded with the white. 
 
 The effects observed to accompany this change are defect and 
 progressive loss of memory, inattention to momentary impressions, 
 apathetic indifference to the present and the future, and slight diffi- 
 culty of articulation, followed by abolition of appetites, desires, and 
 ideas, increased loss of speech, palsy, or at least want of command 
 over the muscles, fatuity, wasting, and death. 
 
 That this change in the consistence of the brain is the result of 
 a slow organic process succeeding to inflammation, M. Pinel infers 
 from the symptoms during life, from the collateral effects after 
 death, and from the state of the meningeal and cerebral vessels 
 which is known to precede the change. That this is not remote 
 from the truth many circumstances tend to show. I have above 
 mentioned the relation between hemorrhagic injection of the brain 
 and induration as noticed by M. Serres and Bouillaud. A proof 
 still more unequivocal is found in the fact, that inflammation, both 
 in the membranes and in the cerebral substances, is known to be 
 followed by induration of the latter. Thus Abraham Kaawe Boer- 
 haave mentions the case of a soldier cut off by an epileptic at- 
 tack, in the head of whom, besides firm adhesion of the dura mater 
 to the inner table and the pia mater^ with tubercular deposition, 
 the subjacent convoluted gray substance was hard and scirrhous in 
 various places.* The cheese-like induration recorded by Lalle- 
 mand in the thirtieth case of his second letter is adduced elsewhere. 
 Here, however, I may mention, that in a man of 55, in whom fixed 
 pain of the forehead, slight palsy of the face, and confusion of me- 
 mory were soon followed by death, he found the membranes firmly 
 matted together for the extent of a thirty sous piece at the outerf 
 end of the left hemisphere, and the subjacent cerebral matter, also 
 adhering to the membranes, hardened to scirrhous or cartilaginous 
 firmness. 
 
 Lastly^ M. Bouillaud records a case, in which a man of 68, who, 
 
 • Commentarii de Rebus in Scientia Naturali, Vol. i. Pars i. p. 234. 
 
 -f- Recherches Anatomico-Pathologiques sur I’Encephale et ces dejrondances, par 
 F. Lallemand. Paris, 1820, p. 313. 
 
 4 
 
BRALV. 
 
 325 
 
 after cerebral disease, regarded as chronic softening, laboured un- 
 der impaired memory, headach, and difficulty of expressing ideas, 
 terminating in muscular weakness, and fatal convulsions. In this, 
 with injection of the cerebral substance, was induration passing from 
 the striated body of the left hemisphere through the nucleus, at the 
 upper region of which it formed a cavity with hard yellow M'alls, 
 and a similar hardened portion in the posterior lobe.* 
 
 The disease is not very frequent in this country. One very 
 well marked case, however, came within the sphere of my observa- 
 tion, and was inspected by me after death. The following was the 
 state of the hrain. A considerable portion of the outer part of the 
 left hemisphere was unusually firm and hard, not dissimilar to 
 cheese. The space so changed was a sort of crescentic segment of 
 the hemisphere, being about three-fourths of an inch, or one inch 
 broad in its middle, which corresponded with the middle of the 
 hemisphere, and tapering away to a narrow line or point before 
 and behind. The induration ascended to the upper part of the 
 hemisphere to within one inch of the mesial plane and mesial fis- 
 sure, and below it approached close on the hippocampus major^ 
 part of which was involved in the induration. The indurated seg- 
 ment thus formed, was bounded, as it were, between the segments 
 of two spheres of unequal diameter, the external one being the small- 
 est or of greatest curvature. The portion when divided cut firm, and 
 did not fall down or dissolve on exposure to air. The pia mater 
 adhered to it most firmly, and seemed to be thickened over the in- 
 durated portion. The convolutions were flattened and depressed, 
 and presented in this respect an obvious difference . from those of 
 the opposite hemisphere. At the internal margin of the indurated 
 portion was a band or zone of cerebral substance distinctly soften- 
 ed, while within that again the rest of the brain presented its 
 natural consistence. The indurated portion, both gray and white, 
 presented, I thought, very few small vessels, but a few large ones 
 dispersed through the mass. 
 
 Serous fluid, to a small extent, was effused into the subarach- 
 noid tissue, mostly at the apex and base of the organ, and also 
 within the ventricles. 
 
 To the best of my remembrance, this is the only case of indura- 
 tion of the brain, in which that lesion was associated with softening 
 
 * Traite Clinique et Physiologique de I’Encephalite, Observ. xL p. 200. 
 
326 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 inside. The latter I ascribe to a secondary orgasm or vascidar ac- 
 tion caused by the presence of the indurated portion, nearly as the 
 presence of tumours is occasionally observed to induce softening. 
 
 In this case the individual, a young man about 30, had long 
 laboured under bad health, latterly with epileptic fits of frequent 
 recurrence. The last time T saw him alive, he was dragging his legs 
 in a semiparalytic manner, had an expression approaching to fa- 
 tuous, did not readily comprehend what was said to him, and looked 
 thin, pale, and haggard and stupid. He had consulted or been 
 under the care of different physicians, all of whom diflfered more 
 or less in opinion as to the exact cause of his symptoms. Between 
 three or four weeks after I saw him, he fell into a stupid and co- 
 matose state and died. 
 
 From these and similar facts, no doubt can be entertained of 
 the tendency of the process of inflammation to indurate the brain 
 under certain circumstances. The difficulty consists in ascertain- 
 ing what are the conditions under which a process usually termi- 
 nating in softening should give rise to an opposite change. It is 
 probably premature to attempt any explanation of a process so 
 contradictory in appearance. I shall merely say, that induration 
 seems in general to be occasioned by the encephalic capillaries 
 having their nutritive action so much injured by the inflammatory 
 process, that they cease to deposit healthy cerebral substance. 
 
 The induration now described commences generally in the base 
 of the brain by the hippocampus major, {cornu ammonisj) and these 
 extends to the neighbouring parts. If confined to the brain only, 
 it causes, according to hi. Pinel, mere fatuity, (dementia,) with 
 more or less palsy. But if it affect the annular protuberance, the 
 limbs, or the olivary bodies, or the chord itself, epilepsy, general 
 palsy, and death by marasmus, are the usual consequences. 
 
 b. The change which produces fatuity is the early stage of a 
 more serious lesion of the cerebral substance, atropine hardening, 
 (sclerenhenplialia,) an extreme state of induration found in the 
 brains of idiots. From that already described, it differs chiefly in 
 degree. A portion of brain so changed becomes a compact inor- 
 ganic looking mass, resembling in colour, consistence, and density, 
 indurated egg or even cheese. The cerebral substance is depressed, 
 shrunk, and condensed, and seems utterly void of vessels or ca- 
 pillaries. When exposed to the action of fire, instead of swelling 
 up without odour, and leaving a brownish light residue, it assumes 
 
BRAIX. 
 
 327 
 
 a horny hardness, emits a strong heavy smell, and leaves a com- 
 pact shining blackish residue. This hardening affects the white 
 matter more than the gray, in which ]\I. Pinel has not yet recog- 
 nized it,* * * § 
 
 This change is connected with idiocy either congenital or ob- 
 served soon after birth, in some instances with fatuous stupidity and 
 palsy. In one of the cases, however, the individual appears to have 
 possessed faculties of the ordinary degree of intelligence, till the 
 age of 49, after which repeated attacks of palsy terminated in calm 
 but complete fatuity, (dementia.) 
 
 That the spinal chord is liable to the same change in consistence 
 is proved by the case of Count de Lordat, (Med. Obs. and Inq. 
 Vol. III. p. 270,) and that of M. de Causan, recorded by Portal, 
 in which the cervical portion was so hard as to resemble cartilage, 
 and the membranes were red and injected. This change gave rise 
 to palsy, proceeding fi-om the tingers up the arms of the right side, 
 and from the feet, till the legs lost power, and the whole side be- 
 came atrophied, and eventually the same phenomena in the left 
 side. Similar examples are given by Bergamaschi.f 
 
 \2. Hypertrophy of the Brain. (Hypertrophia.) Though among 
 the writings of authors on morbid anatomy slight notices are found 
 of the lesion characterized as hypertrophy of the brain, and it was 
 mentioned by Bouillaud, as a peculiar lesion, it was not made the 
 subject of special observation, until M. DanceJ and ]\I. M. Laennec,§ 
 cousin of M. R. T. Laennec, and M. Scoutteten in 1828,|| all within 
 a short period, gave examples of it. And in 1835, Dr Sims com- 
 municated to the Medico-Chirurgical Society of London a memoir, 
 containing much information on the characters and nature of hyper- 
 trophy and atrophy of the brain. From the facts given by these 
 authors, it results, that the brain is liable to undergo a morbid 
 
 * Recherches de I’Anatomie Pathol, sur PEndurcissement, &c. par M. Pinel Fils. 
 Joum. de Ph}'sioL Tome ii. p. 191. 
 
 -f- Sulla Mielitide Stenica, &c. Pa\ia, 1820. 2d. 4th, 8th. 
 
 t Observations pour servir a PHistoire de PHypertrophie du Cerveau. Par M. 
 Dance. Breschet, Repertoire Gendral d’Anatomie et de Physiologie Pathologique, 
 Tome V. p. 197. Paris, 1828. (Four cases in adults of 26, 24, and 30 years of age.) 
 
 § Observations sur PHy'pertrophie du Cerveau. Par Meriadee Laennec, M. D 
 Revue Medicale, Decembre 1828. (Five cases, a woman of 32, a woman of 22, a girl 
 of 13 ; and two men of 43 and 44, both white-lead manufactiu'ers.) 
 
 II Observation sur une Hypertrophie du Cerveau. Par M. Scoutteten, M. D. Ar- 
 chives Generates de hledecine. Tome VIII. p. 31. (Case of a boy aged 5i years.) 
 
328 
 
 GENERAL AND PATHOLOGICAL ANATOMY, 
 
 increase in nutrition, distinguished by flattening and approximation 
 of the convolutions, narrowing and diminution of the dimensions of 
 the ventricles, universal firmness and whiteness of its gray and 
 white substance, remarkable dryness of its parenchymatous matter, 
 and of the cavity of the arachnoid membrane ; while the texture of 
 the organ appears not to be sensibly changed ; Id, that this hyper- 
 trophy is constantly observed over the whole encephalic mass, ex- 
 cluding the cerebellum / and, 3c?, that, instead of increasing the 
 energy of the cerebral action, it tends, on the contrary, to diminish, 
 pervert, and suspend that action, by reason of the compression which 
 it necessarily establishes within the cranium. 
 
 The leading anatomical and physical characters of hypertrophy^ 
 therefore, are the following. Increase in the volume of the brain, 
 such that its internal substance presses forcibly the convolutions 
 against the inner surface of the skull and against each other, and 
 thei’eby flattens and depresses these bodies, and causes them to ap- 
 proximate ; while the same internal substance, by pressing the ven- 
 tricles, diminishes their cavity. Increase in weight and density, which 
 is said to have been ascertained in all the cases, the specific gravity 
 being increased. The substance of the brain is also firm, as much 
 as boiled white of egg, pale, and void of blood-vessels, while it is 
 unusually dry. From all these circumstances, it results that this 
 lesion consists in the deposition or addition of new matter in the in- 
 terstitial tissue of the brain ; in short, a great increase in nutrition. 
 
 The effects and symptoms of this lesion, though always present, 
 are not uniform. It is usually preceded or attended by intense 
 headachs, subject to aggravation ; an obtuse or weakened state of 
 the intellectual faculties, perversion of these faculties, and fits of 
 giddiness accompanied with stupor. Afterwards accessions of con- 
 vulsion repeatedly take place, or all at once the patient suffers a 
 general loss of sensation and motion. The pulse is slow ; the tem- 
 perature of the skin natural. Lastly, the patient is unexpectedly 
 cut off in the course of an epileptiform accession. 
 
 The circumstances, under which this disease is developed, are not 
 well ascertained. According to M. Dance, it appears to take place 
 very slowly under the influence of very obscure causes. M. M. 
 Laennec, again, thinks that it is developed much more rapidly than 
 any other hypertrophy ; and in this respect he allows that it resem- 
 bles the lesions of inflammatory character. All the cases given by 
 M. Dance took place in adults. One case given by Laennec was 
 
BRAIN. 
 
 329 
 
 in a young girl of thirteen. The case given by Scoutteten took 
 place in a cliild of five and a-half, with a head so large and heavy, 
 that whenever the child attempted to run, he fell forward from the 
 great weight of the head. Three of the cases given by Laennec took 
 place in persons employed in white-lead manufactories, and liable to 
 lead colic ; and of the four cases given by M. Dance, two occurred 
 in house-painters. The disease had not then been observed in per- 
 sons above 50. In most of the cases, the patients were between 20 
 and 30 ; in two cases among fourteen, the individuals were 37 and 
 39 years of age; and in two men 43 and 44 years of age. 
 
 Andral thinks that the lesion takes place, as it were, in two 
 stages or periods ; that in the first the disease appears like a chro- 
 nic affection, with headach, hebetude of the intellectual faculties, 
 and similar phenomena ; and that in the second, which is attended 
 with epileptiform convulsions, it presents all the characters of an 
 acute and speedily fatal lesion.* 
 
 Dr Sims gives the details of fifteen cases, which tend partly to 
 confirm, partly to modify the results now stated. Among these fif- 
 teen cases, in the first place, the ages of the subjects were as follow. 
 One at 1 1 months ; one at 3 years ; two at 10 years ; one at 16 ; one 
 at 22 ; one at 24 ; two at 29 ; two at 40 ; one at 48 ; two at 60 ; and 
 one at 70. Of none of the cases is the occupation stated, all hav- 
 ing been occupants of the St Mary-le-bonne Charity Workhouse. 
 Eleven were females and four males. Though in most of the cases 
 portions of the brain were unusually firm and consistent. Dr Sims 
 extends the term hypertrophy to cases also, in which the brain is 
 unusually large, without increased consistence. Dr Sims further 
 recognizes two forms of hypertrophy ; one a state of mere enlarge- 
 ment or addition of particles, without appreciable difference from 
 the ordinary state of the organ, congenital or connected with rickets, 
 and early evincing its presence ; the other connected with increased 
 weight of the brain, the flattening of the convolutions, the white and 
 albuminous appearance, and tbe bloodless state of the organ. It is 
 chiefly the latter form of the disease which corresponds with that 
 described by Dance, Laennec, and Andral. He confirms the con- 
 
 * Clinique Medicale. Par G. Andral, il. D., on Choix d’Observations, &c. Li\Te 
 premier ; Itrieme ordre ; 3ieme edit. 1834. Paris. (Three cases ; a female of 27, a man 
 of 29, and a man of 39.) 
 
 Case of Hypertrophy of the Brain, with Spontaneous Obstruction of the Humeral 
 Artery, &c. By Dr Christison. Edin. Med. and Surgical Journal, VoL XLII. p. 257. 
 (A female aged 37, Edin. 1831,) published 1834. 
 
330 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 elusion of these authors that the change affects, so far as is hitherto 
 known, the brain* alone, and not the cerebellum ; but he modifies 
 their inference, that it affects the whole organ. Though this does 
 take place, yet hypertrophy may be partial, affecting only one he- 
 misphere, one lobe, one corpus striatum, or one optic thalamus. He 
 finds, lastly, that the brain may be, in certain circumstances, un- 
 usually large, yet not amounting to hypertrophy, in persons dying 
 of various diseases ; for instance, extensive pneumonia and other 
 diseases of the lungs and heart ; and then the brain is generally 
 very much loaded with blood.* 
 
 From this account it appears that cerebral hypertrophy differs 
 little, if at all, from what is above described as induration of the 
 brain. 
 
 13. Atrophy of the Brain. (^CerehrumEbriosorum; Cerebrum Biha- 
 cium.') The Spirit-dr inker's Brain. The term atrophy is employed in 
 two senses, something different. In one sense, it is employed to in- 
 dicate diminution in the size of the brain, and especially of its convo- 
 luted surface. The convolutions are shrunk, small, narrow, and occa- 
 sionally soft ; the sulci are large and open ; and the brain recedes from 
 the interior of the skull; while the subarachnoid tissue is very much 
 loaded with serous fluid, which has the appearance of a jelly invest- 
 ing the whole brain. This is observed, not only along the superior 
 and lateral regions of the hemispheres, but all over and at the base 
 of the bi'ain. This shrinking of the brain and the supplying of the 
 place by fluid, may amount to the thickness of about one crown- 
 piece, or even two crown-pieces, all over ; and in some extreme 
 cases the shrinking and the filling with serous fluid in the sub- 
 arachnoid tissue amounts to the extent of half an inch in thickness. 
 
 The brain is, at the same time, very soft and watery ; large 
 quantities of fluid escaping both from the convolutions, when the 
 membranes are cut, and from the white substance of the hemi- 
 spheres. The ventricles also are enlarged and capacious, and al- 
 most constantly contain serous fluid in considerable quantity. Much 
 also is found in the lower part of the brain, and escapes from the 
 cavity of the spinal chord. 
 
 This is general atrophy of the brain, or atrophy of the convolu- 
 tions ; and it is supposed to depend on wasting and actual loss of 
 the cerebral substance, both wdiite and gray, while the place of the 
 lost matter is supplied by serous fluid. 
 
 * On Hypertrophy and Atrophy of the Brain. By John Sims, M.D. Medico-Chi- 
 riirgical Transactions, XIX. 315. London, 1835. 
 
BRAIN. 
 
 331 
 
 This is one mode of accounting for this sort of atrophy ; and it 
 is probable that to many examples of the disease it correctly applies. 
 It may be quite true, for instance, of tbe atrophy taking place in 
 old age and in various enfeebling diseases, in which all the Organs 
 suffer more or less waste and loss of substance from imperfect nu- 
 trition ; and in general steatomatous and osteosteatomatous disease 
 of the arteries of the brain. This form of atrophy is nevertheless so 
 frequent in persons who are much addicted to the use of spirituous 
 liquors, to whisky-drinkers, gin-drinkers, and brandy-drinkers, and 
 is so common in those who have either had delirium tremens^ or who, 
 after- a long course of moderate but steady di-inking, have died either 
 of that or some similar affection, that the shrunk convolutions and 
 watery state may be regarded as characteristic of the drunkard’s 
 brain. I do not say that atrophy of the brain does not take place 
 in the temperate. But it is so constantly observed in connection 
 with the habit of incessant drinking, that it may, in a large pro- 
 portion of cases, be considered as the effect of that habit. 
 
 Local forms of atrophy are also observed. Thus portions of the 
 convoluted surface may be depressed, and yellowish and covered 
 with fluid within the membranes. These are the remains of some 
 former congestion of the part. The surface or substance of one 
 corpus striatum may be depressed and, as it were, abraded ; or the 
 surface of one optic thalamus may be less developed than that of 
 the opposite side. These are mostly the effects of some previous 
 attack of capillary congestion, sometimes with effusion of a little 
 blood, or an attack of softening which had stopped spontaneously. 
 
 This local form of atrophy has been examined by Dr Sims ; and 
 it seems quite certain, that these local losses of substance were the 
 effects of previous attacks of disease. Among four cases fully de- 
 tailed, and eleven cases noticed by this author, nine took place in 
 persons above 70 years of age, and in whom they were associated 
 with, or preceded by, attacks of cerebral disease of different kinds ; 
 and two were observed in persons above 60, both with marks of 
 diseased brain. In the other four also, though young persons, very 
 considerable morbid changes of different kinds had taken place in 
 the brain and its membranes.* 
 
 Lastly, the term atrophy has been employed by Cruveilhier to 
 designate that extensive deficiency of portions of the brain which 
 
 * On H^'pertrophy and Atrophy of the Brain. By John Sims. Jledico-Chirurgical 
 Transactions, London, Vol. XIX. p. 364. London, 1835. 
 
332 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 takes place in the foetus, in consequence of diseased action during 
 intra-uterine life. This is altogether different from the sense in 
 which the term, as above explained, has been employed ; for the 
 atrophy in the cases here considered is not congenital, but acquired 
 in the progress of life. The atrophy of Cruveilhier, on the other 
 hand. Is congenital, and is the most common cause of idiocy. As 
 such it is considered under the head of Anencephalous Malforma- 
 tion or Deficient Brain, (Enkephalelleipsis.') 
 
 14. Organic changes, morhid growths, or tumours . — Of these va- 
 rious forms have been observed by different authors. But they 
 have not in all instances distinguished accurately between tumours 
 originating in the cerebral substance, and those which, originating 
 in the membranes, affect the substance of the organ secondarily. 
 As this distinction must be observed, at least in pathological ana- 
 tomy, I shall not be liable to the charge of futile innovation, if I 
 attempt to trace the distinction in the following sketch. 
 
 The different forms of tumour occurring in the brain may be 
 referred to the following heads : a, the simple cerebral tumour ; (3, 
 the adenoid or fleshy tumour ; 7, strumous tumours, comprehend- 
 ing tubercles and tubercular deposits ; S, the gelatiniform tumour, 
 (colloma ;) s, the adipose, lardaceous, or wax-like degeneration, (cc- 
 roma ,-) the cholesterine tumour, (margaroides ;) »j, the cartilagi- 
 nous tumour, (^chondroma;) 6, calcareous or bony deposits; /, en- 
 cysted tumours, including o, the hydatid-cyst or vesicular tumour, 
 b, the blood cyst, (Jicernatoma,) c, the fungoid tumour, and iZ, the 
 melanotic cyst. 
 
 a. Simple cerebral tumour. {Scleroma.) Of considerable indura- 
 tion of particular regions of the brain, I have already spoken. 
 When the indurated portion is definite in limits, and the rest of 
 the organ preserves its usual characters, these indurated portions 
 have been vaguely described under the general name of tumours. 
 It is more correct, however, to regard them as portions of brain 
 indurated to an unusual degree, and perhaps changed in intimate 
 structure. As the simplest form of tumour incident to the brain, 
 this claims the first place. 
 
 Of this change the most authentic examples have been recorded 
 by Platerus, Meckel, Roedei’er, Perotti, and Greding. From the 
 descriptions given by these authors, part of the cerebral substance 
 appears to acquire unusual firmness, and to become somewhat like 
 coagulated albumen. It is not much changed in colour, unless in 
 losing some of its whiteness, and assuming a pale yellow or orange- 
 
BRAIN. 
 
 333 
 
 gray tint. The surrounding cerebral substance is almost invari- 
 ably softened. Water is effused into the ventricles ; and if the in- 
 dm'ated mass is seated near the convoluted surface, the membranes 
 become opaque and thick, and morbidly adherent. 
 
 The following references to the cases will communicate some idea 
 of the nature of this change. 
 
 Felix Platerus, Kb. i. p. 108. — In the fore part of the left hemisphere of a man of 
 24, who had headach, amaurosis, and mental imbeciKty, a globular tumour like a gland, 
 as large as a hen’s egg, but irregular, and Kke a pine cone ; its interior substance white, 
 firm, and uniform, Kke boiled egg, but harder, inclosed in a firm vascular membrane. 
 Weight 14 oz. 
 
 Buonaventura Perotti in Raccolta d’OpuscoK Scientifici e Fisiologici in Venezia, 
 Tom. xlvK. p. 339. 1751. — A woman of 25, who had headach for several years, died 
 
 lethargic. The convoluted gray matter of the left hemisphere was destroyed. In the 
 right hemisphere, though externally sound, a hard body as large as a nut penetrated 
 from the gray to the white interior substance. — Commentar. de Rebus in Scientia Na- 
 turaK et Medicina observatis, Vol. Ki. 
 
 Meckel, Mdmoires de I’Academie Royale de BerKn, 1761. Tom. vii. — In a man of 
 SO, right hemisphere externally harder, more resisting and more elastic than natural. 
 Left hemisphere before the same ; posterior lobe soft ; upper posterior part of left he- 
 misphere firm ; pia mater opaque and thickened; arachnoid adhering to dura mater ; 
 substance of the hemisphere posterior to corpxts striatum soft, diffluent, and moist with 
 fetid serum. In the posterior part of the left hemisphere, behind the ergot, a hard 
 body, the size of three nuts, consisting of three spherical protuberances, aggregated to- 
 gether, weighing 2 oz. and 2 drs. ; surrounding substance soft and pulpy. 
 
 In a child of 4, the white matter of the posterior lobe of the left hemisphere a scir- 
 rhus (hardened mass) the size of a nut ; surrounding part vascular and injected. 
 
 Roederer, J. G. Programma de Cerebri Scirrho, Goettingae, 1762. This after some 
 search 1 have not been able to see. 
 
 Vincenzio GalK negK atti dell’ Academia deKa Scienzi di Siena delta Fisico-critici, 
 Tom. K. — A man of 40, who had laboured under severe cephalalgia, which was reKeved 
 by venesection, but afterwards recurred irith giddiness and delirium, terminating in 
 death. Inflammation of the membranes ; effused serum in the cavities ; in the right 
 ventricle, stretching from the optic thalamrus to the corpxts striatum, a tumour as large 
 as a hen’s egg, \vith irregular surface, and external substance dense, firm, and ash- 
 coloured. 
 
 M. Marcot, chez Memoires de la Societe de MontpelKer, Tom. i. p. 334. Lyon, 
 1766. — A man of 47, attacked mth giddiness, headach, impaired fusion, palsy of right 
 side, followed by paraplegia, concisions, lethargy, and apoplectic death. The poste- 
 rior part of the brain corresponding to the tentorium, to the branches and Kmbs of the 
 vault (fornix ), was scirrhous and almost cartilaginous, requiring to be divided by good 
 scissors, and grating against the cutting instrument. 
 
 F. Lallemand, Recherches Anatomico-Pathologiques. Paris, 1820. Lettre 2xieme, 
 No. 30. 1820.^ — A girl of 14, ivith right hemiplegj’, followed after four months by 
 
 paraplegjq uisensibiKty of the skin, palsy of the sphincters, and paralytic dyspnoea ad- 
 vancing progressively to fatal asphyxia. The white matter of the left hemisphere, 
 immediately above the lateral ventricle, for the space of 1 ^ inch long, 1 inch broad, 
 and 2 or 3 Knes thick, converted into a hard substance Kke Gruyere cheese, and re- 
 sisting the knife. 
 
 Dr Abercrombie, Researches, &c. p. 431. Notes. — In a child of 4, unable to walk. 
 
334 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 with imjjei'fect articulation, deficient intelligence, difficult deglutition and respiration, 
 and frequent convulsions, terminating at the end of eighteen months in death, the oli- 
 vary bodies, peduncle of the cerebellum, and mammillary eminence, were in a state of 
 cartilaginous hardness. 
 
 M. Andral Fils, Journal de Physiologic, Tome ii. p. 111. 1 822. — In a girl of about 
 
 20 months, with alternate motion of the head to the right and left, terminating in fatal 
 coma, without convulsion or palsy, several of the convolutions of both hemispheres had 
 become extremely hard, and assumed the colour of ivory; When pressed between 
 the fingers they resisted like fibro-cartilage ; when drawn, they recoiled. Similar in- 
 durations were found in the substance of the liemisirheres to their base. The right 
 hemisirhete of the cerebellum contained a round cyst uith smooth walls, of the capa- 
 city of a nut, containing minute, hard, irregular shaped concretions, of strong consis- 
 tence, and similar to the spiculre of a fractured bone. 
 
 M. J. Bouillaud, Traite de I’Encephalite. Paris, 1825. P. 161, Obs. 33. — A man 
 of 57, with impaired sireech, after a cerebral disorder ; in the anterior lobe of the left 
 hemisphere an albuminous mass, the size of an egg, sprinkled with drops of blood, and 
 drops of purulent fluid. 
 
 Ibid. Observat. 36, p. 183. — A man of 57, wnth right hemiplegy, intellectual imbe- 
 cility, and involuntary reiretition of the last words siroken to him, after an apoplectic 
 attack, terminating in complete fatuity^ and death, rvith injection of the membranes 
 and cerebral substance, in the anterior third of the left hemisphere was found an in- 
 durated nut, the size of an egg, surrounded by bloody clots and distinct injection. A 
 longitudinal section presented yellowish colouring and red-broum' points, depending on 
 the presence of blood coloured with the substance in which it was effused. The sub- 
 stance of the indurated mass resembled concrete pus mixed with blood, grating under 
 the knife, and containing minute bloody effusions with filamentous substance, and, 
 though much firmer' than the rest of the brain, falling easily under the finger. It was 
 separated from the surrounding brain by a circle of well injected capillaries. In the 
 middle lobe of the same hemis]5here was a similar mass, less extensive, and rather 
 softened than indurated. 
 
 This appears to be an albuminous tumour in its early stage. 
 
 In the following cases the diseased change was found in the ce- 
 rebellum. 
 
 Joannis Harder!, Apiarum Basilese, 1687. 4to. Observat. 58, p. 238. — A girl of 
 17, of scrofulous habit, who suffered severe lancinating pains of the head, followed by 
 fatal convulsions. The membranes containing much yellow serum ; vessels minutely 
 injected ; in the cerebellum, near its termination, three hard globular bodies, (scirr/w,) 
 one as large as a nutmeg in the beginning of the spinal chord. They contained yel- 
 lowish matter of considerable consistence. 
 
 Ephemerides Naturte Curiosse. Decade iii. Ann. iv. p. 148. — In a hydrocephalic 
 subject, the cerebellum indm-ated, adhering to the dura mater and skull without inter- 
 mediate cavity. 
 
 J. Mar. Lancisi, De Noxiis Paludum Effluviis, Lib. ii. Eqiid. iii. c. vi. 21 8. — In the 
 cerebellum of a man subject to convulsions, cut off by intermittent fever, was a hard 
 white body, two inches broad and three long, composed of several globular masses 
 aggregated, invested with membranes. 
 
 Memoires de I’Academie Boyale des Sciences, 1705, No. 13. — In a boy of 44, who 
 was stupid for two years before death, the cerebellum, with the posterior half of the 
 medulla oblongata, (the restiform bodies?) was changed into a hard white homoge- 
 neous mass. 
 
 Morgagni, Epist. Ixii. 15. — A man aged 48, pursuing the occupation of a cook, and 
 
BRAIN. 
 
 335 
 
 exposed to charcoal fmnes, laboured, for a year before death, under acute pains of the 
 head, and weakness of the lower extremities, which terminated in paraplegy, rvithout 
 affection of the arms, finally became soporose during the day, with slight raving at 
 night, and with lucid intervals, and died. The cerebellum was hard to the knife. In- 
 stead of the usual apjiearance of ramified arrangement, which had disappeared, was 
 one of parallel white streaks, firm, (scirrhosa,) of a uniform colour, approaching to 
 pale carnation ; and when minutely examined appearing to consist of roundish atoms, 
 mutually aggregated, without membrane or blood-vessel. This change, which affect- 
 ed the whole left hemisphere, encroached a little only on the right. 
 
 La Peyronie, Memoires de I’Academie Ro)mle des Sciences, 1741. P. 208, 4to, 
 283, 12mo. — A man of 30, who for ten years passed for a melancholy hypochondriac, 
 complained during the three last months of life of weight and pains of the head to- 
 wards the occipital region and neck ; had conruilsions about half an horn- in all the 
 members ; and two days after perished in a fresh attack, lasting only a quarter of an 
 horn’. Attached to the fourth ventricle was a hard tumour as large as a hen’s egg, 
 occupying the place of the cerebeUiuu, which was reduced to a glairy membrane as 
 thin as a hne, investing the tumour. This tumour, which compressed the tubercula 
 quadrigemina, appears to have been attached to the choroid plexus of the fourth ven- 
 tricle, and probably grew from it originally. 
 
 Brisseau mentions a hard tumorrr, as large as a pigeon’s egg, in the middle of the ce- 
 rebellum, producing palsy. — Obs. iii. p. 27. 
 
 From this list, which contains, if not the whole, at least the most 
 authentic cases of this form of cerebral tumour, it may he inferred, 
 that it consists in a portion of hrain becoming unusually hard, as- 
 suming a white or yellow white tint, and in losing much of its ap- 
 pearance of organization, especially fibrous structure and vascular 
 ramification. The hardness of these tumours varies from that of 
 granular cheesy matter to firm indurated albumen. Of some the 
 structure is said to be fibrous ; hut in such cases the fibrosity of 
 sound cerebral substance is not meant. In the presence of a cap- 
 sule or a vascular spherical shell there is some variation, which 
 seems to depend on the stage of growth which the tumour has at- 
 tained. If recent, it is generally surrounded by such a vascular 
 cyst. If of long standing, it is generally surrounded with a layer 
 of softened brain, the result of the vascular irritation established in 
 the confines of of the tumour. 
 
 Adenoid or fiesh-like tumour. {Adenoidea.) To the second 
 head may be referred a sort of tumour which has been described 
 sometimes under the vague name of scirrhus ; sometimes under that 
 of scrofulous tumour ; but which cannot be admitted to possess un- 
 equivocal characters of either. It is generally described as similar 
 to a mass of flesh, or an enlarged absorbent gland. Its colour is 
 light pink or pale flesh-colour ; its firmness is considerable ; and 
 in some instances it is compared to the kidney. To this head be- 
 long the following cases : — 
 
336 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Felix Plateius Observation. Lib. i. p. 13. — A military man of equestrian rank, 
 who had for two years laboured under mental derangement, ndth much loss of memory 
 and natural appetites, and with frequent somnolence at table, at length expired. Up- 
 on the mesolobe, upon separating the hemispheres, was found a remarkable globular 
 tumour, fleshy like a gland, hard, but spongy (fungosua), of the bulk of a moderate 
 pippin, enclosed in a proper tunic, vascular, and free from all connection with the 
 brain. 
 
 Did this originate in the pia mater, in which it appears to have been enclosed ? 
 
 Joannes Rhodius, Centuria i. Observat. 55. — In the ventricle of the brain of a noble 
 Bolognian a fleshy tumour gave rise to epileptic fits. 
 
 Miscellanea Curiosa. — In the substance of the brain a tumour like a strumous 
 gland. • 
 
 Johan. Jac. Wagner, Miscellan. Curios. Dec. ii. Ann. 10. — A boy of 14, suffering 
 pain in the forehead and occipital region near the junction with the vertebraj, coming 
 on in paroxysms, relieved by vomiting ; epileptic symptoms and death. In the white 
 matter of the posterior part of the brain (occipital,) a preternatural hard sebaceous 
 gland, friable ; in the convolutions of the anterior lobe two glands ; in the end of the 
 cerebellum, near the calamus scriptorius, one as large as a walnut. 
 
 Memoires de I’Academie Royale. — In the right corpus striatum a glandular substance 
 the size of a bean. 
 
 Joh. Gottfr. Zinn. apud Comment. Soc. Reg. Scientiarum Gottingensis, Tom. ii. 1752. 
 — In an infant affected with enlarged lymphatic glands a hard substance as large as a 
 walnut. Of this, however, he neglected to preserve an accurate account. 
 
 In another infant, part of the left hemisphere of the cerebellum, to the extent at 
 least of two inches, was converted into five hardish bodies of different sizes, yellow, like 
 hardened Ijonphatic glands, mutually adhering. In some parts the traces of the circu- 
 lar leaflets of the cerebellic plates was left ; in others they had disappeared, and left a 
 uniform inorganic mass. The pia mater was readily detached, except at the middle of 
 the hard mass, where it adhered so firmly that it could not be removed without lacera- 
 tion. The contiguous vessels were injected. 
 
 In an adult female, he observed beneath the parietal bone in the convoluted part of 
 the brain three similar hard bodies, each as large as a nutmeg. They adhered to the 
 dwra mater ; and, in all probability, they originated in that membrane. 
 
 Haller, Opusc. Pathol. Obs. 1. — In a beggar girl of six years, with enlarged mesen- 
 teric, inguinal, and bronchial glands, the left hemisphere of the cerebellum was found 
 adhering to the occipital dura mater ; the whole substance, white and gray, changed 
 into a hard mass two inches in diameter on both sides, uniformly thick, fibrous like the 
 kidney, flssOe, destitute of vessels, and without remaining trace either of gray matter 
 or of white ramification. 
 
 John Jac. Huber, Nova Acta Physico-Medico Academ. Ctesarece Leopoldino-Caro- 
 linas, Tom. iii. p. 533 ; also Comment, de rebus in Scientia Natural!, Vol. xviii. p. 335. 
 —In the brain of a boy of 3, cut off by decay {tahes), a hard glandular tumour of the 
 size of a filbert, in colour, hardness, and other qualities like a lymphatic gland. When 
 divided it was found to consist of a thin coat enclosing a hard nucleus, which, though 
 compared to purulent matter, was firm and coloured. 
 
 Jo. Ernest. Grading, apud Ludwig Adversaria Medico-Practica, Vol. ii. p. ii. p. 492. 
 1771. — A woman of 30, of delicate constitution, unmarried, labouring under mania, 
 ivith paroxysms of great violence ; apoplectic attack followed by palsy of left side ; 
 death in about twenty days after. In the right hemisphere, about one inch below the 
 convoluted surface, an ovoid mass, five inches long, three broad, convex-shaped h'ke a 
 lens, one-fifth of an inch thick at middle, resting on the centrum ovale and mesolobe. 
 
BRAIN. 
 
 337 
 
 consisting internally of dark red (airo-rubens) hard granular substance, like half-rotten 
 sandy pear, enclosed all round in gray, soft, inodorous puriform matter, (ramollisse- 
 ment.) 
 
 Mr Henry Earle, in Medico- Chirurgical Transactions, Vol. ui. p. 5.9. 1812.. — A boy, 
 2 years and 9 months old. Dilated pupil ; palsy of lower extremities and sphincters, 
 followed by convulsions of the face, and palsy of the upper extremities and trunk ; 
 death by paralytic asphyxia. In the anterior lobe of the right hemisphere a large 
 dusky red tumour, rather tough. In the posterior lobe of the same hemisphere, and 
 in that of the left, a tumour each. In the cerebral substance, on a level with the me- 
 solobe, four more tumours ; the largest the size of an orange, the smallest not less than 
 a chestnut. They were very firm, of a dusky' red colour, and with streaks of white in- 
 terposed. 
 
 Dr Powell, in Medical Transactions, VoL v. Case xi. p. 211. — A man of 30, with 
 excruciating pain of the head more or less constant, followed by impciired vision, di- 
 lated pupil, and at length an apoplectic attack, which in two days terminated life. 
 From the inferior part of the anterior lobe of the left hemisphere projected a firm 
 mass, of the size of a large walnut, and when cut into resembling a large absorbent 
 gland. It was surrounded by' softened cerebral substance, which was of a light brown 
 colour, and so pulpy as to give the sensation of a semifluid. 
 
 y. Tuhermlar Deposition. (^Tyroma .) — Under the head of tu- 
 bercles and scrofulous growths of the brain, various changes, some 
 not very similar, have been described. Though the terms tubercle 
 and scrofula have been perhaps applied too vaguely, these differ- 
 ences, however, if well examined, will be found to consist more in 
 the external form in which the tubercular matter is deposited, than 
 in any essential change in its intimate characters. The term tit- 
 bercular deposition, therefore, I adopt for the purpose of designating 
 matter of a white or pale-yellow colour, firm, like soft cheese, but 
 less tough, sometimes granular and friable, and consisting chiefly 
 of a large proportion of albuminous matter. The substance thus 
 defined may be deposited in various forms. In the brain these 
 seem referable chiefly to two ; — 1. one, two, or more homogeneous 
 individual masses of considerable size ; and 2. several, sometimes 
 many, minute spherical or spheroidal bodies separate from each 
 other. 
 
 a. One or two homogeneous masses of considerable size. Man- 
 getus is among the first who notices near the corpora quadrigemina 
 a body like a sebaceous gland, hard and friable, which there is rea- 
 son to believe was one solitary tubercular mass. The two similar 
 which he found in the same brain between the convolutions, if not 
 belonging to the membranes, were examples of the same growth in 
 the convoluted substance. 
 
 I have already mentioned under another head the case of Huber, 
 which is probably an example of the same nature. The second 
 one of Merat, if really tubercular, is also an instance of this form 
 
 Y 
 
338 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 of the tubercular deposit. Many others are recorded by different 
 authors. Thus Rochoux gives an instance of a tubercular tumour 
 in the cerebellum, in all respects similar to those of the lungs.* 
 Dr Powell’s seventh case is an instance of large tubercular masses 
 in the white matter of the right hemisphere.f To the same head 
 also belong the cheese -like tumour described by Sir Gilbert Blane;J 
 the white tubercle represented by Baillie, (Plate VII. Fascic. 10;) 
 and the instance given by Coindet in the annular protuberance ;§ 
 the instance of an albuminous mass as large as an egg in the ante- 
 rior lobe of the left hemisphere by Bouillaud ; 1| that recorded by 
 the same author as a steatoraatous tumour in the left hemisphere, 
 containing an opaque homogeneous substance like white paste or 
 thick starch, {Vempois blanc, p. 195 ;) the 76th, 77th, and 78th 
 cases of Dr Abercrombie ; perhaps that of Dr Chambers ;1T a very 
 good instance recorded by M. Piedagnel ;** another by M. Berard 
 in the anterior lobes,f| and perhaps those given by Dr Hooper 
 (Plate XI. Fig. 1.) 
 
 The physical characters of this form of tubercular deposit are 
 tolerably uniform. Varying in number from one or two to four, 
 five, or six, and in size from that of a pea to a walnut, they consist 
 of opaque white matter, with a tint of pale-yellow, of the consist- 
 ence of soft cheese, sometimes granular, but always without vessel 
 or trace of organic structure. It is chiefly albuminous and friable. 
 In general they are surrounded by a vascular cyst of variable thick- 
 ness. Of the manner of their formation little is known. Several 
 of the cases of Dr Abercrombie would lead to the idea, that the 
 white albuminous matter of the tubercle is deposited in a fluid or 
 semifluid shape, which afterwards undergoes slow coagulation.|| 
 M. Bouillaud adduces various facts and arguments to show that 
 they are the result or product of an inflammatory process ; and, if 
 the idea attached to this term be sufficiently comprehensive, the 
 opinion may not be remote from the truth. The tendency of this 
 process is to produce albuminous secretions or depositions in va- 
 
 • Recherches sur I’Apoplexie, Obs. xxxix. p. 151. 
 
 •b Transactions of the College of Physicians, Vol. v. p. 222. 
 
 J Transactions of a Society, Vol. ii. 
 
 § Memoire sur I’Hydrencephale, p. 106 and 107. 
 
 II Traite Clinique et Pathologique, p. 161. 
 
 ^ Medical and Physical Journal, Vol. Ivi. New Series, Vol. i. 1826, p. 5. 
 
 ** Journal de Physiologie, Tome iii. p. 247. 
 
 •ft lb. Tome v. p. 17. 
 
 Pathological and Practical Researches, &c. Cases 83, 84, and 85, in which the 
 cysts contained soft or semifluid albuminous matter, coagulable by heat. Pp. 176-181. 
 
 3 
 
BRAIN. 
 
 339 
 
 rious forms ; and it is not improbable, that, under certain circum- 
 stances, it may be so modified as to cause the deposition of this sub- 
 stance in an indivisible mass, in a limited situation, and from a 
 proper cyst.* Often, however, the formation of these bodies is the 
 result of derangement in the process of nutrition. 
 
 Whatever be the origin of these bodies, it is understood, that, 
 sooner or later, they undergo a change in their interior, which 
 sometimes at the centre, sometimes in several points, simultaneous- 
 ly begins to soften and become fluid. It is at least known, that 
 such bodies are found to have fluid or semifluid contents, consist- 
 ing chiefly of serous liquor with albuminous flakes or curd-like 
 masses in it. Of this description are the tumour of the protube- 
 rance represented by Dr Yelloly as in a state of imperfect suppu- 
 ration ;f the cerebral vomiccz described by Coindet as similar to 
 tumours of meliceris ; the seventy-fifth case of Dr Abercrombie ; 
 that in the protuberance given by Dr Kellie, (Monro, p. 178,) and 
 by Dr Moncrieff in the same work, (pp. 50 — 53.) When the sof- 
 tening or liquefying process is complete, the tubercular mass as- 
 sumes the form of an encysted abscess. Of such abscesses, it may 
 indeed become a question whether the fluid or the solid state is the 
 incipient one. The principal facts in favour of the latter idea are, 
 the circumstances of the fluid being found in the centre while the 
 circumference is solid, and the larger bodies being found soft 
 while the small are Arm. According to this, wliich is the general 
 opinion at present, in the incipient stage the tubercle is said to be 
 crude, in the more advanced to be softened or dissolved. 
 
 b. The second form in which tubercular deposition takes place is 
 when it is found in numerous minute spherical or spheroidal bodies, 
 disseminated through the substance of the brain. Of this the best 
 examples with which I am acquainted are recorded by Reil andM. 
 Chomel. In tbe case given by Professor Reil more than 200 ob- 
 long spherical bodies were found in the gray matter of the brain 
 and cerebellum. They were a little firmer than the brain itself; 
 mostly of a pale yellow ; some few of a very pale blue colour ; of 
 the size of a leutile or a pea ; and when divided, showed internally 
 an adipose-like substance, resembling in colour and consistence 
 boiled or beaten potatoes. From some, which were marked in the 
 centre with a dark point, and seemed to be covered by a thin cyst, 
 the slightest incision discharged a matter like vermicelli. These 
 
 * Traite Clinique et Pathologique, p. 181, 
 
 t Medico-Chinirgical Transactions, Vol. i, p. 182. 
 
340 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 bodies were confined to the gray or external matter, none being 
 found in the white cerebral substance.* Not dissimilar were the 
 bodies found by M. Chomel in the brain of a woman of 30, who, 
 with obstinate vomiting and epigastric pain, had headach at first 
 slight and confined to the hind head, latterly extending to the 
 frontal region, when it was constant and severe. Though the in- 
 tellectual powers are stated to have been unimpaired to the last, 
 death was preceded by sudden aggravation of her sufferings and 
 loss of consciousness. In the brain were found about thirty or 
 forty small round bodies, resembling the human crystalline lens in 
 colour, size, and consistence. In the cerebellum wei’e two similar, 
 and in the spinal chord, opposite the last dorsal vertebra, one. In 
 several parts of the organ also were minute abscesses, supposed to 
 be produced by the softening of similar tubercles.f 
 
 The two cases now noticed are considered as of a strumous nature 
 by the authors under whose observation they fell. It is unfortu- 
 nate that they have given almost no information on the physical 
 and chemical qualities of the matter thus deposited in the substance 
 of the brain. Though its nature is thus left undetermined, I have 
 ventured to I'efer them to the present head, because, they seem to 
 be deposits of albuminous matter slightly modified, and because 
 they doubtless present some alliance with certain of the forms of 
 tubercular deposition in other textures. 
 
 F rom the researches of Dr H. Green , it results that Tyroma of 
 the brain is a disease principally of early life. Among 30 cases in- 
 spected, all were between the ages of 1 9 months and 1 2 years ; and 
 13 cases occurred between the ages of two and four years inclusive. 
 As to sex, 14 cases took place in boys and 16 in girls. It is a chro- 
 nic disease, and causes few symptoms until it has encroached much 
 on the cerebral substance. J 
 
 h. The Gelatinifurm tumour. ( Colloides . ) To this head I refer 
 a peculiar sort of new growth which 1 have seen extending over the 
 base of the brain from the optic chiasma backwards to part of the 
 protuberance, and on each side over the hemispheres. The body was 
 soft and jelly-like, not dissimilar to white currant jelly or thin glue, 
 tremulous, and easily lacerable. It varied in thickness, being in some 
 
 * J. C. Reil, Memorabilia Clin. Vol. ii. Fasc. i. No. 2. 1792. 
 
 f Nouveau Journal de Med. Mars 1818, p. 191-1 96. A similar is given in the sup- 
 plement to Dr Abercrombie’s work, fiom Prof. Nasse, p. 431. The case of Dr Hawkins, 
 (Aled. and Phys. Journal, Vol. Ivi. p. 8,) may probably be of the same description. 
 
 + Observations on Tubercle of the Brain in Children. By P. II. Green, M. D., Me- 
 dico-Chinirgical Transactions, Vol. XXV. p. 192. London, 1842. 
 
 4 
 
BRAIN. 
 
 341 
 
 parts as thick as half an inch, in others not more than the thickness of 
 two crown pieces or even one. Its outline was irregular. It had 
 produced softening of the hrain on the part where it pressed, and 
 the base of the cranium on which it rested was absorbed, rough, and 
 carious. The dura mater corresponding was thin, and detached from 
 the inner table. I do not think that this substance, which was void 
 of organization, resembled any other sort of tumour which I have 
 seen either in the brain or elsewhere. It was too soft and too la- 
 cerable to be compared to the colloid tumour. It was contained 
 within a thin arachnoid membrane, different, as it appeared to me, 
 from the arachnoid membrane of the brain. 
 
 The individual in whose brain this production took place had 
 been long in state of infirm health ; two years at least. The first 
 symptoms were epileptic seizures ; then loss of memory of that 
 kind, that with every wish and effort to recall either a name or ob- 
 ject, or an event, he was quite unable to do so. Latterly the fits 
 became more frequent ; the memory more thoroughly impaired ; 
 and for some time before death he became blind and paralytic. 
 Death was preceded by great debility and slight stupor. But the 
 epileptic attacks had ceased to recur. This person’s intellect was 
 originally good ; his memory was powerful ; and his disposition was 
 mild, gentle, and amiable. On these mental qualities, excepting 
 the memory, his disease seemed to make no impression. I was as- 
 sured, that a day or two before his death his intellect was clear ; 
 and it was merely the remembrance of past transactions in which 
 he was confused. He could by no means be said to be insane or 
 even fatuous. 
 
 i. Adipose tumour, lardaceous degeneration. {Keroma.') Peter 
 Borelli is the first who notices the existence of much fat-like matter 
 in the brain of an epileptic subject. The adipose tumour describ- 
 ed by the Wenzels seems to be the same with that which was pre- 
 viously mentioned by Merat, and winch has since been noticed un- 
 der the name of lardaceous degeneration by M. Hebreart formerly 
 of the Bicetre. The first author describes, under the name of tu- 
 bercle behind the upper part of the medulla oblongata, a fatty, red- 
 dish, or rose-coloured body, the size of a nut, consisting internally 
 of homogeneous substance traversed by minute red lines, probably 
 blood-vessels. It was contained in a fine thin envelope. A similar 
 one, though somewhat less, was found in the middle of the left ce- 
 rebellic hemisphere. By the Austrian anatomists it is represented 
 as externally smooth, and of a yellow colour, and internally, when 
 
342 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 divided, as consisting of adipose ash-coloured solid substance, tend- 
 ing in some parts to bony.* Among the many brains which these 
 anatomists examined two only presented this change of structure. 
 Though found near the exterior or convoluted surface, they pene- 
 trated pretty deep into the substance of the organ. 
 
 According to the cases given by M. Hebreart this change may 
 occur either under the shape of a conversion or degeneration of the 
 cerebral substance into matter of a yellowish colour and lardaceous 
 consistence, or in the formation of a distinct tumour in the sub- 
 stance of the organ. Though from his account it appears to he by 
 no means so rare as might be expected from the observations of the 
 Austrian anatomists, he gives only two cases of its occurrence in 
 the brain, and two in the cerebellum. In the first of the former, 
 a distinct tumour, consisting of matter of a yellow-colour and lard- 
 like consistence, the size of a nut, in the anterior part of the an- 
 terior lobe of the right hemisphei’e, gave rise to idiocy. In the se- 
 cond, a square inch of the posterior lobe of the left hemisphere was 
 converted into a yellowish pulpy substance, which was separated 
 from the contiguous sound brain by hardened cerebral matter. 
 This in a man of 40 caused epileptic paroxysms onee or twice a 
 month, terminating in asphyxia, which at length proved fatal. In 
 the first of the cerebellic cases, in a young man, who had been 
 idiotic for six years, the cerebral substance forming the walls of 
 the fourth ventricle had, for the depth of more than one line, been 
 converted into yellowish lardaceous matter. In the second, that 
 of an incurable maniac, a space six lines in diameter of the lower 
 part of the right hemisphere of the cerebellum had become hard, 
 lardaceous, and of a yellowish colour, not only in the gray lamel- 
 lated matter, but penetrating for some lines into the white sub- 
 stance. In this change the membranes also participated. f A si- 
 milar case is related in the Bulletins de la Faculte de Medecine, 
 May 1816. 
 
 I know not whether to these cases should be added the third, 
 
 * “ Tumor exterius Isevis erat, colore luteo, (couleur jaunatre, of M. Hebreart,)” &c. 
 “ Persecantes tumorem, intrinsecus inveniebamiis quandam adiposam, (“ ime dege- 
 nerescence de consistence lardacee” of M. Hebreart,) subcineream, admodum solidam, 
 (“ substance devenue dure, lardacee, de couleur jaunatre”) substantiam quse parvo 
 quodam loco tactu velut ossea erat.” Josephus et Carolus Wenzel de Penitiori Struc- 
 tura Cerebri Hominis et Brutorum. Tubingse apud Cottam, 1812, Fol. p. 104 et 105. 
 
 Observations sur quelques maladies du cervelet, du cerveau, et de leurs mem- 
 branes, recueillies a I’hospice de Bicetre ; par M. Hebreart, Medecin ordinaire des 
 Alienes, &c. Annuaire Medico-Chirurgical, &c. Paris, 1819, p. 579. 
 
BRAIN. 
 
 343 
 
 given by the same author. In this a man of 50, who became ma- 
 niacal, with lucid intervals, however, lost judgment, speech, memory, 
 and finally became paralytic and idiotical. These symptoms were 
 found to depend on the conversion of the lower surface of the left 
 cerebellic hemisphere into a jelly-like matter, separated from the 
 sound part of the organ by walls of hard polished cerebellic sub- 
 stance. It is possible that this jelly-like matter may have been 
 either the result of the process of softening in a part previously 
 hard, or the incipient stage of what was afterwards to acquire the 
 lardaceous consistence. 
 
 Margaroid and Cholesterine tumour. (^Margaroides.) Cru- 
 veilhier describes and illustrates with figures a tumour consisting 
 of white glistening globular masses, like pearls ; and indeed the tu- 
 mour appears to consist of minute or middle-sized pearls aggre- 
 gated together. These bodies vary in magnitude, from the size of 
 vetches to that of peas. The colour was that of dead silver, pearl, 
 or whitish-gray wax. The tumours thus formed varied in size, 
 from that of a nut to a walnut, or a small pippin. In general the 
 tumours had greater latitudinal extent than thickness. They were 
 irregularly round ; but seemed in some instances to consist of two 
 or more tumours aggregated together. 
 
 These bodies were situate mostly on the base of the brain, over 
 the protuberance, or that and the limbs of the brain, or the lower 
 surface of the cerebellum. 
 
 This sort of tumour is formed in the subarachnoid cellular tis- 
 sue, that is between the arachnoid membrane and the pia mater. 
 As it increases in size, however, it encroaches on the base of the 
 brain, and it may, as in one case given by Cruveilhier, destroy the 
 floor of the third ventricle and the contiguous parts, and present 
 itself immediately beneath the fornix. 
 
 This tumour presents no trace of organic structure. It is a se- 
 creted product or deposit formed within the cells of the cellular 
 tissue ; a sort of adipose matter having the consistence of marrow 
 or suet, covered by a layer of more coherent matter imitating the 
 brilliancy of silver or pearl. 
 
 When this substance was examined chemically, it was found to 
 consist almost solely of cholesterine. 
 
 Of the cases given by Cruveilhier, one occurred in a young wo- 
 man of 18 years; another took place in an old soldier of 40 years.* 
 
 The effects produced by tumours of this kind are very similar to 
 * Anatomie Pathologique. Deuxieme Livraison. PI. VI. 
 
344 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 those resulting from other tumours developed in the substance or 
 on the surface of the brain. Hebetude of the intellectual faculties, 
 loss of memory, epileptic seizures frequently recurring, a fatuous 
 and vacant expression of countenance, sometimes blindness or 
 squinting, then stupor and palsy, and finally death, are the ordinary 
 consequences of the presence of this deposit. 
 
 The same cholesterine deposit in scales is occasionally found on 
 the spinal chord. 
 
 ri. Cartilarjinous induration ; Scirrhus ; {Chondromad) This is 
 probably to be regarded either as a variety of the first kind, or as 
 intimately connected with it. Unhappily the term scirrhus has 
 been so vaguely applied to every kind of tumour, if a little hard, 
 that no precise idea is communicated by it. In the brain especially 
 all authors have comprehended, under this general appellation, 
 every change of texture which was harder than that of the surround- 
 ing organ, without much regard to the anatomical characters of the 
 new substance. Hence we find all the instances already adduced 
 recorded as examples of scirrhus, though in many of them no proof 
 of this structure is given, and in none is there any other proof than 
 the greater consistence of the part. 
 
 Without attempting to define the character of scirrhus when oc- 
 curring in the brain, I refer to the present head those instances of 
 morbid structure in which, with hardness approaching to that of 
 cartilage, there is a fibrous arrangement, and more or less tendency 
 to cancerous ulceration. Even with this limitation it may be doubt- 
 ed whether this disease occurs primarily in the cerebral substance. 
 Meanwhile, however, for want of more satisfactory elements in the 
 arrangement of the organic changes incident to the brain, to this 
 head may be referred the following examples: — 
 
 AI. Jean CniveCliier, Essai sur I’Anatomie Pathologique, Tome ii. p. 80. Paris, 
 1816. — A woman of 40 was brought to the Hotel- Dieu in a state of idiocy, in which 
 slie was stated to have been for six months after severe mental distress. She lived a 
 month without much sign of intellect, became comatose and died. In the right he- 
 misphere, beneath the mesolobe, corresponding to the striated body on the outside, and 
 projecting into both ventricles, was found a hard tumour of a triangular shape, the 
 posterior angle elongated, the right anterior angle advancing to the anterior extremity 
 of the right lobe. It consisted of two sorts of structure; — one in tlie centre, as large as 
 a pigeon’s egg, had the consistence of fibro-cartilage, and resembled fibrous substances 
 proceeding to the cartilaginous state; the other exterior, grayish, was confounded with 
 the cerebral substance from which it appeared to be formed. 
 
 L. N. Rostan, Recherches sur une Maladie encore pen connue. Paris, 1820. P. 84. 
 Observ. 20ieme. 1820. — A woman of G2 had during the course of life been deranged 
 several times, during which she committed extravagant acts, though rare and of short 
 duration. She had now constant headach, with occasional raving, giddiness, and vo- 
 
BRAIN. 
 
 345 
 
 miting, followed by palsy of the right side, and complete derangement. In a few days 
 more she became comatose, and, with complete right hemiplegia and stertorous respi- 
 ration, she expired. In the upper middle of the left hemisphere, which was softened 
 all round, a little beneath the convoluted substance, was a small yellowish granular 
 nut. Anteriorly in the striated body was a cancerous tumour as large as a nut, com- 
 pressing the ventricle. In the right hemisphere, which was sound and consistent in its 
 anterior three-fourths, but injected towards the posterior- inferior region, was a cancer- 
 ous tumour as large as a small nut, with pulpy destruction of the surrounding sub- 
 stance. 
 
 This account is deficient in failing to state the physical characters 
 of the several tumours. A record more instructive is found in the 
 following : — 
 
 M. Andral Fils, Cancer du Cerveau, from La Charite, in the wards of M. Lerminier, 
 Journal de Physiologie, Tome ii. p. 105, 1822. — A man of 58 felt fifteen years before 
 acute pain of the right temple, radiating in the right side of the head and face, and 
 lasting for six weeks. Diu'ing subsequent years it returned at irregular intervals, and 
 continued for periods of various duration till two months pre^'ious to admission, when 
 it became so intense, as to oblige the patient to give up his usual employments. With- 
 out affection of sensation, intellect, or motion, he suffered severe tearing pain in the 
 whole right side of the head, and slight convulsive motions of the face, followed after 
 eight days by palsy of the lower limbs, and soon after by coma, which continued in a 
 greater or less degree for a few days, when he died. In the centre of the right hemi- 
 sphere, outside of the optic thalamus and corpus striatum, the space of four finger- 
 breadths long, and two or three wide, was a reddish-gray, knotty, rough, unequal sur- 
 face, which when cut resisted like the scirrhous masses of the stomach or liver. In 
 the resisting points was a substance of areolar texture, bluish-white colour, semitran- 
 sparent, very hard, presenting here and there minute cavities containing a fluid like 
 apple-jelly ; (scirrhus proceeding from the crude to the softening stage). In other 
 points was a firm texture of dirty white colour, traversed by reddish lines crossing in 
 various directions (supposed to be encephaloid texture in the crude stage.) In other- 
 points was seen a reddish-purple, which appears to have been simply softened brain. 
 
 Bouillaud, Traite Clinique et Physiologique de TEnceqihalite. 1825. — A lady of 77, 
 with conr-ulsive motions of the left arm, followed by palsy of that and of the left leg, 
 impah-ed speech, complete hemiplegia, and death by exhaustion, without loss of con- 
 sciousness, a firm, yellonfish, lardaceous, bulky, many-lobed mass, occupying the greater 
 part of the posterior lobe, almost the whole of the middle lobe, and part of the anterior 
 lobe of the right hemisphere. Contiguous to the optic thalamus, which was entirely 
 softened, a lobule penetrated below the striated body, and reached the exterior of the 
 middle lobe, where it was connected with the membranes and the bone. Softening all 
 round.* 
 
 Ibid. — A man of 66. Right hemiplegy twice, followed by raving, unintelligible 
 speech, insensibility, coma, and death. In the central and posterior part of the left 
 hemisphere a hard irregular mass, internally of a saffron-yellow colour in some parts 
 of a rust-yellow in others, jaspered, marked by numerous small white bodies varying 
 from the size of a lentile and a pea to that of a filbert, furrowed in various directions by 
 minute filaments. The hardest of these bodies M. Bouillaud regards as scirrhous mat- 
 ter in the crude stage. Others resembling a white concentrated glue, he thinks, might 
 
 * This case is stated to be already published in the work of M. Rostan. This, however, appears to 
 be a mistake. The only example of cancer in the brain recorded in that work is the case above men- 
 tioned of Marie Gerard. With this it evidently does not correspond, either in age or in other 
 circumstances. A case of tumour called cancerous is also given in the " Observations'’ of M. Lenni- 
 nier. — Annuaire Medico-Chirurg. p. 225. 
 
346 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 be the colloid or glue-like cancer of M. Laennec. While the gi’eater part of thia body 
 was hard, its centre was reduced to a yellow diffluent pulp. 
 
 Mr R. Wade, Medical and Physical Journal. — In the upper part of the left lobe 
 (hemisphere) of the brain, a hard body of the size of a small hen’s egg, like medullary 
 sarcoma, but as firm as scirrhus of the female breast. The greatest part consisted of 
 yellow-white striae, as hard as cartilage, the remainder dark-gray and less firm, not very 
 distinguishable after maceration. Pulpy destruction around. 
 
 Under his fifth head, Dr Monro has shortly noticed seven speci- 
 mens of this change of structure preserved in the University 
 Museum. Its hardness, irregular surface, and cartilaginous struc- 
 ture, with a resemblance to a section of the kidney, are the circum- 
 stances principally remarked. 
 
 From the above acconnts, which I consider to be the most au- 
 thentic on record, a general idea of the anatomical characters of 
 what is meant by scirrhus of the brain {chomdroma) may be ob- 
 tained. A mass generally of irregular shape, distinguished from 
 the surrounding cerebral substance by its firmness, sometimes a 
 lobnlated structure, by its interior substance consisting of a pro- 
 portion more or less considerable of yellowish matter as hard as 
 cartilage, arranged sometimes in streaks or bands, in other cases 
 in round nodules, constitutes the principal characters of this mor- 
 bid growth in its crude or early stage. At a more advanced pe- 
 riod cavities begin to be formed, in which is contained a fluid or 
 semifluid matter sometimes jelly-like, at other times thinner, and 
 occasionally tinged with blood. Before this process of softening 
 has advanced far death takes place in general by suspension of the 
 functions of the organ. 
 
 The cartilaginous tumour may be deposited in a tubercular form, 
 and perhaps consisting partly of tubercular or albuminous matter. 
 Of this a good instance is given by Bayle in his Treatise on Pul- 
 monary Consumption. A printer of 58, with complete paraplegy, 
 and obliteration of the intellect almost to idiocy, followed by weak- 
 ness of the arms and sudden loss of speech, died with lethargy and 
 paralytic dyspnoea. In the anterior part of the right hemisphere 
 was a tubercular and cancerous mass the size of a turkey’s egg, 
 nearly spherical, and of considerable consistence and specific gra- 
 vity. With a reddish-gray surface irregularly knobbed, traversed 
 by blood-vessels, it consisted internally of a canary-yellow, thick, 
 granular, pasty matter, void of vessel or trace of organization, re- 
 sembling serofulous tubercles beginning to soften, with this diffe- 
 rence, that in some points it was humid and infiltered with serous 
 
BRAIN. 
 
 347 
 
 fluid. This was the case in the walls of an anfractuous irregular 
 cavity without membrane, and containing two spoonfuls of clear 
 yellowish fluid. The tubercular matter formed the centre and the 
 three upper fourths of the tumour. The rest was what is described 
 as cancerous, — a firm grayish- white shining tissue, traversed in all 
 directions by blood-vessels, and presenting even a minute bloody 
 effusion. Though the tumour was without cyst, its surface was 
 covered by a celluloso-vascular tissue, which sent numerous irre- 
 gular productions into the substance. It was surrounded by a layer 
 of cerebral matter, reduced as usual to the consistence of thick 
 cream.* 
 
 6. Calcareous or Bony deposits, and Concretions . — This morbid 
 deposition is by no means so common in the brain as in its mem- 
 branes ; and a large proportion of the cases termed ossification or 
 petrification of the brain are doubtless examples of ossific tumours 
 originating in the membranes. It appears, nevertheless, that some 
 instances have occurred to different observers. Kerkringius men- 
 tions as a cause of fatuity, a concretion weighing thirteen grains in 
 the right ventricle.! Kentmann- notices an ash-coloured one, the 
 size and shape of a mulberry Deidier found the left corpus stria- 
 tum osseous ;§ and Tyson mentions the case of a man who died of the 
 efiects of a blow on the head, in whom one of the inferior corpora 
 quadrigemina was as large as a nutmeg, and contained a chalk mass 
 like a cherry-stone, with pulpy destruction of the organ. || Blegny saw 
 a stone as large as a bean at the union of the optic nerves in the 
 brain of a lady, who, after violent pains of the head with fever, be- 
 came blind, and died.f In the brain of a man who had suffered 
 long from acute pain of the hind head, notwithstanding the use of 
 blisters, setons, &c. M. Boyer found a hard plaster-like concretion as 
 large as a filbert.** In the hrain of a boy of 16, an idiot from birth, 
 Sir E. Home found the protuberance, cerebellic peduncles, and 
 part of the cerebellum, containing so much earthy matter as to be 
 with difficulty cut by the knife.tt Professor Nasse found in the left 
 
 * Recherches sur la Phthisie Pulmonaire, &c. Par G. G. Bayle. A Paris 1810 
 P. 305. 
 
 t Observat. Anatom. 35. 
 
 ^ De Calciibs LibeUns. 
 
 § Des Tnmeurs, p. 351. 
 
 II Philosopbical Transactions, No. 228. 
 
 ^ Zodiacus Gallicus, Obs. xiv. p. 81. 
 
 ** Cruveilhier, Essai sur PAnatomie Pathologique, T. ii. p. 84. 
 
 -t”t- Phil. Trans. 1814. 
 
348 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 lobe of the cerebellum a body one inch long and ten lines broad, 
 composed of alternate layers of chalky matter, fluid albumen and 
 solid albumen.* Lastly, Andral in a phthisical subject found, in 
 the substance of the left hemisphere, near its upper anterior extre- 
 mity, a granulation the size of a large pea, with the consistence of 
 the calcai’eous concretions of the lung.f 
 
 In such cases a minute portion of brain appears not to be con- 
 verted into bone, but to be infiltrated with chalky matter, void of 
 animal substance so far as can be discovered. Of these earthy de- 
 posits no analysis has yet been made. It is, however, not impro- 
 bable that they consist chiefly of lime, united either with carbonic 
 or phosphoric acid, or both. Dr Hooper has delineated in his 
 twelfth engraving a bony tumour, or what he names a tubercle, 
 which is said to consist of the same materials as healthy bone, with 
 a little more animal matter. It is not stated whether this was 
 found in the cerebral substance or connected with the membranes. 
 From its appearance, however, and the fact now stated of its che- 
 mical character, I think it next to certain that it was of the latter 
 description. Upon the whole, it may be inferred that the sub- 
 stances denominated concretions of the brain consist of infiltrations 
 or depositions of calcareous matter in the substance of the organ. 
 
 To this head may be referred the concretions found in the cona- 
 rium or pineal gland. In this body small sabulous or calcareous 
 particles have been very often found ; and it was long supposed, 
 partly in consequence of the hypothetical opinions of Descartes, 
 that this change could not fail to affect materially the functions of 
 the entire organ. For correct information on this point, we are 
 indebted to Soemmering, who showed by the collation of numerous 
 cases, that scarcely any person arrived at the age of puberty, 
 though in the best health and the most perfect enjoyment of his 
 faculties, could assure himself that his conarium did not contain 
 calcareous matter. He regards it as part of the natural structure. 
 
 Though Soemmering states that sabulous deposition is found in 
 the conarium of infants as well as adults, he nowhere specifies the 
 exact authority for this fact ; and the youngest subjects on which 
 he records its occurrence v'ere 14 and 16.j; The Wenzels assert 
 
 ■* Abercrombie, Pathological and Pract. Researches, p. 42(i. 
 
 + Journal de Physiologie, Tome ii. p. 110. 
 
 X S. T. Soemmering de Acervulo Cerebri Dissert. Apud Ludwig, Scriptorum Ncu- 
 rolog. nunc Delect, p 322, 329. 
 
BRAIN-. 
 
 349 
 
 that they have seen stony particles so early as the 7th year, and a 
 substance very similar a few months after birth.* I am satisfied 
 that I have seen in the pineal glands of young children, whose ages 
 I could not ascertain, but who certainly did not exceed 9 or 10, 
 small sabulous particles ; but my personal observation does not en- 
 able me to say how far the statement of the Austrian anatomists 
 as to earlier periods is correct. 
 
 The couarium itself consists chiefly of firm reddish gray cerebral 
 matter, at the basis or posterior end of which are two whitish 
 threads, which proceed on each side to the optic thalamus, and form 
 what are termed the peduncles of the gland, from which they are 
 separated by a small linear depression. Behind the union of these 
 peduncles, covered here by part of the choroid web, is placed inva- 
 riably an irregular-shaped mass, varying in size from that of a 
 small pin-head to a grain of hemp-seed. When seized by the for- 
 ceps this is found to grate like sand or grains of stone ; and when 
 examined it actually consists of minute granules aggregated to- 
 gether by membranous filaments of animal matter. This irregu- 
 lar-shaped sandy mass is what is termed by Soemmering acervulus 
 conarii. The granules in the centre are generally larger than 
 those at the surface ; and its irregular shape depends on the num- 
 ber and size of the small superficial granules. They are generally 
 yellow or citron-coloured, hard, rough, semitransparent, and dis- 
 tinctly grating on a steel instrument. 
 
 Besides the situation now mentioned, — the union of the pedun- 
 cles, — sandy particles are occasionally found anterior to the pe- 
 duncles close on the basis of the gland, or disseminated in its sub- 
 stance. In infants before the 7th year, it is never found in the 
 substance of the conarium, but generally in the plate which con- 
 nects it to the thalami. The most ordinary place for it in adults 
 is the pit between the conarium and its peduncles ; and in aged 
 subjects it may be found in all the three situations. It has been 
 found in natives of every European nation almost, and in Africans. 
 
 According to the analysis of Muller these stones contain calca- 
 reous earth ; and from some experiments of Miinch it appears that 
 the lime is united with oxalic acid. 
 
 Whatever be the quantity of this deposition, it is well ascertained 
 that it exercises no influence on the cerebral functions. It is ne- 
 vertheless difficult to imagine it to be a natural or healthy product. 
 
 * De Penitiori Stmctxira Cerebri, pp. 155 — 157. 
 
350 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 From its situation I have often been inclined to think that it is a 
 secretion from the vessels of the choroid web. 
 
 Petrifaction, or osseous induration of tbe whole brain, has not 
 been seen in tbe human subject. Instances, however, of this in the 
 lower animals have been recorded by Duverney, Simson, Pitchell, 
 and Renauld. 
 
 Encysted Tumours . — Of these any of the forms may probably 
 be found in the brain. Hitherto, however, those actually said to 
 occur may be referred to one or other of the following heads. 
 
 a. Plydatoid or vesicular tumours. It may be justly doubted 
 whether the genuine animal hydatid, (^Cysticercus cellulosus, Ru- 
 dolphi,) has ever been found in the brain. Though stated gene- 
 rally by Bremser, he mentions no authority ;* it is never noticed 
 by Rudolphi ;•]- and seems to be denied entirely by Blainville. 
 None of the social hydatids (^Coenuri and Echinococci') were found 
 in that situation, till M. C. Rendtorff discovered, in 1811, a cluster 
 of the latter sort in the right ventricle of a girl of 8, who, after re- 
 maining hemiplegic for some months, died lethargic.^; 
 
 Notwithstanding this, instances of bodies described as hydatids 
 occurring in the brain have been mentioned by Scultetus, Panaroli, 
 Paw, Borelli, Lancisi, Wepfer, Home, Rostan, Headington, and 
 IMorrah. In the case of Scultetus, a cyst as large as a hen’s egg, 
 not unlike a hydatid, was found in the left hemisphere. § In that 
 of Panaroli, several whitish round bladders, containing pituitous 
 fluid {hygroma ?) were found in tbe mesolobe.|| In that of Paw, a 
 bladder containing half a pound of limpid fluid was seated over the 
 commissure of the optic nerves.^ The case of P. Borelli was a 
 cyst containing watery fluid, attached to the nates and infundibu- 
 lum.**' That of Lancisi is styled a hydatid as large as a pigeon’s 
 egg, thin, yellowish, jelly-like lymph, in the posterior part of the 
 right hemisphere.ft The case of Wepfer, which was a cyst as 
 large as a hen’s egg, containing a turbid brownish liquor, appears 
 to belong rather to the head of hygroma.\\ Those of Home,§§ Ros- 
 
 * Traite Zoologique, &c. Paris, 1824, P. 141, chap. ii. 
 
 •f- Entozoorum Synopsis. Mantissa, Gen. 28, p. 546. 
 
 J De Hydatidibus pra;sertim in cerebro repertis. 
 
 § Armamentarium, Obs. 10 and 11. 
 
 II Pentecoste I. Obs. 17. ^ Petri Pawdi, Observat. 2. 
 
 ** P. Borelli, Obs. Medico-Physicse. 
 
 -]”t- De Mortibus Subetaneis, Lilj. i. cap. xi. 13. 
 
 HistoriiE Apoplecticorum. 
 
 §§ Phil. Trans. 1814, p, 483. 
 
BRAIN. 
 
 351 
 
 tan,* * * § Headington,f and IMorrah,;}; though more recent, are not 
 more unequivocal, since their authors give no description of the 
 physical characters by which their claim to the title of hydatids 
 might be determined. 
 
 Upon the whole, though the occurrence of the genuine solitary 
 animal hydatid in the brain may not be impossible, it is not clear 
 that any of the cases hitherto recorded belong to this head. They 
 are to be regarded rather as serous or vesicular cysts, (Portal, 
 Anat. Med. Tome IV. p. 72,) or examples of the tumour called 
 (hygroma). Of this kind also are the case described by Forlani of 
 Sienna, containing glutinous matter like white of egg,§ and the 
 globular cysts so beautifully represented by Dr Hooper in his four- 
 teenth engraving. The cases mentioned by Fischer, Zeder, and 
 others, belong to the membranes. 
 
 b. Steatoms are mentioned by Drelincurtius, Thomann, Home, 
 and Bouillaud. 
 
 c. The blood-cyst, (hcBmatoma). The occurrence of this in the 
 brain, though not common, has been observed. Like hccmatoma 
 in other regions, it consists of a membranous cyst, sometimes con- 
 taining small cysts, the inner surface of which is composed of a 
 vascular tissue, from which blood or bloody fluid exudes by exha- 
 lation, forming a mass resembling layers of coagulated blood. Of 
 this disease the most distinct example is given by Rochoux. A 
 man of 65, about twenty months after a violent blow on the head 
 which stunned him, began to feel pain and weight of the head, with 
 occasional moments of forgetfulness. These symptoms became 
 more severe and more frequent, were followed by embarrassed 
 speech, palsy of the left side of the face, great general weakness, 
 coma, and death. In the anterior and external part of the left he- 
 misphere was found a firm red-brown tumour, the size of an egg, 
 round, flattened, filled with blood, which in certain places appeared 
 to be contained as in the spleen, in others in small clots of a line 
 diameter of an areolar-cellular tissue, grayish, dense, and analogous 
 in appearance to the matter of tubercles. Adhering without to 
 the dura mater of the arachnoid, which was red and much thick- 
 
 * Recherches, &c. Chap. x. Acephalocystes, p. 166. 
 
 t Medical and Surgical Joiunal, Vol. XV. 504. 
 
 X Medico-Chinirgical Transactions, Vol. II. p. 262. 
 
 § Caspar M. Forlani, Obs. Med. Pract. Anat. Senis, 1769. 
 
352 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 ened, it was lodged in a depression of the hemisphere. The con- 
 tiguous cerebral matter was in the state of yellow ramollissement.* 
 
 In his tenth engraving Dr Hooper gives a good delineation of 
 an example of this disease. In this case the tumour, which was of 
 an irregular oblong spheroidal shape, about 3-| inches long and 2^ 
 broad, ^arose by a broad base from the white cerebral substance of 
 the left hemisphere near the ventricle, but not communicating with 
 that cavity. Externally it was of a pink-red, or pale carmine co- 
 lour, and of an irregularly lobulated arrangement. Though soft 
 to the touch, it was elastic and cut firm, exposing a vascular mot- 
 tled surface of a reddish-yellow colour, with portions of blood-like 
 structure here and there. Besides the jna mater, which it raised, 
 it was covered by a delicate and very vascular membrane, laminat- 
 ed and shaggy. 
 
 A tumour of similar characters is described under his sixth head 
 by Dr Monro Tertius,\ formerly Professor of Anatomy. In a 
 young man who had suffered from headach, impaired vision, and 
 nausea, followed by epilepsy terminating fatally in a few hours, in 
 the middle lobe of the right hemisphere was a body the size of an 
 orange, somewhat soft, but elastic, and of the colour and consist- 
 ence of clotted blood. The surrounding brain was in a state of 
 pulpy destruction. 
 
 These two last cases are regarded as similar to the tumour named 
 haematoid fungus. I am not prepared to prove that they do not 
 belong to this head ; but their general resemblance in anatomical 
 characters to that described by Rochoux, induces me to refer them 
 to the head of Hcematoma. 
 
 To the same head may be referred that described by Dr George 
 Gregory,! who, in a man labouring under headach, irritable sto- 
 mach, and epileptic fits, and finally destroyed by epilepsy, found 
 within a cyst in the anterior cornu of the left ventricle, before the 
 striated nucleus, a body as large as a nutmeg, hard and fleshy, la- 
 minated interiorly an inch thick like coagulated blood, with a cavity 
 in the centre. 
 
 d. Fungus Hcematodes. Encephaloid or Cerehriform tumour . — 
 This morbid growth has been often found in the brain either ex- 
 clusively or in common with other textures. Enclosed almost in- 
 
 * J. A. Rochoux, Recherches sur TApopIexie. A Paris, 1814. Obs. 38, p. 149. 
 
 t The Morbid Anatomy of the Brain. By Alex. Monro, M. D. &c. p. 56. chap. i. 
 
 :[: Medical and Physical Journal, Vol. LIV. p. 462. 
 
BRAIN. 
 
 353 
 
 variably in a cyst, it consists of soft, compressible, spongy matter, 
 of the consistence of foetal brain, and not dissimilar in colour to 
 gray cerebral matter, with a tinge of red, a shining aspect, divided 
 in lobulated masses, which move on each other when slightly 
 touched. Though found chiefly in young subjects, it may occur in 
 the brains of adults; but is rarely seen in the aged.* 
 
 e. Melaiiosis. The melanotic deposit has not been very often found 
 in the brain. Streaks of dark matter along the blood-vessels were 
 seen by Dr Alison and Mr Fawdington and Dr Hooper deline- 
 ates melanotic masses of small size in the substance of the organ.J 
 Of these several changes now 'enumerated, the effects, in general 
 uniform, may be said to vary only according, Is^, to the morbid 
 changes induced in the contiguous cerebral substance ; 2d, accord- 
 ing to the extent which the organic change occupies ; and ^dly, 
 according to its relative situation in the organ. 
 
 1. All the tumours above enumerated, independent of the changes 
 proper to their own structure, agree in producing certain common 
 changes in the contiguous cerebral substance. All of them tend 
 to derange the capillary circulation of the brain and its membranes. 
 In the former they induce not only a general injection of the cere- 
 bral capillaries, but a local action in the immediate confines of the 
 tumour, and pulpy destruction of the cerebral substance. It often 
 happens also that the whole organ is, in consequence of the capil- 
 lary injection, infiltrated by pale or bloody serous fluid. In the 
 membranes these tumours also induce injection, terminating in in- 
 filtration of the subarachnoid tissue, and effusion from the choroid 
 web into the ventricles. The effects on the cerebral functions are 
 then precisely similar to those which result from derangement of 
 the capillary circulation taking place primarily. If local and in- 
 termittent, that is, recurring on the operation of certain causes, the 
 irritation from the tumour and its disturbance on the capillary cir- 
 culation induces chronic headach, with epileptic attacks. When the 
 vascular orgasm becomes more general and constant, loss of memory, 
 and sometimes of judgment, irregular contractions of the members, 
 and more or less palsy, are the consequences. As it advances to 
 pulpy destruction, the involuntary contractions of the muscles are 
 followed by palsy ; the abolition of sensation, recollection and in- 
 
 * Observations on Fungus Hematodes, by James AVardrop. Edinburgh, 1809. To 
 this belongs the case of Dr Latham, in Medical and Physical Journal, Vol. Ivi. p, 1. 
 t A Case of Melanosis, &c. by Thomas Fawdington. 
 
 The Morbid Anatomy, Plate XII. 
 
 Z 
 
354 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 tellect, give rise to fatuity ; and life may be terminated either by 
 coma, with or without convulsion, or by a sudden apoplectic attack. 
 
 2. Most of these organic changes, if small or limited in extent, 
 exercise little influence on the functions ascribed to the brain. Even 
 when large, their influence seems to be referable chiefly to the mor- 
 bid changes in the capillary circulation now mentioned. In many 
 instances no change in sensation, intellect, or locomotion is induced 
 till within a few days before death, when the convulsions, palsy, 
 and coma, which preceded this event, must be ascribed chiefly to 
 vascular injection taking place a little before these external effects 
 become manifest. 
 
 3. The situation of the morbid substance and of the disordered 
 action is certainly of some moment in modifying the effects pro- 
 duced. To determine the influence of local situation in this respect 
 attempts, direct and indirect, have been made by La Peyronie, Zinn, 
 Lorry, Haller, and Saucerotte, and more recently by Rolando, 
 Elourens, Serres, Bouillaud, and others. Without attempting to 
 inquire into the merit of the experimental and argumentative inves- 
 tigations of these authors, I shall merely state some of the most im- 
 portant conclusions, which they have thought their researches justified. 
 
 1. Injury done to the anterior lobes of the brain causes, accord- 
 ing to M. Bouillaud, more or less loss of speech, depending either 
 on disorder or abolition of memory, or on that of the muscular mo- 
 tions of the organs of speech.* 
 
 2. According to the observations of M. Serresf and MM. Fo- 
 ville and Pinel Grandchamp, when the corpus striatum, that is, the 
 anterior part of the striated nucleus, is injured, the motions of the 
 legs are disordered and impaired ; and when the optic thalamus, or 
 the posterior region of the striated nucleus, is injured, the motions 
 of the arms are impaired. 
 
 3. Though M. Serres has endeavoured to demonstrate the posi- 
 tion of M. Gall, that lesions of the middle lobe of the cerebellum 
 have a particular influence on the generative organs, this is rendered 
 very doubtful by the researches of Rolando, Flourens, and especi- 
 ally Bouillaud. M. Flourens endeavours to show that the cere- 
 bellum regulates, influences, or co-oi’dinates the voluntary motions. 
 
 * Recherches Cliiiiques, &c. Par M. J. Bouillaud, D. M. Archives Generales, 
 Tome viii. p. 2.5. Traite Clinique et Physiologique, p. 157-161. Paris, 182,5 ; and 
 Note sur une article de M. Pinel Fils, &c. Journal de Physiol. Tome vi. p. 19. 
 
 + Annuaire Medico-Chirurgical et Journal de Physiologie, Tome III. p. 123-128, et 
 ensuite. 
 
BRAIN. 
 
 355 
 
 Bouillaud shows that, though it cannot be said to regulate the whole 
 of these motions, it co-ordinates those concerned in equilibrium, the 
 state of rest, and the different forms of locomotion. It seems fur- 
 ther to be the seat of a modification of memory, that of voluntary 
 motion. When disordered, the memory is obliterated, the motions 
 are impaired or disordered, and the patient exhibits all the pheno- 
 mena of imbecility, in willing any regular or steady motion, or in 
 preserving any sensible attitude of rest.* 
 
 15. Anencephalous Malformation, Deficiency of the lohole Brain 
 or of its parts. {Enhephalelleipsis. ) — This should be noticed else- 
 where, under the head of afiections dependent on the membranes 
 and blood-vessels. But it may render the history of the abnormal 
 states of the brain more complete, to introduce here a short account 
 of a species of malformation arising from interruption of the process 
 of development 
 
 Instances of acephalous foetuses, as they have been named, are 
 numerous from the first records of anatomy to the present time. 
 They vary in degree from deficiency of the whole brain to that of 
 more or fewer of its parts. All of them depend, so far as is hither- 
 to ascertained, on the same general cause, a sudden check given 
 to the process of growth in this organ or some of its parts, while the 
 others continue to increase. The general accuracy of this conclu- 
 sion is established by the researches of Meckel,f of Duncan, Junior, J 
 of Breschet,§ and of Serres.|| In 1835 I collected from different 
 sources several cases, in order to illustrate the nature of the malfor- 
 mation, and the mode in which it is effected and subsequently the 
 subject bas been elucidated by Cruveilbier.** 
 
 The mode in which the growth of the brain is arrested may be 
 understood from the history of the progressive development of 
 the organ, which I have above stated is formed by deposition 
 from the vascular membrane, commencing near the centre of the 
 
 ■* Recherches Experimentales, &C. Par J. Bouillaud, Merabre-Adjoint, &c. Archives 
 Generales, Tome xv. p. 64. 
 
 t Handbuch der Pathologischen Anatomie. Von J. F. Meckel. Leipzig, 1812. 
 
 J Case of Hydrocephalus with Bifid Brain, in Medico-Chirui'gical Trans. Edin. Vol. i. 
 p. 205. 
 
 § Note sur deux enfans nouveaux-nes hydrocephales et manquant de cerveau- Par 
 J. Breschet, Journal de Physiologie, Tome ii. p. 269. Ilde Note sur des enfants Nou- 
 veaux-nes, &c. Par G. Breschet, Jour, de Phys. Tome iii. 232. 
 
 II Essai sur une Theorie Anatomique des IMonstrosites Animates. Revue hledicale, 
 Tome vi. p. 180. Paris, 1821, 
 
 *f Edinburgh Medical and Surgical Journal, Vol. XLIV. p. 527, Oct. 1835. 
 
 ** Cinquieme Livraison et Huitieme Livraison. Paris, 1833. 
 
356 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 hemispheres, and proceeding in both directions towards the convo- 
 luted and the central surfaces. When the process of nutritious 
 deposition is arrested at an early period, the brain is entirely want- 
 ing, and one or two imperfectly shaped tubercles only denote the 
 site of the corpora quadrigeminn, the thalami, or the protuberance. 
 If at a later period, the cerebellum and the lower part of the brain, 
 with several of its objects, may be completed. But separating the 
 two hemispheres above, there is found a large chasm, filled by wa- 
 ter, and in which neither mesolobe, vault, septum, nor thalami can 
 be recognized. This interruption M. Sevres ascribes to imperfect 
 development of the arterial system going to the brain. But this is 
 only a collateral effect. 
 
 In some instances a hemisphere is wanting ; in others the anterior 
 lobe is deficient ; in others both anterior lobes are wanting; and in 
 others there is a general diminution in the size of one whole 
 hemisphere, and the magnitude of its component convolutions, while 
 the other presents its normal dimensions and proportions. 
 
 All these phenomena are produced in the same way and proceed 
 from the same cause. An attack of meningeal inflammation or hy- 
 drocephalus in the womb, before birth, or immediately after that 
 event, — not sufficient to extinguish life, — arrests the nutritive action 
 of a certain order of the cerebral capillaries. The nutritive action 
 is employed in secreting serous fluid. The growth of part of the 
 brain affected is suddenly stopped ; and while the growth of the rest 
 advances, that remains stationary. 
 
 This interruption of normal action of vessels depends on a sud- 
 den change somehow effected in them, in consequence of which the}' 
 no longer continue the nutritious process. The proof that the im- 
 perfect development of the arterial system is only a collateral 
 effect, is found in the fact, that the development of these vessels is 
 always equal and sometimes superior to the progress of the abnormal 
 action and its effects. 
 
 It is manifest that, in cases of this nature, the atrophy of the 
 brain is not a primary or idiopathic lesion, but is indeed the eflfect 
 partly of the excessive distension of the walls of the brain by an 
 extraordinary quantity of fluid, and partly of mechanical compres- 
 ion by the fluid inducing som.etimes condensation of the parts, some- 
 times softening, but always more or less destruction of the proper 
 structure. Atrophy, indeed, is one of the effects of great effusions 
 of fluid. It cannot be denied that in cases of this class the brain is 
 not nourished, or is even deprived of nourishment. But it must 
 
 4 
 
BRAIN. 
 
 357 
 
 be borne in mind that the suspension or interruption of nutrition 
 is the effect of a preceding morbid state, in which the blood-vessels, 
 the natural nutrients of the organ, are made to assume a new and 
 perverted action. 
 
 From the cases now recorded it further appears that the atro- 
 phied parts of the brain are diminished in size or shrunk, and that 
 they also cease to possess their characteristic physical and physio- 
 logical properties, and to perform their functions duly. Thus in 
 all the cases with the diminution in size of the parts, there is more 
 or less loss of motion and sensation in some of the voluntary organs. 
 Loss of memory appears occasionally to take place ; but loss of in- 
 tellect is not invariable. This, however, may depend on the part of 
 the brain atrophied, and on the extent of the atrophy. The mental 
 energy is generally enfeebled ; but the most characteristic feature 
 is that one faculty may retain considerable force, while others are 
 disproportionately weak. The intensity of the intellect is unequal. 
 
 This is a frequent cause of congenital idiocy, surd- muteness, palsy 
 of one side or various parts of the body ; and unequal development 
 of several organs. 
 
 Often one or more members may be shrunk, withered, and pa- 
 ralytic ; and occasionally one side is hemiplegic. 
 
 As to the intimate nature of the change induced in the parts so 
 shrunk and diminished we have as yet no precise information. It 
 may arise either from arrest of the growth of the parts, or from 
 the removal of parts by absorption, or rather by disruption and 
 breaking down. The pressure increased by the presence of a new 
 fluid may be adequate to prevent growth of the parts compressed, 
 and even to break down and disorganize. 
 
 Atrophy of the brain, therefore, may differ according as it takes 
 place during the process of development or after that process is 
 completed. If it take place during the process of formation, then 
 that process is suddenly interrupted, and the brain presents more 
 or fewer of its parts in an incomplete or rudimentary state. Thus 
 in cases in which the process is interrupted previous to the forma- 
 tion of the convolutions, and in which serous fluid more or less 
 copious is effused from the nutrient vessels, the brain resembles a 
 shapeless uniform bladder of membranous and cerebral matter en- 
 closing serous fluid. This is perhaps the most complete example 
 of the atrophy of the brain, and corresponds with the agenesia of 
 M. Cazauvieilh (Archives de Med. xiv.) 
 
 The parts which next to tliese are most generally wanting are 
 
358 
 
 GENERAL AND RATIiOLOGICAL ANATOMY. 
 
 the meso-lobe,yb;■?^^a.• and septum lucidum. Reil observed the want 
 of this part in an idiotic female who had attained the age of thirty 
 years. 
 
 Independently or along with themeso-lobe and fornix, the upper 
 region of the hemispheres may be wanting as far as the ceiling of 
 the ventricles. But it is difficult to distinguish the atrophy of this 
 part from atrophy of the convoluted surface of the brain. 
 
 Atrophy may next affect the corpora striata or optic tlialami^ in 
 the form of diminished bulk and general dimensions, proceeding 
 to such extent that these bodies may be altogether wanting. 
 
 The same lesion may occur in the cerebellum, the annvdar pro- 
 tuberance, or in the peduncles and the spinal bulb. 
 
 The spinal chord or vertebral portion of the brain is in like 
 manner liable to atrophy, both during the process of developmenE 
 and after its completion. 
 
 In the first case the chord is entirely or partially wanting, and 
 its place is supplied by serous fluid, more or less copious, contained 
 within the membranes. Thus in many cases of spina bifida, as it 
 is denominated, that disease is the effect of some interruption given 
 to the process of growth in the spinal marrow, by reason of which 
 the arterial action is expended in the effusion of fluid, which fills 
 and distends the membranes, prevents the further deposition of 
 cerebral matter, and preventing also the union of the spinal plates 
 on the mesial plane, gives rise to a soft elastic tumour at the most 
 yielding and dependent part of the spinal column. In general the 
 spinal marrow is either partially or entirely wanting in some part 
 of its course in cases of this kind. Its continuity is interrupted 
 either without a single trace, or with a few streaks of cerebral 
 matter on the one side, or at the anterior part of the column, M'hile 
 the vacancy is supplied by serous fluid or shreds of cerebral matter. 
 
 In other instances of this species of atrophy, each lateral half of 
 the chord is in a very slender and imperfect form of development, 
 and is separated from that of the opposite side by the interposition 
 of serous fluid. In cases of this kind, it is not uncommon to find 
 the median canal persistent long after birth, imitating in this respect 
 the structure observed in the spinal chord of the lower animals^ 
 
 It may be doubted whether it be quite correct to apply the term 
 atrophy to those lesions of the spinal chord, in which the breaking 
 down, the softening or shrinking of the parts, is evidently due to in- 
 flammatory action excited in them from disease of the membranous 
 
 investments or the bones. Thus, in cases of disease of the vertebrce, 
 
 3 
 
]st:rvous tissue. 
 
 359 
 
 inflammation of a chronic character is very soon propagated to the 
 membranes and the chord, and part of it is softened and disorgan- 
 ized. The injury may not be suflficient to extinguish life; and 
 after some time, when the active part of the inflammatory process 
 has subsided, part of the spinal marrow is contracted in size, and 
 compressed by the new products ; and this constitutes, according 
 to the strict understanding of the term, the anatomical characters 
 of atrophy. In admitting this application of the term, therefore, 
 it ought to be distinctly understood, that the term atrophy desig- 
 nates, not a primary lesion, but a lesion which is the effect of 
 another previous action. Several cases of the kind are recorded 
 by Ollivier and others. 
 
 CHAPTER II. 
 
 B. The Distributed Part of the Nervous System. 
 
 Section I. 
 
 NERVE, NERVOUS TISSUE. — (Nsu^ov, — Nervus , — Tissu Nerveux , — 
 Systeme Nerveux.) 
 
 The structure of the nerves has been examined with different 
 degrees of accuracy and minuteness by a great number of anato- 
 mists. The more ancient authors, who wrote at a period when ob- 
 servation was much corrupted by fancy, and most of those who give 
 descriptions in general systems, maybe without much injustice passed 
 over in silence. It is sufficient to say, that some good facts are 
 given in the works of Willis,* Vieussens,f Morgagni, j; and Mayer ;§ 
 that Prochaska,|] Pfeffinger,!! and the second Monro,** are the first 
 who professedly wrote on the structure of the nerves ; that the 
 
 ■* Thomas Willis, Cerebri Anatome Nervorumque Descriptio et Usus. Amsterdam, 
 1682. 
 
 -f- Raymimdi Vieussens Neurographia Universalis. Lyon, 168-1. 
 
 i Adversaria Anatomica, 4to. Lugduni Bat. 1 723. 
 
 § J. C. Mayer Abhandlung vom Gehirn, Ruckenmark, und dem Ursprunge der Ner- 
 ven. Berlin, 1779. 
 
 II Georgii Prochaska de Structura Nervorimi Tractatus Anatomicus. Vienna, 1779 
 and 1800, ap^ld Op. Minora. 
 
 H Jo. Pfeffinger, de Structura Nervorum. In Ludwig, Scriptomm Neurolotr. 
 Select. Tom. I. 
 
 ■** Monro on the Structure and the Functions of the Nervous System. Edinburgh, 
 1783. Folio. 
 
360 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 works of Reil,* Bichat, and Gordon, contain the most accurate 
 information on the nervous chords in general ; and that the trea- 
 tises of Scarpaf and W utzerj contain the most satisfactory infor- 
 mation on the arrangement of those parts named ganglions and 
 plexus. Lastly, by the microscopic researches of Ehrenberg, Tre- 
 viranus, Muller, Valentin, Weber, and Remak, some facts, though 
 rather discordant, have been communicated on the minute structure 
 of the nervous filaments. 
 
 Each nerve forms connections in three different ways ; IV, A 
 nerve must be connected to some part of the central mass by one 
 of its extremities, — the cerebral or spinal end ; 2d, It must be con- 
 nected to some texture or organ, or part of an organ by the other 
 extremity, — the organic end; and, Zd, It may be connected to 
 other nerves by a species of junction called anastomosis, (ansa ) — 
 anastomosing or uniting point. By means of the two first connec- 
 tions, it is supposed to maintain a communication between the cen- 
 tral mass and the several organs ; and by the latter it is understood 
 to be subservient to a more general and extensive intercourse, which 
 is believed to be necessary in various functions and actions of the 
 animal syst nn. 
 
 Every nerve consists essentially of two parts ; one exterior, pro- 
 tecting and containing ; the other interior, contained, and func- 
 tional, forinii'g the indispensable part of the nervous structure. 
 
 The first of these, which has been known since the time at least 
 of Reil by the name neurilema, (nv^civ, hXew, nervi involucrum,) 
 
 or nerve-coat, (Nervenhaut, Reil ; Nervenhulle, Meckel;) has the 
 form and nature of a dense membrane, not quite transparent, which 
 is found on the outside of the nervous chord or filament, and in- 
 vests the proper nervous substance. It must not, however, be 
 imagined that the neurilema forms a cylindrical tube, in the inte- 
 rior of which the nervous matter is contained. This latter disposi- 
 tion, if it actually exists, applies to the smaller nerves only, and to 
 some of those which go to the organs of sensation, — a peculiarity 
 which we shall notice subsequently. 
 
 Any large nervous trunk, for example, the spiral or median of 
 the arm, or the sciatic nerve of the thigh, is found to be composed 
 
 * J. C. Reil, Exercitationes Anatomicae de Structura Nervorum. Haller, 1797 
 
 T Anatoinicarum .Annotationum, Lib. Prim, de Nervorum Gangliis et Plexibus. 
 Auctore Antonio Scarpa. 
 
 J De Corporis Humani Gangliorum Fabrica atque Usu, Monograpliia. Auctore 
 Carolo Gulielmo Wutzer, Med. Chirurg. Doct. &c. Berolini, 1817- 
 
NERVOUS TISSUE. 
 
 361 
 
 of several small nervous chords placed in juxtaposition, and each 
 of which, consisting of appropriate neurilema and nervous substance, 
 is connected to the other by delicate filamentous tissue. These, 
 however, do not, through their entire course, maintain the parallel 
 disposition in respect to each other, but are observed to cross and 
 penetrate each other, so as to form an intimate interlacement of ner- 
 vous chords and filaments, each of which, however minute, is accom- 
 panied with its investing neurilema. The neurilema, in short, may 
 be represented as a cylindrical membranous tube, giving from its 
 inner surface many productions foi’ming smaller tubes ; ( Canaliculi, 
 Die Nervenrohre ; primitive cylinders of Fontana ;*) in which the 
 proper nervous matter is contained. 
 
 Of this arrangement the consequence is, that each nerve or ner- 
 vous trunk, enveloped in its general neurilema, is composed, never- 
 theless, of a number more or less considerable of smaller chord- 
 like nervous threads {funiculi nervei, Prochaska; chordcc, funes^ 
 Nervenstraenge, Reil,) into which the nerve, by maceration and 
 suitable preparation, may be resolved. Each chord, again, or 
 nerve-string^ as Reil terms it, though invested with a proper nuri- 
 lem, may be further resolved into an infinite number of minute fili- 
 form or capillary filaments, {Fila, fibrillce, Nervenfasern, Reil,) 
 which, invested in a delicate covering, are understood to constitute 
 the ultimate texture of the nerve. 
 
 This threefold division may be easily observed in the brachial 
 and spiral nerves of the arm, and still more distinctly in the sciatic 
 in the thigh. The utility of understanding the internal arrange- 
 ment from which it results will appear forthwith, when the struc- 
 ture of those parts termed ganglions and plexuses comes under 
 examination. 
 
 Of this arrangement in different nerves, and in different regions, 
 this membrane undergoes great modification ; and all opinions on 
 its nature derived from thickness or transparency are liable to con- 
 siderable fallacy. Scarpa seems to view it as connected, in ana- 
 tomical origin and character, with the hard membrane, {meninx 
 dura^ dura mater.) Reil, who devoted more care and time to the 
 examination of its nature and structure than any other inquirer, 
 represents it as consisting of cellular substance, many blood-vessels, 
 and some lymphatics.f Bichat thought it resembled the soft mem- 
 
 * Observations sur la strUctiu'e des Nerfs, &c. apud Traite sur le Venin, &c. par M. 
 Felix Fontana. 
 
 •f De Structura Nervorum, cap. i. p. 3. 
 
362 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 brane of the brain, {{pia meninx, pia mater,') and was derived from 
 it.* Gordon considers the neurilema of the cerebral nerves as con- 
 sisting of soft membrane, {pia mater) at their origin, but in all 
 other situations as a species of cellular membrane. 
 
 By Mayer the neurilema is accounted a fibrous tissue, for the 
 following reasons. Is?, It consists almost entirely of tendinous 
 fibres, and is cellular only where it is very thin. 2r/, The trans- 
 verse folds presented by most of the nerves, and which give them 
 a dentilated form, are derived from the neurilema, are of fibrous 
 character, and are similar to those observed in tendinous sheaths. 
 3fZ, Several nervous productions are actually converted into tendi- 
 nous or fibrous filaments; for example, the brain of the snail tribe, {li- 
 maqons,) and the spinal chord both in these and other animals at the 
 cauda equina. 4?/i, The neurilema is either a continuation of the pro- 
 per cerebral membrane, {pia mater,) or very similar to it ; and this 
 membrane is fibrous and aponeurotic at the spinal chord, and even 
 at its upper end, and, according to Mayer, forms the denticulated 
 ligament, which is a fibrous tissue.f 
 
 These views, which are the result, not of observation, but of hy- 
 pothesis, it is impossible to adopt. Its connection with the jna mater 
 was disproved by Reil ; and though its analogy with the denticu- 
 lated ligament were established, it would prove nothing regarding 
 the neurilema. Upon the whole, the idea communicated by Reil 
 is the most probable. According to the observations of this ana- 
 tomist, who examined the neurilema after fine and successful injec- 
 tion, it is liberally supplied with blood-vessels. These derived from 
 the neighbouring arteries penetrate the filamentous sheath of the 
 nerve : and, immediately on reaching the neurilema, divaricating 
 at right angles, generally run along the nervous threads, {funes,) 
 parallel to them, forming numerous anastomotic communications, 
 and divide into innumerable minute vessels, which penetrate between 
 them into the minute neurilematic canals. So manifold is the ra- 
 mification, and so perfect the distribution, that in these canals not 
 a particle of nervous substance is found which is not supplied with 
 a vessel. j; The arrangement of the veins is analogous. 
 
 It appears, therefore, that the neurilema is a tissue of membra- 
 
 * Anatomic Generale, p. 137, &c. 
 
 -I Discours sur I’Histologie, par le Docteur Mayer. Bonn, 1819, Journal de Ale- 
 decine, Vol. XIII. p. 99. 1 822. 
 
 J Joannis Christian! Reil, Exercitationum Anatom, de Structura Nervorum, cap. .5, 
 
NERVOUS TISSUE. 
 
 363 
 
 nous form, with a multiplied mechanical surface, liberally supplied 
 with blood-vessels, from which the nervous matter is secreted and 
 nourished. It is impossible, indeed, to doubt, that of the two parts 
 which compose the nervous chord, it is the most perfectly organized; 
 and that, though it may not be similar in structure to the pia mater, 
 it is quite analogous in the use to which it is subservient. Like 
 that membrane, it sustains the vessels of the nerve ; it presents a 
 multiplied surface, over which the vessels are distributed ; and by 
 penetrating deep into the body of the nerve, it conveys the nutri- 
 tious vessels in the most capillary form to the inmost recesses of 
 the nervous substance.* 
 
 The arrangement which has been above described is the only 
 one which can be regarded as general. It varies in particular re- 
 gions ; and these varieties in the neurilematic disposition occur 
 principally in the nerves which are distributed to the proper organs 
 of sensation.-f- Is^, The olfactory nerve is soft, pulpy, and desti- 
 tute of neurilema, from its origin in the sylvian fissure, to the gray 
 bulbous enlargement which terminates its passage in the cranium ; 
 but as soon as it reaches the canaliculi or grooves of the ethmoid 
 bone, and begins to be distributed through the nasal anfractuosities, 
 it is distinctly neurilematic. 2d, The optic nerve is still more pe- 
 culiar in this respect. The instant it quits the optic commissure, 
 {commissura tractuum,'} it begins to be invested by a firm general 
 neurilema, which sends into the interior substance of the nerve va- 
 rious membranous septa or partitions, forming separate canals, in 
 which the nervous matter is contained. These partitions, however, 
 are so thin, that at first sight the optic nerve seems to consist mere- 
 ly of one exterior membranous cylinder inclosing the proper mem- 
 branous substance. 3(f, Lastly, we remark, that the auditory 
 nerve, or the soft portion of the seventh pair of most anatomical 
 writers, the eighth pair of Soemmering, is the only nerve in which 
 this covering cannot be traced. 
 
 The neurilema is much thinner and more delicate in the nerves 
 which are distributed to tbe internal organs, as the lungs, heart, 
 stomach, &c. (nerves of the organic life, great sympathetic and 
 pneumogastric nerves, par vagum), than in those belonging to the 
 muscular system. 
 
 The second component part of the nervous chord or filament is 
 
 * Reil, ibid. chap. i. 
 
 t By the term “ proper organs of sensation” is understood those of sight, hearing, 
 Smell and taste, which are confined to a fixed spot in tlie system. 
 
364 
 
 GENIiRAL AND PATHOLOGICAL ANATOMY. 
 
 the proper nervous matter which occupies the cavity of the neurile- 
 matic canals. Little is known concerning the nature or oreaniza- 
 tion of this substance. It is whitish, somewhat soft, and pulpy ; 
 but wbether it consists of aggregated globules, as was attempted to 
 be established by Della Torre and Sir Everard Home, or of linear 
 tracts disposed in a situation parallel to each other, as appears to 
 be the result of the inquiries of Monro, Reil, and others, or of ca- 
 pillary cylinders containing a transparent gelatinous fluid, as Fon- 
 tana represents, seems quite uncertain. It has been presumed, 
 rather than demonstrated, that it resembles cerebral substance. 
 But this analogy, though admitted, would throw little light on the 
 subject ; for at present it is almost impossible to find two anatomi- 
 cal observers who have the same views of the intimate nature of 
 cerebral substance itself. Whatever be its intimate arrangement, 
 it appears to be a secretion from the neurilematic vessels. (Reil.) 
 
 The structure of the nervous chord may be demonstrated in the 
 following manner. When a portion of nerve is placed in an alka- 
 line solution, the whole, or nearly the whole, of the nervous mat- 
 ter is softened and dissolved, or may be washed out of the neurile- 
 matic canals, which are not affected by this agent, and the disposition 
 of which may be then examined and demonstrated.* Aqueous 
 maceration may likewise be advantageously employed to unfold this 
 structure ; for it separates and decomposes the cellular tissue by 
 which the neurilematic canals are united, and subsequently occa- 
 sions decomposition of the nervous substance, while it leaves, at 
 least for some time, the neurilema not much affected. When, how- 
 ever, the maceratioTi is too long continued, it is separated and de- 
 tached like other macerated textures. 
 
 Lastly, If a large nerve be placed in diluted acid for the space 
 of one or two weeks, the neurilema is gradually dissolved, and the 
 nervous matter becomes so much indurated and consolidated that 
 it may be separated from the contiguous chords in filaments with 
 great facility.* In undergoing this change the portion of nerve 
 becomes much shorter and considerably contracted, — is subjected, 
 in short, to the process of crispation ; so that unless a large nerve 
 like the sciatic be employed for the experiment, it may be impossible 
 
 * J. C. Reil de Structura Nervorum, cap. i. p. 3 and 5. 
 
 T According to the experiments of Reil, nitrous acid diluted rvith water answers best. 
 Muriatic acid, though equal or even superior in effecting solution of the neurilema, 
 softens the nervous matter too much, and separates the component filaments too com- 
 pletely. — De Structura, cap. iii. p. 16. 
 
NERVOUS TISSUE. 
 
 365 
 
 to obtain the result in the most satisfactory form. These experi- 
 ments, with many others of the same nature, were first performed 
 by Professor Reil, and afterwards repeated and varied by Bichat 
 and by Dr Gordon. Personal repetition of them enables me to 
 assert, that, when correctly conducted, they never failed to give the 
 results as described by these authors. 
 
 Nervous, tissue, like all others, receives a proportion of what may be 
 denominated the systems of distribution, — cellular tissue and blood- 
 vessels. In the substance of the former, the disposition of which 
 we have already remarked, we find the more conspicuous branches 
 of the latter distri buted. In a more minute and divided form they 
 penetrate the neurilema and nervous substance. Reil, who derived 
 his conclusions from the result of delicate and successful injections, 
 perhaps overrated the quantity of blood which in the sound state 
 they convey; for it is quite certain, that, in the healthy state, hardly 
 any red blood enters the nervous tissue, as may be easily shown by 
 exposing the sciatic nerve of a dog or rabbit. 
 
 No good chemical analysis of nervous matter has yet been pub- 
 lished. Every chemical examination of it has been conducted on 
 the assumption that it is analogous to cerebral matter. Of this, how- 
 ever, there is no direct proof. In the analysis by Vauquelin the 
 neurilematic covering appears not to have been detached, — a pro- 
 ceeding always necessary to obtain correct results in this inquiry. 
 The effects of acids and alcohol show that it contains albuminous 
 matter ; but beyond this it is impossible at present to make any pre- 
 cise statements. 
 
 This description may communicate an idea of the structure of the 
 nervous chord in general. In particular situations this structure is 
 considerably modified. The modifications to which we allude occur 
 under two forms — ganglions (Die knoten ;) and plexuses (Die Ner- 
 vengeflechte. ) 
 
 Every ganglion consists essentially of three parts ; 1st, an exte- 
 rior covering; 2d, a collection of minute nervous filaments; and, 
 3d, a quantity of peculiar cellular or filamentous texture, by which 
 these filaments are connected, and which constitutes the great mass 
 of the ganglion. 
 
 The ganglions are of two kinds, the spinal or simple, and the 
 non-spinal or compound. These two kinds of bodies differ from 
 each other, Is^, in the situation which they respectively occupy; 2d, 
 in the kind of envelope with which they are invested ; 3d, in the 
 mode in which the nervous filaments pass through them and from 
 
36G 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 them. By Wutzer, who considers the ganglion of Gasserius, the 
 ciliary and the maxillary of Meckel, as cerebral ganglions, they are 
 divided into three sets, those of the cerebral system, the spinal sys- 
 tem, and the vegetative^ or those connected with the organs of invo- 
 luntary motion.* 
 
 Void of the dense strong coat with which the others are invested, 
 the cerebral ganglions consist of soft secondary matter, connected 
 to the filaments of one, or at most two branches, and are arranged 
 with less complexity. (Wutzer.) 
 
 The spinal ganglions are said to possess two coverings, one 
 of which resembles the hard cerebral membrane, {ineninx dura^ 
 the other the soft cerebral membrane, [meninx tenuis^ pia mater.') 
 The non-spinal, or compound ganglions, have also two coverings, 
 which are merely different modifications of filamentous tissue less 
 dense and compact than in the former. Both these sets of ganglions 
 being by maceration stripped of their tunics, and deprived of the 
 soft pulpy cellular matter, are resolved into an innumerable series 
 of nervous threads, most of which are minute and scarcely percep- 
 tible ; all are continuous with the nerve or nerves above and below 
 the ganglion. It appears that the nervous chord, when it enters 
 the one apex of the ganglion, begins to be separated into its com- 
 ponent threads, which diverge and form intervals, between which 
 the delicate cellular tissue is interposed ; and that these filaments 
 are subsequently collected at tbe opposite extremity of the ganglion, 
 where they are connected with the other nerve or nerves. Scarpa, 
 to whom we are indebted for the most of the knowledge we possess 
 on this subject, t compares the arrangement to a rope, the compo- 
 nent cords of which are iintwisted and teased out at a certain part. 
 Lastly^ In the simple ganglions, the filaments of which they con- 
 sist, invariably follow the axis of the ganglion; but in the compound 
 ones they are found to rise towards the sides and emerge from them ; 
 and upon this variety in the direction and course of these filaments 
 depends the variety of figure, for which these two orders of gan- 
 glions are remarkable. These nervous threads {stamina s.Jila ner- 
 vea) described by Scarpa, correspond to the medullary filaments 
 (fila niedullaria ) of Wutzer. According to this anatomist these 
 filaments, when about to enter the ganglion, lay aside their neurilem ; 
 yet they are sufficiently tough to resist a certain degree of tension. 
 
 * De Corporis Ilumani Gangliorum Falarica, &c. cap. i. ii. § 41, jr. S2. 
 
 t Anatomicarum Annotationum Liber Primus de Nervorum Gangliis et Plexiibus. 
 Auct. Ant. Scarpa. 
 
NERVOUS TISSUE. 
 
 3G7 
 
 Wiitzer mentions a cluster of vesicles or cells (cancelli) in the 
 filamentous tissue of the ganglion. But he was not enabled by any 
 means, mechanical or chemical, to ascertain their exact nature. 
 
 The ganglions are well supplied with blood-vessels, derived in 
 general fi’om the neighbouring arteries. The intimate distribu- 
 tion is represented by Wutzer to be the following. The artery 
 proceeding to a ganglion gives vessels to the filamentous tissue ; 
 and, perforating the proper coat, is immediately ramified into in- 
 numerable minute canals, the first order of which forms vascular 
 nets on the inner surface of the tunic ; while the residual twigs 
 penetrate the flocculent texture, and the individual vesicles of the 
 secondary or filamentous matter of the ganglion.* * * § 
 
 This short exposition of the structure of the ganglions shows the 
 mistaken notions of Johnstone, Unzer, Bichat, and others, on the 
 structure and uses of these bodies. The idea first advanced 
 
 by Johnstone,t and Unzer, J adopted by Metzger,§ Hufeland,|| 
 Prochaska,^ Sue, and Harless,** and afterwards applied with 
 much ingenuity by Bichat, that the ganglions are so many nervous 
 centres or minute brains, is disproved by strict anatomical observa- 
 tion. 2d, That they are connected with the order of involuntary 
 actions, and influence these actions, appears to be the only inference 
 that can at present be admitted regarding them. Ganglions are 
 not observed on any of the nerves proceeding to organs of volun- 
 tary motion. Sensation, circulation, nutrition, and secretion are 
 the functions, over which they preside. Sd, Lastly, we remark, as 
 a circumstance of some importance, that the only difference between 
 a ganglion, and any other part of a nervous chord, is, that in the 
 former the minute nervous filaments appear to be uncovered with 
 neurilema, and lodged in a mass of cellular tissue, which is then 
 inclosed in the neurilematic capsule ; while in the latter each ner- 
 vous filament has its appropriate neurilema, and the cellular tissue, 
 instead of being within, is on its exterior, and connects it to the 
 contis:uous filaments. 
 
 O 
 
 * De Corporis Humani Gangliorum Fabrica, &c. cap. ii. § 41. 
 
 f Philosophical Transactions, V'ol. LIV. LVII. and LX. and Essay, &c. 
 
 t J. A. Unzer, Physiologic thierischer Korper. Leipzig, 1771, p. 66. 
 
 § I. D. Metzger Opuscula Anatomica et Physiolog. Gothas, &c. 1790. 
 
 II C. W. Hufeland Ideen uber Pathogenic, &c. Jena, 1795. 
 
 ^ G. Prochaska Lehrsatze der Physiologic, &c. I. ter Band. “Wien, 1797. 
 
 ** J. J. Sue, Recherches Physiologiques, &c. Paris, an. vi. German Translation 
 bv I. C. F. Harless, 1797, p. 2. Nurnberg, 1799, p. .3. 
 
368 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 In various situations two, three, or more nervous trunks or chords 
 mutually unite hy means of some of their component threads, and 
 after proceeding in this manner for a short space, again separate, 
 but not in the same number of original trunks, or preserving the 
 same appearance. In general, the number of chords into which 
 they finally separate is greater than that of which they consisted 
 before union. Three or four nervous trunks, for example, after 
 uniting in this manner, will form on their final separation five or 
 six nerves or nervous chords ; and it is quite impossible to deter- 
 mine which of the latter order was derived from any one or two of 
 the former, or what number of individual chords it has received 
 from each. Between the two points also, the first point of union, 
 and the last of separation, many of the more minute component 
 threads are detached from two or more of their trunks, and after 
 first uniting with each other in an indistinct network, are again 
 united to two or more of the nervous chords near the point at 
 which they finally separate from the further end of union. This 
 arrangement has been termed a plexus, plait, or weaving, in conse- 
 quence of the manner in which the nervous chords are interlaced 
 or plaited together. The arrangement which we have noticed as 
 consisting of the more minute nervous threads has been called a 
 smaller plexus •, {plexus minor.) It is a subordinate plexus within 
 a larger one. 
 
 The best and most distinct example of a plexus is that commonly 
 named the brachial or axillary.* This, as is well known, is situate 
 in the space contained between the broad dorsal muscle {latissimus 
 dorsi) behind, and the great pectoi’al muscle before, and is formed 
 in the following manner. The fifth, sixth, seventh, and eighth 
 cervical nerves, and the first dorsal, after forming the usual con- 
 nections, {ansae,) pass downwards from the vicinity ^of the vertebrae 
 between the middle and anterior scaleni muscles, and nearly opposite 
 
 * Imo nullibi fortasse clarior atque evidentior est hsec multarum conjugationum 
 nervearum consociatio atque commixtio, quam in hac nervorum spinalium implicatione 
 plexwm hrachialem appellata. Ibi enini quinque memorati nervi spinales cervicales 
 una convenientes, qua primum cohaerent, aut tribuunt aut mutuo dant et accipiunt a 
 sociis stamina, quae demum in plures ramos consociata de plexu exeuntes brachiorum 
 nervos faciunt ex omnibus illis quinque conjugationibus spinalibus, aut ex earum pie- 
 risque, composites. Atque exinde sequitur, ut nervi brachiales dicti, qui a plexu ad 
 brachium, manum digitosque ejus omnes derivant, minime ad unam, sed ad plures 
 spinalium conjugationes, nempe ad quatuor cervicales inferiores et dorsalium primum 
 pertineant. — Anatom. Annotation, cap. iii. § 9. pp. 4. 
 
NERYOUS TISSUE. 
 
 369 
 
 the lower margin of the seventh cervical vertebra, or about the level 
 of the first rib, begin to be united by the component threads of 
 each nerve. Threads of the fifth and sixth cervical unite, — some- 
 times to form a single chord ; in other instances to be connected a 
 short space onward with threads of the seventh cervical in a similar 
 manner. The seventh and eighth form two kinds of union. "When 
 the seventh is large, it divides almost equally into two chords or 
 branches, one of which is connected first with the fifth and sixth, 
 afterwards with the eighth, and with the first dorsal by interlace- 
 ment of minute nervous threads. The other either passes down- 
 ward to form one of the separate brachial nerves, or is also con- 
 nected with the eighth cervical and first dorsal in a plexiform 
 manner. 
 
 From this arrangement immediately arise the individual nervous 
 branches which form the nerves of the arm, and which are named 
 brachial nerves. The interlacement of minute nervous threads be- 
 tween the seventh and eighth cervical, and the first dorsal, is what 
 Scarpa has termed the plexus minor. He says it is peculiar, in be- 
 ing quite uniform, and in connecting those nervous branches 
 which, from their subsequent destination, are called IMedian and 
 Ulnar. 
 
 This description, though not generally applicable, will commu- 
 nicate some faint idea of the nervous unions and interlacements 
 termed plexus or weavings. For more minute information on the 
 distribution, arrangement, and configuration of this part of the 
 nervous system, I refer to the work of Scarpa already quoted.* 
 
 Plexiform arrangements are not confined to the exterior regions 
 of the body. They are more numerous internally ; and almost all 
 the organs of the chest and belly have each a plexus, sometimes 
 two, from which they derive their nervous chords. 
 
 Plexiform arrangements are generally situate in the neighbour- 
 hood of blood-vessels, and in some instances inclosing considerable 
 arterial trunks more or less accurately. Thus the axillary plexus 
 surrounds the axillary artery. The cceliac artery is surrounded 
 with the solar plexus : and the coronary, hepatic, splenic, supe- 
 rior mesenteric, and renal, are also surrounded with plexiform 
 nervous filaments. In some instances these nervous filaments are 
 so intimately connected with the arterial tubes as to lead some 
 
 * Annotation. Anatom. § 9. cap. iii. pp. 94, 95. 
 
 A a 
 
370 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 anatomists to consider them as forming a peculiar net-work sur- 
 rounding the vessel, and to exercise great influence on the circu- 
 lation. (Wrisberg, Ludwig, and Haase.) 
 
 It is remarkable that the structure of the nervous chords which 
 form a plexus, has either appeared so simple as not to demand par- 
 ticular attention, or is so obscure as to be never noticed. Have 
 the nervous chords and threads in such situations their usual enve- 
 lope ? Is the nervous matter in the chords quite the same as in 
 other situations ? Is there any other means of union, save the 
 nervous substance itself? We believe there is no doubt that every 
 chord in a plexus is provided with its neurilema as in other plaees ; 
 but this neurilema is generally thinner and more delicate ; and the 
 general neurilema seems to be wanting. Its mechanical properties 
 of cohesion and resistance have not been examined. 
 
 The view which has been given of the structure or arrangement 
 of the nervous plexus has led Scarpa to consider them as nearly 
 allied to ganglions. The same separation of the component threads 
 or filaments of the nerve or nerves, the same interlacement, and the 
 same or similar formation of new chords, appear to take place in 
 both orders of structure. A ganglion, indeed, he conceives, is a 
 condensed or contracted plexus ; and a plexus is an expanded or 
 unfolded ganglion. The great anatomical purpose of both appears 
 to be simply a new arrangement or disposition of nervous branches, 
 previous to their ultimate distribution in the tissues or organs to 
 which they are destined. This is nothing but the expression of a 
 fact, — the interpretation in intelligible terms of an arrangement of 
 organized parts without reference to any supposed \ises. 
 
 The minute structure of the nerves has been examined by Fon- 
 tana, Prochaska, Bauer, Ehrenberg, Valentin, Muller, Wagner, 
 and Remak. 
 
 M. Bauer found the optic nerve to consist of many bundles of 
 very delicate fibres, connected together by means of a jelly-like, 
 transparent, semifluid, viscid substance, easily soluble in water. 
 These fibres consisted of globules, which are from to ^g^gth 
 
 part of an inch in diameter, with a few at gg^octh part of an inch in 
 diameter, the latter being the size of the red globules of the blood 
 deprived of colouring matter. The retina appeared like a conti- 
 nuation of the bundles composing the optic nerve, consisting of the 
 same sized globules connected into fibrous lines, and forming bun- 
 dles radiating from the end of the nerve to the circumference of 
 
 4 
 
NERVOUS tisslt;. 
 
 371 
 
 the retina, where they disappear, terminating in smooth mem- 
 brane.* 
 
 The olfactory, optic, and auditory nerves, Ehrenberg found to 
 consist of varicose or moniliform medullary tubules, directly con- 
 tinued from the moniliform tubes of the white cerebral matter. 
 The moniliform tubules of the olfactory nerves are the thickest 
 known, and vary fi'om leijlh to juoth part of a line in diameter. 
 Those of the optic nerve are smaller, being from gnotii to j^gth 
 part of a line in diameter ; and tubules of the same dimensions are 
 observed in the chiasma or decussation, in which the tubes are re- 
 presented crossing each other ; while the retina consists of articu- 
 lated tubules so’soth part of a line in diameter, traversing medul- 
 lary grains about jgoth part of one line in diameter. It contains 
 also mace-like or club-shaped bodies. 
 
 The structure of the auditory nerve is also peculiar. The sim- 
 ple tubules of this nerve Ehrenberg found considerably thicker than 
 those of the others, and the spheroidal enlargements or ampullulos 
 flatter and less prominent, yet everywhere distinctly seen. In other 
 respects it was similar to the olfactory and optic nerves. 
 
 The great sympathetic nerve, in like manner, consists of articu- 
 lated cerebral tubules ; but there is a mixture of simple cylindri- 
 cal tubes at each extremity. 
 
 The nerves now specified, the olfactory, optic, auditory, and 
 great sympathetic, are articulated or moniliform nerves. 
 
 All the other nerves consist, not of articulated or moniliform 
 tubes, but of simple cylindrical tubules, somewhat larger, being 
 from iloth to ijoth part of one line in diameter. These tubules are 
 surrounded and inclosed by vascular networks, and contained within 
 ligamentous or neurilematic partitions ; and they contain a medullary 
 substance, semifluid, but capable of expression from them, and coa- 
 gulation within their interior. These are tubulated nerves.f 
 
 The ganglia vary in structure. All consist of articulated or 
 bead-like cerebral tubules, which, either alone, as in the chiasma, 
 form the knot, or, as in all the ganglia of the sympathetic examined, 
 are mingled with large cylindrical nervous tubules, inclosed within 
 a close slender vascular network, between the meshes of which are 
 deposited granules similar to those observed in the retina. 
 
 * Philosophical Transactions, 1821 and 1824. 
 
 t Beobachtung einer auffaUenden bishcr unbekannte structur des Seelenorgan im 
 Menschen undThieren ; and Edin. Med. and Surg. Journal, VoL XLVIII. p. 282. 
 
372 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 The tubules and cylinders now specified, which correspond with 
 the primitive cylindei’s of Fontana, are merely in juxtaposition, and 
 do not intermingle in substance with each other. 
 
 The general accuracy of the facts now stated has been confirmed 
 by Muller, Krause, Wagner, and Remak. Neither Ehrenberg 
 nor Muller have been able to recognize in the roots of the sensi- 
 ferous and motiferous nerves any essential difference in microsco- 
 pical structure. 
 
 In the hypoglossal and glossopharyngeal nerves are seen only 
 cylindrical tubes. 
 
 I have already shown what is meant by tbe organic end or ter- 
 mination of a nerve. Althougb the nervous trunks are distributed 
 in every direction tbrougb the animal body, they do not terminate 
 in all tbe tissues or organs indiscriminately ; and have been observed 
 to be lost in tbe following only. Is?, the proper organs of sensa- 
 tion, the eye, ear, nose, palate, and tongue ; 2d, the muscles, whe- 
 ther subservient to voluntary or to involuntary motion, as the heart, 
 stomach, intestines, &c. ; 3(f, the mucous surfaces; Atli, the skin ; 
 5th, glands, salivary, liver, kidneys, &c. ; Qth, bones. 
 
 Nerves, therefore, are not, strictly speaking, organs of general 
 distribution. According to Bichat, they have never been traced 
 to the following tissues : — the cartilages, both articular and of the 
 cavities ; fibrous textures, viz. peidosteum, dura meninx, capsular 
 ligaments, aponeurotic sbeaths, aponeurosis in general, tendon and 
 ligament ; fibro-cartilaginous textures ; those of the external ear, 
 nose, trachea, and eyelids, (cartilages of other authors) ; the semi- 
 lunar cartilages of the knee-joint ; those of the temporo-maxillary 
 articulatioir ; those of the intervertebral spaces ; marrow ; the 
 lymphatic glands. 
 
 To this we may add the testimony of a professed anatomist of the 
 nervous system, whose reputation for patient and industrious re- 
 search cannot fail to sanction every thing which he has advanced. 
 “ In every subject,” says Walter of Berlin, “ in which I was desir- 
 ous to trace the nerves, I injected the arteries with red-coloured 
 wax, the veins with green, and even the lymphatics with quicksilver, 
 so that I was able to distinguisb the nervous filaments from each 
 of these orders of vessels. By this contrivance, though it occupied 
 much time and labour, yet I was satisfactorily convinced that the 
 pleura, the pericardium, the thoracic duct, and the peritoneum, re- 
 ceive no nerves. Nay, that, contrary to the opinions of the most 
 
NERVOUS TISSUE. 
 
 373 
 
 eminent recent anatomists, no nerves terminate in the lymphatic or 
 conglobate glands. Sometimes, indeed, these organs are perforated 
 by one or two twigs, as I have often had occasion to observe ; but 
 they instantly proceed to the next place assigned to them, and in 
 which they are finally lost,”* If after this conclusion of Walter 
 personal testimony can be of any use, I may add, that I have exa- 
 mined the dura mater^ the periosteum, and most of the synovial 
 membranes repeatedly, to discover nervous filaments in them, and 
 always without success ; and I may say the same regarding the ab- 
 sence or non-appearance of nerves in the peritoneum and pleura. 
 
 The nerves have different uses in the different organs and tissues 
 to which they are distributed. 1. In the organs of sensation they 
 receive the mechanical impressions made on the mechanical part of 
 the organ. In the eye, the retina receives the last image formed 
 by the transmitting powers of the transparent parts. In the ear, 
 the terminations of the auditory nerve are affected by the oscilla- 
 tions or minute changes in the fluid of the labyrinth, occasioned by 
 the motions of the tyrapantil bones. In the mucous membrane of 
 the nasal passages, the filaments of the olfactory nerve are affected 
 by aromatic particles, dissolved or suspended in the air. In the 
 palate, tongue, and throat, the gustatory nerves are affected by 
 sapid bodies dissolved in the mouth, or applied in a fluid state to 
 the mucous membrane of that cavity, 2. In the system of volun- 
 tary muscles the nerves retain the action of the muscular fibres in 
 a state of uniformity and equality, and keep them obedient to the 
 will. In the involuntary muscles they appear merely to keep their 
 action equable, regular, and uniform ; and in both they maintain 
 a communication, or consent or harmony of action between different 
 parts of the same system of organs, or even between different organs 
 concurring to the same function. 3. In the glandular organs the 
 nerves certainly exercise some influence over the process of secre- 
 tion ; but what is the exact nature of this influence, or in what de- 
 gree it takes place, is quite uncertain. 
 
 When we observe the nerves distributed to organs of sensation 
 and organs of motion, it is a natural thought to inquire whether the 
 nerves minister to both functions, and whether different nerves or 
 different sorts of nerves minister to each function. It seems to have 
 been an idea of considerable antiquity, that one set of nerves are 
 sensiferous, and another set motiferous. Erasistratus derives the 
 
 * Praefat. Tab. Nerv. Thoracis et Abdominis, J. G. Walter. 
 
374 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 nerves of motion from the brain and cerebellum, and those of sen- 
 sation from the membranes ; and Galen distinguishes the nerves 
 into Nsvga AiaDirixa and K/v»jr/^a, the former, soft, from the 
 
 brain, the latter, hard, from the spinal marrow. This distinction 
 was not altogether lost sight of among the anatomists and physio- 
 gists of the eighteenth century ; but it was rather maintained as a 
 probable speculation, than elucidated and enforced as an established 
 doctrine, pregnant with important results. It was recognized by 
 Glisson, and taught by Boerhaave,* and received and promulgated 
 by his pupils, Tissot and Van Eems;f but opposed by HallerJ and 
 Cullen. The distinction was, nevertheless, maintained by Lecat, 
 Morin, and Pouteau, the last of whom was led from various examples 
 of persons, who, after injuries, had lost sensation, but retained the 
 power of movement, to espouse it with considerable energy.§ 
 
 In 1784 George Prochaska, Professor of Anatomy at Vienna, 
 published on the functions of the nerves a commentary, in which 
 he gave, after Plaller, Caldani, Whytt and Unzer, a more precise 
 and correct view of the uses, properties, and powers of these or- 
 gans, than had hitherto been formed. In this commentary he fully 
 recognizes the distinction between sensorial nerves or those devoted 
 to sensation, and motific nerves or those ministering to motion ; 
 he shows that sensorial impressions or impressions made on the sen- 
 sitive nerves, are reflected or transmitted in a reflex direction to the 
 motific nerves ; that the latter nerves are thereby excited to action ; 
 that the purpose of this reflex operation is the preservation of the 
 individual ; and that the whole are under the influence of the Sen- 
 sorium Commune. Pie distinctly states, that this reflected action is 
 
 ■* Prselectiones Academicse in proprias Institutiones Rei Aleclicse, Editaeet Notis Auc- 
 ta, ab Alb. Haller. VII. Toini. l"2mo. Goettingae, 1745. 
 
 T Hermann! Boerhaave, Phil, et Med. Doct., &c. Pralectiones Academic® de Mor- 
 bis Nervorum, Quas ex Manuscriptis collectas edi curavit Jacobus Van Eems, Medi- 
 cus Leydensis. Tome I. and II. Lugduni Batavor. 1761. “ Omnes (nervi) inser- 
 
 viunt motui vel famulantur sensui ; sed in illis qui cordi, pulmoni, hepati, aliisque 
 partibus vitalibus destinati sunt, sensus non deprehenditur. Qui motui inserviunt, 
 abeunt ad musculos, et in iis ita mollescunt, ut in verum quasi cerebrum degenerent. 
 Ramuli, qui sensibus famulantur, in ipsis organis mollitie fere difHuunt, uti patet in 
 expansione nervi optici, olfactorii, ubi se applicat ad os ethmoides, et acoustic! in laby- 
 rintho,” p. 261. 
 
 + Elementa Physiologise, Liber X. Sect. VIII. § xxii., Tomus Quartus, p. 389. 
 
 § Memoire et Recherches sur la difference a etablir entre les nerfs du sentiment et 
 les nerfs du mouvement, a I’occasion de quelques observations sur cette espece rare 
 de paralysie, qui prive un membre de tout sentiment, sans lui oter I’usage du mouve- 
 ment. Oeuvres Postumes de M. Pouteau, Docteur en Medecine et Chirurgien en Chef 
 de I’Hotel-dieu de Lyon. Tome II. p. 480. Paris, 1789. 
 
NERYOUS TISSUE. 
 
 375 
 
 not regulated by physical laws, where the angle of reflection is 
 equal to the angle of incidence, but obeys peculiar laws impressed 
 by nature, as it were, on the sensor ium, and which laws we can 
 understand from their effects alone. This reflex action further 
 takes place either without or with the consciousness of the soul. 
 The motion of the heart, stomach, and intestines, is independent of 
 the cognizance of the soul ; and in many other instances of senso- 
 rial impressions being transmitted to motific nerves, though the soul 
 is conscious, it can neither prevent them nor promote them.* 
 
 The commentary of Prochaska is the first precise view of the 
 functions of the nervous system in modern times ; and the first in 
 which the automatic and instinctive phenomena enumerated by 
 Whytt are referred to a reflex operation. 
 
 In 1811, Sir Charles Bell, in a tract containing the Idea of a New 
 Anatomy of the Brain, stated that he had proved experimentally that 
 “ the posterior fasciculus of spinal nerves, which are gangliophorous, 
 might be detached from its origin without convulsing the muscles 
 of the back ; whereas, on touching the airterior fasciculus with 
 the point of the knife, these muscles were immediately convulsed.” 
 From this it seemed a probable inference that gangliophorous nerves 
 had no concern in motion, and that nerves void of ganglion mini- 
 stered in some way to that fnnction. 
 
 In 1818, Charles Francis Bellingeri published at Turin,f a Dis- 
 sertation treating, among other subjects, of the anatomy and phy- 
 siology of the fifth and seventh pairs of nerves. In this he showed 
 that the great portion of the fifth pair or trifacial nerve, which forms 
 the large semilunar plexus called Gasserian ganglion, is a nerve, 
 not of motion but of sensation ; that its three branches are distri- 
 buted to certain parts of the eye, the nasal cavities, the palate and 
 tongue ; ministering in these parts not to motion, but to sensation, 
 and probably to circulation, nutrition, and secretion ; and that the 
 small branch of that nerve (jiervus masticatorius), is distributed to 
 muscles, (temporalis, masseter, pterygoideus, buccinaiorius,') and is a 
 
 * Georgii Prochaska, M. D., Professoris Anatomice, Physiologise et Storborum Ocu- 
 lorum in Universitate Vinclobonensi, Operum jMinorum. Pars II. Vienn®, 1800. 
 8vo. Commentatio de Functionibus Systematis Nervosi. 
 
 -)- Caroli Francisci Bellingeri E. S. Agatha Derthonensi. PhiL et Med. Doct. Am- 
 plessim Med. Collegii Candidati Dissertatio InauguraUs quam public® defendebat. 
 In Athenaeo Regio Anno MDCCCXVIII. Die IX. Maii ; hora IX.na. matutina. 
 August® Turinorum. 8vo. 1818. Ex Anatome ; De Nervis Faciei ; Ex Physiologia ; 
 Quinti et Septimi Paris Functiones, «Scc. 
 
376 
 
 GENERAL AND rATHOLOGICAL ANATOMY, 
 
 nerve of motion. He also showed that the seventh pair, or late- 
 ral facial, presides over sensation and m otion in the functions of the 
 head, face, and neck, but mostly over motion. 
 
 In 1821 , Sir Charles Bell undertook to establish the principle, 
 that of the two nervous trunks distributed to the face, viz. the trige- 
 minus^ or fifth cerebral nerve, and the portio clura^ or seventh cere- 
 bral nerve, the lateral facial, the former presides over the sensations 
 or common sensibility of the head and face ; that it also possesses 
 branches going to the muscles of mastication ; whereas the latter nerve 
 regulates the muscular motions of the lips, nostrils, and velum palati, 
 and especially in associated action with the motions of respiration. 
 
 About the same time Magendie claimed the merit of showing 
 experimentally the fact of the distinction between nerves minister- 
 ing to sensation and nerves ministering to motion, and of proving 
 that, of the double row of nervous roots issuing in parallel lines from 
 the lateral regions of the' spinal chord, the anterior are destined for 
 motion, and the posterior for sensation. 
 
 Lastly, Mr Mayo, partly by dissection, partly by experimental 
 inquiry and reasoning, arrived at the conclusion that almost all the 
 bi’anches of the large or gangliophorous portion of the trifacial 
 nerves are nerves of sensation, while those of the small fasciculus, 
 which is void of ganglion, are nerves of motion. 
 
 In this manner, by successive steps, has been established one of 
 the most important doctrines on the functions of the nervous chords 
 in modern physiology ; and its justice h;js been confirmed by the 
 labours of many observers. The distinction is most clearly proved 
 by the original experiment of Sir Charles Bell. If the spine be 
 laid open, especially in a cold-blooded animal, as a frog, and the 
 posterior or gangliophorous roots alone be irritated, no movement 
 is produced ; but the moment the anterior roots are touched, the 
 extremities are agitated by active convulsive motions. 
 
 Of the cerebral nerves, the first or olfactory, the second or optic, 
 and the eighth or auditory, are pure nerves of proper sensation, 
 and are distributed to the sensitive parts of the eye, the nasal cavi- 
 ties, and the cochlea and labyrinth respectively. The third, fourth, 
 and part of the sixth, or abducent, are motific nerves connected 
 with the movements of the eye. The fifth or trifacial is a very pe- 
 culiar nerve. The gangliophorous, or rather plexiforra part of it, 
 communicates with all the organs of proper sensation, — the eye, 
 the ear in a small degree, the nasal cavities largely, and the palate. 
 
NERVOUS TISSUE. 
 
 377 
 
 mouth, and tongue largely ; and it is distributed extensively along 
 with the minute arteries of the face. Of this arrangement the re- 
 sult is, that it is a nerve neither of vision, nor of hearing, of smell 
 nor of taste, or deglutition nor of touch, or physiognomical expres- 
 sion, exclusively, but over the whole of these faculties and their 
 proper organs exercises a general modulating power. It maintains 
 between them a mutual consent or harmony of action, absolutely 
 necessary to the due separate exercise of each and the conjoined ex- 
 ercise of all. Lastly, by accompanying the arteries of the face, it 
 regulates the circulation of that region, and may he the means of 
 maintaininsr between the brain and the facial circulation those con- 
 
 O 
 
 ditions and expressions which arise from various mental emotions ; 
 as paleness, blushing, indignation, the sense of joy, triumph, the 
 sublime, and similar emotions. 
 
 Not less peculiar is the seventh, the small sympathetic of Wins- 
 low, Though mostly a motiferous nerve, yet it ministers to mo 
 tions of a particular order. It is, however, as a nerve distributed 
 to the skin of the face, a nerve contributing to, if not regulating 
 animal sensation and involuntary motion. It is, in fact, as shown 
 by Wrisberg, a double nerve, the large portion of which is devoted 
 to the purposes of animal life, and the small one to those of organic 
 life. It is a musculo-cutaneous nerve of the head and face. 
 
 In proceeding further in explaining the respective functions of 
 the nerves, it is requisite to keep in view not only their ganglio- 
 phorous character and the reverse, but their position as anterior 
 and as posterior nerves, and nerves consisting of anterior and pos- 
 terior roots. 
 
 The ninth pair, (iiervus glosso-pharyngaus,) consists of two parts, 
 one large, completing sensation to the root of the tongue and pha- 
 rynx, the other smaller, moving the pharynx, and connected, not- 
 withstanding, with the tenth pair, pneumogastric, and the great 
 sympathetic. 
 
 The tenth pair, {nervus vagus,) or pneumogastric nerve, is chiefly 
 a sensiferous nerve, regulating the sensations of the larynx, the 
 oesophagus and stomach, and the lungs, and placing these organs 
 in harmony as to function. One particularly, the recurrent 
 branches, appear to be motiferous. All the other brauches appear 
 to regulate circulation and secretion. 
 
 To the accessory nerve, or eleventh pair, seems to belong the 
 function of placing the pulmonary and laryngeal divisions of the 
 
378 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 pneumogastric in harmony and relation with the external muscles 
 of the hack and lateral regions of the neck. 
 
 Lastly, the hypoglossal, or twelfth pair, having mostly an anterior 
 origin, are motiferous. They form the motiferous nerves of the 
 muscles of the tongue. 
 
 It is to he observed, nevertheless, that though this distinction in 
 functions belongs to particular nerves, yet nerves ministering to 
 sensation, and regulating organic or involuntary functions, and 
 nerves ministering to motion, and regulating either voluntary mo- 
 tions, instinctive motions, or involuntary, but associated and neces- 
 sary motions, are often closely connected, and proceed together in 
 the same sheath, or in close apposition to the same organ. This, 
 which is observed in the fifth, the seventh, the ninth, tenth, and 
 eleventh, is rendered necessary by the offices which the organs have 
 to perform. The impulse or impression is communicated to the 
 organ, and received by its sensiferous nerves. By these the proper 
 sensation is transmitted, and the motiferous nerves are excited to 
 action. This appears to he the mode in which such actions as 
 sneezing, coughing, yawning, deglutition, and numerous other in- 
 stinctive and associated actions are called into operation. 
 
 Of the spinal nerves it is almost superfluous to speak after the 
 explanations now given. The splanchnic or great sympathetic ap- 
 pears to he a nerve of organic sensibility and impression, and as 
 such regulates the circulation of the abdominal organs, and trans- 
 mits their impressions to the central connections. The further 
 continuance of these by its spinal connections establishes a har- 
 monic action with the spinal marrow, always for good purposes, but 
 often under disease producing painful and destructive etfects.* 
 
 This may he said to comprehend all that is accurately known 
 regarding the uses of the nerves. Every other doctrine relating 
 to sensibility, sympathy, irritability, &c. is either unfounded, not 
 proved, or altogether imaginary and hypothetical. 
 
 In the foetus the nerves are developed with remarkable perfec- 
 tion. I cannot speak from personal observation much earlier than 
 the sixth month, when I have found the nerves of the extremities 
 
 * For further information and illustrations of the principles now stated, I refer the 
 reader to Arnold’s Illustrations of the Nerves of the Head and Face,* and an account 
 of the same work in the forty-thu’d volume of the Edinbiu’gh Medical and Surgical 
 Journal, January IdJo, p. 22S. 
 
 * Frederici Arnold! leones Nervorum Capitis. Heidelbergse, 1834. Folio. 
 
NEEVOUS TISSUE. 
 
 379 
 
 and voluntary muscles large and distinct. At the eighth mouth 
 they are still more conspicuous. The anterior crural nerves are 
 in the form of flat white cords one and a-half line hroad, and their 
 branches like good sized threads. The sciatic is still more distinct. 
 In the form of a thick cylindrical cord, fully a line in diameter, 
 and not unlike a piece of whip-cord, it is tough, stringy, and resists 
 tension, and its constituent threads are well marked. I immersed 
 a portion of this nerve three and a-half inches long in aqua po- 
 tassce, when it first became much firmer and denser than before, 
 assumed in two days the satin fibrous appearance first described by 
 Fontana, and at length by solution of the nervous matter was se- 
 parated into chords and neurilematic canals. In this state, pre- 
 served in spirit of turpentine, it conveys a tolerably correct idea of 
 the arrangement of the neurilematic canals. 
 
 The nerves of the involuntary muscles are equally distinct in 
 proportion. Those of the lung, heart, and splanclmic system are 
 distinct and manifest at the eighth month. 
 
 The neurilem is much more vascular in the foetus than in the 
 adult. In the same foetus of about eight months I found the neu- 
 rilem of the sciatic nerve, from the ischiatic notch to its divarica- 
 tion in the ham, covered with a thick net-work of m.inute vessels, 
 all injected with dark blood. 
 
 • 
 
 Section II. 
 
 1. Inflammation^ spontaneous and from injury, — Nerve-ach, Neu- 
 ritis. Neuralgia. (Neurilemmiaj Various observers, asBoerhaave, 
 have doubted the spontaneous occurrence of inflammation of a 
 nerve (neuritis;) and certainly the disease is not very common. 
 Others, on the contrary, have gone to the opposite extreme, and 
 thought that it was a frequent affection. Peter Frank, for instance, 
 and Joseph Frank, maintain that there is no doubt that neuritis 
 arises spontaneously, and that it is a lesion not uncommon; and in 
 this they are supported by the testimony of Nasse, Nicod, and other 
 authorities. It is nevertheless as a primary affection, and not in- 
 duced by injury, or previous disease of the bones, or of the soft tex- 
 tures, not very frequent. 
 
 When it takes place, the morbid action may affect either the 
 nerve-coat or the nervous matter, or both. In the first case the 
 neurilema is thickened, hardened, and rendered rigid. The ner- 
 
380 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 vous matter is also enlarged ; and often a perceptible enlargement 
 is formed at the point at which this morbid orgasm is established. 
 Lymph and blood are also effused; and to this, indeed, the enlarge- 
 ment is owing. Inflammation of the neurilema is certainly a com- 
 mon accompaniment, if not a cause of neuralgic pain. 
 
 When inflammation affects the nervous matter, it may produce 
 softening from slight effusion of serum or suppuration, or indura- 
 tion from the effusion of lymph. Our knowledge of these effects 
 is obtained mostly either from injuries of nerves, as when they are 
 torn, bruised, or divided, or from observing the results of experi- 
 ments on the lower animals. In this point of view, I shall have 
 occasion to recur to the subject afterwards. 
 
 Nervous tissue, therefore, is liable to inflammation. Tins may 
 arise spontaneously, or inconsequence of injury, as contusion, wound, 
 laceration, ligature, &c. It is accompanied first with gnawing pain, 
 which is oftener periodical than constant, spreading along the course 
 of the nerve, sometimes its branches, with a sense of heat often very 
 disagreeable, and a peculiar tenderness of the surface. After some 
 time the pain is less violent, but more constant ; and more or less 
 dei’angement iii the functions of the parts to which the nerve goes 
 takes place. The skin becomes numb, cold, and insensible. Of 
 muscular parts the motions are variously disordered, becoming ir- 
 regular, spasmodic, and little under the influence of the will, s^as 
 to constitute convulsions, and finally being lost in different degrees, 
 so as to cause palsy more or less complete. This constitutes one 
 form of neuralgia or nerve-ach. It is most frequent in the sciatic, 
 partly in consequence of its exposed situation, and sometimes in 
 consequence of actual violence locally inflicted, as in falling. {Is- 
 cliias nervosa of Cotunnius.) I have, however, seen this affection 
 arising in other nerves; for example, the median or spiral, in the 
 arm, and sometimes the posterior tibial, in the leg, in consequence 
 of similar causes. In one instance it was confined with accuracy 
 to the anterior branch of the radial nerve, which goes to the thumb 
 and index finger. In such cases the inflammatory action is con- 
 fined pretty accurately to a part of the neurilematic coat, which be- 
 comes firm, vascular, and more or less tender. 
 
 In neuralgia of the face {tic doloureux, Yothev^xW^) {prosopalgia, 
 Frank, Weisse,) it is not easy to say what is the pathological cause. 
 It is undoubted that it is seated in the nerve ; and though some 
 forms of this malady evidently depend on inflammation of the neu- 
 
NERVOUS TISSUE. 
 
 381 
 
 rilema, yet others of them, which are of long continuance, and are 
 attended by other peculiarities, are not perhaps to be ascribed to 
 this cause. It is not requisite to suppose that the long continuance 
 of this action, without producing suppuration or other changes, is 
 an argument against its inflammatory character. The inflamma- 
 tion may be, like those in fibrous tissue, of long continuance, with- 
 out inducing any other effect save that of thickening and stiffness 
 by effusion of lymph. 
 
 One of the most painful and least managable forms of nerve-ach 
 is that which is produced by previous disease either of a bone or its 
 periosteal covering. Chronic periosteal inflammation, for instance, 
 attacks the bones of the face, and affects some one of the foramina, 
 through which a nervous chord emerges. The periosteum becomes 
 thickened as the periosteal disease proceeds ; the bone itself is af- 
 fected, and exostosis is formed. This tumour compresses the nerve 
 and its covering, which are also perhaps inflamed ; and if the newly 
 formed bone is sharp, rough, or spicular, by lacerating and stretch- 
 ing the nerve, it causes to the patient acute pain and much suffering. 
 
 Neuritis should be distinguished from Neurilemmia, though often 
 they are associated and consequently cannot be distinguished. Jo- 
 seph Frank, nevertheless, thinks that the constancy of the pain in 
 the former, and its occasional remission and periodical recurrence 
 in the latter, may serve to distinguish the two affections. 
 
 An idea has been advanced by Reil, that general inflammation 
 of the neurilema takes place in typhus fever, and is the pathologi- 
 cal cause of that disease.* That the vessels of this tissue may be 
 gorged, and their blood poisoned and rendered hurtfnl, in common 
 with those of every other, is exceedingly probable, and may be often 
 the case. But it is manifest that this is one only of many simulta- 
 neous effects; and it is further evident, that neither observation nor 
 anatomical inspection can justify the conclusion, that inflammation 
 of the neurilema is the pathological cause of fever. 
 
 2. Neurilemmia Chronica. Inflammation of nervous tissue may 
 terminate, in resolution; 2d, in effusion of lymph; 3(i, in ul- 
 ceration ; or, 4ith, it may induce a low chronic action, accompanied 
 with enlargement of the nerve, or morbid growth by deposition of 
 new matter. These phenomena are most distinctly seen in the 
 changes which follow wounds of nerves. In this case effusion of 
 lymph is common, and is not unfrequently succeeded either by lo- 
 
 * Fieberlehre, Band. IV. p. 56. 
 
S82 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 cal palsy, or by a train of symptoms similar to nerve-ache. {Neu- 
 ralgia.) 
 
 Dr Denmark saw a contused wound of the radial nerve produce 
 neuralgic symptoms requiring amputation.* Charles Bell saw the 
 same result succeed contusion without wound in the popliteal nerve, 
 and the inflammation occasioned by the application of quicksilver to 
 the same nerve. f Mr Wardrope saw neuralgic symptoms succeed 
 a puncture of the finger, in which he thinks a nerve was injured \\ 
 and in another instance similar effects from wound of the thumb, 
 in which a branch of the radial nerve close to the digital artery was 
 punctured.§ In venesection it sometimes happens when the cutane- 
 our nerves are pierced, that numbness and tetanic stiflness, with 
 spasmodic twitches, are felt in the arm or fore-arm for some time 
 after. These symptoms it is justifiable to ascribe to chronic inflam- 
 mation, with thickening and induration of the nerve. |1 (Denmark.) 
 This thickening depends partly on extreme and undue distension 
 of the neurilematic vessels, partly on exudation of lymph, which 
 proceeds from the same source. 
 
 In the remarkable case described by Mr Pearson, in which he 
 ascribes severe and complicated neuralgic and paralytic symptoms 
 to ‘‘a morbid condition of the nerves distributed to the extremity 
 of the thumb, ”1T this morbid condition was probably chronic inflam- 
 mation of some part of their neurilematic covering. 
 
 Patients who have undergone amputation sometimes complain of 
 acute pain in a single point of the stump, liable to aggravation 
 when touched, and spreading up the limb in the course of the nerves. 
 It is usual to ascribe such complaints to implication of the nerve in 
 the cicatrix ; but it is more likely that a minute branch has been 
 included in the ligature of some of the vessels. In such circum- 
 stances it is manifest that a cause is given for the most severe and 
 obstinate form of neurilematic inflammation. Lastly, I may notice, 
 that to the same head is to be referred a painful gnawing sensation 
 of contraction ascending up the arm from the finger, which I have 
 
 * Medico-Chirurgical Transactions, Vol. IV. p. 48. London, 1813. 
 
 + Surgical Observations, &c. By Charles Bell. London, 1816, p. 440. Case of 
 Baron Driesen. 
 
 ;j: Medico-Chirurgical Transactions. Lond. Vol. VIII. p. 246. 
 
 § Medico-Chirurgical Transactions, Vol. XII. p. 205. 
 
 II “ The nerve was found thickened to twice its natural diameter, and contracted.” — 
 Transact. Vol. IV. p. SI. 
 
 ^ Account of Remarkable Symptoms, &c. By John Pearson, Esq. &c. Medico- 
 Chirurg. Trans. Vol. VIII. p. 252. 
 
NERVOUS TISSUE. 
 
 383 
 
 seen follow the communication of the inflammation of whitloe to one 
 of the small branches of the radial nerve. 
 
 3. Ulceration of nervous tissue, though rare, may occur either 
 after wound, laceration, or contusion of a nerve, as in the case of 
 ligature, or in consequence of an ulcer of the contiguous parts 
 spreading to the nerve. It does not appear to occur spontaneously 
 after inflammation. 
 
 4. Division and De-union; Excision or Removal, and Reproduc- 
 tion. When a nerve is cut across, no doubt can be entertained 
 that it is again reunited. But it is questionable whether it is re- 
 united by simple adhesion, by the growth of new nerve, or by the 
 growth of new matter entirely different. The latter point has been 
 a particular subject of inquiry to many anatomists and physiologists 
 in the case of excision, or removal of portions of a nervous trunk. 
 Though the nerves have been divided by many, the first accurate 
 experiments made with a view to ascertain their reproductive power 
 were performed by Cruikshank. This anatomist found, that, when 
 a portion of nerve is removed by incision, its place is supplied by 
 blood and lymph, which first becomes vascular and organized, and 
 is afterwards converted into a substance of the same colour as 
 nerve ; and which, though not fibrous, he regarded as nervous.* 
 These experiments were repeated by Fontana, who, after much 
 hesitation, came to the conclusion that nervous matter is repro- 
 duced ;f by Arnemann, who denied that the new-formed matter is 
 nerve ; J by Haighton, who inferred that this substance is really and 
 truly nerve ;§ by Baronio,|l Michaelis,1f . and Meyer,** who have 
 arrived nearly at the same general result, and assert that nervous 
 filaments may be traced through the ne\^;^atter of the cicatrix. 
 
 According to Arnemann, who describef^^ process of reunion 
 particularly, shortly after section, the end of the upper portion of 
 cut nerve inflames and swells, forming a grayish, long, and hard 
 
 * Experiments on the Nerves, particularly on their Reproduction. By William 
 Cruikshank, F. R. S. &c. Phil. Transactions, 1795. Parti, p. 177. 
 
 •f- Experiences sur la Reproductions des Nerfs, apud Traite sur la Venin de la Vi- 
 pere, &c. Par Felix Fontana. Tom. II. Florence, 1781, p. 177. 
 
 J Ueher die Reproduction der Nerven. Goettingen, 1786. Versuche Ueber die 
 Regeneration der Nerven. Ibid. 1787. 
 
 § An Experimental Inquiry on the Reproduction of Nerves. By John Haighton 
 M. D. Philosophical Transact. Lond. 1795. Part I. p. 190. 
 
 II Memorie de Matematica e Fisica, Vol. IV. 
 f Fr. Michaelis Ueber die Regeneration der Nerven. Cassel, 1786 
 ** Meyer apud Reil Archiv. fiir die Physiologie, II. Band. p. 449. 
 
384 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 knot ; the end of the lower portion undergoes the same change, but 
 in less degree ; the knotty parts unite ; and the substance which 
 thus connects the cut portions of nerve, though it continues hard 
 and large, is considered as either nervous matter, or as containing 
 a considerable portion of that substance, for the sensations and mo- 
 tions of the parts are in most cases restored shortly after union. 
 
 This ])rocess, according to Bichat, therefore, consists of four 
 stages. Isf, After incision the cut ends inflame, and the capillaries 
 of the divided portions effuse coagulating or organizable lymph, 
 which is penetrated with blood-vessels. 2d, This effusion, which 
 takes place chiefly from the neurilema, forms a sort of cellular 
 tissue, in which nervous matter is afterwards deposited. This cel- 
 lular tissue, and the new matter in general, is in quantity according 
 to the spaces to be filled up. If it be large, the new matter is aug- 
 mented by successive effusion and granulation ; and when small, 
 the connection by deposition appears to be very speedily eflfected. ?>d. 
 The adhesion of the individual granulating bodies and consolidation 
 of the part. Ath, The deposition or exhalation of nervous substance 
 in the new matter.* Is this, which is said to be the last stage of 
 the process, not co-existent and simultaneous with the effusion of 
 new matter in general ? What are the proofs which show that the 
 proper nervous matter is last deposited? 
 
 When a nerve has been divided under circumstances which pre- 
 vent it from uniting in any manner with its detached segment, as 
 in amputation, the extremity enlarges and becomes vascular, from 
 the neurilematic vessels assuming the inflammatory action ; blood 
 and lymph are effused both from the cut extremity and into the in- 
 terstices of the neurilematic canals ; more or less adhesion is con- 
 tracted with the contiguous textures ; and when the active state of 
 this process has subsided, a hard knotty tubercle is left in the site 
 of the cut extremity. This tubercle is at first rendered vascular, 
 afterwards grayish, solid, and so firm that the knife may be blunted 
 in dividing it. (Arnemann.) The changes now mentioned I have 
 often traced in the surface of stumps during healing. The size and 
 shape of the tubercle vary according to circumstances not well as- 
 certained. When situate not exactly at the extremity, as observed 
 by Van Horne, f it merely shows that the inflammatory process had 
 spread farther up the nerve than usual. 
 
 • Anat. Gen. Tom. I. Art. iii. sect. 3, p. 176. 
 
 -|- De iis qu£e in partibus membri amputatione vulneratis notanda sunt. Lugduni 
 Batav. 1803. 
 
NERVOUS TISSUE, 
 
 385 
 
 It was at one time supposed that the morbid growth called blood- 
 like fungus (fungus hcematodes ) was peculiar to the nervous tissue. 
 This idea is now known to be incorrect ; and it appears that there 
 is no process of disorganization peculiar to nerve, and not occurring 
 in other textures. 
 
 Nervous texture is sometimes unnaturally soft ; as in dropsy, 
 fatal hemorrhages, and diseases of long wasting. (Autenrieth.) Is 
 it ever unusually soft primarily, and without being the result of 
 another disease? It undergoes mollescence (ramollissement) in 
 consequence of mechanical injury ; but it is exceedingly doubtful 
 if this takes place spontaneously. 
 
 4. Local forms of palsy, that is, loss of mobility in an order of 
 muscles, or in a limb, is a common result of injury done to a nerve 
 or nerves. The effect of such injury is in general to produce in- 
 flammation or extravasation, and subsequent destruction of the 
 proper nervous matter. It becomes soft, pulpy, and disorganized. 
 In this state the nerve is no longer fit to perform its usual func- 
 tions, and it loses the influence which it possessed over the muscles 
 to which it is distributed. In the course of this process irregular 
 motions, or what are termed spasms, not unfrequently occur. 
 
 5. Tetanus . — Punctured or lacerated wounds of nervous tissue may 
 be followed by tonic spasms, {tetanus,) or by convulsive motions in 
 general. It is uncertain in this case whether the irregular motions 
 depend on injury of the nerve, or its neurilematic sheath. 
 
 The following facts I have ascertained in several cases in which 
 tetanus followed fracture of the fingers with contused wounds of 
 the soft parts. 
 
 In two cases I may mention, in which the injuries were very si- 
 milar, viz. fracture of the middle phalanges of the finger, the symp- 
 toms of tetanus came on about three weeks after the infliction of 
 the injury, and proceeded in the course of a few days to the fatal 
 termination. In the first case, the body of a cart, which had been 
 emptied, and for this purpose had been raised, fell on the hand of 
 the person, and caused fracture of the bones of the finger with con- 
 tusion. In the second case, the mast of a boat which had been 
 raised, and was standing not securely, fell on the hand of the per- 
 son, and in like manner produced fracture of the phalanges of the 
 thumb. 
 
 In both cases the nerve-coat connected with the injured part was 
 reddened, vascular, and injected, and manifestly thickened, while the 
 nervous matter of the nerve was reddened, swelled, and softened. 
 
 B b 
 
386 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 In the first of these cases, which took place in the person of a 
 young raan, who had been brought from Musselburgh to the Edin- 
 burgh Royal Infirmary, I examined the whole spinal chord with 
 care. I found it quite sound, except in the cervical portion, where 
 the envelopes were reddened, and had evidently been the seat of 
 inflammatory injection. Beneath these envelopes, the spinal chord 
 in the cervical portion was reddened and softened for the space of 
 between one inch and a-half and two inches. So far as I could 
 determine, this was the point which gives origin to, or is connected 
 with those branches of the cervical nerves which proceed to and 
 chiefly form the brachial plexus. 
 
 In this case, therefore, I inferred, that the injury done the 
 finger, and the subsequent inflammation, especially of the digital 
 nerve and its nerve-coat, had been reflected, as it were, to the spinal 
 origins of these nerves, and thus induced inflammation and irritation 
 of the spinal marrow, then softening ; and that these were the efii' 
 cient causes of the tetanic symptoms and their fatal termination. 
 
 In the second case, in which the patient died under the care of 
 my friend. Dr Paterson of Leith, and by whose attention I was 
 present at the inspection, we found the contused ends of the nerve 
 red and softened, and its tunic in like manner red, injected, and 
 thickened ; and in the same manner, on inspecting the spinal mar- 
 row, a portion of that organ in the cervical region not less than 
 two inches in length, very distinctly reddened and softened, indeed, 
 quite creamy, while the rest of the chord was firm and of normal 
 consistence. 
 
 The spot thus affected with softening corresponded very accu- 
 rately with the origins or spinal connections of the cervical nerves 
 which contribute to form the brachial plexus. 
 
 It is proper to say, that I had mentioned to Dr Paterson what 
 I expected to find in the spinal marrow, and my reasons for this 
 expectation as founded on the facts of the previous case. The dis- 
 covery of the connection between the inflamed nerve and the re- 
 flected irritation and inflammatory softening of the spinal chord was 
 not the effect of accident. 
 
 I have repeatedly seen the nerve or nerves of parts injured and 
 contused in tetanic cases, presenting redness, vascularity, thickening 
 of the neurilemma, and softening of the nerve. But I have not had 
 opportunities of examining the spinal chord in any other case. 
 
 I think, nevertheless, that it is reasonable to infer, that the irrita- 
 tion is propagated from the injured parts in the reflex direction to the 
 
 3 
 
NERVOUS TISSUE. 
 
 387 
 
 spinal connections of the nerves ; that there it is followed hy another 
 irritation and hy inflammation of the spinal marrow ; and that the last 
 is the cause of the tetanic symptoms. This further seems most pro- 
 bable when we consider that some time always elapses between the 
 date of the infliction of the injury, and that of the development of 
 the tetanic symptoms ; that is to say, the establishment of the in- 
 flammatory irritation of the spinal marrow. 
 
 At the same time, to render this theory of the cause of tetanus 
 complete, it would he requisite to inspect in the same manner cases 
 in which fractures or other injuries of the lower extremities had been 
 followed by tetanus. This I have not had opportunities of doing. 
 
 Traumatic tetanus is almost invariably a fatal disease ; and the 
 reason of this is, that it follows or is caused by a severe lesion of 
 the spinal chord at parts essential to the continuance of life. 
 
 Q. Tumours. A. (iVewrowzaof Odier.) Tumours of various size and 
 structure have been found in nervous trunks. These may be either 
 common to nerve with other tissues, or proper.* * * § Of the former an 
 example is given in the encysted tumour (hygroma) which Chesel- 
 dent found in the centre of the cubital (iilnar) nerve. Of that met 
 with by Grooch in the axillary nerve, the account is not so distinct, j; 
 Sir Everard Home mentions a tumour removed from the middle of 
 the right arm hy John Hunter, and in which the musculo-cutaneous 
 nerve was found imbedded, divided into two portions, each much 
 flattened. § This tumour appears to have originated in the neurilem. 
 In another instance Sir E. Home removed a tumour, in which one 
 of the large nerves of the axillary plexus was encased. 
 
 Lastly^ Odier describes, under the name of neuroma, in the per- 
 son of a member of his own family, an instance of tumour in the 
 radial nerve, in which its component threads were separated from 
 each other in the manner of a fan, or like the ribs of a melon, 
 
 * It is singiilar to remark with how little precision pathological writers speak of these 
 tumours. Odier compares the one mentioned by Cheselden to a firm one noticed by 
 Gooch, and to the yellow-whitish tumour which he met in the radial nerve of a rela- 
 tive. Meckel also refers to Cheselden ’s case in speaking of tumours, considerably hard, 
 roundish, yellow-whitish, of fibrous structure, and approacliing to fibro-cartilage. The 
 case of Cheselden should have been careful!}’ distinguished from the tumours intended 
 to exemplify this description. For that surgeon states specifically, that “ it was of the 
 cystic kind, but contained a transparent jeUy.” It was in truth an instance of 
 hygroma, and, as I have stated in the text, it was common to the nervous and other 
 tissues. 
 
 t The Anatomy of the Human Body, p. 256. London, 1778 and 1781. 12th Edit. 
 
 J Cases and Practical Remarks in Surgery, Vol. II. 
 
 § Trans, of a Society, &c. Vol. II. p. 152. An Account, &c. 
 
388 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 while the centre was filled with white and yellow matter, effused in 
 the intervals of an infinite number of transparent vessels, mutually 
 interlacing.* Examples of similar tumours are mentioned by 
 Marandel,t Neumann, :j: Von Siebold,§ Spangenberg,|l Alexan- 
 der,1f Mojon, and Covercelli.** 
 
 Of the cases recorded by Von Siebold, one occurred in the per- 
 son of an aged female with varicose veins of both legs and feet. 
 Two small nervous tumours were situate near each other at the 
 instep, between the ankles. They caused severe pains, which were 
 alleviated neither by narcotics nor stimulants. His father applied 
 caustic, and the disease disappeared, but soon returned. Von 
 Siebold himself again employed caustic more efficaciously, and ex- 
 tirpated the disease. 
 
 The case recorded by Neumann took place in an old man of 70, 
 on tbe middle and lower part of whose fore-arm a tumour as large 
 as a pea, very painful on being touched or sustaining the slight- 
 est pressure, had continued for thirty years. It was ascribed to 
 a violent blow received on the arm. The skin covering it was 
 healthy and movable, though the tumour itself was immovable, 
 in consequence of attachments to muscles. Neumann recommend- 
 ed excision. But the surgeon was afraid, lest, in dividing the nerve 
 he should injure the artery, and be attempted to remove it by excit- 
 ing suppuration produced by. the application of caustic. Meanwhile 
 the patient was destroyed by apoplexy. 
 
 Of the cases described by Spangenberg and Alexander, two 
 occurred to Dubois. One as large as a walnut, was situate on 
 the patella. Another, as large as a middle-sized melon, was con- 
 nected with the median nerve of the right arm. It was slightly 
 movable without discoloration of the skin. Both were extirpated. 
 
 The great evil of these tumours is, that from their relations 
 they cause much pain. Thus Nicod states, that in 1816 he removed 
 from the chest of a female aged 40, a lenticular tumour from six 
 to seven lines in diameter, movable in the subcutaneous cellular 
 tissue, apparently covered by the skin, w^hich was attenuated so 
 
 * Manuel de Medecine Pratique, &c. Par Louis Odier, Doct. et Prof, a Paris et 
 Geneve, 1811. Cl. IV. Ord. v. 17, p. 362. 
 
 t Bulletin apud Journal de Medecine continue, Vol. XI. 
 
 $ In Von Siebold Sammlung Chirurg. Beobachtungen. 
 
 § Von Siebold I. Band. p. 80, 82. 
 
 II In Horn Archiv. V. Band, 2 Heft, St. 2. 306. 
 
 H F. S. Alexander, Dissertatio de Tumoribus Nervorrun. Lugd. B. 1810. 
 
 ** Chiron, Band 1. St. 3| and Memorie della Societate di Genova. 
 
NERYOUS TISSUE. 
 
 389 
 
 much as to present a faint brownish tint. This colour, with the 
 severe pains which totally prevented sleep for months, made it be 
 taken by several medical men for cancerous. It was encysted, and 
 its removal was followed by sound sleep, which lasted that day and 
 the ensuing night and day.* 
 
 Some years ago I saw, in the arm of a woman about thirty, an 
 oblong pyriform hard body, extending along the inner margin of 
 the biceps flexor, in the site of the brachial vessels and nerves, to the 
 anterior tuberosity of the humerus. It was attended with prickling 
 pain, and alternating with numbness of the arm, fore-arm, and fin- 
 gers. From these symptoms (Home,) the absence of pulsation and 
 its situation, no doubt could be entertained that it implicated the 
 brachial nerve. The woman refused, however, to submit to have 
 it removed ; and I have not since heard of her. The evidence of 
 dissection as to its precise nature is therefore still wanting. 
 
 It is not easy to determine which of these tumours are to be re- 
 garded as common, or proper to the nervous chord or the neurile- 
 matic tissue. It is manifest that the case of Cheselden, and perhaps 
 that of Gooch, and the second one of Home, were common. That 
 of Odier, and the first of Home, appear to have been seated either 
 in the neurilema, or. its cellular tissue, and probably consisted in 
 deposition of new matter in the interstices of the neurilematic 
 canals. In the former case the filaments of the nerve are more or 
 less expanded and separated. In the latter they pass through the 
 body of the tumour in a mass. 
 
 The anatomical structure of these tumours is probably most fully 
 illustrated by a case recorded by Alexander, in which a tumour as 
 large as a hen’s egg was removed from the left arm of a soldier of 
 19 years of age, and in whom it was believed to be seated in the 
 ulnar nerve. In this case the neurilema formed an external cap- 
 sule. The ulnar nerve divided longitudinally for nearly half an 
 inch above the tumour was found sound, to the point where it 
 was dilated ; as it was also sound below the tumour, where in 
 like manner about half an inch of the nerve was removed by the 
 incisions, which embraced the longitudinal extent of four inches. 
 
 The colour of the tumour was the same as that of the nerve, 
 though more brilliant. The naked eye distinguished longitudinal 
 fibres, invested by some transverse fibres. It was hard to the 
 touch, elastic, and it was then observed to enclose a. liquid. 
 
 When divided longitudinally, the external wall was more resist- 
 
 * Nouveau Journal de Medecine, Not. 1818. 
 
300 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 ing than that of the nerve, and of a consistence about tendinous, but 
 not cartilaginous. By a small opening there escaped a limpid fluid 
 similar to serum, and coagulating ; and when this was forced out 
 by the elasticity of the external tunic, the volume of the tumour di- 
 minished one-third. 
 
 The external wall or neurileraatic tunic of the tumour was hard 
 and thicker than in the sound state of the nerve. At the middle 
 of the tumour this capsule was expanded into a thin though consis- 
 tent membrane. The inner surface of the capsule, when examin- 
 ed by a lens, presented fine parallel fibres. 
 
 The cavity formed within the neurilema was lined all over by a 
 dense pulpy plate ; leaving in the centre of the tumour an oblong 
 cavity like that of an egg, in which was contained the sero-albumi- 
 nous fluid. 
 
 In the interior of the tumour, the pulp, differing from that in the 
 sound state, presented a morbid aspect, well marked, was half an inch 
 thick, presented no straight parallel fibres, but a mass of numerous 
 small round bodies, firm and covered by an envelope, similar to fibres 
 twisted in the spiral direction, aggregated, resembling those which 
 Fontana recognized, by the aid of the microscope, in the medullary 
 matter of the nerves, and in the cortical matter of the brain. 
 
 In another case recorded by Alexander, in which a very painful 
 neuromatic tumour was extirpated by Reich from the right elbow of 
 a gentleman of 44, in whom it had been growing since the eleventh 
 year of his age ; though it was not so easy to ascertain the anato- 
 mical characters, it was observed, that the nervous fibrils were en- 
 larged, and filled with serous fluid at the place of the tumour ; that 
 their neurilema was indurated and contained a fluid ; and that in 
 this investment were seen firm tendinous fibres.* 
 
 Cruveilhier represents a spheroidal tumour the size of a small 
 nut, which was formed in the substance of the radial nerve, where 
 it passes between the supinator longus and the brachiaeus anticus. 
 The long supinator was thinned, and thrown outward by the tumour 
 on which it was moulded. The substance of the nerve seemed in- 
 terrupted at the site of the tumour ; yet most of its filaments were 
 continuous though separated, and could be traced, some before and 
 others behind the tumour. Several were lost in the fibrous cover- 
 ing ; none traversed the tumour. Cruveilhier considers this a carci- 
 nomatous tumour, and the effect of secondary cancerous infection. f 
 If that view be correct, it should not be regarded as neuroma. 
 
 -|- Livraison xxxv. 
 
 * Observatio secuiida. 
 
NERVOUS TISSUE. 
 
 391 
 
 The gangliophorous or organic nerves, as well as those of animal 
 life, are liable to the formation of tumours. Cruveilhier represents 
 in the cervical ganglions of the great sympathetic oblong spheroidal 
 tumours of fibrous character, which had been formed in these gang- 
 lions. These tumours he considers as instances of the fibrous de- 
 velopment with hypertrophy ; a statement from which little is to be 
 learned.* It is certain that the ganglions are much enlarged, and 
 that their substance is indurated ; that these swellings are contained 
 within a tumour or capsule of some thickness and firmness ; and 
 that the substance enclosed presents a fibrous arrangement, yet 
 with some remains of the original matter of the ganglion. They 
 seem, indeed, to be examples of neuroma. 
 
 On the whole, it seems probable that the neuromatic tumour is not 
 in all cases the same ; that sometimes it is the result of sero-albumi- 
 nous fluid eflfused interstitially in the texture of the nerve at one 
 point in consequence of chronic inflammation, and afterwards coa- 
 gulating ; that sometimes, from the operation of the same cause, a 
 cavity or cavities are formed, containing sero-albuminous fluid un- 
 coagulated ; that the nervous fibrils are seldom destroyed, but are 
 often separated and stretched, irritated, and compressed ; and that 
 never in the proper neuroma is new or heterologous matter deposited. 
 
 B. Neuromation, (Nsi;5o,aar/ov.) (Subcutaneous tubercle of Mr 
 Wood.) By this name may be distinguished those pisiform tumours 
 or hard tubercles which form beneath the skin, and of which I had 
 already occasion to speak when enumerating the morbid states of 
 the filamentous tissue. I then had occasion to remark, that there 
 is strong reason for thinking that this painful disease consists in the 
 hard body being seated in some of the nervous twigs beneath the 
 skin. I am now to advance such evidence as may show, that little 
 doubt can be entertained that this is the true pathology of the sub- 
 cutaneous tubercle. 
 
 Valsalva had early observed an instance of a small hard tumour 
 at the ankle of a lady, in whom it continued from the 16 th year, 
 and gave rise to pain so intense, that she would herself have at- 
 tempted extirpation, had she not been prevented by her domestics. 
 It was removed and the pain returned no more. 
 
 Hard, painful, pisiform tumours beneath the skin are next men- 
 tioned by Cheselden, who met with three cases in which he employ- 
 ed excision, without being aware that they might be seated in the 
 nerves or their coverings.! The next recorded case is that given by 
 
 * Liviaison I. Planche iiiieme. 
 
 -j- Anatomy of the Human Body. By William Cheselden, p. 136. 
 
392 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Dr Short, who in 1720 found in the leg one causing epilepsy, and 
 which he removed by excision.* Camper is, so far as I am aware, the 
 first anatomist, who remarks the occasional occurrence of minute 
 hard tubercles, not larger than a pea, in the cutaneous nerves; 
 where he represents them as giving rise to excruciating darting 
 pains night and day, admitting of no alleviation from external re- 
 medies. Of this kind he met with one in the musculo-cutaneous 
 nerve of a woman at Franequer, and another in the knee of a wo- 
 man at Amsterdam. Both he removed by excision, and found 
 them white internally, of gristly hardness, elastic, and seated with- 
 in the neurilema.f 
 
 The next notice of this disease is by Dr Bisset, who observed it 
 in the form of an irregularly-oval tumour, the size of a filbert, on 
 the outside of the left leg, six inches above the outer ancle, also in 
 a woman of twenty-nine years.f Soon after it was observed by 
 Mr Pearson in the subcutaneous nerve which accompanies the sa- 
 phmna vein, in the leg of a woman of fifty-one ; in the back of the 
 leg, near the Undo Achillis ; and at the bend of the arm, near the 
 median vein,§ in a young married woman. Since this time the dis- 
 ease was fully and accurately described by Mr William Wood of 
 this city ; I| and occasional cases have been published by other au- 
 thors.^ 
 
 Mr Wood questions the justice of the opinion of Camper, that 
 the tubercle is seated in the nerve-coat, or is a nervous tumour ; 
 and thinks that it is a distinct or peculiar species of tumour, situate 
 in the subcutaneous cellular membrane. It may not perhaps be pos- 
 sible to prove that every little subcutaneous tubercle is of this descrip- 
 tion. But the observations of the authors above mentioned, and those 
 of A. Petit,** Tissot, Lassus, Jacopi,ft Monteggia,|| and Alexander, 
 
 * An Epilepsy from an Uncommon Cause. By Ur Thomas Short, Physician at 
 Sheffield. Medical Essays and Observations, Vol. IV. art. xxvii. p. 416. Edinburgh, 
 1738. A tumour the size of a pea in the posterior tibial nerve, near the lower end of 
 gastrdcnemii- 
 
 -j- Petri Camper Demonstrationum Anatomico-Pathologicarum, Lib. i. Caput 2. § 5^ 
 p. 11. Lugduni Bat. Folio Imp. 
 
 J Memoirs of the Medical Society of London, Vol. III. p. 58. Case of Irritable 
 Tumour. By C. Bisset, M. D. &c. London, 1792. 
 
 § Medical Facts and Observations, Vol. VI. p. 96. Account, &c. 
 
 II Medical and Surgical Journal, Vol. VIII. p. 283, 429. Edinburgh Medico-Chi- 
 rurgical Transactions, Vol. III. Edinburgh, 1829. 
 
 Ibid. Vol. XL XVII. XVIII. 
 
 ** Essai sur la Medecine, &c. A Lyon, 1806. 
 
 tt Prospetto della Scuola di Chirurgia Pratica, &c. Vol. I. cap. 9. Milano, 1813. 
 
 Istituz. Chirur. Vol. II. Capo xiv. p. 197. Milano, 1813. 
 
NERVOUS TISSUE. 
 
 393 
 
 show manifestly that the nerves are liable to tubercles of this kind. 
 The proofs, in short, which may be adduced in favour of this idea, 
 are the following. 1 . In many instances of subcutaneous tubercle 
 the lenticular body has been formed in the substance or coat of a 
 nerve. (Short, Camper, Bisset, A. Petit, Tissot, Lassus, Jacopi, &c.) 
 2. In the majority of cases the tubercle can be traced distinctly to 
 the branch, twig, or filament of a subcutaneous nerve. 3. The pain- 
 ful sensation of which it is the seat, though severe and constant, is 
 always aggravated by handling or pressing the tumour, and may be 
 always traced along nervous branches. 
 
 In the cases in which the neuromatic tubercle has been dissected, 
 it has been found hard, cartilaginous, and slightly vascular. It 
 seems in general to consist in morbid change of the neurilema, by 
 deposition of albuminous matter in the neurilematic interstices. 
 (Jacopi.) It is much more frequent in women than in men, in the 
 proportion nearly of from seven to one, and from ten to one. 
 Monteggia states that he found the entire nervous system occupied 
 with numerous (centinaia,) neuromatic tubercles, which would in- 
 dicate, as he observes, in some instances a neuromatic diathesis.* 
 The cause of their formation is not known ; but from the effects of 
 ligature, division, and other injury, it may be in some manner con- 
 ceived. 
 
 It is important to observe, that in both classes of cases, the pre- 
 sence of these tumours gives rise to various remarkable effects. 
 Thus they may, by the irritation which they cause in the nerve, 
 induce not only intense pain, but give rise to epileptic motions. 
 This is shown by the remarkable case given by Dr Short so far 
 back as in 1720,j by the cases recorded by Mojon and Covercelli,^ 
 and by one mentioned by Portal.§ Is it not probable that, of the 
 cases described as preceded by aura epileptica several belong to 
 this head, and are cases in which there is in a nerve either a tubercle 
 or some similar source of irritation ? 
 
 In other instances, these tumours are attended with anomalous 
 and sometimes severe nervous symptoms. Pain and prickling or 
 the feeling of the electric shock from the tumour along the limb. 
 
 * Istituzione Chirurgiche, Vol. II. p. 197. 
 
 An Epilepsy, &c. Med. Essays and Observ. VoL IV. p. 416. 
 
 J Memorie della Socjetate di Genova. Und Von Siebold, Chiron, Band I. St. 3, 
 where the Memoires of Mojon and Covercelli are translated. 
 
 § Anatomie Medicale. Par A. Portal, Tome IV. p. 246. A body like a hard corn 
 near the articulation of the first with the second phalanx on the palmar surface of 
 the thumb. 
 
394 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Occasionally spasmodic motions take place ; and in certain cases 
 the functions of the part are destroyed. Thus a man of 36 years 
 of age lost his sight in consequence of the formation of a neuromatic 
 tumour in the optic nerve, (Sedillot,) a little larger than a hemp- 
 seed.* In a man of 60, who suffered from symptoms of asthma, a 
 tubercle the size of a pea was found in the right diaphragmatic nerve. f 
 
 The causes of neuroma and neuromation are little known. In 
 several of the cases, the formation of the tumour was preceded by 
 violence or injury. In others it arose spontaneously. The circum- 
 stances of the following case show the effect of chronic inflamma- 
 tion arising from causes operating on the system at large, and pro- 
 bably on the digestive functions. 
 
 A student in medicine, an internal pupil at the Hotel Dieu of 
 Angers, occupying an apartment situate several feet below the level 
 of the court, and sleeping in a recess formed in the substance of 
 the wall of the hospital, suffered, at the end of some months’ abode 
 in this unhealthy place, an attack of arthritis in the great toe ; and, 
 shortly after, there was formed, beneath the skin covering the in- 
 ternal saphena vein and nerve in the leg, a hard tumour, of the 
 size of a grain of wheat, and, whenever it was touched by the pa- 
 tient, either in dressing or undressing, or under any other circum- 
 stances, eaused pain, shooting like an electric shock upon the foot, 
 in the direction of the ramifications of the nerve. 
 
 Having obtained from the administrators of the hospital another 
 apartment, he was at the end of some months cured of the neural- 
 gia and the neuromatic tubercle. The same individual, when some 
 years afterwards at Paris, had under the chin a little boil, the ci- 
 catrix of which continued for several months the seat of acute pain, 
 caused by the friction of the razor, and which spread in a radiating 
 direction over the neck and chest. The subject of this case was the 
 late M. Beclard.J 
 
 7. Considerable wasting and shrinking were seen in the optic 
 nerves by Spigelius, Riolan, Rolfinck, Morgagni, Santorini, and 
 Benninger ; and complete destruction in the olfacient nerves by 
 Falkenburg. These changes, which take place generally at the 
 cerebral end of the nerve, are accompanied with diminution or loss 
 of function. 
 
 * Journal de Medecine, Tome L. 
 
 •j- Dissertation sur les Affections Locales des Nerfs. Par Pierre Jules Descot, D. M. 
 Paris, 1825. P. 257. 
 
 J Ibid. p. 212. 
 
BOOK III. 
 
 STEREOMORPHIC TEXTURES. KINETIC 
 TEXTURES. 
 
 The textures which next come under observation are those which 
 give solidity and figure to the body, or the Stereomorphic Tex- 
 tures ; and as in general they are the agents of movement, they 
 may be called Kinetic Textures. These are muscle, sinew, or 
 tendon, white fibrous system, yellow fibrous system, bone, cartilage, 
 and fibro-cartilage. 
 
 CHAPTER I. 
 
 Section I. 
 
 FLESH, THEW, MUSCLE. Mu?, — Mvig — Musculus, — Lacertus, 
 
 Tori . — MUSCULAR TISSUE. — Tissii Miisculaire. 
 
 The ordinary appearance of the substance named flesh or muscle 
 must be familiar to all ; and it is unnecessary to enumerate those 
 obvious characters which are easily recognized by the most careless 
 observer. A portion of muscle, when carefully examined, is found 
 to consist of several animal substances. It is traversed by arteries 
 and veins of various size ; nervous twigs are observed to pass into 
 it; it is often covered by dense whitish membranous folds, (^fascia,) 
 or by serous or mucous membranes, all which will be examined af- 
 terwards ; and it is found to contain a large proportion of fila- 
 mentous tissue. But it is distinguished by consisting of numerous 
 fibres disposed parallel to each other, and which may be separated 
 in the same manner by proper means. The appearance, arrange- 
 ment, and characters of these fibres demand particular notice. 
 
 According to Prochaska, muscle in all parts of the body may be 
 resolved, by careful dissection, into fibres of great delicacy, as mi- 
 nute as silk-filaments, but pretty uniform in shape, general appear- 
 ance, and dimensions. Their diameter appears not to exceed 
 
396 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 part of an inch, whatever be their length. They seem all more or 
 less flattened or angular, and appear to be solid diaphanous fila- 
 ments. Prochaska appears not to doubt that these muscular threads, 
 {Jila earned) are incapable of further division ; and he therefore 
 terms them primary muscular fibres. 
 
 The microscopical examination of the atomic constitution of the 
 muscular filament, which was first attempted by Lewenhoeck, and 
 afterwards prosecuted by Della Torre, Fontana, Monro, and Pro- 
 chaska, was in 1818 and 1826 revived by M. Bauer, the indefati- 
 gable assistant of Sir E. Plome. From the observations of this accu- 
 rate inquirer, each muscular filament appears to consist of a series 
 of globular or oblong spheroidal atoms, disposed in a linear direc- 
 tion, and connected by a transparent elastic jelly-like matter.* 
 
 The primary muscular fibres are placed close and parallel to 
 each other, and are united in every species of muscle into bundles ; 
 (^fasciculi; Zaccr^z;) of different, but determinate size; and, accord- 
 ing as these bundles are large or small, the appearance of the 
 muscle is coarse or delicate. In the deltoid the bundles are the 
 largest. In the vasti,, glutcei, and large pectoral muscles the bundles 
 are greatly larger than in the psoce. In the muscles of the face, 
 of the ball of the eye, of the hyoid bone, and especially in those of 
 the perinaeum, these bundles are very minute, and almost incapa- 
 ble of being distinguished. The number of ultimate filaments 
 which compose a bundle varies in different muscles, and probably 
 in different animals. In a muscular fibre of moderate size in the 
 human subject, Prochaska estimates them to vary from 100 to 200; 
 and in animals with larger fibres, at double, triple, or even four 
 times that number, f There is reason to conclude, from correct 
 microscopic observation, that the largest do not exceed the ^th of an 
 inch, and that the smallest are not less than ^Ith. 
 
 By cutting a muscle across, these bundles are observed to differ 
 not only in size but in shape. Some are oblong and rhomboidal ; 
 others present a triangular or quadrangular section ; and in some 
 even the irregular pentagon or polygon may be recognized. 
 
 These bundles are united by filamentous tissue of various degrees 
 of delicacy, as may be shown by the effects of boiling; and the 
 
 * The Croonian Lecture. On the changes the blood undergoes in the act of coagu- 
 lation. By Sir Everard Home, Bart. V. P. R. S. Phil. Trans. 1818, p. 175. — The 
 Croonian Lecture. On the stnicture of a muscular fibre, from which is derived its 
 elongation and contraction. By Sir E. Home, Bart., &c. &c. Phil. Trans. 1826, Part 
 2d, p. 64. 
 
 -f De Came Museulari, Sect. i. Chap. iii. 
 
MUSCULAR TISSUE. 
 
 397 
 
 muscle thus formed is penetrated by arteries, veins, and nervous 
 twigs, and is enclosed by filamentous tissue, which often contains 
 fat. 
 
 This fascicular arrangement appears to be confined to the muscles 
 of voluntary motion. It is not very distinct in the heart or dia- 
 phragm ; and in the urinary bladder and intestinal canal I have 
 not recognized it. Nor is the parallel arrangement of the ultimate 
 filaments always strictly observed in the involuntary muscles. The 
 component fibres of this order of muscles are often observed to 
 change direction, and unite at angles with each other. This fact, 
 which was observed by Lewenhoeck, has been verified by Prochaska. 
 
 Among microscopical observers it has been recently the prac- 
 tice to distinguish muscular fibres into three sorts. Muscular 
 
 fibres with cross stri(B, or articulated, moniliform fibres, containing 
 the voluntary muscles ; 2d, INIuscular fibres with the characters of 
 the fibres of the middle arterial coat, the examples of which are 
 found in the fibres of the stomach and intestinal tube, and the mus- 
 cular coat of excretory ducts, for instance, the vas deferens ; and, 
 3c?, Muscular fibres with the character of ligamentous tissue, of 
 which the iris and the tunic of the lymphatic vessels are understood 
 to be good examples. 
 
 The fibres of the voluntary muscles, as seen in the flesh of ani- 
 mals and the human body, are separated by maceration or boiling 
 into smaller or more slender fibres, which are the primitive fibres. 
 The course of these is either straight or cmded, I'arely spiral. The 
 individual inflections of the curled fibres, (^fihrce cirrosce,) are most- 
 ly in sharp angles opposite each other, in a zig-zag direction ; and 
 the angles of the zig-zag inflections are more or less acute. 
 
 The diameter of the primary fibres in man and the mammalia 
 varies. The most are from io§oo to tosoo of a Paris line, though 
 some attain not the size of of a Paris line, and others again 
 
 are so thick that they are from jo^oo to xoioo ™ breadth. Only 
 the smallest approach the cylindrical shape. The largest are flat, but 
 they are never so flat as inarticulated muscular fibres. The large 
 primary fasciculi are by dark, frequent but interrupted longitudinal 
 strice again divided into smaller fasc 2 cuh'. 
 
 INIany, and especially the fine primary fibres, have a feebly 
 granulated membranous covering, void of structure, and distin- 
 guishing them from the fibrous content. 
 
 The surface of a primary fasciculus is often covered with more 
 
398 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 or less numerous nucleated cells, which become distinct by immer- 
 sion in vinegar. 
 
 These are either broad, oblong oval, with nucleated cells, or col- 
 lected in long or short, small stricB, acuminated at both ends, 
 which are incurvated in the semilunar or serpentine form, like the 
 corpuscles in the roots of the hair; or they may be in rows of three, 
 four, or six small dark nuclei. The nuclei lie sometimes detached ; 
 sometimes alternating, or placed with their edges opposite each 
 other ; sometimes on the surface of the fasciculi in great quantity. 
 Most of them are straight, with their long axes parallel ; but 
 sometimes they are oblique or transverse. 
 
 The circumstance that principally distinguishes the animal mus- 
 cles from the other two sorts of muscular fibres, and from all other 
 tissues, is the striated arrangement of fasciculi which run both 
 transversely on the fasciculi, and in the longitudinal direction, and 
 preferably sometimes in one, sometimes in tbe other directior. 
 Only in the heart, especially in the neighbourhood of the external 
 and the internal covering, are seen fasciculi, which are sometimes 
 small-grained, like the smooth muscular fibres, but are also undu- 
 lating and curled, like ligamentous tissue, and even intermediate 
 between the two. Others are observed in the heart, and sometimes 
 also in the muscles of the trunk, which appear to have a fine-grained 
 content ; but tbe granules or punctula of which are not arranged 
 in determinate lines. 
 
 It would exceed the limits within which these notices ’must be 
 confined, were I to describe the whole as represented by the micro- 
 scope. It is enough to say that the fibres of the voluntary muscles 
 are distinguished by this character of being varicose, like a string 
 of very minute beads, or moniliform, that is, consisting of granules 
 or nuclei arranged in rows, so as to form a beaded filament ; that 
 in some of these longitudinal striae predominate, in others trans- 
 verse striae ; and in others, the appearance of the longitudinal striae 
 is such that they seem to be cirrose or curled ; and in others, 
 again, the transverse beading is so strongly marked, that it seems 
 to obscure and disguise the longitudinal arrangement. 
 
 2. The second order of muscular fibres is that of the muscles 
 formed after the type of the middle arterial coat. If the muscular 
 layer of the stomach or bowels, or that of an excretory duct is se- 
 parated into fibres, there are similar, often long flat lamellce, as in 
 the annular tissue of arteries, or the longitudinal fibrous coat of 
 
MUSCULAR TISSUE. 
 
 399 
 
 veins, with the same nuclei^ and the same transformation of nuclei 
 to dark stri<B. Over the middle of the lamellcB^ in their long di- 
 rection, passes sometimes a longer or shorter and proportionally 
 broader granular patch, sometimes a long slender fine dark streak, 
 sometimes an interrupted row of fine dark punctula. ' 
 
 Besides these lamellse, which are most abundant in the neigh- 
 bourhood of the serous coat, are individual fragments of broad, 
 very flat, stiff fibres. These lie in the muscular coat, in general 
 parallel to each other, united in greater or smaller numbers in 
 bundles. They seldom pass by oblique anastomoses into each 
 other. Between and over them run the nucleated fibres, which often 
 form a similar net-work, as the nucleated fibres of the middle arterial 
 coat. They are more translucent, more slender, and less nume- 
 rous than in the middle arterial coat. The breadth of the granulated 
 muscular fibres is from f® t/o®oo line; the breadth 
 
 of the fibrils about y o§oo of one line. 
 
 This species of muscular fibres, which are known as flat, inarti- 
 culated organic or involuntary fibres, belong chiefly to the viscera, 
 or organic and internal muscles. 
 
 Of the third species, embracing the iris and lymphatic vessels, 
 it is unnecessary to speak here. 
 
 The colour of muscle varies. In man and the mammiferous ani- 
 mals, at least adult, it is more or less red ; in many birds and fishes 
 it is known to be whitish ; in young animals it is grayish or cream- 
 coloured ; and the slender fibres which form the middle coat of the 
 intestines in all animals are almost colourless. The colour of the 
 muscles of voluntary motion in man is red or fawn ; but repeated 
 washins or maceration in alcohol or alkaline fluids renders them 
 much paler. 
 
 The examination of the physical properties of muscle has occu- 
 pied the industry of Muschenbroek, Croone, Browne Langrish, 
 Wintringham, and others of the iatro-mathematical school. I can- 
 not perceive that minute knowledge of these properties is of much 
 moment to the elucidation either of its sound or its morbid states. 
 Amidst the variable results necessarily obtained in such an inquiry, 
 the only point which is certain is, that muscular fibre has much less 
 tenacity and mutual aggregation thau most other tissues. It sus- 
 tains much less weight and force of tension without giving way. 
 
 Chemical analysis has not yet furnished any satisfactory results 
 on the nature of muscular tissue ; but the general conclusion of 
 the numerous experiments already instituted show that muscle con- 
 
400 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 tains fibrin, albumen, gelatine, extractive matter (osmazome,) and 
 saline substances. It is difficult to say how far the gelatine is to 
 be regarded as proper to muscle, or derived from the filamentous 
 tissue, in which it certainly exists. The saline matters are common 
 to muscle with most other organic substances. There is reason to 
 believe that fibrin in considerable quantity, and albumen and osma- 
 zome in smaller proportion, are the proper proximate principles of 
 muscle. Though the various proportions of these principles have 
 been stated in numbers by chemists, there can be no doubt that in 
 the present condition of animal chemistry it is impossible to place 
 on them any reliance. It is also to be remembered, that the 
 relative proportion of the proximate principles varies at different 
 periods of life. In early life the muscular fibre contains a large 
 proportion of gelatine, and very little albumen, fibrin, or osmazome. 
 In adult age, however, the gelatine is very scanty, and the fibrin 
 is abundant. The albumen and gelatine found in muscle seem to 
 be derived chiefly from the filamentous tissue, and the aponeurotic 
 intersections. 
 
 During life the muscular fibre possesses the property of shorten- 
 ing itself or contracting under certain conditions. These may be 
 referred to tbe following heads. The will in the voluntary 
 
 muscles. 2d, Proper fluids in the involuntary muscles, as the blood 
 to the heart, articles of food or drink in the stomach, chyme in the 
 small intestines, excrement in the large intestines, urine in the blad- 
 der, &c. M, Mechanical irritants in all muscles. 4^/t, Chemical 
 irritants; and, 5th, Morbid products generated in the course of 
 disease. 
 
 This property of contracting has received various names ; con- 
 tractility (vis contractilis of L. Bellini), irritability (Grlisson), (vis 
 vitalis of De Gorter and Gaubius), excitability, mobility, vis insita, 
 vis propria of Haller, and the organic contractility of Bichat. 
 
 It is peculiar to muscular fibre, and is found in no other living 
 tissue. 
 
 The influence of the brain and nerves over muscular contrac- 
 tion, and tbe inquiry of the properties peculiar to muscles, form an 
 interesting subject of investigation, on which many facts have been 
 communicated since the time of Haller and Whytt, and especially 
 by Nysten, Le Gallois, Wilson Philip, Brodie, Bell, Magendie, 
 Mayo, Flourens, Fodera, Rolando, and Marshall Hall. But it is 
 
 too extensive to be considered in this place ; and, for information on 
 
 4 
 
MUSCULAK TISSUE. 
 
 401 
 
 the subject, I refer to the ordinary physiological works, and to 
 those journals in which these researches are detailed.* 
 
 The muscles have been divided according to the manner in which 
 the phenomena of contraction take place, — into, muscles obe- 
 
 dient to the will, or voluntary ; 2d, muscles not under the influence 
 of the will, or involuntary ; and, Zd, muscles of a mixed character, 
 the motions of which are neither entirely dependent or independent 
 of the will. 
 
 The first order comprehends all the muscles of the skeleton ; the 
 second comprehends the hollow muscles, as the heart, stomach, and 
 intestinal canal ; and the third comprehends such muscular organs 
 as the diaphragm, intercostal muscles, bladder, rectum, &c. 
 
 Section II. 
 
 1. Myositis . — Muscle is liable to inflammation, which may be 
 acute or chronic in duration, and may differ according to its kind. 
 One form of muscular inflammation seems to constitute a species 
 of rheumatism (Carmichael Smyth ),f and when this continues long, 
 it terminates in loss of power, constituting a local palsy. 
 
 a. Myositis Purulenta . — Another form, equally serious and more 
 certainly injurious, is the suppurative form of muscular inflamma- 
 tion. In this the muscular structure suppurates and sometimes 
 sloughs extensively ; and, whether acute or chronic, is generally a 
 fatal disease. The most familiar instance of the chronic form of 
 suppurative inflammation in muscle is that which constitutes lumbar 
 abscess, — inflammation of the great psoas muscle. j: Of this Schoen- 
 mezel records a good example in the person of a muscular young 
 man of 28, in whom the whole of the psoas magnus and iliacus of 
 
 * Elementa Physiologise, Tome iv. Lib. xi. Sect. ii. 
 
 Physiologie de PHomme, par N. P. Adelon, 4 tomes, 8vo. Paris, 1823-1824. 
 
 Outlines of Human Physiology. By Herbert Mayo, F. R. S. &c. 3d Edition. Lon- 
 don, 1833. 4th Edition. London, 1836, 8vo. 
 
 Handbuch der Physiologie des Menschen fiir Vorlesungen. Von Johannes Muller, 
 Ordentlich Offentl, Prof, der Anatomie und Physiologie U. S. W. in Berlin. Zwey 
 Band. Coblenz, 1835 und 1840, 8\'o. 
 
 Journal de Physiologie, Tomei. ii. <Scc. &c. Archives Generales,^(ws-t/». 
 
 t Medical Communications. Vol. II. p. 21”, 218. 
 
 $ “ The most remarkable and complete destruction of muscle which occurs from 
 suppuration is that which is seen in the disease called psoas abscess, where the whole 
 or the greater part of the muscle often disappears, and its capsule is filled with the 
 matter of suppuration.” — Thomson on Inflam., p. 152. — Lectures, p. 15.9. 
 
402 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the right side was destroyed and converted into purulent matter, 
 forming a sac extending from the last lumbar vertebra along the 
 surface of the ilium to the small trochanter.* Three similar cases 
 described by Mr Howsbip form the clearest account of the anato- 
 mical characters of this disease.f In such instances, since there 
 is either no affection, or at least no primary affection, of the bones 
 of the spine, it must be inferred that the disease consists in sup- 
 purative inflammation either of the muscular tissue, or at least of the 
 filamentous tissue of the muscles. The structure of these muscles, 
 especially that of the psoas, is greatly more delicate than that of any 
 other large muscle, and may have some influence in the destructive 
 sero-purulent secretion which follows. Is the muscular texture de- 
 stroyed or merely separated ? I have seen discharged along with 
 the fluid of lumbar abscess capillary filaments, brownish, firm, and 
 evidently the remains of the muscular fibres. At the same time, 
 in the dissections above quoted, no fibres are mentioned in the 
 purulent cyst. In a case by Mr Milroy fibres are stated to have 
 been discharged. 
 
 The acute form of muscular inflammation is more rare, but some- 
 times occurs in the muscles of the abdomen, of the chest, of the 
 thigh or leg, in persons of broken constitution and diseased habits. 
 By some authors, however, the muscular fibre is believed to be in- 
 capable of inflammation ; and the instances ascribed to it are by 
 them said to be inflammation of the intermuscular cellular tissue. 
 On this head, I refer to the section on Diffuse Inflammation of tlie 
 Cellular Membrane. 
 
 /3. Carditis . — Another example of inflammation of muscular 
 tissue is presented in that of the heart. The testimony of Dr Baillie 
 shows that this is a rare disease, and is almost never primary, but 
 the result of inflammation of the pericardium, from which it spreads 
 to the filamentous tissue, and partly to the muscular fibres of the 
 organ. The general accuracy of this statement is confirmed by 
 Laennec, who contends, that though partial inflammation in minute 
 spots is not uncommon, yet general inflammation of the cardiac 
 substance, either acute or chronic, is a thing almost unknown in the 
 records of medicine. The cases adduced by Corvisart he regards 
 as examples of pericarditis ; and the same may be said of those of 
 
 * Francisci Schoenmezel, Med. Prof. Heidelbergensis Observatio de Musculis Psoa 
 et Iliaco suppuratis. Heidelberg®, 1776. Frank Delectus, Vol. V. p. 169. 
 
 •j- Practical Observations on Surgery and Morbid Anatomy. 
 
MUSCULAR TISSUE. 
 
 403 
 
 Dr Davis.* The possibility of the fact, nevertheless, he admits on 
 the evidence of the case of Meckeht Stronger proof he might 
 have found in a case by Mr Stanley, in which the cut substance of 
 the heart was exceedingly dark-coloui'ed from injection of the capil- 
 laries ; the fibres were soft, loose, easily separable, and compres- 
 sible between the fingers ; while sections of each ventricle exhibited 
 numerous small distinct collections of dark-coloured purulent 
 matter among the muscular fasciculi, — some deep, approaching the 
 cavity of the ventricle, others superficial, raising the pericardium. 
 The muscular substauce of the auricles was softened and loaded 
 with blood ; but without purulent deposits, j; 
 
 In this case, which took place in a boy of 14, the chief symptoms 
 were those of intense inflammatory fever, with great heat, deli- 
 rium, and feverishness, and some frontal headach. On one day 
 the patient complained of pain in the thigh and knee ; but at no 
 time in the whole course of the symptoms, which lasted only four 
 days, did he give any indications of pain within the chest. Death 
 was preceded by difficult breathing. The case, indeed, was one of 
 great acuteness and rapidity in progress. 
 
 It cannot be denied that in this case the muscular tissue of the 
 organ exhibited marks of inflammation ; but the purulent deposits 
 might be seated in the intermuscular filamentous tissue, which, 
 though delicate, is abundant. 
 
 In 1828, Dr P. M. Latham, after remarking the rarity of finding 
 purulent matter as a proof or effect of inflammation of the substance 
 of the heart, added that, nevertheless, he had met with two examples 
 of this lesion. In one instance the whole heart was deeply tinged 
 with dark-coloured blood, and its substance was softened ; and upon 
 section of both ventricles, innumerable small drops of purulent 
 matter oozed fi-om various parts among the muscular fibres. This 
 was the result of a most rapid and acute inflammation, which ter- 
 minated in death, after an illness of only two days’ duration. 
 
 In another instance, after death, which terminated an illness of 
 long duration, and characterized by symptoms referable to the heart, 
 a distinct abscess was found in the substance of the left ventricle, 
 closed externally by a portion of adherent pericardium, and con- 
 
 • Inquiry into the Symptoms, &c. of Carditis. By J. Ford Davis, M D. Bath 
 1808. 
 
 t Memoires de I’Academie de Berlin. 
 
 t Medico-Chirurgical Transactions, Vol. VII. p. 323. 
 
404 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 nected internally with an ossified portion of the lining mem- 
 brane.* 
 
 In the descriptive catalogue of Mr Langstaff’s museum, are se- 
 veral preparations in which the muscular substance of the heart is 
 said to have been inflamed. No. 298, a female of 46, 303, a boy 
 of 8. (The muscular structure showed all the signs of carditis.) 
 303, a man of 47. No specific details, however, are furnished. f 
 In the Morbid Anatomy Collection of the University of Edinburgh 
 is a preparation of a heart, (P. 1 2,) in which a large abscess with 
 an irregular inner surface, which contained lymph and purulent 
 matter, occupies the whole extent of the septum cordis, and com- 
 municates, by a small orifice the size of a quill with the left ventri- 
 cle. In this case inflammation must have affected the septum, per- 
 haps the neighbouring parts of the left ventricle, and may have 
 eventually been concentrated on the septum, in which it induced 
 suppuration, confined within the walls of a distinct cavity. Twelve 
 months previous to death the patient laboured under symptoms of 
 pneumonia, and at last died suddenly. 
 
 An instance not less decisive is recorded by Mr Salter of Poole, 
 in the person of a man of 50 years. The disease appears in this 
 case, however, to have been at first slow in progress, and chronic in 
 duration, as the symptoms continued for about six weeks. These 
 were dull, heavy, but not lancinating pain, in the lower part of 
 the chest, rather inclining to the left side ; much distressing oppres- 
 sion in breathing, aggravated at intervals, and never quitting the 
 patient ; frequent small pulse ; considerable uneasiness in the left 
 arm frequently recurring, and a feeling as if he could not live. 
 No cough nor any sign of pulmonary affection was observed. All 
 the symptoms assumed an aggravated form with great orthopnoea, 
 anxiety, and restlessness, for sixty-five hours only before death. 
 
 In this case the heart was rather larger than natural and of 
 moderate firmness. Large white and yellow clots were contained 
 within the chambers of the organ, and marks of incipient ossification 
 were observed in the ascending aorta, but no disease in the endo- 
 cardium or in the valves. The muscular substance of the heart 
 
 “ Pathological Essays on some Diseases of the Heart ; being the substance of Lec- 
 tures delivered before the College of Physicians. By P. Mere Latham, M. D., Physi- 
 cian to St Bartholomew’s Hospital. London Medical Gazette, Vol. III., p. 119. 
 London, 1829. Essay III. 
 
 t Catalogue of the preparations illustrative of Normal, Abnormal, and Morbid 
 Structure, constituting the Anatomical Museum of George Langstaff, F. R. C. S., &c. 
 London, 1842. 8vo. 
 
MUSCULAE TISSUE. 
 
 405 
 
 was of a light yellow colour, yet preserving the fibrous texture of 
 muscle ; and it presented purulent matter at the surface of the vari- 
 ous sections made in it. In some parts were observed small cavities 
 filled with purulent matter, varying from the size of a pin-head to 
 that of a small pea. 
 
 The pericardium was unusually vascular ; a state ascribed by 
 the author to inflammation, but its surface presented no lymph.* 
 It is probable that the inflammatory state of the cardiac muscular 
 fibres had spread to the investing membrane. 
 
 All these cases, it must be admitted, afford examples of inflamma- 
 tion either of the muscular substance of the heart, or of the connect- 
 ing filamentous tissue, or of both. Indeed, it is not easy to conceive 
 the one tissue to be inflamed without the other ; and whether we 
 say that the inflammatory process begins in the filamentous tissue, 
 and thence spreads to the muscular, which is probable, or begins 
 in the muscular tissue and spreads to the filamentous, the result is 
 the same. 
 
 It is impossible therefore to doubt, that the muscular substance 
 of the heart is liable to be affected by inflammation, and its most 
 common product suppuration ; and from the cases now recorded 
 it seems to result, that the inflammation is often very acute and 
 rapid in progress, and in other instances is slow and more chronic. 
 The process also appears sometimes to attack the whole organ ; in 
 other instances only one part of it, or after attacking the whole, to 
 become concentrated on one point. 
 
 Lastly, Bouillaud gives various examples of what he denominates 
 Inflammation of the substance of the heart. His views, however, on 
 this subject are so peculiar, that I think they may be more properly 
 introduced under a different head. Aneurism of the heart he con- 
 siders as the effect of inflammation. 
 
 Abscess and ulceration of muscular tissue are the result of local 
 or punctuate inflammation. In the former case, a cavity, with 
 smooth walls, containing purulent matter, is formed in one region 
 of the muscular substance. In the latter a rugged irregular sur- 
 face, produced by ulcerative absorption or erosion, takes place near 
 the surface of the muscle. The examples of both forms, as they 
 take place in the heart, are the most interesting to the pathologist. 
 Of abscess in this organ, instances are given by Poterius, Benive- 
 nius, Cornax, Nicolaus Massa, Pantoni, and Laennec. Of ulcers 
 
 * Case of Carditis by Thomas Salter, Esq, Surgeon, Medico-Chirurgical Transac- 
 tions, Vol. XXII. p. 72. London, 1039. 
 
406 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 on the outer surface, instances were seen by Olaus Borrichius,* 
 RiveriuSjf Job a Meekren,| Peter de Marchettis,§ Malpighi, |1 
 Peyer,1T, Graetz, and Morgagni.** The ulcer occurring in the 
 inner surface of the heart was seen by Morgagni, (Epist. xxiv. 17,) 
 and by Laennec, who found one an inch long, half an inch broad, 
 and more than four lines deep in the centre, in the inner surface of 
 the left ventricle, which was hypertrophied, and at length rupured. 
 
 7. Myositis emolliens . — To this head may be referred the softened 
 or pulpy state occasionally observed in the substance of the heart 
 in weak extenuated subjects liable to fainting-fits, and also in those 
 cut off by fever. The muscular fibres then assume a light fawn 
 colour or pale yellow, like the dead leaf, become flabby and friable, 
 and so easily lacerable as scarcely to sustain handling. By Laen- 
 nec this is regarded as the result of error of assimilation or defec- 
 tive nutrition ; while Bouillaud ascribes it to inflammation.. One 
 variety of softening appears to be the consequence of inflammation, 
 and may be considered as gangrene of the heart. Most usually, 
 however, it is the result of imperfect nutrition of the organ during 
 disease, either chronic or subacute. 
 
 2. Hyper trojjhy . — There is reason to believe that the condition 
 described as hypertrophy of muscles is mere enlargement with 
 thickening and induration of the constituent fibres, depending on 
 chronic inflammation. It is certainly quite different from the 
 enlargement occasioned by exercise, to which it has been erro- 
 neously compared. In the heart and bladder, in which it has been 
 most frequently found, not only is tbe muscular substance thick- 
 ened and enlarged, but it is rendered hard, firm, and in some parts 
 almost cartilaginous. In the early stage the colour is simply brown ; 
 subsequently it acquires in certain parts a leaden-gray tint, which 
 seems to depend on parts of the muscle assuming the cartilaginous 
 induration. The substance of the organ then cuts firm, and resists 
 the knife. The change seems either to depend on, or to be con- 
 nected with, a process of chronic injection ; for the vessels are large, 
 distended, and abundant. In the deltoid and biceps of the fencer,, 
 and the ylutaei and yastrocnemii of the dancer, though large and 
 
 * Bartholini, Acta Med. Haf. Vol. I. Obs. 69. 
 
 t Cent. i. Ob. 87. + Obs. Chimrg. 35. 
 
 § Observ. Med.-Chir. 46. |1 Morgagni, Ep. xxv. 17. 
 
 *[J Method. Hist. Anat. c. vi. in Schol. 
 
 ** Epist. xvi. 17. 
 
MUSCULAR TISSUE. 
 
 407 
 
 well developed, no change of this description can be recognized. 
 They are indeed firm and tough, like the muscle of entire male 
 animals, but present nothing of the morbid enlargement, conges- 
 tion, and induration found in the hypertrophied heart and bladder. 
 In proof of the justice of these views it may be added, that the in- 
 stances in wdiich the muscular coat of the stomach is admitted to 
 be hypertrophied, are those in which scirrhus, or some similar 
 chronic inflammatory state, affects the collateral tissues. (Louis.) 
 
 Hypertrophy of muscular organs takes place most commonly in 
 connection with some permanent resistance opposed to their action. 
 Thus hypertrophy of the heart is connected with permanent con- 
 traction of the aortic orifice and disease of the valves, or with an 
 unnaturally irritant state of the blood, as in rheumatism and disease 
 of the kidney. Hypertrophy of the bladder, in like manner, usu- 
 ally takes place as an effect of stricture of the urethra, and some- 
 times of chronic inflammation or other disease of the mucous coat, 
 or enlargement of the prostate gland. 
 
 3. Atrophy of muscles, or diminution of size, is more frequent, 
 and may arise either from general disease, as in consumption, 
 dropsy, &c. or from local debility, as in rheumatism, palsy, &c. ; 
 or, in short, from defective local nutrition, or, as after unreduced 
 luxations, from want of exercise of particular muscles. The best 
 example of complete atrophy is that which takes place in muscles 
 poisoned by lead, which become small, shrunk, pale, and void of 
 irritability. 
 
 4. Steatosis ; Adipijication. — I cannot understand upon what 
 grounds the fatty degeneration of muscle is denied by Bedard ; 
 for there is no doubt that authentic instances are recorded of this 
 change occurring in the muscles both of man and of the lower ani- 
 mals, under certain diseases. Independent of its being seen in the 
 muscles of the sheep by Vaughan,* it has been observed in those 
 of the human subject by Haller, Louis, Maugre, Vicq-D’Azyr, 
 Dumas, Emmanuel, Laennec, and Adams. Louis, so early as 
 1739, in amputating the right leg, found the gemelli^ plantaris, 
 poplitaeus^ solaeus, the long common flexor of the toes, the proper 
 flexor of the great toe, and the tibialis posticus converted into fat.f 
 
 ’ Some Account of an Uncommon Appearance, &c. By W. Vaughan, M. D. 
 London, 1813. 
 
 t Rapport sur line Observation, &c. Journal General de Medecine, Tome XXIV. 
 
408 
 
 GENERAL AND RATHOLOGICAL ANATOMY. 
 
 Maugre found the muscles of the same region, excepting the ye- 
 vielli^ which were greatly diminished in size, converted into an adi- 
 pose mass easily divisible by the knife.* Vicq-D’Azyr, in an old 
 subject, saw the psoas and iliacus^ the glutcBus medius and minimus, 
 the adductors, the deep posterior muscles of the leg, and the plan- 
 tar muscles, completely changed into fibro-cellular fat, without 
 traces of remaining fibre. In the sciatic portion of the semitendi- 
 nosus and biceps, the gemelli, the extensors of the toes, that of the 
 great toe, and the tibialis anticus only, was it possible to recognize 
 fibres with distinct direction. The sartorius presented the gradual 
 transition from muscle to fat, being muscular above and adipose 
 below. The fat into which these muscles were changed is describ- 
 ed as white, firm, contained in numerous minute cells ; the uniting 
 cellular tissue whitish, looser, and more separable than usual ; and 
 the fat is not deposited between its filaments, but forms part of 
 their substance. Examined by a good glass, it presents a mass of 
 soft transparent fibres of various diameters, in different parts of 
 their length.j Dumas saw the muscles of the fore part of the chest, 
 and those of the posterior region of the shoulder and arm, reduced 
 to an adipose mass, contained in condensed cellular membrane ; 
 those of the abdomen and the triceps adductor much changed ; and 
 the glutaeus maximus and first adductor half changed into fatty 
 matter. I Emmanuel, in the person of a woman of 38, dead of child- 
 bed fever, found the abdominal muscles entirely changed into fat.§ 
 
 Lastly, this transformation was seen by Laennec and Adams in 
 the human heart. The changed portions assumed a pale-yellow 
 colour, which is most distinct externally, and approaches to the na- 
 tural tint as it proceeds inwards, at which the muscular fibres are 
 less changed. According to an analysis by Cruveilhier, it consists 
 of solid adipocerous fat, oily fluid, (elaine'), and a little gelatine. 
 
 5. Elongation and shortening of muscular fibres are mentioned 
 among morbid changes. 
 
 6. Rupture or laceration. — Of this occurrence in muscular or- 
 gans, the most important example is that of rupture of the muscular 
 substance of the heart. Instances of this have been collected by 
 
 * Rapport sur une Observation, &c. Journal General cle Medecine, Tome XXIV. 
 
 p. 6. 
 
 t Journal General de Medicine, Tome XXVI. p. 11. 
 
 + Ibid. Tome XXIII. p. 61. 
 
 § Ibid. Vol. XXIV. p. 4. 
 
 3 
 
MUSCULAR TISSUE. 
 
 409 
 
 Morand,* * * * Morgagni, f Haller,^ Portal,§ Brera,|| Baillle, Rostan,1[ 
 Blaud,** * * §§ Rochoux,|t and Adams.Jt According to the results ob- 
 tained by these observers, rupture of the heart is most frequent in 
 the left ventricle, which gives way by a longitudinal fissure near 
 the base and middle of the ventricle. In most of the cases, this 
 rupture may be traced to previous ulceration, (Morgagni, Haller, 
 Portal, Brera, &c.) and appears to be the result of the ulcerative 
 process advancing from one surface of the ventricle to the other. 
 Of rupture of the right ventricle too little is known to determine 
 whether it he also the result of ulceration or not. So far, there- 
 fore, as is hitherto known, laceration of the muscular substance of 
 the heart is not so much the consequence of being violently or forci- 
 bly torn, as of its being previously wasted, extenuated, and weakened. 
 
 Transverse laceration of muscular fibres, or forcible detachment 
 from the tendons, may happen in consequence of external violence. 
 This was seen by ’W’olfius,§§ Wynandts,|||| Cheselden,^1[ Por- 
 tal,***' Derame,ttt Bichat, and Wardrop.§§§ 
 
 Rupture of the muscular coat of the stomach, which is not un- 
 frequent, is in like manner the consequence of ulceration or erosion 
 of its villous membrane, and shall be noticed under that head. 
 
 7. Bony induration or deposition. — This, though not very fre- 
 quent, is not unknown. Morgagni mentions in his first case of 
 ulcerative rupture a bony mass an inch thick, shaped like a half 
 ring, being found in the muscular substance of the left ventricle, 
 adhering, however, to the mitral valves, also ossified. A similar 
 case is recorded by Haller ; and to such instances it may be justly 
 objected, that they are not so much examples of conversion of mus- 
 cular fibre into bone as deposition of bony matter in collateral tis- 
 sues progressively encroaching on the muscular layer. One of the 
 most distinct examples of seeming conversion of muscular fibre into 
 
 * Mem. (le I’Acad. Roy. des Sci. 1732. 
 
 t Epist. xxvii. 2, 5, 8 ; Ixiv. 15. + Elem. Physiolog. 
 
 § Mem. de I’Acad. Roy. des Sci. 1784. 
 
 II Sylloge Vo). X. Opusc. vi. p. 202. 
 
 ^ Nouv. Journ. de Med. Avvil, 1820. Tome VII. p. 280. 
 
 ** Bibliotheque Med. Aout, 1820. 
 
 •|"t Sur les Ruptures des Coeur. 
 
 Dublin Hospital Reports, Vol. IV. 
 
 §§ Haller Bibl. Chir. I. p. 223. 
 
 Anatomy, p. 207. 
 
 Mem. de la Soc. Med. I. p. 159. 
 
 §§§ Medico-Chirurgical Transact. Vol. VII. ]). 278. 
 
 nil Verhand. von Haarlem 
 Anat. Med. II. p. 412. 
 ttt Anat. Gen. Tome III. p. 234. 
 
410 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 calcareous matter is given by Renaudin in the person of a man of 
 33, subject to violent palpitation. The substance of the left ven- 
 tricle was infiltrated with sabulous and crystalline grains. This 
 calcareous deposition must not be confounded with ossified pericar- 
 dium, — the usual example of ossified heart. 
 
 8. Accidental productions and tumours. — Muscular structure is 
 liable to tubercular deposition, to scirrho-carcinoma, to lardaceous 
 degeneration, {lieroma)., to encephaloid tumours, and to the mela- 
 notic deposit, (Cullen.) Serous cysts {hygrotna) are said to be rare; 
 but they have occasionally been observed. 
 
 9. Parasitical animals have been observed in the muscles of the 
 human subject. The solitary hydatid (^cysticercus cellulosce) is not 
 uncommon.* The latter especially has been seen in the trapezius, 
 serratus posticus, psoas, iliacus, glutaeus, and other large muscles, 
 (Werner, Rudolph!,) and in the heart by Morgagni, (xxi. 4.) Por- 
 tal, Mr Price, and Mr Evans. 
 
 Mr D. Price found in the muscular substance of the heart of a 
 boy of ten years, who expired suddenly, a large hydatid, of the cha- 
 racter of which no details are given. There is good reason, never- 
 theless, for believing that it was an acephalocyst.f More satisfac- 
 tory information is given in the history of another case recorded by 
 Mr Herbert R. Evans. In this case, which took place in a female 
 aged 40, of slender frame and weakly appearance, the individual 
 became languid and feeble, and unable to ascend an acclivity or a 
 staircase without breathlessness. Occasionally she felt a sort of 
 sharp pain darting, as it were, through the heart. These feelings 
 lasted for five or six months ; when, in consequence of attempting, 
 on the 20th April, to run up stairs quickly, she was attacked with 
 a paroxysm of great dyspnoea, accompanied with throbbing and 
 pain in the region of the heart. These symptoms continued with 
 little intermission for six weeks; and death took place on the 1st of 
 June. The cavity of the pericardium contained about one ounce of 
 fluid. The membrane was covered by lymph over part of the ante- 
 rior surface. The apex of the heart was lost or rendered round 
 and obtuse in a considerable tumour, which communicated to the 
 touch a sense of fluctuation. This tumour, which formed a consi- 
 
 * Bremser, Traite Zoologique, xi. p. 280. 
 
 t Case of Sudden Death, in which a large Hydatid was found in the Substance of 
 the Heart. By David Price, Esq. Medico-Chirurgical Transactions, Vol. XI. 
 p. 274. London, 1821. 
 
MUSCULAE TISSUE. 
 
 411 
 
 derable projection encroaching on the cavity of the right ventricle 
 was globular and about three inches in diameter ; and when laid 
 open it was found to be a cyst containing a number of small cysts 
 or hydatids, varying in size from that of a pea to the bulk of a pi- 
 geon’s egg, the interstitial spaces between them being filled by a 
 soft curd-like substance of a yellow colour. These hydatids were of 
 the irregular spheroidal shape, and resembled in all respects the ace- 
 phalocyst.* The muscular substance of the heart was attenuated. 
 
 Trichina Spiralis . — There is also found in certain circumstances 
 in the muscles of the human subject, a small capillary or hair-like 
 worm coiled up in the spiral form. It has from these circumstances 
 received the name of trichina spiralis. At the same time it must he 
 observed, that all cylindrical worms are in general coiled up in the 
 spiral or spherical form, so as to constitute little balls contained within 
 membranes. This is probably the foetal or oviform stage of these 
 animals. In the case of the trichina., its presence is indicated at first 
 sight by the appearance of little vesicles or bags ; and when these 
 are brought under the field of the microscope, it is found that they 
 contain hair-like worms of extreme minuteness and delicacy, coiled 
 up in the spiral shape. 
 
 It is not well known under what peculiar circumstances these 
 parasitical animals are found in the animal body. In one body in 
 which I saw them, the person had died of pulmonary consumption, 
 that is, tuber culation and vomiccE in tbe lungs. In others it appears 
 in the bodies of persons in a bad state of general health, emaciated 
 and enfeebled with disease of the liver, or the intestinal tube. 
 
 Tbe zoological and physical characters of the animal have been 
 very accurately described by Mr Owen, to whose work I refer for 
 more ample details. 
 
 * Case in which a Cyst containing Hydatids was found in the Substance of the; 
 Heart. By Herbert R. Evans, Esqr Surgeon. Medico-Chirurgical Transactions, VoL 
 XVII. p. 507. London, 1832. 
 
412 
 
 GENERAL AND PAinOLOGICAL ANATOMY. 
 
 CHAPTER II. 
 
 Section I. 
 
 SINEW, TENDON, Tetldo. 
 
 Sinew or tendon was united by Bichat with ligament, fascia, 
 aponeurosis, and periosteum, under the general name of fibrous 
 system ; and the substance of this arrangement has been adopted 
 by Gordon, Meckel, and Beclard. I am inclined, however, from 
 personal observation, to regard tendon as essentially distinct, at 
 least in the present state of knowledge, from these substances. 
 Examined anatomically, it does not bear a very close resemblance 
 to any of them, and in its known chemical properties, it is consi- 
 derably different. 
 
 The appearance of this substance must be familiar to all. Al- 
 most cylindrical in shape, but flattened at the muscular end, and 
 tapering where inserted, a tendon consists of numerous white lines 
 as minute as hairs, of satin-like glistening appearance, placed 
 parallel and close to each other. A tendon is easily divided, and 
 torn into longitudinal or parallel portions, and by the forceps very 
 minute fibres may be detached and removed with ease, its whole 
 length. These facts show the great tenacity of this tissue, and the 
 regular parallelism with which the component fibres are united. 
 The last circumstance distinguishes them completely from liga- 
 ments and periosteum, in which the fibres cross in all directions, 
 and in consequence of which these tissues cannot be so easily split 
 or separated. These fibres are united by filamentous tissue. 
 
 Tendon is softened and more easily separable by maceration in 
 water or alkaline fluids ; it is crisped by acid fluids, and rendered 
 translucent by immersion in oil of turpentine. It has not been in- 
 jected, but it is presumed to have blood-vessels and absorbents. 
 No nerves have been traced into it. 
 
 Tendon when boiled becomes soft and large, assumes the ap- 
 pearance of a transparent gelatinous substance; and finally, if the 
 boiling be continued, is dissolved and converted into gelatine. 
 This fact, which is well known to cooks, who prepare jellies from 
 tendinous parts of young animals, shows that tendon consists prin- 
 cipally of gelatine, disposed in an organized form. 
 
TENDON. 
 
 413 
 
 A species of flattened tendons, to which the name of aponeurosis 
 has been given, may justly be united with this tissue. The best 
 examples are in the aponeurotic or tendinous expansion of the ex- 
 ternal oblique muscle of the abdomen, the aponeurotic part of the 
 occipito-frontal muscle of the head, and the upper or broad end of 
 the tendo-Achillis, The anatomical structure and the chemical pro- 
 perties of each of these varieties of animal substance are quite simi- 
 lar, and somewhat different from that which has been termed fascia. 
 
 Section II. 
 
 In tendon inflammation is rarely spontaneous, and is generally 
 tbe result of wound, tear, bruise, twist, wreneb, or burn, when the 
 effects vary according to the nature of the injury. Simple division 
 of tendon may unite without much difficulty, though the medium 
 of union appears to be filamentous tissue with some gelatino-albu- 
 minous matter. In laceration complete reunion will depend upon 
 the extent of the injury. That of the tendo- Achillis is the most 
 frequent. I have seen complete rupture of the extensor tendon of 
 the middle finger unite in the course of four months without per- 
 ceptible trace of the accident, and with complete restoration of the 
 functions of the finger in about four or five months more. Twists 
 or wrenches of the joints often injure not only tendons, but liga- 
 ments, fasciae, and even cartilage, and occasion inflammation of all 
 these textures at once. Of this the injury termed sprain is an ex- 
 ample. Tendinous texture readily sloughs under inflammation, 
 either spontaneous or from injury. In whitloe the tendons of the 
 flexor muscles of the fingers are often killed and thrown off by ul- 
 ceration ; and when tendons are injured by burns or gunshot wounds 
 death of their texture is almost invariable. In this state tendon 
 loses its silvery white appearance and lustre, assumes a dull leaden 
 gray aspect, and becomes thick and doughy . 
 
 The process of inflammation is most distinctly seen in wounds of 
 the extremities, and in lacerations or ruptures of the tendons. 
 They become enlarged, sometimes expanded in various affections 
 ot the joints. Punctured or lacerated wounds of tendinous struc- 
 ture are sometimes succeeded by tetanic motions, which terminate 
 fatally. Ossification, so common in the tendons of birds, is almost 
 unknown in the human subject ; unless the sesamoid bones be ad- 
 mitted as examples of this transformation. 
 
414 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 CHAPTER III. 
 Section I. 
 
 WHITE FIBROUS SYSTEM. Ligament^ — m heiMi •, Periosteum; 
 
 Dura Mater ; Fascia. 
 
 Against the formation of this order of tissues fewer objections 
 can be urged, though ligament and periosteum undoubtedly furnish 
 its most perfect examples; and it may be doubted whether fascia 
 ought to he referred to it, or arranged with tendon and aponeu- 
 rosis. The dura mater, the tunica albuginea, and the fibro-synovial 
 sheaths, are to be regarded as compound membranes. 
 
 Ligament and periosteum are easily shown to consist of strong 
 whitish or gray fibres, as minute as threads or hairs, interwoven to- 
 gether in various directions, and thus forming an animal substance 
 which is not to be split or torn asunder as tendon ; but when rup- 
 tured by extreme force presents an irregular ragged surface or 
 margin. Maceration in water or alkaline fluids separates the com- 
 ponent fibres, and shows their irregular disposition more distinctly. 
 They are crisped by affusion of boiling water, or immersion in 
 acids; and they become translucent by immersion in oil of turpen- 
 tine. 
 
 The properties of this tissue are chiefly physical. Those which 
 are vital are referable to its organization and nutrition. It is 
 powerfully resisting, and is one of the toughest and strongest tis- 
 sues in the animal body, as is shown by the numerous experiments 
 recorded in the writings of the iatro-mathematical physiologists. 
 It is supposed to possess the exhaling ends of arteries and colour- 
 less veins. No nerves have been recognized; and Bichat expresses 
 his ignorance of absorbents being traced into it. 
 
 Ligament when boiled yields a small portion of gelatinej but 
 obstinately resists the action of boiling water, and retains both its 
 shape and tenacity or cohesion. The crispation which it undergoes 
 in boiling water, alcohol, and diluted acids, seems to indicate that 
 albuminous matter forms its chief chemical principle. 
 
 As to their mechanical shape, the ligaments are divided by Bi- 
 chat into two sorts ; those in regular and those in irregular bundles. 
 
WHITE FIBROUS SYSTEM. 
 
 415 
 
 The former comprehends all the distinct clusters of ligamentous 
 structure, which sometimes in a'cylindrical, sometimes in a flatten- 
 ed shape, connect the articulating ends of bones, and form the la- 
 teral ligaments of the various articulations. The latter consists of 
 those loose parcels of ligamentous fibres which are found in various 
 regions of the skeleton , not in regular cylindrical or longitudinal 
 bands, but irregularly connecting bones not admitting of articular 
 motion; for instance at the symphysis pubis and the sacro-iliac 
 junction. The division of Bedard into articular, non-articular and 
 mixed, is more comprehensive and more natural. The first are 
 those which connect the articular extremities of difierent bones. 
 The second are those which, attached to different parts of the same 
 bone, convert notches into foramina, as in the orbitar arch and the 
 supra-scapular hollow, or close openings, and give attaehment to 
 muscles, as the obturator ligament. The last are those which, like 
 the sacro-ischiatic or the interosseous ligaments of the fore-arm 
 and leg, connect bones susceptible of little or no motion, and es- 
 pecially give attachment to muscles. The two latter species of 
 ligaments approach closely in their characters, physical and anato- 
 mical, to periosteum, and are probably to be regarded as modifica- 
 tions of this membrane. 
 
 The articnlar or perfect ligaments are naturally divisible into two 
 subgenera, — the capsular and the funicular. 
 
 The capsular ligaments or the fibrous capsules, (Bichat), consist 
 of cylindrical ligamentous sheaths attached all round to the ends of 
 the articulating bones, and intimately interwoven with the perios- 
 teal tissue. Consisting essentially of fibro-albuminous matter 
 strongly compacted, they are surrounded by cellular tissue, or rather 
 celluloso-adipose tissue, and are lined internally by synovial mem- 
 brane. Though the most perfect examples of the capsular form of 
 ligament are presented in the scapulo-humeral and coxo-femoral 
 articulations, less complete ones, nevertheless, are seen in the other 
 joints. In those of the knee and elbow, an arrangement of this 
 kind may be demonstrated ; and minute capsules may be shown to 
 connect the oblique articular surfaces of the vertebrae with each 
 other. 
 
 The funicular ligaments, which consist of round chords or) flat 
 bands, are employed in eonnecting the articular ends of bones either 
 without or within the cavity of the joint. Of those of the former 
 description, the best examples are seen in the elbow and knee-joints. 
 
416 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 and in the wrist and ankle, where they are termed lateral liga- 
 ments, ( 1 . lateralla^ accessoria.) Of the latter instances, are the 
 round ligaments, {Ugamenta teretia,^ of the shoulder and hip-joints, 
 and the crucial ligaments of the knee-joint. These receive an in- 
 vestment of synovial membrane. 
 
 Of the white fibrous tissues one of the most important is that de- 
 nominated jfizscza. Consisting in intimate structure of long fibrous 
 threads placed in parallel juxtaposition, sometimes obliquely inter- 
 woven, and closely connected by filamentous tissue, it forms a whit- 
 ish membranous web, variable in breadth, of some thickness and 
 great strength. Fascia is perhaps, not excepting the skin, the most 
 extensively distributed texture of membranous form in the animal 
 body. It not only covers, if not the whole, at least by far the 
 greatest part of the muscles of the trunk and each limb, but it sends 
 round each muscle productions by which it is invested and sup- 
 ported, and even penetrates by minute slips into the substance of 
 individual muscles. Of several of the large muscles it connects 
 the component parts, as is seen in the recti abdominis ; to many it 
 affords points of origin or insertion ; and to all it furnishes more or 
 less investment and support. Most of the tendons, especially the 
 flexor and extensor tendons, are enclosed by it ; and their synovial 
 sheaths derive from it their exterior covering. At the extremities 
 of the bones it is connected with the ligaments and periosteum, with 
 which it is closely interwoven ; and it forms a general investment 
 to the articular apparatus. 
 
 Though fascia may thus be viewed as one membranous web con- 
 sisting of many parts all directly connected with each other, it is 
 the practice of anatomists to distinguish its divisions, according to 
 the region which they occupy. Thus in the fore part of the neck 
 and chest is found a fascia, the relations and uses of which have been 
 well described by Mr Allan Burns.* In the cervical region we 
 find a firm fascia descending from the occipital bone along the ver- 
 tebrae, covering and connecting the muscles of each side till it reaches 
 the loins, where, in the form of a thick strong membrane, it forms 
 the lumbar fascia, (fascia lumborum. ) It may further be traced 
 over and between the glutaei muscles ; connected afterwards with 
 the broad femoral fascia, (fascia lata ;) and thence over the knee 
 and leg to the foot. Much in the same manner a membranous 
 web, thinner and more delicate, but of the same structure, may be 
 * Surgical Anatomy, pp. 33, 36. 
 
WHITE FIBROUS SYSTEM. 
 
 417 
 
 traced from the chest along the upper extremity, till at the wrist 
 it is identified with the annular ligament, and in the hand with the 
 palmar fascia. In all these situations the general fascial envelope 
 sends slips or productions {fascias intermusculares) between the 
 muscles, and into their substance.* 
 
 Section II. 
 
 The morbid relations of this system are important. But in con- 
 sequence of their being often combined with other tissues, it is diffi- 
 cult to distinguish them properly. 
 
 1. Inflammation in various forms is not uncommon, and may 
 take place either spontaneously, or as the effect of accident. 
 
 a. Desmodia. — Inflammation of ligament may be spontaneous or 
 the result of injury. In the former case it is generally chronic, and 
 is attended with much thickening of the desmoid tissue. The mor- 
 bid action spreads to the synovial membrane on the one side, caus- 
 ing it to thicken and effuse morbid fluid, and on the other, to the 
 peridesmoid cellular tissue, which is then infiltrated with jelly-like 
 fluid, and becomes separated and somewhat indurated and granular. 
 These changes take place in those forms of articular disease com- 
 monly known under the vague name of loMte swelling ; {tumor al- 
 bus ; fungus articuli ; der Grliedschwamm.) After some time this 
 morbid state of the extra-articular cellular tissue may proceed to sup- 
 puration, butw'ithoutnecessarilyopeningthe cavity of the articulation. 
 The capsular ligament, however, and even the funicular ones, may 
 be so much changed in structure as to become unfit for their func- 
 tions. 
 
 Though the process now described is that which takes place in 
 inflammation of ligament when primary, it is necessary to mention, 
 nevertheless, that inflammation in these tissues is much more fi’e- 
 quently the consequence of previous disease in the synovial mem- 
 brane or the articular cartilages. This is particularly the case in 
 the knee-joint and elbow. 
 
 |S. Ulceration of ligament is the result either of traumatic inflam- 
 mation proceeding to suppuration, or of suppuration within the ar- 
 ticular cavity. Even in the latter case the desmoid tissue itself is 
 rarely destroyed; and the opening takes place between its fibres, 
 
 * Surgical Anatomy, by Abraham Colies. Dublin, 1811. 
 
 D d 
 
418 
 
 GENERAL AND PATHOLOGICAL ANATOAIY. 
 
 which are loosened and separated. The most frequent instancesof ul- 
 cerated destruction of this tissue are seen in destruction of the round 
 ligament and part of the capsule in the coxo-femoral articulation, 
 and in that of the crucial ligaments in the femoro-tibial articulation. 
 
 7. Periostitis. Periosteum is liable to inflammation either from 
 injury, spontaneously, or from the operation of the syphilitic or the 
 mercurial poison. In fractures of the extremities the periosteum 
 may be seen reddened, thickened, and depositing semifluid sub- 
 stance, which appears to coagulate and unite the broken or wound- 
 ed portions. When it takes place spontaneously, it is said to de- 
 pend on the strumous diathesis, of which it is believed to bean in- 
 dication. The membrane becomes thick, painful, unusually vascu- 
 lar, and, unless the action subsides, or is controlled by art, semi- 
 fluid lymph is effused beneath it, and even bloody, sanious, puru- 
 lent matter may be formed. If the inflammation be confined to 
 one spot, the thickened membrane, with the lymphy induration be- 
 neath it, gives rise to the swelling termed node ; {nodus). When 
 suppuration takes place, it is too often followed by caries of the 
 subjacent bone if of soft spongy texture, as in the sternum ; or 
 death {necrosis) if in one of more compact structure, as in the 
 skull. The distinction, however, is not invariably observed ; for 
 caries of the tihia or ulna is seen to follow periosteal inflammation 
 in these bones.* The appearances produced in the bones by this 
 process belong to another head. Though any part of the perios- 
 teum may be attacked by inflammation, certain regions seem more 
 liable to it than others. Node, whether from strumous, syphilitic, 
 or mercurial origin, generally takes place in parts of the periosteum 
 where that membrane approaches the surface. Thus the anterior 
 surface of the tibia, the posterior internal surface of the ulna, the 
 outer surface of the radius, and the anterior surface of the clavicle 
 and sternum, are usual situations for periosteal inflammation. 
 Strumous periosteal inflammation in the phalanges of the fingers I 
 have seen only in young children. The phalanges are then rough 
 and denuded ; and the discharge of fetid sanious matter gives rise 
 to sinuous ulcers not easily healed. These effects are to be attri- 
 buted to the suspension of the nutritious powers of the periosteal 
 vessels. 
 
 In some instances inflammation of the periosteum terminates in 
 
 * Practical Observations in Surgery and Morbid Anatomy, &c. By John Howship, 
 London, 1816, p. 176. 
 
WHITE FIBROUS SYSTEM. 
 
 419 
 
 a bony swelling, or a deposition of hard osseous matter on the sur- 
 face of the bone. (^Exostosis.) The exact nature of the process is 
 not well understood. But there is reason to believe, that what is 
 originally a deposit of lymph as in node, becomes eventually pene- 
 trated by calcareous matter.* 
 
 The perichondrium is not very dissimilar in morbid relations to 
 the periosteum. Its inflammation may cause in like manner thick- 
 ening, morbid deposits, and ulceration, or even death of the subja- 
 cent cartilage. Such is the course of phenomena occasionally ob- 
 served in the cartilages of the larynx and those of the ribs. 
 
 Sparganosis. Rheumatmnus. Rheumatism. Fascial inflam- 
 mation. Though I have above admitted, on the authority of Car- 
 michael Smyth, inflammation of muscular tissue as a cause of rheu- 
 matism, I doubt whether it is entitled to the character of a genuine 
 or uniform pathological cause of that disease. Independent of the 
 fact, that the rheumatic pains occur often round joints, in which 
 there are no muscles, the theory is at best only an ingenious as- 
 sumption, and is not supported by any strong facts or arguments. 
 
 Though rheumatic pain is often referred to muscular pai’ts, it is 
 less frequently so than to joints and parts covered by aponeurotic 
 sheaths axiA. fascice. Of 520 cases, Haygarth observed in 388 the 
 rheumatic action to be seated in joints, in 1 18 in muscular parts, and 
 in 14 wandering, general, or migrating through the limbs. Of 170 
 cases, in 154 one or more joints were inflamed; in 33 cases, both 
 joints and muscles were simultaneously affected; and in some cases 
 only were the muscles affected without the joints. 
 
 Though from these facts Dr Haygarth infers that acute rheuma- 
 tism is seated chiefly in the joints, he does not attempt to ascertain 
 the particular texture, in the affection of which the disease consists. 
 It is further manifest, that while it is impossible to exclude affection 
 of the muscles entirely, it results that this affection is only secon- 
 dary. The proof adduced by Dr Scudamore from pressure of the 
 whole course of a muscle, and grasping its suhstance during severe 
 rheumatism, to show that the fleshy part is not the seat of complaint, 
 is entitled to attention. Combined with those already mentioned, 
 and with other considerations to be adduced immediately, it results 
 that the rheumatic action is seated in a texture, which, confined 
 neither to the site of the joints, nor to that of the muscles exclu- 
 sively, is common to both, and which, from its extensive distribution 
 and complicated arrangement, accords best with the phenomena, 
 
 * Medico-Chirurgical Transactions, Vol, VIII. p. 90. 
 
420 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 progress, and effects of the disease. It is unnecessary to repeat 
 the considerations above adduced from the anatomical relations and 
 characters of fascia and its various divisions. That they are the 
 chief seat of acute rheumatism may be inferred from the following 
 circumstances. 
 
 1. When the rheumatic action is seated in muscular parts, in- 
 stead of being confined to the muscular fibres, it may always be 
 referred to the aponeurotic membrane which covers or penetrates 
 them. 2. The peculiar pains of rheumatism are always most dis- 
 tinct in those situations in which several folds of aponeurotic mem- 
 brane meet ; and their migrations may be traced from one extre- 
 mity to another of an aponeurotic membrane, and along the course 
 of its principal divisions. 3. The kind of pain which attends rheu- 
 
 f| 
 
 matism resembles that of the fibrous tissues in general when inflamed 
 
 in undergoing aggravation under the influence of external heat and 
 during the night. 4. This view of the seat of rheumatic disorder 
 affords the most probable explanation of the effusion which takes 
 place in the tendinous sheaths (bnrscB mucosa. ;) and even occasion-, 
 ally within the joints ; for since each sheath is partly enveloped in 
 aponeurotic membrane, and every articulation is covered by fas- 
 cise inserted into the capsules or periosteum, the inflammatory pro- 
 cess which takes place in the fascia soon gives rise, as in analogous 
 cases, to effusion, critical or non-critical, from the contiguous syno- 
 vial membrane. 5. This view also affords the most rational expla- 
 natioia of the fact remarked by all authors, that rheumatism almost 
 never terminates in suppuration. To suppose that muscle does not 
 suppm’ate, is perhaps erroneous from what has been above adduced. 
 That fascia and fibrous tissue in general is little disposed to suppu- 
 rate, unless when mechanically injured, is manifest from a number 
 of circumstances ; and this may perhaps be regarded as the true 
 explanation of the fact now noticed. 6. It must further be remarked, 
 that inflammation in this tissue renders it thick, hard, and rigid, 
 and occasionally causes between its fibres effusion of lymph, which 
 increases this thickening, induration, and rigidity. On these changes 
 depend the immobility of rheumatic parts, and the loss of power 
 which follows long and obstinate, or neglected and repeated, attacks 
 of the disease. 
 
 The question, whether there be any thing peculiar in the nature 
 of rheumatic inflammation is not undeserving attention. This, how- 
 ever, is not the place for discussing it; and if the views now advanced 
 
 i 
 
 li 
 
WHITE FIBROUS SYSTEM. 
 
 421 
 
 be well-founded, it may be inferred that its peculiarities consist in 
 the anatomical and physical qualities of the texture in which I have 
 attempted to show it is seated. 
 
 Though in acute rheumatism the inflammation affects a large 
 proportion, if not the whole of the fascial system, local forms of 
 the disease may occur, in which it is confined with more or less 
 accuracy to one or two fasciae. Thus inflammation of the fascia 
 of the temporal and masseter muscles produces rheumatism of 
 the temple and rheumatic locked jaw ; that of the occipito-frontal 
 fascia rheumatism of the head ; that of the cervical fascia crick in 
 the neck ; that of the pectoral fascia and the intersections of the 
 intercostal muscles spurious pleurisy {pleiirodijne ;) that of the ab- 
 dominal fasciae a rheumatic belly-ach ; that of the lumbar fasciae 
 lumbago ; and that of the aponeurotic parts of the glutael muscles 
 genuine sciatica or hip- gout. 
 
 2. Fascia is liable to undergo, in consequence of the operation 
 of certain agents, a peculiar degree of thickening and rigidity of 
 its tissue, with contraction, which has the effect of impeding much 
 or abolishing entirely the motions of the parts with which it is con- 
 nected. Thus the fascia covering the joints is liable, in consequence 
 of articular rheumatism, or that affecting the capsule and synovial 
 membrane, to be affected by more oiTess thickening, rigidity, and con- 
 traction. The most usual situation, however, in which this change is 
 seen is the palmar aponeurosis, which becomes thickened, crispated, 
 and shortened, and the effect of which is to inflect forcibly the ring- 
 finger into the palm of the hand, preventing it from being extended, 
 then the little finger, and afterwards the index and middle fingers. 
 
 This change is most usually observed in those w'ho have to make 
 efforts with the palm of the hand in handling and compressing hard 
 bodies ; for instance, the hammer, the oar, or the whip. Hence 
 wine-dealers, who have to pierce wine-casks, and coach-drivers, w'ho 
 have to handle the whip, masons and similar workmen, are liable 
 to suffer from this disorder. 
 
 Patients feel the approach of this malady by a sense of stiffness 
 in the palm, and difficulty in extending the finger. Soon the fingers 
 remain incurvated one-fourth, one-third, or one-half ; in some in- 
 stances the tips of the fingers are forcibly incurvated into the palm. 
 At first is felt on the palmar surface of the fingers and hand the 
 sensation of a cord, w-hich is more tense when any effort to stretch 
 the fingers is made, and which almost entirely disappears when the 
 
422 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 fingers are completely bent. Tins cord is rounded in form ; and 
 its most prominent point is at the top of the articulation of the 
 finger with the metacarpal bone supporting it. There this cord 
 forms a sort of bridge. 
 
 Little pain is felt in the course of this disease, which is confined 
 entirely to the fascia, and in wdiich the prominent feature is stiffness 
 and inextensible incurvation of the fingers.* 
 
 3. Tyroma . — The tyromatous deposition in the tubercular form 
 may take place in the periosteum. The tubercles, which in colour 
 and physical qualities resemble tyromatous matter in other situa- 
 tions, are minute, irregularly spheroidal, and occupy the substance 
 of the membrane. Their presence gives rise to chronic inflamma- 
 tion of the membrane, which becomes thick, spongy, and vascular, 
 and is at length detached from the bone by effusion of purulent 
 fluid ; and their liquefaction eventually forms a bad suppuration. 
 This is one of the forms of what is usually termed strumous disease 
 of the bones. 
 
 4. Chondroma . — Cartilaginous induration of the white fibrous 
 tissue is so common that it scarcely requires separate notice. The 
 ligaments are often affected with this, especially in stiff and anky- 
 losed joints, and appear then to acquire the properties of genuine 
 cartilage. This, which may be regarded as one of the effects of 
 chronic inflammation, with long disease of the articular tissues, I 
 conceive, is what is meant by inordinate rigidity of the ligaments, 
 much dwelt on by practical authors. It never occurs, I am satis- 
 fied, unless under the circumstances now mentioned. In the peri- 
 osteum I have seen the same change resulting from the same 
 causes. It takes place after compound fractures, occasionally after 
 amputation, and, in short, in all circumstances in which the raern-,, 
 brane is inflamed. 
 
 5. Ossification . — Partial or general conversion into bone, though 
 not uncommon in the v.'hite fibrous system, is nevertheless restrict- 
 ed in a peculiar manner. It is, for instance, much less frequent 
 in ligament than in periosteum ; and in fascia it is scarcely known. 
 Ossification in ligament commences at the point connected with the. 
 periosteum ; and it is uncommon to observe it extend over the 
 
 • Lefons Orales de Clinique Chirurgicale Faites a I’Hotel Dieu de Paris. Par M, 
 le Baron Dupuytren, Chirurgien en Chef. Recueillies et Publiees par MM. le Doc- ' 
 teurs Brierre de Boisraont et Marx, 2xieme edit. Tome IV. Paris, 1839. Article xL 
 p. 473.. 
 
WHITE FIBROUS SYSTEM. 
 
 423 
 
 whole ligament, unless in cases of anchylosis and stiff joint, in which 
 it is rather a sort of cartilaginous rigidity and induration than 
 actual conversion into bone. The former appears to be the origin 
 of the bony nodules or sesamoid bones occasionally found in the 
 substance of the funicular ligaments. In the irregular filaments, 
 especially the sacro-ischiatic, it is not unusual to find ossification in 
 aged subjects. 
 
 That the periosteum may be converted into bone is a point which 
 has been alternately admitted and denied during a whole century. 
 While the numerous experiments of Du Hamel* * * § and Trojaf tend 
 to establish it in the affirmative, it is rendered very doubtful by the 
 facts and arguments of Leveille and Richerand. From the expe- 
 riments of the former authors it results that the periosteum becomes 
 thick, highly vascular, very firm, and eventually acquires a bony 
 hardness in its inner layer under either of the following circum- 
 stances ; — Is^, when it is detached from the bone ; 2t?, after frac- 
 tures during the process of reunion ; and when the marrow 
 
 or its membrane is destroyed. That in the two former instances 
 the inner layers of the periosteum truly undergo conversion into 
 bone, may be regarded as established, not only by the experiments 
 of Du Hamel and Troja, but by those of Dupuytren,| Cruveil- 
 hier,§ Breschet,|| and Villerme,^ and especially by the phenomena 
 of reunion after fractures by gunshot wounds. The third case, 
 that of injury of the marrow and its vessels, is perhaps more ambi- 
 guous. It appears, nevertheless, from the experiments of M. Cru- 
 veilhier, that only when the medullary membrane is destroyed, 
 with the permanent continuance of a foreign body in the canal, 
 ossification at the surface of the bone takes place at the expense 
 not only of the periosteum, but even of the muscles. The condi- 
 tion necessary for the ossification of the periosteum after injury ap- 
 pears to be, that the concomitant inflammation produces albuminous 
 effusion only ; for when the membrane is in contact with purulent 
 matter, effusion of albuminous or coagulable fluid is precluded ; 
 and in this sense only, perhaps, are the inferences of Leveille to be 
 admitted. 
 
 * Mem. cle ]’Acad. des Sciences, 1741, &c. 
 
 -f- Mem. de la Societe Roy. de Med. 1776. 
 
 J Journal Univers. des Sci. Med. T. xx. p. 131. 
 
 § Essai sur I’Anatomie Pathologique, Tome ii. p. 25, &c. Paris, 1816. 
 
 II Quelques Rechercli. Hist, et Exper. sur le Cal. Paris, 1819. 
 
 f Quart. Joum of Foreign Medicine, No. ii. London, 1819. 
 
424 
 
 GENERAL AND RATHOLUGICAL ANATOMY. 
 
 On this subject, however, I shall have occasion to make some 
 observations in the fourth chapter, when treating of Nekrosis. 
 
 In fascia, I have said, and I may add tendinous aponeurosis, 
 ossification is almost unknown. To this head, however, may per- 
 haps be referred the instance recorded by Hoernigk of alleged os- 
 sification of the tendinous centre of the diaphragm and part of the 
 intercostal muscles;* that of chondro-osteoid induration of the right 
 half of the diaphragm by Lieutaud from the Petersburgh Trans- 
 actions ;f a similar case seen by Leveille in 1793; and that of ossi- 
 fication of the tendinous centre of the same muscle mentioned in 
 the body of Collalto by Cruveilhier. The instance of cartilaginous 
 induration of the deep-seated muscles of the leg, found by Dupuy- 
 tren in the body of a man affected with Arabian elephantiasis, 
 though considered by Cruveilhier as ossification of the muscles, is 
 probably with greater justice to be viewed as of the same descrip- 
 tion.! 
 
 A singular instance of ossification of the fibrous septum of the 
 corpus cavernosum, so complete as to requre excision, occurred to 
 Dr M‘Lellan of Baltimore in the United States.§ 
 
 6. Some of the forms of osteosteatoma and osteosarcoma appear 
 to originate in the periosteum. The former is generally an en- 
 cysted tumour, and, according to the observation of Meckel, may 
 primarily affect this membrane. The latter, from its anatomical 
 characters, bears a greater affinity with this source ; and I think, 
 in several cases, I have been able to trace osteo-sarcomatous tu- 
 mours to the periosteum. II Of neither, however, are the local re- 
 lations, when examined, so simple or distinct as to enable the pa- 
 thologist to determine the question positively. Does true cancer 
 {scirrho-carcinoma) ever originate in the periosteum? The tu- 
 mours to which this name has been applied are rather examples of 
 osteosarcoma than of genuine scirrhus. Such at least is the cha- 
 racter of most of the tumours of the maxillary sinus. 
 
 7. When the encephaloid degeneration (^fungus hcematodes') ap- 
 pears in the periosteum, it may often be traced to the contiguous 
 muscles, or to some of the adjoining articular tissues, or to the bone 
 itself. In the latter case, however, it is almost impossible to de- 
 
 * Haller, Disputationes Medico-Pract. Tom. VI. p. 344. 
 
 + Historia Anatomico-Med. Tome II. p. 99. 
 
 ^ Essai sur TAnatomie Pathologique, Tome II. p. 73. 
 
 § Philadelphia Monthly Journal, Nov. 1827. Vol. I. No. 6, p. 256. 
 
 11 Mr Howship in Medico-Chir. Trans. Vol. VIII. p. 95 and 99 ; where the same 
 conclusion is formed. 
 
 3 
 
AVHITE FIBROUS SYSTEM. 
 
 425 
 
 termine whether the hone or periosteum were the original seat of 
 the disease. 
 
 8. Punctured and contused wounds of the white fibrous system, 
 especially of the ligaments and periosteum, are liable to be succeed- 
 ed by tetanic motions, more or less general ; and wounds with 
 much laceration in subjects of all ages are too often followed by 
 gangrenous inflammation terminating fatally. This I have seen 
 several times, not only in compound dislocations of the larger 
 joints, but in contused wounds of the feet, in which the white fi- 
 brous system is much injured. Partial laceration of the capsular 
 ligaments occasionally takes place in dislocation. (A. Bonn, De- 
 sault, Howship, Sir A. Cooper.) 
 
 9. Dcsmectasis. Excessive relaxation is mentioned as an abnor- 
 mal state occurring in ligaments. It is the result of repeated over- 
 distension, as in luxation or subluxation, or in consequence of the 
 weakness sometimes left after local inflammation, or long-continued 
 disease. Though this may happen to the ligaments of any joint, 
 it is most frequently seen in those of temporo-maxillary and sca- 
 pulo-humeral articulations. Distortions of the spine are ascribed 
 by Dr Harrison to relaxation of the vertebral ligaments. But if 
 this be the cause, it is merely as the efiect of previous disease ; and 
 it is quite inadequate to produce the extreme deformity so frequent- 
 ly observed in the vertebral column of young persons. 
 
 On the new or accidental production of the fibrous system in 
 other tissues, much has of late years been written by Bichat, Bayle, 
 Laennec, and other foreign authors. Without positively denying 
 the principle, that the fibrous system may be accidentally developed, 
 I think with Meckel, that in general these products partake of the 
 cartilaginous character. The notice of them, therefore, will more 
 conveniently be introduced under that head. 
 
426 GENERAL AND EATHOLOGICAL ANATOMY. 
 
 CHAPTER III. 
 
 YELLOW FIBROUS SYSTEM. Ligamenta Flava ; Ligamentum Nucha. 
 Tissu Fibreux jaune, Bedard. 
 
 The yellow ligaments {ligamenta flavai) which connect the spinous 
 processes of the vertebrae to each other differ considerably from the 
 articular ligaments and the periosteum, and suggested to Bedard 
 the necessity of establishing a particular order of fibrous tissues, to 
 whicb he applied the denomination yellow or tawny fibrous sys- 
 tem. Under this he includes also the proper membrane of the ar- 
 teries ; that of the veins and of the lymphatic vessels ; the membranes 
 which form excretory ducts ; that of the air-passages ; the fibrous 
 covering of the cavernous body of the urethra, and perhaps that 
 of the spleen. The actions and occasional distensions of which 
 these parts are the seat require, it is said, a tissue, the resistance 
 and elasticity of which may at once counteract any extraordinary 
 effort, and cause them to resume their original state, when the dis- 
 tending cause ceases to operate. In the lower animals this pur- 
 pose is more conspicuous than in the human subject. The posterior 
 cervical ligament (ligarnentum nucli(B.i Arab. ; cervicis, Lat.) coun- 
 teracts the tendency to inclination of the head ; and a similar mem- 
 brane strengthens the abdominal parietes, and resists the weight 
 and distending power of the viscera. In the feline tribe, an elastic 
 ligament inserted into the unguinal phalanges retains them ex- 
 tended so long as the muscles do not alter their direction. The | 
 shells of the bivalve molluscous animals, as oysters, mussels, &c. ,^ 
 are opened by a similar fibrous tissue as soon as the muscles which" M 
 close them are relaxed. J 
 
 The disposition of the component fibres is the same in the elastic ■ 
 as in the common white fibrous system. Their colour, which is 3 
 yellow or tawny, is generally more distinct in the dead subject. ^ 
 They are said to be less tenacious, but more elastic than those of/§ 
 any other tissue. In respect to chemical composition, they appear;.! 
 to contain a considerable quantity of fibrine in a peculiar condition, 
 combined with some albumen and a little gelatine. Their other 
 properties are not very conspicuous. I 
 
 The morbid changes incident to them are quite unknown. 9 
 
 
BONE. 
 
 427 
 
 CHAPTER IV. 
 
 Section I. 
 
 Bone, oaov. Os , — Ossa , — Tissu Osseux, die knochen. 
 
 No animal substance has been more frequently or thoroughly 
 examined than bone ; and the greatest difficulty in describing its 
 general anatomy consists in selecting and concentrating informa- 
 tion.* 
 
 Several attempts have at different times been made to ascertain 
 the atomic constitution of bone, but without much success. Mal- 
 pighi, though he corrected the extravagant fiction of Gagliardi re- 
 garding the osseous plates and nails, fancied bones to be composed 
 of filaments, which Lewenhoeck represented as minute hollow tubes; 
 (tubuli.) By Clopton Havers, again, the ultimate particles of bone 
 were imagined to be fibres aggregated into plates {lamin<B) placed 
 on each other, and traversed by longitudinal and transverse hollows 
 or pores, This view was adopted by Courtial,| Winslow,§ 
 
 Palfyn,|| IMonro,^ and Reichel,** the last of whom was at some 
 pains to demonstrate this arrangement of plates and minute tubes by 
 microscopical observation. 
 
 The justice of these notions was first questioned by Scarpa, who, 
 in 1799, undertook to show, by examinations of bone deprived of 
 
 ■* The principal authors on the structure of bone are Dominici Gaghardi, AvMorae 
 Osshim, novis inventis illmtrata. Romae, 1 689. 
 
 Malpighi, De Ossium atnictum ex Op. Post, who corrected the fictitious riews of the 
 former. Marcelh Malpighii Opera Omnia Tomis Duobus Comprehensa. Londini, 
 1686. Foho. Opera Posthuma. Londini, 1697. 
 
 Clopton Havers, Osteolor/ia Nova, or Some New Observations of the Bones and the 
 Parts belonging to them. London, 1691. 
 
 De La Sone, Memoire sur I'organisation dcs os, Mem. de PAcademie, 1754. 
 
 G. C. Reichel, de Ossium ortu atque structura. Lips. 1760. 
 
 Ext. in Sandifort Thesaur. VoL ii. p. 171. 
 
 Antonii Scarpa, de Peiiitiori Ossium Structura Comment. Lips. 1799. Republished 
 in Be Anatome et Pathologia Osskini, Commentaiii, Auctore A. Scarpa. Ticini, 1827. 
 
 Papers by Mr Howship in the sixth and seventh volumes of the Medico-Chirurgicai 
 Transactions. 
 
 •f- Osteologia Nova. London, 1691, p. 34, 37, 41, 46. 
 
 J Nouvelles Observations sur les Os. A. Leide, 1709. 
 
 § Exposition Anatomique. || Anatomie Chirurgicale. 
 
 Anatomy of the Bones. ** De Ossium Ortu, &c. § v. 
 
428 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 its earth by acid, and long macerated in pure water, that it consists, 
 both externally and internally, of reticular or cellular structure.* 
 So far as I understand what idea this eminent anatomist attaches 
 to the terms reticular and cellular, I doubt whether this opinion is 
 better founded than any of the previous ones. After repeating his 
 experiment of immersing in oil of turpentine, bone macerated in 
 acid, 1 cannot perceive the reticular or cellular arrangement which 
 Scarpa describes as demonstrable in bone. It must, I conceive, be 
 the result of the mode of preparation. Recently bone has been 
 submitted to microscopic examination by Mr Howship, who has 
 been led to revive the opinion of the existence of minute longitu- 
 dinal canals, as maintained by Lewenhoeck, Havers, and Reichel, 
 but with Scarpa maintains the ultimate texture not to be laminated 
 but reticulated. I Lastly, the existence of fibres and plates, which 
 is admitted by Blumenbach, Soemmering, Bichat, and Meckel, ap- 
 parently on insufficient grounds, is to be viewed as an appearance 
 produced by the physical, and perhaps the chemical qualities of the 
 proper animal organic matter of which bone consists. Though it does 
 not demonstrate, it depends on, the intimate structure of this body. 
 
 The minute structure or atomic constitution of bone is probably 
 the same in all the pieces of the skeleton, and is varied only in 
 mechanical arrangement. When a cylindrical bone is broken, and 
 its surfaces are examined with a good magnifying glass ; or when 
 minute splinters are inspected in a powerful microscope, it appears 
 to be a uniform substance without fibres, plates, or cells, penetrated 
 everywhere by minute blood-vessels. Its fracture is uneven, pass- 
 ing to splintery. In the recent state its colour is bluish-white ; but 
 in advanced age the blue tinge disappears. Delicate injection, or 
 feeding an animal with madder, shows the vascularity of this sub- 
 stance. 
 
 To have a clearer and more accurate idea of the minute struc- 
 ture of bone, it is requisite to break transversely a long bone, and 
 examine its fractured surface by a good glass, or to examine in 
 the same manner the transverse fracture of a long bone which has 
 been burnt white in a charcoal fire. The broken surface presents 
 a multitude of minute holes, generally round or oval, which are 
 larger towards the medullary cavity, but become exceedingly mi- 
 nute towards the outer surface of the bone. Of these minute holes 
 
 * De Penitiori Ossium Structura, 4to. Lips. 1799. 
 
 + Experiments and Observations, &c. Medico-Chir. Trans. Vol. vi. p. 287, and Micro- 
 scopic Observations, &c, Vol. vii. p. 392, &c. 
 
BONE. 
 
 . 429 
 
 no part of the bone, however compact in appearance, is destitute ; 
 and the only difference is, that they are more minute, and more 
 regularly circular towards the outer than towards the medullary 
 surface. These circular holes are transverse sections of the tubuli 
 of Lewenhoeck, the longitudinal pores of Havers, {Osteologia, p. 43 
 and 46,) the pores and tubuli of Reichel, and the longitudinal ca- 
 nals of Howship. They communicate with each other by means 
 of their great multiplicity and slight obliquity and tortuosity. 
 They contain not blood-vessels exclusively, but divisions of the 
 vascular filamentous tissue, which secretes the marrow. They are 
 seen very distinctly in bones which have been burnt. After many 
 careful examinations, I have never been able to observe holes in 
 longitudinal fractures of bones ; and I therefore infer that there 
 are no transverse pores. 
 
 These capillary pores are seen in the flat bones of the skull. I 
 find them in the compact matter of the outer and inner tables of 
 the occipital bone when well burnt, in which they seem to pass 
 gradually from the lattice-work of the diploe to the distinct pores 
 of the tables. I doubt, however, whether these pores can be said, 
 as in the long bones, to indicate canals. They seem rather to be- 
 long to a very delicate cancellated structure. 
 
 These pores are most numerous and distinct in the bones of 
 young subjects. In the humerus of a child burnt to whiteness, I 
 find them to be large, numerous, and distinct, even at the perios- 
 teal sm’face of the bone. In that of a young man of 28, they are 
 larger, more numerous, and more distinct than in bones of older 
 subjects. In a very dense ulna before me, though distinct through 
 a good glass, they are exceedingly minute, and quite imperceptible 
 to the naked eye. 
 
 Though these circular pores are most distinct in calcined bones, 
 and might therefore be thought to be the result of the burning, 
 yet that they are not, I infer from the circumstance that they are 
 seen by a good glass in the transverse fracture of splinters of the 
 femur and other large bones. 
 
 If a portion of bone be immersed in sulphuric, nitric, muriatic, 
 or acetic acid properly diluted, it becomes soft and pliable, and 
 when dried, is found to be lighter than before ; yet it is impossible 
 to discover that any particle of its substance has been mechanically 
 removed, or that its shape and appearance are changed. 
 
 If a portion of bone be placed in a charcoal fire, and the heat be 
 
430 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 gradually raised to whiteness, it burns first with flame, and at 
 length becomes quite red. If then it be removed carefully and 
 slowly cooled, it appears as white as chalk, is found to be very 
 brittle, and to have lost something of its weight. Yet neither in 
 this case does any part of its substance appear to be removed, nor 
 is its mechanical figure or appearance altered. 
 
 Chemical examination, however, informs us that in the first case 
 a portion of earthy matter (phosphate of lime) is removed by the 
 agency of the acid, and held suspended in the fluid, while the pliant, 
 but otherwise identical piece of bone consists chiefly, if not entirely, 
 of animal matter ; and that, in the second case, this animal matter 
 is removed by destructive decomposition, while the earthy matter 
 is left little changed by the action of fire. It is therefore to be 
 concluded, that every particle of bone, however minute, consists of 
 animal or organic, and earthy or inorganic matter intimately united; 
 and that it is impossible to touch with the point of the smallest 
 needle any part of bone which is not thus constituted. A piece of 
 bone consists not of cartilaginous fibres varnished over, as Heris- 
 sant imagined, with earthy matter, but of a substance in which 
 every constituent atom consists essentially of animal and earthy 
 matter intimately combined. 
 
 There is therefore no rational ground for dividing osseous tissue 
 into compact and spongy, as the older anatomists did ; for though 
 the middle or solid parts of long bones are denser and heavier than 
 the ends of these bones, or the bodies of the vertebrae, the differ- 
 ence consists not in chemical composition, but in mechanical ar- 
 rangement and structure. On dividing the head of a long bone, 
 the lattice-work or comce///, as they are named, are formed by many 
 minute threads of bone, crossing and interlacing with each other. 
 But each thread is quite as dense, and consists of the same quan- 
 tity of animal and earthy matter as the most solid part of the centre ‘ 
 of the same bone. These threads, however, instead of being dis-' 
 posed closely and compactly with each other, so as to take a small' 
 space, are so arranged that they occupy a large one, and present 
 a considerable bulk. 
 
 The minute anatomical structure of bone was again investigated^ 
 by Deutsch in 1834, and by Muller and Miescher in 1836. 
 
 The former observed the pores or tubules of Havers, (canaliculi 
 Haversiani) to be surrounded with concentric lamdlcE, and the me- 
 dullary canal in the cylindrical bones to be inclosed by another 
 
BONE. 
 
 431 
 
 order of lamella, and the same canals in the flat bones proceeding 
 from the parallel of the surface. Tliese tubules he describes as 
 crowded and passing across from one lamella to the next. He 
 also mentions the oblong corpuscula, which have been discovered 
 by Purkinje to be everywhere dispersed through their texture. 
 
 In many circumstances, the observations of Muller and Mies- 
 cher agree. Both admit the existence of lamella, of corpuscula, 
 and of canaliculi o^ tubular canals, the pores of Havers. 
 
 The lamella, says Miiller, are so translucent, that, when laid on 
 written paper, the characters may be easily read through them. 
 When these lamellae are examined under the lens on a dark ground, 
 it is seen that the whiteness of bones depends on the corpuscula, 
 and that their intermediate substance is entirely transparent. 
 
 Lamina or lamella are not observed in the bones of infants. 
 But they are distinctly seen in the compact tissue of the cylindrical 
 bones of adults, in which they form the external surface or com- 
 pact tissue. Near the medullary canal, where the number of in- 
 tersecting canaliculi increases, they gradually, and at length com- 
 pletely vanish. 
 
 The thickness of these lamina is estimated by Deutsch at 
 part of an inch. This Miescher thinks the result of typographical 
 error, and he makes them ^l^gth part of an English inch, or -0027 
 of one line. In the thigh-bone of the ox, in which the lamina may 
 be separated into lamella much more easily and more distinctly 
 than in human bones, the component lamella appeared as it were 
 to be separated or united by fibres interposed ; and in parts where 
 the lamella were most closely united, Miescher observed slender, 
 tapering fihrilla following the longitudinal direction, of a brown 
 colour, and firm, which, throughout, penetrated the lamina, and 
 which he regards as certainly the same with the nails or claviculi 
 of Gagliardi, and the fibres described, in 1818, by Medici. The 
 lamellae may be divided by needles into several very slender /o/zbZa 
 or leaflets. 
 
 The canaliculi are found in all the compact osseous tissue, and, 
 in general, their direction follows that of the process of ossification 
 in the foetus. Thus, in the cylindrical bones, they proceed from the 
 middle of the shaft to the articular extremities ; and in the frontal 
 and parietal bones, from the centre to the circumference. 
 
 The interior of these canals is cylindrical, and it is smallest in 
 those near the surface ; conversely, near the medullary canal, they 
 
432 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 become larger, so that they may be three or four times more ample 
 than those at the compact surface of the hone. The intersection of 
 these canals, also near the medullary cavity with their enlarged 
 size, produces the formation of cells, which communicate with se- 
 veral of the canaliculi. 
 
 The wall of the canaliculi is composed of from 10 to 15 con- 
 centric lamellse, and is from jgoth to ^^gth part of an English inch 
 broad. These canals contain marrow or a substance like it. 
 
 The corpuscula^ which were known to Leewenhoeck, but have 
 been fully examined only by Purkinje, Deutsch, Miescher, and 
 Muller, are oblong oval bodies, flattened, and pointed at each 
 end, situate between two lamellce, so that their long diameter pre- 
 serves an oblique direction to the lamella. They are observed in 
 bone which has been deprived of its earthy matter by acid, like 
 minute specks of a brown colour, transparent in the middle and 
 bounded by a distinct opaque line. Their size varies. From 
 them proceed many dark-coloured striae, so that they present the 
 appearance of ovoidal bodies with small fibrils or roots proceeding 
 from them. Their long diameter is from .0048 to .0072 ; and 
 their transverse diameter from .0017 to .0030 of one line. 
 
 These bodies are formed in the primary or ossifying cartilage; 
 around them ossification takes place ; and it appears that their pre- 
 sence is of great importance to the oi'iginal formation of the bone. 
 
 When these corpuscula are examined, by a powerful microscope, 
 with refracted light, they appear like black oblong specks, with the 
 dark strice proceeding from their surface in all directions, but most 
 abundantly from their lateral regions. When they are examined 
 
 by reflected light, they appear like bluish-white specks of a milky 
 colour, with the stricB of the same colour proceeding from them. 
 
 of much inquiry. When laminae of bones finely polished are boil- " 
 ed in potass, and thereby deprived of their translucency, the cal- 
 careous matter of the part formerly translucent adheres, exactly as 
 if the structure of the animal matter had been in no way changed. 
 
 In alt the intermediate spaces the substance of the corpuscula ap- 
 pears finely granulated ; and the white grains equal nearly the 
 size of the diameter of the radiating canals of these bodies. 
 
 Muller thinks it merely probable that these corpuscula may be 
 a sort of secreting organs to deposit osseous matter ; and he there- j 
 fore is disposed, though not very confidently, to term them organa 
 
 What the nature of these corpuscula may be, has been a source 
 
BONE. 
 
 433 
 
 chalikophora, or earth-bearing organs. He allows, however, that 
 it is impossible on this subject to speak with certainty. 
 
 Miescher states the following conclusions : Isf, The spongy or 
 cancellated tissue is nothing but enlarged canaliculL 2(f, The 
 medullary canal, as to formation and signification, must be regard- 
 ed as the union of such canaliculi. 3d, The canals, therefore, sur- 
 rounded by concentric lamellae, and containing marrow, furnished 
 with abundant blood-vessels, are the primary form of the osseous 
 tissues completed by growth.* 
 
 In these results there is nothing new. Indeed, the only new 
 fact in the whole is the existence of the corpiiscula. The idea of 
 lamellcR is not new. Their existence was maintained by Gagliardi, 
 Havers, Reichel, Blumenhach, and Soemmering; and it may be 
 doubted if the opinion be well founded. 
 
 As to the corpuscula, they are stated to exist in the primary or 
 ossifying cartilage or callus ; and it is very probable that they in 
 some manner contribute to the formation of bone, as it is even- 
 tually observed to exist. 
 
 Though hone has been submitted to analysis by many eminent 
 chemists, the results hitherto obtained cannot be said to be quite 
 satisfactory. The most complete is that of Berzelius, who, in 100 
 parts of bone from the thigh of an adult, gives the following pro- 
 portions: of gelatine, 32.17; blood-vessels, 1.13; phosphate of 
 lime, 51.04 ; carbonate of lime, 11.30 ; fluate of lime, 2.00 ; phos- 
 phate of magnesia, 1.16 ; hydrochlorate of soda and water, 120. 
 
 These results by no means agree with those obtained by Four- 
 croy and Vauquelin, who found neither fluoric acid nor phosphate 
 of magnesia, but discovered oxides of iron and manganese, silica? 
 and alumina, in bone. The statement of Berzelius regarding the 
 presence of fluate of lime has, on the other hand, been confirmed 
 by Dr George Wilson, who found it in recent bones of the human 
 body, and in those of various mamm.alia, and in fossil bones. 
 Sulphate of lime, which was found in the experiments of Hat- 
 chett, was shown by Berzelius to be formed during calcination. 
 
 It is, however, obvious that a little more than a third part of 
 bone consists of animal matter, which appears to be either entirely 
 gelatine, or a modification of that principle ; and that the remain- 
 der, nearly equal to two-thirds, consists of earthy matter, which is 
 chiefly phosphoric acid combined with lime. From the experiments 
 of Dr Rees it results that |-ths are earthy matter ; and |ths are 
 
 * De Inflammatione Ossium, eorumque Anatome Generate. Exercitatio Anatomi- 
 co Pathologica. Auctore Friderico Miescher, Med, et Chirurgias Doct., cum Tabulia 
 Quatuor Aeneis. Berolini, 1836. 4to. 
 
 E e 
 
434 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 animal matter. Is the carbonic acid said to be united witii lime 
 also not a result of the decomposition of the animal matter ? The 
 other saline substances are not peculiar to bone, but being common 
 to it and the other animal tissues, and even the fluids, may be sup- 
 posed, without much injustice, to be derived from the blood left in 
 the bone at the moment of death. 
 
 The cylindrical bones of the extremities contain more earthy 
 matter than those of the trunk ; the bones of the upper extremity 
 contain more earthy matter than the corresponding bones of the 
 lower extremity ; and the bones of the head contain considerably 
 more earthy matter than the bones of the trunk.* 
 
 It is most difficult to say what is the nature of the animal matter 
 of bones. At one time it was presumed to he cartilage ; but this 
 appears to be a mere assumption, derived from the superficial re- 
 semblance which it bears to this substance. It does not appear to 
 be mere gelatine ; for though this principle is obtained in quantity 
 from bone, and bones are economically used in manufacturing glue, 
 they do not furnish the same proportion of jelly as tendon, nor are 
 they so useful in making soups, as was once paradoxically and ab- 
 surdly enough maintained by some chemists. It is probable that 
 the gelatine, as we have already stated, is under a peculiar modi- 
 fication, or combined with some principle which is not well under- 
 stood. Is there no albumen in this animal matter ? The sulphur 
 formed during calcination seems to show that there is. There is 
 no fat in bones; and in the experiments in which this substance has 
 been found, it is evident that it was merely marrow which had been 
 mingled with the bones employed, or which had not been removed. 
 
 Though bones were arranged by the ancients among the blood- 
 less organic substances, they receive a considerable proportion of 
 this fluid, and injection shows them to be highly vascular. In early 
 life, especially, these vessels are numerous ; and even in the grown 
 adult, when death takes place by strangulation or by drowning, the 
 bones are found to be naturally well injected. In old age the 
 vessels are less numerous, but they are larger. From the capillary 
 vessels distributed through their substance, bones derive the pale 
 blue or light pink colour by which the healthy bone is characterized. 
 When this tint becomes intense, it indicates inflammation or some 
 morbid state of the vessels of the bone. When it is lost, and the 
 bone assumes a white or yellow colour, the part so changed is dead. 
 
 Anatomists distinguish three orders of vessels which enter the 
 substance of bones ; the first, those which penetrate the bodies of 
 
 * On the Proportions of Animal and Earthy Matter, &c. By G. 0. Rees, M. D. 
 Mediso-Chirurgical Transactions, Vol. XXI. p. 406. London, 1838. 
 
BONE. 
 
 435 
 
 long bones to the medullary cavity, (arterias nutritice, arterice me- 
 dullares ;) the second, those which go to the cellular structure of 
 the bone ; and the third, those which go to the compact or dense 
 matter of the bone. This view is only partially correct. The large 
 vessels termed nutritious certainly proceed chiefly to the cavity of 
 the bone, and are distributed in the medullary membrane. These, 
 however, are not the only vessels which proceed to this part of the 
 bone. jFi'rsi, I have often traced several large vessels, entering not 
 by the middle, but the ends of the long bones, into the loose can- 
 cellated texture, and actually distributed on the medulla in this part 
 of the bone. In dried bones also the canals of these vessels may 
 be demonstrated extending from the surface to the body of the 
 bone. Secondly^ the nutritious vessels are not constant ; and when 
 they are wanting, those of the ends of the bone, or of the cancelli, 
 are much larger and more numerous than in ordinary circum- 
 stances. The communication between these and the branches of 
 the nutritious vessels, which is admitted by Bichat, may be easily 
 demonstrated. The third order of vessels are those which may be 
 termed periosteal^ in so far as they consist of an infinite number of 
 minute capillaries, some red, some colourless, proceeding from the 
 periosteum to the bone, and contributing to maintain the connec- 
 tion between the two. The short bones and the flat bones, which 
 are destitute of nutritious arteries, receive blood from tbe two latter 
 orders, but principally from the periosteal vessels. In the skull 
 these vessels are often highly injected in apoplectic subjects, and in 
 persons killed by drowning or strangulation. 
 
 The veins of bones are peculiar in their arrangement. The nu- 
 tritious artery is accompanied by a social vein ; the articular and pe- 
 riosteal vessels are said to be destitute of corresponding venous ves- 
 sels. According to Dupuytren, however, minute venous capillaries 
 arise from the substance of the osseous tissue, precisely as in other 
 tissues, and, uniting in the same manner, form twigs, branches, 
 and trunks, which finally terminate in the neighbouring veins. 
 
 Lymphatics are not found in the substance of bones. Bichat, 
 however, thinks analogically, that nutrition implies exhalation and 
 absorption ; but it is manifest that this does not demonstrate the 
 existence of true lymphatics. Nerves in like manner have not been 
 traced into this substance.* 
 
 To complete the anatomical history of bone, it is requisite to 
 examine shortly the marrow. The interior of the long bones con- 
 
 * On these points see Scarpa, cZfi Anatome et Pathnlogia Ossium Comment, p. 38, 
 &c. ; and Howship, Med. Chir. Tr. Vol. VIII. p. 66. 
 
436 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 tains a notable quantity of fat, oleaginous matter, which has been 
 long known under the name of marrow (^[j^uiKog Iht%, medulla ;) and 
 a similar substance, though in much smaller quantity, is found in 
 the loose cancellated tissue of the flat and short bones. It is in the 
 first situation only that it is possible to examine the anatomical cha- 
 racters of this substance. It is sufficiently similar to fat or animal 1 
 oil in other parts of the body to lead us to refer it at present to that 
 head. In other respects, its chemical qualities have not been much 
 examined ; hut an analysis by Berzelius shows that it consists ^ 
 chiefly of an oily matter, not unlike butter in general properties. 
 
 The filaments, blood-vessels, albumen, gelatine, and osmazome found *■ 
 by this chemist in marrow, are to be regarded as derived from the ^ 
 filamentous tissue in which the medullary particles are deposited, 
 and by no means to be arranged with it. They did not exceed 4 
 parts in the 100. The medullary membrane, which has been con- 1 m 
 sidered as an internal periosteum, is but imperfectly known. There 
 can be no doubt, however, of its existence, which is easily demon- 
 strated by opening either transversely or longitudinally the medul- % 
 lary canal of a long bone, and boiling it for about two hours. The ; , 
 marrow then, as is well known to cooks, drops out ; and it will be 
 found on examination to be deposited in the interstices of a fila- 
 mentous net-work of animal matter, which is not unlike very fine 
 filamentous or cellular tissue, which may be traced not only into 
 the lattice-work of the extremities, but into the longitudinal canals " 
 of the cylindrical bones. It is traversed by blood-vessels, which 
 are observed to bleed during amputation. No nerves have been 
 found in it. The medullary membrane, in short, may be regarded 
 as an extensive net-work of very minute capillaries united by deli- 
 cate filamentous tissue. From these capillaries the marrow is de- 
 posited as a secretion. — (Mascagni, Howship.) 
 
 The development or progressive formation of the osseous system I 
 has given rise to many interesting researches by Kerckringius, i 
 Vater,* Baster,! Duhamel,:{; Nesbitt,§ Haller,|| Dethleef,1[ Reichel, 
 Albinus,**David,Troja, Scarpa, John Hunter,!! Senff,!!Howship,§§ | 
 
 * De Osteogenia Natural! et Prseternaturali. Haller, Disput. Anat. Vol. VI. p. 227. I 
 t De Osteogenia. Haller, Disp. Anat. Vol. VII. I 
 
 J Alem. tie I’Academie Royale, 1741-42, &c. i 
 
 § Human Osteogeny, &c. By Ro. Nesbitt, M. D. Lond. 1736. I 
 
 l| Opera Minora, Tom. II. XXXIII. p. 460. , 
 
 Dissert. Ossium Calli generationem exhibens. Goett. 1753. 
 
 Annot. Anat. et Eikones Os. Foet. Hum. Lug. Bat. 1763. i 
 
 f.(- Medical and Chii-urgical Transactions, Vol. II. 
 
 :J;f. Nonnulla de Incremento Ossium, &c. Halle, 1781. I 
 
 §§ Medico-Chirurgical Transactions, Vol, VI. p. 263. | 
 
BONE. 
 
 437 
 
 Meckel,* Medici, Serres, Lebel, Schultze, Bedard, and Dutro- 
 chet ; and it is a proof of the difficult and complicated nature of 
 the subject, that it still continues to give rise to fresh investigation. 
 The inquiry naturally resolves itself into two parts, — the history of 
 the process of ossification, as it takes place originally in the foetus 
 and infant, and the history of its progress as a process of repair 
 when bones are divided, broken, or otherwise destroyed or removed. 
 
 From the first formation of the embryo to the termination of 
 foetal existence and thenceforth to the completion of growth, the 
 bones undergo changes, in which various stages may be distinguished. 
 In the first weeks of foetal existence it is impossible to recognize 
 anything like hone ; and the points in which the bones are after- 
 wards to be developed consist of a soft homogeneous mass of ani- 
 mal matter, which has been designated under the general name of 
 mucus. Sometime between the fifth and the seventh week, in the 
 situation of the extremities, may be recognized dark opaque spots, 
 which are firmer and more solid than the surrounding animal mat- 
 ter. About the eighth week, the extremities may he seen to consist 
 of their component parts, in the centre of each of wdiich is a cylin- 
 drical piece of bony matter. Dark solid specks are also seen in 
 the spine, corresponding to the bodies of the vertehrse ; and even 
 the rudiments of spinous processes are observed in the shape of mi- 
 nute dark points. In the hands and feet rings of bones are seen 
 in the site of the metacarpal and metatarsal bones. All the joints 
 consist of a semi-consistent jelly-like matter liberally supplied by 
 blood-vessels. At ten weeks the cylinders and rings are increased 
 in length, and are observed to approach the jelly-like extremities, 
 which are acquiring the consistence of cartilage, and when divided 
 present irregular cavities. At the same time the parts forming the 
 head are highly vascular ; and between the membranes are depo- 
 sited minute points of bony matter, proceeding in rays from a centre, 
 which, however, is thinner and more transparent than the margin 
 or circumference — (Howship.) 
 
 Between thirteen weeks and four months the cavities in the jelly- 
 like cartilaginous matter receives injection. The membranes of the 
 head are highly vascular, transmitting' their vessels through the in- 
 tervals of the osseous rays, which are occupied abundantly by stiff, 
 glairy, colourless mucilaginous fluid. 
 
 In the seventh month, the bony cylinder of the thigh-bone and 
 its epiphyses contain canals perceptible to the microscope. In the 
 
 * Journal Complementaire, Tome II. p. 211. 
 
438 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 head, the bones are proceeding to completion ; the pericranium and 
 dura mater are highly vascular ; and a quantity of reddish semi- 
 transparent jelly between the scalp and the skull, which contained 
 numerous minute vessels, Mr Howship regards as the loose cellu- 
 lar state of the foetal pericranium. This is, however, doubtful. 
 The cylindrical bones have at this period no medullary cavity, but 
 present in their interior a loose bony texture. 
 
 Between the seventh and eighth months, in a foetus ten inches 
 long, I find the humerus consisting of a cylinder of bone placed 
 between two brownish firm, jelly-like masses, which correspond to 
 the epiphyses, enclosed by periosteum, which adheres loosely by 
 means of filamentous and vascular productions. The radius is- a 
 thin bony rod, also between two jelly-like epiphyses. The ulna is 
 still thinner, more slender and flexible, and even compressible. 
 The interosseous ligament is a continuous duplicature of the peri- 
 osteum. The metacarpal bones are much as before, only larger. 
 The hands and fingers are complete ; but the phalanges consist of 
 minute semi-hard grains, enclosed in periosteum, which forms a ge- 
 neral sac to them, and to the intermediate connecting parts. The 
 middle and unguinal phalanges can scarcely be called osseous. The 
 femur, like the humerus, is an osseous cylinder between two jelly- 
 like epiphyses, enveloped in loosely adhering periosteum. The 
 tibia and fibula like the radius and ulna. The metatarsal bones 
 are cylindrical pieces, firm, but not very hard. The first phalanx 
 of the toes is complete ; the other two, though the toes are fully 
 formed, are much of the consistence of cartilage. The carpal and 
 tarsal hones are in the state of the epiphyses, but of a gray colour. 
 
 In this state of the osseous system, the periosteum, which is con- 
 tinuous, and appears to make one membrane with the capsular li- 
 gaments and the deep-seated portions of the fascia, adheres to the 
 bone chiefly by arteries and filamentous productions ; and so loose 
 is this connection, that a probe may be inserted beneath it, and 
 carried round or inwards, unless where these connections are situate. 
 Another point where the periosteum adheres firmly is at muscular 
 insertions. Thus it adheres to the humerus most firmly at the inser- ? 
 tion of the deltoid, and to the femur at that of the glutcBus ; and at 
 these parts the bone is already rough. 
 
 In the vertebral column the bodies of the vertebrae and the spi- 
 nous plates are formed ; and minute specks are beginning in the 
 site of the transverse processes. 
 
BONE. 
 
 439 
 
 III the skull, the parietal bones are well-formed shells of bone, 
 though very deficient at the mesial plane, the anterior margin, and 
 the upper anterior angle. The pericranium is distinctly membra- 
 nous and vascular; and the red jelly-like fluid noticed by Mr How- 
 ship is exterior to this membrane. 
 
 At the period of birth, the cylindrical bones contain tubular 
 canals filled with a colourless glairy fluid, and terminating in the 
 surface of ossification. As the bones previous to this period are 
 homogeneous, and contain no distinct medullary cavity, but present 
 in their interior a soft or loose bony texture, it is reasonable to sup- 
 pose that the development of the longitudinal canals is connected 
 with the formation of the medullary cavity. At birth in the femur 
 may be distinguished a medullary cavity beginning to be formed, 
 about half a line broad, but still very imperfect. 
 
 After birth the two processes of the formation of tubular canals 
 and medullary cavity go ou simultaneously ; and at the same rate 
 nearly the outer part of the cylindrical bones acquires a more dense 
 and compact appearance. The epiphyses, also, which are in the 
 shape of grayish jelly-like masses, begin to present grains and points 
 of bone. Preliminary to this, Mr Howship represents them, while 
 still cartilaginous, as penetrated by canals or tubes, which gradually 
 disappear as ossification proceeds. The carpal and tarsal bones ap- 
 pear to observe the same course in the process of ossification. 
 
 In the bones of the skull, however, a difiereut law is observed. 
 The osseous matter is originally deposited in linear tracts or fibres, 
 radiating or diverging from certain points termed points of ossifi- 
 cation. Each bone is completed in one shell without diploe or dis- 
 tinguishable table. Afterwards, when they are completed late- 
 rally, or in the radiating direction, the cancellated arrangement of 
 the diploe begins to take place, apparently in the same manner, in 
 which the medullary cavity and compact parts of the long bones 
 are formed. 
 
 It has been generally supposed that the formation of cartilage is 
 a preliminary step to that of bone. This, however, seems to be a 
 mistake arising from the circumstance, that cartilage is often ob- 
 served to be converted in the living body into bone. Neither in 
 the long nor in the flat bones is anything like cartilage at any time 
 observed. The epiphyses, indeed, present something of the con- 
 sistence of cartilage, but it has neither the firmness nor the elasti- 
 city of that substance. It is a concrete jelly, afterwards to be pe- 
 
440 
 
 GENERAL AND Px\.THOLOGlCAL ANATOMY. 
 
 netrated by calcareous matter. The flat bones are from the first 
 osseous ; and though their margins are soft and flexible, in conse- 
 quence of their recent formation and moist state, they have still a 
 distinct osseous appearance and arrangement, and bear no resem- 
 blance to cartilage. In short, true bone seems never at any period 
 of its growth to be cartilaginous. 
 
 The period at which ossification may be said to be completed 
 varies doubtless in different individuals. It may be said to be in- 
 dicated by the completion of themedullary canal, by the ossification 
 of the epiphyses, and their perfect union with the osseous cylinder, 
 {(liaphysis.) The first circumstance is always indefinite. The two 
 latter, though more fixed, are still liable to great variation. The 
 epiphyses are rarely united before the age of 14 or 15; and they 
 may continue detached till the 20th or 21st year. I preserved the 
 greater part of the skeleton of a man, who was known to be about 
 28, and in whose bones the epiphyses were imperfectly united, 
 and many had dropped off. In general, however, they begin to 
 unite, or to be knit, as is said, between the 15th and 20th years. 
 
 Little doubt can be entertained that the main agents of original 
 ossification are the periosteum and the periosteal arteries. The 
 proofs of this inference are manifest. The formation of bone has 
 never been ascribed but to the vessels of two agents, — the perios- 
 teum and the medullary membrane. That the latter cannot be con- 
 cerned in the production of bone in the foetus must be inferred from 
 the fact, that at that period it cannot be said to have existence. 
 To the periosteum, therefore, and its vessels must be ascribed the 
 process of foetal ossification. Of this a cumulative proof may be 
 found in the circumstance, that the periosteum adheres more firmly 
 at the ends than the middle of the bones ; and that the pericranium 
 and dura mater, which perform the part of periosteum to the bones 
 of the skull, are visibly concerned in the formation and successive 
 enlargement of these bones. But though the periosteal vessels are 
 the main agents of ossification originally, there is reason to believe 
 that the medullary vessels contribute to its growth and nutrition 
 after it is formed. This may be inferred from the phenomena of 
 fractures, of diseases of the bones, and of those experiments in which 
 the medullary membrane is injured. The periosteum, however, 
 does not act by ossification of its inner layers, as Du Hamel, misled 
 by a false analogy between the growth of trees and bones, laboured 
 to establish. This leads naturally to the examination of the ijhe- 
 
BONE. 
 
 441 
 
 nomena of ossification as a process of repair. This, however, is in- 
 troduced more properly under the next section. 
 
 The teeth, as a variety of bone, demand attention. Every tooth 
 consists of two hard parts ; one external, white, uniform, somewhat 
 like ivory, the other internal, similar to the compact structure of 
 bone. 
 
 The first, which is named enamel, is seen only at the crown of 
 the tooth, the upper and outer part of which consists of this sub- 
 stance. It is white, very close in texture, perfectly uniform and 
 homogeneous, yet presenting a fibrous arrangement. Extending 
 across the summit of the tooth in the manner of an incrustation, it 
 is thick above, and diminishes gradually to the root, where it dis- 
 appears. This fact is demonstrated by macerating a tooth in dilute 
 nitric acid, when the bony root becomes yellow, while the crown 
 remains white. 
 
 The enamel is not iujectible, and is therefore believed to be in- 
 organic. It is also filled and broken without being reproduced ; 
 nor does it present any of the usual properties which distinguished 
 organized bodies. The piercing sensation which is communicated 
 through the tooth from the impression of acids seems to depend on 
 the mere chemical operation, and not on the physiological effect. 
 Upon the whole, the enamel is to be viewed as the result of a pro- 
 cess of secretion or deposition, but as inorganic entirely. 
 
 The bony part of the tooth is the root and that internal part 
 which is covered on the sides and above by the enamel. It con- 
 sists of close-grained bony matter, as dense as the compact walls of 
 the long bones, or the petrous portion of the temporal bone. The 
 fibres which are said to be seen in it are exactly of the same nature 
 as those in bone. 
 
 In the interior of the bony part of each tooth is a cavity which 
 descends into the root, and communicates at its extremity with the 
 outer surface by openings corresponding with the number of 
 branches into which the root is divided. This cavity, which is 
 larger in young or newly formed teeth, and small in those which 
 are old, contains a delicate vascular membrane, which has been 
 named the pulp of the tooth. It is best seen by breaking a recent 
 tooth by a smart blow with a hammer, when the soft pulpy mem- 
 brane may be picked out of the fragments by the forceps. It then 
 appears to be a membranous web with two surfaces, an exterior 
 adhering to the bony surface of the dental cavity by minute vessels; 
 
442 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the other interior, free, and, so far as can be determined of a body 
 so minute, resembling a close sac. 
 
 The development and growth of the teeth is a process of much 
 interest. 
 
 At what time the first rudiments of teeth appear seems not to 
 be determined with accuracy. In the foetus, between tbe seventh 
 and eighth month, I can merely distinguish in the centre of 
 the vascular membrane of the alveolar cavity a minute firm body 
 like a seed. I have, however, seen the crowns of teeth formed in 
 foetuses, which I have reason to believe had not attained the seventh 
 month. But whatever may be the exact period, the process is 
 nearly as follows. 
 
 As the bones of the upper and lower jaw are in the process of 
 formation between the third and fifth months,* cavities at their 
 lower and upper margins are gradually formed by the growth of 
 the osseous plates, which afterwards form the alveoli. As these 
 cavities are formed, they are lined by a large, soft, membranous, 
 vascular sac, which, in the manner of a serous membrane, consists 
 of two divisions, one lining the alveolus., the other folded within 
 that, and forming a closed cavity. In the inside of this cavity the 
 process of dentition commences some time between the fifth and 
 seventh month, by the deposition of matter from the vessels at the 
 lowest point of the alveolar division of the sac. This matter is to 
 constitute the crown of the tooth, which is invariably formed first. 
 After the deposition of the first portions, these are pushed upwards 
 by tbe addition of successive layers below them, and necessarily 
 carry the inflected part of the sac before them. As this process of 
 deposition advances, the tooth gradually fills the sac, and rises till 
 it reaches the level of the alveolar margins. If a tooth be examined 
 in situ, near the period of birth, it is found to consist of the crown, 
 with portions of enamel descending on every side, and forming a 
 cavity in which a cluster of blood-vessels, proceeding from the sac, 
 is lodged. 
 
 After the enamel has been deposited the bone begins to be 
 formed ; and as this process advances, the tooth is still forcibly 
 tbrust upwards by the addition of matter to its root. When the 
 latter is well completed, the vessels become smaller and less abun- 
 dant ; until, when the tooth is perfect, they shrink to a mere mem- 
 brane, which lines the cavity of the tooth, and still maintains its 
 * Fourth and Fifth, Bichat, p. 93, Tome iii. 
 
BONE. 
 
 443 
 
 original connection with the alveolar membrane, by the minute 
 vascular production which enters the orifice or orifices of the root. 
 
 Physiological authors have thought it important to mark the 
 period at which the teeth appear at the gums ; and in general this 
 takes place about the sixth or seventh month after birth. This 
 mode of viewing the process of dentition, however, gives rise to 
 numberless mistakes on the period of teething. The process, as 
 we see, commences in the early period of foetal existence ; and the 
 time at which they appear above the gums varies according to the 
 progress made in the womb. In some the process is rapid ; in 
 others it is tardy ; and even the fabulous stories of Richard III. 
 and Louis XIV. may be understood physiologically, without the 
 aid of the marvellous. Grenerally speaking, the crown is com- 
 pleted at the period of birth ; and, according as the formation of the 
 root advances with rapidity or slowly, dentition is early or late. 
 
 What is here described is tbe process of the formation of the first 
 or temporary set of teeth, which consist, it is well known, of 20. 
 In that of the second set the same course is observed. In the same 
 manner is observed a row of follicular sacs, though not exactly in 
 the original alveoli ; in the same manner deposition begins at the 
 bottom of the free surface of the sac by the formation of the crown ; 
 and in the same manner the crown is forcibly raised by the succes- 
 sive accretion of new matter to its base. The moment this process 
 commences, a new train of phenomena takes place with the primary 
 teeth. The follicular sacs of the new or permanent teeth are libe- 
 rally supplied with vessels for the purpose of nutrition ; and as these 
 blood-vessels increase in size, those of the temporary teeth dimi- 
 nish ; and the supply of blood being thus cut off, the latter undergo 
 a sort of natural death. The roots which, as being last formed, are 
 not unfrequently incomplete, now undergo a process of absorption ; 
 and the tooth drops out in consequence of the destruction of it& 
 nutritious vessels. Some authors have ascribed this expulsion to 
 pressure, exercised by the new tooth. They forget, however, that 
 before tbe new tooth can exert any pressure, it must be in some 
 degree formed ; and to this a vascular system is indispensable. 
 
 Tbe increased number of the teeth when permanent, the enlarge- 
 ment of the jaws, and the consequent expansion of the face, though 
 interesting, are foreign to the present inquiry. 
 
 Another part of the osseous system requiring notice are the sesa- 
 moid bones. These derive their name, it is well known, from their 
 
444 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 minuteness, (^ariaaiMri, a grain,) most of them, excepting the knee- 
 pan, being of the size of a grain or pea. They are confined to the 
 extremities, and are situate chiefly in positions in which they give 
 points of support to the tendons of the flexor muscles. (Tendons 
 of the gemelli, tibialis posticus, peronccus largus, &c.) The pecu- 
 liarity of these bones is, that they are formed invariably in the sub- 
 stance of fibrous organs, as tendons in the case of the knee-pan and 
 the sesamoid bones of tbe gemelli, tibialis posticus, and peronccus 1. ; 
 or ligaments in tbe case of those situate between the metacarpo-pha- 
 langeal and metatarso -phalangeal articulations. With this pecu- 
 liarity their mode of ossification corresponds. At first albuminous 
 or fibro-albuminous, in process of time they are penetrated by cal- 
 careous matter, and present an osseous texture, which, however, is 
 much less firm than that of genuine bones. The period at which 
 this deposition commences and is completed varies in different indi- 
 viduals ; and hence, scarcely in any two persons of the same age is 
 the number of sesamoid bones tbe same. Though tbe patella may 
 be ossified at the 20th year, the minute sesamoid bones are some- 
 times not formed before the 30th or even the 40th. In the patella, 
 when ossified, we find a medullary organ. But it is uncertain 
 whether the others acquire this mark of osseous character. These 
 bones resemble the epiphyses in uniting, when divided, by fibro- 
 albuminous matter. 
 
 Section II. 
 
 Osteitis ; Inflammatio. — Though all practical authors admit that 
 bones may be inflamed either spontaneously, or in consequence 
 of injury, yet it is remarkable that none have communicated any 
 precise idea of this process ; and while they admit it as a patholo- 
 gical fact, they have too often lost sight of it in one or more of 
 the changes to which it gives rise. To Mr Howship we are in- 
 debted for the first attempt to determine with precision the anato- 
 mical characters and pathological nature of this process. 
 
 It may at first sight seem doubtful whether genuine bone is sus- 
 ceptible of such a process as inflammation. For though a bone 
 constituted as already described is doubtless an organized substance, 
 and therefore liable to the actions of organized bodies, yet whether 
 a particle of completed bone, as in the compact parts of the cylin- 
 drical bones, becomes itself the seat of inflammation, may seem 
 
 3 
 
BONE. 
 
 445 
 
 questionable. The morbid process, however, to which the actual 
 bony particles may not be competent, the membranous covering and 
 the vascular filamentous penetrating web, are unquestionably power- 
 ful agents in efiecting. In short, while bone as a secretion is almost 
 passive in its morbid relations, we observe it obeying the slightest 
 infiuence of the periosteum and its vessels on the one hand, and 
 those of its medullary system on the other. 
 
 Having premised these remarks, it is to be observed that infiam- 
 mation occurring in bone may assume various forms. 
 
 1. Adhesive Inflammation . — Of these the simplest is that which 
 takes place in the process of union after fractures , — the healthy ossi- 
 flc inflammation of Mr Hunter, a variety of the adhesive. In this 
 three distinct stages are enumerated. In the first, effusion of blood 
 from the periosteal vessels into its substance, and from the medul- 
 lary vessels into the fracture, is after coagulation followed by eflru- 
 sion of a colourless viscid fluid, which also coagulates into a jelly. 
 (J. Hunter, Bichat, Howship, &c.) In the second, the soft parts, 
 and especially the periosteum, become hot, red, swollen, and, in 
 short, are in a state of inflammation. ^ (Du Hamel, Howship, &c.) 
 If at this time the fracture be examined, the periosteal and medul- 
 lary arteries at the line of fracture are large, numerous, and are 
 seen emitting vessels into the coagulated blood and lymph efiused 
 beneath the periosteum, and from the broken ends, and converting 
 them into organized masses, sometimes distinct like granulations, 
 sometimes irregularly continuous. This substance, which is of a 
 reddish-gray colour, and of the consistence of firm jelly, is what is 
 named callus. The third stage may be distinguished by the ap- 
 pearance of osseous points which now begin to be deposited from 
 the new vessels, which penetrate from the periosteum and medul- 
 lary filaments to the callus. As the arterial action advances, these 
 osseous points extend from the broken surface and coalesce. The 
 exterior swelling at the same time diminishes and disappears ; the 
 periosteum falls to its natimal size and its ordinary rate of vascu- 
 larity ; the medullary canal is restored in greater or less perfec- 
 tion ; and the broken portion of bone after some time recovers the 
 same organization and firmness nearly which it originally possessed. 
 Instead of the longitudinal canals which are found in compact 
 healthy bone, however, the renewed part presents a series of irre- 
 gular cavities, varying in size and direction, and which contain a 
 vascular, filamentous, medullary web. (Howship.) According to 
 
446 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Mr John Bell it remains for years more vascular than the con- 
 tiguous bone.* According to Howship it possesses a larger propor- 
 tion of animal matter, f 
 
 In some instances of fracture union is not accomplished in this 
 perfect manner ; but is effected merely by a fihro-albuminous cica- 
 trix, which unites the fragments loosely. This is observed espe- 
 cially in fractures of the neck of the thigh-bone, (Bell, Desault, 
 Cooper, Howship;) of the knee-pan, (Camper, Callisen;)of the 
 olecranon, and other parts consisting of loose cancellated structure. 
 Upon the reasons of this physiologists are not agreed. By some it 
 is ascribed to defect of periosteum, as in the neck of the thigh-bone 
 (A. C. Hutchinson ;) by others it is attributed to inefficient nutri- 
 tion in the part broken off, which is then certainly less freely sup- 
 plied by blood-vessels. (J. Bell, Sir A. Cooper.) 
 
 Further, in fractures in which there is much contusion and com- 
 minution, and especially where it is complicated by a communicat- 
 ing wound of the soft parts, reunion is rarely complete. The sup- 
 purative inflammation which then succeeds precludes the adhesive 
 and ossific, and generally renders the latter imperfect or entirely 
 abortive. In such circumstances more or less of the bone dies, and 
 is thrown off in dead splinters. In some instances even necrosis 
 may be produced, as is exemplified in compound fractures produced 
 by gunshot. 
 
 Even in simple fracture may occur a variety of incomplete union. 
 
 In some subjects, in whom the fragments have been badly applied, 
 in whom they have been often moved, or in whom the vessels are 
 inadequate to assume the ossific action, though blood and lymph 
 are effused from the periosteum and medullary vessels, and under- ^ 
 go coagulation, adhesion is only partial and imperfect. It is not fl 
 penetrated by vessels so as to become organized ; or those vessels 
 are rent asunder by repeated motions. Under such circumstances, H 
 the intermediate substance, instead of acquiring solidity, and be-;^ 
 coming penetrated by bone, is partly absorbed ; while the broken ^ 
 ends are converted into a secreting surface, which discharges se-T® 
 
 * Principles of Surgery, Vol. I. p. 507. Disc. 12. “ Having cut off the limb of a sol- H 
 dier whose limb had been broken in America twelve years before, I found upon in- ® 
 jecting the bone, that while the bone itself received the red colour of the injection ,, 
 pretty freely, the callus, which goes in a zig-zag form, joining together the several ends 
 and points of a very oblique fracture, was very singularly red.” 
 
 f Experiments and Observations, &c. By J. Howship. Med. Chir. Trans. Vol. IX. 
 p. 143. 
 
 
BONE. 
 
 447 
 
 rous, purulent or sero-purulent fluid in small quantity. This forms 
 what is false joint. 
 
 In the pregnant, or persons labouring under scurvy, and in those 
 affected with the constitutional symptoms of syphilis, fracture is not 
 united by bony union. 
 
 2. Diastasis. — Next to fracture may be placed detachment or 
 disunion of the epiphyses, {diductio epiphysium.) In young sub- 
 jects, while the epiphyses are still imperfectly united to the diapTiy- 
 sis, this may occur, in consequence of forcible stretching, or injury 
 of the bone. In this manner it is noticed by Palfyn, Reichel,* Wil- 
 mer,t and others. Reichel saw it in the humerus, and Wilmer in 
 the tibia. I have seen it in the humerus and in the femur, in which 
 chiefly it occurs. Sometimes it may be traced to injudicious efforts 
 by bone-setters in pulling a thigh-bone supposed to be dislocated. 
 It is liable to be confounded with fracture of the neck of the thigh- 
 bone. If not disturbed, the injury is repaired by union either in 
 the ordinary manner, or with more or less extensive ossification of 
 the neighbouring parts, causing generally stiff-joint. Consecutive 
 disunion of an epiphysis may happen in mollities ossium and in spi- 
 na ventosa. (Trioen, Reichel.) 
 
 The variety of disunion now mentioned is generally confined to 
 the epiphysis of one bone. A more general disunion, however, oc- 
 curring in most of the epiphyses of the skeleton, may take place in 
 scurvy. This was remarked especially in the scorbutic epidemic of 
 Paris 1743, and has since been occasionally seen. (Lind.) Inspec- 
 tion shows that the bones are penetrated by bloody extravasation, 
 — that the vessels are relaxed and atonized, — and that nutritious 
 deposition is suspended. This scorbutic diduction, which depends 
 on a disease affecting the whole system, may be removed by the 
 same means which remove that morbid condition. Too often, how- 
 ever, it takes place in that stage of the disease in which recovery 
 is impossible. 
 
 3. I have above stated that it may be justly questioned whether 
 bone itself undergoes tlie organic process of inflammation. Most 
 of the facts hitherto collected, when well investigated, favour the 
 inference, that the inflammatory conditions of bone are to be re- 
 ferred to inflammation taking place either in the periosteum ; or 
 the tomentose medullary web ; or, finally, in the articular synovial 
 
 * M. Georgii Ch. Reichel, de Epiphysium ab Ossium Diaphysi Diductione. Sandi- 
 fort Thesaur. Vol. I. p. 1. 
 
 f Cases and Remarks, &c. Lend. 1779. P. 228. 
 
448 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 membrane or cartilage ; and most of the morbid states observed by 
 authors in bone may be traced to some variety or degree of inflam- 
 mation in one or more of these textures. 
 
 a. "When the periosteum becomes inflamed, one of several effects 
 may follow. 
 
 a. It may induce effusion of coagulable lymph into its substance, 
 or between that and the bone, — constituting simple node, and the 
 tumour termed gumma* 
 
 (3. By a modification of this action it may effuse lymph, which 
 afterwards becomes ossified, — constituting the ossi/ic node of Hun- 
 ter and Howship, or simply, osseous node, (periostosis.) This ap- 
 pears in the form of loose bony masses, plates, or scales,, on the 
 surface of such cylindrical bones as the tibia and ulna^ which are, 
 nevertheless, quite natural. In some instances this osseous node 
 appears to consist in ossification of the inner part of a circular area 
 of inflamed periosteum. In both cases, instead of the regular ar- 
 ranged longitudinal canals, the new osseous deposition presents 
 irregular cavities, varying in size and direction.* This, together 
 with great vascularity, constitutes the anatomical character of such 
 deposits. In one skull under 7 in my collection, periosteal in- 
 flammation has produced on the parietal bone a circular area the 
 size of a shilling, of minute spherical or spheroidal eminences, sur- 
 rounded by a smooth whitish ring, and that enclosed by a darker 
 coloured ring. The circular area, with rough eminences, marks 
 the space from which the periosteum was detached. It is thicker 
 and less translucent than the rest of the bone. The white ring 
 indicates the tract where the pericranium was inflamed, but not 
 detached. 
 
 7. If the inflammation be acute, as in that from injury, it may] 
 produce ulcerative absorption of the subjacent bone, which then 
 presents a denuded, rough, reddish surface, progressively increasing Jf 
 in extent and depth. This occurs particularly in young subjects. ^ 
 I have seen it in the bones of the skull destroy both tables, and 
 expose the dura mater ; and the fact shows that the tendency to 
 suppurative inflammation in the bones of the young is great. Of this 
 the following case is a good example. 
 
 A young girl of 10 or 11 years of age received on the head 
 a blow from a stone, which divided the scalp down to the 
 bone, but without causing fracture or depression. The wound 
 
 * Chirurgical Observations and Cases. By William Bromfield, Surgeon to Her 
 Majesty and to St George’s Hospital. Vol. II. Chap. i. p. 14. London, 1772. 
 
 T Howship in Medico-Chirurg. Trans. Vol. VIII. pp. 90, and 105, 106. 
 
 
BONE. 
 
 449 
 
 bled freely and was dressed in the ordinary way. A few days after 
 the parents requested the advice of an able surgeon, who, finding 
 the wound swelled, hot, and painful, with scanty discharge, recom- 
 mended the application of an emollient poultice, and the use of low 
 diet with laxative medicine. In the course of a few days, suppura- 
 tion took place to a great extent, yet without any appearance of 
 the wound healing or adhering. The patient also complained of 
 pain in the head, especially girding frontal headach ; the appetite 
 was gone; the pulse was quick, above 120; she looked pale and 
 unwell ; and occasionally felt shivering sensations. 
 
 At this stage, about 15 or 16 days after the infliction of the 
 wound, the surgeon requested me to see the child. The following 
 was the state of matters. The lips of the wound were red, large, 
 and gaping; much matter was proceeding from it; and it was 
 the seat of very distinct pulsation, synchronous with that of the arte- 
 ries; while, when the child cried, or breathed strongly, or coughed, 
 matter issued copiously from the wound. When this matter was re- 
 moved by the use of dry charpee, it w'as then distinctly seen that an 
 aperture had been completely formed through the bone into the 
 dura mater ; that the brain and its membranes were exposed at 
 the bottom of the wound, showing the two motions of the brain. 
 The wound was in the right parietal bone near the coronal suture. 
 
 The question was, what w'as to be done ? I recommended that 
 a little blood should he drawn from the arm ; that the poultices 
 should be given up ; that the wound should he kept clean and cool 
 by occasional ablution with cold water ; that a light dressing con- 
 sisting of lint dipped in cold vrater, or a solution of sulphate of 
 zinc, should be applied over the surface of the wound ; and that the 
 patient should be kept quiet, and on moderate unstimulating diet. 
 
 This plan was immediately adopted. In a few days the headach 
 had subsided, the discharge was greatly diminished, the pulsating 
 and heaving motion of the wound w'as no longer observed ; new 
 bony matter was deposited, and closed the aperture in the parietal 
 bone ; and in about 10 days more the wound was entirely healed. 
 
 In this case, as there was ulceration of bone and loss of its sub- 
 stance, there must have been deposition and new formation of it. 
 The process I regard as peculiar to the young. 
 
 It takes place also in the tibia, in the sternum, and other super- 
 ficial bones. In a more chronic form I have seen it cut through 
 both nasal bones by insensible ulcerative absorption. This process 
 corresponds with the insensible ex foliation or decomposition of Tenon ; 
 
450 
 
 GENERAL AND PATHOLOGICAL ANAT05IY. 
 
 the ahsorption produced by tumours, aneurisms, and other compres- 
 sing agents ; (Louis, Wilmer ;) and the peculiar absorption described 
 by Mr Russell.* 
 
 A similar process, by causing suppurative destruction or even 
 death of the periosteum, may kill the subjacent bone (nekrosis,) 
 which then becomes white, yellow, or black, and presents a de- 
 nuded but uniform surface, bounded at certain points by an irre- 
 gular rough line; (crena.) This line, which denotes the establish- 
 ment of ulceration on the confines of the living bone, becomes 
 more complete and deeper, till the dead portion is loosened and 
 removed. This process is denominated exfoliation^ and the part so 
 removed is said to be exfoliated f By Weidmann, who justly re- 
 marks that these terms are too limited, the process is designated by 
 the general name of separation ; while the part separated is distin- 
 guished by the epithet ramentum. Though it takes place chiefly 
 in the bones of tbe skull and in the front of the tibia, it may occur 
 in the low'er jaw,J in those of the pelvis,§ in the femur, and 
 wherever the structure is close and compact. In this manner the 
 odontoid process of the epistrophe {vertebra dentata) has been known 
 to be removed. II In bones containing much cancellated structure, 
 for instance the vertebrae, sternum, the carpal and tarsal bones, this 
 suppurative destruction and death of the periosteum produces not 
 death and exfoliation, but caries or ulceration, with death 
 
 of minute particles of bone, {separatio insensibilis.) 
 
 £. Certain forms of periosteal inflammation give rise simulta- 
 neously to osseous deposition and ulceration or caries. Thus no- 
 dose inflammation of the tibia and fibula may terminate in ulcers 
 of the periosteum, and produce irregular deposition on the surface 
 of these bones, which appear thick, but without the usual aspect of 
 healthy bone, present irregularly shaped masses of structure, partly 
 like honey-comb cells and partitions, partly like confused network. 
 The course of phenomena here is first chronic thickening and in-, 
 duration of the periosteum, with deposition of bone beneath it; 
 
 * Edinlmrgh Medico-Chirurgical Transactions, Vol. I. p. 74. 
 
 T Memoires sur I’Exfoliation des Os, par M. Tenon, dans Mem. de I’Academie R. 
 des Sciences, 1758. P. 661, &c., and 1760. See, among others, good cases in How- 
 ship's Practical Observations, Case 107, pp. 404, and 113, p. 434. 
 
 :J; Exfoliations of the lower jaw from disease or injury of the alveolar processes are 
 common. The hasty and reckless use of the tooth-key I have known produce not a 
 few examples of exfoliation of both jaw-bones. 
 
 § In Mr J. Bell's case of Gluteal Aneurism exfoliation from the ilium and sacrum 
 took irlace. Principles, Vol. I. p. 423. 
 
 11 Mr James Syme’s Case in Med. and Surg. Journal, Vol. XXV. p. 311. 
 
BONE. 
 
 451 
 
 then ulceration of the periosteum ; and lastly, ulceration or caries 
 in the new bony matter, which appears to continue to he deposited 
 irregularly. This, which is the carious ulcer (ulcus cariosum,') of 
 practical authors, may be seen in the legs of those who have been 
 affected by the constitutional symptoms of syphilis, and who have 
 undergone for its cure repeated courses of mercury.* * * § In the cases 
 in which I have seen it, it gave rise to extreme local pain and great 
 constitutional disorder, requiring amputation ; and one case ter- 
 minated fatally. Occurring in the bones of the cranium, which it 
 occasionally does, it is one of the forms of the disease described by 
 the older authors under the fantastic appellation of the garland of 
 Venus ;( CbroHo Veneris.) 
 
 Exostosis Periostei. Osteosarcoma. That the periosteum 
 may be concerned in extensive but morbid secretion of osseous 
 matter, giving rise to that form of tumonr which has been term- 
 ed by some exostosis, and by others osteosarcoma, has been al- 
 ready noticed. (P. 424.) The periosteum becoming thicken- 
 ed and morbidly vascular and painful, assumes additional energy 
 in the deposition of bony matter over a certain space. But 
 the bone so deposited is never arranged in the manner of heal- 
 thy bone. Sometimes it is in the form of a large shapeless pro- 
 minence deposited on the outer surface of the original bone. 
 This, which was remarked by Pouteau,f Houstet,! Herissant,§ 
 Flajani,! and Monteggia, has been verified by Howship. Some- 
 times it occurs in one point of the bone in the form of a spheroidal 
 tumour, in which the osseous matter is arranged in the form of 
 long needle-like fibres, radiating from one or more points, not un- 
 like radiated zeolite. In other instances it occurs in the form of 
 amorphous masses of bone, much like pieces of calcareous sinter. 
 (Houstet.) In others again, a central granular mass is surrounded 
 by acicnlar bony fibres. 
 
 Of these growths the interior structure varies. They are never 
 masses of solid bone ; but the bony matter is so arranged that it 
 leaves spaces or intervals filled in some instances with soft flesh- 
 coloured spongy matter ; (the fungous exostosis of Sir A. Cooper ;) 
 
 * Of this kind appear to be the tibia and fibula delineated by Roberg. See his 
 Dissert, in Haller Disp. Chimrg. Tom. IV. p. 561. 
 
 t CEu-STes Posthumes, Tom. III. 
 
 + Mem. de I’Acad. de Chir. Tom. III. p. 130. 
 
 § Mem. de I’Acad. Roy. des Sciences. 1758, p. 676. 
 
 II Collezione d'Osservaz. e Rifless. Tom. II. 
 
452 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 in others with cartilage; (J. Bell, A. Cooper,) (the cartilaginous 
 exostosis ;) in others with colloid or jelly-like matter, (J. Bell ;) 
 in others with semifluid blood-like matter, (Houstet ;) and in some 
 instances they have been known to contain hydatids, (Keate, &c.) 
 In all cases the periosteum is thickened ; the tumour is penetrated 
 by numerous large vessels ; and the bone in which the exostosis is 
 formed is more or less thinned and destroyed by absorption. 
 (Houstet, J. Bell, Palletta,* Sir A. Cooper.) 
 
 Though periosteal exostosis may take place in any bone of the 
 skeleton, it most frequently appears on the inner side of the thigh- 
 bone above the internal condyle, or upon the shaft, which it may 
 enclose completely, (Houstet ;) next upon the tibia, which, with 
 the fibula, it may encompass more or less perfectly ; next upon the 
 humerus, (J. Bell and Cooper ;) next in the bones of the pelvis, 
 (Cheston and Sandifort ;) and finally, on such bones as the lower 
 jaw, the temporal, and other bones of the cranium. It is most 
 likely to take place at muscular or tendinous insertions-f 
 
 In these forms of osseous deposition the vitality of the new deposit 
 is small. Its organization is indistinct and imperfect; and in no 
 long time it proceeds, apparently by pressure, to destroy the struc- 
 ture of the adjoining bone, which then becomes rough, yellowish, 
 or even black, and undergoes absorption. The bony mass at the 
 same time is changed interiorly, presenting cavities containing ge- 
 latinous or sanious fluid. The adjoining soft parts are generally 
 destroyed by pressure ; and when they give way are wasted by bad, 
 but not cancerous ulceration. The bone thus exposed is generally 
 black, rough, and carious. Though no exact analysis of these os- 
 seous tumours has yet been made, it is known that they consist of 
 phosphate of lime with animal matter. 
 
 The bony tumours occurring in the carpal, metacarpal, and pha- 
 langeal bones, as described by Severinus, Mery, and Mr John Bell, 
 I am inclined to refer to the head of exostosis depending on disease 
 of the medullary membrane. 
 
 b. The medullary filamentous web is perhaps still more impor- 
 tant than the periosteum in its morbid influence on bone. It is, in 
 the first place, liable to inflammation ; and, according as this takes 
 place in the medullary web of the cylindrical bones, or in that of 
 their epiphyses, or of the short irregular bones, different effects re- 
 sult. 
 
 * Exercitationes Pathologic*, Cap. ix. Art. iii. p. 112-115. 
 
 f On Exostosis, by Sir A. Cooper in Surgical Essays, Part i. London, 1818, p. 155. 
 
BONE. 
 
 453 
 
 Cl. Nekrosis. The term nekrosis means the process or state of 
 dying or mortification in general ; but it is restricted by pa- 
 thologists and surgeons to designate death taking place in 
 bone. This may be accomplished in various ways, and may 
 be the result of the operation of various agents. A compound 
 comminuted fractui’e, a gun-shot which breaks and shatters a bone, 
 or any other considerable degree of violence, may be followed 
 by death of the portions most directly injured, and even those 
 less immediately injured. It is observed also in the course of dis- 
 eases and accidents that when any one of the compact bones is de- 
 nuded of its periosteum, the part so denuded is very liable to be- 
 come dead and to be then separated as a lifeless part. In some 
 instances it has been observed that the agency of fire applied to the 
 human body accidentally or intentionally has caused, by denuding 
 the bone, the same result. Thus the actual cautery applied to the 
 scalp has caused death of the external table ; and I have seen a 
 portion of the same external table destroyed, and made to exfoliate 
 in an epileptic patient who in one of his fits had fallen into the 
 fire. 
 
 A peculiar sort of nekrosis of the bones of the face, especially 
 the superior jaw, has been made known by one of the manufactures 
 of modern times. It is observed, that persons engaged in lucifer- 
 match manufactories are liable to be attacked with pain and swelling 
 of the face ; and eventually it is observed, that the soft parts about 
 the nostrils suppurate, and portions of dead bone are discharged 
 evidently from the upper jaw. The process is chronic, tedious, and 
 exhausting; and sometimes the face is greatly deformed. This 
 disease is ascribed to the agency of phosphorus in vapour, which 
 is believed in this manner to produce death of the bones of the up- 
 per jaw. 
 
 All these are modes in which nekrosis or death of bone may be 
 produced. 
 
 The terra is nevertheless most commonly applied to designate 
 death in any of the cylindrical bones, in which the disease is seen 
 in its greatest perfection ; and, as it is sometimes under certain cir- 
 cumstances attended with attempts to form new bone to supply the 
 place of the dead bone, the term has been often understood to em- 
 brace the latter process as well as the former. The formation of 
 new bone, nevertheless, does not take place always ; and that must 
 be regarded as a distinct part of the process. 
 
 Nekrosis may come on in different modes. Often it is sponta- 
 
454 
 
 GENERAL AND rATHOLOGICAL ANATOMY. 
 
 neous in origin, and its appearance cannot be traced to any exter- 
 nal cause. In other cases it is observed to appear some time after 
 a blow, or other injury, in which the bone has suffered considerable 
 concussion. 
 
 The disease may make its appearance in two forms ; either as a 
 chronic malady, which is most usual ; or as one of great acuteness, 
 with intense symptoms of general and local disorder. 
 
 When it approaches as a chronic disease, the individual has pains 
 in the leg, or thigh, or arm of the part to be affected, which is re- 
 ferred to the bone ; the pain is aggravated by walking and all mo- 
 tion ; and there is in the limb a sense of weight with weakness, 
 which makes the patient afraid lest anything is to injure it. After 
 some time swelling takes place all over the limb. Occasionally 
 attacks come on like rose affecting the limb ; and either soon or 
 after several of these attacks matter is formed ; and upon being 
 discharged spontaneously or by art, the bone is found bare, in more 
 or less extent, and sometimes rough and parts of it loose. 
 
 In another class of cases the patient suffers deep-seated gnawing- 
 pain, referred to one part of the bone, which is aggravated and 
 extended over the whole bone on attempting to walk or otherwise 
 persisting in using the limb. The patient is also lame and in ge- 
 neral little able to walk. The limb is swelled ; over the bone much 
 thickening and swelling are felt ; generally pain on pressure is felt ; 
 and the surface is unusually hot. At length, from some very slight 
 and inadequate cause, as endeavouring to stand on the limb, or in 
 the course of walking, if that has not been abandoned, the patient 
 is seized with sudden and immediate loss of power in the limb, and 
 he falls down helpless and motionless. When the bone is examin- 
 ed, it is found that fracture has taken place. 
 
 In some rare cases this fracture unites after a considerable time 
 in the usual way, with much effusion of callus and deposition of 
 bone. In a much larger proportion of cases suppuration takes 
 place ; matter finds its way to the surface ; and when by an opening 
 by art or spontaneously, it is allowed to escape, the bone is found 
 to be extensively stripped of periosteum, to be rough and irregular, 
 and without any attempts at union. This suppurative process ad- 
 vances, enfeebling the patient, who pines away in hectic fever, and 
 in no long time dies. 
 
 The state of the bone is then remarkable. No attempt at union 
 is observed ; the broken ends of the bone are white, rough, and 
 
 lifeless, and for a considerable space deprived of periosteum. The 
 
 l 
 
BONE. 
 
 455 
 
 medullary caual contains purulent matter ; on the removal of which 
 the cancelli are observed also to be white and rough, while a little 
 farther away from the fragments the medullary web is vascular, 
 swelled, and discharging purulent matter. In general, beyond the 
 white portion of bone, a rough depressed line is observed between 
 the living and dead parts, the former having In general the peri- 
 osteum attached, and which is thickened, vascular, and evidently 
 in a state of inflammation. 
 
 The acute form of the disease is greatly more violent in pheno- 
 mena and more rapid in progress. All at once a limb or a por- 
 tion of it, for instance the leg or thigh, is attacked with general 
 swelling, diffused over the whole limb, great and intense pain both 
 superficial and deep, while the surface is hot and tense, of a dull 
 red colour, or sometimes very faintly red ; and the patient, be- 
 sides a feeling of great weight in the limb, is entirely deprived of 
 all powers of moving it. The constitutional disorder is great. 
 Generally there are rigors succeeded by heats ; the pulse is quick, 
 full, and strong ; pain is felt in the head ; the tongue is furred and 
 dry ; the patient distressed with thirst, restlessness, and anxiety, 
 and is in certain cases delirious ; the complexion is brownish-red 
 as in phlebitis j the eyes are glaring ; and the expression is a mijt- 
 ture of wildness and great suffering. This general disorder is in 
 certain cases so intense, and causes so great a shock to the system, 
 that the patient expires in the course of three or four days ; and 
 before the local disorder has lasted sufficiently long to produce 
 suppuration. 
 
 If the patient, however, survive this period, the swelling invari- 
 ably proceeds, until suppuration takes place in one or more parts. 
 In the course of one or two days more, matter points in one, two, 
 or three places simultaneously or successively ; and when this is 
 allowed to find issue either by art or spontaneously, it is ascertained 
 that inflammation has existed over the whole bone and the soft co- 
 verings, and that this has proceeded most extensively to suppura 
 tion. The skin and adipose membrane are by this detached from 
 ihefascice; the fasciae are detached from the muscles; the muscles 
 from each other ; and the whole soft parts are more or less detach- 
 ed from the periosteum, which, again, is either shreddy and killed, 
 or is detached in parts from the subjacent bone, which is in these 
 points rough, white, and evidently either deprived of vitality or 
 very much injuj-ed in texture. When the bone is cut open longi- 
 
456 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 tudiiially, the medullary membrane is swelled and very vascular, 
 loaded with blood and serum, and presenting in various points drops 
 of purulent matter. 
 
 The veins of the limb are inflamed ; and their coats are thicken- 
 ed and sometimes obliterated. The arteries are denuded, brittle, 
 and present traces of having partaken in the general inflammatory 
 orgasm. 
 
 This form of nekrosis appears very similar to an attack of diffuse 
 inflammation of the adipose and filamentous tissue; and I have 
 occasionally entertained doubts whether it ought not to be regarded 
 as such primarily, or as general inflammation of the soft parts af- 
 fecting eventually and necessarily the bone. It also presents some 
 resemblance to inflammation of the blood-vessels, and especially of 
 the veins. The point is practically of little moment. The bone is 
 killed ; whether primarily or secondarily appears of little conse- 
 quence, unless we could thereby discover some means by which 
 an action so destructive might be stayed in its progress. 
 
 An important question presents itself: to determine what is the 
 anatomico-pathological cause of nekrosis ; which is the texture con- 
 cerned in its production ; whether it be always one and the same 
 texture, or whether, in different cases and different forms of the 
 disease, different textures are concerned. This question it seems 
 difficult to determine. All that is already known tends to show 
 that nekrosis may be the effect of previous disease of the perioste- 
 um, previous disease in the medullary membrane or in both, or of 
 the whole of the soft parts investing the bone. The rest may be 
 understood from what follows. 
 
 Nekrosis interna . — That the medullary web of the cylindrical 
 bones is liable to inflammation is a well established point. The ten- 
 dency of this is not so well understood. It may proceed either to 
 suppuration, forming a collection of matter within the cavity of the 
 bone; or by producing effusion within the interstices of the medullary 
 web it may, by causing induration and swelling, induce expansion 
 of the walls of the diaphysis ; or by destroying the medullary mem- 
 brane, it may kill the bone from within outwards. 
 
 That inflammation of the medullary web causes swelling and ef- 
 fusion into its interstices may be regarded as established by the 
 phenomena of fractures, simple and compound, and especially by 
 those experiments in which this texture is expressly injured. When 
 
 it proceeds without being resolved, it may cause a uniform expan- 
 
 3 
 
BONE. 
 
 457 
 
 sion of the bone, which very often precedes the extinction of its vi- 
 tality. 
 
 Thus in most of the instances of the incipient stage of nekrosis, 
 a local enlargement, or rather dilatation of the bone, takes place, 
 while the bone, though its texture is softened, is still alive. This 
 is the process which Scai’pa distinguishes under the name of expan- 
 sion, and in which he imagines the reticular structure to be relax- 
 ed or unfolded. The fact is well established, but the explanation 
 is gratuitous. It is doubtless the early stage of the process which 
 terminates in nekrosis. 
 
 Suppuration in the cavity of the long bones, which was seen by 
 Cheselden, (p. 40), Gooch, (Vol. II. p. 357,) Hey, (p. 26 and 32,) 
 and others, is generally a process so severe as to cause death by 
 constitutional irritation. If it fails to effect this, it first distends 
 and softens the bone, and then kills it from within outwards, in- 
 ducing nekrosis. This may affect either part or the whole of the 
 diaphysis, which is then separated from the periosteum and epiphy- 
 sis, which is rarely killed. In process of time the dead portion or 
 portions (^ramenta,) become enclosed more or less completely by a 
 thick shapeless cylinder of new bone, with or without openings in 
 its sides, and which is placed between the epiphyses and covered 
 by the periosteum, which is much thickened. If death take place 
 at this period, the bone thus formed is found to contain the origi- 
 nal shaft, loose and dead. If life be still prolonged, the old bone 
 generally piecemeal is gradually brought to the surface through 
 the openings in the new osseous case and expelled. The fragments 
 thus discharged, which are of a dirty, yellow, drab, or black colour, 
 and somewhat corroded or worm-eaten at the ends and margins, 
 are named sequestra by Troja,* David,f and other French surgeons ; 
 and ramenta by Weidmann. The channels or openings through 
 which they are expelled, which are temporary deficiencies in the 
 new bone, are termed cloacce.X 
 
 The above is a brief description of the process of nekrosis with 
 regeneration, as it occurs in the cylindrical bones. Its effects were 
 known long before its mechanism was understood. The fact of 
 portions of the cylindrical bones of the extremities being removed 
 or expelled without impairing the motion of the limb, and of one 
 
 * De Novorum ossium regeneratione exp. Paris, 1775. 
 
 t Observations sui une Maladie connue sous le nom de Necrose. Paris, 1782. 
 
 J J. Petr. Weidmann, M. D., &c. De Necrosi Ossium. Francofurti ad Mcenum. 
 1793. Fobo. 
 
458 
 
 GENERAL AND PATHOLOGICAL ANATOMY, 
 
 bone being found within another was remarked Duverney, Ruysch,* 
 a Meek’ren,! Cheselden and others of the older anatomists and sur- 
 geons ; and even Portal speaks of the circumstance of one bone 
 rattling within another as a curious and unexplained phenomenon.^ 
 Next to the case given by Cheselden, Laing§ in 1737, and John- 
 ston|| in 1742, described cases of removal of the tibia and regene- 
 ration of the bone. Trioen^ and Amyand** describe the same ^ 
 facts under the name and as examples of spina ventosa ; and Mac-j ■ 
 kenzie,tt William Hunter,JJ Ludwig,§§ Bromfield,|||| and others de- ' 
 scribe the disease with the process of regeneration under various 
 names, as detachment of the epiphyses^ caries, loss of a bone, or re- 
 production, destruction of the diaphyses, according as any one part 
 of the process was most prominent, without appearing to be aware 
 of its true nature. Ludwig, indeed, appears to have been the first, 
 or among the first, who investigated carefully the nature of the 
 change. He published in 1772 two cases of the disease ; one in the! 
 tibia, with recovery ; and another in the femur, in which the pa-|| 
 tient had died, and in which he described the appearances found in ' 
 the bone. In the latter case a considerable dead fragment of the . ; 
 os femoris had come away in the fifteenth year of the patient, six years 
 after the commencement of the disease, followed by about 30 frag- 
 ments varying in size. This patient survived to her 25th year ; 
 
 • Thesaur. Anatom. VIII. Fig. 2, 3, 4. 
 
 f Jobi a Meek’ren Chirurgi Amsteloclamensis Observationes Medico-Chii'urgicae. 
 Amstelodami, 1682. Cap. LXIX. p. 328. Part of the humervjS. 
 
 $ Anatomic Medicate, Tome I. p. 32. 
 
 § The larger space of the Tibia taken out, and afterwards supplied by Callus. By 
 Mr David Laing, Surgeon at Jedburgh. Edin. Med. Essays, VoL I. Art. XXIII. p. 
 
 238. Edin. 1737. 
 
 II A History of the Tibia taken out and regenerated. By Mr William Johnston,^ 
 Surgeon in Dumfries. Ed. Med. Essays and Obs. Vol. V. Art. XL. p. 452. Edin. 1742. 
 
 Cornelii Trioen, Med. Doc. Observationum Medico-Chirurgicorum Fasciculus. *. 
 Lugduni Batav. 1743, 4to. p. 105. 
 
 ** Some Observations on the Spina Ventosa. By the late Claudius Amyand, Esq., 
 
 F. R. S., &c. Phil. Transactions, Vol. XLIV. Part I. for 1746. London, 1748, p. 193. 
 
 ft A Remarkable Separation of part of the Thigh Bone. By Dr Mackenzie, read 
 14th July 1760. Med. Observations and Inquiries, Vol. II. London, 1762, p. 299. 
 
 An Account of a Diseased Tibia, as a Supplement to the last article. By William ^ . 
 Hunter, M. D. Ibid. p. 303. | 
 
 §§ Tractatio de Diaphysibus ossium cylindricorum laesis exfoliatione separatis et callo 
 subnato restitutis. Ludwig Adversaria Medico Practica, Vol. III. Part I. Lipslae, 
 1772, p. 45, Art. II. 
 
 III! Chirurgical Observations and Cases. By William Biomfield, Surgeon to her Ma- 
 jesty and to St George’s Hospital, Vol. II. p. 18, and Plate I. This represents what is 
 called, “ a very remarkable carious bone from the Museum of Dr Frank Nicholls,” p. 
 
 342. It is a nekrosed os Aamcri. London, 1773. 
 
BONE. 
 
 459 
 
 and after death the shaft or diaphysis of the os femoris was found 
 very thick, rough, irregular, and with a large hole and cavity pass- 
 ing into the interior of the hone. He is the first author who speaks 
 of reproduction of the hone. 
 
 Louis appears to have first applied the epithet nekrosis ; hut Cho- 
 part and David were the first who directed the attention of surgeons 
 to the process of regeneration ; and about the same time Troja and 
 David, and afterwards Blumenhach, Koeler, Macdonald, and De- 
 sault, investigated the manner in which this is eftected. 
 
 hleanwhile Andrew Bonn, who published in 1785 an account 
 of the diseased bones contained in the museum of Hovius, gave 
 six examples of the disease, sometimes without, sometimes with 
 attempts at reproduction of bone. In the cases in which repro- 
 duction took place, the usual phenomena of great and extensive 
 deposition of bone round the site of the old bone, with much irre- 
 gularity of figure and thickness, perforations in the remains of 
 them, on the body of the new osseous matter, and fragments of 
 mortified bone, ulcerated, and showing traces of having been subjected 
 to maceration in purulent matter. His general conclusion deserves 
 attention. “By these various instances,” saysBonn, ‘‘from Plate XV. 
 to Plate XXHI. it is proved, that by a uniform law of nature, a bone 
 diseased and mortified is separated from the living bone, by a notch, 
 [cre«a,] or ulcerated depression, and by the successive growth of 
 membranous matter which is eventually converted into bone.”* 
 
 Two circumstances in the history of nekrosis merit attention ; 
 Jirst, the cause of the death of the bone ; and, second, the agent of 
 its reproduction. I have already stated inflammation of the me- 
 dullary web to be the cause of the former ; and this I conceive to 
 be proved not only by the phenomena of the disease, hut more 
 directly by the experiments of Troja, David, and Macdonald, who 
 have performed experiments of the same description. From these 
 experiments it may be inferred, that suppurative destruction or 
 death of the medullary web is necessarily followed by death of the 
 surrounding bone. 
 
 The same experiments, with the relative situation of the new bone, 
 unequivocally prove that the periosteum and its vessels are the agents 
 of reproduction. Whether by accident or spontaneously the medul- 
 lary web is destroyed, if the periosteum be uninjured, it becomes 
 thick, swollen, and highly vascular ; bony matter in the fluid form 
 
 * Andre® Bonn Descriptio Thesauri Ossium Morbosorum Hoviani. Lipsiae, 1784. 
 Tabulae, 1785, 1789. 
 
460 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 is then deposited with more or less regularity from its interior sur- 
 face ; and after this has acquired a due degree of thickness, the 
 vascularity and swelling of the periosteum gradually diminish, till 
 the membrane is restored to its natural state. When, on the con- 
 trary, the periosteum is injured or destroyed, regeneration is im- 
 perfect or altogether deficient. (M^eidmann.) In some instances 
 also, in which necrosis affects one portion only of the internal sur- 
 face of a cylindrical bone, reproduction appears not to be effected. 
 The outer part of the bone then becomes soft, and at length 
 carious, and forms apertures {foramina grandia, Troja), {cloaca, 
 Weidmann,) similar to those in new osseous cases, through which a 
 sequestrum is discharged. (Weidmann, p, 31.) 
 
 In short, the doctrine of those who have maintained that the 
 periosteum is the chief agent of reproduction, is that the old bone, 
 or that which was first diseased and then mortified, has no concern 
 in the formation of the new bone. It may be the periosteal vessels, 
 or various vessels of the soft parts in general, they argue ; but it 
 cannot be the vessels of the bone, properly so called. 
 
 This doctrine, though supported by the observations and experi- 
 ments of a number of able observers, has nevertheless been strongly 
 controverted, first by Ludwig and Palletta, and afterwards by 
 Scarpa and Richerand. 
 
 Ludwig appears to have early maintained that the new soft mass, 
 by which the loss of bone was to be supplied, grew or sprouted 
 from the sound bone ;* and Palletta, from the facts of a case which 
 he observed with great care in the year 1790, arrived at the con- 
 clusion, that the growth of the new bone proceeds not from the pe- 
 riosteum, which was in this case destroyed, but from the substance 
 of the bone itself. In the case now adverted to, nekrosis of the 
 left tibia was induced in the following manner. A man of 50 was ad- 
 mitted into the hospital, on the 24th December 1789, for an ulcer 
 of the leg, which progressively denuded the whole tibia, so that the 
 posterior sirnface of the bone only was left covered by soft parts. 
 A trihedral portion of the front of the tibia, five Paris inches 
 long, became dead, and was ejected. After this, new flesh sprung 
 from the surface thus exposed, and formed, according to the ac- 
 count, a firm bony support, such, that after the lapse of eight 
 months and a few days, the man could support his person on the 
 limb. He was gradually I'ecovering strength until September 1796, 
 when he was destroyed by an attack of rose. 
 
 ’ Adversaria Medico-Practica, Vol. III. Pars I. p. 62. Lipsise 1772. ’ 
 
BONE. 
 
 461 
 
 The recently repaired bone was of a very blood-red colour, 
 spongy, crowded everywhere by certain smooth nodes, and slightly 
 bent to the outer or fibular side. It was a white, almost cartila- 
 ginous substance, yet sufficiently strong, which Palletta thinks 
 must have become firmer in time. The periosteum was not thicker 
 than natural. It could be drawn from the recent bone, and ap- 
 peared merely laid over it. The bony matter proceeded from both 
 extremities of the tibia to mutual contact. Yet the meeting portions 
 did not coalesce, but were uni ted as it were by intermediate cartilage.* 
 
 Scarpa, who adopts this doctrine, maintains, that what is com- 
 monly regarded as new bone, is the old cortex or compact tissue 
 expanded and relaxed ; that this, by a great effort of nature, is every- 
 where enlarged and becomes spongy ; that growing inwardly it re- 
 pairs the loss of the marrow, and swelling outwardly increases the 
 walls of the bony tube ; that hence the old bone is enclosed, as it 
 were, in a sheath, which, though at first spongy, soft, and flexible, 
 becomes hard by the gradual reception of earthy particles, and at 
 length becomes entirely like the old bone. 
 
 Scarpa, in short, first assumes or maintains in the living tex- 
 tures a vital property which he calls the expanding faculty. He 
 then maintains on the strength of cases of nekrosis and various 
 experiments, that no reproduction of bone takes place except from 
 callus produced from ossific fluid, not secreted from the perios- 
 teum or the cellular tissue in the medullary membrane, but elabo- 
 rated by the intimate structure of the bone, and which is effused 
 sometimes between the ends of the broken or excised bone, some- 
 times exudes from the external surface of bones, and being: har- 
 dened in both situations, assumes the bony organic character.! 
 
 It must be admitted that the hypothesis of Troja and Weid- 
 mann labours under certain difficulties ; and in exposing these 
 difficulties and the objections to which they give rise, Scarpa has 
 been more successful than in establishing his own hypothesis, 
 which is exposed also to difficulties perhaps still more insur- 
 
 • Exercitationes Patliologicse, Auctore Joanne Baptista Palletta. Mediolani, 1820. 
 4io, p. 28. 
 
 t De Anatome et Pathologia Ossium, Auctore Antonio Scarpa. Turin, 1827, p. 
 82- 87-96. 
 
 Verum idcirco, et unicum organon elaborationis, et secretionis succi ossifici est 
 os ipsum ; neque aliunde quam ex universa ossea compage, sive laxa ea sit et reticulata, 
 sive dura et compacta, liquor ille glutinosus plasticus, fila trahens, extillat, qui cum in 
 centro fracturae, turn in marginibus, turn in extima fracti ossis superficie efFusus, cogetur 
 in exiguas rubras carunculas, dein in majora cami similia tubercula, demum in carti- 
 laginem, postremo in os commutatur et calU nomine venit, p. 104, 105. 
 
462 
 
 GENERAL AND PATHOLOGICAL ANATOMY, 
 
 mountable than those belonging to the hypothesis of Weidmann. 
 
 It is impossible here to consider all the facts adduced and the whole 
 train of the reasoning employed by the professor of Pavia. It is 
 sufficient to observe, that, independent of the violent and gratuitous 
 nature of the assumption of the expanding faculty, which he as- 
 cribes to bone, there is some inconsistency in saying, that the old 
 cortex is expanded, and becoming spongy, and advancing inwards, 
 forms medullary membrane, and swelling outwardly increases the 
 walls of the bony tube ; and that thus the old bone is inclosed 
 within a sheath. In this representation the old bone is made at 
 once to inclose and to be inclosed. 
 
 Another objection is still found in tbe following fact. In all the 
 instances in which considerable or large sequestra have come away, 
 how does it happen that these sequestra resemble so closely the 
 shafts or portions of the shafts of old bones as they do ? Except- 
 ing in the circumstance of their broken, irregular, ulcerated ex- 
 tremities, and the carious and worm-eaten appearance of the surface, 
 they present all the characters of an old or dead portion of a cy- 
 lindrical bone. It is to be observed, that from the moment the bone 
 becomes dead from whatever cause, whether external injury or in- 
 flammation of its medullary membrane, instead of being capable 
 either of undergoing this expanding process, or in any way contri- 
 buting to the formation of new bony substance, it is a lifeless, 
 inert mass, and acts as a mechanical irritant, exciting aud main- 
 taining, for the purpose of its own expulsion, an excessive suppu- 
 rative inflammation, which instead of promoting and facilitating the 
 formation of new bone, is the main cause above all others, which 
 retards, impedes, and renders impossible the necessary secretion 
 for that purpose. It is a well-established fact, that as long as the 
 old bone or any of its fragments are in the affected limb, the depo- 
 sition of new bone is so much retarded and often rendered im- *■ 
 practicable. Conversely, it is only when these sources of irritation 
 and wasting suppuration are withdrawn, that new bone begins and 
 proceeds to be regularly and steadily deposited. The irritative 
 actions are excessive, and prevent the effusion of lymph and liquid 
 callus and their consolidation. 
 
 A third argument, which may be advanced against the doctrine 
 of Scarpa, is the following. In all the cases of nekrosis with 
 reproduction, the newly formed bony mass appears to be so cer- 
 tainly the result of the operations of tissues exterior to the bone, 
 that it is impossible to understand, how the old bone can have any 
 
BONE. 
 
 463 
 
 sliare In the process of new deposition. The reproduced bone is 
 always, a large, thick, shapeless mass, sometimes imperfect, that 
 is with breaches or gaps in its bony walls, irregular on the surface, 
 and in every well authenticated case three or four times the diameter 
 of the old bone. It is in contact with, if not closely invested by 
 inflamed and thickened periosteum, all the vessels of which and 
 the surrounding tissues are engaged in conveying blood and 
 lymph to the scene of effusion and deposition. Lastly, it is in some 
 parts soft, loose, and spongy, in others firm and solid, the former 
 being the most recently formed, the latter the last deposited portions. 
 
 Scarpa appears to have adopted the idea of the formation of bone 
 in nekrosis from the phenomena of fractures, in which certainly 
 the vessels of the bony fragments are instrumental in the secretion 
 and modulation of liquid callus. It may be admitted, that in a cer- 
 tain class of cases of what may be called fragmentary or limited 
 nekrosis, taking place chiefly in compound fractures and gunshot 
 wounds, the living fragments of bone may present materials for 
 the formation of new bony matter. But this is a very different 
 process from that which takes place in nekrosis of an entire bony 
 shaft, in which the bone is already dead, in the midst of living parts, 
 and consequently cannot be supposed to be the agent of living actions. 
 
 Notwithstanding these objections, the hypothesis of Scarpa has 
 been espoused more or less strongly by various authors, anatomical 
 and surgical, who have also apparently confined their views to the 
 phenomena of bones comminuted by gunshot wounds or com- 
 pound fractures, for instance, Leveille, Richerand, Jourdan, and 
 a few others. Richerand in particular, "regards the theory of Troja 
 and David as erroneous in this respect, that It represents as a uni- 
 form law, a phenomenon which takes place in a small number 
 of cases only. By others again, as Boyer, Ribes, and Bedard, at- 
 tempts have been made to reconcile the two hypotheses. The 
 attempt seems hopeless and impracticable, unless in the circum- 
 stances already specified, in which portions of living bone are really 
 left to perform the duty assigned. In cases of extensive nekrosis 
 of a cylindrical bone, it seems a contradiction in terms to say that 
 the dead bone can reproduce a living one. 
 
 In 1836, Mr Gulliver examined various points connected with 
 this subject. He doubts the possibility of absorption of the seques- 
 trum, and for this he has probably good reason. He undertakes 
 to prove that tissues, at least bones, being dead, possess the power 
 amidst living tissues of attaching, as it were, from the blood particles 
 
464 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 similar to themselves; and in this he appears to confirm certain of 
 the views of Scarpa.* 
 
 Lastly, several observations by Dr Watson Weinyss favour the 
 inference, that the living parts of the old bone do not contribute to 
 the formation of the new one ; and that in nehrosis, the periosteum 
 is the agent of ossific reproduction.! 
 
 Regeneration is most frequent in the diaphyses oi the cylindrical 
 bones. Many cases of reproduction of the humerus^ the femur, 
 and especially the tihia^ are on record. Of the ulna three only are 
 mentioned, and of the radius only one, of the clavicle one, and of 
 the scapula one. Of the lower jaw, regeneration, either partial or 
 total, has been recorded by various observers. 
 
 The flat bones of the skull are very rarely regenerated ; and per- 
 haps it would be difficult to produce an authentic and unequivocal 
 example, unless that given by Weidmann (pi. xii.) be admitted. 
 Mr Russell, however, states that he has seen instances of apertures 
 of the cranial bones being supplied by solid matter which, to his 
 observation, possessed all the qualities of solid bone. This never- 
 theless resembles more the reproduction after fracture than that 
 after nekrosis. 
 
 The short or cuboid bones appear never to be reproduced. 
 
 3. Spina Ventosa. — Inflammation of the medullary web of the 
 epiphyses and the cuboid or short bones produces very different 
 effects ; and seems occasionally and in certain circumstances to be 
 the cause of the disease so vaguely spoken of under the name of 
 Spina Ventosa. 
 
 The history of this disease is curious, and deserves attention frorn].- 
 the erroneous notions that have at different periods prevailed on its 
 correct pathology. 
 
 The name Spina Ventosa, or flatulent, or wind thorn (DerWind- 
 dorn), was employed by the Arabian surgeons of the tenth century to 
 designate certain painful affections of the bones, which were probably 
 not always of the same kind, and which, there is strong reason to 
 believe, did not depend on the same pathological cause. By Rhazes, - 
 who is believed first to have described the disease, it is represented'' 
 to consist in swelling, erosion, and corruption of the bone, from the 
 presence of hot humours corroding and perforating its substance.J 
 Similar is the view given by Avicenna, who represents the cause of 
 
 * On Necrosis. Medico-Chirurgical Transactions, Vol. XXL p. 1. London, 1838. 
 f Edinburgh Medical and Surgical Journal, Vol. LXIII. p. 302. Edinburgh, 1845. 
 
 J Joannis Freind, M. D., Opera Omnia Medica. Londini, 173,3. Folio. Flistoria 
 Medicina?. Pars Secunda, p. 487. 
 
BONE. 
 
 4-B5 
 
 sphia mntosa to be sharp humours penetrating to the bone and cor* 
 roding it; and the approach of the disease to be indicated by pain 
 in the joints, yet the matter of the disease to be seated in the bone. 
 These ideas, which are derived entirely fi-om external symptoms, 
 were adopted by the surgeons of the 16th and 17 th centuries, with- 
 out question whether they were accordant with fact or not. Such 
 were the doctrines of Joannes de Vigo in 1513, and of Pandolphi- 
 nus a century later. 
 
 Peter de Argellata, indeed, near the close of the fifteenth cen* 
 tury, gave a more definite notion of the distemper by saying, that 
 it consisted in matter collected within the substance of a bone, 
 either from weakness of assimilative power or weakness of the 
 member, and there causing abscess, on opening which by incision 
 the whole substance of the bone is found corrupted.* 
 
 About the beginning of the 17th century, it appears to have been 
 not unusual among anatomists and surgeons to apply the term 
 spina ventosa to caries of the smaller spongy bones. Scultetus tells 
 us, that while he was at Padua, studying medicine and practising 
 surgery, he saw a young nobleman, who had been for several months 
 labouring under oedematous swelling of the left hand, which ter- 
 minated in ulcerated openings. The patient was then submitted to 
 Spigelius, at that time professor of anatomy ; and he, finding, on 
 introducing a probe, the bones bare, rough, and corrupted, imme- 
 diately said that the disease was spina ventosa. As Spigelius died 
 in 1625, in his 47th year, this must have been about 1620. 
 
 Pandolpbinus, who was a surgeon at Fermi, published in 1614 a 
 treatise on the disease, which was by Mercklin, about 60 years after, 
 thought worthy of a learned and elaborate commentary.! The 
 commentary is now more valuable than the text 
 
 Marcus Am’elius Severinus adopted (1629) partly the notions of 
 de Argellata, partly those of Pandolphinus, and modified the doc- 
 trine by views of his own. “While he teaches that spina ventosa 
 consists in abscess within the substance of the bone, he adds that it 
 takes place chiefly if not solely in children, and is mostly found in 
 the joints and ends of bones, and in bones of spongy cancellated 
 
 * Petri de Argellata Chirurgia. Venetiis, 1480. Lib. V. Tract, xxii. Cap. 2. 
 
 “ Ventositas spinse est ossis corruptio cum partis tumore ac intemperie, ab humore 
 cormmpente procedens.” Josephi Pandolphini a Monte IMartiano IMedici ac Philo- 
 sopbi Tractatus de Ventositatis Spinse saevissimo Morbo. Revisus, correctus et anno- 
 tationibus novisque turn proprii turn abenis observationibus, illustratus a D. Georgio 
 Abrahamo Mercklino jun. Med. Noribergse. Noribergse, 1674, 12mo. Cap. III. 
 
4GG 
 
 GENERAL AND PATHOLOGICAL ANATOJIY. 
 
 texture. To me he appears to have eonsidered carious and strumous 
 disease of the small joints, especially in the wrist and fingers and in 
 the tarsal and metatarsal bones, as s-pina ventosa ; and the latter he 
 maintains to be an erroneous and improper name.* He regards it 
 as produced in the manner of the cold or congestive inflammation. 
 
 The great evil of all essays and writings in those days was con- 
 founding the remote, efficient, and proximate or pathological causes 
 together, and rendering all their doctrines more or less obscure by 
 mingling ideas on the generation or formation of a disease with its 
 actual nature. This is the case not only with Fandolphinus and 
 Severinus, but with Peter de Marchettis, who has left a short essay 
 on the subject. (1665.) Amidst these notions, however, it is easy to 
 see that he regards the pathological characters of the disease as 
 consisting in denudation, roughness, and caries of the bones of the 
 wrist or metacarpus, the tarsus or metatarsus, and sometimes of 
 the ends of the radius or ulna, the tibia or fibula. (1665). He also 
 maintains that the bone is first affected, and then the periosteum.f 
 
 If any doubt could be entertained as to the locality of the dis- 
 ease assigned by de Marchettis, it would be dissipated by this cir- 
 cumstance, that he tells his reader, that after the first indications of 
 the disease is pungent, acute, lancinating pain, without swelling, the 
 matter of the disease then raises the affected joint into a swelling, 
 at first soft, loose, and indolent, of the same colour with the skin ; 
 and afterwards becoming hard ; and when the probe is introduced, 
 the bone is felt corrupted or carious. It is clear that he, like Spi- 
 selius and Severinus, describes here the inflammation of the arti- 
 ticular ends of bones taking place in strumous persons. This 
 affection, he further states, he observed mostly in persons of both 
 sexes about the 25 th year. 
 
 A doctrine similar, though in a more decided shape, was about 
 the same time taught by Paul Ammann, professor at Leipsic. Ac- 
 cording to him, spina ventosa is a corruption, abscess, or sphacelism 
 in a bone, not only round joints, but also about other parts, affect- 
 ing the substance of bones earlier than the periosteum, equally com- 
 mon in adults as in children, — arising from inflammation, some- 
 times with great pain, sometimes with dull pain, with change of co- 
 
 * De Recondita Abscessuum Natura. Lib. V. De Paedarthrocace, c. III. IV. V. 
 VI. XL, p. 103. 
 
 Petri de Marchettis Pataviiii et Observat. Medico-Chirurg. Sylloge. Amstelodarai, 
 1665, p. 195, 196, 1.97. 
 
BONE. 
 
 467 
 
 lour in the bone, sometimes with hardness, sometimes with soften- 
 ing of the bone, and always with a thin sanious discharge.* * * § 
 
 Next in this series may be placed the doctrines of Mercklin, as 
 given in his commentary on the treatise of Pandolphinus. This 
 author collects the opinions and observations of all his predecessors 
 and contemporaries ; and, though it be not easy to discover his own 
 views, yet, upon the whole, it may be said that he leans most to 
 those of Ammann. He regards the disease as arising from inflam- 
 mation in the substance of bones, which he thinks may cause either 
 abscess with caries or sphacelus ; and that this inflammation may 
 affect any portion of bones or any order of bones; and may arise either 
 from scurvy, the venereal poison, or the presence of morbid fluids.f 
 
 The nearest approach to the true pathology of this malady was 
 probably made by Freind, who placed the primary action in the 
 marrow, which becoming diseased and enlarged, separates the outer 
 lamella, and distends the periosteum with pain and swelling. J We 
 still require, nevertheless, the collateral illustration of actual cases 
 and dissections. 
 
 Cheselden observed, in 1713, that matter was liable to be formed 
 within the large medullary cavities of the cylindrical bones ; and 
 that this increasing and wanting vent, partly by corroding and 
 rendering the bone cai'ious and partly by pressure, tears asunder 
 the strongest bone in the human body ; and of this he mentions an 
 example, in which all the internal hard part of the bone containing 
 the medulla was separated from the rest, and being drawn out 
 through the plaee where the external caries made a vent, the pa- 
 tient received a perfect cure.§ This was manifestly a case of ne- 
 krosis. In his Osteographia, published in 1733, containing seve- 
 ral views of diseased bones, especially from the effects of mercury, 
 he gives, in his 49th plate, the view of a sequestrum of the os humeri 
 w'hich had been removed from the arm of a girl of 1 3 ; and in his 
 55th plate, another figure of an os humeri, both reproduced, and 
 with the sequestrum or fragment of the old bone.§ These he men- 
 tions without seeming to consider them as making examples of 
 spina ventosa. 
 
 * Pauli Ammann Diss. de Spina Ventosa. Lipsise, 1674. 4to. Cap. ii. 
 
 + Joseph! Pandolphini Tractatus, &c. Cap. v. 3, p. 198, et passim. Noriberg®, 
 1674. 
 
 J Joannis Freind, M. D., Opera Omnia Medica. Historia Medicin®. Pars Secunda, 
 p. 487. Folio. London, 1733. 
 
 § Osteographia. By tVilliam Cheselden. London, 1733. Folio. And Anatomy 
 of the Human Body, 12th edition. London, 1784. P.40. 
 
4G8 
 
 GENERAL AND PATHOLOGICAL ANATOLIY. 
 
 In 1742 and 1743, Cornelius Trioen, a physician-surgeon af 
 Leyden, published a series of medico -chirurgical cases, containing 
 also observations on spina centosa. This he distinguishes into 
 three forms ; spina ventosa, spina venenosa^ and spina mitior. After 
 stating as a general definition that spina ventosa consists in expan- 
 sion or distension of the bony substance, and a sort of separation of 
 the smooth or compact tissue of the bone and its tuhiili from the 
 substance, that is the cancellated tissue of the bone, by which the 
 hone and the incumbent soft parts are enlarged much beyond their 
 wonted diameter ; he adds, that the first is that in which the texture 
 of the bone is not penetrated with purulent matter or other fluids, 
 and that the threatened rupture of the bone is anticipated by death, 
 while the bony substance may be inflated like a large globe. Of 
 this he gives one instance in which the lower extremity of the femur 
 is certainly expanded in this fashion into a large irregularly globu- 
 lar tumour (p. 106, 108,) yet without the presence of ichor, puru- 
 lent matter, or offensive smell, and in which the patient was de- 
 stroyed by repeated hemorrhage. It must be allowed that the 
 figure given of this case resembles much that kind of disease to 
 which several surgeons in recent times have applied the name of 
 Spina ventosa. 
 
 The second form of the disease admitted by Trioen corresponds, 
 it appears to me, with caries as it shows itself in the short or irre- 
 gular bones of spongy cancellated tissue; for instance the hones of 
 the carpus and metacarpus, and the tarsus and metatarsus, and the 
 vertebrae. These he allows to be attended with swelling, small, 
 livid, deep ulcers, admitting the probe to rough, denuded, often 
 softened bones, and as occurring mostly in young persons of deli- 
 cate constitution, corresponding to the Paedarthrocace of Severinus; 
 
 (p. 111.) 
 
 The third form of the disease, which he terms spina mitior, corre- 
 sponds, if we judge from the example of it adduced, with nekrosis. 
 He describes it as affecting the middle or hard substance of bones, 
 and after inducing swelling, causing the separation of the compact 
 substance like plates, with discharge of matter, yet without fcetor. 
 Of this he gives three examples taking place in the tibia, in each; 
 of which the fragments of dead bone were separated and expelled,- 
 with recovery of the patient. (P. 115, 118.)* 
 
 It appears, therefore, that Trioen knew and described under the- 
 
 * Comelii Trioen Medicinae Doctoris Observationum Medico Chirurgicarum Fasci- 
 culus. Lugduni Batavorum, 1743. 4to. 
 
 1 
 
BOXE. 
 
 469 
 
 ssrne iiaaie of sp'ma ventosa three forms of disease of the bones ; 
 the first enlargement and expansion of the extremities of the long 
 bones, the second caries or chronic strumous inflammation of the 
 short irregular bones, and the third nekrosis, as it appears in' the 
 cylindrical bones. 
 
 In 1746, there was read to the Royal Society by the late Claudius 
 Amyand, Sergeant-Surgeon to the King, a paper containing observa- 
 tions on spina ventosa, and giving in illustration two instances of ne- 
 hrosis, one in the os humeri of a man of 22, aiiother in the same bone 
 of a man of 26. Mr Amyand begins by observing, that “ what prac- 
 titioners generally understand by the spina ventosa is a caries in the 
 bone from the extravasation of some sharp juices within it relaxing 
 the tone of the fibres, and swelling and increasing its bulk beyond 
 the natural bounds.” He farther allows that in certain cases the 
 cariosity is encrusted and covered with an exostosis, that is, with 
 bony matter ; that when the bone swells, the nutritious fluid is de- 
 posited outside, and forms callus ; that in certain cases, in the first 
 stage of the disease, purulent matter lodged within the substance or 
 cavities of the bone, causes some exfoliation or detachment of it ; 
 and that, in the last stage of the disease, the bone is perforated with 
 holes, tubulous cavities, and fistulous openings; and that it is highly 
 probable that a suppurated phlegmon in the marrow was the ori- 
 ginal cause of the spina ventosa in the two cases recorded. 
 
 From these facts it appears that Mr Amyand describes as spina 
 ventosa the disease now known by the name of nekrosis; that he 
 rightly inferred that this disease, nekrosis^ arises from inflammation 
 of the medullary membrane of cylindrical bones; that he was 
 aware that new bony matter was formed outside the old or original, 
 but diseased bone ; and that the original or diseased bone was ex- 
 foliated and detached.* 
 
 In 1751, the Treatise on the Diseases of Bones, by M. Du Ver- 
 ney, appeared. Though this surgeon noticed various cases of ne~ 
 crosis, yet he does not mention spina ventosa. The editor, however, 
 in his preface, mentions shortly that inflammation of the medulla 
 produces pain, heat, throbbing, swelling, abscess, caries of a bad 
 character, and even spina ventosa, if the cause be internal ; and 
 that the corruption of the medulla without external wound, or that 
 which is produced by an internal cause, is called spina ventosa., in 
 consequence of the corrosion and destruction of the bone attended 
 
 • Some Observations on the Spina Ventosa ; l>y the late Claudius Amyand, Esq. 
 F. R. S. Sergeant- Surgeon to his Majes^v. Phil. Trans. 1746, Vol. XLI V. p. I. p. 193 , 
 London, 1748. 
 
470 
 
 GENERAL AND PAIIIOLOGICAL ANATOMY. 
 
 with pungent pain and swelling.* * * § There is good reason to think 
 that the author has in view some of the multiplied eflfects of second- 
 ary syphilis or mercurial disease. 
 
 It appears, indeed, for a long time, to have been a common prac- 
 tice to regard as sf ina ventosa many of these affections of the bones, 
 which arise either from the operation of the syphilitic poison, or the 
 hurtful effects of mercurial medicines; and I think it certain, that 
 many of the painful affections of bones, dependent on one or other 
 of these causes, were regarded as instances of spina ventosa. Such 
 appear to have been the ideas of the first Monro, Cheselden, and, 
 at a later period, Schlichting, who states that he observed the spina 
 ventosa to be very like the venereal disease, and to corrupt the hu- 
 mours and vessels of the body.f Cheston, (1766,) who was desirous 
 chiefly to distinguish the disease from white swelling, after refer- 
 ring to Avicenna and Mercklin, concludes with them that it begins 
 originally within the bone, which is more or less enlarged. It is 
 evident, however, that he had not formed any very clear or distinct 
 idea of the nature of the maladj’. j 
 
 Warner places it (1756, 1784) in the marrow and vessels of the 
 bone,§ (p. 322); and Bromfield, we have seen, (1773) regards it 
 as abscess of the marrow, without appearing to be aware of the re- 
 lation between this and nelirosis\. (P. 20-22). 
 
 It is not wonderful, therefore, that Augustin, who published in 
 1797 a learned treatise on the subject, complains of the confused 
 ideas and contradictory views given on this disease. He had en- 
 deavoured, after studying the preparations in the museums at Ber- 
 lin, Halle, and Goettingen, to form a distinct and precise notion of 
 the disease ; and he has certainly added to our knowledge. Yet 
 it cannot be said that his distinctions are so clear and precise as 
 might have been expected. At that time it appears that several 
 teachers called every internal caries by the name of spina ventosa ; 
 others confounded it with every sort of sv/elling in bones. 
 
 Spina ventosa Augustin represents to consist in internal inflam- 
 
 * Traite des Maladies des Os. Par M. Du Verney, M. D. &c. Paris, 1751, Tom. 
 I, Preface. VII. 
 
 + Philosophical Transactions. London, 1742. No. 466. 
 
 Pathological Observations and Inquiries on Surgery from the Dissection of Mor- 
 Ijid Bodies. By Richard Browne Cheston, Sui-geon to the Gloucester Infirmary. 
 Gloucester, 1766, 4to. p. 117. 
 
 § Cases in Surgery, with Introductions, Operations, and Remarks. By Joseph 
 Warner, F. R. S., Senior Surgeon to Guy’s Hospital. London, 1760 and 1784. 
 
 II Chirurgical Observations and Cases. By William Bromfield, Surgeon to Her Ma- 
 jesty, &c. London, 1773. Vol. II. pp. 20 and 22. 
 
BONE. 
 
 471 
 
 mat! on of a bone with swelling, universal in a small bone, partial 
 in a large one, causing the greatest pain, terminating successively 
 in swelling of the soft parts, not unfrequently in fistulous ulcers, 
 and caries, by all which the aflfected bone is converted into a large, 
 irregular, and tuberous mass of hard or highly corrupted struc- 
 ture. From caries he distinguishes it by the presence of swelling 
 or enlargement, and by the absence of ulceration ; and fi’om exos- 
 tosis and hyperostosis by the parietes of the bone being separated and 
 destroyed.* * * § 
 
 Among the four figures given by Augustin to elucidate the cha- 
 racter and nature of the disorder, it appears that, with great irre- 
 gularity and spiny roughness of the bones affected, and enlarge- 
 ment, there is deposition of bone in irregular forms and masses. 
 It is in these an abnormal nutrition or misnutrition in the bony 
 texture. In one, (fig. 3,) a tibia, there is enlargement and separa- 
 tion of the walls of the bone, and irregular exostotic deposits ; and 
 in another, (fig. 4,) the lower third of the osfemoris is enlarged in- 
 to a great irregular mass, very irregular on its surface, and with 
 manifest indications of new bony depositf 
 
 These views, nevertheless, appear to have been overlooked by 
 Petit, Bordenave, Portal, and others, who, regarding it as a variety 
 of exostosis occurring in the scrofulous, and complicated with^sup- 
 puration in the substance of the bone, by a wish to simplify, have 
 rendered the subject moi’e complex. Scarpa, especially in his Com- 
 mentaries, maintains that spina ventosa differs in degree only from 
 exostosis and osteo-sarcoma.\ The opinion of Bichat is not very 
 distinct.§ That of Monteggia and Pal]etta|| is much more explicit. 
 The former represents it as commencing in the marrow, which in- 
 flames slowly, swells and wastes, or passes into a slow suppm-ation, 
 distending the parietes of the bone all round, and then bursting its 
 compact shell, giving vent to the medullary sanies, and causing the 
 inflammation and suppuration of the soft parts, at the bottom of 
 which the bone is found bare and carious, or covered with fungous 
 gi’anulations, but with one or more orifices penetrating into the 
 medullary cavity.lf 
 
 * De Spina Ventosa Ossium. Scripsit Fridericus Ludovicus Augustin, Med. et 
 Chirurgise Doctor. Halae, 1797, 4to. Accedunt leones IV. § 4, § 5, g 7, § 34. 
 
 -f- De Spina Ventosa Ossium, § 27, § 28, § 29. 
 
 J De Anatonie et Pathologia Ossium, p. 76 and 78. Ticini, 1827, 4to. 
 
 § Anatomie Generate, Tome III. p. 112. 
 
 II Exercitationes Patholog. Mediolani, 1820, p. 120. 
 
 TI Istituzione Chirurgiche, Vol. II. 64.5, p. 275. 
 
472 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 This view errs only in placing the disease in the marrow, which, 
 as an inorganic secretion, is incapable of orgasm, healthy or mor- 
 bid. The true agent of the process is the vascular medullary web, 
 especially of the epiphysis^ of such bones as the vertebrse, the car- 
 pal and tarsal bones, and the phalanges. The cancellated arrange- 
 ment of the osseous matter and of its medullary web in these bones 
 explains the progress and phenomena of the disorder. 
 
 Palletta adopts the distinctions of Trioen ; and admits, in true 
 spina ventosa, expansion of the bony walls. Spina mitior he allows 
 to be the same as nekrosis. 
 
 Though various modern surgeons have directed their attention 
 to this subject, it is still surrounded with confusion and uncertainty. 
 Some allow that the disease does not affect the epiphyses, but the 
 shafts of the bones, and admit, however, the expanding process. 
 Dupuytren, who was aware of the confusion in the application of 
 the term, has not, however, done much to remove it. From the 
 few cases which he records under this head, it appears that the dis- 
 ease affects the head of the humerus by enlargement a,nd expansion 
 of the osseous walls, and the phalanges and metacarpal bones in 
 the same manner. He admits that the disease is seated in the ca- 
 vity of the bone ; that in certain cases there is a deposit of cancer- 
 ous matter which distends the bone ; that it is an affection of the 
 medullary membrane ; and that there is secreted a new substance, 
 fungous, gelatiniform, gray, yellow, lardaceous, sometimes gypse- 
 ous and serous.* 
 
 It is clear, from the account now given, that this eminent sur- 
 geon had formed on the intimate nature of this disease no distinct 
 or precise ideas ; and he has left the subject in as great confusion 
 as when he found it. The subject is certainly unsettled from the 
 contradictory and inaccurate manner in which the term has been 
 employed. 
 
 From the facts here adduced, the following conclusions may be 
 established. 
 
 IsA It appears that the early writers on spina ventosa had no 
 distinct or precise notions on its characters and nature, and that 
 most of them, like Vigo, de Argellata, Pandolphinus, and Severinus, 
 regarded as spina ventosa, caries of the articular ends of bones, -, 
 chiefly dependent on chronic inflammation of the medullary mem- 
 brane. 
 
 ^ Lecons Orales de Clinique Chirurgicale. Tome Deuxieme, Article XII. p. 26,S — 
 275. Paris, 1839. 
 
 
BONE. 
 
 473 
 
 2d. It appears that several surgeons during the 18th century, 
 as Trioen, Amyand, and Bromfield, when the knowledge of morbid 
 processes was deriving advantage from anatomical enquiry, regarded 
 as instances of spina ventosa, cases which were examples of nekrosis. 
 
 3(7. It appears that, up to the present time, very great confusion 
 and inaccuracy prevails as to the exact import of the term spina 
 ventosa, which with one set of observers means an ordinary though 
 morbid affection of bone, and with others is employed to designate 
 a malignant or heterologous disease of bone. 
 
 And 47A. It appears, nevertheless, that all agree in considering 
 enlargement of the bone and expansion of its bony walls as a uni- 
 form result. 
 
 If we look to specimens in collections, we find that the opinions 
 of surgeons are by no means the same, and present much dis- 
 cordance. Thus we find, in one pathological museum, marked 
 as spina ventosa, a greatly enlarged end of a long bone, the bony 
 wall extruded, and a large irregular cavity formed internally. In 
 other instances, we find placed under the head of spina ventosa in- 
 stances of enlargement of the metacarpal bones and phalanges. In 
 others, again, we find bones with great enlargements, and covered 
 with numerous rough spines and spiculce, considered as spina ven- 
 tosa. In short, every disease of bone not previously referred to a 
 definite place, is accounted by different individuals spina ventosa. 
 
 From the specimens which I have examined, I think that enlarge- 
 ment of the bone and expansion of its osseous walls must be admit- 
 ted as one character. Two points, however, remain to be deter- 
 mined, which is the agent of this enlargement ; and are the new de- 
 posits analogous or heterologous ? In general I think that they 
 are analogous, that its products are those of inflammatory action of 
 a peculiar kind, or at most of misnutrition. They do not, in legiti- 
 mate Apma aen76)5(J!, appear to be scirrhous or cancerous. The fungous 
 granulations appear to be the product of the medullary web in 
 these particular circumstances. 
 
 That this is the seat of its action is to be inferred first from the phe- 
 nomena of the disease ; and secondly, from its effects, as seen in dis- 
 eased bones. Spina ventosa never occurs in a bone with distinct me- 
 dullary canal, unless at the epiphyses, where the structure is cancel- 
 lated. When it takes place in these situations, it first induces en- 
 largement of the epiphyses, with extreme pain deep in the bone. 
 Soon after the periosteum becomes thick and swelled ; and in no 
 long time sanious matter is found beneath it issuing from the can- 
 
474 
 
 GENERAL AND RATHOLOGICAL ANATOMY. 
 
 ce///, which are then softened, partially destroyed, and excavated. 
 If in this state such a bone be examined, the broken eancelli are 
 filled with a reddish, soft, spongy vascular mass, producing flabby 
 granulations passim^ and secreting bloody sanious fluid. The 
 compact shell is partly destroyed by irregular ulceration, and part- 
 ly extruded by the distending force of the swelled medullary web. 
 The diseased epiphysis then presents a large irregular anfractuous 
 cavern filled with soft spongy substance, which is either the web 
 itself, or the new products which its inflammation has generated.* 
 In this manner it is frequent in the upper end of the tibia, or the 
 lower end of the femur, or in the extremities of the radius or ulna. 
 
 With deference, therefore, to the observation and assiduity of Mr 
 Howship, I cannot agree with this author, that spina ventosa is an 
 enlargement affecting the cylindrical bones, unless with the limita- 
 tion above stated. The only cylindrical bones in which its occur- 
 rence may give colour to this opinion are the phalanges. These, 
 however, have no distinct medullary cavity, and resemble in all re- 
 spects the epiphyses and the short irregular bones in general. In 
 these the disease occurs in children and young persons. It occurs 
 also in the lower jaw, and occasionally in the vertebrae. 
 
 7. Enosf.osis. Medullary Exostosis . — To this head I do not re- 
 fer the examples quoted by Houstet from Ruysch, Cheselden, and 
 Daubenton, and which I conceive belong to necrosis. There are 
 nevertheless instances of cylindrical bones having an accretion of 
 bony or osteo-colloid matter deposited in their interior, to such an 
 extent as at once to enlarge much the dimensions of the bone, and 
 obliterate the medullary cavity. Examples of this are recorded by 
 Cheselden,t Mery,| Tripier, Houstet, § and J. Bell ; and Sir A. 
 Cooper describes the disease at length under the name exostosis of 
 the medullary membrane. According to the observation of this 
 experienced surgeon, the disease occurs in two forms, the fungous 
 and the cartilaginous. Both originate from the medullary web ; 
 both produce enlargement, expansion, softening, and separation of 
 the osseous walls ; and both ultimately terminate in ulcerative ab- 
 sorption of the affected bone. In certain circumstances, however, 
 they differ from each other. The fungous exostosis consists of lo- 
 
 * See Observations on the Morbid Appearances and Structure of Bones, &c. By 
 John Howship, Esq. Med. Chir. Tr. Vol. x. p. 176, and several fine delineations of the- 
 disease. 
 
 -h Osteographia, p. 53. 
 
 J Mem. de I’Academie des Sciences, 1706, p. 245. 
 
 § Mem. de I’Acad. Roy. Chimrgie, Tome hi. p. 130. 
 
 1 
 
 
BONE. 
 
 475 
 
 bulated masses of soft, spongy, vascular substance like fat, brain, 
 or clotted blood, which emits malignant and discharges blood- 
 coloured serum. After some time it not only distends, separates, 
 and destroys the bone, but it undergoes an alternate process of 
 sloughing and hemorrhage. Though, in compliance with the views 
 of Sir A. Cooper, I placed it under this head, it is scarcely entitled 
 to the character of enostoxis or exostosis, but is manifestly of the 
 nature of the encephaloid tumour. The cartilaginous, or genuine 
 enostosis, consists of masses of firm chondrodesmoid structure, 
 whitish-red or gray, producing by its enlargement progressive se- 
 paration and destruction of the bone, but not possessing the fun- 
 gating or malignant tendency.* 
 
 M. A. Severinus, Mery, and Mr J. Bell have described a va- 
 riety of monstrous enlargement of the bones of the hand, which I 
 think is to be viewed as belonging to the head of enostosis. Though 
 they are termed tumours of the phalanges, it is impossible to doubt, 
 from perusing the authentic description of Mery especially, that the 
 disease consisted of inordinate enlargement of the ends or articular 
 heads of the phalanges.! This enlargement was confined to the 
 ends of the metacarpal and middle row. The shell of the bones 
 was extenuated, and in some parts broken. The interior structure 
 consisted of irregular bony masses, fibrous and cellular, or caver- 
 nous, containing reddish semifluid jelly. The contiguous articula- 
 tions were ankylosed. These changes depend doubtless on mor- 
 bid action of the medullary web. Any change in the structure of 
 the bone and periosteum in such circumstances is secondary. A 
 similar case is given by Scarpa, (Tab. 6.) 
 
 h. Padartlirokahe. Osteo-arthritis. Joint-iil of Children. — This 
 name was applied by Pandolphinus, Marcus Aurelius Severinus, 
 Mercklin, and various other authors of the 17th century, to designate 
 a disease which they conceived to be the same with spina ventosa. 
 From the facts already adduced on this head, it is clear that they 
 committed a great mistake, and that they confounded two diseases 
 which are essentially different. It is evident that the disease which 
 they most frequently saw, was that in which the articular ends of 
 the bones, more especially the small bones of the extremities, be- 
 come affected with caries, in consequence of previous disease of the 
 synovial membrane, or chronic inflammation of the medullary mem- 
 
 * Surgical Essays by Sir A. Cooper. Part i. Pp. 165-173. 
 
 -|- Memoires de PAcad. des Sciences, 1720, p. 583. See also J. Bell's Principles 
 
 Surgery, Vol. iii. pp. 73 and 80. 
 
47fi 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 brane of the epiphyses. The last circumstance, nevertheless, is of 
 small moment. The main fact to be attended to is, that the arti- 
 cular ends of the small bones of the extremities are liable to be- 
 come denuded of their membranous coverings, to be rough and 
 softened on their surface, to be swelled, and discharge a bloody, 
 serous matter, and that no tendency to eject the diseased portion 
 in mass is exhibited ; while minute atoms of the bone are removed 
 by ulceration and carried away in the discharges. 
 
 This disease may originate either in the synovial membrane of 
 the articulation, and proceed thence to the subjacent cancellated 
 tissue of the bone, or, beginning in the medullary membrane of the 
 cancellated tissue, it proceeds outwards to the synovial membrane, 
 which is affected with secondary inflammation and ulceration. 
 
 This sort of disorder may affect any articulation in the whole 
 body. But those, in which it is most usually observed, are the ar- 
 ticular surfaces of the carpal and tarsal bones, the articular ends 
 of the metacarpal and metatarsal bones, and those of the phalanges 
 of the fingers and toes. A considerable number of examples of 
 the disease in the bones of the wrist, metacarpus, and fingers, I 
 have seen in young females ; and I think, that in them it is more 
 frequent than in males. 
 
 The first indication of the approach and presence of the disease 
 
 is sw'elling, generally of a puffy character, over the joint attacked .^ 
 Pain is also felt; and the surface is in general hot and red. Th^S 
 disease, however, whether originating in the medullary tissue or!™ 
 in the synovial membrane, proceeds so rapidly and insidiously, that|p 
 often the whole articular end of one bone, if not both of those of 
 the articulation, is stripped of its covering, rough, and irregular, 
 before the true nature of the malady is suspected. I 
 
 The cancelli thus attacked are softened and reddened; and the part 
 immediately affected is manifestly enlarged. In cases where opportu- 
 nities of inspecting the bones have been afforded, they are found f- 
 dcnuded of synovial membrane, cartilage, and periosteum. Their 
 exposed surface is rendered irregular by numerous holes or cavities 
 varying in size; and from which is seen issuing a reddish or brown-M 
 coloured sero-purulent matter, with which also the cancelli or lattice-^ 
 work of the bone is filled. 
 
 The whole of this destruction is occasioned most commonly b)™ 
 inflammation of the cancellated medullary membrane, in some in- 
 stances by that of the synovial membrane. Yet, notwithstanding 
 the nature of the parts affected, recoveries are occasionally observed^ 
 
BONE. 
 
 477 
 
 to take place. Adhesive inflammation comes on ; lymph is eff’used ; 
 a stop is put to the disorganizing action ; and new ossific matter 
 being formed, sometimes with the preservation of the articulation, 
 sometimes with ankylosis, partial or complete, the disease altogether 
 disappears. 
 
 The disease is liable to afiect the vertehrcB, and often does affect 
 them. There, however, it is much less likely to subside. In short, 
 as it most frequently attacks bones which have cancellated tissue, 
 as the short bones and the vertebrae, so it in them causes most ha- 
 voc, and is least likely to undergo this spontaneous cure. 
 
 This disease affects mostly and preferably young persons. It 
 begins to appear about the 6th or 7 th year ; and may take place 
 at any time between that and the 21st year. After the latter pe- 
 riod it is much less common, but may take place, especially in fe- 
 males. I have seen it, nevertheless, in some rare cases, affecting 
 the bones of the feet in men above 40 and 50. 
 
 c. The third source of disease in the osseous texture are the arti- 
 cular synovial membranes and cartilages. Inflammation of the 
 first soon passes to the second, in which it causes erosion or ulce- 
 rative absorption. From the cartilage this may proceed progres- 
 sively to the epiphyses, the upper surface of which is sooner or 
 later excavated into numerous holes or caverns of various size and 
 shape. This process, which I refer to the vessels passing from the 
 cartilage to the medullary web of the epiphyses, is accompanied 
 with deep-seated aching pain, particularly distressing during the 
 night. It is very common in that form of disease of the joints 
 which arises from inflammation of the synovial membrane and car- 
 tilages ; and several instances are recorded by authors.* It occurs 
 in the hip-joint and knee-joint especially, and is one of the preli- 
 minary steps to ankylosis. I have seen this take place in the knee- 
 joint,'and have ascertained the point by dissection. 
 
 This also is one of the modes in M'hich the vertebrae become ca- 
 rious. Chronic inflammation affects the synovial membrane and 
 cartilages of an oblique process, and passing into the bone produces 
 ulceration and carious excavatious. This process not unfrequently 
 causes in the incumbent and contiguous textures, irritative suppu- 
 ration constituting an extensive abscess, which, according to cir- 
 cumstances, may take the anterior, the posterior, or the inferior di- 
 
 * See Cheston, who delineates two examples of it, and is at some pains to distin- 
 gnish it from sj^ina ventosa. 
 
478 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 rectioii. As the original seat of the disease is generally the lower 
 dorsal or upper lumbar vertebrae, the disease is termed lumbar ab- 
 scess.* It may appear either in the lumbar region, at the margin 
 of the rectum, or in the ‘groin. Several vertebrae are found exca- 
 vated or destroyed by caries. As in the other articulations, how- 
 ever, this disease may terminate in irregular osseous union of seve- 
 ral vertebrae, forming a species of ankylosis. 
 
 The forms of disease now enumerated are chiefly varieties or ef- 
 fects of the inflammatory process. Those which yet demand atten- 
 tion, though dependent in like manner on some abnormal action of 
 the periosteal or medullary vessels, are nevertheless so peculiar, 
 that it is impossible to refer them to the same general head. 
 
 d. Cartilaginous union of the ribs and other bones. In September 
 1828 I met with a singular instance of malformation in the ribs of a 
 child, to which I have not yet heard of any example entirely similar. 
 
 In the body of a boy, two years and four months old, I was 
 struck by the shape of the anterior surface of the chest. On each 
 side, instead of the usual convex swell of the ribs, there was a re- 
 markable depression extending from the third to the seventh rib in- 
 clusive, commencing about two inches from the sternum, and ex- 
 tending in breadth along the chest from one inch and a half to two 
 inches. This depression consisted in each of these ribs presenting 
 a defect of conformation from their posterior convexity to the junc- 
 tions with the cartilages. At the former point each rib was sud 
 denly bent from its normal curvature to an angular or sharp turn, 
 as if it had been broken, and thence proceeded flat, and in some 
 sense straight, to the cartilage, its union with which was marked by 
 a depression and a large and evident knob or tuberosity not unlike 
 an articulation. The deformity thus produced was so distinct, that 
 any one would have readily pronounced it the result of a fracture. 
 But to this idea, the circumstance of its extending through so many 
 ribs, and being found with the same uniformity on both sides, form- 
 ed an objection of some weight. To obtain some light on the mat- 
 ter, I removed several of the ribs, and made of these longitudinal 
 and transverse sections. By this means the following facts were 
 ascertained. 
 
 The bony portion of the third, fourth, flfth, sixth, and seventh 
 ribs, underwent at the posterior-lateral convexity a sudden change 
 
 * Camper, Demonst. Anat. lib. ii. cap. 1. art 6. Cheston’s Pathological Inquiries 
 and Observations, Case iv. p. 128, and v. p. 1.30. Howship, Morbid Anatomy, cliap. 
 vii. p. 365. 
 
BONE. 
 
 479 
 
 of direction, so that the second or straight portion formed with the 
 first or curved a sharp turn sufficient to constitute exactly a right 
 angle. Longitudinal and transverse sections of these ribs showed 
 that no breach of continuity had taken place, and, therefore, that 
 this turn was not the result of fracture. It presented a uniform, 
 firm surface, ash-gray in colour, and traversed, as usual, by minute 
 red lines, yet without manifest trace of interrupted continuity. F rom 
 this rectangular bend the substance of the bone was of the usual 
 appearance, but looser and more cancellated as it approached the 
 sternal extremity, which was large, soft, and very sectile. It was 
 also forced inward from the cartilage, so as to form the remarkable 
 depression observed on the exterior of the chest, while the cartilage 
 itself projected in the shape of a large round tubercle or eminence. 
 Nothing like false joint was observed either at the point of curva- 
 ture or at the cartilages.* 
 
 These appearances were observed in the third, fourth, fifth, sixth, 
 and seventh ribs ; in the four last most distinctly ; in the third and 
 eighth faintly, but still sufficiently well to contribute to the general 
 aspect of deformity on the exterior of the chest. All the ribs were 
 soft and flexible, and spongy and sectile ; and I cannot convey the 
 idea of this condition more distinctly than by simply stating the 
 fact, that in removing several of the ribs and making sections, I did 
 not use the saw, but simply cut them both transversely and longi- 
 tudinally. As has been already stated, they were in all respects 
 the same on both sides of the chest. 
 
 Connected with this was a peculiarity in the bones of the skull not 
 dissimilar. Before dividing the scalp there was observed a deep lon- 
 gitudinal furrow in the situation of the sagittal suture between the 
 two parietal bones ; and another transverse one extending, though 
 less deep, on each side along the coronal suture, between the posterior 
 margin of the frontal bone and the anterior edge of the parietal 
 bones. Not only was the fontanelle incomplete for about two 
 inches ; but no attempt had been made, or was likely to be made, 
 to unite the two parietal bones with each other, and these with the 
 frontal, by the ordinary process of dove-tail ossification. The lon- 
 gitudinal furrow in the situation of the sagittal suture was so large 
 as to leave an inch at least between the parietal bones ; and along 
 this space these bones were united by firm fibro-ligamentous struc- 
 ture. The coronal suture on each side down to the temporal bone 
 
 * Edinburgh Medical and Surgical Journal, Vol. XXXII. Plate I. Edinburgh, 1829. 
 
480 
 
 GENERAL AND rATIIOLOGICAL ANATOMY. 
 
 was so much divided in like manner, that the transverse furrow 
 thus formed easily admitted the introduction of the tip of the finger ; 
 and the frontal and parietal bones were also united by firm fibre- 
 ligamentous tissue. When this was inspected attentively, it ap- 
 peared to consist of pericranium and dura mater firmly adhering, 
 and without the smallest trace of intermediate bone. This was 
 shown, in deed, by the state of the fontanelle, at which the pericranium 
 adhered so firmly to the dura mater, that it was impossible to sepa- 
 rate them otherwise than by the knife. This double membrane was 
 quite fibro-cartilaginous, and was so tensely stretched between the 
 bones, that while it was bound down in the centre to the dura mater, 
 it was raised to the margins of the bones on each side of the de- 
 pressed channel or sulcus. Much the same substance surrounded 
 the whole parietal bones, though with less separation of the lamb- 
 doidal and temporo-parietal sutures, and with more traces of ossi- 
 fication. Yet so imperfect was this process, that I removed both 
 parietal bones by strong scissors ; and without using the saw, in- 
 spected the whole brain completely. The other peculiarities will 
 be understood by a short sketch of the appearance of the right pa- 
 rietal bone. 
 
 The bone is very thin, and, in the situation of the parietal pro- 
 tuberance, translucent. The anterior or frontal margin presents 
 no serrated appearance ; but becoming quickly attenuated, termi- 
 nates in fibro-ligamentous structure, which was leaden gray colour- 
 ed, opaque, and very tough, but which has dried very hard and 
 brittle, and is translucent and traversed by red vascular lines. At 
 the upper mesial extremity of this margin, the bone, instead of pre- 
 senting the usual rectangular process, is very deficient, and termi- 
 nates in a portion of fibro-ligamentous membrane, at least eight' 
 lines broad. The inner or mesial margin, which forms the sagittalj 
 suture, which is equally void of serrated edge, is completed by the] 
 same sort of texture ; but the posterior margin, corresponding to the' 
 occipital anterior of the bone, is firmer, and presents in some partsj 
 points of ossification ; and one of these is what would afterwards have] 
 constituted a Wormian bone. The inferior margin, where it corre- 
 sponds to the temporal bone, is separated from that bone by a thin 
 portion of the same membranous substance, about two lines broad, 
 but without trace of bony matter. The bone was soft and sectile, 
 as indeed were the bones of the skull in general ; and as a proof of ‘ 
 this, the instrument has divided the scaly portion of the temporal 
 bone, and left it attached by ligamentous matter to the parietal. 
 
BONE. 
 
 481 
 
 Though the sudden rectangular turn, or change of direction had 
 at first sight the appearance of a fracture which had been after- 
 wards consolidated, yet there was no reason to think, from the his- 
 tory and circumstances of the case, that this injury was the cause 
 of the malformation. The peculiar bad configuration of these ribs 
 had existed from the moment of birth, and appeared to have at- 
 tracted little attention from the relatives. It was found, as already 
 stated, on both sides of the chest ; and it was impossible, in making 
 sections of several of the ribs, to discover any of those marks, by 
 which the existence of a previous fracture is recognized. 
 
 The state of the cranial sutures is less uncommon than that of 
 the ribs. For I believe it may be regarded as a variety of that 
 malformation which has been distinguished by some authors as 
 opening of the sutures. Portal especially, in speaking of the oc- 
 currence of this phenomena in young subjects, remarks, that though 
 rare, it is occasionally observed to the age of two or three years ; 
 but adds, that at a more advanced age it is uncommon to find the 
 sutures separated, in consequence of the operations of an internal 
 cause.* 
 
 This child had been destroyed by bronchitis. But all the other 
 internal organs were sound. 
 
 On the cause of this deficiency in the bones of the chest and head 
 it is difficult to ofier even a conjecture. It was the opinion of se- 
 veral relatives of the mother, that the peculiar misshaping of the 
 chest had been caused by tight lacing and excessive compression dur- 
 ing pregnancy. To the operation of this cause being adequate, the 
 chief objection is the fact, that it is difficult to imagine any degree 
 of compression of this kind, which would not rather have caused the 
 death of the child, f 
 
 In 1828 M. Dupuytren published in the Repertoire Generate 
 d' Anatomie, with four illustrative cases, an account of a malforma- 
 tion or deformity in the bones of the chest, not dissimilar. This he 
 represents to consist in a depression more or less considerable of 
 the bones of the chest, in proportional prominence of the sternum, 
 of the belly anteriorly, and of the vertebral column posteriorly. 
 In infants affected by this deformity, the sternum projects forward 
 like the keel of a vessel ; the spinal column rises like the back of an 
 ass ; and the ribs are not only flattened but depressed towards the 
 
 * Anatomie Medicate, Tome i. p. 96. 
 
 t Account of an Instance of Malformation in some of the Bones of the Skeleton. 
 By David Craigie, M. D. Edinburgh Medical and Surgical Journal, Vol. XXXII. p. 
 51. Edinburgh, 1829. 
 
 H h 
 
482 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 chest, nearly as if at the period, when they were soft, flexible, and 
 capable of taking all shapes and curvatures, they had been com- 
 pressed from one side to the other, as is done in killing pigeons, 
 by placing the fingers beneath the wings and compressing the sides 
 of the chest. This deformity is so considerable in some children 
 that it is possible to embrace both sides of the chest with the fingers 
 of the same hand. The transverse diameter of the chest is dimi- 
 nished from one-fourth to one-third, or even one- half, while the 
 antero-posterior and vertical diameters are in a similar rate increased. 
 
 This change in the natural figure and dimensions of the bony 
 
 walls of the chest exerts great and hurtful effects on the functions of 
 
 the contained organs. 
 
 Respiration is habitually short and oppress- 
 ed, with inexpressible anxiety and anguish, and threatening suffo- 
 cation ; the infant cannot suck ; afterwards speech is short, inter- 
 rupted, and panting. The motions of the heart are oppressed, con- 
 strained, and irregular. Sleep is disturbed, noisy, and accompanied 1 
 with great labour in breathing ; while the suflTerers lie with the] 
 mouth open. Their repose is often interrupted by frightful dreams.i 
 
 Of the anatomical state of the bones M. Dupuytren says, that] 
 M. Breschet only recognized some retardation in the development] 
 of the skeleton, disjunction of the bones of the cranium at a period] 
 at which these bones should normally liave been united, persistence] 
 of the epiphyses, or swelling of the extremities of the cylindrical] 
 bones, sundry torsions of their dinphyses, and little consistence] 
 in their tissue, so that they were sectile rather than fragile, and re- 
 sembled bones softened by immersion in weak nitric acid. Denti- 
 tion was retarded; the teeth of the first or second dentition altered] 
 the crown eroded, partly destroyed, and furrowed on their anteriorl 
 surface. 
 
 The most remarkable circumstance in the internal and soft or-' 
 gans observed by Dupuytren in this sort of deformity, is the swel- 
 ling of the tonsils, with which it is almost invariably attended. 
 These glands are often so much enlarged as seriously to impede 
 respiration, and require to be partly or wholly resected.* 
 
 The lungs are depressed towards the vertebral column ; and ge- 
 nerally bear on their surface the impression of the ribs. The 
 
 • Memoire sur la Depression Laterale des Parois de la Poitrine. Par M. le Baron 
 Dupuytren. Repertoire Generale d’Anatomie et de Physiologie, Tome Vqmeme, p. 
 110. Paris, 1828. 
 
 Leqons Orales de Clinique Chirurgicale, &c. Tome Imier. Deuxieme edition. 
 Paris, 1829. Article ix. p. 182. 
 
 I 
 
BONE. 
 
 483 
 
 children are sometimes affected with pulmonary catarrh, and em- 
 physema of the lungs. 
 
 This disease may prove fatal during the first days or weeks of 
 existence; and if it do not, it gradually wears dowm the sufferers by 
 certain steps to extreme emaciation and debility, terminating in 
 death. 
 
 Though I have mentioned these two instances of deformity of the 
 bones together, and though in several respects they strongly re- 
 semble each other, yet I am not sure that they are exactly alike. 
 It is remarkable that M. Dupuytren says nothing of any cartilagi- 
 nous union of the ribs at the point of depression, — a circumstance 
 which, if present, could scarcely have escaped the notice of M. 
 Breschet. 
 
 On the other hand, in the case detailed by myself, though the 
 child had died of a bronchitic attack, the tonsils were not larger 
 than usual. Again, I see daily young persons wdth tonsils more 
 or less enlarged, some so much that 1 know the presence and degree 
 of the enlargement by hearing them speak ; yet in these I see no 
 deformity of the walls of the thorax. 
 
 I think it, nevertheless, highly probable that both affections, 
 whether they are to be regarded as alike or different, depend on, or 
 are connected with the same general cause ; some peculiar state of 
 the osseous system, by which its ossification at the normal rate is 
 retarded. 
 
 It is necessary to say, that this congenital depression of the tho- 
 racic walls must not be confounded with a depression which also 
 takes place in infants and children, in connection with chronic pneu- 
 monia, pleurisy, empyema, tubercles, and other affections of the 
 lungs. The depression here adverted to is the effect of the great 
 and incessant efforts made to dilate and compress the lungs, in the 
 laboured actions of respiration induced by morbid states of the lungs. 
 
 5. Rickets. Rachitis . — This disease, of which no distinct trace 
 is found in the writings of the ancients, or in those of the authors 
 of the middle ages, was first described by Glisson as appearing in 
 England in the course of the 17th century. Though still frequent 
 in these islands, it is not peculiar to them ; and it is by no means 
 unknown in other countries of Europe. In the time of Petit it 
 was common in France. At present it appears to be occasional- 
 ly seen in Belgium and Holland. Notwithstanding the fact above 
 mentioned, the disease is not to be regarded as new. Its oc- 
 currence in infancy only was the cause of its escaping observa- 
 
484 
 
 GENERAL AND PATHOLOGICAL ANATOMY 
 
 tion. Its influence, however, in leaving more or less deformity of 
 the skeleton must have at all times attracted notice. Deformed 
 dwarfs have been known in all ages. The gibbi^ the vari^ and the 
 valgi of the Romans must have been more or less rachitic in infancy. 
 From this cause the deformity of Thersites might have originated. 
 It is also to be remarked, that Fabricius Hildanus delineates the 
 serpentine lateral curvature of the spine in a girl of 8, v'hose bones 
 were soft as wax,* which could be produced by no other cause save 
 rickety softness. 
 
 When the disease first attracted notice, and the chemical con- 
 stitution of bone was understood, it was believed that rickets con- 
 sisted merely in the late deposition of phosphate of lime. Of this 
 theory the defect is its simplicity. Though the earthy matter is 
 doubtless very deficient, this is not the sole change in the rachitic 
 skeleton. The bone is light, spongy, and cellular. The close or 
 compact structure is said to disappear. The truth is, that it is not 
 yet formed. The interior of the bone is homogeneous like that of 
 a foetal bone, without distinct medullary cavity, without cancellated 
 structure, and without compact bone ; but presenting the loose 
 cellular or areolar arrangement observed at that period of life. 
 The interstitial cells are filled with brownish jelly-like substance,! 
 which appears to be a secretion from the medullary arteries. The 
 bone is soft, of the consistence of cartilage, and is easily cut by the 
 knife. Its colour is some shade of red, but varies from light pink 
 or brown to an orange or fawn-coloured tint. This it derives from 
 its vessels, which are numerous, large, and loaded with dark-co- 
 loured blood deficient in fibrin. The periosteum is generally 
 thickened, and occasionally detached. (Cheselden, Bichat, Bonn.) 
 In short, the rachitic bone is the foetal bone in internal structure, 
 but destitute of its proportion of calcareous matter. 
 
 One of the peculiarities of the rachitic condition of the osseous 
 system is, that though the bones present the characters now enu- 
 merated during its continuance, they afterwards acquire equal or 
 even greater firmness and density than sound bones, by the depo- 
 sition of calcareous matter. While this takes place, the distinction 
 between the cancellated and compact structure begins to be esta- 
 blished, and the formation of medullary canal is also begun. 
 
 * Cent. 6, Obs. 76. , 
 
 + Morel in Jour, de Med. Paris, 1767, V'ol. VII. p. 432 ; Portal sur ia Nature du 
 Racliitisme, 2de Partie, Art. iii. p. 246 ; Tacconi in Comm. Bonon ; and Stanley in 
 Med, Chir. Tr. Vol. VII. p. 407. 
 
 I 
 
BONE. 
 
 485 
 
 When this process once commences, it proceeds much as in healthy 
 bone. In one respect, however, its completion is peculiar. Instead 
 of the compact matter of the bone being equally distributed on each 
 side of the medullary canal, as in sound bones, it is more abundant 
 at the internal than the external side of the incurvated bone. Thus 
 if the femur, as generally happens, is incurvated outwards, the 
 greatest deposition of compact bone is at the internal wall. This 
 deposition may be so considerable in bones which are much bent, 
 as to obliterate entirely the medullary canal.* The restored ra- 
 chitic bone is said to contain more earthy matter than healthy bone. 
 
 6. Mollities Ossium ; — Malakosteon ; — Osteo-malacia ; — Osteo- 
 sarcosis . — To the ancients this peculiar state of the osseous system 
 appears to have been as little known as rickets. Omitting the un- 
 certain traces of its existence, which are found in the writings of 
 Ebn-Sina, and several of his European commentators, the first dis- 
 tinct record of the malady was given in 1665 by Bauda, who, in 
 1650, observed for ten years the progress of the disease in the case 
 of a citizen of Sedan and in 1688 by Gabriel, who found 
 all the long bones of a lady soft, flexible, and converted into a 
 reddish flesh-like substance, void of fibres.| Still more distinct 
 cases were published by Saviard in 1691,§ and by Courtial and 
 Lambert in 1700.|| About the same time Valsalva met with an 
 instance, which, however, was published only in 1760 by Morgagni, IT 
 Previous to this, however, had been published a case by Mr S. Be- 
 van in 1742 ;** that of the woman Supiot, the details of whose his- 
 tory were given in France by M. Morand, and in England by Mr 
 Bromfield ;|t the case of Mary Hayes by Pringle and Gooch ;:ft 
 
 ’ Observations on the condition of the Bones in Rickets, &c. By Edward Stanley, 
 Esq. &c. Med. Chirurg. Tr. Vol. VII. p. 404. 
 
 Traite des Maladies des Os. Par M. Du Verney. Paris, 1751. Tome I. Pre- 
 face V. p. 136. 
 
 J Eph. Nat. Cur. Dec. 3, An. 2, Ohs. 3. This is the case noticed by Gagliardi the 
 followng year, 1689, which Scarpa also mentions as the first. The Professor of Pavia 
 seems not to be aware that the case did not belong originally to Gagliardi but to Ga- 
 briel. The earliest case, however, appears to have been that of Peter Siga of Sedan. 
 
 § Nouveau Recueil, Ac. Obs. 62, p. 274. 1702. 
 
 II Histoire dePAcad. R. des Sciences, 1700, Obs. 2. et Relation de la Maladie de 
 Bernarde d’Armagnac, &c. This young woman, a native of Thoulouse, died in the 
 Hospital of St Jacques de la Grave on the 19th November 1699. 
 
 H Epist. Iviii. 4. ** Phil. Tr. Vol. xlii. p. 488. 
 
 ft Histoire de la Maladie Singuhere, Ac. Par M. IMorand Fils, 1752. hlem. de 
 I’Acad. 1753. The particulars of this case are published also in the Philos. Transact, 
 for 1753-1754, Vol. xlviii. where she is called Queriot, and in Bromfield's Chirurgical 
 Observations and Cases, Vol. ii. 
 
 Phil. Tr. 1753, Vol. xlviii. p. 297. 
 
486 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 and that of E. Winckler by Ludwig,* Since that time cases have 
 been published by Mr IL Thomsonf, Acrel4 Renard,§ and How- 
 ship-ll 
 
 From these and similar cases it results, that In this disease 
 the bones gradually lose their firmness and consistence, become 
 soft, flexible, and may even be broken. The change is remarked 
 first in the cylindrical bones, and though it extends to the others, 
 it there continues to be most conspicuous. It consists in the bone 
 becoming soft, sectlle, reddish, and something like a mass of flesh. 
 When any part remains unchanged, it is in the shape of thin scales 
 or crusts at the outer part of the diaphysis^ or occasional bony 
 plates like portions of egg-shell intermixed. The cancellated struc- 
 ture of the epiphysis entirely disappears, and in its place is found 
 a soft homogeneous reddish mass. The situation of the marrow is 
 occupied by a red, thick, semifluid matter like clotted blood, mixed 
 with grease or suet. The flat bones of the skull are generally 
 equally soft, flesh-like, and sectile. The cancellated structure of 
 the diploe is equally destroyed, and its place is occupied by a uni- 
 form soft reddish substance, from sections of which bloody serum 
 exudes. The periosteum is sometimes thickened, but is often un- 
 changed. 
 
 The cause of this change is quite unknown. The most ingeni- 
 ous and probable conjecture regarding it is that by Howship, who, 
 from the necroscopic appearances of a well-described case, infers 
 that it is the effect of a morbid action of the capillary arteries upon 
 the medullary membrane within the bone ; and that the disappear- 
 ance of the latter is the effect of absorption exercised by the morbid 
 secretion.^ 
 
 7. Friability. Fragility. In the disease now described the bones 
 may be broken by the weight of the person, or slight action of the 
 muscles ; and perhaps most cases of spontaneous fracture are re- 
 ferable either to incipient osteo-sarkosis, to nekrosis, or to spina oen^ 
 tosa. One instance of this I certainly traced to incipient nekrosis. 
 Others, perhaps, are more equivocal. Is the animal matter ab- 
 sorbed ? 
 
 8. Interstitial absorption. — Under this name Mr B. BellJun. de- 
 
 * Haller Disp. Med.-Pract. Tom. vi. p. 327, Lips. 1757. 
 
 t Med. Obs. and Inquiries, Vol- v. p. 259, 
 
 4; Dissertatio, &c. Upsalse, 1788. 
 
 § Ramollissement Remarkable, &c. Mayence, 1804. 
 
 II Medico-Chir. Tr. Ed. VoL ii. p. 136. 
 
 ^ Case of MIollities ossium, &c. Med.-Chirurg. Tr. Edin. Vol. ii. p. 13.6, 
 
BONE. 
 
 487 
 
 scribes a peculiar sinking or condensation of the cancellated texture 
 of the neck of the thigh-bone, occurring chiefly in aged subjects.* 
 The aflfected part of the bone is highly vascular. In the only in- 
 stance of this in my possession, the head of the bone has lost its 
 spherical shape, and is flattened down upon the neck not unlike the 
 pileus of a mushroom. The most internal part of its cartilaginous 
 covering presents a series of holes passing into the cancelli. The 
 neck is about one-third of its usual length, so that the head of the 
 bone is lower than the great trochanter. This change must have 
 been eflPected by the medullary vessels of the head and neck of the 
 bone. 
 
 9. Angiectasis . — The arterial system of bones is liable to a pe- 
 culiar abnormal development, in which they become much enlarged, 
 and forming a cyst in the substance of the bone, gradually eflfect 
 its absorption. Cases of this description I have already stated were 
 observed by Pearson and Scarpa. Similar cases have occurred to 
 M. Lallemand and M. Breschetf 
 
 10. Eburneoid, or Ivory-like Induration. — This, which consists in 
 bone acquiring extraordinary hardness, density, and closeness, is 
 occasionally seen in bony tumours, or exostosis, in bones which 
 have been fractured, and sometimes in those of the skull, without 
 evident morbid condition. In the case of Petit, however, an osse- 
 ous tumour as large as a melon, and of the ivory aspect and con- 
 sistence, was developed in the temporal bone.J 
 
 A species of eburneoid or porcelain degeneration is liable to 
 attack the articular extremities of bones after synovial rheumatism. 
 An efihsion of sero-albuminous fluid first takes place ; and when 
 this undergoes coagulation, it is found to contain some earthy mat- 
 ter, which some have said is lithate of soda, and others cai’bonate 
 of lime. After some time, by the motion of the articular surfaces, 
 this deposit undergoes a degree of polish ; and the more the articu- 
 lar surfaces are moved, the smoothness increases, communicating 
 the aspect of ground-ivory, or porcelain. In some instances, also, 
 the cartilages are worn or removed by absorption, as the effect of 
 the same disease ; and their place is in some degree supplied by 
 this eburneoid or porcelain-like deposit. The subject shall be no- 
 ticed under the head of the synovial membranes. 
 
 * Essay on Interstitial Absorption of the thigh-bone, Ed. 1824. 
 
 + Repertoire Gen. de Breschet, T. ii. part 2d. Paris, 1826. 
 
 i Maladies des Os, Tome ii. p. 292. 
 
488 
 
 GENERAL AND PATHOLOGICAL ANAT03IY. 
 
 11. Osteo-sarhoma. — Though this is mentioned as a distinct va- 
 riety of morbid change, it is probably of the same nature as exos- 
 tosis. In this light it is viewed by Scarpa and Boyer. Upon the 
 whole, though I cannot agree with the former in accounting it of 
 the same nature as s-pina ventosa^ I think the examples of osteo-sar- 
 koma may be referred to the cartilaginous variety either of perios- 
 teal or medullary exostosis. 
 
 12. Encysted Tumours, a. Osteo-steatoma. — The formation of 
 steatomatous tumours in the substance or at the surface of bones, 
 has been noticed by Kulm,* Hundtermark,f Herrmann,:}; Pott,§ 
 Murray,!! Sandifort,1f Beil,** Von Siebold,tf and above all, by 
 Palletta|| and Weidmann.§§ The tumour is generally encysted; 
 and though it is represented by J. Bell as originating in the medul- 
 lary tissue, it seems occasionally to arise from the periosteum. Its 
 contents are not invariably, as its name seems to indicate, of an adi- 
 pose nature. They vary from gelatinous, oleaginous, and melice- 
 ritious, to atheromatous and sebaceous, irregularly intermixed with 
 spiculcR and lamella of bone. Their progressive enlargement causes 
 by pressure and absorption destruction of the contiguous bone. 
 This is the process which by Palletta is termed ossivorous. 
 
 b. Hcematoma ; (Blood-cyst.) — Of all the examples of this dis- 
 ease (abscessus sanguineus,) collected by Palletta, one only I find 
 originated in the substance of a bone, — the tibia in its upper epi- 
 physis, which was consumed by carious absorption. (Case 22.) In 
 several, however, the tumour, though originating in the adjoining 
 tissues, had produced by progressive encroachment the same effect. 
 
 c. Fungus Hamatodes. — This is the same as the fungous me- 
 dullary exostosis above noticed. Whether it originates in this 
 manner, or from the contiguous textures, it produces the same ero- 
 sive destruction of the bones. An instance of this originating in 
 the peritonaeum I saw destroy the bones of the pelvis, and reduce 
 the upper half of the right osfemoris to a thin net-work of bone, 
 which broke asunder a few days before death. 
 
 13. Scirrho- Carcinoma . — Though this seems never to originate 
 
 * Haller, Disp. Mecl.-Chir. Vol. V. p. 653. 
 t Haller, Disput. Med.-Pract. Tome VI. p. 349. 
 
 5 Diss. Inaug. J. G. Herrmanni de Osteo-steatomate, Lipsiae, 1767. 
 
 § Phil. Trans. No. 459. || Dissert, de Osteo-steatomate, Upsalae, 1780. 
 
 ^ Mus. Anat. I. 161. ** Archiv. III. B. 453. 
 
 tt Sammlung Chirurg. Beobacht. u. s. w. II. B. p. 310 and 412. 
 
 Exercitat. Patholog. p. 111. §§ De Steatomatibus, Mogimtiae, 1817. 
 
BONE. 
 
 489 
 
 in the osseous texture, it often spreads to it from the contiguous 
 one. Thus most surgeons have seen cancer of the lip or scirrhus 
 of the parotid affect the lower jaw ; cancer of the female breast 
 erode the ribs ; cancer of the penis affect the ossa pubis ;Xand can- 
 cer of the eye or eyelids, in both sexes, affect the frontal, malar, 
 or superior maxillary bones. 
 
 14. Tubercular destruction may occur in bones ; but it most 
 frequently originates in the periosteum or adjoining tissues, and 
 passes thence to the enclosed bone, in which it produces the usual 
 destructive erosion. (Palletta.) 
 
 15. Hydatids of the social form were seen in the tibia by Cul- 
 lerier.* 
 
 16. In early life the growth of the osseous system may be sus- 
 pended or interrupted, so that the parts of the skeleton are incom- 
 plete. This deficiency generally takes place on the mesial plane, 
 at the line where the bones of each side are approaching to unite 
 with each other. It is most common in the spinous processes of the 
 vertebrae, in the bones of the head, and those of the upper jaw and 
 palate. In the spine it is generally connected with the abnormal 
 effusion of fluid from the membranes of the chord, or the chord it- 
 self, when it constitutes spina bifida or cleft spine. The same de- 
 ficiency I have seen in the frontal and nasal bones ; and in hare-lip 
 it is by no means uncommon in those of the palate and superior 
 jaw. 
 
 17. Before concluding this chapter, a few words may be said on 
 the morbid states incident to the teeth. 
 
 The enamel is liable to be worn down by the mutual attrition of 
 the teeth of the upper and lower jaw. This detrition, which has 
 been particularly described by Procbaska,f is most conspicuous in 
 the crowns of those of the lower jaw, which in some subjects are so 
 much worn down as to expose the central osseous pith of the tooth. 
 Though effected chiefly by attrition, it is much facilitated by the 
 use of acid substances, and by those states of the stomach and ali- 
 mentary canal which favour the formation of acid. Another form 
 of the same destruction may take place in the corresponding sides 
 of two teeth which are too closely implanted together. The mu- 
 tual pressure exercised during the process of mastication appears to 
 be the first cause of this. After it is once established, it destroys 
 
 * Cruveilhier, Anat. Pathol. Vol. I. p. 230. 
 
 t Observationes Anatomicae de Decremento Dentiimi Corporis Humani. Apud 
 Oper.uTi Minorum. Paitem Ildam, p. 355, &c. Viennae, 1800. 
 
490 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 first the enamel, and then the bone of the tooth, causing caries in 
 the latter, which become blue or black, and is gradually excavated 
 into a hole. 
 
 The most frequent cause of disease of the teeth, however, is in- 
 flammation of their internal pulp. This, which is attended by in- 
 tense pain, by progressively destroying the membrane, impairs the 
 nutrition of the tooth, which becomes carious in the bony pith, 
 while the enamel cracks, and is cast off in the form of concave 
 scales or crusts. The bony part thus exposed proceeds still more 
 rapidly to destruction. It becomes excavated, breaks down, and at 
 length is expelled in fragments. 
 
 Inflammation of the membrane of the alveolar cavities also, by 
 injuring the connecting vessels, may cause carious destruction of 
 the teeth. But it is generally combined with more or less affection 
 of the pulp. In the rachitic its destruction causes the develop- 
 ment of the teeth to be checked, rendering the individual toothless. 
 
 CHAPTER V. 
 
 GRISTLE, CARTILAGE, Cartilago^ — Tissu Cartilagineux. 
 
 Section I. 
 
 The cartilaginous system or tissue is found at least in three dif- 
 ferent situations of the human body ; 1st, on the articular extremi- 
 ties of the movable bones ; 2d, in the connecting surfaces or mar- 
 gins of immovable bones ; 3d, in the parietes of certain cavities, 
 the motions or uses of which require bodies of this elastic substance. 
 
 The organization of gristle is obscure and indistinct. On exa- 
 mination by the microscope, its structure is said to be uniform and 
 homogeneous, like firm jelly, without fibres, plates, or cells. Wil- 
 liam Hunter, however, represents the articular cartilages as con- 
 sisting of longitudinal and transverse fibres.* Herissant represents 
 those of the ribs as composed of "minute fibres mutually aggregat- 
 ed into bundles connected by short slips, and twisted in a spiral 
 or serpentine direction.! By Lassone, the articular cartilages are 
 
 * Phil. Transact. Vol. XLIII. No. 470. 
 
 + Mem. de I’Acad. Roy. 1748. P. 355. 
 
GRISTLE. 
 
 491 
 
 said to consist of a multitude of minute threads mutually connected 
 and placed as right angles to the plane of the bone, but so as to ra- 
 diate from the centre to the circumference.* The general fact of 
 fibrous structure is confirmed by Bichat, who says, that with a little 
 attention it is possible to recognize longitudinal fibres, which are 
 intersected by others in an oblique or transverse direction, but 
 without determinate order. In its purest form no blood-vessels are 
 seen in it, nor can they be demonstrated even by the finest injec- 
 tions. In the margins of those pieces of gristle, however, which are 
 attached to the extremities of growing bones, blood-vessels of con- 
 siderable size may often be seen, even without the aid of injec- 
 tion. In young subjects a net-work of arteries and veins, which 
 is described by Hunter under the name of circulus articuli vascu- 
 losus, may he demonstrated all round the margin of the cartilage 
 at the line between the epiphysis and it. They terminate so ab- 
 ruptly, however, that they cannot be traced into the substance of 
 the latter. The most certain proofs, however, of the organic 
 structure of this substance are the serous exudation which appears 
 in the course of a few seconds on the cut surface of a piece of 
 cartilage after a clean division by the knife ; and that it becomes 
 yellow during jaundice, and derives colour from substances found 
 in the blood. Neither absorbents nor nerves have been found 
 in it. The cellular texture said by Bichat to form the mould for 
 the proper cartilaginous matter appears to be imaginary. 
 
 The articular cartilages adhere to the epiphyses by one surface, 
 whicli consists of short perpendicular fibres placed parallel to each 
 other, and forming a structure like the pile of velvet. This is 
 easily demonstrated by maceration first in nitric acid and then in 
 water. The free or smooth surface is covered by a thin fold of sy- 
 novial membrane, which comes off in pieces during maceration. 
 The existence of this, though recently denied by Gordon, was ad- 
 mitted by William Hunter, and may be demonstrated either by 
 boiling, maceration, or the phenomena of inflammation, under 
 which it is sensibly thickened. All other cartilages are enveloped, 
 unless where they are attached to bones, by a fibrous membrane, 
 which has been therefore named perichondrium. The existence of 
 this may be demonstrated by dissection, and also by boiling, which 
 makes it peel off in crisped flakes. 
 
 The chemical properties of cartilage have not been accurately 
 
 * Mem, de I’Acad. Roy. 1752. P. 255. 
 
492 
 
 GENEEAL AND PATHOLOGICAL ANATOJIY. 
 
 examined. Boiling shows that it contains gelatine ; but as a good 
 deal of the matter is undissolved, it must be concluded also that it 
 is under some modification, or united with some other principle, 
 perhaps albumen. Immersion in nitric acid or boiling fluids in- 
 duces crispation ; and it dries hard and semitransparent, like horn. 
 
 Section II. 
 
 Cartilage is subject to inflammation, which in the chronic form 
 passes into ulceration or erosion, — an affection common in the ar- 
 ticular cartilages of the thigh-bone and tibia. 
 
 In this state cartilage becomes reddish or vascular, and flaccid, 
 or soft and spongy, with a lardaceous appearance and distinct fibrous 
 arrangement. It swells and acquires a size double or even four 
 times larger than natural. In this state it does not become yellow, 
 nor is dissolved by boiling. This is most common in the hip-joint. 
 (Bichat.) 
 
 When inflammation continues some time, it produces erosion. 
 The first trace of this consists in minute reddish perforations ap- 
 pearing at the synovial surface of the cartilage, and gradually ex- 
 tending and becoming deeper. At first they are circular ; but as 
 these perforations by extension coalesce, irregular abraded patches 
 are produced, which at length become so deep as to expose the de- 
 nuded bone. When this takes place, as the process advances, ir- 
 regular excavations are hollowed in the epiphyses, which then pre- 
 sent the state described at p. 477. This form of caries, which re- 
 sembles in some respects spina ventosa, is, I conceive, the one to 
 which Severinus alludes, and to which he wishes to restrict the 
 epithet of paedarihrokake. I have seen it in adults, however ; and 
 it is most frequent in the knee-joint, in which I have seen it re- 
 move every trace of cartilage. In this process Hunter represents 
 the transverse fibres as giving v'ay first ; but this distinction is too 
 refined. The disease may terminate in bony ankylosis. It occurs 
 also in the hip-joint and in the elbow-joint. 
 
 In the cartilages of the larynx inflammation takes place either 
 primarily or by extension from the perichondrium or the mucous 
 membrane of the throat. When it takes place primarily, it is re- 
 presented by Mr Porter as preceded by ossification. When it takes 
 place secondarily, it may occasionally be traced to ordinary inflam- 
 mation from exposure to cold, the poison of syphilis, or the unfa- 
 vourable operation of mercury. In either case it produces a bad 
 
GKISTLE. 
 
 493 
 
 species of ulceration, with mortification of the cartilages, which are 
 soraetiuies coughed up as dead sloughs. This constitutes one of 
 the worst forms of laryngeal consumption, {phthisis laryngea.*') 
 
 In strumous subjects the cartilages of the nose are subject to a 
 species of enlargement or thickening, accompanied with increased 
 vascularity, and terminating in unfavourable ulceration. In some 
 instances, tyromatous deposition in the tubercular form takes place, 
 and renders the nostrils tumid, irregularly knobbed and painful. 
 This, which also tends to very bad ulceration, is one of the forms 
 of the disease described under the general name of Noli me tangere. 
 That it originates in the cartilages I have observed more than once; 
 and its ravages are seldom stopped till they are completely destroy- 
 ed, leaving much deformity. 
 
 It has been supposed that cartilage does not readily granulate. 
 But this must be a mistake, unless in regard to the laryngeal and 
 tracheal cartilages ; for when bones are removed from articular ca- 
 vities, granulations have been known to rise from the cartilagi- 
 nous surface ; and there is no doubt that wounds of cartilaginous 
 tissue are fi'equeutly united by granulation. All that fact and ob- 
 servation permit to be said is, that often they do not readily gra- 
 nulate. 
 
 Cartilage is also liable to ossification, as is seen in those of the 
 larynx and of the ribs. In these the osseous matter is disseminated 
 in irregular points and patches. In diseases of the hip-joint, the 
 cartilages of the thigh-bone and acetabulum become not only bony, 
 but may be converted into a substance similar to ivory. (Bichat.) 
 
 When textures, originally cartilaginous, have thus become pe- 
 netrated by bony or calcareous matter, they manifestly lose part 
 of their vital properties. They are much less capable than for- 
 merly of resisting the approaches of disease. They are more liable 
 to inflammation. And they are prone to become affected by mor- 
 tification or nekrosis exactly as bone ; and in this condition they 
 cause as much irritative suppuration as dead bone. This disorder 
 is observed principally on the cartilages of the larynx. 
 
 A new formation of cartilage is frequently found in various tis- 
 sues, hut especially in the serous and synovial membranes, to which 
 it is not uncommon to find cartilaginous bodies attached. Cartila- 
 ginous texture is also found in those sarcomatous tumours which 
 eventually pass into insanable ulceration. 
 
 • Observations on the Surgical Pathology of the Larynx and Trachea, &c. By W. 
 H. Porter, A. M., &c. Dublin and London, 1826. 
 
494 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 CHAPTER VI. 
 
 FiBRO-CARTiLAGE, — Cartilago Fibrosa^ — Tissue Fibro-Cartila- 
 gineux ^ — Chondro-Desmoid Texture. 
 
 Section I. 
 
 Intermediate between the cartilaginous and the fibrous tissues, 
 Bichat ranks that of the fibro-cartilages, which comprehends three 
 subdivisions. 1st, The membranous fibro-cartilages, as those of 
 the ears, nose, windpipe, eyelids, &c. ; 2d, The inter-articular fibro- 
 cartilages, as those found in the temporo-maxillary and femoro- 
 tibial articulations, the intervertebral substances, and the cartila- 
 ginous bodies uniting the bones of the pelvis ; 3c?, Certain portions 
 of the periosteum, in which, when a tendinous sheath is formed, the 
 peculiar nature of the fibrous system disappears, and is succeeded 
 by a substance belonging to the order of fibro-cartilages. 
 
 Bedard follows Meckel in rejecting the first of these subdivisions, 
 the individuals of which are quite similar to ordinary cartilage. 
 Like it, they do not present the distinct fibrous structure, but are 
 covered by perichondrium, the fibres of which have evidently 
 caused them to be regarded as fibro-cartilages. On tins principle 
 Bedard gives tbe following view of the fibro-cartilages. 
 
 Is?, Fibro-cartilages free at both surfaces; those in the form of 
 menisci, which are placed between the articular surfaces of two 
 bones; {Jibro cartilagines inter-articulares.) These are seen in the 
 temporo-maxillary, sterno-clavicular,and femoro-tibial articulations, 
 and occasionally in the acromio-clavicular and the ulno-carpal 
 joints. These ligaments are attached either by their margins or 
 their extremities, and are enveloped in a thin fold of synovial mem- 
 brane. 2c?, Fibro-cartilages attached by one surface. Of this de- 
 scription are those employed as pulleys or grooves for the easy 
 motion of tendons ; for instance the chondro-desraoid eminences 
 attached to the margin of the glenoid cavity for the long head of 
 the biceps, and at the sinuosity of the ischium for the tendons of the 
 obturatores. 3d, Fibro-cartilages, which establish a connection be- 
 tween bones susceptible of little individual motion, as the interver- 
 tebral bodies ; or which unite bones intended to remain fixed, unless 
 
FIBRO-CARTILAGE. 
 
 495 
 
 under very peculiar circumstances, as those which form the junction 
 of the pelvic bones. (Symphysis puhis^ sacro-iliaa synchondrosis.') 
 
 The peculiarities of these substances consist in their partaking 
 in different proportions of the nature of cartilage and white fibrous 
 tissue, and, consequently, in possessing the toughness and resist- 
 ance of the latter with the flexibility and elasticity of the former. 
 The structure of the fibro-cartilaginous tissue is easily seen in the 
 intervertebral bodies, or in the cartilages uniting the pelvic bones. 
 In the former, white concentric layers, consisting of circular fibres 
 placed in juxta-position, constitute the outer part ; while the inte- 
 rior contains a semifluid jelly. The concentric fibrous layers are 
 cartilage in a fibrous shape. In the latter situation, the fibrous 
 structure is equally distinct ; while the cartilaginous consistence 
 shows the connection with that organic substance. A similar ar- 
 rangement is remarked in the interarticular cartilage of the temporo- 
 maxillary articulation, and in the semilunar cartilages of the knee- 
 joint. In all, the fibrous is said to predominate over the cartila- 
 ginous structure. Their physical properties are distensibility with 
 elasticity. Though they are at all times subjected to considerable 
 pressure, they speedily recover their former size. Their chemical 
 composition appears to be entirely unknown. 
 
 Section II. 
 
 There is little doubt that the fibro-cartilages are liable to inflam- 
 mation, either originally commencing in their own substance, or 
 communicated to them from contiguous parts, especially synovial 
 membrane, with which many of them are invested. Suppuration 
 of that which forms the symphysis pubis was seen by a friend of 
 Hunter,* and by Ludovici, in the person of a puerperal female. 
 This was the effect of excessive stretching during labour. In other 
 instances they are torn asunder, so as to cause diastasis without 
 suppuration. In one instance, separation of this kind appears to 
 have been congenital. Palletta and Brodie have described a va- 
 riety of vertebral disease which always commences with, and some- 
 times consists in erosion of the intervertebral cartilages ; and most 
 surgeons have seen the semilunar cartilages of the knee-joint in- 
 flamed and eroded. The intervertebral fibro-cartilages have been 
 found softened, swollen, and distended with fluid. Ossification is 
 not uncommon, and in those of the sacro-iliac and pubal junctions 
 * Med. Obs. and Inquiries, VoL IL 
 
496 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 {symphyses), is remarked in adults, or those advanced in life so 
 frequently, that it cannot be regarded as disease. In the vertebrae 
 it is also observed, though less frequently. It has been seen most 
 generally in the dorsal and lumbar vertebrae, which are thirs indis- 
 solubly ankylosed. 
 
 The accidental, or new development of the chon dro- desmoid 
 tissue, is not uncommon ; and its appearance constitutes the ana- 
 tomical character of the most usual form of scirrho-carcinoma. In 
 this state irregular or amorphous masses of fibro-cartilage are de- 
 veloped in isolated points of the organs ; and by their coalescence 
 progressively invade or destroy the original texture of the part. 
 In some instances, a mass of cartilage is traversed irregularly by 
 intersecting white or yellow fibrous bands. In others, irregular 
 nodules of cartilage are separated by ligamentous partitions. This 
 deposition, which ever manifests a tendency to fatal disorganization, 
 is most frequent in the female breast, in the womb, in the lacrymal 
 and parotid glands, and in the intestinal canal of both sexes. In 
 its progress to ulceration, cavities are formed containing brownish 
 jelly-like fluid ; and as it approaches the surface, fungous growths 
 and hemorrhage are frequent. 
 
BOOK IV. 
 
 MEMBRANOUS, ENCLOSING, OR INVESTING 
 TISSUES. 
 
 The organic substances, which have been already described, 
 consist either of those which are ramified or distributed extensively 
 through the animal body, or of those which are confined to definite 
 situations. Those which are now to be examined, are extended 
 continuously over considerable spaces, and tissues or organs very 
 different sometimes from each other. They are envelopes or mem - 
 branes^ and consist of skin, mucous membrane, serous membrane, 
 synovial membrane, and compound membrane. 
 
 CHAPTER I. 
 
 Section I, 
 
 SKIN, Cutis, Pellis, CUTANEOUS TISSUE. DERMAL TISSUE. La 
 
 Peau, Tissu Dermoide . — die haut ; das fell, fell, old Eng- 
 lish. WITH ITS appendages, SCARF-SKIN OR CUTICLE, NAIL, 
 HAIR. EPiDERivns; cuTicuLA. UNGUES. PILL — Tissu Epider- 
 moide et Tissu Pileux, 
 
 Skin has been said to consist of three parts, true skin, (cutis 
 vera,) mucous net, (rete mucosum,') and scarf-skin, or cuticle. 
 Haller, Camper, and Blumenbach are inclined to deny the exist- 
 ence of the mucous net in the skin of the white, and to admit it in 
 that of the negro only ; and, in point of fact, indeed, its existence 
 has been demonstrated in the negro race only, and inferred by 
 analogy to exist in the white. “ When a blister has been applied 
 to the skin of a negro,” says Cruikshank, if it has not been very 
 stimulating, in twelve hours after, a thin transparent grayish mem- 
 brane is raised, under which we find a fluid. This membrane is 
 
498 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the cuticle or scarf-skin. When this with the fluid is removed, the 
 surface under these appears black; but if the blister had been very 
 stimulating, another membrane, in which this black colour resides, 
 would also have been raised with the cuticle. This is rete mucosum, 
 which is itself double, consisting of another gray transparent mem- 
 brane, and of a black web very much resembling the -pigmentum 
 nigrum of the eye. When this membrane is removed, the surface 
 of the true skin, as has been hitherto believed, comes in view, and 
 is white like that of a European. The rete mucosum gives the co- 
 lour to the skin ; is black in the negro ; white, brown, or yellow- 
 ish in the European.”^ 
 
 Cruikshank distinguished the membranes spread over the sur- 
 face of the true skin into five, each of which he conceived are cu- 
 ticles or secretions from the outer surface of the skin, undergoing 
 transformation into cuticles. 
 
 The first and most external of these is the cuticle or epidermis, 
 properly so named, that is the completed covering investing the 
 whole, and which is semitransparent. This is constantly rubbed 
 off or falling off in scales ; and its place is as constantly supplied 
 by layers arising from and secreted by the next covering. 
 
 This is the rete mucosum, which according to Cruikshank is 
 double, consisting of an outer or consistent layer, and an inner or 
 softer, and which is secreted by the vascular surface of the true 
 skin. These two with the cuticle proper form three coverings. 
 
 The next or fourth is more equivocal in existence. It is a vas- 
 cular membrane spread over tbe outer surface of the true skin, 
 which becomes most distinct in various cutaneous inflammations, 
 as small-pox, measles, and scarlet fever. In this the small-pox 
 pustules are situate ; and certainly it seems to form the layer in 
 which these pustules are first developed. 
 
 Lastly, when a piece of skin has been macerated, and this fourth 
 vascular membrane is removed, it is possible to observe a fifth rest- 
 ing immediately on the surface of the true skin. 
 
 These distinctions seem rather minute. The cuticle is probably 
 one membrane only secreted by the rete mucosum as it is required ; 
 the external layers being bard and firm, the inner soft and pulpy. 
 
 The rete mucosum is evidently a secretion from the outer vascu- 
 lar surface of the skin. 
 
 With regard to the other two they seem to be the external surface 
 
 * Experiments on the Insensible Perspiration of the Human Body, showing its 
 affinity to Respiration. By William Cruikshank. London, 1795, p. 3 and 4. 
 
SKIN. 
 
 499 
 
 of the true skin itself. It was, however, the opinion of Cruikshank, 
 that these membranes are not created, but only demonstrated or 
 rendered distinct by eruptive diseases in consequence of the large 
 quantity of blood impelled into the skin. 
 
 Bichat denies the existence of a mucous coating or varnish {cor- 
 pus mucosum^ such as Malpighi describes it, and regards the vas- 
 cular surface of the corion as the only mucous net. 
 
 According to Chaussier, the skin consists of two parts only, the 
 derma {Ss^/mu) cutis vera or corion, and the epidermis, cuticle, or 
 scarf-skin ; the first embracing the organic elements of this tissue ; 
 the second being an inorganic substance prepared by the organic, 
 and deposited on its surface. This opinion is adopted by Gordon, 
 according to whom the skin consists of two substances placed above 
 each other like layers or plates {lamincB,) the inner of which is the 
 true skin, the outer the cuticle or scarf-skin. Bedard, on the con- 
 trary, thinks that a peculiar matter, which occasions the colour by 
 which the several races are distinguished, is found between the 
 outer surface of the corion and the cuticle ; and that no fair race 
 is destitute of it except the albino, the peculiar appearance of whom 
 he ascribes to the absence of the mucous net of the skin. 
 
 According to M. Gaultier, the mucous body of the negro skin 
 consists of four parts ; Isf, a series of minute vascular bundles, to 
 which M. Gaultier applies the name of gemmulce sanguinece, and 
 which are really the termination of vessels ramified on the papillae ; 
 2d, the deep whitish layer, consisting of white vessels, and indicat- 
 ed in an oblique section of the negro skin, by a white line between 
 the surface of the corion and a darker undulating line ; 3d, the 
 coloured layer, named by INI. Gaultier gemimdce — the true colour- 
 ing matter of the skin, — indicated by the undulating line already 
 noticed ; Ath, the superficial white layer, consisting of serous ves- 
 sels as the first, indicated by a white line between the dark undu- 
 lating line and the cuticle. 
 
 The vascular eminences, {gemmulce sanguinece) of M. Gaultier, 
 are the termination of the cutaneous papillae ; and this induces 1\I. 
 Dutrochet to give the following view of the constituent parts of the 
 cutaneous tissue. Is?, the derma, or corion, the true skin of the 
 ancient anatomists; 2d, the papillae, or minute elevations of this 
 membrane ; 3d, the epidermal membrane of the papillae, which is 
 the deep whitish layer of M. Gaultier ; Ath, a coloured layer, the 
 proper colouring matter of the skin ; 5 th, a. horny layer, which 
 
500 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 corresponds to the superficial whitish layer of Gaultier ; and, Wt, 
 the epidermis, or cuticle. 
 
 The corion of the human skin, (j)ellis, corium^ derma, cutis vera) 
 seems to consist chiefly of very small dense fibres, not unlike those 
 of the proper arter ial coat closely interwoven with each other, and 
 more firmly compacted the nearer they are to its outer or cuticu- 
 lar surface. The inner surface of the corion is of a gray colour ; 
 and in almost all parts of the body presents a number of depres- 
 sions varying in size from one-twelfth to one-tenth of an inch, and 
 consequently forming spaces or intervals between them. These 
 depressions, which correspond to eminences in the subjacent adipose 
 tissue, have been termed areolae. They are wanting in the corion 
 of the back of the hand and foot only. 
 
 The outer or cuticular surface of the corion is quite smooth, of 
 a pale or flesh-red tinge, and is much more vascular than its inner 
 surface. It presents, further, a number of minute conical emi- 
 nences {^papillae,') which, according to the recent observations of 
 Gaultier,* and Dutrochet,f are liberally supplied with blood-ves- 
 sels {gemmulae sanguinece,) and are the most vascular part of this 
 membrane. In the ordinary state of circulation and temperature 
 during life these eminences are on a level with the surrounding 
 corion ; but when the surface is chilled, this membrane shrinks, 
 while the papillse either continue unchanged, or shrink less propor- 
 tionally, and give rise to the appearance described under the name 
 of goose skin ; {cutis anserina.) This surface was said by the older 
 anatomists to present numerous openings, oriflces, or pores ; but 
 according to Gordon, if we trust to mere observation, no openings 
 of this kind can be recognized, either by the eye or the microscope, 
 except those of the sebaceous follicles. The hairs, indeed, are 
 found to issue from holes in the corion, but they fill them up com- 
 pletely. 
 
 In certain situations, for instance at the entrance of the external 
 auditory hole, at the tip of the nose, on the margins of the eyelids, 
 in the arm-pits, at the nipple, at the skin of the pubes, round the 
 anus, and the female pudendum, are placed minute orifices, from 
 which exudes an oleaginous fluid, which is quickly indurated. These 
 openings lead into small sacs or cavities called follicles, (J'olliculi,) 
 
 * Rechei'ches sur I’org. de la peau, &c. Paris, 1809 and 1811. 
 
 f Observations sur la structure, &c. Journal de Phys. Mai 1819, and Observations 
 sxu' la structure de la peau, Jour. Compl. Vol. V. 
 
SKIN. 
 
 501 
 
 or sebaceous glands, {glandules sebacea.') Of these sacs the struc- 
 ture is simple. They appear to consist simply of hollow surfaces 
 secreting an oleaginous fluid, which is progressively propelled to 
 the orifice, where it soon undergoes that partial inspissation which 
 gives it the sebaceous or suet-like aspect and consistence. In the 
 negro races the secretion exhales a peculiar strong odour ; and in 
 the fair or red-haired European races the odour is also strong. 
 
 The corion is liberally supplied with blood-vessels, nerves, and 
 absorbents. After a successful injection, its outer surface appears 
 to consist of a uniform net-work of minute vessels, subdivided to an 
 infinite degree of delicacy, and containing during life blood coloured 
 and colourless. It can scarcely be doubted that this vascular net- 
 work {rete vasculosum) is the only texture corresponding to the 
 reticular body of the older anatomists. 
 
 It is well known that this membrane when boiled sufficiently long 
 is converted into a viscid glutinous liquor, which consists chiefly of 
 gelatin, (Chaptal, Seguin, Hatchett, Vauquelin, &c.) and that glue 
 is obtained in great quantity from it for the purposes of art. As, 
 however, in these operations a portion of matter is left undissolved, 
 and as glue is completely soluble in water, while skin resists it for 
 an indefinite time, it may be concluded, that though the chief con- 
 stituent of the corion is gelatin, it is under some peculiar modifi- 
 cation not perfectly understood. The union of this organized 
 gelatin with the vegetable principle denominated tannin forms 
 leather, which is quite insoluble in water. 
 
 Cuticle or scarf-skin, {epidermis, cuticula'), is a semitransparent, 
 or rather translucent layer of thin light-coloured matter, extended 
 continuously over the outer surface of the corion. Its thickness varies, 
 being thinnest on those parts least exposed to pressure and fric- 
 tion, but thickest in the palms and soles. It is destitute of blood- 
 vessels, nerves, and absorbents ; and there is reason to believe, from 
 observing the phenomena and process of its reproduction, that it is 
 originally secreted in the form of a semifluid viscid matter by the 
 outer surface of the corion ; and that, as it is successively worn or 
 removed by attrition, it is in like manner repaired by a constant 
 process of secretion or deposition. This semifluid viscid matter, 
 which, in point of fact, is found between the outer surface of the 
 corion and the firm cuticle, appears to be the substance men- 
 tioned by Malpighi, and so often spoken of as the mucous body 
 or net ; {corpus mucosum,) It is certainly quite inorganic ; and it 
 
502 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 is impossible to explain its production otherwise than by ascribing 
 it to the outer or vascular surface of the corion. 
 
 Cuticle is rendered yellow, and finally dissolved by immersion in 
 nitric acid. It is also dissolved by sulphuric acid, in the form of a 
 deep brow'n pulp. These, and some other experiments performed 
 by Hatchett, appear to show that it consists chiefly of albuminous 
 matter somehow modified. 
 
 This description shows, that, if strict observation be trusted, the 
 mucous net has no existence, at least in the European. In the 
 Negro, Caffre, and Malay, however, a black membrane is said to 
 be interposed between the corion and cuticle, and to be the cause 
 of the dark complexion of these races. On this subject I refer to 
 the description given by Cruikshank,* v/hich is the best, the Essay 
 of M. Gaultier already quoted, and the observations of Bedard. 
 What is found in the skin of the mixed or half cast races, i. e, the 
 offspring of an African and European, or of a mulatto and Euro- 
 pean ? and how is the transition between this colouring layer and 
 its insensible diminution effected ? 
 
 Nail is a substance very familiarly known. On its nature and 
 structure we find many conjectures, but few or no facts in the writ- 
 ings of anatomists ; and almost all that has been written is the re- 
 sult of analogical inference, rather than of direct observation. It is 
 known that the nails drop off with the scarf-skin in the dead body ; 
 that they are destroyed or diseased by causes which act on the 
 outer surface of the corion, and produce disease of the cuticle ; and 
 that, if forcibly torn out, the surface of the corion to which they 
 were attached, bleeds profusely and inflames. In other respects 
 they are quite inorganic ; but these facts appear to warrant the con- 
 clusion, that the root of the nail is connected with the organic sub- 
 stance of the corion, and that the whole substance is the result of 
 a process of secretion quite similar to that by which the cuticle is 
 formed. 
 
 According to the experiments of Hatchett, they consist of a sub- 
 stance which possesses the properties of coagulated albumen, with a 
 very small trace of phosphate of lime. 
 
 The root of a hair is not only that part which is contained in the 
 bulb, but the portion which is lodged in the skin. The middle part 
 and the point are those which project beyond the surface of the skin. 
 The hull) is a small sac fixed in the inner surface of the corion, in 
 
 * Experiments, &c. p. 31. 
 
SKIN. 
 
 503 
 
 the contiguous filamentous tissue, and receiving the extremity or 
 root of the hair implanted in it. 
 
 Every hair is cylindrical, tapering regulaidy from the root to the 
 point, and solid, but containing its proper colouring matter in its 
 substance. The colour varies, but the root is always whitish and 
 transparent, and softer than the rest ; the fixed or adhering part of 
 the root is almost fluid. When hair is decolorized, it becomes 
 transparent and brittle, and presents a peculiar silvery-white colour ; 
 and as hairs of this kind are few or abundant, it gives the aspect of 
 gray, hoary, or white-hair. 
 
 The bulb, though visible in a hair plucked out by the root, is too 
 small in human hair to be minutely examined ; and Chirac, Gaul- 
 tier, and Gordon, have therefore described its structure and appear- 
 ances from the bulbs of the whiskers of large animals, the seal for 
 example, in which it is much more distinct. According to researches 
 of this kind, every bulb forms a sort of sac or follicle, which con- 
 sists of two tunics, an inner one, tender, vascular, and embracing 
 closely the root of the hair ; and an outer, which is firmer and less 
 vascular, and surrounds the inner one, while it adheres to the fila- 
 tnentous tissue and the inner surface of the corion. When the hair 
 issues from the bulb, it passes through an appropriate canal of the 
 corion, which is always more or less oblique, but which, as has been 
 already said, it fills completely ; and it afterwards passes in a simi- 
 lar manner through the scarf-skin. Nervous filaments have been 
 traced into the bulbs of the whiskers of the seal by Rudolph! and 
 the younger Andral. The bulb or follicle, in short, is inorganic, 
 and forms by secretion the inorganic hair. 
 
 The structure of hair itself appears to be either so simple, or so 
 incapable of being further elucidated, that anatomists have not given 
 any facts of consequence regarding it. Its outer surface is believed 
 to be covered with imbricated scales, because in moving a single 
 hair between the finger and thumb, it follows one direction only. 
 
 Hair is believed to be utterly inorganic, though the phenomena 
 of its growth, decoloration, and especially of the disease termed 
 Polish plait, {plica Polonica^ have led various authors to regard it 
 as possessed of some degree of vitality. These phenomena, how- 
 ever, may be explained by the occurrence of disease in the bulhs or 
 generating follicles. Hair is insoluble in boiling water, but Vau- 
 quelin succeeded in dissolving it by the aid of Papin’s digester. 
 From the experiments of this chemist, and those of Hatchett, it may 
 
504 
 
 GENERAL AND PxiTHOLOGICAL ANATOMY. 
 
 be inferred that hair consists of an animal matter, which appears to 
 he a modification of albumen, a colouring oil, and some saline 
 substances.* 
 
 Section II. 
 
 The cutaneous texture and appendages are liable to many forms 
 of disease. Most of them, however, may be referred to some form 
 of the inflammatory process, or to changes in texture either original 
 or acquired. 
 
 I. Inflammation assumes in this texture a great variety of forms, 
 which it is the province of pathological anatomy to distinguish ac- 
 curately. This was first attempted by Cullen, whose phlegmon and 
 erythema were intended to designate two forms of cutaneous in- 
 flammation, according as the vessels of the internal or external sur- 
 face are the seat of morbid action. The distinction, though judi- 
 cious, was overlooked ; and those who confided in his practical in- 
 structions, without attending to the correctness of his pathology or 
 the fidelity of his descriptions, transferred the seat of phlegmon from 
 the skin, in which it was placed by Cullen, to the cellular tissue, 
 where it has since remained. This error was abetted by J. Hunter 
 and C. Smyth, whose distinctions of inflammation, according to the 
 tissues in which it occurs, place rose in the skin, and phlegmon in 
 the cellular membrane. These views were generally adopted till 
 the appearance of Bichat, who attempted, after the example of 
 Cullen, to distinguish cutaneous diseases according to their seat in 
 the cutaneous tissue.f As this is obviously the most rational 
 method, and, though not much followed by practical authors, has 
 received the approbation of such observers as Meckel and Bedard, 
 it is best calculated for the order to be observed in the present 
 treatise. 
 
 Cutaneous inflammation, though it eventually affect the sub- 
 stance, which, however, is not frequently, may he conveniently dis- 
 tinguished in the following manner. First, it may be seated in 
 the exterior or cuticular surface of the corion ; secondly, it may 
 affect the papillae or minute elevations of the corion ; thirdly, it 
 may affect the substance of the corion ; fourthly, it may occur at 
 the inner or attached surface of this membrane ; fifthly, it may af- 
 fect the sebaceous follicles ; and sixthly, it may be connected with 
 * Annales de Chimie, 1805. Tome LVIIL, and Philosoph. Trans. 1800, Vol. XC. 
 11 . .327, ct seq. 
 
 t Anatomie Geiierale, Tome IV. p. 721. 
 
 1 
 
SKIN. 
 
 505 
 
 the sacs and bulbs of the hairs. If these circumstances be adopted as 
 the basis of general division, subordinate characters may be,^derived 
 from the mode in which the inflammatory process advances, and from 
 the effects which it produces, in the following order. 
 
 § I. Diffuse or spreadinr/ inflammation. — I. Cutaneous inflammations seated in the outer 
 or cuticular sm'face of the corion, {cutis vera, derma,) and generally spreading along 
 it. 
 
 Measles, 
 
 Rubeola. 
 
 MorbiUose eruption. 
 
 Morbilli. 
 
 Rash fever, scarlet fever. 
 
 Scarlatina. 
 
 Nettle-rash, 
 
 Urticaria. 
 
 Rose-rash, 
 
 Roseola. 
 
 Common rash. 
 
 Erythema. 
 
 § 2. Effusive inflammation. — II. Cutaneous inflammation seated in the outer surface of 
 the corion, producing a fluid which elevates and detaches the cuticle. 
 
 Rose, St Anthony’s fire. Erysipelas. 
 
 Bleb fever, bullose fever, Pemphigus, febris' bullosa. 
 
 Simple blebs, Pompholyx. 
 
 § 3. Punctuate papular inflammation. — III. Cutaneous inflammations commencing in 
 circumscribed or definite points of the corion, producing minute eminences. 
 
 Gum, gown, red gum, tooth gum. Strophulus. 
 
 Sun-rash, prickly heat. Lichen. 
 
 Itchy rash, Prirrigo. 
 
 § 4. Punctuate desquamating inflammation. — IV. Cutaneous inflammations of the outer 
 surface of the corion, more or less circumscribed, affecting its secreting power, and 
 producing exfoliation of the cuticle. 
 
 Scaly leprosy. Lepra. 
 
 Scaly tetter, Psoriasis. 
 
 Dandriff, Pityriasis. 
 
 Fish-skin disease. Ichthyosis. 
 
 § 5. Punctuate vesicular inflammation. — V. Cutaneous inflammations originally affecting 
 the outer surface of the corion, circ'rmscribed, definite, or punctuate, producing ef- 
 fusion of fluid first pellucid, afterwards slightly opaque, \vith elevation of cuticle, 
 with or without further affection of the corial tissue. 
 
 Miliary rash. Miliaria. 
 
 Shingles, vesicular ringworm, or fret. Herpes. 
 
 Heat spots, or red-ffet. Eczema. 
 
 Limpet shell vesicle and scab, Rupia. 
 
 Cow-pox vesicle. Vaccinia. 
 
 Chicken-pox, Varicella. 
 
 § 6. Punctuate phlegmonous or pustular inflammation. — VI. Cutaneous inflammations 
 originally affecting the outer surface and vascular layer of the corion, afterwards its 
 substance, sometimes the sacs and bulbs of the hairs, and producing pm’ulent mat- 
 ter more or less distinct. 
 
 Small-pox, 
 
 Variola. 
 
 Plague, 
 
 Pestis. 
 
 Malignant pustule, Persian fire. 
 
 Anthrakion. 
 
 Itch,- 
 
 Scabies. 
 
 Moist or running tetter. 
 
 Impetigo. 
 
 ScaU or pustular ringworm. 
 
 Porrigo. 
 
 Great pox. 
 
 Ecthyma. 
 
506 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 § 7. Punctuate chronic phlegmonoiis inflammation. — VII. Cutaneous inflammations ori- 
 ginating in the substance of the corion, or in the sebaceous follicles, sometimes at 
 the bulbs of the hair, and terminating in partial or imperfect suppuration, wth 
 formation of scales, crusts, &c. and more or less destruction of the sebaceous folli- 
 cles, the piliparous sacs, or of the corial tissue. 
 
 Boil, Phyma, Furunculus. 
 
 Carbuncle, Anthrax ; Carbunculus. 
 
 Whelk, Acne. 
 
 Scalp or chin whelk. Sycosis. 
 
 Soft tubercle, Alolluscum. 
 
 Canker, Lupus, noli me tangere. 
 
 White scall, Vitiligo. 
 
 Yaws, Framboesia, rubula. 
 
 Sivvens, Sibbenia. 
 
 § 8. Pu/nctuatc phlegmono-tubercular inflammation, chronic. — VIII. Cutaneous inflam- 
 mations, chronic, attended with general affection of the fibro-mucous tissues. 
 
 Arctoic leprosy, Radesyge, 
 Lombard^evil, Pellagra, 
 
 Scherlievo, Falcadina, 
 
 Asturian itch or scab, Mai di Rosa, 
 Crim evil, Krimmische krankheit, 
 Arabian leprosy. 
 
 Wart, 
 
 Lepra Norwegica. 
 Pellagra. 
 
 Lepra Pedemontana. 
 Lepra Asturiensis. 
 Lepra Taurica. 
 Elephantiasis. 
 Verruca. 
 
 § 1. Cutaneous inflammations seated in the outer or cuticular sur- 
 face of the corion, and generally spreading along it . — Inflammation of 
 the outer surface of the corion may be diffuse and continuous, as in 
 scarlet fever, diffuse and interrupted, as in common rash {erythema^ 
 nettle-rash, and rose-rash, or diffuse and of determinate figure, as in 
 measles and morbilli. The redness with which superficial cutaneous 
 inflammation is attended varies. Though it disappears on pressure, 
 it returns immediately. In scarlet fever, though its tint is indi- 
 cated by the name, it often has a shade of brown ; in erythema, or 
 simple rash, it is rarely so vivid as in other forms of cutaneous in- 
 flammation ; in rose it has a tinge of yellow. In measles it as- 
 sumes the shape of crescentic or lunular patches. In simple rash 
 it terminates gradually in the sound skin ; but in one variety of 
 this rash, {erythema marginatum^ and in rose, it is marked by a 
 distinctly circumscribed edge, or is said to be marginate. The 
 swelling of superficial cutaneous inflammation is rather a general 
 distension than obvious elevation. When it is obvious to the eye, 
 or felt by tbe finger, and is at the same time confined to definite 
 red patches, these are named wheals. A familiar instance of this 
 occurs in the effect produced by the bite of several insects, the blow 
 of a whip, or the stinging of nettles. Spontaneously it is seen in 
 
 the disease named nettle rash. In rose, elevation, extensive and 
 
 3 
 
SKIN. 
 
 507 
 
 continuous, conterminous with the redness, and like it bounded by 
 a distinctly circumscribed edge, is uniformly observed. 
 
 Superficial cutaneous inflammation being seated in the extensive 
 vascular net-work, {rete vascidosum, reseau vascnlaire^') of the co- 
 rion, always destroys to a greater or less extent its scarf-skin, which 
 comes away in small portions or scales, sometimes in larger pieces, 
 while a new but thinner and more transparent scarf-skin is formed. 
 The process by which these changes are effected is termed desqua- 
 mation, and is observed in measles, scarlet fever, nettle-rash, rose- 
 rash, common rash, and rose when it does not proceed to the for- 
 mation of blebs. As the process thus defined forms a good mode 
 of distinguishing its varieties when seated in the outer or cuticular 
 corial surface, I adopt it on the present occasion. 
 
 According to the definition above given, it comprehends the fol- 
 lowing diseases : — Measles, rash-fever or scarlet fever, nettle-rash, 
 rose-rash, common rash. 
 
 This must be regarded as the simplest form of cutaneous inflam- 
 mation. It may indeed be doubted whether it can justly be termed 
 inflammation ; for though the capillaries of the cuticular surface 
 of the corion are unnaturally distended with blood, and the usual 
 functions of secretion and perspiration are suspended, it does not 
 induce those consequences which succeed the inflammatory process 
 in other tissues, or even in the same tissue, in a state of unequivocal 
 inflammation. It may, however, be remarked, that, in other re- 
 spects, the phenomena of the disorders referred to this head afford 
 fair examples of inflammatory action. The skin is permanently 
 red, either continuously or in patches, or in spots of definite figure, 
 diffusely swelled, and unusually warm, or rather hot and dry. Its 
 sensations are also deranged ; for the parts are either painful, 
 smarting, or itching, as in nettle-rash, rose-rash, and common rash, 
 or the skin is generally tense and sore, as in measles and scarlet 
 fever. In each of these diseases, also, the capillaries of the outer 
 or cuticular ■ surface of the corion are inordinately distended with 
 blood, which appears to move very slowly, or stand entirely mo- 
 tionless in them. The skin of a person cut off during the progress 
 of measles or scarlet fever is marked by innumerable minute ves- 
 sels disposed in various modes, arborescent, asteroid, reticular, &c. ; 
 and, in some instances, minute specks of blood are effused on the 
 corion or into its substance. In scarlet fever, confined chiefly to 
 the skin, the outer surface of the corion of the face, neck, and 
 
508 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 trunk, is particularly injected ; and towards the close of the dis- 
 ease, this capillary injection is brownish or purple. The injection 
 of the mucous surfaces shall be noticed afterwards. In nettle-rash, 
 this injection is in circumscribed patches, and accompanied with 
 elevation, but disappears greatly after death. In erythematous in- 
 flammation I have observed the cuticular surface of the corion of a 
 scarlet red, and soft velvety texture, and distinctly traversed by 
 numerous minute arborescent and asteroid patches, wbicb, however, 
 become much paler in a few days. 
 
 § 2. Cutaneous inflammations situate chiefly in the outer surface 
 of the corion, producing sero-alhuminous fluid, which elevates the scarf 
 skin into pushes, blebs, or blisters, (Bullae, Phlyctaenae,) commencing 
 in certain parts of the corion, but spreading continuously. 
 
 The outer surface of the corion may be inflamed in such a manner 
 as not to terminate in desquamation or resolution, but to pour forth 
 a sero-albuminous yellowish fluid, which detaches the cuticle and 
 elevates it in the form of a bleb or blister. This is very well seen 
 in the instance of scalding by boiling fluids, on the application of 
 the blistering fly, (il/eZoc vesicatorius,) or even in some cases of fric- 
 tion to parts naturally tender. In each of these cases, in a short 
 time large watery elevations or bladders appear. The same pro- 
 cess takes place spontaneously in rose, in common blebs, and in the 
 bullose or bleb fever. The form of these blebs is not determinate; 
 nor even are they always uniform in appearance. The action by 
 which they are produced, though more violent in degree, is not 
 different in kind from ordinary cutaneous inflammation. It is at- 
 tended, nevertheless, with more swelling of the corion, more exqui- 
 site burning heat, and more searing or scalding pain, than the other 
 forms of superficial cutaneous inflammation. The fluid secreted by 
 this process is sero-albuminous. When the raised cuticle is divided 
 a yellowish transparent watery fluid escapes ; and when the cuticle 
 is detached so as to expose the inflamed spot, the inflamed skin is 
 found covered by a quantity of soft, cellular, gelatinous matter, of 
 a yellow-white colour, somewhat tough, and similar to coagulable 
 lymph. This substance is traversed by firm linear partitions, not 
 uniform in number or direction, but forming interstices from which 
 serous fluid, the same as that which escaped first, is discharged. 
 The coagulable matter, which is albuminous, at the same time 
 contracts, and forming a covering to the corion, while the lat- 
 ter begins to secrete a new cuticle, is at length thrown off in the 
 
SKIN. 
 
 509 
 
 form of opaque patches. In the liquid secreted by the coriou 
 during the application of a blister, and that contained within the 
 vesications produced by scalding, the same facts may be recog- 
 nized. That obtained from the vesication of a blister separates 
 spontaneously into coagulable and fluid portions ; and the addition 
 to the latter of the smallest portion of nitrate of silver is followed 
 by a copious formation of opake albuminous matter. These facts 
 show that the new secretion, though discharged fluid, afterwards 
 separates into a serous and an albuminous portion, and is an im- 
 perfect or modified coagulable lymph ; that both are the product 
 of the inflammatory process ; and that the latter is analogous to 
 that producing albuminous exudation from serous membranes. 
 This analogy has not escaped Bichat, who remarks, that vesications 
 do not occur in the latter, solely because they want epidermis. 
 To this head belongs the inflammation of cutaneous whitloe. 
 
 § 3. Cutaneous inflammation commencing in circumscribed or 
 definite points of the outer surface of the corion, and producing mi- 
 nute eminences or pimples (papulse,) which disappear gradually or 
 terminate in scurf, or minute exfoliations of the cuticle. 
 
 When cutaneous inflammation appears in the form of innumer- 
 able minute points, which, without spreading or coalescing, remain 
 in general distinct, it diflFers in nature from that which has been 
 already considered as the spreading or diff’use inflammation. The 
 simplest form under which this is observed to occur, is that which 
 consists of the minute pointed elevations named pimples fapulcB,) 
 which may be described as small conical eminences, surrounded 
 by a red circle, and sometimes attended with superflcial redness 
 of the neighbouring skin, but without definite figure. They are 
 slow in progress, do not proceed to suppuration, and after remain- 
 ing an uncertain time, subside gradually, occasioning a branny or 
 scurfy exfoliation of the scarf-skin, with which they are covered. 
 
 These seem to have been the circumstances which induced Dr 
 Willan to consider pimples as arising from inflammation of the 
 papillce or conical eminences of the corion. I cannot say that per- 
 sonal observation has enabled me to determine, whether this is at 
 all times truly the case or not ; and I therefore will not positively 
 deny the accuracy of the opinion. On this point, however, I re- 
 mark, — that I have seen and daily see instances of strophulus in 
 which the papular eruption can neither in form nor distribution be 
 traced to the cutaneous papillm; that the eruption of lichen in 
 
510 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 adults appears in situations in which the papillae are few, as regu- 
 larly and abundantly as in those in which they are numerous ; and 
 that we meet with local examples of papular eruption in which it is 
 difficult to suppose the disease to be an affection of the papillae of 
 one region of the skin only. For these reasons it may be justly 
 doubted whether in all instances papular eruptions consist in in- 
 flammation of the papillae. 
 
 Of the anatomical characters of pimples, little is accurately 
 known. They are not diseases necessarily fatal ; and when death 
 takes place during their presence, their distinctive characters are 
 either much changed, or entirely gone before the anatomist can 
 inspect them. In some instances of strophulus in infants cut off 
 by other diseases, I have seen the corion rough and slightly raised 
 in irregular spots, which were the seat of closely-set pimples during 
 life. 
 
 § 4. Cutaneous inflammation of the outer surface of the corion, more 
 or less circumscribed, affecting its secreting poioer, and thus produc- 
 ing first, exfoliation of the scarf-skin, aftericards vitiated scarf-skin. 
 
 Though the scarf-skin {cuticula, epidermis,) and nails are inca- 
 pable of injection, and are therefore believed to be inorganic, the 
 former is remarked to be more sensible, when thin and semitrans- 
 parent, than when thick and opaque, which it may be in certain 
 regions. It is also observed, that when it is removed by a blister, 
 or the effect of a scald, the surface of the corion, when it ceases 
 to discharge the sero-albuminous fluid already noticed, becomes 
 covered by a thin pellicle of transparent membrane, so delicate, that 
 it affords very little defence to the subjacent skin. This same 
 transparent pellicle is observed in the skinning or cicatrization, as 
 it is named, of cutaneous wounds. If, under these circumstances, 
 the formation of this pellicle be observed, it will be found that it is 
 deposited from the outer or cuticular surface of the corion, like a 
 secreted substance in a viscid or semifluid state, and afterwards be- 
 coming hard, dry, and semitransparent. When the first and thin- 
 nest pellicle is formed, the outer surface of the corion, which in the- 
 healthy state never suspends its secreting function, continues to de- 
 posit more of the semifluid, viscid matter, which in like manner, 
 but more slowly, becomes Arm ; and as successive depositions con- 
 tinue to be formed beneath that last secreted, the cuticle in its 
 perfect state consists of successive layers of matter secreted from 
 the outer surface of the corion. It is not to be imagined, never- 
 
SKIN. 
 
 511 
 
 theless, that they can be distinguished from each other. The secret- 
 ing or depositing power of the corion is a process which is inces- 
 sant and uninterrupted ; and after the first secreted portions become 
 firm, others subjacent undergo in like manner incessant deposition 
 and induration. 
 
 While this process of repair is going on at the surface of the 
 corion, a process of wearing or destruction is with the same rapidity 
 in the healthy state going on at the outer or exposed surface of the 
 cuticle. A piece of black or blue cloth rubbed gently over the 
 skin becomes quickly whitened by minute portions of scarf-skin, 
 which ai-e thus detached from the firmer and more recent portions. 
 A black silk stocking drawn on the leg for a very short time, even 
 when the skin has been carefully washed with soap and water, comes 
 oflF covered with numerous thin white amorphous scales, which are 
 found to be minute portions of decayed cuticle, ready to be thrown 
 off by the first slight friction. In like manner, the friction of dress, 
 of washing, rubbing, &c. tends to remove the exposed portions of 
 cuticle. These several facts show that this membrane is a sub- 
 stance secreted from the outer surface of the corion ; that its pro- 
 duction is a successive and incessant process; and that it undergoes 
 a constant wearing or detrition. As numerous facts show that it 
 is an albuminous substance much indurated (Hatchett,) so it would 
 appear that when this induration becomes extreme, as takes place 
 in the exterior portions, their connection with the recent and softer 
 portions is destroyed, and detachment is the result. Such is the 
 course of phenomena in the healthy state. 
 
 When the outer surface of the corion becomes inflamed or other- 
 wise disordered, its secretion is no longer performed with the same 
 perfection or regularity. The eflTect of this is seen in the vitiated state 
 of the scarf-skin, which is no longer the uniform, continuous, firm, 
 semitransparent membrane observed in health, but becotnes broken, 
 thickened, opaque, and divided into numerous scales. Of the various 
 modes in which this secretion may be deranged, and of the varieties 
 in cuticular disease to which it may give rise, too little is known to 
 speak with precision of their individual forms. But it may be con- 
 sidered as certain, that every morbid state of the outer surface of the 
 corion gives rise to certain unnatural conditions of the cuticle, and 
 that every abnormal state of the cuticle depends originally on a mor- 
 bid state of the cuticular or secreting surface of the corion. In 
 general, this morbid state consists in some degree of inflammation. 
 
512 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 or at least it is attended with some degree of this proeess, though in 1 
 the chronic form. In some instances, this chronic inflammation I 
 is obviously the immediate cause of the derangement of secretion ; I 
 but in other instances, the disordered secretion continues after the ^ 
 inflammation subsides. The former is observed in the Greek le- J 
 prosy (^Lepra,) and the scaly tetter, (^Psoriasis,) in both of which ? 
 the formation of the morbid opaque scales is preceded and attended ? 
 by a red inflamed state of the corion taking place in minute spots. § 
 It is less obvious in dandriff, (^Pityriasis in which the surface of ]; 
 the corion, though dry, harsh, and rough, is not particularly red 
 or vascular, and which, therefore, appears to exemplify the latter » 
 statement. The fish-skin eruption (Ichthyosis,) is in general so I 
 chronic, that it is difficult to say, whether it is or is not attended j | 
 with any degree of the inflammatory process ; but when its com- J 
 mencement can be traced, it is generally possible to recognize 
 marks of inflammation of the outer surface of the corion. | 
 
 ‘ §5. Cutaneous hiflammatio7i 07'iginally affecting the outer surf ace of ~ 
 the corion, circumscribed, definite, or punctuate, producing effusion of k 
 fluid, first pellucid, afterwards slightly opaque, with elevation of ' " 
 cuticle, with or withoxit further affection of the corial tissue. ^ 
 
 Inflammation may be developed in many minute points of the 
 corion simultaneously, and, continuing limited to these points with- 
 out spreading, may terminate in each in the formation of a pellu- ill 
 cid fluid, afterwards becoming more or less opaque. These may 
 either be confined to the outer surface of the corion, without affect- 
 ing its substance, or beginning originally at the surface, may thence 
 affect its substance. 
 
 a. The individual points appear first like a common rash, with 
 general redness of the skin, sometimes like pimples or minute ele- I 
 vations, with a good deal of redness surrounding them. After 
 some hours, a white pearly point appears at their summits, while 
 the surrounding redness diminishes in breadth, so as to form a mere i 
 circle or hoop (areola,) which, if minutely examined, is found to 
 consist of a zone of vessels, circumscribing the inflammatory pro- s' 
 cess, and forming in their centre the fluid which gives the elevation ’ 
 the white appearance. After 12, 20, or 30 hours more, accor-i 
 ding to circumstances, the white pearly appearance extends, as-'S 
 Slimes a tint of yellow, and is depressed on the summit, indicating* 
 the advancement of the process of circurascrihed inflammation. In® 
 the course of two or three days, there is detached a thin crust or ft 
 
SKIJf. 
 
 513 
 
 scab, which consists of the cuticle of the part with the dried fluid 
 adhering to it. Minute elevations of this description have been 
 termed vesicles (vesiculoe)^ and the contained fluid lymph by Dr 
 Willan. The fluid thus distinguished is not the same as the coa- 
 gulable lymph of J. Hunter. It is nevertheless sero-albuminous, 
 and appears to be quite similar to thaj: which is secreted in the first 
 stage of suppuration. The process, by which it is secreted, is con- 
 fined to the vascular surface of the corion, and is not attended by 
 ulceration of that surface in millet rash, shingles {herpes)^ and the 
 red-fret or mercurial eruption {eczema . ) In chicken-pox it is some- 
 times attended by ulceration of the corial surface, sometimes not. 
 
 b. In the other two forms of vesicular inflammation, though the 
 process commences at the surface of the corion, it finally affects the 
 substance of that membrane. 
 
 c. In the limpet-shell vesicle(/zqoza), inflammation of the punctuate 
 or circumscribed character commences in one or more points of 
 the outer surface of the corion, and causes the secretion of a thin 
 clear fluid, which first elevates the cuticle into a broad flat vesicle, 
 and soon becoming opaque, oozes through the broken cuticle, and 
 is hardened into thin, superficial, but in general laminated scabs. 
 These vesicles are surrounded by a red, hard, and painful margin 
 or base, indicating slow inflammation of the corial tissue. 
 
 The progress of this form of cutaneous inflammation demon- 
 strates clearly and satisfactorily the gradual transition of the morbid 
 action from the surface to the substance of the corion. The in- 
 flammation confined at first to a small spot by the usual zone or 
 areola, causes merely sero-albuminous secretion and consequent 
 elevation of the cuticle. If at this time the cuticle be removed 
 accidentally or intentionally, the subjacent surface of the corion is 
 intensely red, soft, or velvety and pulpy, elevated, and extremely 
 tender, while the surrounding ring or hoop of skin is hard, and 
 equally elevated and red. From the softened inner portion the 
 secretion of sero-albuminous fluid, generally of a reddish tint, con- 
 tinues ; and the surface itself begins to become rough, and to lose 
 its velvet aspect. This indicates incipient ulceration, which pro- 
 ceeds to affect the substance of the corion, until it is either much 
 or wholly destroyed, generally in the form of an inverted cone ; 
 while the place of the destroyed skin is supplied by the sero- 
 albuminous secretion, which hardens as it is formed, and seems 
 thus to sink deeper and deeper into the skin. In the meanwhile, 
 
 K k 
 
514 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the surrounding portion of the skin is much indurated and inflamed, 
 and seems to form a hard ring in the skin ; and the whole process 
 is attended with extreme pain, searing heat, and constitutional dis- 
 tress. These phenomena are most distinctly seen in the rupiapro- 
 minens and r. escharotica, and in a variety of the eruption, which I 
 have witnessed in the persons^of those who have been affected with 
 the constitutional symptoms of syphilis, and who have for this been 
 subjected to repeated courses of mercury; (i-upia cacliectica.) 
 
 This is an example of inflammation with destruction of parts, 
 either by ulcerative absorption, or by phagedenic ulceration. 
 
 d. Cow-pox (vaccinia,) whether in the teat of the cow, or the skin 
 of the human subject, consists in local inflammation of the outer 
 surface of the corion, which, by causing the secretion of a thin 
 semitransparent fluid, elevates the cuticle into a vesicle. At the 
 same time, the surrounding skin is red, sore and hard (areola;) 
 and the inflammatory process denoted by these signs causes suppu- 
 ration of the corion, with some destruction of its substance, or 
 what is termed ulceration. 
 
 If the thin fluid secreted by the vaccine vesicle either in the teat 
 of the cow, or in the skin of the human subject, be taken before it 
 has become opaque or puriform, and applied to the surface of the 
 human corion exposed by scratching, slight incision, or suitable 
 abrasion of the cuticle, it is followed by local inflammation of the 
 same characters as those of the original sore or vesicle, from which 
 the morbid fluid is taken. The vaccine inflammation is naturally 
 divided into two stages. 
 
 1 . About the second or third day, or fi*om fifty to seventy hours, 
 after insertion of the fluid, the point of skin becomes red and 
 slightly raised. This redness and elevation continue to increase, 
 till the cuticle is gradually elevated about the fifth or sixth 
 day into a flat pearl -coloured spot or vesicle, which is found to de- 
 rive its appearance from the secretion of thin semitransparent fluid, 
 formed during the inflammatory process of the corion. The figure 
 of this spot or vesicle varies according to the manner in which the 
 vaccine fluid has been applied to the part. If it is by a longitu- 
 dinal incision or scratch, as is commonly done, the shape of the 
 vesicle is oval ; if it has been by longitudinal and transverse ones 
 of nearly equal size, or by simple puncture, then it is more or less 
 regularly circular ; and if the scratches have been numerous and 
 irregular in direction, or if the fluid has been applied irregularly, 
 the shape of the vesicle is also irregular. From its first appearance 
 
SKIN. 
 
 515 
 
 its upper surface is uneven, the margin being more elevated than 
 the centre, and shining, firm, and distended, so as to project slightly 
 beyond the plane of its base, or unaffected cuticle. This appearance 
 it presents till the eighth day, when the surface is observed on the 
 ninth to be even ; and in some instances the centre may be higher 
 than the margin. At this time, when the vesicle is supposed to 
 be fully formed, it is found to consist of many minute communicating 
 cells, in wbicb tbe fluid is contained. This cellular disposition is 
 characteristic of the vaccine vesicle ; for it is found to occur under 
 every variety of circumstances when the origin of tbe vesicle is 
 genuine, and its progress uninterrupted. 
 
 2. The circumstance now remarked may be regarded as denot- 
 ing the termination of the first and the commencement of the second 
 stage. About the same time, the skin round the vesicle becomes 
 hard, tense, and red, so as to form a ring or hoop, from one to two 
 lines broad all round, and from a quarter of an inch to two inches in 
 diameter, according to the size of the vesicle. This hard red hoop, 
 which has been named areola, marks an augment or increase of 
 inflammation in the substance of the corion, which continues with 
 pain, tension, and hardness, in some instances with obvious swell- 
 ing of the contiguous parts, till the end of the tenth or the begin- 
 ning of the eleventh day. At the same time the fluid of the vesi- 
 cle becomes opaque and thick like purulent matter, rendering the 
 centre yellowish, and depriving it of its pearly distended aspect. 
 On the eleventh and twelfth days, as the marginal redness fades, 
 the surface of the vesicle becomes brown in the centre, and less 
 clear on the margin; the cuticle begins to be separated; and the fluid 
 of the vesicle gradually thickens into a hard round scab or crust 
 of a reddish or yellow brown colour, which afterwards becomes 
 black, dry, and shrivelled, and is loosened, and drops oflP about the 
 twentieth day after the time when the vaccine fluid was first ap- 
 plied. It leaves a permanent uniform scar, distinguished by mi- 
 nute pits or depressions corresponding to the number of cells of 
 which the vesicle consisted. 
 
 During the progress of the local inflammation some disorder of 
 the constitution takes place generally about the seventh or eighth 
 day, in the form of loss of appetite or sickness, slight thirst and heat, 
 and dryness of the skin. The pulse is almost never affected. The 
 vaccine vesicle may also produce sundry cutaneous inflammations, 
 very transitory, and of a secondary nature. Of these the vaccine 
 rose-rash {roseola vaccina) is the most important and frequent. 
 
516 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 It must not be understood that vaccine fluid ■when applied to the 
 human body ever produces a general eruptive disease like itself 
 over the person. This, indeed, was believed to be the case at first 
 by Jenner, Pearson, Woodville, and perhaps some others. But 
 more correct knowledge of the history of the disease shows, that its 
 action is confined in the human body to the identical spots, to which 
 it is applied ; that these, and these only, become the seat of genuine 
 vaccine inflammation ; and, that whatever eruptions or other morbid 
 changes in the skin succeed, or have been said to succeed, the com- 
 munication of cow-pox to the human body, are not the result of its 
 genuine or proper action. It is strictly and truly a local morbid 
 process. 
 
 The history above given of the progress and characters of the 
 vaccine vesicle, shows clearly that the application of the vaccine 
 fluid, under proper conditions, is succeeded by a local inflamma- 
 tion of the corion, which observes a definite progress, divisible into 
 two stages. In the first of these stages, which may be termed the 
 primary or immediate^ the inflammatory process is confined with 
 great accuracy to the cuticular surface of the corion, and, diflPusing 
 itself very uniformly from the point of insertion at equal distances 
 in every direction, terminates in effusion of lymph or sero-albumi- 
 nous fluid, and elevation of the cuticle. During the first stage, 
 which lasts about seven or eight days, the minute cells are formed. 
 They appear to consist in separate points of inflammation, at which 
 the corial vessels discharge, as in other examples of the inflamma- 
 tory process, sero-albuminous fluid, which is soon coagulated in a 
 definite form. The coagulated portions form the partitions of the 
 cells, within which the fluid part is contained. The appearance of 
 the red ring, (areola), which takes place about the eighth day, indi- 
 cates the commencement of the secondary inflammation. This con- 
 sists in the action being propagated to the substance of the corion, 
 which is effected to some depth in the formation of puriform or pu- 
 rulent matter, and in destruction of part of its tissue. The subse- 
 quent phenomena and eflects are easily understood. 
 
 It is a remarkable property of cow-pock inflammation, that it 
 modifies considerably not only the variolous inflammation, but that 
 produced by itself. The second application of the vaccine lymph 
 in a person who has previously undergone this disease, produces a 
 smaller vesicle of the same characters, but less intensely marked. 
 If the application be made while the first is still in progress, and 
 before its areola has appeared, it produces a vesicle which runs its 
 
SKIN. 
 
 517 
 
 course more rapidly than the original one, and terminates nearly 
 at the same time with it. This constitutes the test-pock or vesicle 
 of Mr Bryce. ( Vaccinella . ) 
 
 e. Of chicken-pox as a cutaneous inflammation sometimes aflecting 
 the corial substance, I have already merely spoken. Like instances 
 of the punctuate inflammation, though it commences at the surface 
 of the corion with sero-albuminous secretion, it very often proceeds 
 to suppuration, and occasionally affects the corial tissue. This is 
 seen in the lenticular and more distinctly in the conoidal chicken- 
 pox, in which the suppurated points are marked by depressions. 
 The cutaneous punctuate inflammation of chicken-pox may be con- 
 sidered as the link which connects the vesicular and the pustular 
 eruptions. 
 
 The facts now adduced show that it is impossible to draw a dis- 
 tinct line between the vesicle and the pustule, as was attempted by 
 Willan and Bateman. Looking only at the pathological process 
 by which they are developed and advance to maturity, it is more 
 natural to consider them as differing in degree only, and as gliding 
 by imperceptible shades into each other, than as always capable of 
 being accurately distinguished. What is a vesicle ^yhen first ob- 
 served, may assume the appearance of a pustule on the following 
 day ; and the thin sero-albuminous fluid, by which they have been 
 supposed to be distinguished, may be converted into purulent mat- 
 ter before the termination of the disease. As the terms, neverthe- 
 less, are useful as precise distinctions in nomenclature and descrip- 
 tion, and as they occasionally may be traced to a pathological dif- 
 ference, I retain them in the present observations. 
 
 § 6. Cutaneous injinmmation originally affecting the outer surface 
 and vascular layer of the corion^ afterwards its substance, sometimes 
 the sacs and bidbs of the hair, and producing purulent matter more or 
 less perfect. 
 
 Inflammation of the minute circumscribed kind, though com- 
 mencing originally on the surface, may speedily affect the sub- 
 stance of the corion, and in its progress may produce more or less 
 loss of substance, with formation of purulent matter. The objects 
 thus formed are named pustules, and are to be viewed as instances 
 of genuine phlegmonous or rather purulent inflammation of the 
 skin. Practical authors enumerate four forms under which this 
 species of cutaneous inflammation may take place: — 1st, the psy- 
 dracium; 2d, the achor ; 3d, ihe favus ; and, 4th, \\\<i phlyzacium. 
 To this number I add the phlyctidium. 
 
518 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 1. The psydradum may be viewed as the connecting link between 
 the vesicle and pustule. It is small, often irregularly circumscrib- 
 ed, producing but slight elevation of the cuticle, and terminating 
 in a laminated scab. It is attended with little or no redness of the 
 surrounding skin {areola)^ does not affect the corion deeply, and 
 rarely, almost never, leaves a hollow scar. Several of them often 
 appear together, and becoming confluent after discharging the 
 scanty puriform matter which they furnish, pour out a thin watery 
 fluid, which on drying forms an irregular incrustation. 
 
 2. The achor differs not much from the psydracium. It appears 
 in the form of a minute pointed elevation, of a yellow colour, and 
 succeeded by a thin brown or yellowish scab. It contains straw- 
 coloured matter of the appearance and consistence of strained ho- 
 ney ; it is surrounded with little inflammatory redness, and seems 
 to affect the corion as little as the psydracium. In ordinary cir- 
 cumstances it leaves no scar. 
 
 3. The favus may be esteemed the next degree of inflammation 
 of this tissue. It is larger and flatter than the last-mentioned pus- 
 tule, not pointed, and contains a more viscid matter than the achor. 
 It is surrounded by a slight-red, irregular, marginal ring, indicat- 
 ing a more considerable affection of the corial tissue. It is suc- 
 ceeded by a yellow, semitransparent, and sometimes cellular scab, 
 like honey-comb. 
 
 4. A form of pustule referable neither to these nor to that which is 
 to follow, I must here mention, — i\\Q phlyctidium or genuine small- 
 pox pustule. It consists in a circular or annular spot of inflamma- 
 tion of the corion, encircled by a red ring or zone, which is ob- 
 served to consist of the outer corial surface highly vascular and 
 elevated. W ithin this suppuration takes place. Though the phlyc- 
 tidium is observed spontaneously in the distinct small-pox, it is al- 
 so produced artificially by friction of tartar-emetic ointment, 
 
 5. HhQphlyzacium is the most perfect example of the most violent 
 degree of this form of cutaneous inflammation. It is described as 
 a large pustule, raised on a hard circular base, of a lively red co- 
 lour, and succeeded by a thick, hard, dark-coloured scab. It is 
 generally slow in progress, and, commencing at once on the sur- 
 face and in the substance of the corion, is attended with consider- 
 able surrounding inflammation ; and the suppurative process which 
 follows is always accompanied with more or less destruction of the 
 
 corial tissue. It often leaves a hollow scar. The surrounding 
 
 3 
 
SKIN. 
 
 519 
 
 redness, hardness, and elevation ; the slow progress and sometimes 
 tedious suppuration ; and lastly, the loss of corial substance, are 
 the circumstances which indicate the peculiar seat of this form of 
 cutaneous inflammation. 
 
 Into the pathological characters of the individual pustular in- 
 flammations, the limits of this treatise do not permit me to enter. 
 On one or two of them, however, I shall offer a few remarks, which 
 may tend to illustrate the general nature of cutaneous pustular in- 
 flammation. I begin with small-pox as one of the most interest- 
 insf. 
 
 a. From Dorainico Cottugni we learn that it was the opinion of 
 Astruc, that the poisonous matter of small- pox {venenum variolarum) 
 affects particularly and exclusively the mucous body (coj'pus muco- 
 sum), which Malpighi describes between the skin and cuticle, and 
 that it was the property of this poison to induce in it the peculiar 
 variolous inflammation. This opinion appears to Cottugni to be 
 correct, because it is confirmed by dissections made by him of the 
 incipient and complete small pox pustule. These dissections, Cot- 
 tugni states, showed the incipient pustule to consist of the raised 
 cuticle without affection of the substance of the corion ; that this 
 elevation of the cuticle was occasioned by the intermediate mucous 
 body {corpus mucosum) being expanded like jelly, without separa- 
 tion of parts or intervening cavity ; and that such separation and 
 cavity could be perceived only when the pustule was completed. 
 Variolous pustules, he then asserts, are of two kinds, the umbilicate 
 or depressed^ and the vesicular or crystalline. The umbilicate are 
 those, the apex of which is, from the very beginning, flattened or 
 truncated, and which are rather lenticular than conical, as most 
 pustules, except the variolous, are. This shape they retain until in 
 the course of inflammation they grow to their full size, which may 
 equal or exceed that of a lentil either on the eighth or ninth days, 
 or on the tenth and eleventh. The cause of this depressed figure 
 is the navel {umbilicus) in the centre of the pock, which is at first 
 like an indistinct point, but afterwards, as the pock grows, becomes 
 more elevated, with a flatter figure. From this central point or 
 navel he represents all the actions of the pock, inflammation, sup- 
 puration, and drying or scabbing to proceed. F or while it, as a seat 
 of the poison, remains fixed, the surrounding paid, not of skin, but 
 of mucous body, is raised into an inflammatory ring or mound, 
 which prevents the morbid action from spreading. In the conflu- 
 
520 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 ent small-pox this provision is not observed. No outer swelled or 
 red ring is observed, and the mucous body of Malpighi is not in 
 such circumstances affected with the just and laudable action of the 
 disease. These results he ascribes to the spongy structure of the 
 Malpighian membrane, which swells and secretes a lymphy fluid. 
 In the crystalline small-pox, the fluid of which is almost pellucid, 
 he asserts that the mucous body, instead of being converted into 
 good matter, is filled with a caustic eroding humour, which seldom 
 fails to leave deep scars.* 
 
 Though these crystalline poets are nearly allied to his second 
 kind, the vesicular, they must not be entirely confounded with them. 
 They are utterly destitute of depression from their origin, are quite 
 similar to minute blisters, and he conceives them to be generated 
 in a similar manner, that is, by the inflammatory action operating 
 like a scald, and detaching very rapidly from the raucous body the 
 cuticle, so as to form vesicles or vesicular pustules. The purple- 
 like pocks he explains in a similar manner. They are merely ve- 
 sicular elevations of the cuticle, containing at first a watery fluid, 
 but mixed afterwards with blood or bloody fluid exuding from the 
 mucous body or vessels of the skin. They are generally mixed 
 with petechial spots, the origin of which depends on the same 
 cause. 
 
 In short, the doctrine of Cottugni is explicitly the following. 
 The natural and ordinary character of the small-pock is to pro- 
 duce in the mucous body (vascular web) of the skin a pit or de- 
 pressed point, which is soon surrounded with an elevated circle, in- 
 dicating inflammation of the corial surface. As this inflammatory 
 process proceeds from the central pit or navel to the circumference, 
 the elevated ring of mucous or vascular web is gradually convert- 
 ed into purulent matter, which necessarily renders the summit of 
 the pock flatter and more extensive, while its centre remains de- 
 pressed. The formation of purulent matter is indicated, he says, 
 by the appearance of a whitish ring [albidus annulus^) which is at 
 first at tlie vertex, but extends successively to the base of the pock. 
 In this course, he says, it does not affect the corion {cutis) if the 
 pocks be good ; for before it reaches this membrane the purulent 
 matter occupying the circumference of the pock either by bursting 
 it escapes, or by the itching which it causes at length gets an out- 
 
 * Dominici Cottunnii Regii Anatomes Professoris de Sedibus Variolarum Syntag- 
 ma. Vienna, 1771. Ixxx. paragr. 
 
SKIN. 
 
 521 
 
 let. Meanwhile the site of the pit or navel (umbilicus,) which was 
 previously sunk and hollow, not only attains the uniform convexity 
 of the rest of the pustule, which renders it spherical instead of len- 
 ticular, but is raised into a top or apex, which first allows the con- 
 tained matter to escape. This hardening forms a crust which 
 covers the pustule during the subsequent process of drying (persic- 
 catio,) which now commences ; when this is completed the crust or 
 scab drops oflT, leaving the skin uninjured. 
 
 This is, according to Cottugni, the natural and most perfect pro- 
 cess of variolous suppuration, from which all others are more or 
 less deviations. Thus the umbilicate pocks may degenerate into 
 the gangrenous, corruptive, crystalline, and warty ; the vesicular 
 deviate into the purple-like pox only. 
 
 The most doubtful point of this account of the variolous inflam- 
 mation, is that which relates to the disease being entirely confined 
 to the mucous body of Malpighi. The existence of this membrane 
 is very doubtful, and if it cannot be demonstrated, the opinion of 
 small-pox being confined to it is obviously inconclusive. If the term 
 outer surface or vascular layer of the corion be substituted for mucous 
 body, the whole description maybe regarded as not far from the truth. 
 The depressed pit or navel of which Cottugni speaks, corresponds 
 with the central slough of John Hunter, to wTich I shall advert in 
 its proper place. At present, the process of variolous inflamma- 
 tion, if divested of hypothetical language and opinions, may be stat- 
 ed in the following terms. 
 
 The small-pox eruption consists of circumscribed points of in- 
 flammation developed simultaneously in many spots of the corion. 
 These inflamed spots (phlyctidia), always commence at the cuticu- 
 lar or outer surface, and in general penetrate to a depth which is 
 greater or less in different circumstances. After no long time, 
 each phlyctidium is surrounded with a hard red circle somewhat 
 raised, which may be conceived to indicate the process of cutaneous 
 inflammation. Hunter would say, and perhaps did say, that this 
 inflammation is of the adhesive kind, and arises from lymph effused 
 into that part of the corion which is red, hard, and swelled. I 
 believe it cannot be in every instance shown that this hard swelling 
 depends on effusion of lymph ; and it may be doubted whether it 
 arises from such effusion in the case of small-pox. First, hardness 
 and swelling take place at a period of the eruption so early, that 
 it appears unreasonable to ascribe them to effused lymph ; Secondly, 
 
522 
 
 GENERAL ANI) PATHOLOGICAL ANATOMY. 
 
 hardness and swelling accompany every example of circumscribed 
 or definite inflammation ; Thirdly^ it is not easy to understand in 
 what particular part the lymph could be effused, for the corion does 
 not contain cells or cavities like the filamentous tissue, but the outer 
 surface consists of a smooth dense membrane, abounding in minute 
 blood-vessels ; Fourthly^ it is as easy and more natural to think 
 that if effusion took place, it would do so into these minute ves- 
 sels. In point of fact, the capillaries of the corion of the pustular 
 redness and hardness are numerous and distended ; and I believe 
 that the truest conclusion is, that the redness, hardness, and swel- 
 ling of each pock, consist in the unusual distension of the corial 
 capillaries with blood. 
 
 Pustular inflammation of the skin naturally terminates in sup- 
 puration, which may be either with or without destruction of the 
 corial tissue. In the variolous phlyctidia, when distinct, destruc- 
 tion of the skin is rare, but may occur. There is reason to infer 
 that it takes place in eonsequence of a true process of ulceration. 
 
 According to the observation of John Hunter, there is another 
 mode in which destruction of the corion, and a permanent scar may 
 be effected. “ The most eertain character,” that is the most cer- 
 tain pathological character, ‘‘ of the small-pox,” says this writer, 
 “ is the formation of a slough, or a part becoming dead by the vari- 
 olous inflammation, a circumstance which hitherto, I believe, has 
 not been taken notice of. This was very evident in the arms of 
 those who were inoculated in the old way, where the wounds were 
 considerable, and were dressed every day ; which mode of treat- 
 ment kept them from scabbing, by which means this process was 
 easily observed ; but in tbe present method of inoculation it is 
 hardly observable. The sore being allowed to scab, the slough 
 and scab unite and drop off together. The same indistinctness at- 
 tends the eruptions on the skin ; and in those patients who die of, 
 or die while in the disease, where we have an opportunity of exa- 
 mining them while the part is distinct, this slough is very evident. 
 This slough is the cause of the pit after all is cicatrized ; for it is a 
 real loss of substance of the surface of the cutis, and in proportion 
 to this slough is tbe remaining depression.” 
 
 ‘‘ The chicken-pox comes the nearest in external appearance to 
 the small-pox ; but it does not commonly produce a slough. As 
 there is generally no loss of substance in this case, there can be no 
 pit. But it sometimes happens, although but rarely, that there is 
 
SKIX. 
 
 523 
 
 a pit in consequence of a chicken pock ; then ulceration has taken 
 place on the surface of the cutis, a common thing in sores.”* 
 
 The circumstance of a slough at the bottom of each pock or in- 
 flamed point has been particularly insisted on by Joseph Adams, a 
 most zealous admirer of the pathology of Hunter, and an active 
 commentator on his principles. “ We have before seen,” says 
 Adams, “ that the peculiar property of some morbid poisons is to 
 produce death in a part, whether the inflammation be violent or 
 not. Of this kind is the small-pox, every individual pustule of 
 which is found with a slough at the bottom, which may be removed 
 with ease, after time has been allowed for its separation by suppu- 
 ration. The progress of the small-pox is therefore to form a num- 
 ber of sloughs under the skin, (on the cuticular or outer surface of 
 the corion,) and the danger depends on the number formed, and 
 the violence which the constitution suflfers from the first shock of 
 that stimulus which excites it into this process. If the stimulus of 
 the small-pox virus is moderate, its local action follows by adhe- 
 sive inflammation and slough ; after which, the parts and constitu- 
 tion have sustained the first shock, and the subsequent process of 
 suppuration, to separate the slough, is accomplished with so much 
 ease, that the constitution is rarely sensible of any general incon- 
 venience. But the face having sustained the first shock, the actions 
 on that part began with the greatest rapidity, and continue so 
 throughout their whole progress ; in consequence of which the pus 
 has a higher tinge, and the progress of skinning beginning as soon 
 as the slough begins to separate, this irregularity produces an in- 
 equality in the surface of the pustule. On the contrary, the actions 
 being slower in other parts, the pustules acquire the property of 
 common sloughs, and granulation follows suppuration for the re- 
 storation of the lost part.”f 
 
 According to the observations of Cruikshank, this white slough 
 is not situate in the corion, but in a vascular membrane exterior to 
 it, and immediately beneath the cuticle. This anatomist macerated 
 in water for a week several portions of small-pox skin, which he had 
 previously injected, and kept for some time in spirits. “ The spirits 
 with which they had been impregnated made them resist the efiects 
 of this water longer. Cluticle and rete mucosurn w'ere already tuimed 
 down ; and upon the eighth or ninth day I found I could separate 
 a vascular membrane from the cutis, in which were also situated the 
 
 * Philosoph. Transactions, VoL LXX. p. 133. Mr Hunter’s account of a woman 
 who had small-pox during pregnancy. 
 
 t Morbid Poisons, p. 364, 
 
524 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 injected small-pox pustules. These last consisted of circles of long 
 floating villi at the circumference, but of a white uninjected sub- 
 stance in the centre. This central part Mr Hunter had previously 
 said was a slough formed by the irritation of the variolous matter.”* 
 He subsequently comes to the conclusion, that on the surface of the 
 skin (corion) lie five membranes, the outermost of which is cuticle, 
 the next two-fold is 7-ete mucosurn^ and the fourth is the first vascu- 
 lar membrane in whicb the small- pox pustules are chiefly seated. 
 
 From these facts and observations, as well as those which it has 
 occurred to myself to make, the following conclusions may be drawn. 
 
 The phlyctidium or pustule of small-pox consists of a cutaneous 
 inflammation, which may produce ; — 
 
 Is?, Secretion of puriform fluid without permanent injury or de- 
 struction of the corion. In lenticular chicken-pox, and distinct 
 small-pox, there is no doubt tliat though suppuration takes place 
 from the cuticular surfoce of the corion, it is not necessarily con- 
 nected with destruction or ulceration of that membrane. 
 
 2d, Suppurative iilceration of the corion. In conoidal chicken- 
 pox, in some instances of distinct small-pox, and in many instances of 
 small-pox partially or wholly confluent, each pock proceeds to ul- 
 ceration of the corion. It does not appear that the pock slough de- 
 scribed by Hunter is present in every case. It is admitted by Adams 
 to be wanting in the vesicular small-pox, which appear after cow- 
 pox, and in some other occasions. 
 
 3fZ, Death of numerous spots of the corion constituting sloughs. 
 In some cases of distinct small-pox this has been observed ; but it 
 is most frequent in tbe confluent eruption. It then appears in the 
 form of a white circular patch lying at the bottom of each pock. 
 
 4?A, Along with sloughs at individual points, an extensive spread- 
 ing redness of the skin rapidly terminating in sloughs of irregular 
 shape and limits not unfrequently occurs in certain bad forms of 
 variolous eruption. 
 
 b. Oriental plague I place among the examples of pustular cuta- 
 neous inflammation, because the carbuncle to which its poison gives 
 rise, is, I conceive, an instance of punctuate inflammation of the 
 corion. I am aware that Willan, and after him Bateman, placed 
 this disease among the order of tubercular eruptions. But this 
 they have done, I am satisfied, without due consideration either of -- 
 the characters of the pestilential carbuncle, or of those which they 
 assign to the order of tubercles. 
 
 * Experiments, &c. p. 41. 
 
SKIN. 
 
 525 
 
 From careful comparison of the most authentic accounts of pes- 
 tilential carbuncle, it commences as an inflamed spot in the corial 
 surface and substance. The inflammation of the surface speedily 
 induces sero-albuminous secretion and detachment of the cuticle, 
 which is elevated in the form of a bluish irregular blister ; while be- 
 yond this the skin is of a fiery-red colour, hard, and the seat of 
 searing pain. The simultaneous inflammation of the corial sub- 
 stance speedily kills that membrane, which is then felt in the form 
 of a hard black mass, surrounded by living but highly inflamed 
 skin. This dead portion is afterwards, if the patient survive, de- 
 tached in the form of a mortified slough. The carbuncle of oriental 
 plague seems not to be quite similar to the ordinary carbuncle seen 
 in this country. 
 
 c. Of the disease termed malignant -pustule by the French, and Milz- 
 brand, and Black -Pocks by the German authors, (^Anthrahion ; Nar 
 al-Parsi ; Persian fire,) we can scarcely speak from experience in 
 this country, in which, so far as I am aware, the disease is unknown. 
 From the description given by Enaux and Chaussier, Vicq-D’Azyr, 
 Pinel, Ozanam, Rausch, Hoffmann,* and Regnier,f it appears to 
 consist in inflammation of the outer surface of the corion, speedily 
 depriving that membrane of its vitality. It may commence in one 
 of two modes ; First, as a hard, red, burning, not elevated point, 
 speedily causing bluish or reddish-blue fluid secretion, elevating the 
 cuticle into a purple or pale-blue blister, {plilyctuena ;) Secondly, 
 as a bard, knotty substance slightly elevated into a doughy swell- 
 ing, and causing detachment of the cuticle by similar effusion. In 
 both cases the affected corion undergoes mortification, partial or ge- 
 neral, and is then detached as a foreign body. In some respects 
 this resembles the ordinary carbuncle of this country. But it dif- 
 fers particularly in this, that the malignant pustule {anthrakion,) is 
 ascribed by the best authorities to contagion, and very often is 
 traced to epizootic contagion, or pestilence occurring among the 
 lower animals. Its presence depends on the local application of 
 a morbid animal poison. 
 
 d. The great pock, (ecthyma,) consists in an eruption of red, hard, 
 sore pustules, {phlyzacia,) distinct, seldom numerous, without pri- 
 mary fever, and not contagious. In the three species of ordinary 
 
 * Der Milzbrand, oder Contagiose Caifunkel der Menschen. Von Johann Frie- 
 drich Hoffmann, Oberwundarzt in Bemburg. Stuttgart, 1827. 8. 
 
 De la Pustule Maligne, ou Nouvelle Expose des Phenomenes observes pendant 
 son cours, Par J. B. Regnier de Semur, Cote-d’or, D. M., &c. Paris, 1829. 8. 
 
526 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 {E. vulgare), infantile (^E. infantum)^ and dingy pock {E. luridwnri), 
 the pustules are round or oval hard masses fixed in the substance 
 of the skin, which is red, hard, and swelled, and terminating first 
 in elevation and desquamation of the cuticle, and then in imperfect 
 softening, discharging a serous and generally blood-coloured fluid, 
 which concretes into a foul dark-brown or reddish scab, which at 
 length drops off, leaving the subjacent skin reddish, and marked 
 by a depressed scar, indicating the affection of the corial substance. 
 
 It seems probable that these ecthymatous pustules may occasion- 
 ally be seated in the sebaceous follicles. If so they ought to be ar- 
 ranged under the following head. 
 
 § 7. Cutaneous inflammations originating in the substance of the 
 corion^ sometimes at the bulbs of the hair^ sometimes in the cutaneous 
 follicles, terminating in "partial or imperfect suppuration, with forma- 
 tions of scales, crusts, and occasionally sloughs, and more or less de- 
 struction of the corial tissue. 
 
 The pathological reader may perceive that the last disease, which 
 came under consideration, forms a preparatory step to those of the 
 present order. The hard phlyzacious pustules, by which it is dis- 
 tinguished, denote a more complete affection of the corial substance 
 than is known to take place in any previous cutaneous inflammation; 
 while the slow, crude, and imperfect solution which they undergo, 
 and the discharge of blood-coloured rather than purulent fluid, in- 
 dicate a variety of the inflammatory process different from those 
 already examined, and approaching to those now to follow. The 
 transition, therefore, if not insensible, is at least natural, to a tribe 
 of diseases of which the general character is inflammation of the 
 corion, which, modified in various ways, gives rise to the varieties 
 of disease referred to this kind. The principal modifying circum- 
 stances may be referred either to duration, to circumscription, to 
 difference in kind, or to the integral elements of the skin affected. 
 
 1. The influence of duration is observed in the comparative dif- 
 ference of progress of the common boil, which is rapid, and that of 
 the whelk {acne'), canker (lupus), and yaws (framboesia), which arc 
 slow and tedious. 2. The influence of circumscription or diffusion 
 is evinced in those inflammations which are confined to a spot, and 
 those which spread to some extent. In the whelk and boil the in- 
 flammatory process is restricted to one point ; in carbuncle, on the 
 other hand, it affects a great extent of the corion through its entire 
 thickness. 3. Whether the inflammation of the corial substance be 
 different in one disease from what it is in another, there are few means 
 
SKIN. 
 
 527 
 
 of ascertaining. Though various facts seem to indicate something 
 of this nature, too little is known to justify positive conclusions. 
 
 a. The boil or bile (Die Beule; Furunculus; le Clou; il Ciccione;) 
 may be adduced as an instance of acute inflammation of the corion 
 confined to a certain spot. Pearson admits that its seat is the skin ; 
 but, by afterwards saying that it may occur in any part which 
 abounds in cellular membrane, leaves the alternative either that 
 skin contains this substance abundantly, or that boils may occur in 
 many other tissues. Boyer, by placing its seat in the cellular tis- 
 sue, confounds it with phlegmon. The opinion of Bichat diflFers 
 from either, but partakes of both. This anatomist represents the 
 corion to be penetrated by a great quantity of cellular tissue, which 
 fills its areolcB, and is the exclusive and proper seat of the boil. 
 The truth of this opinion depends on the idea attached to the term 
 cellular tissue. If by this be meant the loose fatty matter with its 
 intersecting threads, on which the inner surface of the corion rests, 
 the opinion is erroneous ; for this is the proper subcutaneous cel- 
 lular tissue. To this, doubtless, the inflammatory action of boil 
 may descend ; but the phenomena and termination of the disease 
 show, that it consists at first of circumscribed inflammation of the 
 corial substance, soon but slightly aflfecting the subjacent cellular 
 tissue. The circumstances which indicate the corion, or its follicles, 
 as the seat of furuncular inflammation are, — the defined knotty tu- 
 mour with which the complaint begins, the minute pustule to which 
 it gives rise, and the imperfect and tardy suppuration with formation 
 of sloughs, and the perforated appearance of the skin. 
 
 In various instances the presence of boils seems to depend on a 
 peculiar aflfection, either of the sebaceous follicles, or of the pilipa- 
 rous sacs. A sebaceous follicle becomes inflamed, and is affected 
 by mortification. It then requires to be ejected as a dead substance ; 
 and, to accomplish the object, suppuration is excited all round. This 
 is a frequent cause of cutaneous boil. The core, as it is called by 
 .surgeons, is the mortified sebaceous follicle. 
 
 Of the same nature and tendency is inflammation of a hair-sac 
 or bulb. When this takes place, it is much disposed to cause death 
 in the sac or bulb, or both. Or one hair-sac or bulb may be at 
 once smitten with death, and then it equally acts as a foreign body ; 
 and, to accomplish its ejectment, suppuration is excited. The fre- 
 quency, with which boils are observed to originate round hairs, is 
 familiar to many observers. 
 
 It is further to be remarked, that the boil of the sebaceous fol- 
 
528 
 
 GENERAL AND rATHOLOGlCAL ANATOMY, 
 
 licle is often induced by full or rather gross living, by the transi- 
 tion from moderation to some degree of excess ; and sometimes 
 boils are critical, as in diseases of the lungs, and in some of those of 
 the alimentary canal. 
 
 b. Of the same nature are the inflammatory tumours termed Epi- 
 nyctis and Terminthus mentioned by all authors almost from Celsus 
 to Wiseman. 
 
 c. Though in this place I notice carbuncle as an example of spread- 
 ing inflammation of the substance of the corion, yet the question 
 of its precise seat is not free from ambiguity. Hunter believed it 
 to begin in the skin, and going deeper to affect principally the cel- 
 lular membrane, in which it caused mortification ; and with this 
 Pearson agrees. Boyer places it in the integuments and subcuta- 
 neous cellular tissue ; while Monteggia, who repeats the fact that 
 it destroys a considerable portion of the teguments and cellular 
 substance down to the muscles, seem to regard it as a peculiar 
 action affecting several tissues simultaneously and successively. 
 
 The statement of Hunter I was at one time disposed to regard 
 as exhibiting a just view of the pathology of carbuncle, and to 
 think that Willan laboured under a mistake in referring the seat 
 of carbuncle to the skin. From observing the progress of several 
 carbuncles from their origin to their termination, and from cutting 
 them open more than once and examining their morbid relations 
 as carefully as it is possible to do in the living body, I am satisfied 
 that the opinion of Hunter is not correct, and that that of Willan 
 is not altogether wrong. In several carbuncles which I have ob- 
 served from the beginning, the inflammatory action commenced in 
 the skin in the form of a hard knotty pustule ; a circumstance 
 which corresponds with the admission of Hunter. If cut open at 
 this time, which may be done not only with safety, but with benefit, 
 the corion is found to be thicker than natural, much redder, and 
 more vascular ; and these marks of inflammation pervade not only 
 the substance of the corion to a considerable extent, but the sub- 
 cutaneous cellular membrane in a slighter degree. This inflam- 
 mation of the cellular membrane spreads indeed along with that 
 of the skin ; but it also kills this tissue almost immediately, or at 
 least speedily gives it the usual appearance of mortified matter. 
 At the same time, the inflammation of the corion extending quickly, 
 kills at least its exterior surface ; and Hunter is inaccurate in say- 
 ing that the skin does not die, but gives way by ulceration. Death 
 of the corion is an early effect of carbuncular inflammation ; and 
 
SKIN. 
 
 529 
 
 though it does not preclude the formation of ulcerated openings, 
 it may take place without them. According to my own observa- 
 tion, death takes place most generally in patches of the corion, 
 which may afterwards burst as it were by distension ; ulceration 
 takes place at points which have not been killed, and in general at 
 the union of the dead and living skin. 
 
 There is no ground for believing that the subcutaneous cellular 
 membrane is killed by the confinement of matter in its cells, as 
 Hunter imagines. The ordinary mode in which this appears to 
 take place is by tbe spreading inflammation of the corion, extending 
 along its lower surface, and producing death, as it appears to do 
 in diflPuse inflammation, in which it spreads and does not readily 
 cause suppuration. 
 
 Upon the whole, it may be concluded that the corion is the pri- 
 mary seat of disease in carbuncle, and that the affection of the cel- 
 lular membrane, with which it is uniformly accompanied, is the ef- 
 fect of inflammation of the corial tissue spreading to the adipose 
 membrane. 
 
 4. Diseases affecting chiejiy the sebaceous follicles. — These, which 
 are acne, sykosis, and molluscum.i show the influence of texture or 
 the elements of the skin affected. 
 
 The whelk {acne ; ionthos ; varus, vari, Celsus ;) consists of mi- 
 nute portions of corion, round, oval, or spheroidal, hard, circum- 
 scribed, and elevated. Of the four sorts enumerated by Bateman, 
 three only, the simple (A. simplex), the inveterate {A. indurata), 
 and the crimson (A. rosacea)^ can be considered as examples of in- 
 flammation of the substance of the corion ; and even these are affec- 
 tions of the cutaneous follicles. 
 
 d. Acne simplex and Acne indurata are manifestly affections seat- 
 ed in the sebaceous follicles of the skin, and appear to consist partly 
 in changed secretion in the surface of these minute glands, partly 
 in chronic inflammation of the substance of the glands. 
 
 They may appear either on the face or on the person. Their 
 character is that of small tumours or tubercles, mostly ovoidal, si- 
 tuate in the follicles, the orifices of which are swelled and closed. 
 They are chronic in duration and slow in progress ; and often, 
 when they begin to appear, they continue to distress the patient for 
 years. Their appearance is believed to be connected with some 
 deranged state of the alimentary function. 
 
 When this eruption appears on the person, it is chiefly the pos- 
 
 L 1 
 
530 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 terior surface of the trunk which the pustules occupy. They then 
 appear in the form of oblong ovoidal tubercles, with the long dia- 
 meter corresponding to the axis of the body. There also they are 
 slow in progress. It is possible by a glass, sometimes by the eye, to 
 recognize the orifice of the follicle closed ; and the follicle swelled 
 and enlarged all round. In general these swellings undergo slow 
 and partial suppuration ; and in some severe cases, the follicle is 
 mortified and ejected by suppuration, like a' part deprived of life. 
 
 Both the simple and indurated whelk may produce ulcerative 
 destruction of the true skin, and leave a smooth depressed scar ; 
 and I have seen them by extending to the roots of the hairs ren- 
 der the skin entirely depilous. 
 
 The black whelk (Acne punctata), doubtless arises from disease 
 and obstruction of the mucous follicles, or sebaceous glands. 
 
 Demodex Folliculorum. Follicular worm . — A singular circum- 
 stance relating to the sebaceous follicles of the face and their dis- 
 eases, is the fact that they become the residence of a peculiar spe- 
 cies of parasitical animal or worm, not dissimilar in appearance to 
 the grub of a common fly. The existence of this animal in the 
 sebaceous follicles of the face was first discovered in 1842 by Dr 
 Simon of Berlin ;* and since that time it has been repeatedly seen 
 by observers in this city, and is fully described by Mr Owen. 
 
 The animal belongs to the lowest organized forms of the order 
 Arachnida ; and like the parasitic Cymothoe and Bopyrus of the 
 Crustaceous class, makes a transition from the Annelides to the 
 higher Articulata. In length the animal, which has been named 
 the Demodex folliculorum, ranges from one-fiftieth to one-hundredth 
 part of one inch. The head and mouth are confluent with the ab- 
 domen. The thoracic appendages, eight in number, as in the Ai’- 
 ticulata, are simple and rudiniental, and are terminated by three 
 short setoe. The integument of the abdomen is minutely annulat- 
 ed. The mouth is suctorial and proboscidiform. The entozoon 
 occupies the hair follicles and the sebaceous follicles.f 
 
 e. The crimson whelk (A. rosacea, gutta rosea ; dartre pustuleuse 
 couperose of Alibert), is an affection rather complicated ; and I 
 doubt whether it is justly classed with those now mentioned. It is 
 doubtless an affection of the corial substance ; but it commences 
 
 * Muller’s Archiv fur Physiologie. Berlin, 1842. P.218. 
 
 t Lectures on the Comparative Anatomy and Physiology of the Invertebrate Ani- 
 mals. By Richard Owen, Esq. &c. London, 1843. 
 
SKIN. 
 
 531 
 
 with redness and slight diffuse swelling of the skin of the nose and 
 cheeks, not unlike that of erythema marginatum. This is followed 
 by the appearance of two or three small seedy particles very hard, 
 but red and tending to suppurate, which they at length do partial- 
 ly at their summits, while the base remains hard, red, and firm. 
 As the red appearance of the skin spreads, the roughness increases ; 
 fresh particles of the same seedy consistence arise and undergo the 
 same course; and some coalescing form broad tubercular blotches 
 of a crimson or livid colour, and irregular notched surface. The 
 skin is not, however, in this state at all times permanently red. I 
 have seen this affection in patches on the cheeks and nose so light 
 coloured, that in the morning it could not be recognized ; but in 
 the latter part of the day, after taking wine, and becoming warm, 
 they assumed an intense red inclining to crimson. In the advanced 
 stage, when numerous tubercles appear, and the surface is gene- 
 rally rough and red, the skin swells diffusely and becomes doughy, 
 and is traversed by tortuous purple veins ; the nose is enlarged ; the 
 nostrils become distended, their surface notched into lobular masses ; 
 the red hard bodies of the cheeks become large and coherent ; and 
 the whole countenance is converted into a crimson tumid mass, in 
 which the original features are prodigiously deformed. These 
 whelks do not often undergo suppuration, but are constantly cast- 
 ing the cuticle in the form of peelings, or scales, or crusts. When 
 suppuration occurs it is liable to terminate in bad and intractable 
 sores. 
 
 f. The chin and scalp whelk, (Sykosis ; Mentagra ; dartre pustu- 
 leuse mentagre,) consists in chronic pustular inflammation of the 
 substance of the corion at the bulbs or conduits of the hairs, and 
 probably of various sebaceous follicles besides.* 
 
 g. On the subject of molluscum contagiosum much information has 
 been recently communicated by the researches of Dr Robert Pater- 
 son, Dr Reid, and Dr A. Thomson. 
 
 According to the observations of Dr Paterson the appearance of 
 the bodies commences in the shape of minute pearly granulations, 
 which increasing in size, become more of the natural colour of the 
 skin. When as large as a vetch, on their apices appears an open- 
 ing emitting a whitish milky fluid. Their size varies from a pin- 
 head to that of a hazel-nut ; and their progress in attaining the 
 largest size, though varying, is slow. 
 
 * Celsi, Lib. vi. 3. 
 
532 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 The structure of the small bodies is that of numerous cells se- 
 creting the milky fluid, which under the microscope is entirely com- 
 posed of nucleated cells oblong or ovoidal in shape. These are 
 about one- thousandth part of one inch in diameter.* 
 
 From the position which the tubercles of contagious molluscum 
 occupy in the face, it seems certain that they are seated in the fol- 
 licles. They are generally found round the lips, or on the chin, 
 near 'the nose, and in those situations in which the follicles are 
 mostly placed. 
 
 h. The chronic soft tubercle {rnolluscum diuturnurn)^ is a rare 
 disease ; and I have seen only one example of it in the person of a 
 man of 40, in whom these bodies were disseminated over the cu- 
 taneous surface of the face and scalp, the trunk, the upper extre- 
 mities, the nates and thighs. Of two of the larger tumours which 
 were removed from the palpehi'ce^ the greater part was composed 
 of firm, tough, whitish gray matter of the consistence of condensed 
 cellular texture, penetrated through its whole extent by numerous 
 minute blood-vessels, but exhibiting in no other respect traces of or- 
 ganization. This substance, when macerated in water, was resolved 
 into gelatinous, flocculent filaments, easily lacerable, and present- 
 ing no definite sti’ucture. Imbedded in this, and removable most 
 easily by maceration, were several small bodies not larger than a 
 pin-head like fat in appearance, of a regularly spheroidal shape, of 
 a lemon-yellow colour, and specifically lighter than water. The 
 matter of these bodies was unctuous. It communicated an oily 
 stain to paper ; it liquefied and became transparent at a temperature 
 not exceeding 97° Fahrenheit, so that, when attached to the body, it 
 must have been fluid ; it was insoluble in alcohol, ether, and water, 
 but formed in the volatile oil of turpentine a colourless solution. 
 When this was exposed to the temperature of the spirit-lamp, the 
 greatest part of the volatile oil was evaporated, leaving a transpa- 
 rent, colourless, but viscid and semifluid substance, communicating 
 to paper a stain becoming less deep, but not wholly removable by 
 exposure to a high temperature. These results favour the idea 
 that the matter of these bodies is oleaginous; but I was unable to 
 observe any action of aqua potasscB or aqua ammonia, after repeated 
 
 ■* Cases and Observations on the Molluscum Contagiosum of Bateman, \vith an Ac- 
 count of the Minute Structure of the Tumours. By Robert Paterson, M. D. Edin- 
 burgh Medical and Surgical Journal, Vol. LVI. p. 279. Edinburgh, 1841. 
 
 f Du Molluscum Recherches Critiques sur les formes, la nature, et le traitement des 
 AlFections Cutanees de ce nom. Par Maximihan-Maurice Jacobovics, Docteur Me- 
 decin de la Faculte de Pesth. Paris, 1840, 8vo. 
 
SKIN. 
 
 533 
 
 trials, both at the ordinary temperature of the atmosphere, and 
 when liquefied by a gentle heat. By the sulphuric acid it is har- 
 dened and blackened; by the nitric acid its yellow colour is rendered 
 more intense.* 
 
 Whether the presence of these yellow adipocirous bodies is 
 uniform in the molluscum I have had no subsequent means of ascer- 
 taining. If they are, it may be reasonably conjectured, that their 
 formation depends on some morbid or vitiated state of the sebaceous 
 follicles. I have indeed no doubt that in the case referred to the 
 small tumours consisted in lesion of the cutaneous follicles. 
 
 i. Under the head of canker, lupus ^ (iioli me tangere^ wolf of 
 Wiseman and others, dartre rongeante, Pinel and Alibert,) may be 
 noticed a disease consisting in hard elevated tubercles set in the 
 corion, from which they appear to grow. The name of noli me 
 tangere is applied by Wiseman to a “ small round acuminated 
 tubercle” without much pain, unless when “ touched, rubbed, or 
 otherwise exasperated by topics.” Though most frequent on the 
 face, it may occur on other parts. One of these, of a bluish 
 colour, and looking like a vein, appears from the description to 
 have been of the nature of erectile tissue. 
 
 One example of bluish spherical tubercle I have seen in the 
 person of a woman of about 65 years of age, otherwise healthy. 
 It was situate on the side of the nose near the middle of the nasal 
 bone. It appeared first in the form of a small red prominence less 
 than a pea, but gradually shot up from the skin, so as in the course 
 of twenty months or two years from its commencement, to project 
 at least one-third of an inch from the surrounding skin. It was 
 then round or spherical, smooth, and even shining, and of a blue 
 or light purple colour, which, on close examination, wms derived 
 from numerous minute vessels. It was connected to the skin by a 
 neck, the base being narrower than the summit, but did not adhere 
 to the bone. What was the ultimate fate of this person I did not 
 learn ; but no doubt can be entertained that if life were continued 
 a sufficient time, the tubercle would terminate in destructive fun- 
 gating ulceration. 
 
 I have seen also many cases of ragged ulceration of the coun- 
 tenance, and one or two in the incipient state before it spread to 
 
 • A good painting of the subject of this case was made by my late friend, Staff- 
 Surgeon Schetky, and by him deposited in the pathological collection of Chatham 
 Hospital. 
 
534 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 any extent. One mode in which this disease appears to commence 
 is by the formation of a patch of hard red skin, slightly but diffusely 
 swelled, and which is the seat of a hot, gnawing, smarting sensa- 
 tion. Though smooth on the surface, it is found by examination 
 to be irregular, or very soon becomes so by the formation of small 
 hard round bodies, (pustulo-tubercular), which after some time begin 
 to be acuminated, and cast the cuticle in thin peelings. Occasion- 
 ally they give rise to thin watery vesicles of no determinate shape, 
 which cither burst the cuticle and discharge their fluid, or appear 
 to cause an insensible dewy oozing all over the surface. The most 
 usual seat of this form of cutaneous inflammation is the side of the 
 nose, one of the alae^ or a small portion of the cheek. After sub- 
 sisting in this form for some time, it may disappear spontaneously, 
 the skin becoming of its natural colour, soft and without pain. 
 More frequently, however, the cuticle continues to be cast off in 
 peelings ; vesicles and pustules continue to be formed ; and one or 
 other more red and painful than the rest is at length covered by a 
 scab, which dropping off discloses a small sore with a smooth un- 
 granulating surface, and a scanty, thin, bloody-coloured, puriform 
 discharge, which generally forms a fresh crust or scab. This either 
 spreads without showing any disposition to heal, or coalesces more 
 or less completely with other sores which are generated in the same 
 mode, and undergo the same process. After proceeding in this 
 manner for weeks or months, a tendency to heal is manifested in 
 some parts, while others continue to spread. The parts which heal 
 are irregularly seamed and scarred. This form of disease appears 
 to correspond with what Wiseman describes under the name of 
 Herpes Exedens. 
 
 k. Another form of local pustulo-tubercular disease I have seen 
 take place on the skin of the face, generally on the forehead, in 
 the form of round hardish bodies, with flat summits, to the number 
 of eight, ten, or twelve, disposed in a circular arrangement. The 
 surface of the skin was red, glossy, and occasionally casting cuti- 
 cular scales and shreds. These bodies were stated to be the seat 
 of an uneasy sensation of heat rather than of pain. They had 
 not advanced to ulceration. Upon removal by the knife, they be- 
 came pale, white, and considerably shrunk. Internally they con- 
 sisted of gray coloured substance, interspersed with a few blood- 
 vessels, not hard, so much as doughy, tough, and fibro-cartilagi- 
 pous. They did not, nevertheless, present the characters of car- 
 
 1 
 
SKIN. 
 
 535 
 
 cinoma, but seemed to consist in an inflammatory induration of the 
 corial tissue. 
 
 On the anatomical characters of the white scall (vitiligo)^ I 
 possess no accurate information. I have often suspected that the 
 appearances referred to this disease are in truth the effects of others 
 more known. 
 
 1. (Yaws) {frambcesia\ consist in chronic inflammation of the 
 corion taking place in circumscribed spots, attended partly with death 
 of a portion of the corial substance, partly with growth of granular 
 fungi, — the result of a peculiar morbid poison. 
 
 On the nature and characters of this disease much misconception 
 has prevailed, chiefly fi'om the erroneous notions to which its sta- 
 tion, in the arrangement of Cullen, gave birth. These were first 
 corrected in 1791 by Dr Jonathan Anderson Ludford, who showed 
 that yaws is a true cutaneous inflammation, which, though more 
 chronic, yet, like small-pox and other acute cutaneous eruptions, is 
 preceded by febrile motions, and observes regular periods of acces- 
 sion, height, and decline.* The general accuracy of these facts has 
 been confirmed bythe testimonyof Dr William Wright, f Dr Winter- 
 bottom,! Dr Joseph Adams,§ and Dr James Thomson, || who ob- 
 served the phenomena of the disease in negroes or Europeans in 
 the West Indies or elsewhere. Dr Dancer, who admits that they 
 seldom make their appearance without previous indisposition, alone 
 doubts the propriety of comparing them with small-pox and other 
 eruptions. IF 
 
 It cannot be doubted, that the appearance of yaws is invariably 
 preceded by more or less indisposition, — as languor, pains of the 
 limbs like those of rheumatism, chillness or shivering succeeded by 
 general heat and uneasiness, amounting in most cases to fever, and 
 always more severe and distinct in children than in adults. The 
 first trace of eruption is a white mealy scurf covering the whole 
 cutaneous surface. A few days after small firm pimples may be 
 
 • Tentamen Med. Inaug. de Framboesia et Jon. Ludford Ed. 1791. 
 
 Apud Adams on Morbid Poisons. 
 
 X Account of the Native Africans, &c. by T. M. Winterbottom, M.D. London, 
 1803, Vol. II. c. viii. 
 
 § Observations on Morbid Poisons, &c. by Jos. Adams, M.D. 2d Edit. Lond. 1807, 
 chap. xvi. 
 
 II Observations and Experiments, &c. Med. and Surg. Jom'nal, Vol. XV. 321, and 
 XVII. 31. 
 
 H The Medical Assistant, &c. by Thomas Dancer, M.D. Kingston, 1801, chap. ix. 
 p. 201. 2d Edition. St Jago de la Vega, 1809. P. 226. 
 
536 
 
 GENERAL AND PATHOLOGICAL ANATOJIY. 
 
 seen on the forehead, face, neck, groin, and round the anus. 
 These increase for six or ten days, when their tops are covered by a 
 crust ; and an opaque whitish fluid, which is ill formed matter, may 
 be recognized. Thus converted into pustules, they gradually en- 
 large, still covered by crusts, which are loose and irregular, until 
 they attain the size of a sixpence or even of a shilling, — the largest 
 being in general those which apjjeared first. If in this state the 
 crust be removed, it exposes a foul sloughy sore, or, according to 
 Adams, a rough whitish surface consisting partly of slough, partly 
 of living animal matter. The pustules may also burst spontane- 
 ously, and discharge thick viscid matter, which hardens into a foul 
 crust or scab on the surface. In the large pustules from this sur- 
 face at length shoots up a red granulated excrescence composed of 
 minute lobes, not unlike a wild rasp or mulberry, which is the 
 proper yaw, and gives the disease its peculiar appearance and cha- 
 racter. Its size varies according to that of the pustule from which 
 it rises, from a pea to that of a mulberry of considerable dimen- 
 sions. Its colour also varies according to that of the general health 
 of the subject. In the healthy and robust it is red like a piece of 
 flesh and prominent ; in the weakly and puny it is pale and white 
 like a piece of cauliflower, not elevated, and bleeds on the slightest 
 touch. The yaw-fungus has little sensibility, and does not smart 
 when capsicum-juice is applied, never suppurates perfectly, but 
 discharges a sordid glutinous fluid, which dries into a scab round 
 the edges of the excrescence and covers its upper part, if much 
 elevated, with white sloughs. This glutinous fluid is the proper 
 yawey matter, and communicates the disease by inoculation. 
 
 The time at which the fungous granulation rises is irregular. 
 Thomson met with it so early as one month and so late as three 
 after the first appearance of the eruption ; and he concludes that 
 its formation cannot be taken as a mark of the second stage of the 
 disease, as was thought by Adams.* Each pustule, as it attains a 
 certain size, undergoes the same process. After remaining some 
 time, the yaw gradually contracts, diminishes in height, and, as the 
 pustule heals, is finally covered by skin. It leaves in general no 
 mark except in those places in which inflammation has been violent, 
 when a scar similar to that of cow-pock, but broader and more su- 
 perficial, is left. 
 
 This description shows not only that yaws are an inflammatory 
 * Morbid Poisons, p. 201. 
 
SKIN. 
 
 537 
 
 disease of the skin, but that they are not, strictly speaking, an ex- 
 ample of tubercular disease of that membrane, as in the arrange- 
 ment of Willan is erroneously represented. The phenomena show 
 that they consist in an inflammatory process of the corion, com- 
 mencing in minute points, and gradually spreading in extent and 
 penetrating in depth, till it generates a peculiar morbid product, 
 which, after undergoing certain changes, is at length spontaneously 
 removed, and allows the sore to heal. Thomson justly remarks, 
 that the disease is first papular, then pustular, and afterwards con- 
 sists of yaw, though the latter is not constant, as the ulcer may 
 heal without this substance, when it must be accounted pustular. 
 At no period does it appear to be tubercular; for the yawey growth, 
 to wTich alone this term can be applied, is rather an effect of the 
 pustular or chronic corial inflammation modified by the proper 
 yawey action. It may, in short, be inferred, that when the yawey 
 action is sufficient without being excessive, it generates the proper 
 fungous growths, under which the corion is either not materially 
 injured or is regenerated ; if the action be too violent, this growth 
 is either destroyed or prevented from appearing ; and in either 
 case the corion is irreparably injured. 
 
 m. Siwens, though a disease affecting not only the skin, but the 
 fibro-mucous membranes, is entitled to notice in this place, as caus- 
 ing cutaneous inflammation not dissimilar to that of yaws. Like 
 most inflammations depending on the action of a morbid poison, 
 when it affects the constitution it induces inflammation of the corion 
 in the shape of pustules terminating in bad ulceration and sloughs, 
 — of furuncular tubercles and ulcers, — and of pustular sores afford- 
 ing the raspberry granulating fungus. * 
 
 § 8. Cutaneous inflammations, chronic, affecting at once the sur- 
 face and the substance of the corion, and attended with general af- 
 fection of the fibro-mucous tissues. 
 
 Of the disorders which I refer to this head, several are so similar, 
 that they are probably to be viewed as varieties of the same morbid 
 action. Of this kind are the Radesyge, Spedalsked, Liktraa or 
 northern leprosy, the Pellagra or Lombard evil, the Scherlievo of 
 the same place in Italy, the ]\Ial di Rosa of Asturia, and a cuta- 
 
 * Gilchrist in Essa) s and Observations, Phys. and Lit. Vol. III. Art. xi. Ed. 1771. 
 
 Diss. Inaug. de Syphilitide Insontium, &c. Auct. A. Freer. Ed. 1776. 
 
 Cases in Surgerv', &c. By James Hill, Snrgeon. Ed. 1772. 
 
 Observations on !Morbid Poisons, &c. By Joseph Adams, M. D. London, 1807, 
 Chap. XV. 2d Ed. 
 
538 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 neous disorder prevalent in Grim Tartary. In whatever points 
 these disorders differ, all of them agree in being preceded by dis- 
 tinct febrile commotion, in consisting of inflammation affecting the 
 corion in definite points, and in causing at the same time more or 
 less inflammation, punctuate or diffuse, of the mucous and fibro- 
 mucous membranes of the nasal cavities, the throat, the Eustachian 
 tube, and tympanal cavity. 
 
 In these diseases the affection of the corion is neither pustular 
 nor tubercular, but consists in inflammation of its substance occur- 
 ring in many minute points, and causing first an appearance like 
 papulae, or sometimes only an extensive diffuse redness and rough- 
 ness of the skin ; then desquamation of the cuticle ; then pustulo- 
 tubercular or minute hard eminences seldom suppurating com- 
 pletely, but sometimes causing, partly by sloughing, partly by ul- 
 ceration of the corion, deep foul sores, destroying the corial texture 
 and the bulbs of the hair. This is particularly the case in the Ra- 
 desyge, the form of disorder prevalent in Iceland, the Scandinavian 
 peninsula, the Feme Islands, and the peninsula of Jutland. In 
 those prevalent in Italy, Asturia, and Grim Tartary, ulceration of 
 the corion appears to be less frequent. 
 
 The limits of this treatise do not permit me to enter at large into 
 the history of these diseases, which are not to be viewed as merely 
 cutaneous affections ; and I shall simply refer to the best sources 
 for further information.* 
 
 * For Radesyge, Dissert. Inaug. de morbo cutaneo luem veneream consecutivam 
 simulante, auctore C. F. Ahlander. Upsaliee, 1806. 
 
 Diss. Inaug. sistens obs. in exanthema arct. vulgo Radesyge, auctore Isaaco Vought. 
 Gryphese, 1811. 
 
 Geograpbische Nosologie von Fried. Schnurrer, M. D. p. 440. 
 
 Morbus quern Radesyge vocant, &c. Commentatio Auctore Fred. Holst, M. D. 
 Christianiae, 1817. 
 
 Ueber die Aussatzartige Krankheit Holsteins, &c. Von Ludwig Aug. Struve, M. D. 
 1820. 
 
 Die Radesyge Oder das Scandinavische Syphiloid. Aus Scandinavischen Quellen 
 dargestellt. Von Dr Lud\vig Hiinefeld, Professor zu Greifswalde. Leipzig, 1828. 
 8vo. ^ 
 
 Erkenntniss und Cur des Sogenannten Dithsmarsischen Krankheit. Von Dr E. A. ' 
 
 L. Iliibener, Pract. Aertze en Heide. Alton a, 1835. 
 
 For Pellagra, S. Const. Titii orat. de Pellagrs Pathologia. Viteberg. 1792. 
 
 De Pellagra Obs. quas collegit Caietano. Strambio, 1784-89, Mediol. , 
 
 Franc. Frapolli. Mediol. Animadvers. in Alorbum vulgo Pellagra, Med. 1771. jS 
 N. X. Jansen de Pellagra, Lug. 1787. Frank Delect. Tom. IX. p. 325. ^ 
 
 Holland in Medico- Chirurgical Transactions, Vol. VII. 
 
 For Mai de Rosa, Thierry Observations de Physique et Medecine, Tom. II. Chap. vi. W- 
 
SKIN. 
 
 639 
 
 To this head also may be referred some of the cutaneous erup- 
 tions which occur either among the secondary symptoms of syphilis, 
 or in the persons of those who, for this disease, have been subjected 
 to one or more courses of mercurial medicines. Though these 
 eruptions may appear sometimes in the form of papules, sometimes 
 as a variety of rupia, and sometimes as ecthyma, they are also not 
 unfrequently of the chronic pustulo-tubercular nature, originally 
 taking place in the corion, and causing more or less ulceration of 
 that membrane. Their connection with inflammation of the mucous 
 and fibro-mucous membranes is well known. 
 
 Upon elephantiasis so much accurate information has been col- 
 lected by Dr Adams, Mr Lawrence, and Dr Lee, that little diffi- 
 culty can be experienced in settling its characters as a morbid 
 state of the skin. The case described so well by the last of these 
 observers, 1 had repeated opportunities of seeing; and the appear- 
 ance of the skin could leave no doubt of the disease affecting the 
 substance of tbe corion. The exact nature of this affection is per- 
 haps less easily determined. By calling it a tubercular eruption, 
 after the manner of Dr Bateman, little exact information is com- 
 municated. Bichat states that he has seen the corion manifestly 
 disorganized in elephantiasis,* but says nothing of the anatomical 
 characters of this disorganization. Pinel, Bedard, and Meckel, 
 are equally silent on this subject. In short, though we have good 
 descriptions of the external visible appearances of Arabian leprosy, 
 an accurate description of its anatomical characters is still a desi- 
 deratum. 
 
 Wart and corn are believed to depend on morbid accumulation 
 of cuticle. The former, however, is vascular at its basis ; and it 
 may therefore be inferred that its production depends on morbid 
 action of the surface of the corion at the particular point at which 
 it appears. 
 
 II. § 1. Dermatcemia, Dermatorrhagia . — Hemorrhage of the skin 
 appears under two forms ; either that of a bloody or blood-coloured 
 fluid oozing from certain regions, or of blood eflPused in the form 
 of purple specks, spots, patches, or livid stripes on the surface of 
 the corion below the scarf-skin. The former discharge is rare, 
 and takes place chiefly as a supplementary evacuation to some na- 
 tural one accidentally suppressed, as the menstrual discharge in 
 
 For Scherlievo, Annali Universali de Medecina. 
 
 For Grim Tartary Disease, the Travels of Falk, Gueldenstadt, and Pallas. 
 
 * Anat. Generale, Tome IV. p.'688. 
 
540 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 females. The latter is of a different nature, and is both the effect 
 and proof of a morbid state of the system. 
 
 Restricted in this manner, hemorrhage from the corion may 
 take place in two modes ; either when the corion only is affected, 
 or when it is affected in common with many other membranes. 
 The first case constitutes the simple purple disease {purpura sim- 
 plex) of authors ; of the second we have examples in the hemor- 
 rhagic purples {purpura hemorrhagica) or land-scurvy, and in the 
 genuine sea-scurvy, {scorbutus.) 
 
 The anatomical characters of the disease consist in bright red or 
 crimson spots, becoming in a day or two purple or livid, afterwards 
 brown, and when about to disappear, assuming a yellow tint. They 
 are occasionally attended with long livid stripes {vibices, molopes), 
 or patches {ecchymomata ;) and in some instances the cuticle is 
 raised into vesicles or large purple blebs, {phlyctcence,) containing 
 bloody or purple serous fluid. These spots consist of blood or 
 bloody fluid, effused on the outer surface of the corion, which is 
 soft or pulpy, velvety, and reddish, from injection of its vessels. 
 
 § 2. Angiectasis . — Anastomotic aneurism is frequent in the corion, 
 and has been observed by J. Bell, Freer, Travers, and Wardrop. 
 Though congenital, it must not be confounded with the ncevus ma- 
 ternus or birth-spot {Venvie.,) which appears to consist in a peculiar 
 original malformation of the corion. A similar congenital defect 
 is the white-spot {leucosis.^ leuccethiopia,) which consists in the ab- 
 sence of the polished vascular surface of the corion. Occasionally 
 it takes place during life, and in minute spots is observed to follow 
 diseases in which the cuticular surface of the corion has been de- 
 stroyed by ulceration. 
 
 III. Tumours . — § 1. Meliheris ; Cutaneous or Follicular Wen. 
 The only encysted tumour which takes place in the skin consists in 
 the immoderate enlargement of one or more of its mucous follicles, 
 in consequence of obstruction of the excretory duct. When from any 
 cause this takes place, the sebaceous matter, which in the healthy 
 state is propelled to the surface and removed, accumulates in the 
 interior of the follicle, which is thus inordinately distended, till by 
 removing tbe obstruction the orifice is opened and the inspissated 
 matter eliminated. It almost invariably again accumulates, unless 
 care be taken to keep the excretory duct pervious, — an object which 
 is most easily and certainly attained by frequent ablution. This 
 mode of explaining the origin of the cutaneous folliculated tumour 
 
 3 
 
SKIN. 
 
 541 
 
 was understood by Morgagni,* Haller, Plenck,f and Monteggia,$ 
 and has been recently revived by Sir Astley Cooper. § 
 
 § 2. Keloid or Cheloid Tumour ; {Kells'^ Cheloidea.) — This name 
 has been applied by M. Alibert to a peculiar tumour of the skin, which 
 bears a resemblance to the scar or discoloured, irregular, and puck- 
 ered cicatrix of a burn, or any sore which has healed in similar 
 circumstances. In shape it is oval or cylindrical, generally ele- 
 vated above the level of the skin. The colour is of various shades 
 of red, sometimes deep-red, wine -red, or pink-coloured, and some- 
 times only flesh-red. The surface is irregular, that is, elevated into 
 eminences, with intermediate depressions ; and often it is seamed or 
 scarred. In general, it is a little firmer than the surrounding skin ; 
 but in some cases it presents a sort of velvet-like or spongy softness, 
 which allows it to be pressed. From the margins of the tumour 
 occasionally proceed processes like the feet of an animal ; and this 
 circumstance, with its irregular appearance in general, has been 
 supposed to be the reason, why it is occasionally called the cheloid 
 or crab-like tumour. 
 
 The keloid tumour may consist of one, two, or three portions, 
 the lateral margins of which are deeply implanted in the skin. The 
 surface is hard and in general resisting, communicating a sensation 
 quite diflerent from that of the sound skin. It is void of pulsation, 
 and in this respect difiers fi’om cutaneous ncBvus. 
 
 The origin of this disease, and the causes on which its formation 
 depends, are not well known. It is rarely congenital. When it 
 first appears, it is small, but is liable to enlarge in extent. It pro- 
 ceeds, however, very slowly ; and months or years may elapse be- 
 
 * Adversaria Anatomica. 
 
 t “ Sedes meliceridis,” says Plenck, “ in glandula subcutanea esse videtur. Quic- 
 quid ergo porum excretorium glandulae subcutanese obdurat, contentum succum in- 
 spissat, vel ejus absorptionem impedit, meliceridem producere valet.” Systema Tumo- 
 rum, Cl. vii. p. 153. Viennae, 1767. 
 
 J Istituzione Chirurgiche, Volume ii. § Surgical Essays, Part 2. 
 
 II It is quite uncertain whether this term should be written Cheloid or Keloid. M. 
 Alibert, to whose neological talents we are indebted for the term, gives the followin'’- 
 aynonymes. Kelos ; Cheloide ; Cancroide ; Tvherealea durs ; Cancelli ; Cancrama ; 
 Cancre Mane ; Le Crabe. If the name be derived from the supposed resemblance to 
 the crab, then the orthography is Cheloid. On the other hand, the term Kelis, Macula, 
 a spot, was used by various ancient authors to signify a foul scar or ulcerated mark ; 
 and as one of the characters of the keloid tumour is, that its surface and margins 
 sometimes resemble the cicatrix of a burn, this may be with most propriety regarded 
 as the term from which the denomination for this cutaneous affection should be taken. 
 
542 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 fore much change in its size or appearance can be detected. In 
 some instances its formation has been preceded by a burn or some 
 ulcerative process of the skin ; in some by an attack of small-pox ; 
 in other instances, it is said, by the syphilitic poison affecting the 
 skin. Most commonly it occupies the sternal region; but it has 
 been observed on the face and neck. 
 
 As to the nature of Kelis^ though some have regarded it as allied 
 to cancer, this seems by no means well established. The tumour j 
 has been observed to remain a long time on the body, without 
 showing any tendency to pass into cancerous ulceration. 
 
 § 3. Scirrho-carcinoma of the skin is not uncommon. Though it || 
 may occur in any part of the cutaneous covering, it commences I 
 most frequently in situations where the corion is delicate and thinly 
 covered. The skin of the face, especially of the eyelids, prolabium, i 
 and nose, is a frequent seat of this disorder ; and next to these, per- ! 
 haps, are to be placed the nipple of the female and the penis of the i 
 
 male, the corion of which are liable to be affected by this morbid i 
 
 structure. The scrotum is very often the seat of that peculiar car- 
 cinomatous destruction occurring in the persons of chimney sweep- 
 ers. In all these cases the structure is much the same. 
 
 It may appear either in the shape of tubercular cancer, or in 
 that of reticular cancer. In the former case small hard tubercles i 
 appear to be formed either in the substance of the corion, or in the 
 cutaneous follicles. These coalesce and become elevated, forming 
 a patch of skin, red, hard, irregular, hot, and the seat of stinging 
 pain. After some time, scales are formed on the surface; and 
 along with or after these slight softening takes place. The scales 
 and crusts are ejected ; and in general there is left a hollow, ul- 
 cerating, non-granulating surface, secreting serous fluid, and gra- 
 dually increasing in depth and extent. Commonly two or three tu- j 
 
 bercles, simultaneously or successively, are the seat of this process, I 
 
 so that the part presents several hollow ulcers, with hard, elevated 
 edges beginning to be everted or already everted. 
 
 When the disease assumes the reticular shape it generally affects 
 a considerable portion of skin with hard, scirrhiform swelling, ir- 
 regular in surface, and tending, after some time, to the formation 
 of an ulcerated surface, with sanious discharge, and hard, elevated, 
 everted edges. The internal structure of reticular scirrhus in the 
 skin is similar to that structure in other tissues. 
 
 In the situation of the corion is seen a tough firm substance of 
 
SKIN. 
 
 543 
 
 fibre -cartilaginous structure, the fibrous bands being generally ar- 
 ranged in a waving direction. In the most distinct example of the 
 disease which I examined personally — a case of scirrho-carcinoma- 
 tous degeneration of the whole skin of the penis, these fibrous bands 
 were disposed transversely to the long direction of the part, and ap- 
 peared to consist of a fibro-cartilagiuous long band folded repeat- 
 edly on itself. 
 
 IV. Reproduction. — The reparation of the corion when destroyed 
 has been maintained by many authors. Notwithstanding their as- 
 sertions, however, this membrane is never, after its substance has 
 been injured, restored to its original state. The breach is filled up 
 by firm cellular tissue, the upper surface of which never acquires 
 the organization of the outer surface of the corion. It is neverthe- 
 less capable of furnishing cuticle by which this new corion is co- 
 vered. These facts may be verified in the cicatrization of burns 
 and other injuries in which the corion has been destroyed.* 
 
 V. Parasitical Animals. — By these the skins both of animals and 
 the human race are liable to be infested. One of these proper to 
 the human race, (Demodex Folliculorum) has been already noticed 
 when speaking of acne. Besides these there are others more 
 easily recognized, especially the several species of Pediculi ; the 
 Ped. Capitis ; the Ped. Corporis ; and the Ped. Pubis, or 3fo7'~ 
 piones. These are well known, and require no notice here. Of 
 one parasitical animal, however, the existence has been so much 
 contested for two centuries, that it was alternately admitted and 
 denied, until, by the aid of the microscope, its existence and nature 
 were placed in 1833 beyond the reach of doubt. I refer to the 
 itch insect, (the Sarkoptes scabiei). A rapid notice of the discovery 
 and recognition of this animal is all that can be admitted in these 
 pages. 
 
 For several centuries the inhabitants of tbe south of Europe re- 
 cognized the existence of an insect in itch, and were in the habit of 
 extracting and destroying it. In the 12th century it is mentioned 
 by Abenzohr ; and in the 15th and 16th centuries moi’e or less 
 fully by Ingrassias, Gabucinus, and Laurence Joubert, each of 
 whom agreed in ascribing to the movements and ravages of this 
 animal beneath or within the skin the fierce itching of scabies. 
 
 * Ottonis Huhn Commentatio de Regeneratione, &c. 1787. P. 23, &c. Andre® 
 J. G. Murray, Commentatio de Redintegratione, 1787. P. 50. A Dissertation on 
 the Process of Nature in the filling up of cavities, &c. By James hloore. Member 
 &c. London, 1789. Sect. ii. p. 54, &c. 
 
544 
 
 GENERAL AND PATHOLOGICAL ANATOMT. 
 
 These facts, which were known to the industrious Thomas Mouf ■ 
 fet, are confirmed in 1 634 by the testimony of his own observation ;* 
 and about the same time, Hauptmann and HafenreuflPer noticed the 
 existence of the insect. The fact, nevertheless, appears by many 
 to have been received with scepticism or positively denied ; and 
 even in 1683, when Bonomo addressed to Redi a letter on the 
 existence of the insect of the itch, it was supposed, to be one of 
 those examples of credulity which foreign naturalists occasionally ex- 
 hibit.! Bonomo, nevertheless, had described the animal from nature; 
 and in 1703 his description was communicated to the Royal Society, 
 by Mead,! and afterwards by Baker and Schiebe, in such a manner 
 that showed that the latter two had ascertained the existence of the 
 animal, and examined it by tbe microscope. 
 
 The authority of Bonomo prevailed with various foreign natu- 
 ralists ; and Linnaeus, who admitted the existence of the insect as 
 a species of Acarus or mite, adopted the description of the Italian 
 naturalist. II Bonomo, however, had committed an error in consider- 
 ing the itch insect as similar to the common mite ; and this was rec- 
 tified by De Geer, who in 1778 both established the existence of the 
 
 * “ S3Tones have no certain form ; only they are round. Our eye can scarcely dis- 
 cern them ; they are so small that Epicurus said it was not made of atoms, but was 
 an atom itself. It dwells so under the skin, that when it makes its mines, it will cause 
 a great itching, especially in the hands and other parts affected with them, and held 
 to the fire. If you pull it out with a needle, and lay it on your nail, you shall see it 
 move in the sun, that helps its motion ; crack it with the other nail, it will crack with 
 a noise ; and a watery venom comes forth ; it is of a white colour, except the head; 
 if you look nearer, it is blackish, or from black it is something reddish. It is a wonder 
 how so small a creature that creeps with no feet, as it were, can make such long fur- 
 rows under the skin. This we must observe, by the way, that these syrones do not 
 dwell in tbe pimples themselves, but hard by. For it is their property not to remove 
 far from the watery humour, collected in the little bladder or pimple, and where that 
 is wasted, or dried up, they all die shortly after.” Insectorum sive Minimomm Ani- 
 malium Theatrum, olim ab Wottono Gesnero, et Pennio inchoatum. Folio. London. 
 1634. The Theatre of Insects or Lesser Living Creatures. By Thomas Mouffet, 
 Doctor in Physick. London, 1658. Folio, Chapter xxiv. p. 1094 of Topsel. 
 
 -f- G. C. Bonomo Osservazioni intorno a pellicelli del corpo umano. Florenza, 
 1683. 
 
 G. C. Bonomo Obs. circa humani corporis teredinem. Ephem Nat. Cur. Dec. TI. 
 Ann. X. App. p. 33. 
 
 J An Abstract of part of a Letter from Dr Bonomo to Signor Redi, containing some 
 Observations concerning the Worms of Human Bodies. By Richard Mead, M. D. 
 Phil. Trans, for 1703, No. 283, p. 1296. Vol. XXIII. London, 1704. 
 
 II Linnaeus Exanthemata Viva. Amoenitatis Academicae, V. n. 82, et VIII. p. 73 
 and 283. 
 
SKIN. 
 
 545 
 
 animal, and specified the diflPerential characters between it and the 
 vegetable mite.* * * § In 1786 and afterwards in 1791, Wichmann, a 
 physician at Hanover, published a work on the itch insectt ; and 
 his descriptions were verified by Goeze. 
 
 From the testimony of these observers it might have been ex- 
 pected that the existence of the itch insect was recognized as esta- 
 blished. English dermatologists were, however, sceptical ; and they 
 were supported on the continent by the authority of Sagar, Bal- 
 dinger, Jonasf, Volkraann,§ Harttgann,|| Weise, Alexander, and 
 Mieg; and this feeling was increased by Joseph Adams, who, while 
 he showed that a particular kind of insect(oucao) burrows in the skin 
 in the natives of Madeira, maintained that, as this was not the itch 
 insect, no animal of that kind existed. This scepticism, both among 
 English and French physicians, was much increased by the pro- 
 ceedings of M. Gales, a pupil of Alibert, who, in 1812, presented 
 as the genuine itch entozoon, figures and bodies of the common 
 cheese mite. 
 
 At length, however, in 1831, M. Raspail having discovered in 
 the itch pustules of the horse, an insect similar to that delineated 
 hy De Geer, was satisfied that it was possible to discover a similar 
 parasite in the itch eruption of the human race. It was, however, 
 still the entomologists of the south of Europe who were to deter- 
 mine this as an unquestioned fact M. Renucci, a student of me- 
 dicine from Corsica, surprised to find the existence of the insect 
 questioned, showed it to several observers, among others to hi. 
 Raspail ; and it is solely to the labours of the latter that we are in- 
 debted for a correct description of this long doubted and doubtful 
 animal.1T 
 
 The itch insect is white at first sight, but with some reddish- 
 brown points on its circumference. It may be seen without a 
 
 * De Geer Memoixes pour servir a I’histoire des Insectes. Stockholm, 1778. 4to, 
 T. VII. p. 92, PL 5: 
 
 t Jo. Ernest Wichmann .ffitiologie von der Kraze. Hanover, 1786. 
 
 J Jonas Dissert. Dubia circa ^tiologiam Wichmannianam Scabiei. Halae, 1787. 
 
 § Volkmann Diss. sistens quaestiones medicas super Wichmanni jEtiologia Scabiei. 
 Francofurti ad Viadr, 1787. 
 
 II Hartmann Dissert. Quaestiones super Wichmanni aetiologia Scabiei. Fr., 1789. 
 
 U Bulletin General de Therapeutique, Septembre 1834. 
 
 Raspail Memoire Comparatif sur I’histoire naturelle de llnsecte de la Gale. Fig. 
 8vo. Paris, 1834. 
 
 M m 
 
54G 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 magnifying glass moving on a coloured surface, especially if dark. 
 It is about xiola parts of one inch in diameter. With one glass, 
 the feet may be numbered, the mouth distinguished, and all the other 
 details of outline recognized. The head and fore feet are capable of 
 being concealed under the body by incurvation downwards ; and in 
 this attitude these five members seem withdrawn within coverings. 
 The posterior portion of the body placed in the same position pre- 
 sents eight setcB or hairs, gradually decreasing in size, till they ap- 
 proach the vent. Four of them belong to the hind feet; and of 
 the other four, two are inserted on each side of the vent. 
 
 When examined lengthwise hy the microscope, the animal ap- 
 pears flattened ; and in the transparent places it presents parallel 
 curved striae, which give it the appearance of the shell of a fish 
 viewed by the same magnifying power. These strics cover the 
 whole surface of the body of the insect, forming a large cellular 
 network, the cellulcB of which are linear and hollow, the interstitial 
 partitions relieved and prominent. This network strongly re^sts 
 cutting instruments, so that it is difficult to kill the insect with the 
 point of a needle while extracting it. 
 
 When placed on the back, so as to examine the anterior or infe- 
 rior surface, the organization of this insect appears greatly more 
 complicated. The head and the four anterior feet are implanted 
 in an equal number of cases, not dissimilar to incomplete ehjtrce. 
 The head is simple and curved downwards by the snout or probo- 
 scis, or sucker. Placed in acetic acid, two transparent vesicles come 
 into view, which might be taken for eyes. The articulations of the 
 legs require long observation to be quite visible. Each of these 
 articulations is covered by hairs, of which those only on the sides 
 are visible. The last joint is covered with short prickles, and armed 
 beneath with a stiff hair, which is terminated beneath by a flexible 
 cavity capable of producing a vacuum, like the soft glutinous pads 
 of certain animals much higher in the scale, such as the tree-frog. 
 To these pads, which enable the animal to fix itself in any position, 
 M. Raspail applies the denomination of ambulacra. 
 
 There are four posterior legs, which are smaller and shorter, and 
 less easily distinguished than the anterior legs. They are so small 
 and slender that by De Geer they were mistaken for hairs or setcB. 
 They have the same organization and the same locomotive apparatus 
 
 as the anterior legs, excepting the part called by Raspail ambulacrum., 
 
 3 
 
SKIN. 
 
 547 
 
 instead of which are very long hairs. The anterior or abdominal 
 surface of the insect is striated as well as its dorsal surface. 
 
 This insect is not an acarus, as imagined by Linnaeus and other 
 entomologists. In consequence of the differential characters, it has 
 been referred by Raspail to a separate genus under the name of 
 Sarhoptes, or Flesh-roaster, caro ; Oirraw, torreo.) 
 
 It has now been seen by so many observers, both in France and 
 this country, that there is no chance that its existence can again be 
 questioned. It works its way beneath the cuticle by making bur- 
 rows or paths in the vascular layer of the skin. 
 
 The nails, like the cuticle, may be diseased in consequence of a 
 morbid state of the corial surface and vessels by which they are 
 nourished. In one or two instances of strumous children, I have 
 seen them fissured into several longitudinal portions, much thick- 
 ened, and indurated like horn, and incurvated. In others of the 
 fingers of the same individuals, they were small and imperfectly de- 
 veloped ; and in some their place was supplied by a small portion 
 of thick horny cuticle. Similar changes are sometimes induced by 
 disease or by injury. 
 
 Of the hairs, the most extraordinary morbid state is the Polish 
 plait (^plica Polonica ,-) so named from being endemial in Poland, 
 Lithuania, Hungary, and Transylvania, from the source of the Vis- 
 tula to the Carpathian mountains. It occurs also in Prussia, Rus- 
 sia, Switzerland, and in some parts of the Low Countries. It is 
 impossible to doubt that this abnormal condition of the hairs depends 
 on disease taking place in their bulbs or nutritious sacs. This is 
 proved by the state of the skin from which the diseased hair grows, 
 and by the unctuous, viscid, and blood-coloured fiuid which the 
 hairs in this state contain. We nevertheless possess no very pre- 
 cise information on the nature of this diseased state of the capillary 
 bulbs ; and in the absence of exact facts I abstain from offering 
 conjectures. 
 
 The piliparous sacs lose their energy under certain morbid states 
 of the system ; for instance, fever, pulmonary consumption, and the 
 constitutional symptoms of lues. The hairs then drop out ; and if 
 at this time the bulbs be examined, the sacs are found to contain, 
 according to Bichat, at least in persons who have passed through 
 fever, the rudiment of new hairs. The shedding of the hairs, which 
 takes place in the decline of life, and the period of which varies re- 
 
548 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 raarkably in different individuals, Bichat represents as depending 
 on a total death of the piliparous sacs. 
 
 Accidental and abnormal developement of hairs is not uncom- 
 mon. In the skin this appears in the shape of hairy moles and 
 similar congenital marks.* Their occurrence in the stomach, in- 
 testines, and bladder, as noticed by a variety of authors, is also to 
 be regarded as abnormal. Lastly, the accidental developement of 
 hairs is observed in encysted tumours, especially those of the ovaries, 
 in which masses or balls of hair mixed with fat, oleaginous, or adi- 
 pocirous matter, have been frequently found. f On the mode in 
 which these hairs are formed nothing satisfactory is known. J 
 
 CHAPTER II. 
 
 Section I. 
 
 MUCOUS MEMBRANE, VILLOUS MEMBRANE. — Membrana mucosa, 
 M. mucipara, M. villosa , — Tissu Muqueux, Bichat. 
 
 The organic tissue or membrane, to which the name of mucous 
 or villous has been applied, consists of two great divisions, the gas- 
 tro-pulmonary, and genito-urinary. 
 
 A. The first or gastro-pulmonary mucous surface comprehends 
 that membranous surface which commences at the various orifices 
 of the face, at which it is contiguous with the skin ; and is continu- 
 ed through the lacrymal and nasal passages, and even the Eusta- 
 chian tube, by the larynx on the one hand to the windpipe and 
 bronchial membrane, and by the oesophagus on the other through 
 the entire tract of the alimentary canal, at the opposite extremity 
 of which, it is again identified with the skin. 
 
 B. The distribution of the second division, or the genito-urinary 
 mucous membrane, is slightly varied according to the differences 
 of sex. In the male it is connected with the skin at the orifice of 
 the urethra, from which it proceeds inwards toward the bladder ; 
 
 * Haller, Elementa Physiologia:, Lib. XII. Sect 1. § XVII. 
 
 Bichat, Tom. IV. p. 828. 
 
 J Meckel, Joiun. Compl. T. IV. and Bricheteau, Journ. Compl. T. XV. 
 
MUCOUS MEMBRANE. 
 
 549 
 
 sending previously small prolongations through ducts on each side 
 of the oeru montanum, from which it is believed to be continued 
 through the vasa deferentia, to the vasa efferentia of the testicle. 
 Continued over the inner surface of the urinary bladder, it is pro- 
 longed through the ureters to the pelvis and infundibula of the 
 kidney. In the female, besides passing in this direction, it ascends 
 into the womb, and passes through the Fallopian or uterine tubes> 
 at the upper extremity of which it terminates in an abrupt opening 
 into the sac of the peritonaeum, — the only instance in the whole 
 body in which a mucous and serous surface communicate freely 
 and directly. 
 
 These two orders of membranous tissue have each two surfaces, 
 an attached or adherent, and a free one. The adherent surface is 
 attached, Is?, to muscles, as in the tongue ; most of the mouth and 
 fauces, oesophagus, and whole alimentary canal, and the bladder ; 
 2c?, to fibrous membranes, as in the nasal cavities and part of the 
 larynx, in which it is attached to periosteum or perichondrium, the 
 palate, ureter, and pelvis of the kidney ; 3c?, to fibro-cartilages, as 
 in the windpipe, {trachea,') and bronchial tubes. 
 
 The free surface is not uniform or similar throughout. The ap- 
 pearance of the pituitary or Schneiderian membrane is different 
 from that of the stomach or intestines ; the surface of the tongue 
 and mouth is different from that of the trachea; and the free sur- 
 face of the urethra is unlike that of the bladder. These variations 
 depend on difference of structure, and are connected with a diffe- 
 rence in properties ; yet anatomists have improperly applied to the 
 whole what was peculiar to certain parts only, and have thus creat- 
 ed a system, in which some truth is blended with much misrepre- 
 sentation. 
 
 Mucous membrane consists, like skin, of a corion or derma, and 
 an epidermis or cuticle. 
 
 The mucous corion is a firm dense gray substance, which forms 
 the ground-work of the membrane in most regions of the body, but 
 which is evidently represented by the fibrous system, e. g. the pe- 
 riosteum or perichondrium, in some other situations. It is most 
 distinctly seen in the mouth and throat, and in various parts of the 
 alimentary canal. In the first situation it is more vascular, less 
 gray and dense than in the intestinal mucous membrane. 
 
 It possesses two surfaces, an inner, adherent to the submucous 
 filamentous tissue, and an outer or proper mucous surface. In the 
 
550 
 
 GENERAL AND EATHOLOGICAL ANATOJIY. 
 
 stomach, the mucous corion is in the form of a soft but firm mem- 
 branous substance, about one-sixth or one-eighth of one line thick, 
 tough, of a dun-gray or fawn colour, (intermediate between Sienna- 
 yellow and ochre-yellow, Syme,) slightly translucent, and sinking 
 in water. The attached or inner surface is flocculent and tomen- 
 tose, and a shade lighter than the outer, which presents a sort of 
 shag or velvet, consisting of very minute piles. This, when exa- 
 mined by a good lens at oblique light, appears to consist of an in- 
 finite number of very minute roundish bodies closely set, but sepa- 
 rated by equally minute linear pits, and occasionally circular de- 
 pressions. In the ileum it presents much the same characters ; but 
 the minute bodies of its shaggy surface are still larger and more 
 distinct, and may be seen by the naked eye. In the windpipe, 
 again, it is rather thinner and lighter coloured ; and while its outer 
 surface presents numerous minute pores, it is much smoother than 
 in the alimentary canal, and entirely destitute of those minute bodies 
 seen in the latter. It nowhere presents any appearance of fibres. 
 
 The mucous corion rests on a layer of filamentous tissue, pretty 
 firm and dense, and of a bluish white colour,— a character by which 
 it is easily distinguished from the soft fawn-coloured mucous mem- 
 brane. This submucous filamentous tissue is what is erroneously 
 termed the nervous coat by Ruysch, Albinus, and some of the older 
 anatomists. In certain parts the mucous corion is covered by a 
 thin membrane, which has been named the epidermis or cuticle. 
 
 It is exceedingly difficult to demonstrate this membrane dis- 
 tinctly. It is very thin, quite transparent, and is perhaps most 
 easily shown by boiling or scalding a portion of mucous membrane, 
 and then peeling off with care the outer pellicle. This experiment 
 succeeds best in the mucous membrane of the mouth and palate, 
 in which, therefore, the existence of mucous epidermis cannot be 
 doubted. In cases of death by swallowing boiling water, the epider- 
 mis is raised in the form of vesications on the base of the tongue, on 
 the epiglottis, and even sometimes at the arytenoid membrane ; and 
 I have seen the epidermis of the epiglottis forming vesications in con- 
 sequence of the deglutition of sulphuric acid. The observations 
 of Wepfer, Haller, and Nicholls, and especially of Bleuland,* ai-e 
 sufficient to prove its existence in the oesophagus. Bichat admits 
 that, though it can be demonstrated at the cutaneous junctions of 
 
 * Jani Bleuland, M. D. Observatioiies Anatomico-Medicae de Sana et morbosa ceso- 
 phagi structura. Lug. Bat. 1785. 
 
MUCOUS MEMBRANE. 
 
 551 
 
 the mucous surfaces, it can no longer be shown to exist in the 
 stomach, intestines, bladder, &c. Bedard renders this conclusion 
 precise, by showing experimentally that mucous epidermis cannot 
 be traced in the oesophagus beyond the cardia ; in the genito- urinary 
 system beyond the neck of the womb, and that of the bladder. 
 
 The termination of the epidermis at the lower end or cardiac 
 junction of the oesophagus is very remarkable. It is seen by the 
 eye, but more clearly by the aid of a good glass. It is observed 
 to form or send out long triangular processes, the base connected 
 with the oesophageal epidermis, the apices free, leaving also between 
 them triangular spaces. The length of these processes varies from 
 one-third of an inch to half an inch and two-thirds of an inch. 
 Their number is also variable, and sometimes in the same subject 
 they differ in size. They are rendered very distinct by immersing 
 the oesophagus in boiling water, which renders them opake, or in 
 nitric acid, which imparts to them an orange-yellow tinge, leaving 
 the intermediate and adjoining mucous corion little changed. 
 
 In the uterus it is quite easy to see that the epidermis does not 
 advance beyond the upper extremity of the vagina. The uterine 
 mucous membrane presents no appearance of epidermis. 
 
 The structnre of mncous membrane varies in every situation and 
 in every organ ; and as the mucous membrane of the alimentary 
 canal has been most frequently examined, on that, accordingly, 
 the greatest amonnt of information has been communicated. 
 
 This division of the mucous system presents most distinctly and 
 in greatest perfection three sets of objects, the true structure of 
 which it is believed highly important to understand arigbt. 
 
 These are the tubulo-cellular structure of the stomach, the villi.^ 
 and the muciparous follicles or glands. 
 
 The mucous membrane of the stomach, which first deserves atten- 
 tion, is not villous, properly speaking, so much as cellular. Hewson 
 had early observed, that at the upper part of the stomach, the vil- 
 lous coat appears in a miscroscope like a honey-comb, or like the 
 second stomach of ruminating animals in miniature, that is, full of 
 small cells which have thin membranous partitions. Towards the 
 pylorus these partitions are lengthened so as to approach to the 
 shape of the villi in the jejunum. 
 
 These cells Sir E. Home represents as found in the form of 
 a honey-comb in the upper end of the stomach, and to be of 
 greatest depth in this region, though seen over the whole cardiac 
 
552 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 portion, but so faintly that a high magnifying power is required 
 to render them visible. In the pyloric portion the same cellular 
 appearance continues ; but here and there are small clusters, the 
 sides of which rise above the surface, giving the appearance of 
 foliated membranes. 
 
 These cells are, according to Dr Boyd, about y’^gth of one inch 
 in diameter near the cardia. Not half an inch from the cardia, 
 however, these large cells give place to small regular cells which 
 characterize the whole internal surface of the organ. When the 
 mucous membrane is extended, they appear regular both in shape 
 and size, varying from ^ggth to jggth part of one inch in diameter, 
 being smaller in the young than in the adult. Near the pylurus^ 
 again, they are enlarged, being about iggth of one inch in diameter. 
 The floor of each cell appears perforated by numerous circular 
 openings, as if a number of tubes opened on it; and on making a 
 vertical section of the mucous membrane, it is seen to be composed 
 of stricB or fibres running perpendicularly from the free surface of 
 the membrane to the cellular coat beneath. 
 
 These stricB or fibres are known to be small tubes lying parallel 
 to each other. These tubes are longest, and are most distinctly seen 
 near the pylorus^ and indeed all over the organ. At the cardia 
 they are short, little more than simple rings, lying close to each 
 other. They are about P^^t of one inch in diameter, appear 
 
 to have no immediate connection with the cells into which they gene- 
 rally open, and are supposed to be subservient to a different func- 
 tion.* There is strong reason to believe, nevertheless, that these 
 tubes are concerned in some mode in the secretion of gastric ffuid. 
 
 In the human stomach, glands or follicles are found mostly at 
 the pylorus. In other regions they are, in the state of health, not 
 very distinct. Indeed, the gastric follicles of the human stomach 
 are always in the healthy state indistinct. A kind of minute gland- 
 like bodies nevertheless is sometimes perceptible along the small 
 arch. 
 
 The next peculiarity which it is important to notice is the exist- 
 ence of minute piles or villosities in the gastro-enterie division. 
 These bodies are best seen by detaching, inverting, and inflating a 
 portion of ileum. When this is immersed in pure water, the ob- 
 server may perceive, by means of its refracting power, an infinite 
 
 ■“ Essay on the Structure of the Mucous Membrane of the Human Stomach, by Sprott 
 Boyd, M. D. Edinburgh Medical and Surgical Journal, Vol. XLVI. p. 382. Edin- 
 brngh, 1836. 
 
 4 
 
MUCOUS MEMBRANE. 
 
 553 
 
 number of minute prolongations, which are made to wave or move 
 gently amidst the fluid ; hut even a very powerful magnifying glass 
 does not render them so distinct, as to determine whether they are 
 round or flattened, whether they are solid or hollow, or whether 
 they are ohtuse or acuminated. The shape and structure of these 
 villosities are indeed imperfectly known. 
 
 These piles, die zotten,) though seen by many anatomists, 
 
 were first examined in 172Uby Helvetius, who represents them as 
 cylindrical prominences in quadrupeds, hut conical in the human 
 subject.* * * § Their intimate structure, however, Lieberkuhn under- 
 took first by microscopical observation to demonstrate. According 
 to this observer, each villus receives a minute branch of a lacteal, 
 arterial branches, a vein, and a nerve ; and in each the lacteal 
 branch is expanded into a minute sac or h\B.ddiQv{ampullula,vesicula,) 
 like an egg, the capacity of which he estimates at |th of a cubic 
 line, and in the apex of which may be seen by the microscope a 
 minute opening.f Upon this sac the arterial branches are ramified 
 to great delicacy, and terminate in minute veins, which then unite 
 into one trunk ; while its inner surface he represents as spongy 
 and cellular. The space between the villi^ which do not touch 
 each other, he further represents to be occupied by the open ori- 
 fices of follicles, ■ so numerous that he counted eighty of them, 
 where were eighteen villi ; and both, he asserts, are covered by a 
 thin but tenacious membrane similar to epidermis. 
 
 Hewson, while he admits in each villus the ramification of mi- 
 nute arteries and veins, denies the saccular expansion, and infers 
 that the lacteals are ramified in the same manner as the blood-ves- 
 sels, and that the whole constitute a broad flat body,j the spongy 
 appearance of which he ascribes to the mutual ramification of the 
 latter. With this in general Cruikshank agrees ;§ while Sheldon, 
 who found the villi not only round and cylindrical as Hewson, but 
 bulbous as Lieberkuhn, and even sabre-shaped, rather confirms the 
 statements of that anatomist. || Mascagni and Soemmering agree- 
 ing in the general fact of vascular and lacteal structure, seem to 
 
 * Mem. de I’Acad. des Sciences. 1721. 
 
 -f- J. N. Lieberkuhn, M. D. &c. Dissertatio Anatomio-Physiologica de Fabrica et Ac- 
 tione villorum Intestinomm Tenuium Hominis. Lugduni Batavorum, 1745. 4to ; et 
 cura J. Sheldon. Londini, 1782, § ii. iii. &c. 
 
 J Experimental Inquiries, part ii. p. 175, chapter xii. 
 
 § The Anatomy of the Absorbing Vessels, Ao.'p. 58. 
 
 II The History of the Absorbent System, p. 36 and 37. 
 
554 
 
 GENERAL AND rATHOLOGICAL ANATOMY. 
 
 represent the shape of the villus as that of a mushroom, consisting 
 of a stalk and a pileus. 
 
 Some of these discordant statements Hedwig attempts with equal 
 ingenuity and industry to reconcile. The difference in shape he 
 refers to differences in the animals examined ; and in one class 
 finds them cylindrical, (c. g. in man and the horse ;) in another 
 conical, (the dog ;) in a third club-shaped, (the pheasant ;) and in 
 a fourth pointed or pyramidal, (c. g. the mouse.) The interior 
 structure he also represents as spongy in all the animals which he 
 examined; and invariably also he found at the apex the orifice of 
 the duct, which, after the example of Lieberkuhn, he conceives 
 constitutes the ampullula* 
 
 These conclusions are not exactly confirmed by the researches 
 of Rudolphi, who examined the villi in man and a considerable 
 number of animals. This anatomist never found the orifice seen 
 by Hedwig, notwithstanding every care taken to perceive it. He 
 maintains that the villi are not alike in all parts of the intestinal 
 canal of the same animal, as represented by Hedwig, but may be 
 cylindrical in one part, club-shaped in another, and acuminated in 
 a third. Admitting their vascular structure, which he thinks may 
 be demonstrated, he regards the ampullular expansion as doubtful, 
 and denies its cellular arrangementf 
 
 About the same time Bleuland, who had previously examined 
 the intestinal mucous membrane, after successful injection of its 
 capillaries, undertook to revive the leading circumstances of the de- 
 scription of Lieberkuhn. By examining microscopically well-in- 
 jected portions of intestine, he shows that the villi are composed of 
 a system of very minute arterial and venous capillaries, enclosing 
 a lacteal which constitutes the ampulla, and in the interior of which 
 a certain order of these capillaries terminates. He also revives the 
 statement of the absoi’bing orifice at the extremity of each villus.X 
 The rest of the observations of this author pertain rather to the dis- 
 tribution of the minute vessels, and shall be more particularly no- 
 ticed under that head. 
 
 The observations of Bedard on these bodies are most perspicu- 
 
 * Disquisitio Ampullularum Lieberkuhnii Physico-Microscopica. Lipsiae, 1797. 4to. 
 
 •j- Einige Beobachtungen iiber die Dannzotten von D. Karl A. Rudolphi. in Reil. 
 Archiv. iv. b. 1797, p- 63 and 340. Und Anatomische-Physiologische Abhandlungen, 
 Von Kail Asmund Rudolphi, Mil. Acht Kupfertafeln. Berlin, 1802. 8vo. III. 
 
 X Jani Bleuland, M. D. &c. Vasculorum, in Intestinorum Tenuium Tunicis, &c. 
 Descriptio Iconibus lllustrata. Trajecti ad Rhenum, 1797. 
 
MUCOUS MEMBIiANE. 
 
 555 
 
 ous. According to this anatomist the intestinal villi appear neither 
 conical, nor cylindrical, nor tubular, nor expanded at top, as de- 
 scribed by several authors, but in the shape of leaflets or minute 
 plates so closely set that they form an abundant tufted pile. Their 
 shape varies according to the manner in which they are examined, 
 and according to the part. Those of the pyloric half of the sto- 
 mach and duodenum are broader than long, and form minute plates; 
 those of jejunum are long and narrow, constituting piles;- at the 
 end of the ileum they become laminar ; and in the colon are scarcely 
 prominent. They are semitranslucent ; their surface is smooth; 
 and neither openings at their surface, or cavity, or their interior, 
 or vascular structure can be recognized.* 
 
 Follicles and Crypts. — In most mucous membranes are found 
 minute, oval, or spheroidal bodies, slightly elevated, and present- 
 ing an orifice leading to a blind or shut cavity. As they are be- 
 lieved to secrete a fluid analogous to or identical with mucus, they 
 are named raucous glands; and from their shape and situation they 
 are also denominated follicles (folliculi) and crypta. Though 
 found in all the mucous membranes in more or less abundance, 
 they have been most frequently examined in those of the alimen- 
 tary canal, where they were first accurately described by Peyer 
 and Brunner. ( Glandules Peyeriancs.X) In this situation they are 
 situate in the substance of the mucous corion. Their structure, so 
 far as it can be examined, is simple. The orifice leads into a sac- 
 cular cavity, the surface of which is smooth and uniform, and ap- 
 pears to secrete the fluid which oozes from them. This membranous 
 sac appears to be lodged in a reddish-coloured, dense, abnormal mat- 
 ter, which is probably filamentous tissue enveloping minute blood- 
 vessels ; but of tbe minute structure of which nothing is accurately 
 known. In the state of health these bodies are so minute that it 
 is very difficult to recognize them. I have seen them, neverthe- 
 less, in the tracheo-bronchial membrane by the eye and by a lens. 
 When the membranes are inflamed they become larger and more 
 distinct. In the bladder, the womb, the gall-bladder, and the se- 
 minal vesicles, they are not distinctly seen, and cannot be satisfac- 
 torily demonstrated. It is unnecessary, however, to follow the ex- 
 
 * Anatomie Generale, chap. iii. sect. 2de, p. 253. 
 
 •]- Joannis Conracli Peyeri Pareiga Anatomica et Medica Septem, Ratione ac Ex- 
 perientia^parentibus concepta et edita. Genevas, 1681. Parergon Secundum, p. 7C* 
 De Glandulis Intestinalium, 1681. Brunner de Glandulis Duodeni. Francof. 1715. 
 
556 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 ample of Bichat in trusting to analogy to prove their existence ; for 
 they are not necessary to the secretion of raucous fluid, as he seems 
 to imagine. Those in the urethra, first well described by William 
 Cowper, are distinct examples of follicles in the genito-urinary sur- 
 face.* The sinuosities {lacuna;), first accurately described, if not 
 discovered by Morgagni, j though not exactly the same in confor- 
 mation and structure, seem to be very slightly different. 
 
 The importance of the muciparous follicles in influencing both 
 the functions and the morbid states of the alimentary mucous mem- 
 brane, renders it necessary to consider with some detail the situa- 
 tion, structure, and anatomical peculiarities of these bodies. 
 
 These do not occur at all parts of the alimentary mucous mem- 
 brane ; but are distributed in different modes in difierent regions 
 of the membrane. 
 
 In the oesophagus they are not numerous, but are observed like 
 small bodies about the size of flattened pin-heads in various parts 
 of the membrane, and at irregular intervals from each other. 
 With a good glass may be recognized a minute aperture or pore, 
 which proceeds from the centre of the gland and acts as a sort of 
 excreting duct. 
 
 At the cardia these bodies become more numerous and are more 
 closely set, so that they form a sort of ring round the cardiac orifice. 
 
 In the stomach they are rather numerous along the course of 
 the small arch. But they are observed at uncertain intervals in 
 various other regions of the stomach. At the pylorus also they 
 are abundant, and in that region also they may be more easily re- 
 cognized than in any other part of the organ. 
 
 The duodenum is rather peculiar as to its glandular apparatus. 
 The whole duodenal mucous membrane is provided with numerous 
 minute glandular bodies, which are more closely set than in any 
 other part of the alimentary canal, and give its surface an appear- 
 ance rough and irregular, and a firmer consistence than elsewhere. 
 These bodies nevertheless are not so distinctly observed in man as 
 in certain animals, for instance the horse, ox, stag, dog, and wolf. 
 These glandular or follicular bodies are believed to be seated mostly 
 in the submucous cellular tissue. 
 
 The upper part of jejunum does not present many glandular 
 bodies, and indeed is most commonly without them for several feet. 
 
 * * Two new Glands near the Prostate Gland, with their Excretory Ducts. By Mr 
 William Cowper. Phil. Transactions, No. 258, p. 364. 
 
 + Adversaria Anatomica, IV. 8, 9, &c. 
 
MUCOUS MEMBRANE. 
 
 557 
 
 But the lower part of the small intestine, and what is named ileum^ 
 is provided with two sets of follicles, one solitary (^Z. solitaries)^ or 
 consisting of single isolated follicles, the other aggregated or associ- 
 ated {glandules agminates,) so as to form a patch, plexus, or cluster. 
 
 The solitary glands begin to appear about four or five feet above 
 the lower end of the ileum. They are not always very distinct or 
 visible. When they are, they are disseminated like minute grains 
 through the mucous corion at irregular intervals. They are often, 
 nevertheless, less conspicuous at the lower end of the ileum than a 
 little higher up. 
 
 The aggregated glands begin to appear in the ileum about from 
 four to six feet from its lower end. From the point where they 
 commence showing themselves, they are invariably disposed along 
 the antimesenteric side of the bowel, or that which is opposite to 
 the mesenteric attachment. They appear in the form of patches, 
 sometimes affecting the circular shape, sometimes irregular, most 
 frequently elliptical, with the long diameter corresponding to the 
 axis of the bowel. In size they vary according to the number of 
 integral follicles of which each patch consists. High up in the ileum 
 they are often small, that is, not larger than a silver four-penny 
 piece. But lower down they becomejarger and affect more decid- 
 edly the elliptical figure. They are also closer to each other to- 
 ward the lower portion of the bowel than at its upper part. 
 
 These elliptical patches consist of a great number of follicles or 
 crypts placed contiguous to each other. The number varies from 
 perhaps 20 or 30 to 50, 60, or more. Each isolated component 
 follicle is a small body with a pore or orifice issuing from its centre ; 
 and each follicle consists, so far as can be at present determined, 
 of a peculiar sort of dense matter, which I think is merely a species 
 of close filamento-cellular tissue, through which are distributed 
 many minute arteries and veins. 
 
 In colour, these patches are usually of a darker tint than the 
 surrounding mucous membrane, mostly of a leaden gray, or slate- 
 blue shade ; and when viewed by transmitted light, they are like a 
 dark or opake patch on the more translucent intestine. This, I 
 think, depends on the greater aggregation of their constituent 
 tissue. 
 
 Most usually they are, in the natural state, on a level with the 
 surface of the adjoining portion of intestine. They are not very 
 
558 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 rough or irregular ; but by the eye, or a good glass, it is possible 
 to observe considerable irregularity in surface. 
 
 All these characters become exaggerated under the influence of 
 disease. They then become elevated, rough, irregular on the sur- 
 face, and their opacity is increased. 
 
 At the lower extremity of the ileum^ where it enters the ccecum, 
 the whole membrane is often occupied with a large and extensive 
 patch of agminated glands, most extensive in the long direction of 
 the bowel, without definite shape, or rather the whole of the lower 
 part of the ileum, for the space of from three to four inches, consists 
 of a surface of agminated glands. 
 
 The agminated glands, and also the solitary follicles of the ileum, 
 are generally larger and more distinct caeteris paribus in infancy, 
 than in adult life. In the bodies of infants, they are almost inva- 
 riably easily seen and demonstrated. In the bodies of young sub- 
 jects between 14 and 20 or 25, they are still visible, sometimes 
 very distinctly. In general, however, after this period, they are 
 greatly less distinct, and sometimes they cannot be recognized at 
 all. In old age they cease to be observed. 
 
 In the colon, the mucous follicles are still different both in shape 
 and disposition. 
 
 They appear in the form of small round oblate-spheroidal or 
 orbicular bodies, with circular outline about one line in diameter, 
 not unlike millet-seeds, with a central pore or aperture. These 
 bodies are always isolated, and they are placed at the distance of 
 from half an incli to one inch from each other. They are arranged 
 all round the mucous surface of the bowel, and are not, as is ob- 
 served as to the aggregated glands of the ileum, confined to one 
 side of the bowel only. In different subjects they are presented 
 with different degrees of distinctness. In some they are scarcely 
 visible ; in others they are conspicuous. In dropsical subjects they 
 are usually very distinct, probably from their tissue being infiltrated 
 with serum. Their structure appears to consist of minute colour- 
 less vessels ramified in filamento-cellular tissue, and with a central 
 pore or excretory duct. They are placed immediately beneath or 
 in the mucous corion, which over their surface is thin, and descends 
 through the pore into the interior of the gland. 
 
 At the lov/er extremity of the- colon, or rather the rectum, there 
 are placed several follicles, often of considerable size. Their struc- 
 ture is in all respects similar to that of those of the colon. 
 
MUCOUS MEMBRANE. 
 
 559 
 
 On the minute structure of these follicles, all that is accurately 
 known is the following. If we examine an isolated follicle, it pre- 
 sents the most simple form of glandular arrangement. The intes- 
 tinal mucous membrane is continued through the minute pore, 
 which is situate at the apex of the follicle downward for about 3; goth 
 part of one line, forming a blind-sac, or cavity of a sac, and con- 
 stituting in this manner a crypt or recess. The surface of this 
 short passage is moistened by a fluid which is secreted from it. On 
 this surface are ramified an infinite number of minute arteries and 
 veins, which constitute the vascular system of the follicle. Be- 
 neath the mucous membrane of the crypt is situate a close but fine 
 filamentous tissue, which surrounds the arteries and veins now men- 
 tioned. This filamentous tissue is gradually connected with that 
 of the contiguous intestine. The existence of excretory ducts on 
 the cryptic membrane has not been demonstrated. It is most pro- 
 bable that upon the free surface of this the arteries open. 
 
 The close filamentous tissue now mentioned as forming the pa- 
 renchyma of the follicle, it is difficult to demonstrate in the healthy 
 state. Some describe as silvery white, others as slightly yellow. 
 When the follicles are affected by inflammation, it becomes thick, 
 hard, and swelled, and it is then more distinctly seen. It then also 
 becomes reddish, or yellow, or orange-coloured. 
 
 What the structure of the isolated follicle is, such is that of the 
 aggregated follicles, which, indeed, are merely many isolated fol- 
 licles adjoining to each other, or united so as to form a patch, {ag- 
 men) {glandules agminate^. Each agminated gland has its pore, its 
 crypt, its cryptic membrane, its blood-vessels, and its cellular tissue. 
 
 These glands have been denominated muciparous, and are sup- 
 posed to secrete mucus. The fluid which issues from them appears 
 to be thinner and more liquid than mucus. It may, however, un- 
 dergo changes after its secretion. 
 
 In certain regions of the mucous membranes, more especially at 
 tbeir connections with the skin, are found minute conical eminences 
 denominated papilles. They are distinctly seen in the mucous 
 membrane of the tongue, where they vary in size and shape, and 
 in the body named clitoris. They are elevations belonging to the 
 raucous corion, and they are liberally supplied by blood-vessels, 
 the veins of which present an erectile arrangement, and with mi- 
 nute nervous filaments. Of the intimate structure of these bodies, 
 however, little more is known. They are covered by a true epi- 
 dermis. 
 
560 
 
 GNEERAL AND PATHOLOGICAL ANATOMY. 
 
 In the stomach, duodenum, and ileum, this membrane is collect- ' 
 ed into folds or plaits, which have received in the former situation 
 the name of rug(R or wrinkles, and in the latter the name of plicm j 
 or folds, and valvula conniventes or winking valves. In the vagina I 
 also are transverse rugce^ which in like manner are folds or dupli- 
 catures of its mucous membrane. Those of the oesophagus are lon- 
 gitudinal, and have been described by Bleuland. In the tracheo- | 
 bronchial membrane, and in the membranous and spongy portions 
 of the urethra, we find them in the shape of minute plates or wrinkles 
 in the long direction of their respective tubes, but rarely of much 
 length. These folds or plaits are quite peculiar to the mucous 
 membranes ; and the object of them appears to be to increase the i 
 extent of surface, and to allow the membrane to undergo consider- 
 able occasional distension. 
 
 In certain points, where a communication is observed between 
 the general mucous surface and the cavities or recesses of particu- 
 lar regions, anatomists have not demonstrated a mucous membrane, 
 but have inferred its existence as a continuation of the general 
 surface. In the tympanal cavity to which the Eustachian tube leads, 
 the existence of a mucous or fibro-mucous membrane is rather pre- 
 sumed from analogy than proved by actual observation. We know 
 that, where the biliary and pancreatic ducts enter the duodenum, 
 and for a considerable space towards the liver, the interior appear- 
 ance is that of a fine mucous surface provided with lacun<z and vil- 
 losities ; but it is impossible to say at what point of the hepatic 
 duct, or of the smaller canals of which it is formed, the mucous 
 membrane terminates. 
 
 The tracheal membrane, when traced to the bronchial divisions, 
 presents no arrangement, either of papillcB, piles, or villosities ; and 
 nothing is perceived except a smooth uniform surface, of a colour 
 between gray, dun, and red or purple, which is moistened with a 
 viscid semitransparent fluid, and which is as like the peritonaeum 
 as the intestinal mucous membrane. 
 
 In the ultimate divisions of the bronchial tubes, the mucous mem- 
 brane follows the anatomical arrangement of these tubes to their 
 extremities. It was at one time imagined, that these tubes terminat- 
 ed in enlarged or dilated chambers, which were termed by Malpighi 
 ampullul(B^ and by others air-cells and vesicles ; and it was further 
 believed, especially by Willis and Senac, that various vesicles or 
 ultimate chambers placed at the terminal ends of bronchial tubes 
 communicated with each other in the substance of the lungs. These 
 
MUCOUS MEMBRANE 
 
 561 
 
 cells, indeed, Willis represents as clustered together like grapes. 
 It is certain that this is not established by observation. 
 
 When a bronchial tube is traced to its further extremity, it ter- 
 minates not in an enlarged chamber or cell, but merely in a blind 
 sac or cavity ; and this sac does not communicate with others. 
 The bronchial tubes, in short, though divided to great minuteness 
 in the substance of the lungs, preserve their character of tubes gra- 
 dually tapering and diminishing, but do not form ampullulae, or 
 vesicles or cells properly so named. 
 
 It is nevertheless convenient to retain the name of cells or ve- 
 sicles, understanding thereby merely the terminal ends of the 
 bronchial tubes. 
 
 Lastly, the situation where the existence of the mucous system, 
 though believed, is most uncertain, is in the interior of the vasa 
 deferentia, and where they take their origin from the vasa effe- 
 rentia of the testis. Regarding the organization of these tubes 
 no sensible evidence can be obtained, and whatever is stated 
 concerning it is the result of analogical inference. 
 
 Though these membranes have been designated by the gene- 
 ral name of mucous.^ it is not to be understood that the action 
 of their surface is in every situation the same. It is not easy 
 to limit the signification of the term mucus ; for it appears that 
 this fluid varies in the nasal passages, in the tracheal and bronchial 
 membrane, in the oesophagus, stomach, and intestines, and in the 
 urinary bladder and m-eters. But it may be stated as a certain 
 fact, that many parts of the two mucous surfaces never in the healthy 
 state secrete any modification of this animal matter ; and in others 
 the membrane is almost always moistened by a different fluid. The 
 mucous or-villous membrane of the eyelids is never in the healthy 
 state occupied with mucus, but is uniformly moistened with the 
 tears ; the membrane of the mouth and throat is moistened with 
 saliva only ; the urethra presents a peculiar viscid fluid, which 
 seems to exude from many minute vessels opening along its sur- 
 face, as in the lacunce, but which is widely different from mucus. 
 All those parts, in short, which are not in perpetual, but only oc- 
 casional, contact with foreign or secreted substances, seem to pre- 
 sent no mucus in the healthy state : whereas the surfaces of the 
 stomach, intestines> gall-bladder, and urinary bladder, are con- 
 stantly covered with a quantity, more or less considerable, of this 
 animal secretion. 
 
 N n 
 
562 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 The chemical properties of mucous membranes are completely 
 unknown. The analysis of the fluid secreted by them has been 
 executed by Fourcroy, Berzelius, and others, but is foreign to the 
 subject of this work. 
 
 The mucous membranes are most liberally supplied with blood 
 by vessels which are both large and numerous. This is proved not 
 only by the phenomena of injections, but by the red colour of which 
 many of their divisions are the seat. Tl.is coloration, as well as 
 the injectibility, is not indeed uniform ; for in certain regions mu- 
 cous surfaces are pale or light blue : in others their redness is con- 
 siderable. 
 
 Thus, in those regions in which the mucous membranes coalesce 
 with the periosteum, forming fibro-mucous membranes, e. g. in the 
 facial sinuses, the tympanal cavity and the mastoid cells, the colour 
 is pale-blue, or approaching to light-lilac. In the bladder, in the 
 large intestines, in the excretory ducts, in general, though pale, 
 this colouring becomes more vivid. In the pulmonic mucous mem- 
 brane it is a slate-blue, verging to pale pink. In the stomach, duo- 
 denum, small intestines, and the vagina, it becomes still more 
 marked. In the uterus it varies according to the period or the in- 
 tervals of menstruation. 
 
 If these vessels be examined in the gastro- enteric mucous mem- 
 brane, in which they are probably most numerous, they are found 
 to consist of an extensive net-work of capillaries divided to an in- 
 finite degree of minuteness, mutually intersecting and spreading 
 over the upper or outer surface of the mucous corion. This vas- 
 cular net-work, though demonstrated by Ruysch, Albinus, tialler, 
 and Bichat, has been very beautifully represented in the delinea- 
 tions of Bleuland, who thinks he has traced their minute ramifica- 
 tions into the as above stated. These minute vessels are de- 
 rived from larger ones, which creep through the submucous cel- 
 lular tissue, and which are observed to penetrate the mucous corion 
 to be finally distributed at its exterior surface. The substance of 
 this membrane itself appears to receive few or no vessels. It is 
 well known, that the vessels which supply the mucous surfaces, enter 
 between the folds of the serous membranes, at which they are in the 
 form of considerable trunks. Having penetrated between the folds 
 of these membranes, they divide in the subserous cellular tissue 
 into branches, the size of which is considerable ; and here they form 
 those numerous anastomotic communications which constitute the 
 
 4 
 
MUCOUS MEMBRAKE. 
 
 563 
 
 arches so distinctly seen in the ileum. From the convexity of these 
 arches in general, are sent off the small vessels, which are then fitted, 
 after passing through the muscular layer and the submucous tissue, 
 to enter the mucous corion. 
 
 The capillary terminations, then, of these arteries, and their cor- 
 responding veins, constitute the physical cause of the coloration of 
 the mucous membranes. This coloration, however, is not at all 
 times of the same intensity in the same membrane, and varies 
 chiefly according to the state of the organ which the membrane 
 covers. The coloration of the gastro-enteric mucous membrane 
 undergoes, even within the limits of health, many variations. Thus, 
 according to the absence or presence of such foreign substances as 
 are taken at meals, the mucous membrane is pale, or presents 
 various shades of redness. At the period of menstruation the ute- 
 rine mucous membrane becomes red and injected. Pressure on 
 any of the venous vessels renders the mucous membrane blue, 
 purple, or livid, as is seen in prolapsus, and more distinctly in 
 asphyxia, in which all the mucous membranes assume a livid tint. 
 (Bichat.) The varieties of red colour observed in the gastric mu- 
 cous membrane by Dr Yellowly are to be ascribed partly to the 
 latter cause, partly to the vascular redness which the presence of 
 foreign bodies occasions.* 
 
 Where death is the result of asphyxia, rapid or slow, the gastric 
 and intestinal mucous membranes are often much loaded with 
 blood. In death from disease of the heart, when the fatal event is 
 preceded by great anguish, I have often seen the gastric mucous 
 membrane of a deep red colour, and occasionally livid and approach- 
 ing to black. The dependant portions of the intestinal convolu- 
 tions are, under the same circumstances, much loaded with blood, 
 mostly in veins. These appearances must not be confounded with 
 inflammation. They merely imitate that process, and are pseudo- 
 inflammatory. 
 
 The pulmonary division of this membrane is of an ash-gray or 
 dun colour, inclining to pale-blue or light-red. These colours 
 vary, nevertheless, according to the facility or the difficulty with 
 which the blood moves through the pulmonary capillary system. 
 It is also freely supplied with blood-vessels derived chiefly from the 
 bronchial arteries. These vessels, after accompanying the bron- 
 
 * Observations on the vascular appearance in the Human Stomach, which is fre- 
 quently mistaken for inflammation of that organ. By John Yellowly, M. D. &c, 
 Medico-Chirurg. Trans. Vol. IV. p. 371. 
 
564 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 chial tubes and their successive subdivisions, divide into minute j 
 branches which penetrate the mucous corion, which here is white, 
 dense, and fibrous, and after anastomosing with the capillaries of | 
 the pulmonary artery and veins, form a minute delicate net-work 
 on the outer surface of the pulmonary mucous membrane. Ac- 
 cording to Reisseissen, to whom we are indebted for a careful exa- 
 mination of these vessels, a successful injection of them from the ! 
 bronchial arteries, renders the whole mucous membrane of the bron- 
 chi entirely red to the unassisted eye.* 
 
 The termination of arteries at the mucous surfaces has at all times 
 occupied the attention of anatomists and physiologists ; but it is ij 
 unfortunately not a matter of sensible demonstration. The thin 
 serous or sero-mucous fluid with which they are at all times mois- 
 tened, has led every author almost, and among the rest Haller and 
 Bichat, to infer the existence of arteries with open mouths, or what i 
 are termed exhalant vessels. If this be entirely denied, the patho- 
 logist, as well as the physiological enquirer, is deprived of a con- 
 venient source of explaining many vital phenomena. It has been 
 admitted, nevertheless, more on analogical than direct proofs. The 
 injections of Bleuland are the only experiments after those of Kawe 
 Boerhaave, which, so far as I am acquainted, tend to confirm the 
 conclusion.f These experiments, nevertheless, require to be re- 
 peated and extended. 
 
 That lymphatics are distributed to mucous membranes is a point 
 well established. Cruikshank saw the lymphatics proceeding from 
 the pulmonic mucous membrane loaded with blood in persons and 
 animals dying of haemoptoe. Their existence in the gastro-enteri- 
 tic mucous membrane has been long established. 
 
 The mucous surfaces are also freely supplied by nervous twigs 
 and filaments, derived in general from the nerves of automatic life. 
 
 It is a mistaken view, nevertheless, to ascribe to these filaments 
 the sensibility and other properties of the mucous surfaces. These | 
 mucous membranes possess intrinsically certain vital properties in- | 
 
 dependently of the nervous filaments with which they are supplied ; I 
 
 and the principal use of these filaments appears to be to regulate 
 these properties, especially that of secretion. 
 
 * Franz Daniel Reisseissen, ueber die Ban der Lungen, u. s. w. Berlin, 1822. 
 
 -f- Experimentum Anatomicum, quo Arteriolamm Lymphaticarum existentia pro- 
 babiliter adstruitur, &c. a Jano Bleuland, M, D. Lug. Bat. 1784. Item ; Jani Bleu- 
 land, M. D., &c., Vasculomm Intestinorum tenuium Tunicis subtilioris Anatomes 
 Opera Detegendorum Descriptio Iconibus illustrata. Trajecti, 1797. 
 
MUCOUS MEJIBRANE. 
 
 565 
 
 The progressive development of mucous membrane, and espe- 
 ciall)^ of its has been studied by Meckel in the intestinal tube. 
 This anatomist states, that in the beginning of the third month he 
 first recognized them distinctly in the form of long plaits, (Langen- 
 falten) thickly set on the inner surface of the intestine, and scarce- 
 ly indented on their free edge. The number and depth of these 
 folds, and their indentations, are gradually increased, till in the end 
 of the fourth month, sometimes sooner, in place of the simple long 
 plaits, the observer may distinguish an irregular multitude of mi- 
 nute elevations, which become proportionally larger at a later pe- 
 riod of foetal existence. He therefore infers that the villi are form- 
 ed by the gradual indentation and decomposition (Zerfallung) of 
 simple longitudinal plaits.* 
 
 The connection between the mucous membranes and the skin, I 
 have elsewhere stated, was first well demonstrated by Bonn, who 
 traces their mutual approximation and reciprocal transition into 
 each other, and represents the former as an interior production of 
 the latter enveloping the internal as the skin incloses the external 
 organs.! This view has been adopted by Meckel and Bedard, to 
 whom I refer for the proofs of its accuracy. I cannot conclude 
 the subject, however, without observing that one of the most con- 
 clusive arguments in its favour is derived from the circumstances 
 of the development of the intestinal canal during the first months 
 of uterine life. The history of this curious process, which has been 
 so happily investigated by Wolff and OkenJ, and so well traced by 
 Meckel, shows that at this period the gastro-enteric mucous mem- 
 brane, which is previously formed by the vitellar membrane of the 
 ovum, and the allantois or vesical membrane, which afterwards 
 forms the genito-urinary mucous surface, are in direct communica- 
 tion on the median line, and afterwards at the navel with the skin 
 or exterior integument. § The detailed history of this process be- 
 longs, however, rather to special than to general anatomy ; and I 
 notice it here as the strongest proof which occurs to me of the con- 
 nection between the skin and the mucous membranes, and as an 
 
 ’ Deutches Archiv fur die Physiologie von J. F. Meckel, 3ter Band. Halle und 
 Berlin, 1817. P. 68. 
 
 -f- Specimen Anatomico-Medicum Inaiig. &c. Continuationibus Membranarum, &c. 
 &c. In Sandifort Thes. Vol. II. p. 265. Rotterod. 1769. 
 
 Jenaiscbe Zeitung, S. 207-208. 
 
 § Deutches Archiv fiir die Physiologie, Dritter B. Halle und Berlin, 1817. 
 
566 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 anatomical fact which furnishes the solution of some curious con- 
 genital malformations, and of various morbid processes, which af- 
 fect simultaneously, successively, or occasionally, both orders of 
 membranes. 
 
 Section II. 
 
 The morbid states of the mucous membranes are numerous and 
 important, and constitute a large proportion of the diseases which 
 daily come under the notice of the physician. Generally speaking, 
 these morbid states may be referred to the following heads, inflam- 
 mation and its effects, sero-albuminous effusion, suppuration and 
 idceration, hemorrhage, induration and thickening producing con- 
 traction or stricture, new growths, and malformation. 
 
 T. The inflammatory process in this tissue gives rise to a con- 
 siderable number of diseases which long usage has distinguished 
 according to the region, the mucous membrane of which is diseased. 
 These affections, which agree in general characters, and vary only 
 in certain points depending on situation and local peculiarity, may 
 be conveniently arranged according as they take place; A. in the 
 cephalic or facial mucous membrane; B. in the tracheo-bronchial 
 mucous membrane ; C. in the gastro-enteric membrane ; and D. 
 in the genito-urinary mucous membrane. 
 
 Cephalic 
 ■ division. 
 
 Tracheo- 
 
 B. bronchial 
 division. 
 
 Alimen- 
 
 C. tary divi- 
 
 sion. 
 
 Genito- 
 
 D. Urinary 
 division. 
 
 i Eyelids and eye, 
 
 ) Nasal duct, 
 
 I Nasal passages, 
 
 ( Tympanal cavity, 
 i Throat, 
 
 ) Larynx, 
 
 1 Trachea, 
 
 ( Bronchial membrane, 
 
 i ffisophagus. 
 
 Stomach, 
 
 Ileum, 
 
 Colon, 
 
 ! Ureter, 
 
 Bladder, 
 
 Urethra. 
 
 Womb and vagina. 
 
 Ophthalmia. 
 
 Epiphora. 
 
 Coryza. 
 
 Tympania. 
 
 Laryngia. 
 
 Tracheitis. 
 
 Bronchia. 
 
 ffisophagia. 
 
 Gasteria. 
 
 Enteria. 
 
 Colonia. 
 
 Ureteria. 
 
 Cystidia. 
 
 Urethria. 
 
 Metria. 
 
 Oza;na. 
 
 Otorrhoca. 
 
 Cynanche laryngaea. 
 
 Croup ; catarrh. 
 
 Bronchitis ; catarrh. 
 Inflammation of ossophagus. 
 Dyspeptic symptoms. 
 Diarrhoea. 
 
 Dysenteria. 
 
 Catarrhus vesica. 
 Gonorrhoea, Blennorrhagia. 
 Leucorrhcca, &c. 
 
 In these several divisions of the mucous surfaces the anatomical 
 characters of inflammation are much the same. The process takes 
 place under two varieties, the spreading or diffuse, which extends 
 over the surface of the membrane ; and the punctuate or circum- 
 scribed, which affects many points at the same time. The mem- 
 brane becomes red, injected, traversed by minute red points and 
 
 4 
 
CEPHALIC MUCOUS MEMBRANES. 
 
 567 
 
 vessels, soraetiines arborescent or asteroid, sometimes punctular or 
 in minute points, occasionally in linear streaks, and not unfrequent- 
 ly in red patches ; the surface becomes swelled and villous or pulpy ; 
 and the proper secretions of the part are altered into sero-albumi- 
 nous fluid, puriform mucus, or actual purulent matter. In situa- 
 tions in which there is epidermis, as in the mouth and gullet, this 
 is elevated into minute vesicles and blisters forming aphtha ; or 
 the membrane is cast off in the form of exfoliated patches. In the 
 gastro-enteric membrane the villi are removed, and the surface is 
 rendered plane like that of the rectum or bladder. The inflamma- 
 tion may terminate in the formation of ulcers ; or in induration and 
 permanent thickening of the mucous tissue by effusion of lymph 
 beneath it, and into its substance. The follicles are at the same time 
 liable to become enlarged and vascular, and occasionally proceed 
 to ulceration ; but this is more fi'eqnent in the chronic form of the 
 process. The minute peculiarities will be more conveniently noticed 
 under their respective heads. 
 
 A. CEPHALIC MUCOUS MEMBRANES. 
 
 § 1. Ophthalmia serosa et puriformis . — The ophthalmic mucous 
 membrane (^conjunctiva) may be become the seat of inflammation, 
 with secretion of sero-albuminous fluid, puriform fluid, or purulent 
 matter. In the former case, in which the natural fluid appears 
 simply to be much augmented, the inflammation is confined chiefly 
 to the ocular conjunctiva, which is reddened and elevated, forming 
 in severe cases round the cornea a prominent ring or excrescence, 
 which appears to start from the eyelids — a state denominated by 
 the ancient surgeons chasm or gaping (chemosis), because a small 
 opening corresponding to the cornea is left in the centre of the 
 swelled membrane. This severe form of the disease occasionally 
 terminates in suppuration, ulceration, or sloughing. 
 
 Of the second form, two varieties are mentioned, the purulent 
 opbthalmy of infants, and the purulent ophthalmy which afi'ects 
 epidemically large bodies of men in close intercourse with each 
 other. In both cases, the mucous surface of the eye and eyelids is 
 very red, swollen, villous, and pulpy, and puckered into folds by 
 the violent action of the muscles ; while the cornea is generally 
 completely concealed by more or less chemosis, and the eyelids are 
 everted. After continuing in this state for eight or ten days dis- 
 charging much puriform yellow fluid, it may terminate in infants 
 
568 
 
 GENERAL AND PATHOLOGICAL ANATOMY, 
 
 in resolution, but more generally produces specks or opacity of the 
 cornea, ulceration, pustules, or chronic inflammation and thicken- 
 ing of the cornea, rendering that tunic opaque. In adults, pro- 
 ceeding much in the same manner, its effects are generally more 
 serious. If it do not at an earlier period of the disease cause opa- 
 city, the cornea may he ruptured partially or generally, so as to 
 allow the eseajie of the humours. The membranous inflammation 
 becoming in all cases also chronic, the surface of the conjunctiva 
 becomes irregular by numerous minute hardish eminences or gra- 
 nulations; and this granularstate of thepalpebral conjunctiva, 
 originally an efihct, becomes afterwards a cause of further inflamma- 
 tion. 
 
 The puriform ophthalmy originating from the gonorrhoeal poison, 
 though differing in its cause, is the same in its pathological effects. 
 
 Q. A pustular form of ophthalmy is sometimes observed. It 
 consists in the appearance of minute eminences of the sclerotic mu- 
 cous membrane near the circumference of the cornea. These bo- 
 dies, which may be considered either as aphthae or pustules, are 
 conoidal, and surrounded by a cluster of vessels which run into 
 them either all round in a circular area, or from one side, most 
 commonly the temporal. When they are situate a line or two from 
 the margin of the cornea, they are broad and flattened. This dis- 
 ease seldom under proper treatment advances to suppui’ation or ul- 
 ceration ; and I have seen it disappear in thirty hours after being 
 first seen. It seems in some instances to consist in a punctuate 
 deposition of lymph, in others to be a peculiar concentration of 
 blood-vessels. It is not impossible for it, however, to proceed to 
 suppuration and form a minute abscess of tbe conjunctiva. When 
 these pustular eminences appear in the corneal mucous membrane, 
 they generally pass into ulcers. 
 
 In some instances, with abatement of pain, diminution of swell- 
 ing, and alleviation of other symptoms, the vessels appear much 
 distended and distinct, though tortuous, the membrane is thickened 
 in patches or continuously, and sero-albuminous fluid is deposited 
 in spots or along the course of the vessels. These appearances 
 mark the transition of the disease into the chronic form. Their 
 persistence too often leaves the superficial speck (nebula), the tri- 
 angular web, (j)terygium), or the opaque spot, (leucoma.) 
 
 § 2. Watery eye ; Epiphora . — The mucous membrane of the eye 
 and eyelids communicates with that of the nostrils by the narrow 
 tube termed lacrymal duct. A minute capillary opening at the 
 
 3 
 
CEPHALIC MUCOUS MEMBEANES. 
 
 569 
 
 nasal extremity of each eyelid, termed lacrymal {piinctum lacry- 
 mnle), forms the upper or palpebral end of this canal ; and its in- 
 ferior or nasal extremity is a considerable opening in the lower 
 nasal passage, between the lower spongy bone. This canal is lined 
 by a fibro-mucous membrane, the free surface of which is moisten- 
 ed by a tliin semitransparent, glairy fluid, not like the mucus of the 
 nasal or tracheal membrane, but merely viscid enough to facihtate 
 the descent of the tears, and to maintain a free communication be- 
 tween the eyelids and nostrils. This membrane may be inflamed 
 in any part of its course, especially at the palpebral extremity ; and 
 the swelling attendant on this process in a canal so narrow produces 
 a temporary obstruction to the transmission of the tears, — consti- 
 tuting the simple and acute form of the watery eye or epiphora. 
 In ordinary circumstances this terminates in resolution, and the 
 canal again becomes pervious in a few days. In more severe cases, 
 however, either in consequence of thickening of the fibro-mucous 
 membrane, or the effusion of albuminous fluid, the obstruction is 
 more permanent ; and if not seasonably removed, may induce se- 
 condary inflammation of the parietes of the canal, and ulceration 
 and false openings ; (fistula.) In all cases the inflammatory pro- 
 cess may affect the subjacent periosteum of the lacrymal, nasal, and 
 superior maxillary bones, and induce caries in one or more of them. 
 With or without this latter complication, the disease constitutes la- 
 crymal fistula. In either mode it is sometimes the result of syphi- 
 lis, and very often where mercury has been given for the treatment 
 of that disease- 
 
 similar disease of the lacrymal duct may take place in conse- * 
 quence of previous chronic inflammation of the eyelids and Meibo- 
 mian glands. 
 
 The mucous membrane of the nasal passages is inflamed in Co- 
 ryza.^ — an affection forming the preliminary part of catarrh. A 
 secondary coryza occurs in nasal polypus ; and ozana, which con- 
 sists in chronic suppurative inflammation of the nasal membrane 
 lining the nasal and covering the spongy bones, is always preceded 
 by similar inflammation. The same process is not unfrequent in 
 the fibro-mucous membrane of the maxillary sinus, in which it ge- 
 nerally proceeds to suppuration, forming abscess of that cavity. 
 
 § 3. Otitis. — The membrane of the external auditory passage is, 
 strictly speaking, neither skin nor mucous membrane, but a tex- 
 ture intermediate between both. In its morbid relations it is, how- 
 
570 
 
 GENERAL AND PATHOLOGICAL ANATOMY". 
 
 ever, more closely connected with the latter, and is often the seat 
 of inflammation producing a yellow puriform discharge {otorrhoea), 
 from the outer surface of the tympanal membrane, and the mem- 
 brane lining the ear-hole. The membrane is then red, soft, villous, 
 and highly tender. The average duration of this disease is from 
 fifteen days to three weeks, after which the fluid discharged becomes 
 thicker, and in colour, consistence, and odour, resembles caseous 
 matter. The ceruminous glands are disordered during its pre- 
 sence ; but as it recedes their secretion becomes abundant. 
 
 § 4. Tympania . — Though the membrane of the tympanal cavity 
 and the Eustachian tube presents a smooth uniform surface, moist- 
 ened by a thin watery fluid possessing little resemblance to mucus, 
 yet, as continuous with the naso-guttural membrane, and as similar 
 to that of the facial sinuses, it may be placed in pathological pro- 
 perties in this situation. Bichat indeed corrects the error of those 
 anatomists who represent the membrane of the tympanal cavity as 
 periosteum ; but in his anxiety to maintain its mucous he overlooks 
 its fibrous character. Its adherent surface cannot be distinguished 
 from the periosteum of the bones to which it adheres. When re- 
 moved and dried it is thin, crisp, and semitransparent. During 
 the inflammatory process it becomes red, thick, soft, and actually 
 villous ; and it secretes first serous, afterwards yellow puriform 
 fluid, which cannot be distinguished from genuine purulent matter, 
 though without ulceration.* In this disease an opening takes place 
 in the membrane, which becomes fungous, or is eventually destroyed; 
 the tympanal bones are discharged ; and not unfrequently the in- 
 flammatory process spreading into the mastoid cells, fills these ca- 
 vities with matter more or less viscid. In sucli circumstances it 
 may aflFect the periosteal surface and cause caries of the bones, 
 which are then found denuded and rough. Not unfrequently it 
 causes inflammation of the dura mater^ and cerebral membranes, 
 and the brain itself. 
 
 § 5. Thrush ; Aphthce . — The mucous membrane of the mouth 
 and throat is liable to this foian of inflammation, which depends on 
 the presence of epidermis in this region. It is then elevated into 
 whitish or ash-coloured vesicles or blisters, sometimes round or 
 oval, sometimes irregular. The contained fluid is separated into 
 two parts, one albuminous, forming the rudiment of new epidermis, 
 
 * “ Le cadarre d’un homme expose a ces ecoulemens pendant sa vie, m’a presente 
 une epaissem- et line rongeur remarquables de la membrane du tympan, mais sans 
 nulle trace d’erosion.” Anat. Generale, Tome III. p. 430. 
 
TRACHEO-BRONCHIAL MUCOUS MEMBRANE. 
 
 571 
 
 the other serous, which escapes while the old epidermis is cast in 
 the form of scab or slough. 
 
 The mucous membrane of the throat and soft palate is affected 
 by diffuse redness, swelling, and other marks of inflammation 
 during the sore throat of scarlet fever. That of quinsy is more 
 frequently seated in the submucous cellular tissue. 
 
 B. TRACHEO-BRONCHIAL MUCOUS MEMBRANE. 
 
 h. Inflammation of the tracheo-bronchial membrane may be dis- 
 tinguished as the process is developed; Is^, in the larynx; 2c/, in 
 the windpipe or proper tracheal membrane ; 3c/, in the bronchial 
 membrane; and, 4//c, in the small bronchial tubes or pulmonic 
 membrane. Though these inflammations possess certain common 
 characters, each is attended by peculiarities which require attention. 
 
 § 1. a. Laryngia, Laryngitis. CynancUe Laryngaea, Laryngia 
 acuta . — Though this disease appears not to have been unknown to 
 Cullen and some previous authors, we are indebted to Dr Baillie, 
 Dr Farre, Dr Percival, Mr Lawrence, and Mr Howship, for a 
 more accurate account of its pathology than we previously pos- 
 sessed. 
 
 The proper seat of laryngitis, indeed, its characteristic symptoms 
 and nature, had been overlooked in the attention paid to croup ; 
 and when it v/as first observed carefully, as in the case of General 
 Washington, it was called Croup in the adult. It is impossible to 
 deny that the disease named laryngitis affects children as well 
 as adults; and it may have often been mistaken for croup. From 
 this, however, laryngitis differs in the parts which it affects, in the 
 effects which it produces, and, in short, according to my own ob- 
 servation, in its anatomico-pathological nature and characters ; and 
 for these reasons I consider the disease separately. 
 
 It may be stated as a well-established fact, that the symptoms of 
 this disease arise from inflammation circumscribed to a definite re- 
 gion of the larynx. Though the whole laryngeal membrane, from 
 the epiglottis to the tracheal rings, is red and swelled, the particular 
 point at which this morbid action is most injurious is that part of 
 the mucous membrane which covers the arytenoid cartilages, and 
 forms the chink called glottis. Though this part of the laryngeal 
 membrane may not be more swelled than any other, a moderate 
 degree of swelling soon diminishes the aperture so much that inspi- 
 ration is rendered difficult or impossible, and the danger of suffo- 
 
572 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 cation becomes urgent. It must nevertheless be observed, that in 
 many instances the margins of the glottis are occupied by an cede- 
 matous or puffy swelling, similar to that which occasionally affects 
 the eyelids, prepuce, and female laUa ^ — from sero-albuminous in- 
 filtration of the submucous filamentous tissue, and the effect of which 
 is to diminish, or in some instances to obliterate, the aperture which 
 regulates the admission of air into the trachea. The redness and 
 swelling of the laryngeal membrane is occasionally more conspicu- 
 ous at its posterior part than elsewhere ; and the epiglottis is some- 
 times swelled and thickened with injection of its membrane ; but 
 whatever variations the disease presents, its effect on the membrane 
 of the glottis is uniform; and this aperture is either much contracted 
 or completely obliterated. 
 
 With redness and swelling, the laryngeal membrane is generally 
 occupied by thick viscid mucus, which contributes by adhering to 
 the margins of the glottis to obstruct the aperture. It is most 
 abundant in the recesses called sacculi, where it assumes the appear- 
 ance of purulent fluid. In some rare instances suppuration takes 
 place with breach of surface ; and purulent abscesses have been 
 found between the thyroid or arytenoid cartilages, and their in- 
 vesting membrane. Reddening of the tracheal membrane is a 
 complication. Inflammation confined chiefly to the membrane of 
 the epiglottis is described by Sir E. Home ;* and this with the 
 arytenoid affection, Dr M. Hall shows, is the effect of the accidental 
 attempt to swallow boiling water.f 
 
 Of laryngeal inflammation three terminations may be enume- 
 rated; \st, resolution, which takes place some time between the 36th 
 and 60th hour ; 2f/, fatal suffocation, which may take place any 
 time after the 30th hour; and, M, a chronic state, with redness and 
 thickening of the mucous membrane, sometimes with suppuration 
 or ulceration of some part of the organ, which may be apprehended, 
 if the disease continues without proving fatal for four revolutions of 
 24 hours. 
 
 /3. Laryngia chronica . — The latter result is most usual after 
 attacks so lenient as not to suffocate, but too severe to be completely 
 resolved. The membrane then continues injected, thickened, and 
 corrugated, rendering the individual hoarse and incapable of laryn- 
 geal speech. The duplicatures called superior vocal chords in par- 
 ticular, are irregularly thickened, partly by accumulation of blood 
 within their vessels, partly by effusion of sero-albuminous fluid 
 * Transactions of a Society, Vol. III. T Medico- Chirurg. Trans. Vol. XI. 
 
TRACHEO-BRONCHIAL MUCOUS MEMBRA.NE. 
 
 573 
 
 into the submucous cellular tissue. Often the epiglottis becomes 
 much thickened. Its investing membrane is always reddened and 
 rough. After some time ulceration may take place in the epiglottis, 
 and destroy the top or anterior extremity of it. This I have ob- 
 served several times : the round apex of the epiglottis being cut off 
 as it were transversely by ulceration. In other instances, it is merely 
 rendered thick, rigid, and inflexible, so that it no longer, when the 
 tongue is depressed, covers accui'ately the upper aperture of the 
 larynx. 
 
 Other appearances are the following. The lower or true vocal 
 chords become thickened. The membrane forming the ventri- 
 cles of the larynx (^sacculi laryngis,) is thickened, and occasion- 
 ally presents minute ulcers of the surface. The apices of the 
 arytenoid membranes are red, thickened, and abraded or ulcerated; 
 and sometimes this ulceration descends to the subjacent cartilages 
 or their perichondrial covering. Constantly the perichondrium, 
 when the disease lasts any time or has recurred several times, is 
 thickened and rendered rough. 
 
 Even when the ulcers of the mucous membrane have been healed, 
 the membrane itself remains much thickened, rough, and sometimes 
 irregular by tubercular growths ; and the perichondrium of the 
 cartilages is thick, soft, and easily detached. 
 
 In this state the diseased action is liable to spread to tbe carti- 
 lages, rendering them thick, painful, and sometimes producing 
 ulceration, and occasionally imperfect ossification. 
 
 In one or more points ulceration takes place generally in oval 
 patches, which spread and become deep, affecting the submucous 
 tissue and the perichondrium. The ulcers which were previously an 
 effect, become now a cause of inflammation, and obstinately resist- 
 ing all tendency to heal, continue to spread with chronic inflamma- 
 tion, and give rise to more or less wasting with hectic fever. This 
 constitutes the disease described under the name of laryngeal con- 
 sumption ; (^phthisis laryngaea.) (Cayol.) 
 
 In some instances suppuration of the submucous filamentous 
 tissue takes place previous to ulceration of the membrane ; and 
 though, by affecting the perichondrium on the one side, and the 
 laryngeal mucous membrane on the other, it may cause the same 
 chronic process as that now described, it is generally a milder and 
 more sanable disease. 
 
 In others it spreads to the cartilages, and by inducing ulceration 
 
574 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 or death of these bodies, causes an insanahle disease speedily fatal. 
 In Mr Dyson’s case, in which the epiglottis and upper part of the 
 trachea were ulcerated, the os hyoides became carious, and was 
 exfoliated dead.* 
 
 Of both acute and chronic laryngitis, it is a peculiar character, 
 that death often takes place suddenly, and sometimes when not ex- 
 pected. 
 
 The causes of chronic laryngitis are the same as those of the acute 
 form ; that is, exposure to cold, previous attacks of the acute form, 
 and extraordinary efforts of the voice in speaking, crying, or shout- 
 ing. One cause, however, is so peculiar that it deserves mention. 
 It consists in the use of mercury, often in repeated courses. In 
 almost all the cases of chronic laryngitis which have come under my 
 observation during tlie course of twenty-five years, the sufferers had 
 been subjected to one or more full courses of mercurial medicines, 
 and sometimes to several repeated courses. The effect of this was 
 to render all the mucous surfaces prone to irritation and inflamma- 
 tion ; and especially where these surfaces are near the periosteum or 
 perichondrium. The cases are always susceptible of alleviation ; 
 but the symptoms invariably recur, showing the chronic nature of 
 the disorder, and the firm hold which it takes of the larynx. 
 
 y. Ulceration, of the Laryngeal and Tracheal membrane in phthisis. 
 — In persons cut off by tubercular consumption, minute ulcers of 
 the laryngeal and tracheal membrane are not unfrequent. They 
 vary in size, and are irregular in shape ; but in general they ap- 
 pear in the form of angular or oval spots, from w’hich the mucous 
 membrane has been entirely removed. In the larynx of a young 
 woman in my collection, I count five of these eroded spots affecting 
 the oval shape, none of more extent than one square line, and one 
 patch evidently formed by the coalescence of two, as large as the 
 section of a split pea ; and in the tracheal membrane of the same 
 subject, at the bronchial bifurcations, large patches of the same de- 
 scription are visible. In the latter situation, indeed, this destruc- 
 tion is more common and more extensive than in any other point. 
 
 The most frequent site of ulcers of the larynx, according to 
 Louis, is the junction of the vocal chords ; then the vocal chords 
 themselves ; and lastly, the base of the arytenoid cartilages, the 
 upper part of the larynx and the sacculi. In the traehea these 
 ulcers occupy chiefly the posterior part. The bronchial mem- 
 * Mem. Med. Society, Vol. TV. 
 
TRACHEO-BRONCHIAL MUCOUS MEMBRANE. 
 
 575 
 
 brane is, according to the same authority, less frequently ul- 
 cerated ; but when not so, it is almost invariably reddened. 
 
 S. Ulceration of the Tracheal Membrane and Cartilages . — This 
 is not a very frequent lesion, but it is liable to take place. It is 
 seen mostly in the posterior surface of the trachea; and though 
 probably it may take place in several points, yet I have never seen 
 more than one or at most two ulcers, one generally large. No 
 doubt can be entertained that ulcers of this kind are the result of 
 inflammation attacking the raucous membrane of the trachea ; but 
 on the early history of these ulcers we possess no correct informa- 
 tion. The following details will convey some idea of the appear- 
 ance and characters of these ulcers. 
 
 In one case, taking place in a man of about 48 or 50 years of 
 age, the individual suflfered much from constant difficulty of deglu- 
 tition, a sense of soreness and rawness in the throat, great hoarse- 
 ness, cough, difficult breathing, and scanty expectoration occasion- 
 ally streaked with blood. All solids and fluids caused during de- 
 glutition much suffering, and a feeling of impending suffocation; and 
 the patient of his own accord I’equested food of a semifluid character. 
 Even this was swallowed with little less difficulty, and with much of 
 the gasping and suffocating feeling. Soon after death took place. 
 
 The laryngeal mucous membrane was red, thickened, and co- 
 vered with a considerable quantity of thick puriform mucus. This 
 was abundant in the sacculi between the superior and inferior vo- 
 cal chords. The laryngeal mucous membrane presented abrasions 
 and ulcerations. The epiglottis was thickened, reddened, rigid, and 
 ulcerated at its apex. The tracheal membrane was very much red- 
 dened, and as if roughened. About one inch and a half below the 
 cricoid cartilage, immediately above the bifurcation of the trachea 
 on the posterior surface, was first one elliptical ulcer, then another 
 smaller, both with the long axis in the long direction of the wind- 
 pipe. The first ulcer was about three-fourths of one inch or nearly 
 one inch long; the other about one-fourth of an inch long. Both were 
 formed by total destruction of the mucous membrane and part of the 
 sub-mucous tissue ; and the base of the ulcer was formed by part of 
 that connecting the windpipe to the oesophagus. The edges of both 
 were ulcerated, irregular, and ragged, and consisted of jagged points; 
 but this was caused by the projection of the extremities of the cartila- 
 ginous rings, which were cut right across, and being less destroyed 
 than the connecting mucous membrane, left between them hollow 
 spaces. The cartilages also projected into the interior of the trachea, 
 
576 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 being no longer held down by the raucous membrane uniting with 
 those of the opposite side. 
 
 This man, like many persons under laryngeal disease, had been 
 previously subjected to several courses of mercurial medicines. 
 
 In another case I saw an ulcer of the trachea take place under 
 j)eculiar circumstances. 
 
 A female between 40 and 45 years of age was affected with 
 chronic laryngitis ; and over this was super-induced an acute at- 
 tack so intense, that immediate suffocation was threatened. For 
 relieving her sufferings and averting the fatal termination, it was 
 deemed necessary to perform the operation of laryngotomy or tra- 
 cheotomy. This was accordingly done with very beneficial results, 
 the breathing being much relieved, and the urgent symptoms of 
 suffocation in the meantime removed. The tube was inserted and 
 kept in the wound for about three weeks or longer, being with- 
 drawn only to cleanse the wound, and remove mucus and purulent 
 matter. 
 
 About this time it was recommended to the patient to try to 
 breathe without the tube ; but she found that this was impracticable. 
 Meanwhile the same course was pursued for about three weeks | 
 longer, during which the patient did not appear to be recovering 
 the power of breathing through the larynx. Uneasiness and sore- 
 ness were felt in the windpipe; and this it was natural to ascribe 
 to the wound. After some days longer of struggling, irritation, 
 distress and agony, the patient suddenly expired. 
 
 The laryngeal membrane was red, thickened, rough, and irregu- 
 lar ; and when the abundant mucus was removed, minute ab- 
 rasions were observed. The chords, both superior and inferior, were 
 thickened and swelled. The wound was healthy and granulating, 
 though slowly and irregularly. At the posterior surface of the 
 trachea, about one inch and a-half below the cricoid cartilage, a 
 large elliptical ulcerated destruction of the mucous membrane had 
 taken place. The edges and outlines of this were irregular. The 
 long diameter corresponded to the axis of the trachea. In some 
 parts this ulcer was deep, almost proceeding through to the ceso- | 
 phagus ; in others it was more superficial. The ulcerated extremi- 
 ties of the cartilaginous rings were, however, exposed in the same 
 manner, and prominent, as in the case last mentioned; and gave 
 the ulcer the same ragged appearance. 
 
 This large ulcer corresponded so accurately to the extremity of 
 
TRACHEO-BRONCHIAL MUCOUS MEMBRANE. 
 
 57 ? 
 
 the tube, which was kept in the wound, that it seemed impossible 
 to doubt that it had been produced by the constant pressure and 
 irritation of the tube on the posterior surface of the windpipe. I 
 am aware that it may be said, that if the tube were so placed, it 
 was improperly placed ; and not only must have produced irritation 
 in the windpipe, but could not have acted as a tube to convey air 
 into the windpipe and out again in the actions of respiration. It is 
 also possible that some ulcer or ulceration may have existed there 
 previously, and may have been associated, as is often the case, with 
 chronic disease of the larynx. To this it is not necessary to give 
 any other answer than merely stating the facts of the case. 
 
 This patient had been subjected to the use of mercury in full 
 courses, more than once ; and of this the laryngeal aflPection was 
 the result. 
 
 § 2. «. Croup (^Bronchiasis albuminosa) may be defined to be 
 inflammation of the tracheo-bronchial mucous membrane, termi- 
 nating in sero-albuminous exudation. The points deserving atten- 
 tion in the pathology of this disease, are, Ist^ the fact of inflamma- 
 tion ; 2d, the extent of the process ; and, 2>dly, its effects. The in- 
 flamed state of the tracheo-bronchial membrane is estabb’shed be- 
 yond doubt. Home observed that it was redder than natural when 
 the concrete covering is detached; Rumsey recognized manifest traces 
 of inflammation ; in Cheyne’s cases the vessels of the membrane 
 were large, distinct, and sometimes numerous, (9th.) The same 
 was seen by Albers, Jurine, and Bretonneau. In short, whether 
 the membranous exudation be present or absent, the tracheo- 
 bronchial membrane is always more or less red, bloodshot, vil- 
 lous, and swollen ; and puriform fluid oozes from the bronchial 
 tubes. 
 
 This inflammation is seated in the tracheo-bronchial membrane 
 solely. It begins immediately below the cricoid cartilage, and ex- 
 tends along the tube into the bronchi and bronchial membrane. 
 It is less frequently observed to affect the laryngeal membrane ; and 
 when it does so, this is to be viewed as a complication not essential 
 to genuine croup. It may, nevertheless, in extreme cases, affect 
 the pharynx, larynx, and trachea, covering their surface with a false 
 membranous exudation. The disease, from this circumstance, re- 
 ceives the name of Diphtheritis, 
 
 The effect of this inflammation is to produce from the surface of 
 the membrane a fluid or semifluid secretion, which soon undergoes 
 
 o 0 
 
578 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 coagulation after exposure to the aii’. In the upper part of the 
 trachea this substance is firm and in the form of a tubular mem- 
 brane moulded on the canal ; below and in the bronchial divisions 
 it is less firm ; in the tubes it is completely fluid.* (Home, Cheyne, 
 Bretonneau.) The nature of this morbid exudation has been a 
 matter of ambiguity. Home, who remarked that the tubular mem- 
 brane when complete is tough and thick, might be soaked in water 
 for days without dissolving, that it does not adhere to the wind- 
 pipe, as there is always fluid matter beneath it, and that beyond it, 
 the windpipe, bronchial tubes, and pulmonic vesicles, are covered 
 by pus or purulent mucus, thought it of the nature of thickened 
 mucus. In one case Rumsey calls it viscid mucus or phlegm ; in 
 others he likens it to the buffy coat. Field regards it as coagulable 
 lymph ; Cheyne, with some confusion, compares it to the exuda- 
 tion of the inflamed pleura or peritonaeum, and accounts it thickened 
 puriform fluid ; while by Pinel and most of the recent authorities, 
 it is identified with albuminous exudation. According to the in- 
 vestigation of its chemical properties by Schwilgue, Maunoir and 
 Peschier, and Jurine, it appears to contain albumen in various pro- 
 portions, and to owe to this principle its tenacity and firmness. 
 Bretonneau, in particular, endeavours to establish a distinction 
 between the ti’acheo-bronchial exudation, the albuminous concre- 
 tions of serous membranes, and the buffy coat, but without success.f 
 It may be inferred, therefore, that this substance, without being 
 either wholly coagulable lymph, or thickened mucus, or dried pu- 
 rulent matter, is a morbid product secreted from the tracheo-bron- 
 chial mucous surface, in a semifluid form, and undergoing, in con- 
 sequence of the presence of albuminous or album ino-gelatinous 
 matter, coagulation, as it is more freely exposed to air. 
 
 Death is produced in this disease chiefly by the albuminous fluid 
 in the bronchial tubes and vesicles excluding the air from the pul- 
 monary membrane. 
 
 j3. Bronchiasis albuminosa adultorum. Polypose injlammation of 
 the trachea. — Not very dissimilar is that morbid state of the tracheo- 
 bronchial membrane, in which a membranous concretion, moulded 
 on the tube, is, from time to time, brought up by coughing either 
 
 ■* “We can even demonstrate,” says Cheyne, “ the adventitious membrane degene- 
 rating into the puriform fluid, and again gaining consistence in different parts of thc- 
 same membrane.” 
 
 t Des Inflammations du Tissu Muqueux, et en particulier de la Diphtherite, &c. 
 Paris, 1826. P. 293. 
 
TRACHEO-BRONCHIAL MUCOUS MEMBRANE. 
 
 579 
 
 in fragments or entire. Instances of this disease, which is not com- 
 mon, were first observed by T. Bartholine,* N. Tulpius,t Ruysch,:!; 
 Clarke,§ Lister, Cheselden, Bussiere,|| Samber,ir F. Nicholls,** 
 Warren,f| John Andrew Murray, Callisen, §§ Baillie, and 
 Laennec. 
 
 The mode of their formation is not established without ambiguity. 
 In many instances they are the result of a modification of the in- 
 flammatory process. In some, however, in which they are connected 
 with bronchial or pulmonary hemorrhage, they appear to be formed 
 by the coagulation of blood not discharged at the time of hemor- 
 rhage. 
 
 § 3. Bronchial Injiammation, acute, and chronic. Bronchiasis puri- 
 formis ; Bronchitis . — Bronchitis may be distinguished into two varie- 
 ties, according to the portions of the air-tubes which it affects. The 
 disease may be confined chiefly, if not solely, to the large and middle- 
 sized bronchial tubes, in short, where the mucous membrane lines 
 tubes, properly so called ; or it may either, with or without affec- 
 tion of these, be seated principally in the terminal ends or vesicles 
 where the membrane is more delicate, and the tubes are much 
 smaller. In the former case, the impediment to respiration is much 
 less considerable than in the latter, in which, from their small size, 
 any thickening or new secretion produces most serious and alarm- 
 ing labour in breathing, with great anxiety and distress. The former 
 may be termed tubular bronchitis, the latter vesicular bronchitis, 
 or bronchitis of the vesicles, or of the small bronchial tubes and 
 terminal ends of the small bronchial tubes. 
 
 I am aware that the latter is by some believed to constitute pneu- 
 monia or inflammation of the lungs ; and, in point of fact, in all 
 cases of pneumonia or inflammation of the substance of the lungs, 
 there is a considerable affection of the terminal ends of the bronchi ; 
 and in cases of affection of the vesicles on the other hand, there is , 
 sooner or later some affection of the pulmonic tissue. In short, 
 the two diseases pass into each other, and in most cases co-exist. 
 
 * Centur. iii. Hist. 98. -t Obs. Lib. ii. Obs. 7. 
 
 J Epistola Anatomica, VI. p. 9 et 11. Amstelodami, 1659. Op. Om. Tom. II. 
 
 § Phil. Trans. No. 235, p. 779 and 780. Vol. XIX. 
 
 II Ibid. No. 263, p. 545. Vol. XXII. 
 
 H Ibid. No. 398, p. 262. ** Ib. No. 419, p. 123. 
 
 -ti" Transactions of College of Physicians, Vol. I. p. 407. 
 
 Commentatio de Poly pis Bronchioram. Goettingas, 1773. Opnscula, Vol. I. 1785. 
 VI. p. 255. 
 
 §§ Observatio de Concretione Polyposa, Cava, Ramosa, tussi rejecta. Acta Societatis 
 MedicEe Havniensis, Vol. I. Ha^'ni£e, 1777. Art. IV. p. 76. 
 
580 
 
 GENERAL AND PATHOLOGICAL ANATOMY, 
 
 This, however, is no reason for confounding these affections in a 
 work like the present, in which morbid processes are considered in 
 an analytical manner, according to the individual elementary tex- 
 tures which they affect. This analytical method leads to no error ; 
 and it enables the pathologist more clearly to understand the cha- 
 racteristic differences of closely allied diseases. 
 
 a. Tubular bronchitis. Bronchitis affecting the large and middle- 
 sized air-tubes. — In tubular bronchitis, then, tbe inflammatory disorder 
 is very much confined to the large and middle sized bronchial tubes ; 
 and as this disease as a primary affection is not often fatal, and is 
 chiefly so by recurring frequently, or by the morbid action extending 
 to the small tubes and the vesicles, itis not possible to speak accurately 
 of its anatomical characters as an isolated affection. When in these 
 circumstances the membrane isexamined,it is found brown-coloured, 
 sometimes dark red, rough, and swelled, with more or less contrac- 
 tion of the area of the bronchial tubes. These tubes are lined by 
 viscid jelly-like mucus, streaked with blood or embrowned. In 
 some instances tbe mucus is puriform, yet adheres to the mem- 
 brane. 
 
 This form of bronchitis takes place not only in catarrh, but in 
 the course of continued fever, of typhus fever, in measles, in scarlet 
 fever, and in small-pox. It is also an invariable accompaniment of 
 tubercular destruction in consumption, and is frequent in cases of 
 diseased heart, especially hypertrophy and valvular disease. 
 
 By frequent recurrence it is liable to produce symptoms of 
 asthma, or to pass into chronic catarrh, with dyspnoea, or into dry 
 catarrh. It then gives rise to winter cough. 
 
 Tubular bronchitis may terminate in health by the gradual sub- 
 sidence of the inflammation ; in vesicular bronchitis by extending 
 to the vesicular mucous membrane; in thickening of the tubular 
 membrane and contraction of the tube, {stenochoria bronchorum,) 
 causing symptoms of asthma, breathlessness, and more or less chro- 
 nic cough, aggravated especially in the winter, during cold weather, 
 and on the accession of any slight cold ; in emphysema of the lungs 
 with breathlessness ; in oedema of the lungs ; in serous effusion 
 within \he pleura {liydropleura ; hy dr othor ax general dropsy. 
 
 The formidable terminations last mentioned seldom take 
 place until the disease has recurred several times; and as it i.^ 
 alw'ays liable to recur after the first attack, it necessarily renders 
 tbe bronchial tubes less fit for the pui'pose of admitting air to 
 the vesicles. In the bodies of those destroyed under this ad- 
 
TRACHEO-BRONCHIAL MUCOUS MEMBRANE. 
 
 581 
 
 vanced stage of the disease the following appearances are recog- 
 nised. 
 
 1. Collapse of the lungs, on opening the ehest, either imperfect 
 or none ; the lungs inelastic, doughy, and gorged with venous 
 blood ; sometimes oedematous, sometimes slightly solidified. 2 . 
 The bronchi and large bronchial tubes containing a considerable 
 quantity of viscid, opaque, tenacious mucus adhering firmly to the 
 membrane ; the membrane itself in the bronchi and large tubes red- 
 dened, rough, in some parts swelled, and of a colour more or less 
 brown. 3. Several of the bronchial tubes present portions in which 
 the area of their canal is more or less, sometimes considerably, con- 
 tracted, forming a degree of bronchial stricture. 4, Parts of the 
 lungs, especially near their margin, present air in their filamentous 
 tissue, and sometimes bladders of air, forming emphysema of the 
 lungs. 5. In some instances a few of the bronchial tubes, especially 
 towards the lower part of the lung, may be dilated to a gi’eater 
 capacity than natural. 6. In certain cases they are narrowed, or 
 altogether closed and obliterated. 
 
 b. Vesicular Bronchitis. Injiammatio Vesicular um.—lx\ the 
 second variety, either w'ith or without the affection of the membrane 
 of the large and middle-sized tubes, inflammation attacks the 
 pulmonic or vesicular division of the bronchial mucous mem- 
 brane. 
 
 The pathology of this disease, though understood by Mor- 
 gagni, De Haen, and Stoll, has been more fully illustrated by 
 the researches of Chevalier, Badham, Abercrombie, Hastings, and 
 Laennec. Dissections of persons cut off in different stages of the 
 disease show that the bronchial membrane is much reddened and 
 injected, villous or pulpy, and thickened or swelled. As the disease 
 proceeds, it discharges viscid puriform mucus, or muco-purulent 
 fluid, which fills the air-cells or vesicles, and prevents the lungs 
 from collapsing when the chest is opened. The tracheal membrane 
 may be reddened or traversed by arborescent red lines ; and though 
 the bronchial membrane is in general entire, in some instances 
 small ulcerated breaches are observed in various parts. 
 
 In the chronic form, the membrane, though red and villous, is 
 rarely so much swelled as in the acute disease ; but minute ulcers 
 or patches of ulceration' are more common. 
 
 The effect of this process in the bronchial membrane is to aug- 
 ment the quantity and change the quality of the fluid secreted in 
 the natural state. At the commencement of the process, the bluish. 
 
582 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 semitransparent, and particled mucus of health is mixed with muci- 
 laginous, semitransparent, and grayish fluid, not unlike white of 
 egg, which is secreted in considerable quantity. As the process 
 advances, it becomes thicker, more viscid and opaque, and sinks in 
 water; and when fully established, this viscid mucus is either 
 mingled with, or converted into yellowish opaque fluid, which can- 
 not be distinguished from purulent matter, and which is generally 
 more or less streaked with blood. These changes may be effected 
 without breach of continuity or ulceration of the membrane. This 
 fact, which was first established by De Haen,* has since been fully 
 confirmed by Willan,f Badham,J George Pearson,§ and Hastings. || 
 The process of suppurative secretion is attended with hectic fever 
 and wasting. 
 
 Though ulcers, however, are not essential to chronic inflammation 
 of the bronchial membrane, they may occur, and are most common 
 in the lungs of those whose occupation exposes them to inhalation 
 of irritating mechanical powders. Such, for example, has dissec- 
 tion shown to be the state of the bronchial membrane in stone- 
 cutters,^ glass- grinders, needle-grinders, and leather-dressers. 
 
 c. Pustular Inflammation , — On the nature of a form of ulcer con- 
 siderably different we have less certain information. In several 
 cases of bronchial disease, the membrane becomes the seat of nume- 
 rous minute eminences, which, as they may be traced through the 
 stages of inflammation, suppuration, and ulceration, maybe regarded 
 as pustules of the pulmonic mucous membrane. The ulcers thus 
 formed are in general round or oval, rarely irregular, with margin 
 slightly raised, and surrounded by a red circle, (areoZa,) more or 
 less distinct. The matter expectorated consists of purulent fluid, 
 streaked with blood, and mingled with a considerable proportion of 
 dense mucus. The analogy between this and certain ulcers of the 
 intestinal raucous membrane is obvious. It gives rise to wasting 
 and hectic fever. 
 
 d. Induration,! Consolidation , — When chronic inflammation sub- 
 sists long, the inflammatory action extends to the submucous fila- 
 mentous tissue, which unites the bronchial tubes and vessels to the 
 serous membrane of the lungs — the parenchymatous or cellular tissue 
 
 * Rationis Meclendi, I. xi. p. 60. t Reports, 1796, 20th March. 
 
 + Observations on the Inflammatory Affections of the Mucous Membrane of the 
 Bronchiee, &c. pp. 48 — 76. 
 
 § Phil. Trans. 180.9, Part ii. p. 315 — 321. 
 
 II Treatise on Inflammation of the Mucous Membrane, &c. 
 
 K Johnstone of Worcester, Mem. Med. Society. 
 
 3 
 
TRACHEO-BEONCHIAL JIUCOUS MEMBRANE. 
 
 583 
 
 of the older anatomists. Of this the first effect is redness, with vas- 
 cular injection of the submucous tissue (infarctio.) As the morbid 
 state of the blood-vessels continues or increases, sero-albuminous 
 fluid is effused into its interstices ; the part loses its natural softness 
 and elasticity ; and as the process extends, the lung loses the spongy 
 lightness which depends on permeability of its vesicles. In a lung 
 in which the chronic inflammation of the submucous tissue has 
 subsisted for some time, the following phenomena are recognized : — 
 Isf, On opening the chest and admitting the air, though there are 
 no adhesions, the lung collapses imperfectly or not at all ; 2d, The 
 pulmonic tissue surrounding a portion of inflamed membrane be- 
 comes hard and dense, and floats deep or sinks in water ; 3d, De- 
 prived of its elasticity and compressibility, it cannot be inflated, 
 does not crepitate, and resembles a portion of solid flesh. In such 
 circumstances bronchial inflammation is complicated with pneu- 
 monia. 
 
 e. Bronchitis from the presence of foreign bodies. — Bronchitis 
 alienorum. — A variety of chronic bronchial inflammation, important 
 from its close resemblance to consumption, is that occasioned by the 
 presence of foreign bodies which have dropped accidentally into the 
 windpipe. Of this species of disease many cases are recorded, as 
 having occurred to diflPerent observers ; and the facts of these cases 
 show at once the influence of the cause alleged iti producing chronic, 
 bronchial, and occasionally pulmonary inflammation, closely imitating 
 pulmonary consumption, and the great efi’orts made by the system 
 in striving to get rid of a source of great and possibly fatal irrita- 
 tion. 
 
 Foreign bodies which drop into the air passages may produce 
 one of two effects. First, a foreign body dropping into the larynx 
 may, by fixing itself in the ventricles, or in the rima glottidis, cause 
 immediate suffocation. This result will depend on its shape, or its 
 consistence, and its size. Thus, portions of food masticated, or 
 imperfectly masticated, are occasionally observed to produce suffo- 
 cation and immediate death. Or, secondly, a foreign body may 
 drop into the larynx, and by passing entirely through the rima 
 glottidis, may get into the windpipe and one of the bronchial tubes, 
 and stopping there, cause great irritation and inflammation of the 
 parts, indicated by frequent, urgent, and distressing cough ; fits of 
 difiicult breathing ; expectoration of dense, puriform mucus, often 
 with blood ; and wasting of the flesh and strength of the individual, 
 nearly in the same manner and to the same extent as in pulmo- 
 
584 
 
 GENERAL AND PATHOLOGICAL ANATOMY, 
 
 nary consumption. It is, indeed, remarkable that, in all the re- 
 corded cases, the symptoms thus produced have home so close a 
 resemblance to 'phthisis, that they have in most instances been con- 
 sidered as examples of consumptive disease, and by several they 
 are described as such. 
 
 The bodies which have in this manner been known to drop into 
 the windpipe are various ; beans,* nuts,t walnuts, | cherry stones,§ 
 plumb stones, II an iron nail,^ a leaden shot,** teeth, natural and 
 artificial, tt ears of grass,J|, fragments of bones, a fragment of nut- 
 meg,§§ pieces of money, || || and similar substances. Of various pointed 
 and well authenticated examples of this accident and its effects, I 
 published in 1834 a collection, with the view of showing the true 
 nature and effects of the lesion and its degree of frequency ; and 
 the most instructive mode of presenting the results of this series of 
 cases, I believe to be placing them in the tabular form which is here 
 subjoined. This list I might have enlarged more than I have done. 
 But I believe that the present table gives a sufficient number of 
 well established and accurately detailed facts to enable the reader 
 to form just ideas on the nature of the disorder, and to compare 
 the facts with the inferences deduced. 
 
 * Boussier de la Bouchardiere. Journal de Medecine, xlv. p. 267. Guincourt in 
 Journal de Medecine, continue, xii. p. 44. 
 
 Allard, Joui'nal de Physique, T. li. 
 
 Klein Chirurgische Bemerkungen, p. 168. Vicq D’Azyr Memoires de la Societe 
 de Medecine, Vol. IV. Chir. N. 3, fatal on 6th day. 
 
 + Ephemerides Naturae Curiosorum, Dec. ii. Ann. i. Obs. 144. 
 
 Ephemerides Naturae Curiosorum, Decad. iii. Ann, iii. Obs. 18. Dr Scott’s case in 
 Dr Craigie’s Memou'. 
 
 § Ephemerides Naturae Curiosorum, Dec. ii. Ann. x. Obser. 66. Desault Oeuvres 
 Chirurgicales, 2ieme Tome. 
 
 1| Deschamps in Journal de Medecine, continue, ii. p. 555. 
 
 U Morton Phthisiologia, Lib. iii. cap. vi. p. 143. London, 168ft. 
 
 Howship’s Practical Observations in Medicine and Morbid Anatomy, p. 222. 
 
 Dr Craigie’s Case. See page 590. 
 
 ** Birch History of the Royal Society, Tome III. Robert Hooke, Collections. 
 Transactions of a Society, Vol. III. Lond. 1812. 
 
 ft Cases in Memoir by Dr Craigie. Edin. Medical and Surgical Journal, Vol, 
 XLII. p. 103. Edin. 1834. 
 
 Histoire et Memoires de Thoulouse, II., ejected by abscess in the side ; phthisical 
 symptoms ; and Dr Donaldson’s case in Edinburgh Medical and Surgical Journal, Vol. 
 XLII. p. 102. Edin. 1834. 
 
 §§ Borelli P. Observationes Medico-Pbysicae. Cent. IV. Obs. 63. 
 
 Ill De la Martiniere dans Memoires de I’Academie de la Chirurgie, Tome V. Rc- 
 ?nained five years. Mr Key’s Case ; and the Case of Sir I. Brunell by Sir B. Brodie, 
 W edico-Chirurgical Transactions. 
 
i 
 
TRACHEO-BRONCHIAL MUCOUS MEMBRANE. 
 
 589 
 
 This tabular statement contains 24 cases, among which eight ter- 
 minated in death, five of these being cases in which the body was 
 not ejected. 
 
 In each of the cases terminating favourably the usual symptoms 
 of chronic, bronchial, and even of pulmonary inflammation were 
 induced ; and purulent expectoration with occasional hemoptysis, 
 and hectic and great wasting, threatened certain death. In each, 
 however, after a lapse of weeks, months, or years, the foreign body 
 was rejected by coughing when least expected, and recovery even- 
 tually took place. Though this favourable issue prevents the pa- 
 thologist from ascertaining with certainty the exact nature and ex- 
 tent of the lesion, it is reasonable, from the facts disclosed by in- 
 spection of the fatal cases, to infer that the bronchial membrane 
 certainly, and probably the pulmonic tissue, were maintained in a 
 state of chronic inflammation during the presence of the foreign 
 body. 
 
 Among the fatal cases are six in which the state of the parts 
 was inspected after death ; and from these we learn several instruc- 
 tive facts. 
 
 ] . In the case given by Morton, the patient, after the first irri- 
 tative symptoms were over, suffered so little inconvenience, and was 
 apparently so well, that for several months he pursued hisbusiness or 
 profession as a whitewasher, and entered into the matrimonial state. 
 On the evening of the day of marriage, however, he was attacked 
 with most acute pain of the breast and side, difficult breathing, and 
 frequent dry cough, so urgent that he could neither lie in bed 
 nor sleep. Fever followed ; and, notwithstanding the active and 
 judicious use of approved remedies, the symptoms of pulmonic in- 
 flammation and suppuration with hectic were established, and death 
 took place at the end of five weeks. 
 
 The three nails were found a little below the division of the 
 bronchi, buried, as it were, in a bed of purulent matter, which was 
 also spreading gradually through the lungs. The cavity of the 
 pleura contained about six pints of purulent matter. 
 
 2. In the case of the engraver recorded by De la Martiniere and 
 Louis, the left lung was sound. The right lung was almost entirely 
 destroyed by suppuration. The right cavity of the chest was filled 
 with purulent matter ; and the Louis d’or was found placed perpen- 
 dicularly at the upper part of the right lung at the first bifurcation 
 of the bronchus on this side. 
 
588 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 In this case the piece of money had produced inflammation, first 
 in tlie large hronchial tubes, where it was fixed, then in the lung, 
 and afterwards in the pleura.* 
 
 3. In the case communicated hy M.Lenglet to M. De laMartiniere 
 in which a splinter of bone triangular in shape, with sharp angles 
 and cutting edges, one side 9 lines long, had remained 10 months 
 in the bronchial tubes, the right lung was natural, hut the left in a 
 state of putrefaction. About four inches below the bifurcation on 
 the left side was a preternatural cavity of the capacity of a large 
 nutmeg ; and in this cavity the bone had been lodged.f 
 
 4. In the case given by Dr Milroy, in the centre of the right 
 lung was found a large abscess containing about twenty ounces of 
 purulent matter, of reddish-brown colour, and fetid odour. The 
 piece of chicken bone, which was light and porous, weighing only 
 six grains, lay in the upper part of the right bronchus^ close to the 
 bifurcation of the trachea. This tube (I suppose the right hron- 
 elms) communicated with the upper part of the abscess. 
 
 5. In the case given by Schroeder, the right lung was occupied 
 by several tubercles, among which was a vomica in the middle 
 lobe, filled not with purulent matter but with black gore. The 
 left lung contained everywhere tubercles and several small vomicce, 
 and in the left bronchus about one inch from the bifurcation of the 
 trachea was a splinter of hone covered with black viscid mucus. 
 This bone was rough, and its angles had so completely penetrated 
 the bronchial mucous membrane, that it could be moved neither 
 upwards nor downward. 
 
 6. In the case given by Dr Houston, the broken tooth was found 
 lying in the right hronchial tube about one inch beyond its com- 
 mencement, with the fangs directed towards the lung, and the 
 broken surface of the crown towards the larynx. It lay loose 
 and unattached, and when caught between the points of the scissors 
 was readily removed. The broken surface fitted accurately to that 
 of the crown as presented by the patient to Dr Houston. 
 
 The right lung adhered to the -pleura costalis everywhere except 
 behind, where bloody fluid lay between the pleurae. The adhesions 
 were soft and easily broken ; the right pulmonic pleura was livid. 
 The substance of the right lung was dense and indurated through- 
 
 • Memoires tie I’Academie Royale de Chirurgie, Tome V., p. 528-531. Paris, 
 1774. 
 
 t Ibid. p. 533. Paris, 1774. 
 
TRACHEO-BRONCHIAL JIUCOUS MEMBRANE. 
 
 589 
 
 out; and lacerable; much loaded with blood and serum. The 
 left pleurae adhered universally ; and the left lung, though less 
 heavy and gorged, was everywhere reddened and ejected. 
 
 The mucous membrane from the larynx to the smallest branches 
 of the bronchial tubes in both lungs was swelled, softened, and of 
 a deep red colour ; and the bronchial tubes were filled with muco- 
 purulent fluid round the tooth, but without abscess or breach of 
 surface in the vicinity of the spot where it was lodged. 
 
 From the facts now adduced, it seems reasonable to establish 
 the following conclusions. 
 
 1. Foreign bodies, such as kernels and stones of fruit, nuts, or 
 fi’agments of them, teeth, natural or artificial, pieces of metal, wood, 
 or fragments of bones, which pass the glottis and drop into the 
 windpipe, if they do not produce immediate suffocation, cause irri- 
 tation of the windpipe, bronchi, and bronchial membrane, indicated 
 by fits of coughing, more or less continued and severe, wheezing, 
 breathlessness, and weight and oppression in the chest. 
 
 2. These symptoms of irritation are speedily succeeded by symp- 
 toms of inflammation, sometimes acute, sometimes chronic, but 
 always afterwards becoming chronic, indicated by cough, expecto- 
 ration of dense puriform or purulent mucus, occasionally streaked 
 with blood ; weight and anxiety in the chest ; quick pulse ; and 
 eventually, hectic fever, with wasting, 
 
 3. Bodies of the kind now specified drop not constantly but most 
 frequently into the right bronchus ; and their presence is followed 
 by inflammation first in the right bronchial tubes and lungs of 
 right side. The right bronchus is normally more directly in con- 
 tinuation with the tracheal canal than the left bronchus. One or 
 two instances, nevertheless, of foreign bodies falling into the left 
 bronchus have occurred.* 
 
 4. These bodies, there is reason to believe from their size and 
 shape, must be arrested in the large or middle-sized bronchial 
 tubes; and it must be anatomically and physically impossible for 
 them to descend into the small tubes or the pulmonary vesicles. 
 
 5. The disease induced by their presence must therefore be, in 
 the first instance, tubular bronchitis ; and though the inflammation 
 may afterwards extend to the vesicular membrane, it is chiefly the 
 tubular variety of the disorder throughout. 
 
 6. In all the recorded cases, the symptoms, however intense 
 
 * Schroetier Van Der Kolk. 
 
590 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 during the abode of the body in the bronchi^ and though enduring 
 from the space of from six to seven weeks, as in the cases of Bor- 
 sieri, Dr Donaldson, and Dr J. Scott, to that of several months, 
 as in the case by Dr Lettsom, that of Dr Nooth, and the case by 
 Mr Howship, or for years, as in those by Desault, Louis, Sue, and 
 Holman, in general rapidly subided as soon as the foreign body 
 was ejected. 
 
 7. In two cases only, that by M. Sue, and the one which occurred 
 to myself, did partial and temporary recovery take place, before the 
 ejection of the foreign body. 
 
 8. In certain cases in which the mechanical configuration of the 
 body is unfavourable for detachment and expulsion, the bronchitic 
 symptoms are liable to be extended to the lung, in which suppura- 
 tion is caused, and to the pleura, in which effusion of lymph and 
 purulent matter is induced. 
 
 As the case which occurred within my own experience has not 
 yet been published, and as its progress and termination illustrate 
 well the usual characters of cases of this class, I subjoin a short 
 account of it. 
 
 Master L. M., an interesting and apparently healthy boy of about 
 five years of age, had suffered occasionally from cough during winter. 
 
 In April 1843 he had measles, and made a very favourable recovery. 
 Soon after he was attacked by cough of extreme violence. 
 
 For these symptoms remedies were judiciously employed by 
 Dr Watson Wemyss. The cough nevertheless proceeded and 
 became daily more urgent and distressing ; expectoration, at first 
 scanty, was attended with the excretion of dense puriform mucus, i 
 occasionally slightly streaked with blood ; fever was added and be- 
 came constant ; and some loss of flesh as well as of strength had 
 taken place. 
 
 In May 1843 I was requested to see the boy. I found the res- 
 piration from 32 to 36 in the minute, with little or no motion cf 
 the upper part of the right side of the chest, and manifest dulness 
 on percussion all over the subclavicular, pectoral, and scapular re- 
 gions of the right side. Air did not during the motions of inspira- t 
 tion enter the right side of the lungs freely ; and seemed to be^W 
 stopped and thrown back when the attempt to inspire was made. i 
 The voice was a little resonant over the right mammary region ; 
 and the beats of the heart were heard as strongly, clearly, and dis- 
 tinctly as if the heart was beating under the ear. Occasionally 
 
TRACHEO-BRONCHIAL MUCOUS MEMBRANE, 
 
 591 
 
 slight wheezing and faint mucous rattles were heard immediately 
 below the right collar bone and through the right scapula ; and 
 when the patient coughed, the expiration sound came against the 
 ear at times faintly, at other times with unusual force. The child 
 complained of pain in the right mammary region ; stretching 
 sometimes to the shoulder. The pulse was never under 120 ; the 
 child perspired much during the night, and in the morning violent 
 and alarming fits of coughing came on and continued long. 
 
 On the left side of the chest no morbid sounds were recognized. 
 The motions of the chest were rapid and frequent ; but air seemed 
 to enter and quit the bronchial tubes of the left side without much 
 impediment, excepting what arose from the rapid motion of that 
 side, and of the diaphragm and abdominal muscles. 
 
 Leeches were applied over the right side of the chest several 
 times, according to the strength of the patient, the urgency of the 
 symptoms, and the eflrects of the discharge. Antimonial medicines 
 had been given ; and ipecacuanha wine, with occasional doses of 
 tincture of hyoscyamus were tried. The bowels were kept open 
 by means of calomel and rhubarb, or castor oil ; and afterwards 
 small doses of the gray powder, {hydrargyrus cum creta) were 
 given. Leeches were applied often, as they seemed to give most 
 relief ; and once or twice the surface of the right side of the chest 
 was blistered. 
 
 At length after treatment of this kind for the space of between 
 five and six weeks, the cough became less urgent and frequent ; 
 the amount of expectorated mucus was diminished ; the pulse be- 
 came less frequent ; the night sweats diminished and better sleep 
 was obtained ; and appetite returning, the child took food with 
 some relish. The breathing was reduced to between 24 and 26 in the 
 minute ; but there was still much dulness over the whole right 
 mammary region, and little motion of that side of the chest was 
 observed, while the beats of the heart were heard as clearly and 
 distinctly as before. 
 
 Sufficient amendment was produced, however, and sufficient 
 strength was recovered to justify the cessation of medical treatment, 
 and to enable the patient to proceed to a country situation in July 
 1843. Here he remained for six weeks, and improved much in 
 health and strength. The cough had left him ; the expectoration 
 had ceased ; and he had recovered his wonted looks. In this state 
 he remained the early part of the winter of 1843-4. As the season 
 
592 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 advanced, however, the cough returned in a more violent form ; and 
 in the spring of 1844, in March, symptoms of another attack of ca- i 
 tarrh appeared. li 
 
 At first the usual remedial means were employed. But the cough 
 became daily more urgent, rending, and frequent; the muco-purulent 
 expectoration with the night sweats returned ; the pulse was never 
 below 120; the flesh was wasting fast; and, in short, the patient 
 was again rapidly returning to his state in May 1843. 
 
 At this time the respiration was 36 in the minute, with almost 
 no motion of the right side ; the mammary region emitted a dull 
 sound, and was visibly flattened and depressed ; the voice was re- 
 sonant ; and the cardiac beats were clearly and distinctly heard all 
 over the mammary region before, and the scapular region behind. 
 Little respiration was audible, and only now and then a slight rattle. 
 About one inch below the right collar-bone, extending downwards 
 about three inches ; and from one inch from the sternum to the 
 outer margin of the large pectoral muscle before, little or no natu- 
 ral respiration was heard. The same phenomena were recognized 
 behind. When inspiration was observed, it appeared that the air 
 never penetrated further down than half an inch, or three-fourths | 
 
 of one inch below the right collar-bone, and about the same corre- i 
 
 spending point behind. Respiration was performed mostly by the j 
 diaphragm. 
 
 On the other hand, over the whole of the left side respiration was 
 clear and good ; and though there v/ere rattles in several points, 
 they indicated nothing very bad. 
 
 I was satisfied at this time, March 1844, that there had been pleu- 
 risy with considerable effusion ; pneumonia with consolidation ; and 
 bronchitis, but of what nature it was not easy to say. From the 
 recurrence of the symptoms, it seemed probable that the lungs were 
 tuberculated ; and although there was no distinct evidence of any 
 vomica, or excavated part, the sounds heard led me to think that 
 almost no respiration was performed by the upper and middle lobes 
 of the right lung. 
 
 Treatment was resumed, very much of the same kind as before, i 
 regulating the diet as carefully as possible. The symptoms proceed- ■ 
 ed, being sometimes more intense, sometimes alleviated, but never 
 disappearing. At length, after a long, violent, and distressing fit 
 of coughing on the morning of the 10th March 1844, the patient 
 coughed up an iron screw nail, about three-fifths or three-fourths 
 of one inch long, with a head with very sharp edges, covered with 
 
TRACHEO-BRONCHIAL MUCOUS MEMBRANE. 
 
 593 
 
 purulent matter and a little blood, and completely rusted. This 
 was presented to me at my visit ; and though the symptoms were 
 still urgent and by no means diminished, I inferred now that there 
 was every prospect that the patient would get rid of his disease. 
 
 In this expectation I was not disappointed. At first after the 
 ejection of the screw-nail, the cough seemed to be aggravated ; and 
 expectoration did not immediately diminish in quantity. The pa- 
 tient also suAFered from abdominal pains, which depended on a small 
 umhilical hernia, which was protruded during the fits of coughing. 
 Eventually, however, the cough abated ; the expectoration gradually 
 diminished, and at length ceased ; the respiration fell to 26, 24, 
 20 ; the pulse came down to 80 ; the appetite, which had not been 
 in this attack bad, was active ; and flesh and strength returned in 
 the course of about four or five weeks. 
 
 The surface of the mammary region was still dull ; and little 
 respiration was heard ; but the chest was moving a little ; and the 
 patient appeared to suffer no inconvenience. 
 
 In July he again went to a country situation, and residing there 
 for several weeks, returned home strong and free from any apparent 
 complaint. 
 
 When the screw nail was coughed up by this child, it became a 
 point of importance to ascertain when and how it had been intro- 
 duced into the larynx and trachea. On these points, however, all 
 enquiry was unavailing. One thing only was certain, that the nail 
 must have been in the right bronchus since April 1843, probably at 
 a date previous to that time. It must, therefore, have continued 
 there at least 13 months, probably nearer 14 or 15 months. 
 
 This boy has since that time remained in good health, and free 
 from any bronchial or pectoral ailment. The mammary region is 
 still flatter and more depressed on the right side than on the left, 
 and emits a sound a little dull ; but respiration is performed faintly ; 
 and it is clear that the lower part of the right lung is tolerably 
 good. 
 
 In this case I think, that it is quite impossible to doubt, that the 
 screw nail had been lodged in the right bronchus ; that its presence 
 there had caused first, inflammation of the whole of the upper 
 bronchial tubes ; then inflammation of the substance of the lung in 
 a certain degree ; and at the same time pleuritic inflammation. I 
 have no doubt that the whole upper and middle lobes are adher- 
 ing by their pleura to the pleura costalis. 
 
 pp 
 
594 
 
 GENERAL AND PATHOLOGICAL ANATOTIY. 
 
 Of this case it is a circumstance not the least remarkable, that 
 decided abatement in the symptoms took place in June 1843, and 
 temporary recovery continued during autumn and winter, while the 
 nail was still fixed in the bronchial tubes. 
 
 § 4. Emphysemaof the lungs as a result of bronchitis. — Though this 
 probably should be placed under the head of diseases of the sub- 
 stance of the lungs, yet it may maintain the anatomical connection 
 more closely by considering it here. 
 
 In the early stage, indeed, of bronchitis.^ there is simply a diffuse 
 or spreading inflammation or congestion of the pulmonary mucous 
 membrane ; and after it has subsided under proper treatment, that 
 membrane, both where it lines the bronchial tubes and pulmonary 
 vesicles, sooner or later returns to its natural condition ; while the 
 calibre of these tubes, and the capacity of the vesicles, is little or 
 not at all lessened. Either, however, after repeated attacks or long 
 continuance of this disease, not only does the inflammatory process 
 extend from the mucous membrane to the submucous or pulmonary 
 filamentous tissue, but by its long endurance it renders the former 
 thick, villous, and brownish-coloured, secreting either much viscid 
 mucus, or mucus more or less tinged with blood, and even occasion- 
 ally pure blood, and indurates and solidifies the latter by the extra- 
 vasation of albuminous fluid ; while the increased thickness of the 
 membrane, and the swelling of the submucous tissue, encroach so 
 much upon the area of the bronchial tubes and vesicles, as to dimi- 
 nish remarkably the capacity of these cavities. 
 
 This swelling, however, of the pulmonary mucous membrane and 
 filamentous tissue, is not general over the whole of the tubes, nor 
 even over the whole of one tube, otherwise it would produce fatal 
 asphyxia. But it in general takes place at certain spots in the 
 course of the tubes more remarkably than at others, producing a 
 species of stricture of one or more bronchial tubes in one or both 
 lungs. The effect of this again is various, according to its degree, 
 and according to the component systems and textures of the lung 
 most aflfected. One of the most frequent eflfects of the presence of 
 one of these constricted portions, especially if the membrane secretes 
 much viscid mucus, which requires to be frequently coughed up, is 
 to obstruct the passage so much that expiration becomes either in- 
 adequate or is interrupted. As respiration consists, therefore, in 
 alternate inspiration and expiration, if air has been either inhaled 
 by this tube, or by some of the communicating ones, it cannot, dur- 
 
TRACIIEO- BRONCHIAL MUCOUS MEMBRANE. 
 
 595 
 
 ing ordinary expiration, be easily expelled. The effect is, that the 
 bronchial membrane and pulmonary vesicles are excited by their 
 physiological properties to frequently repeated expiratory efforts ; 
 and, as these are inadequate to expel the air from the lungs, the 
 compression of the expiratory muscles necessarily, by forcing the 
 portion of lung into smaller compass, compresses the air already 
 contained in the vesicles beyond the constricted point. The air 
 thus confined, after many repeated expiratory efforts, forces its way, 
 by its own elasticity, through the delicate mucous membrane of 
 the vesicles into the pulmonic filamentous tissue, and, when once 
 there, it continues to spread rapidly in proportion to the obstruc- 
 tion in the bronchial tubes, and the difficulty of producing efficient 
 expiration. It is then that the air contained in these vesicles ren- 
 ders the chest, when struck, preternaturally resonant ; while the 
 extreme difficulty of breathing, with the dry sonorous rhonchus or 
 sibilism, indicate the laborious struggle which is made in the tubes, 
 contracted by swelling, and obstructed, as they are, by adherent 
 mucus, — to inspire and to expire in an efficient manner. 
 
 In this manner, therefore, bronchial inflammation, either by con- 
 tinuance or repeated attacks, tends to produce emphysema and its 
 usual phenomena ; and there are few cases of emphysematous dis- 
 tension of the pulmonic filamentous tissue which may not be traced 
 to this cause. In the young, when labouring under hooping-cougb, 
 in the aged, after frequently repeated attacks of catarrh, and in the 
 middle-aged after the continuance of bronchial inflammation, in a 
 subacute or chronic state, emphysema is with equal certainty, and 
 in equal perfection, produced. In the first case, indeed, as the 
 bronchial symptoms subside, the tubes become more pervious, and 
 expiration becomes so much freer and less interrupted, that the 
 air ceases to be urged through the vesicular membrane, and that 
 which had been already impelled into the pulmonic filamentous tissue 
 is at length absoi’bed. But in the two latter instances, in which the 
 thickening of the membrane either abates little, or continues un- 
 changed, the emphysematous distension continues to increase, until 
 it has attained an extent almost incredible to those unaccustomed to 
 examine cases of chronic bronchial disease. 
 
 Emphysema, however, is not the only eflfect of this state of the 
 bronchial tubes. The impracticability of inspiring and expiring 
 completely in such a state of the lungs, which implies the absence 
 of the most essential condition of respiration, vfr. the frequent and 
 
596 
 
 GENERAL AND rATIlOLfXaCAL ANATOMY. 
 
 incessant change of air in the hronchial tnhes and vesicles of the 
 lungs, interferes with the necessary changes in the blood of the 
 pulmonary artery and veins, which, therefore, passes from the former 
 vessel into the latter, much less completely aerated than it would 
 be in the healthy state. In addition to this, as the motion of the 
 blood through the pulmonary artery into the pulmonary veins is 
 always more free, in proportion as the expansion of the lung by in- 
 spiration, and its collapse by expiration, is extensive ; and as both 
 the obstruetion of the bronchial tubes by viscid mucus, and the 
 swelled and congested state of the hronchial membrane and sub- 
 mucous tissue, prevent the branches of the artery and veins from 
 freely expanding themselves ; the motion of the blood through this 
 order of vessels begins to be interrupted and retarded, and thus to 
 induce a congested state of the whole pulmonary system, which not 
 only adds to the dyspima and orthopnoea of such patients, but even- 
 tually terminates in dropsical effusion into the pulmonic filamentous 
 tissue, within the cavity of the pleura, and even into the general cel- 
 lular membrane. The pulmonic filamentous tissue is in general 
 the first seat of this dropsical infiltration ; and it is one of the most 
 common changes recognized in inspecting the lungs of persons cut 
 off by long-continued bronchial inflammation. 
 
 Chronic bronchial inflammation, further, by its influence in im- 
 peding respiration and the circulation of the pulmonary artery and 
 veins, has an indirect tendency to induce disease of the heart. In 
 consequence of the difficulty which the blood encounters in passing 
 through the branches of the pulmonary artery, the trunk of that 
 vessel becomes permanently distended ; and the right ventricle, 
 being also distended and incessantly excited to new contractions, 
 becomes affected with hyperti’ophy, sometimes with dilatation, some- 
 times without ; and in other cases it may be merely enlarged with 
 extenuation of its walls. It is, I conceive, in consequence of the 
 union of the two ventricles in the human subject, that this exces- 
 sive distension and inordinate action, by being first confined to the 
 right ventricle, gives I’ise to a similar inordinate action in the left 
 ventricle, that the latter is often found in a state of hypertrophy in 
 persons who have long laboured under chronic bronchial disease. 
 The fact of the connection is at least well-established ; and hos- 
 pital practice presents few instances of bronchial disease in wffiich 
 the heart is not affected ; and in most of the cases of disease of the 
 heart, the bronchial membrane and pulmonic tissue are previously 
 affected. 
 
TRACIIEO-BROXCIIIAL MUCOUS MEMBRANE. 
 
 597 
 
 § 5. Bronchitis from inhalation of particles of sand, dust, and metal, 
 — Next to bronchial disease from the presence of foreign bodies, may 
 be placed that form of the disease which is the result of the inhala- 
 tion of sand, dust, or metallic particles in minute mechanical divi- 
 sion. This has been already mentioned in a general manner. But 
 it may be proper to advert more particularly to the changes induc- 
 ed in the lungs as presented by the artisans of Sheffield. 
 
 These changes are not, indeed, by any means confined to the 
 bronchi or their branches and membrane. But as the primary cause 
 is applied first to the membrane of these tubes, it seems reason- 
 able to consider the different lesions thus arising in the present 
 place. 
 
 In the town and vicinity of Sheffield two sorts of grinding of 
 edged tools are practised ; one dry grinding, on a dry stone, the 
 other wet grinding, on a stone moistened with water. Many ai’- 
 ticles, as scissors, razors, and penknives, are ground partly on 
 dry stone, and partly on the wet stone. Others, as forks and 
 needles, are ground mostly on a dry stone. Table knives are 
 ground principally on a wet stone. Saws, files, and scythes are 
 ground entirely on a wet stone. 
 
 Dry grinding is most injurious, and tends most directly and ef- 
 fectually to induce bronchial and pulmonary disease, and thereby 
 to abridge the duration of life among the grindei's. The dry 
 grinders, therefore, are most speedily destroyed. The life of the 
 wet grinder is often prolonged to a considerable age. 
 
 Of 1000 scissor-grinders above 20 years of age, only 20 attain 
 the age of between 51 and 55 years, only 10 the age of between 61 
 and 65, and none live beyond the latter age ; while of the inhabi- 
 tants of Sheffield generally, 244 in 1000 are found living at 65 and 
 above, and in tbe midland counties, 413 in 1000. Of artisans in 
 this branch 843 in 1000 die under 45 years of age. 
 
 With the fork-grinders it is worse. Among 1000 fork-grinders, 
 aged above 20 years, not one attains the age of 59 ; while in Shef- 
 field, among 1000 persons 155 are living at 59. Of these 1000 
 persons 472 die between 20 and 29 years, 410 between 30 and 39 ; 
 and the residual 115 are all gone before the age of 50. 
 
 Among 1000 razor-grinders above 20 years of age, 749 die un- 
 der 41 years of age ; the rest mostly between 41 and 60; between 
 61 and 65 only 5 are living; and after 65 all are gone. 
 
 Of the pen-knife grinders not one in 1000 arrives at the age of 
 
598 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 60 ; 731 die before the 40th year; and the rest are all destroyed 
 before the 60th year. 
 
 Saw-grinders, file-grinders, and scythe-grinders, who work on the 
 wet stone, are less liable to bronchial disease and are longer lived. 
 The numbers pursuing saw-grinding are not great. Tet among 78 
 persons engaged in it in 1843, 9 were between 60 and 65, and one 
 died betv/een 66 and 70, and one at 79. The number of scythe- 
 grinders is also not great. In 1843 there were 30; and of these 
 8 were between 41 and 60 years of age. Both the saw-grinders and 
 the scythe-grinders are exposed to accidents, sometimes fatal, from 
 the breaking of the stone. 
 
 The lesions which produce this great mortality are of a compli- 
 cated character. The most common lesions are chronic inflamma- 
 tion with thickening of the bronchial membrane, enlargement or 
 dilatation of the bronchial tubes, emphysema, and expansion of the 
 pulmonic tissue.* 
 
 The bronchial glands are enlarged, or converted into a hlack 
 hard gritty substance, varying in size from half a marble to a large 
 hazel nut. In dividing these glands, the sound emitted is the same 
 as if the scalpel were dividing a soft stone ; and the section is black 
 and polished, and grates over the edge of the knife. Such masses 
 are commonly detected in grinders who have belonged to the most 
 destructive branches.f 
 
 Similar soft sectile gritty or stony matter is found in almost 
 every part of the lungs, in portions varying from the size of a cur- 
 rant to that of a bean. 
 
 Adhesions between the pulmonic and costal pleurcB are also fre- 
 quent. 
 
 In some instances the lungs present an appearance as if black 
 currants had been distributed through their whole substance, and 
 accompanied with similar bodies larger in size, but hard and gritty 
 like them. These currant-like bodies are also observed on the sur- 
 face of the lungs. As to their nature Dr Holland gives no opinion. 
 But Dr C. Fox Favell states that frequent examination has con- 
 vinced him that they consist of the dilated extremities of veins con- 
 taining some of the solid constituents of the blood. 
 
 * Diseases of the Lungs from Mechanical Causes. By G. Calvert Holland, M. D., 
 p. 12. London, 1843, 8vo. 
 
 -)- Ibid. p. 41 . 
 
TRACHEO-BRONCHIAL MUCOUS MEMBRANE. 
 
 599 
 
 Tubercles are also occasionally found with their consequences, 
 vomicae. 
 
 Another state frequently observed is engorgement or infil- 
 tration of the lungs with a dark-colourcd fluid, which is ascribed 
 by Dr Holland to the inhalation of the fine black dust floating in 
 the atmosphere during the operation of glazing. 
 
 On the mode of production of these lesions, or the order of their 
 succession, observers are not agreed. Dr Arnold Knight and Dr 
 Holland consider the tracheo-bronchial membrane to be the original 
 and principal seat of the disease, and the tracheo-bronchial irritation 
 to be the primary morbid action, and to give rise to all the other ef- 
 fects ; the dilatation of the bronchi, emphysema, the formation of cur- 
 rant-like bodies, tubercles, pulmonary induration, and pleuritic ad- 
 hesion. Dr Fox Favell, on the other hand, thinks that the pulmonic 
 tissue or parenchyma is the primary and essential seat of the dis- 
 ease, does not regard the mucous membrane as the original seat of 
 the disease, and maintains that the organic changes found in the 
 structure of the lungs constitute the essence of the lesion ; in short, 
 that all the changes seen in the lungs of the grinders depend on 
 congestion and inflammation of their parenchymatous structure.* 
 Dr Favell, in short, ascribes as much to the position, the labour, 
 and the debauched habits of the grinders, as to the inhalation of the 
 dust or powder. The question is not easily determined. But it 
 may safely be asked, how the wet grinding is so little hurtful, and 
 the dry grinding so rapidly, powerfully, and effectually detrimental 
 to the lungs. It is also to be observed, that it cannot be said to 
 follow, because the pulmonic parenchyma is found much diseased, 
 that the tracheo-bronchial membrane is not the primary seat of 
 mischief. It is known that various affections of the tracheo-bron- 
 chial membrane do extend to the lungs ; and there is little reason 
 to believe that the grinder’s asthma constitutes an exception to the 
 rule, 
 
 § 6. Bronchial inflammation takes place secondarily in hooping- 
 cough, measles, scarlet fever, small-pox, and typhous fever. In 
 measles I have seen the membrane red, injected, villous, and secret- 
 ing puriform fluid copiously — tbe usual symptoms of pulmonary 
 consumption having preceded the fatal event. In scarlet fever not 
 only the pulmonic but the facial mucous membrane is inflamed ; and 
 
 ^ Oil Grinder’s Asthma, By Charles Fox Favell, M, D. Ac. Transactions of the 
 Provincial Medical and Surgical Association. New Series. Vol. ii. 1846, p. 143. 
 
 4 
 
600 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 in some severe and fatal cases I have traced the capillary injection 
 along the gastro-enteric division, and in the genito-urinary from 
 the neck of the bladder to the pelvis of the kidney. ' This general 
 affection of the raucous system explains the fatality as well as many 
 of the symptoms of scarlet fever. Inflammation of the tracheo- 
 bronchial membrane is an occasional consequence of inhaling acci- 
 dentally certain of the noxious gases. 
 
 Redness and punctular injection of the tracheo-bronchial mem- 
 brane, with more or less secretion of viscid mucus, was seen in 
 hydrophobic subjects by Beddoes, Babington, Oldknow, Rush, Sat- 
 terley, Brandreth, and Trolliet, the last of whom labours to prove 
 that the rabid poison affects particularly this membrane. Much of 
 this effect is doubtless to be ascribed to the violence of the abnormal 
 motions of the respiratory muscles ; and it is still undetermined 
 how far the appearances now mentioned are primary and essential, 
 or secondary and accessary. 
 
 § 7. Obliteration and Arctation of the Bronchial Tubes . — From the 
 operation of various causes at present not well understood, the bron- 
 chial tubes are liable to be narrowed or contracted, and in certain 
 instances their canal may be entirely closed and obliterated. Arc- 
 tation or narrowing of the bronchial tubes has been already men- 
 tioned as one of the effects of bronchial inflammation, recurring re- 
 peatedly, and becoming at length chronic. In cases of this kind, 
 these walls forming the tube are distinctly thickened by effusion 
 either of blood or lymph, or both, into the submucous tissue ; and 
 the capacity of the tube is proportionally diminished. . In other in- 
 stances the presence of indurated or hemorrhagic portions of lung 
 round small bronchial tubes produce the same diminution in their 
 normal dimensions i 
 
 Of obliteration, M. Reynaud, who has studied this lesion, has 
 observed four forms. ^ 
 
 In the first kind complete coalescence of the walls of a bron- 
 chial tube takes place without foreign matter contained in their in- 
 terior, and without any cause of external compression. 
 
 The simplest and most elementary degree of this obliteration of 
 the bronchi consists in closure or obliteration of the terminal end 
 of one tube or more. 
 
 This sort of obliteration, to which may be referred several lesions 
 of the lungs, takes place both generally over a space of lung more- 
 or less extensive, and locally in one or more bronchial tubes. In 
 
 ■'A 
 
 
TRACHEO-BRONCHIAL MUCOUS MEMBR.yS"E. 
 
 601 
 
 the former case, the substance of the organ, instead of being vesi- 
 cular or spongy, becomes solid, compact, and impermeable to the 
 air. 
 
 A second sort of bronchial obliteration, differing from the pre- 
 ceding one in its seat, is what is observed in bronchial canals of the 
 fifth or sixth order, consequently very near their termination, and 
 some lines from the pleura, yet in the interior of the parenchyma of 
 the lungs. In this variety the obliteration takes place at a part of 
 the bronchial tube, where the area is still considerable enough to 
 furnish divisions. But M'hei’e the lung is divided, the tube is ob- 
 served suddenly to terminate in a blind sac ; and beyond the point 
 of obliteration, the bronchial tube is seen distinctly continuous, with 
 a small firm, resisting cord, itself furnishing small ramifications, and 
 easily detached by slight scraping from the rest of the lung. The 
 bronchial tube may thus be traced to the ■pleura. 
 
 A third sort is that in which the obliteration is seated, as in the 
 second, at a distance nearly equal from the pleura. The chief dif- 
 ference is this, that while the second form can be recognized only by 
 cautiously and gradually dividing the small bronchial tubes by means 
 of delicate scissors, the present form is easily discovered by a common 
 blunt probe, which, when introduced into the principal bronchus, is 
 suddenly stopped, while, if carried into the neighbouring ramifica- 
 tions placed at the same distance, it penetrates more forward. When 
 the bronchus thus obstructed is laid open down to the site of obstruc- 
 tion, it is observed that the obstruction is owing to an obliteration 
 seated in a large tube, which, though near the surface of the lung, 
 does not appear with the characters peculiar to dilatation of the 
 bronchi. The obliterated bronchus is continuous with a fibrous 
 cord ; but this is larger than in the preceding case, though its course 
 to the pleura is not longer. 
 
 To the disposition now mentioned is conjoined another referable 
 to the surface of the lung, and which denotes the presence of the 
 obliteration. This consists in more or less shrivelling of the pul- 
 monic surface at the point corresponding to the seat of the oblite- 
 ration. From this it is reasonable to infer that the shrivelling is 
 in some manner connected with the bronchial obliteration. It is 
 indeed not difficult to understand how the obliteration of a bronchus, 
 not remote from the surface of the lung, involving that of the 
 branches issuing from it, must, by the consequent contraction, pro- 
 duce contraction or shrinking of the pulmonic substance, and 
 
602 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 shrivelling more or less considerable of the surface of the organ 
 at the corresponding point. j 
 
 These shrivelled spots are easily recognized. The pleura is ! 
 drawn to one or two points in a series of wrinkles, imperfectly ra- 
 diated ; the surface is perceptibly depressed ; and, when the part is 
 touched, it is found to he solid, adherent, firm, and inelastic. i 
 
 The fourth and last sort of obliteration is that which is observed i 
 in bronchial tubes larger than those affected in the previous cases, 
 and furnishing tubes to portions of the lung more or less consider- 
 able. This sort of obliteration diJffers from the third in no respect 
 unless in the greater number of bronchial tubes the obliteration of 
 which it involves. It also produces peculiar forms of morbid struc-^,j 
 ture. 
 
 This obliteration is observed in the bronchi at all points of the; ,T 
 bronchial tree, from the branches issuing from the first bronchus, to^: s 
 those which may be divided by ordinary scissors. The obliteratioii^ ,| 
 is known as in the third case, by the abrupt termination of a large : | 
 tube in a blind sac, and with ligamentous cords proceeding froni\ J 
 it through the lung. 
 
 The most common seat of these obliterations is the upper lobe' ' 
 of the lung and especially its apex, a fact of which it is necessary’ i 
 to be aware, in distinguishing these obliterated spots from alleged ^ 
 healed tubercular cavities. They have been found nevertheless in 
 the lower lobe. Reynaud found the lesion twice in this situation. if?™ 
 As to the state of the bronchi and their membrane in this lesion, l1 
 
 I 
 
 it is variable. Sometimes, I believe very rarely, it is found in what / 
 is called perfect integrity, in that portion accessible to air. This 
 is certainly sometimes the case. On the other hand, the membrane 
 may be and often is red, rough, thickened, and covered with viscid 
 opaque mucus. Occasionally the tube is much dilated immediately 
 above the point of obliteration ; and though this dilatation may take 
 place in bronchi of all sizes and in all points, yet it is most common 
 in those in which obliteration affects large trunks, at a short dis- 
 tance from their origin. 
 
 In some instances the adjoining bronchi to one which has been 
 obliterated, are all more or less dilated, and instead of forming cones 
 gradually contracting, as in the healthy state, are either cylinders, 
 or present actual dilated and enlarged portions. In these tubes 
 the membrane is generally reddish, rough, and covered with opaque 
 purlform mucus. 
 
TRACHEO-BEONCHUL MUCOUS MEMBRANE. 
 
 603 
 
 The pulmonary parenchyma round an obliterated bronchus may 
 present two morbid states. It may be either consolidated, dense, 
 and firm, as already mentioned, or it may be emphysematous, that 
 is, containing air in the pulmonic cellular tissue, or in the shape of 
 bladders beneath the pleura. In some instances both states are 
 associated. Immediately round the seat of the obliteration the lung 
 is firm and dense, with shrivelling of the pleura and pulmonic sur- 
 face ; and beyond this dense spot again the surface of the lungs is 
 pale, white, crepitating, and emphysematous; and two or more air- 
 bladders are formed beneath the pleura. Lastly, it is not unusual 
 to find the upper lobe presenting shrivelled patches, and the indi- 
 cations of obliterated bronchial tubes; and the middle and lower 
 lobes to be pale, white, crepitating, and more or less extensively 
 emphysematous. 
 
 The blood-vessels are not obliterated ; except in the minute 
 branches distributed through the indurated portion. 
 
 The solid filaments, the relics of the obliterated tubes, are gene- 
 rally of a deep black colour. 
 
 The causes of obliteration of the bronchial tubes are not posi- 
 tively ascertained. All that is known is this; that obliteration 
 takes place in persons who had laboured under severe, repeated, or 
 long-continued attacks of bronchial inflammation, usually chronic, 
 and those who had attacks of chronic pneumonia. Reynaud is in- 
 clined to ascribe the occurrence of the lesion to diphtheral or albu- 
 mino-facient inflammation of the bronchi; and there is no doubt 
 that the bronchial membrane is liable to this form of inflammation, 
 and that this form of inflammation may produce or terminate in 
 obliteration. He admits also that he has met with cases of acute 
 pneumonia with hepatization of the lung, in which the lesion con- 
 sisted in inflammation, which had in all the small bronchi given rise 
 to the formation of false membranes, which filled more or less ac- 
 curately all their cavities.* 
 
 r rom what I have myself seen, I ascribe the lesion either, as al- 
 ready stated, to severe and repeated attacks of chronic bronchitis^ 
 or to the effects of chronic pneumonia. 
 
 A lady presented the usual symptoms of very severe chronic 
 bronchitis ; that is, cough, expectoration of muco-purulent matter, 
 with hectic fever, and pulse varying from 110 to 120. There was 
 
 ^ Memoire sui- I’Obliteration des Bronches. Par A. C. Reynaud, D. M., &.c. Me 
 moires de I’Academie Royale de Medecine, Tome ivieme. Paris, 1835. 4to. P.117. 
 
604 
 
 GENERAL AND rATIlOLOGICAL ANATOMY. 
 
 strong resonance of the voice at the upper part of the right side of 
 the chest; and the cardiac and arterial beats were heard most audibly. 
 Yet, though the symptoms continued long, there was no distinct 
 indicalion of pectoriloquy. The subclavian and pectoral regions 
 also before, and the scapular behind, emitted a dull sound. These 
 symptoms, which were attended with wasting and much loss of 
 strength, after lasting for many weeks, at length subsided; and 
 she seemed to recover completely. The dull sound on percussion 
 continued, however ; and little respiratory murmur was audible in 
 the uppei’ region of the right demithorax either before or behind. 
 The air, indeed, seemed not to enter the bronchial tubes of the 
 right lung above at all ; and only a little respiration was audible 
 along the back close to the spine, and in the lower region of the 
 chest. She died about two years after of a different disease, and 
 inspection presented the following appearances. 
 
 The whole of the upper lobe of the right lung and part of its 
 middle lobe was firm and solid, and inelastic like a mass of solid 
 flesh. The pleura adhered behind, and partly on the sides, and a 
 little anteriorly. On dividing this portion of solidified lung, the 
 bronchial tubes were found to be closed, except at the apex and near 
 the spine, where they were still pervious for the space of not more 
 than half an inch. The pulmonic substance itself was firm, of a r 
 light red colour, but totally uncrepitating, and did not admit the jL 
 air from the tubes. It sunk in water like a stone. On tracing 
 the tubes, they seemed to be compressed together into ligaments 
 or cords, quite solid and impervious ; but it was not easy to say - 
 whether they had been filled with matter effused from within their ^ 
 canals or exterior to them. 
 
 It seems also impossible to doubt that when pneumonia proceeds 
 to abscess or vomica, it in like manner entails obliteration of the^ 
 bronchial tubes; and, if the patient be not destroyed by the dis- 
 ease, various tubes are found obliterated. 
 
 Obliteration is also observed in those cases in which tuberculaF 
 masses are broke down and expelled by expectoration, whether any 
 attempt to close the vomica and heal it is made or not. 
 
 I.astly, in the form of pneumonia denominated lobular, or 
 where there appears to be inflammation of the terminal ends of the 
 bronchi, obliteration at these ends is very common, in consequence 
 of effusion of albuminous matter from the mucous membrane of 
 their terminal extremities. This effusion or deposit, however, is 
 
 ft I 
 
TRACHEO-BRONCHIAL MUCOUS MEMBRANE. 605 
 
 probably either the same with the tubercular deposit, or very simi- 
 lar to it in the mode and situation in which it takes place. 
 
 § 8. Dilatation and Hypertrophy of Bronchi. — In certain circum- 
 stances of chronic bronchial disease the bronchi become greatly en- 
 larged, and their walls are thickened, with thickening of the mem- 
 brane. The diameter of the tubes may be increased in this state 
 to half an inch. Of this lesion Dr Carsewell gives an excellent 
 representation in his Fourth Division, first engraving ;* and an in- 
 stance is described by Mr W att of Manchester as having been ex- 
 hibited at the Pathological Society of that place.f 
 
 § 9. Dilatation of the Bronchial Tubes . — Of one species of dila- 
 tation I have already partially spoken, as taking place along with ob- 
 struction and obliteration of these canals. There is yet to be noticed 
 another, which, according to my own observation, takes place either 
 solely or principally in connection with aneurismal enlargement 
 and dilatation of the aorta or innominata. Of this I have seen se- 
 veral examples ; and from these, especially one published,^ I give 
 the following characters of the lesion. 
 
 The lesion is seated in the right lung, the lobes of which are 
 generally solidified and inelastic, of a reddish-brown colour, and 
 loaded with blood. The middle lobe and the lower one are gene- 
 rally more completely and extensively solidified than the superior 
 lobe ; and the affection appears often to commence in the lower 
 lobe, and thence proceed to the middle and upper lobes. 
 
 The great change, however, is in the bronchial tubes, which in 
 all the three lobes are greatly enlarged, losing their conical figure, 
 and being converted either into large cylindrical canals, or tubes 
 with wide dilated spaces in their course. Bronchial tubes, which in 
 their natural state are not larger than crow-quills, become, espe- 
 cially in the lower and middle lobe, of the diameter of half an inch. 
 Besides this, at various points in their course they undergo still 
 greater dilatation, so as to form cavities communicating apparently 
 with the bronchial tubes, and thereby with each other, but which, 
 when carefully examined, are seen to be unusually enlarged por- 
 tions of the bronchial tubes themselves.^: 
 
 * Illustrations of the Elementary Forms of Disease. By Robert Carsewell, M. D. 
 Foho. London, 1838. Hypertrophy, Plate 1. 
 
 -|- London Medical Gazette, Vol. xxxix. p. 596. No. 1009. April 2, 1847. 
 
 + Report on the Cases treated during the Course of Clinical Lectures delivered at 
 the Royal Infirmary in the Session 1832-1833. By David Craigie, M. D., &c. 
 Edinburgh Medical and Surgical Journal, I'ol. xli. January 1834. P. 106. Case of 
 Janet Waits. 
 
606 
 
 GENERAL AND rATHOLOGICAL ANATOBIY. 
 
 The bronchial tubes in \his state are filled with thick opaque pu- 
 riform or purulent matter, on the removal of which the membrane 
 is seen to be reddened, softened, and thickened. 
 
 In some instances the dilatation, though sufficiently distinct, does 
 not proceed to the extreme degree already noticed. The bronchial 
 tubes of the middle and lower lobes are merely rendered cylindri- 
 cal like goose-quills, and filled with a sort of viscid albuminous a ; 
 puriform matter. The lung is also solidified, and, losing its elas-K,| 
 ticity, does not crepitate ; and, when divided, puriform matter is-,P 
 sues copiously from the cut bronchial tubes. 
 
 This form of dilatation I have seen only in cases of aneurismal 
 tumours of the aorta and innominata. It appears to be caused prin- 
 cipally by the compression exerted on the superior bronchial tubes 5 
 by the aneurismal swelling. In the cases in which I have observ-%, 
 ed the lesion, the aneurismal tumour invariably compressed muchy 
 the bronchial tubes of the upper lobe, near the mediastinum, so as to r’ 
 flatten them and contract their area, and prevent the free discharge^"" 
 of the matter secreted by their mucous membrane. The matter ; 
 retained appeared to be one of the causes of the great dilatation 
 produced in the small tubes of the middle and lower lobes. , 
 
 At the same time it must be observed, that this same compression 
 causes general inflammation of all the bronchial tubes on which it*^ ' 
 is exerted, and even inflammation of the pulmonic tissue with the 
 usual morbid products. 
 
 In one case the tumour was as large as a good sized pippin, two 
 inches and a-half in diameter, and compressed the right bronchus 
 and its divisions and the mesial or internal margin of the lung. 
 
 In another case the tumour was about the same size, though more , 
 ovoidal, and it equally compressed the right bronchus and its i 
 branches. i 
 
 That this dilatation of the bronchial tubes proceeds from the 
 cause now specified, must be inferred, I think, from the fact, that 
 in the cases in which it is observed, it is generally in proportion to 
 the size, situation, and compressing powers of the aneurismal tu- ; 
 mour, and that the lesion is confined to the bronchial tubes of the 
 right lung, not affecting those of the left lung at all. 
 
 I have no doubt, nevertheless, that were the tumour to be situate 
 in that part and side of the aorta in which it could compress the 
 left lung, the same state of the bronchial tubes of that organ would 
 be produeed. 
 
TRACHEO-BRONCHIAL MUCOUS MEMBRANE. 
 
 607 
 
 In general this state of the bronchial tubes and lung can be 
 known during life. The voice is' hoarse, and like that of a person 
 in croup. The cough is peculiarly hoarse and sonorous, as if is- 
 suing through a brazen tube. The difficulty of breathing is very 
 great, and often amounts to orthopnoea ; and mucous rattling is 
 heard in the middle and lower part of the right lung only, while at 
 the upper region respiration is performed with a harsh croaking 
 sound. 
 
 C. THE GASTRO-ENTERIC MUCOUS MEMBRANE. 
 
 In the gastro-enteric mucous surface inflammation may take place 
 either generally or partially ; and it affects either the villous mem- 
 brane or its follicular apparatus or both. 
 
 § 1. CEsophagus . — In the oesophageal mucous membrane in- 
 flammation seldom appears, unless as part of the same process 
 affecting the stomach and bowels more or less generally. This 
 is particularly the case in inflammation of the gastric mucous mem- 
 brane, with which a similar state of the oesophageal is almost in- 
 variably connected. The surface is red, injected, and more or less 
 villous, and thickened ; and the oesophageal epidermis is occasion- 
 ally elevated into apthae or blebs, leaving, when these are removed, 
 an excoriated or abraded surface. In the chronic form it may 
 affect the mucous glands, and produce ulceration. Irregular patches 
 of the latter I have seen in subjects in whom the colic membrane was 
 extensively covered by ulcers. The cases described by Dr F. Sim- 
 mons and Dr Gartshore appear to have affected the submucous tissue. 
 
 § 2. a. The gastric mucous membrane may be inflamed generally 
 or partially. When a limited portion of the villous membrane is 
 inflamed the disease is seldom violent. The mucous membrane of 
 the inflamed part shows an unusual number of minute vessels, but is 
 rarely much crowded. In some instances, however, it is red or 
 scarlet, with vessels disposed in arborescent, punctular, or striated 
 fashion ; and not unfrequently spots or patches of extra vasated blood 
 are recognized. At the same time, the substance of the mucous 
 coat is thicker than natural, of pulpy softness, and when attempted 
 to be detached, is readily lacerated. 
 
 The gastric mucous membrane is liable, nevertheless, to a more 
 general inflammatory process, in which its surface presents a light 
 rose-coloured blush difiused all over, and secretes mucous or muco- 
 purulent fluid copiously. The mucous membrane is also pulpy 
 
608 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 and softened, but not remarkably thickened. This state of tlie 
 gastric membrane, though occurring spontaneously, may be pro- 
 duced by repletion or improper articles of food, and by several of 
 the acrid poisonous substances. Of this form of gasteria a good 
 delineation is given by Dr Armstrong in the second plate of his 
 first Fasciculus. 
 
 b, Gasteria psilotica ; Psilosis . — In the persons of those who have 
 long pined under various chronic diseases, the gastric mucous mem- 
 brane is liable to a form of disease in which some part of it becomes 
 pale white, bluish, rose-coloured, or gray, continuously or in long 
 narrow stripes, or irregular patches more or less thickly set. The 
 spaces so coloured are simply depressed beneath the level of the 
 adjoining membrane, not ulcerated, soft and thin, and converted 
 into a glairy semitransparent pulp. According to M. Louis, to 
 whom the pathologist is indebted for the correct description of this 
 change, when in narrow stripes, it is distributed nearly uniformly 
 over the whole surface of the stomach ; when continuous, it occu- 
 pies the large extremity of the organ, is rarely confined to the great 
 cul de sac, and in some instances appears at once at the cardiac 
 and pyloric orifices. The vessels of the submucous tissue, which 
 is generally sound, are large, distinct, and empty.* F rom the few 
 instances in which I have seen this change myself, I should say that 
 it consists in removal of the villi by some process analogous to 
 inflammatory absorption. It is certain that in the afiected patches 
 these processes are greatly less distinct, and often totally gone. I 
 may add that this is one at least of the forms of the change which 
 John Hunter describes as digestion of the stomach ;f and also one 
 of these described by Dr Yellowly,j; the greater part of which, it is 
 to be observed, occurred in persons cut off by pulmonary consump- 
 tion. To this head probably are to be referred such cases as that 
 recorded by Mr Douglas, who found the villous coat obliterated 
 except near the pylorus, and the muscular absorbed. § The theory 
 of its production is further exceedingly obscure ; and I abstain from 
 conjecture. 
 
 In similar subjects, but more especially in the phthisical, the gas- 
 tric membrane is liable to become occupied by minute roundish^ 
 eminences, not unlike granulations separated by superficial furrows, 
 
 * Memoires ou Recherches Anatomico-Pathologiques. Pari.*, 1826. 
 
 t Observations on certain parts of the Animal Economy, p. 226, 2.31. 
 
 :J: Medico-Chir. Trans. Vol. iv. p. 2/1, 5 out of 20. 
 
 § Mem. Med. Soc. vol. iv. p. 39.5. 
 
 Ml 
 
GASTRIC MUCOUS MEMBRANE — CHRONIC ULCER, 
 
 609 
 
 with occasional points of ulceration round or oblong form, from 
 one to several lines in diameter. The colour of the membrane is 
 at the same time reddish, or reddish gray, always thickened, and 
 generally softened, and covered with much viscid mucous. This 
 granular state of the mucous membrane is most frequent in the 
 large curvature, and the parts adjoining to the anterior and poste- 
 rior surfaces, at the pyloric extremity, the small curvature, and the 
 great cul de sac, the whole extent of which, however, is rarely af- 
 fected.* The granular eminences appear to be swellings of the 
 mucous glands, which are most abundant in the situations in which 
 it is seen. 
 
 c. Gasteria Diuturna, Gasteria ulcerans^ Gasteria Helkosis . — 
 Chronic inflammation of the gastric mucous membrane is much 
 more frequent than is imagined. The process is in general con- 
 fined to one or two small spots, which are slightly red, often brown 
 or reddish brown, rough, villous, and firmer than natural. Of 
 these appearances the most constant is the rough villous aspect and 
 firm consistence, which are at once recognized by drawing the 
 finger over the part. The inflammation does not spread, but 
 gradually penetrates to the submucous filamentous tissue which is 
 exposed, and terminates in the formation of an ulcer or ulcers of 
 the mucous membrane. 
 
 The most usual appearance of these ulcers is that of depressed 
 breaches in the continuity of the mucous membrane, with a rough, 
 brown-coloured surface, variable in size, but generally small, af- 
 fecting an irregularly round or oval shape, sometimes angular, and 
 with edges smooth, but sharp and accurately marked. This cha- 
 racter, which is that of a piece of the membrane completely cut 
 or scooped out, is certainly derived from the peculiar properties 
 of the mucous corion, which seems in ulceration to undergo a 
 gradual process of absorption. When the first minute percep- 
 tible point of ulceration is formed, the edges are destroyed or 
 absorbed in the same gradual manner, and thus the vdcer is en- 
 larged. The edges are in general some shade of crimson or reddish 
 brown, owing to injected capillaries of the corion ; but in other in- 
 stances the colour does not differ from that of the adjoining surface. 
 
 Many of the examples of this lesion have been described as in- 
 stances of rupture or perforation of the stomach ; and hence it is 
 not easy to ascertain the exact state of the villous membrane in the 
 * Louis, Recherches Anatomico-Pathologiques siir la Phthisie. Paris, 1825, 
 
 Q q 
 
610 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 incipient stage of the disease. It is nevertheless impossible to doubt 
 that these ulcers, whether in the state of ulcers, or appearing aftei’- 
 wards as perforations, must originate in inflammation which proba- 
 bly attacks one point and is circumscribed to that, while it is slow 
 in progress and chronic in character. 
 
 Instances of this lesion have now become numerous. Cases have 
 been recorded by Morgagni,* * * § Dr Carmichael Smyth,! Gerard,! 
 Dr Baillie,§ Dr Crampton, \\ Mr Travers,1T Laennec,** * * §§ Dr Aber- 
 crombie,!! Di' Elliotson,!! M. Duparque,§§ M. Uebersaal,|||l M. 
 Goeppert,1f1F and Cruveilhier. 
 
 From these cases, and seven which have been observed and inspect- 
 ed by myself,*** I conceive the following general conclusions re- 
 garding the nature and character of this lesion may be established. 
 
 It is, in the ^rst place, remarkable that the majority of these 
 cases of ulcerative destruction of the mucous membrane of the 
 stomach are situate either in the small arch of the stomach, or very 
 near the small arch. In the case by Dr Carmichael Smyth, it was 
 in the anterior part towards the cardia. In the first case by Ge- 
 rard, it was in the small arch, one inch from the pylorus. In his 
 fifteenth case also, a circular hole was found at the right and an- 
 terior side of the small curvature. It is unnecessary to refer to 
 all his cases, because he does not distinguish between simple in- 
 flammatory ulceration and that which is the effect of tubercular de- 
 struction and cancer. In the case by Dr Baillie, it was near the 
 small curvature on its posterior side, about two inches from the 
 cardia. In the case by Dr Crampton, it was at the union of the 
 cardiac and pyloric portions. In the instance of the late M. Bec- 
 lard, the anatomist, who had laboured under symptoms leading to 
 
 * De Sed. et Caus. Epist. xxix. 14. I am doubtful whether this case be not the 
 result of tubercular ulceration. 
 
 T Medical Communications, Vol. ii. p. 467. 
 
 J Des Perforations Spontandes de I’Estomac. Par M. Alexandre Gerard, D. M., 
 &c. Paris, 180.5. 
 
 § Morbid Anatomy, Chap. vii. Lond. 1825 ; and Miscellaneous papers and 
 Dissections, p. 199. 
 
 II Medico-Chirurgical Transactions, Vol. viii. p. 228. 
 
 ^ Ibid. Vol. viii. p. 271. , u.' 
 
 ** Revue Medicale, Mars 1824. / 
 
 -]-+ Edin. Med. and Surgical Journal, Vol. XXI. p. 3. 
 
 Medico-Chirurg. Trans. Vol. xiii. p. 26. 
 
 §§ Archives Generales, Vol. xxvi. p. 123. ' 
 
 nil Ibid. Vol. xxvi. 
 
 Ulf Rust’s Magazin, 1830. F. 32. 3. C. 
 
 »** Edin. Med. and Surg. Journal, Vol. xliv. p. 262. Edinburgh, 1835. 
 
GASTRIC MUCOUS MEMBRANE — CHRONIC ULCER. 
 
 611 
 
 the suspicion of chronic inflammation in the gastric mucous mem- 
 brane, and in whom these symptoms had subsided under appropri- 
 ate treatment, after death from disorder of the brain, a cicatrized 
 ulcer was found in the small arch of the stomach the size of a six- 
 pence, about four lines from the cardia* 
 
 In the cases by Ubersaal, Goeppert, and four of the seven seen by 
 myself, the ulceration was situate in the small curvature. In two, 
 indeed, of the first three cases described by me, the ulceration of 
 the villous membrane was bisected by the line of the small arch. 
 
 In other three cases examined by me, the ulcers were situate in 
 the anterior region of the stomach, about midway between the 
 small and great arch. In one case, that of a young female of 23, 
 there were in this situation two ulcers, one rather larger than a 
 sixpenny piece, one less than a fourpenny piece. The largest had 
 given way ; and the rupture was followed by escape of the con- 
 tents of the stomach, and fatal peritonitis in the course of a few' 
 hours. The patient was in her usual health at seven in the even- 
 ing, and she was found lifeless, yet not cold, in bed next morning. 
 
 In another case, which took place also in a young woman of 
 about 22, the ulcer was situate in the anterior part of the stomach, 
 but nearer to the pylorus. 
 
 In the sixth case, which took place in a boy of 1 1 years, who 
 had been labouring under granular disease of the kidney, and 
 dropsical symptoms, extensive peritoneal inflammation, with copious 
 effusion of lymph, had taken place over the intestines. But it was 
 not certain whether this had been caused by perforation or not. 
 There was no distinct evidence of escape of the contents of the 
 stomach, which contained a good deal of blood coagulated and se- 
 mifluid, which must have escaped from some vessel or vessels open- 
 ed in the margins of the ulcer. 
 
 Secondly, Whatever part of the organ they occupy, the diflferent 
 tissues are always destroyed in unequal degrees ; — the villous 
 membrane being most extensively destroyed, the filamentous and 
 muscular less so, and the peritoneal least. Indeed, it is by no 
 means certain that the peritoneal is destroyed by ulceration, as it 
 seems rather to give way after the other tissues have been removed 
 from it and cease to support it, than to undergo loss of substance 
 itself. 
 
 Thirdly, Though the ulcers now mentioned resemble ulcers in 
 other parts of the body, they have nevertheless a very peculiar 
 * Billard de la Membrane Muqueuse. Paris, 1825. P.558, 
 
612 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 character. The mucous membrane is always exactly destroyed to 
 certain well-marked limits ; and the edges which are formed by 
 the mucous membrane are in all cases sharp, manifest, and well 
 defined. They appear as if some time previously a part had been 
 cut or punched out from the villous membrane with a sharp instru- 
 ment, and the edges had healed, so as to present a uniform smooth 
 boundary round the excavation which had been made. 
 
 Fourthly, It is always possible to distinguish at one part of the 
 ulcer, viz. round its edges, whether perforation has taken place or 
 not, the submucous filamentous tissue and the muscular coat, much 
 less extensively destroyed than the villous membrane. From this 
 it may be inferred, that the process had first attacked the villous 
 membrane, and, after destroying that, had proceeded to the fila- 
 mentous and muscular. In some instances, only a portion of the 
 villous coat is destroyed, and the bottom of the ulcer is then form- 
 ed by the filamentous and muscular layers, yet comparatively un- 
 injured, In other instances, however, all the tissues are destroyed 
 down to the peritoneum, in which perforation takes place. 
 
 In the fifth place, the villous membrane forming the edges of 
 the ulcer is often quite free from redness, vascularity, or thickening, 
 and is always completely without either tubercular deposition, irre- 
 gularity, or hardness, such as might be expected in scirrhus. The 
 surrounding structure of the stomach is in appearance healthy and 
 unchanged. Sometimes, however, the margins are a little thick- 
 ened, firm, and sharp, and more or less opaque; and the surround- 
 ing mucous membrane is for some space thickened and of a deep 
 fawn-colour ; — changes which depend on effusion of lymph and the 
 afflux of blood to the neighbourhood of the ulcer. It must be ad- 
 mitted, in short, that the destruction of the villous membrane of the 
 stomach must have been the effect of inflammation, originating most 
 probably in the villous membrane, and giving rise to the ulcerative 
 destruction when the membrane was no longer able to resist the 
 intensity of the action. This is evidently inflammation of the sub- 
 stance of the membrane, circumscribed in character and chronic in 
 duration. Is there any reason to suppose that it was the result of 
 inflammation of the submucous filamentous tissue ? or do these ul- 
 cers originate in affection of the glands of the stomach ? 
 
 In the sixth place, in all these cases it is a common character, 
 that there is at the close of the disease, inflammation of the perito- 
 neal membrane, with effusion of lymph, in proportion as the ulce- 
 rative process affects the peritoneum. 
 
GASTRIC MUCOUS MEMBRANE — CHRONIC ULCER. 613 
 
 In the seventh place, perforation or rupture, though the natural 
 termination of these cases, is nevertheless not necessary to the dis- 
 ease. Death may take place by mere •peritonitis^ without effusion 
 of the contents of the stomach into the abdominal cavity. In this 
 case, the adjoining organs are generally applied accurately over 
 the part of the stomach where the ulcer is situate, and by the ad- 
 hesion effected by the inflammatory exudation, perforation and es- 
 cape of the contents are prevented. No escape took place in four 
 of the six cases inspected by me. Under such circumstances, there- 
 fore, peritoneal inflammation is rarely general or extensive. When 
 perforation takes place, of course the inflammation is very general 
 and intense. This result, however, depends much on the position 
 of the ulcer or ulcers. When they are situate on the anterior part 
 of the stomach, at some distance from the small arch, at which no 
 contiguous organs are applied over the stomach, perforation and 
 escape of the contents of the stomach are very liable to ensue. 
 
 In the eighth place, it deserves to be particularly noticed, that 
 this disease is greatly more common in females, and especially 
 young females, tlian in males. Among the six cases seen by my- 
 self three took place in young females; in those that I have seen 
 examined by professional friends they were mostly in females. The 
 disease seems not unfrequent among female domestic servants. 
 
 The symptoms produced by this disease are not well marked. 
 In all the cases almost which have been recorded, though the pa- 
 tients have not been in perfect health, yet they have been free 
 from any symptom calculated to excite apprehension, and they have 
 been in general suddenly and unexpectedly surprised by death. 
 
 In the cases which came under my own observation, the indivi- 
 duals had for a considerable time laboured under obscure and im- 
 perfectly marked dyspeptic symptoms, with loss of flesh, and in- 
 creasing languor and weakness. In two of them profuse hemor- 
 rhage had taken place from the stomach at different times, — 
 circumstances which were afterwards explained by the position of 
 the ulcer on the line of the coronary artery. A similar source of 
 haematemesis was recognized in the case given by M. Goeppert, as 
 occurring in the person of a young man who had suffered from 
 anorexia and tension at the pit of the stomach, but without being 
 aggravated by pressure. 
 
 Pain is by no means a constant symptom. In the case given by 
 
614 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Dr C. Smyth, the patient had occasional but not severe pain at the 
 stomach. In that by Dr Baillie, the patient had violent occasional 
 pain in the scrobiculus cordis, with vomiting, most liable to ensue 
 after meals. In most of the other cases, the sense of pain was 
 either trifling or not uniform. But in all there appears to have 
 been a sense of dull gnawing or aching, either constant or pretty 
 frequent. In one of the cases seen by myself, though the patient 
 always complained of pain, it was referred to a point deep in the 
 epigastric region, towards the spine,— a peculiarity which I think 
 was due to irritation of the extremities of the nervous filaments sent 
 along the small arch. 
 
 The pulse is not much affected in this disease. 
 
 The circumstances now remarked, however, apply only to the 
 early stage of the complaint, while it is still confined to the villous 
 membrane, or at most does not touch the peritoneum. When the 
 ulcerative action penetrates through the gastric tissues and begins 
 to affect this membrane, it produces also slight and limited 'perito- 
 nitis, which, if there be other organs applied on the part, tends to 
 protract the life of the patient, and retard for a little the approach 
 of the fatal event. With this peritoneal inflammation, the pulse 
 becomes quick and sharp, and the patient complains of more or less 
 pain in the epigastric and umbilical regions. But when the ulce- 
 rative destruction has reached the peritoneum, the life of the patient 
 hangs by a thread. The most casual occurrence, as a fit of sneez- 
 ing, coughing, eructation, or vomiting, or, even without these, the 
 distension of the stomach by drink or by air extricated from flatu- 
 lent food, may produce perforation, and cause the escape of gaseous 
 and fluid contents into the cavity of the abdomen, and general pe- 
 ritoneal inflammation very speedily fatal. 
 
 It is, therefore, too often only at the close of this disease that 
 the practitioner can even conjecture its true nature. 
 
 In every case, however, in which obstinate dyspeptic complaints 
 are accompanied with a gnawing sensation, more or less constant, 
 referred to the region of the stomach, or occasional acute pain, 
 with loss of flesh, weakness and languor, and with the frequent re- 
 jection of ingesta, the presence of chronic inflammation and ulcera- 
 tion may be suspected. This conjecture will be converted into 
 certainty, when, after a course of such symptoms, the patient is 
 suddenly and unexpectedly attacked with feelings of faintness and 
 sinking, acute pain generally radiating from the epigastrium or 
 
GASTRIC MUCOUS MEMBRANE — CHRONIC ULCER. 615 
 
 navel, all over the belly, pale, shrunk features, small rapid pulse, 
 followed by rapid breathing and cold extremities ; and dissolution 
 may then be certainly apprehended. 
 
 This species of gastric inflammation and ulceration has been con- 
 founded by several authors with cancerous destruction. From this, 
 however, it is to be distinguished by the absence of any considerable 
 thickening or induration in the vicinity of the ulcer, or in any other 
 part of the stomach, by its presenting less intense gastric symptoms, 
 and by its taking place either principally in young persons, especi- 
 ally young females, or in persons of all ages ; while cancer is rather 
 the disease of declining years. 
 
 Ulceration aflFecting the mucous follicles of the stomach is some- 
 what different. The surface of the swelled follicle begins to be 
 perforated by innumerable minute reddish points, which gradually 
 coalesce, and when this is completed, a reddish brown I’agged sur- 
 face is formed. 
 
 Ulceration often proceeds, it has been seen, by successive destruc- 
 tion of the submucous, muscular, and peritoneeal coats to perfora- 
 tion, which consists in the occurrence of a ragged opening, through 
 which the contents of the organ escape, and give rise to secondary 
 peritonaeal inflammation, which is invariably fatal. This accident, 
 examples of which are recorded by Morgagni, Lieutaud, Carmi- 
 chael Smyth,* Gerard,! Crampton,f Travers, § Louis, and Dr Aber- 
 crombie, may take place at any part of the stomach, but appears to 
 be most frequent in the space between the great and small arches, 
 but nearer to the former. In some rare instances, in which adhe- 
 sion is formed between an adjoining organ and the edges of the 
 aperture, the contents of the stomach are prevented from escaping, 
 and life may be continued till the progress of ulceration destroys 
 a part where this temporary barrier cannot have place. 
 
 The most important point to be known is, that these ulcers may 
 be cicatrized. Independent of the uncertain cases recorded by At- 
 kinson and Red, we have an authentic and unequivocal example in 
 the person of the late M. Bedard. This able anatomist laboured 
 at one period of his life under obstinate symptoms of gastric dis- 
 ease, the nature of which, though uncertain, seemed to partake of 
 chronic inflammation. The symptoms did not give way without 
 
 * Med. Commun. Vol. ii. p. 467. 
 
 t Ues Perforations Spontanees de I’Estomac. Paris, 1603. 
 
 $ Trans, of the Association, Vol. i. § Med. Chir. Trans. V ol. vii. 
 
616 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 frequent local blood-letting, counter-irritation, and tbe most rigid 
 regimen. After death, there was found in the small curvature, 
 about 4 lines from the cardia, a cicatrized ulcer, the size of a 20 sols 
 piece, with a depressed surface, the middle of which was traversed 
 bya solid cellular band, on each side of which were two lacunce form- 
 ed by peritonaeum. The margins were neither red nor swollen ; 
 and the rest of the stomach was sound.* 
 
 d. Solution of the gastrictunics enfeebled by inflammation. — Besides 
 the ulcerative perforation now mentioned, another variety has beenc" 
 described by Jaeger of Wirtemberg, Zeller of Tubingen, Cruveil- 
 hier of Paris, and Dr John Gairdner of this place, as occurring in 
 the stomach and bowels of infants generally at the breast. From 
 the elaborate examination of this subject by the latter author, it 
 appears that these perforations are probably not the result of pre- 
 vious ulceration, but are effected by some solvent power of the fluids 
 after death ; that, nevertheless, the parts so eroded and perforated 
 appear to undergo a previous change of structure, in consequence 
 of which they are less able to resist the solvent power, f 
 
 Before I conclude this subject, I may remark, that in some in- 
 stances the mucous follicles appear to become enlarged in conse- 
 quence of chronic inflammation, without affection of the gastric 
 membrane. A very good instance of this change is recorded by i 
 Haller, who found in the pyloric end of the stomach of a woman 
 of 64, ten or twelve hemispherical bodies like papilloe, with black 
 or perforated summits, and cavities full of purulent matter. Though 
 the size of these bodies was variable, the diameter of some was three 
 lines, in others a full inch.| 
 
 e. A particular cause of gastric mucous ulceration has been sup- 
 posed to exist in certain substances belonging to the class of corro- 
 sive poisons. That in many instances these substances induce in- 
 flammation, ulceration, and erosion of the gastric tissues, cannot 
 be denied ; and this is true, particularly of the concentrated mine- 
 ral acids, as is shown in the cases and experiments of Tartra, Or- 
 fila, and Brodie, the cases and experiments recorded by Rou- 
 pelle,§ and the instances, now rather numerous, in which sulphuric 
 
 * De la Membrane Muqueuse Gastro-Intestinale, &c. p. 558. Par C. Billard. 
 
 + Medico-Chinirgical Transactions of Edinburgh, Vol. i. p. 31 1. 
 i Opuscula Pathologica Observat. xxvii. 
 
 § Illustrations of the Effects of Morbid Poisons. By George Leith Roupell, M. D. 
 The Plates from Original Drawings. By Andrew Melville M'Whinnie, M. R. C. L. 
 Part I. and II. London, 18.33. Folio. 
 
 4 
 
GASTRIC MUCOUS MEMBRANE — MINERAL ACIDS. 617 
 
 acid has been swallowed accidentally, or used for^tbe purpose of 
 self-destruction. 
 
 Though it is true, however, that these substances produce in 
 many instances inflammation, and in several corrosion, it is not es- 
 tablished that they in all cases cause ulceration. It is very doubt- 
 ful even if arsenic itself, to which this property has been often as- 
 cribed, ever induces ulceration ; for in a large proportion of cases in 
 which particles of the solid oxide have been found in^the stomach, 
 no ulceration has been recognized. The reason of this I conceive 
 to be, that death is eflfected by the severity of the general operation 
 of the agent, before there is time for ulceration. 
 
 From the instances of deglutition of sulphuric and nitric acid 
 which have fallen under my own observation, and from the records 
 of other cases, the following conclusions may, I think, be established. 
 
 Is#, The first effect of sulphuric acid is evinced in its transit 
 over the membrane of the mouth, throat, and oesophagus. It there 
 indurates, crispates, and raises into vesications the mucous epider- 
 mis, and giving it a brownish colour and greater firmness. Nitric 
 acid produces the same effects, imparting, however, a citron yellow 
 colour to the epidermis. Both acids render the terminal boundaries 
 of the epidermis at the cardia much more distinctly visible than in 
 the natural state. 
 
 Both sulphuric and nitric acid produce at the epiglottis and up- 
 per part of the larynx so much detachment of the mucous epider- 
 mis with inflammation generally, as to give rise to symptoms of 
 laryngitis and oedema glottidis, much as after the accidental swal- 
 lowing of boiling water. Even during life the symptoms of gasp- 
 ing and spasmodic depression of the lower jaw are as well marked 
 as in cases of spontaneous laryngitis, and in most instances they are 
 more intense. 
 
 In the stomach the effects vary as the organ is empty or contains 
 articles of food. 
 
 If it contain articles of food, these are generally blackened, 
 hardened, and charred, as it were, by the contact of the acid. If 
 the organ be empty, or contain little food, the parts touched by 
 the acid appear like portions blackened, indurated, and charred. 
 The blood in the vessels is coagulated and blackened; and^the 
 vessels appear as if they had been filled by a dark-coloured injec- 
 tion which has speedily become solid. The blackened and indurat- 
 ed patches vary in size and shape. They may be small, but most 
 
618 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 commonly they are large, as large, that is, as a crown piece or a 
 half-crown piece. Their edges are distinctly circumscribed.* 
 
 In cases in which sulphuric acid is swallowed and death follows 
 speedily, the acid is not only absorbed by the blood but transudes 
 through the tissues ; and the peritoneal covering presents a distinct 
 acid reaction. The acid in like manner acts on the concave 'sur- 
 face and anterior edge of the liver, rendering it hard and friable 
 on the transverse arch of the colon, contracting that bowel and 
 rendering its tissues hard and thick ; on the duodenum, contracting 
 its calibre and rendering the coats firm and thick ; and acting in a 
 similar manner on the adjoining folds oi jejunum and ileum. 
 
 It occasionally happens that a portion of the stomach is dissolved 
 and corroded, forming a ragged irregular opening ; and the con- 
 tents escape into the abdominal cavity. This happened to a woman 
 who had committed double suicide. She had swallowed oil of vi- 
 triol, apparently without its having been known. She then cut her 
 throat with a knife. She was supposed to have died of the effects 
 of the wound in the throat ; and certainly vessels enow were di- 
 vided to cause the loss of much blood ; and blood was found, as is 
 often the case in examples of cut throat, in the bronchial tubes. 
 But besides this, there was in the large arch of the stomach a large 
 ragged irregular-shaped and dissolved opening, which presented 
 all round the usual charring and induration caused by sulphuric 
 acid.f 
 
 When the mineral acids do not immediately kill,They cause in- 
 flammation of the parts touched. The oesophageal epidermis is cast 
 off, and the whole surface of that tube suppurates and secretes 
 lymph and granulates. The mucous membrane of the stomach in | 
 like manner suppurates, or sloughs and suppurates, seci-eting lymph K 
 and granulation. Under this process the patient’s life may be pro- 1 
 traded from five or six weeks to two months, with great suffering, | 
 distress, and wasting. But death at length takes place, and the .1 
 parts are found in the state now described. 
 
 The effects of nitric acid on the stomach are very similar to those® 
 
 * Account of a Case of Suicidal Poisoning by means of Concentrated Sulphuric .3 
 Acid, with notices of other cases. By David Craigie, M. D. &c. Edinburgh MedicaLi 
 and Surgical .Journal, Vol. hii. p. 406. Edinburgh, 1840. 
 
 -)- Cases of Poisoning by Arsenic, Sulphuric Acid, and Muriate of Mercury. By 
 Alexander Watson, F. R. C. S. E. Ibid. Vol. liii. p. 401. 
 
 3 
 
GASTRIC MUCOUS MEMBRANE MINERAL ACIDS. 619 
 
 of sulphuric acid. But the citron yellow coloration of the gastric 
 tissues is here also conspicuous. 
 
 The vapour of nitric acid also operates on the organs of respi- 
 ration. 
 
 Hydrochloric acid is less frequently employed, either accidentally 
 or intentionally, apparently than sulphuric acid. But its effects are 
 very similar. Crispation and detachment of the oesophageal epi- 
 dermis; charring of the interior of the stomach; blackening and 
 coagulation of the blood in the blood-vessels ; corrosion of the gas- 
 tric tissue ; and a dark mottled appearance of the neighbouring 
 viscera ; are all lesions which have been observed after deglutition 
 of this acid. The bile is rendered of a bright grass green wherever 
 the acid comes in contact with it.* 
 
 The duration of life after deglutition of the concentrated mineral 
 acids, varies according to circumstances fi’om four or five hours to 
 twenty-five or thirty hours. 
 
 The further examination of this point, however, belongs to toxi- 
 cology. 
 
 f. In many cases of canine madness the oesophageal and gastric 
 membrane has been found reddened and covered with viscid mucus ; 
 (Morgagni, Baillie, Bahington, Ferriar, Marcet, Powel, Pinckard, 
 &c.) and several authors have here been inclined to ascribe the 
 symptoms of that disease to oesophageal and gastric inflammation. 
 Admitting, however, that appearances of this kind are sufficient to 
 constitute spreading or diffuse inflammation of the mucous surface, 
 it does not follow that this is the cause of the hydrophobic symp- 
 toms. The oesophageal and gastric redness is not constant ; and 
 its presence and degree, which are secondary, depend rather on the 
 violent spasmodic motions of the muscles of deglutition and the 
 diaphragm, than on positive or primary inflammation. 
 
 The affection of the gastric mucous membrane occurring in fever, 
 as remarked by Roederer and Wagler, Sarcone, Pinel, and others, 
 shall be noticed afterwards. 
 
 § 3. The duodenum is liable to morbid lesions similar to those af- 
 fecting the stomach. Chronic inflammation appears to be the most 
 common affection in that part of the alimentary canal. Under its 
 influence the duodenal mucous membrane becomes firm, rigid, and 
 a little thickened. Its glandular apparatus also is liable to be hy- 
 
 * Case of Poisoning by Muriatic Acid. London Medical Gazette, 1839, No. 15. 
 
620 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 pertrophied, rendering the inner surface of the tube irregular and 
 hard. 
 
 Chronic inflammation is liable to attack this organ in the cir- 
 cumscribed form ; that is, affecting a small spot and proceeding to 
 ulceration of the mucous membrane, and destruction of the whole 
 tissues; — producing perforation of a part of the organ not ad- 
 herent. The effects are quite similar to those of ulceration and 
 perforation of the stomach. 
 
 Chronic thickening of the duodenum is liable to take place at 
 any part of the bowel ; in some cases in consequence of inflamma- 
 tion and congestion, in others in consequence of deposition of new 
 matter. If the thickening take place near the point where the 
 common duct enters the bowel, it causes jaundice often of a most 
 obstinate character. It is still worse where the deposit is tubercu- 
 lar or scirrhous. In one case of this kind, the jaundiced colour of 
 the surface was not only very deep, but continued obstinately to 
 the last. It was found after death that the mucous membrane of 
 the duodenum was the seat of a deposition of tubercles near and all 
 round the orifice of the common duct ; and that these had thicken- 
 ed the tissues of the bowel to so great a degree as to obstruct en- 
 tirely the orifice of the duct. The surface of this deposition was 
 beginning to be ulcerated, being irregular and abraded ; and, had 
 life been prolonged, the morbid process would doubtless have de- 
 stroyed the tissue of the bowel and caused perforation. 
 
 Any other deposit is liable to produce tbe same results. 
 
 § 4. Enteria . — Inflammation of the iliac mucous membrane is 
 greatly more frequent than it has been represented by authors. 
 Whatever be the influence of authority to the contrary, it may be 
 shown that the frequent fluid alvine discharges, to which physicians 
 give the name of diarrhoea, are in the greater number of cases to 
 be referred to inflammation of the mucous surface of the intestines, 
 spreading over a considerable extent, and rarely penetrating to the 
 submucous filamentous tissue. 
 
 Though it was originally maintained by Glisson on the evidence 
 of dissection, that in diarrhoea the intestinal mucous membrane is 
 inflamed, and a similar idea was entertained by Baglivi and other 
 Italian physicians, the facts on which this opinion rests, appear to 
 have been overlooked, amidst the zeal and ingenuity with which 
 the hypothesis of inordinate motion {motus ahnormis) of the school 
 of Hoffmann and Cullen was defended. Next to the instance re- 
 
INTESTINAL MUCOUS MEMBRANE. 
 
 621 
 
 corded by Morgagni in his own person and others mentioned in 
 his 31st epistle, in the Reports of Ludovic Bang for 1782 and 1787, 
 may be found distinct traces of the opinion that intestinal inflam- 
 mation gives rise to diarrhoea.* Much about the same time, (1798,) 
 Carmichael Smyth conjectured, “ that in diarrhoeas, from catching 
 cold, the villous or interior coat of the stomach and intestines is 
 sometimes slightly inflamed. ”f This conjecture was afterwards 
 confirmed by the researches of Baillie,f Pinel,§ Hildenbrand,|] 
 Broussais,1T Petit and Serres,** Abercrombie, Andral, Latham, ff 
 and lastly Billard. The proofs collected by these authors it is un- 
 necessary to examine minutely. They establish indisputably the 
 inference, that the red or rose tint of mere injection of the mucous 
 membrane is adequate to produce all the symptoms of diarrhcea 
 passing into dysentery. The state of the intestinal membrane, as 
 discovered by necroscopy, may vary according to the extent of the 
 disease, the kind of the inflammatory process, and the parts of the 
 Intestinal membrane affected. 
 
 Inflammation of the intestinal mucous membrane, to be rightly 
 understood, should be studied both in the villous membrane proper, 
 {Enteria ; Enteritis mucosa ;) and in the intestinal follicles, iso- 
 lated and agminated; (^Adenitis; Adeno-enteria.) 
 
 a. In the villous membrane proper, the process is known by red- 
 ness and vascularity, increased secretion of viscid jelly-like mucus, 
 which is often very adherent, and sometimes tinged with blood, 
 sometimes with a proportion of albumen, so as to form false mem- 
 brane, and generally some thickening and roughening of the mem- 
 brane. This is commonly a diffuse or spreading form of inflam- 
 mation, and in characters acute. 
 
 b. Adenitis ; Adeno-enteria. Follicular inflammation. Dothinenteri- 
 tis . — The intestinal follicles are subject to at least two forms of in- 
 
 * Selects Diarii Nosocomii Regii Hafniensis, Auctore Frederico Ludovica Bang. 
 Vol. i. p. 47, Vol. ii. and 233, 314, 360, 361. 
 
 t Medical Communications, Vol. ii. p. 210. 
 
 J “ It does not always happen,” says BailUe, “ when a person has died from fatal 
 purging, that there are ulcers in the intestines. In two cases which I have opened of 
 persons who died from this complaint, the small intestines were inflamed, so as to pre- 
 sent the appearance of distinct vessels, the small branches of arteries curling most 
 beautifully at the outer surface of the intestine filled with florid blood, and the vUlm.is 
 coat heing slightly red." — Dissections, &c. p. 218. 
 
 § Medecine Clinique et Nosographie Philosophique, Tom. ii. 
 
 II Ratio Medendi in Instit. Clinico. If Phlegmasies Chroniques. 
 
 ** Traite de la Fievre Entero-Mesenterique. 8vo. Paris, 1813. 
 
 tt An Account of the Disease lately prevalent at the General Penitentiary. By P. 
 M. Latham, M. D. &c. Lend. 1825. 
 
622 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 flammatory enlargement. In one the mucous membrane is mostly 
 affected. It swells up, becomes dry at first, then is covered with 
 viscid thick mucus adherent to it, while the pore of the follicle is 
 more or less obstructed in consequence of tbe swelling. When 
 this continues long, it is liable to induce abrasion of the mucous 
 membrane or even ulceration. Yet this does not appear often to 
 take place in this sort of affection of the follicles. The swelling 
 may subside, and the follicle or follicles recover their previous ap- 
 pearance and qualities. , 
 
 In the second form, in which the fine cellular tissue is most af- 
 fected, it is very different. The tissue is raised and swelled out, 
 becomes firm, tough, and often assumes a buff or yellow colour, 
 which shows that it is dying or dead. In short this follicular cel- 
 lular tissue is very easily killed, and then forms a slough below the 
 mucous membrane. The latter, however, being deprived of its 
 support and nutrition, likewise dies, is cast off as a superficial slough, 
 while below there is one more deep. This also is cast off, and a 
 deep ulcer is left, which is almost invariably very difficult to be 
 healed, and which often does not heal, but, by weakening the 
 bowel, causes perforation of the peritoneal coat. 
 
 These are forms of inflammation comparatively chronic, that is, 
 lasting from three to six weeks. 
 
 1. The simplest form is that in which the mucous surface is 
 light reddish, or rose-coloured over a large extent, — an appearance 
 which depends on superficial injection of the villous membrane. 
 The villi are red, and more or less gorged with blood. This state, 
 besides producing copious mucous or sero-gelatinous discharges, 
 is very often the pathological cause of intestinal hemorrhage. In 
 some instances it is shaded from a light rose to blood-colour or 
 wine-coloured crimson. 
 
 2. The intestinal membrane may be marked by redness disposed 
 in various forms, arborescent, asteroid, or punctular, or in slender 
 linear streaks. These appearances may occur independent of in* 
 flammation, as an effect of transudation, or stagnation during the 
 last hours of existence or after death, and should therefore be dis- 
 tinguished from the same forms of redness in connection with the 
 inflammatory process, when they indicate a slight or incipient form 
 of it. 
 
 3. A common form is in red or brown patches, irregular in size 
 and shape, with sensible elevation above the surrounding mem- 
 brane, forming a sort of puffy swelling, the surface of which is 
 rough and irregular, and, though not hard, void of its natural feel. 
 
INTESTINAL MUCOUS MEMBRANE — FOLLICULAR DISEASE. 623 
 
 Though these patches, which are in the follicles isolated and agmi- 
 nated, may occur in any part of the small or large intestine, they 
 are most common at the termination of the ileum, in which they are 
 seated in the agminated patches of glands, and the beginning of 
 the colon, where they are in isolated follicles. F rom petechial and 
 ecchymotic blotches, with which they are liable to be confounded, 
 they may be distinguished by the blood being observed in pieces 
 of intestine held up to the light to be still contained within vessels- 
 (Latham.) These red patches are exceedingly prone to proceed 
 to ulceration, which takes place in one or more points near their 
 centre, and by extension and coalition produce in no long time a 
 breach in the continuity of the mucous corion equal in size to the 
 original patch. This is the form of disease described first by Frost, 
 then by MM. Petit and Serres under the name Entero-mesenteric 
 fever, and which, there is reason to believe, is occasionally epidemic 
 in Paris.* Of the same nature is the disease which was prevalent 
 in the Millbank Penitentiary during 1822 and 1823. According 
 to the description of Dr Latham, the patches, which most frequently 
 were circular, and not exceeding the diameter of a pea, were dispersed 
 at intervals through the whole tract of the intestines. These were 
 evidently in the isolated follicles. When larger and more irregu- 
 lar, they appear to have been the result of the coalescence of seve- 
 ral small patches ; and were most likely in the agminated glands. 
 The transition to ulceration in this instance consisted in the redden- 
 ed mucous membrane becoming elevated, rough, and unequal to 
 the touch, and in erosion taking place at several points.f 
 
 4. A considerable extent of the membrane may be diffusely red 
 or reddish brown, or with a general rose-coloured ground may 
 present red or brown patches of a more intense tint. The mem- 
 brane is at the same time soft, friable, pulpy, and often thickened ; 
 the mucous glands are enlarged and reddish ; and the membrane 
 is covered more or less extensively by thick, semi-opaque viscid 
 mucus of a reddish or wine-eoloured tint. This form of the dis- 
 ease is also said to proceed to ulceration. When it does so, the 
 process takes place not only in spots and patches of the mucous 
 membrane, but in the follicles, which are converted into a number 
 of oval reddish-brown ulcers. 
 
 5. Part of the intestinal mucous membrane may present nume- 
 rous vesicular or pustular elevations, not unlike thrush vesicles 
 
 * Traite de la Fievre Enteromesenterique, p. 13. Paris, 1813. 
 
 t An Account of the Disease, &c. p. 48. 
 
624 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 {aphth(B\ which may terminate in the formation of abi'aded spots 
 or minute ulcers. Excoriation and abrasion is mentioned by va- 
 rious authors ; but I think none of them distinguish between this 
 and ulceration, of which I regard it as the incipient stage. Abra- 
 sion consists, properly speaking, in the removal of epidermis ; but 
 as the existence of this in the gastro-enteric membrane is proble- 
 matical, it may be doubted whether there is other abrasion than 
 what I now admit. These abraded spots or minute ulcers appear 
 to me to be the apices of the isolated follicles proceeding to ulce- 
 ration. 
 
 6. In certain forms of intestinal inflammation, the morbid pro- 
 cess appears in the shape of spheroidal or conoidal circumscribed 
 eminences, which are red, fungous, and irregular, and form con- 
 spicuous prominences of the mucous membrane. These bodies, which 
 thus resemble pustules, and are surrounded by a red hoop (areola)^ 
 consist in inflammation of the isolated mucous follicles of Peyer, 
 as represented by MM. Bretonneau and Trousseau, and many 
 subsequent observers. They are often much elevated above the 
 adjoining mucous membrane, not unlike broad circular mushrooms, 
 and are then sometimes named fungi. There is no doubt, never- 
 theless, that they consist, as above described, of the thickened folli- 
 cular cellular tissue, with morbid secretions in the apex, and they 
 are tinged with the colouring matter of the excrement. Accord- 
 ing to the former of these observers especially, this follicular in- 
 flammation, passing occasionally to ulceration, is a most frequent 
 form of intestinal disease not only primary, but occurring in the 
 course of fevers. Its most constant and frequent locality is the 3, 
 6, or 10 last inches of the ileum, where the agminated patches 
 are largest, and a long space of the ileum consists of agminated 
 follicles without interruption ; and when it affects the colon it is 
 near the ileo-coecal valve, being on both sides of this point much 
 more confluent than at greater distances. This form of intestinal 
 inflammation M. Bretonneau denominates dothinenteria {hohve pus- 
 tula, and ivn^ov intestinum.')* 
 
 Any one of these forms of morbid condition may produce all the. 
 phenomena of diarrhoea or even dysentery. The most uniform and 
 remarkable eflPect, however, is after the first discharges of feculent 
 matter to cause abundant excretion of viscid mucous matter, which, 
 though fluid when discharged, undergoes a species of coagulation 
 * Archives Generales, Tome x. 1826. P. 67 and 169. 
 
INTESTINAL MUCOUS MEMBRANE FOLLICULAR DISEASE. 625 
 
 not unlike jelly. This may be easily recognized^ even when mix- 
 ed with feculent matter. It is free from the peculiar offensive 
 odour of the latter ; and it appears to contain a proportion of al- 
 buminous or gelatinous matter, or both. 
 
 Ulceration of the mucous follicles is very common after the dis- 
 ease in any of the above forms has subsisted long. This was seen 
 in those of the duodenum by Brunner, in those of the ileum by 
 Lecat, Prost, Petit, and Serres, Bretonneau, and Trousseau, Bil- 
 lard, and Dr Bright This form of ulceration is invariably more 
 complicated and more difficult of cure than simple ulceration of 
 the villous membrane. The latter, indeed, without affection of the 
 follicles, is so rare that its existence may be questioned. 
 
 To render the history of inflammation of the intestinal mucous 
 membrane and its follicles complete, I feel it necessary to take a 
 general view of the disorder, as it takes place at different periods 
 of life and in different circumstances; and though in this view I 
 shall not disregard the observations and descriptions of others, yet 
 I deduce it principally from the results of personal observation con- 
 tinued over a long period of years. 
 
 1. Chronic inflammation may attack the mucous follicles of the 
 ileum at six weeks after birth, at three months, at six or eight 
 months, or at twelve months, or two years after birth. After the 
 latter period it is less frequent, but may take place under circum- 
 stances presently to be mentioned. The earliest period at which 1 
 have observed the disease after birth was six weeks. And in the 
 case to which 1 allude, it must be observed, that the disease had 
 been present for three or four weeks ; so that it may be allowed 
 that it commences as early as two or three weeks after birth. 
 
 The aggregated patches, which are generally more distinct in the 
 infant than in the adult, are elevated, with rough prominent edges, 
 rough surfaces, so uneven with elevations and depressions that they 
 have been supposed to be ulcerated, and they have been in this 
 condition by some supposed to be in a state of ulceration. When, 
 however, the surface is carefully cleansed by water, it is seen that 
 it is merely irregular, rugose, here prominent and elevated, there 
 depressed ; and, in short, swelled or in a state of inflammatory con- 
 gestion. 
 
 The reason of this irregularity is that the inflammatory conges- 
 tion and injection affects mostly the follicular cellular tissue, which 
 then rising up, where it most easily does so, causes the elevations ; 
 
 R r 
 
626 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 while the intermediate points, at which it does not readily rise, form 
 the hollows and depressions. 
 
 This state of the ileal follicles may last for weeks, coming and 
 going, or appearing and subsiding alternately. It may take place 
 in consequence of improper food, but seems also to occur sponta- 
 neously or at least without evident cause. It is common in infants 
 fed by the hand or other unnatural modes ; and is often induced 
 at the period of weaning, if care be not taken to effect that change 
 gradually. When it has been once commenced it is liable to recur. 
 
 Follicular irritation and enlargement, if not proceeding to much 
 thickening and to ulceration of the surface, may subside, and leave 
 the membrane in a healthy state. Children who have it are liable 
 to diarrhoea in fits, or are said to have irritable bowels ; but as the 
 follicles return to their natural condition, this symptom disappears.' 
 
 When it continues long or recurs frequently, and gives rise to 
 frequent, habitual, or violent diarrhoea, the follicles are thickened ; 
 and on the apices of several of them small ulcers are formed. But 
 even without ulceration it may prove fatal by the extent over which j 
 it is diffused, the over-action and irritation of the intestines, and the 
 violence of the general symptoms, with its wasting effects on the 
 function of nutrition. It is usually observed in cases thus termi- 
 nating, that numerous invaginations have taken place in the bowel, 
 each invagination being formed over the site of an enlarged aggre- 
 gated patch. Infants and young children with this disorder are JF 
 sometimes cut off suddenly, most usually with symptoms of crowing ^ 
 inspiration; and spasmodic contraction of the thumbs, fingers, and 
 toes. In other cases symptoms of enteritis or ■peritonitis with ob- 
 stinate constipation often take place ; and then ulceration is found et;;. 
 to have extended to the submucous cellular tissue and the perito-?^ 
 naeum. 
 
 2. Follicular inflammation may take place at a subsequent period, 
 that is, at periods after infancy, and between the third and fifteenth 
 year, or even at later periods. 
 
 Though this disease may come on in various modes at the time 
 of life now referred to, the most usual, at least between three and 
 seven or eight years, is the following. 
 
 The patient is unwell, languid, with hot skin, especially at night; 
 the tongue a little furred; the pulse quicker than usual (90, 100, 
 110); and the appetite impaired, with thirst. Sleep is disturbed 
 and unrefreshing ; the patient starts and is alarmed ; and awakes 
 
 'i 
 
INTESTINAL MUCOUS MEMBRANE — FOLLICULAR DISEASE. 627 
 
 in the morning generally more fatigued and exhausted than at 
 night. Yet there are no very conspicuous or prominent symp- 
 toms which denote derangement or disorder of a particular texture 
 or region. This state of matters may proceed for 8, 10, or 12 
 days. The bowels are then observed to be irregular ; sometimes 
 constipated ; more frequently slightly loose. In a few cases uneasi- 
 ness is observed or felt in the umbilical or the right iliac region, or 
 in both. The umbilical region may be somewhat distended ; and 
 beneath the fingers air is felt moving in that region, or in the right 
 iliac. Feverishness continues, and is usually aggravated in the 
 latter part of the day and at or during night. At length pain is felt 
 in the belly, generally about the right iliac region or the umbilical ; 
 and this may increase to symptoms of enteritis or peritonitis. Diar- 
 rhoea stops ; vomiting takes place ; and the bowels are obstinately 
 bound, while the abdomen is swelled, painful, and tympanitic. 
 
 Tbe disease usually under these circumstances terminates fataF 
 ly ; and the intestinal mucous membrane and follicles are found in 
 the following state. 
 
 Much viscid mucus adheres to the villous membrane, and more 
 especially to the aggregated patches. When this is removed, the 
 patches are observed elevated, roughened, and indurated in various 
 degrees. In some the elevation is moderate ; in others it is great 
 and perceptible, giving them the aspect of pustular eminences, or 
 rendering them like buttons on the villous membrane. Usually 
 this considerable elevation depends on thickening and death of the 
 follicular cellular tissue, which is hard, friable, and of a buflP or 
 yellow colour. In certain points the mucous membrane is castoff, 
 disclosing small ulcers ; the base of which is sometimes the yellow 
 thick dead tissue already mentioned, sometimes the muscular and 
 peritoneal coat. These ulcers evidently take place in individual 
 follicles ; but by two or more coalescing, two or more small ulcers 
 may be converted into one large one. The adjoining intestinal 
 membrane is occasionally but not always thickened ; and sometimes 
 vessels are seen traversing it to the patch or patches most thickened. 
 The mesenteric ganglions opposite are enlarged in various degrees 
 and to different extent. At some points a whole cluster of glands 
 enlarged is presented ; at others, two or three are enlarged but se- 
 parate. 
 
 In extreme cases albuminous exudation covers the peritoneum 
 corresponding to the patches or the ulcers ; and the peritoneum 
 has in certain cases given way previous to deatii, allowing the par- 
 
628 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 tial escape of the contents of the bowel, and followed by effusion of 
 sero-albuminous fluid from the internal or free surface of the peri- 
 tonaeum. 
 
 3. In certain cases the isolated follicles are the seat of chronic 
 inflammation, either alone or along with the aggregated follicle. 
 In either case they present the appearance of pustules a little ele- 
 vated, or fungous-looking flat tubercular bodies. These isolated 
 follicles pass through the changes already mentioned in proceeding 
 to ulceration. In the form of pustules they have been repeatedly 
 mistaken for variolous pustules ; and hence it has been said, that 
 they are sraall-pox in the intestinal mucous membrane. 
 
 A peculiar sort of broad elevated button-like appearance is oc- 
 casionally seen in the intestinal mucous membrane in this disorder. 
 The individual bodies are about two lines broad, sometimes three, 
 irregularly circular, with flat tops. They are evidently raised above 
 the level of the surrounding mucous membrane, and sometimes 
 their mai’gins project over the latter. The tops are fungous-look- 
 ing and rough, and of a fawn or dirty yellow colour ; and it seems 
 as if the whole follicular mucous membrane had become thickened 
 and hypertrophied. This is the result of a more chronic affection 
 than the one already described. Occasionally these fungous-look- 
 ing bodies are seated in the isolated follicles ; and sometimes in the 
 agminated follicles. 
 
 4. The disease now described may take place, as already stated, as 
 a mere intestinal affection. Often, however, it is either connected 
 with fever, or it is an effect of the operation of the febrific poison. 
 In children and young persons it is often connected with the fever 
 described as intestinal remittent fever. In adults it takes place 
 along with fever which has been by several observers described as 
 typhous fever. But when it was manifest that typhous fever, in the 
 great majority of cases, took place, and continues to take place, 
 without affection of the intestinal follicles, the fever in which this fol- 
 licular disease was said to take place was denominated typhoid fever. 
 
 The truth is, that the disease takes place in a fever which may 
 present, according to its treatment, typhoid symptoms during the 
 second septenary period, or rather towards the close of that period. 
 But the fever, in which it most commonly takes place, is a remit- 
 tent fever, with evening or afternoon exacerbations ; and the per- 
 sons most usually affected are children from 5 to 10, or young per- 
 sons in general under the 30th year of age. The disease is much 
 more common in certain localities than in others. In Paris it seems 
 
 4 
 
IXTESTINAL MUCOUS MEMBRANE — PERFORATION. 629 
 
 frequent, but affects mostly persons coming from the provinces. In 
 London it is also not uncommon. In Manchester I have seen it 
 affecting the Irish labourers. In Edinburgh it is not very com- 
 mon ; and a physician treating from 200 to 300 patients in the 
 course of the year my see not above three or four cases, and only 
 one of these fatal. In certain seasons it is more common than in 
 others. Thus several cases took place in the winter of 1842-1843 ; 
 and a few cases took place in the end of 1845 and beginning of 
 1846. At the close of the latter year it was again appearing. 
 
 In Edinburgh it is seen in railway labourers, and persons en- 
 gaged in similar out-door labour. 
 
 In Glasgow it is more frequent than in Edinburgh, and is seen 
 mostly among the Irish. 
 
 It appears to me not to be contagious, but to affect spontane- 
 ously, or in consequence of causes, not easily determined, the 
 persons attacked. From the testimony of various foreign observ- 
 ers, as Frenzel, Ebel, Grossheim, Stannius,* Chomel,| Lesser,f 
 and Cramer, § it appears to depend either on telluric miasma, or on 
 some atmospheric conditions. 
 
 c. Perforation . — Though any part of the small intestine from the 
 duodenum to the caecum may be the seat of ulcers, they are most 
 numerous and largest in the lower part of the ileum. In this part 
 of the tube the ulcerative process may advance so far as to affect 
 the submucous tissue, the muscular layer, and the subserous tissue, 
 upon which the peritonaeum generally gives way, and laceration or 
 perforation takes place. That the peritonaeum is removed by ab- 
 sorption, or rather gives way when no longer supported by the col- 
 lateral tissues, may be inferred from the fact observed by M. Louis, 
 to whom we are indebted for the best and fullest account of this 
 accident ; — that the margin of the ulcers in which perforation takes 
 place is sharp and clean ; that the mucous and submucous tissue 
 are destroyed nearly to the same extent ; and that the muscular is 
 less, and the peritonaeum scarcely at all destroyed. 
 
 The effect of perforation is, as in the case of the stomach. Is#, 
 
 • Edinburgh Medical and Surgical Journal, Vol. xlviii. p. 145. 
 
 •)• Lefons de Clinique Medicale, faites a L’Hotel Dieu de Paris. Par le Profes- 
 seur A. F. Chomel. Paris, 1834 ; and Edinburgh Medical and Surgical Journal, Vol. 
 xhx. p. 492, and 1. p. 175. 
 
 + Die Entzundung und Verschwarung der Schleimhaut des Verdauungs Kanales ala 
 selbstandige Krankheit, dargestellt von Ferdinand Lesser. Berlin, 1830. 8vo. Mit 
 Kupfertafeln. 
 
 § Der Abdominal Typhus. Monographische Skizze. Von Dr F. Cramer. Caasel, 
 1840. 8vo. ss. 128. 
 
630 
 
 GENERAL AND PATHOLOGICAL AlSfATOMY. 
 
 escape of the intestinal contents to a greatei' or less extent ; 2J, the 
 development of peritoneal inflammation, with albuminous deposi- 
 tion on the peritoufEum. The period which elapses between the 
 commencement of ulceration and the completion of erosion varies 
 in different cases. According to the observations of Louis, already 
 quoted, it may be inferred that in a space varying from 12 to 25 
 days, the ulcer or ulcers may effect destruction of the intestinal 
 tunics. The occurrence of the final laceration of the peritoneal 
 coat may be conjectured by the patient experiencing all at once in 
 the belly intense tearing pain, aggravated by pressure, speedily 
 followed by shrinking of the features, voiniting, &c. which, con- 
 tinuing with almost incessant severity from 20 to 54 hours, denote 
 intense peritoneal inflammation terminating in death. In one 
 case, which, however, must be regarded as an exception, life was 
 continued for seven days after the appearance of symptoms of per- 
 foration. 
 
 d. Enteria mollescens . — Under this head may be placed a change 
 observed by Louis in the ileum of many persons cut off by phthisis 
 and other chronic diseases. It consists in the mucous membrane be- 
 coming exceedingly soft, almost like mucus or jelly, sometimes thicker 
 than natural, and sometimes redder. In the instances in which I 
 have observed this change in phthisical subjects, the intestinal villi 
 were less distinct than natural. But whether this arose from re- 
 moval of these bodies or from the pulpy swelling of the mucous 
 corion, or from absolute disorganization, I have not been able to 
 determine. It is rarely continuous, and occurs chiefly in large 
 patches, which occupy, however, the whole circumference of the 
 bowel. 
 
 § 5. Chronic ulceration , — To this head I refer a form of disease 
 of which I have seen several instances in children labouring under 
 symptoms of mesenteric wasting ; (tabes.') I have no doubt that it 
 commences in inflammation of the mucous membrane, or rather of 
 the agminated follicles ; but as it was found in the cases to which 
 I allude in the form of ulcerated patches, I prefer, for the sake of 
 obvious and easy distinction, to designate it as above. In the best 
 marked instance in which I have seen it, and the preparation of 
 which is before me, it occurred in the form of three large bands 
 near the lower end of the ileum, extending transversely round the 
 entire circumference of the bowel. The broadest of these bands 
 is about two inches, the narrowest about eight lines. Over the 
 whole of these spaces is the mucous membrane completely removed 
 
INTESTINAL MUCOUS MEMBRANE — CHRONIC ULCERATION. 631 
 
 by the ulcerative process, leaving an irregular surface, partly gra- 
 nulating, partly ulcerated in the mucous tissue. The margins are 
 sharp, clean, and accurately cut, almost as if they had been divided 
 by a knife, and slightly turned up, so as to leave an excavated fur- 
 row beneath the mucous membrane which forms the margins. The 
 colour of the bottom of these ulcerated patches, when recent, was 
 reddish brown, and the contiguous mucous membrane was red, 
 verging to pale rose colour and peach blossom. This, however, 
 has disappeared, and at present it is much the same tint as the 
 healthy part of the mucous surface. The mucous membrane is a 
 good deal thickened and rather firmer than in the sound part of the 
 tube. At each of these ulcerated bands the submucous and sub- 
 serous filamentous tissue is thickened, but indurated and contract- 
 ed, so as to diminish considerably the calibre of the canal. In the 
 first patch, which is about twelve inches from the ileo-caecal valve, 
 this thickening consists of a firm knot like a bean, at the mesente- 
 ric side of the bowel, and the intestine is contracted to about half 
 its usual capacity. In the second, about five inches from the ileo- 
 caecal valve, this indurated knot at the mesenteric attachment of 
 the bowel is equally well marked, and has had, if possible, greater 
 influence in contracting and diminishing the canal of the bowel. 
 The ulcerated surface is very irregular by soft spongy eminences, 
 separated by means of linear furrows. The third occupies the end 
 of the ileum and beginning of the colon, and has entirely destroy- 
 ed, with the mucous membrane of both bowels, the ileo-caecal valve. 
 The destroyed part here presents a surface consisting in very mi- 
 nute round granules ; and in the beginning of the colon are one 
 or two large irregular granulations. The same inflammatory in- 
 duration of the submucous and subserous filamentous tissue has 
 here operated in diminishing the capacity of the bowel ; and, in- 
 deed, previous to being cut open, it seemed almost impervious. 
 The inflammatory process here had produced peritoneal inflamma- 
 tion, and false membrane connecting the ileum^ caput ccecum, and 
 part of the colon together. The vermiform process is unaffected. 
 Opposite to each were enlarged mesenteric glands, and especially 
 at the last mentioned one was a cluster of large knotty masses. 
 
 Though I describe the ultimate effects of this destructive pro- 
 cess, I have no doubt, from what I have seen of other cases in ear- 
 lier stages, that it is the result of chronic inflammation of the in- 
 testinal mucous membrane, originating in the agminated follicles, at 
 
632 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the lower end of the ileum, and from them spreading to the adjoining 
 mucous membrane. I had an opportunity of observing the pro- 
 gress of the disease for more than two years, during which the case 
 was more or less under my care ; and during that period it was 
 possible to recognise occasional attacks of inflammation. The other 
 symptoms were occasional pain of the belly, never severe, unless at 
 the period of the above attacks, and diarrhoea alternating with con- ' 
 stipation, afterwards incessant and uncontrollable diarrhoea, wast- 
 ing, and hectic fever ; — in short, all the symptoms imputed to me- 
 senteric decline ; (tabes mesenterica.) This process, therefore, or 
 chronic inflammation of the intestinal mucous follicles and mem- 
 brane, with or without ulceration, I regard as one of the patholo- 
 gical causes of mesenteric tabes. The enlargement of the glands, 
 in which this disorder has been very generally believed since the 
 time of Wharton, Baglivi, and Richard Russell to consist, is mere- 
 ly secondary, and is a consecutive effect of the irritation exercised 
 at the organic extremities of the lymphatics and lacteals. This 
 view of the relation between enlarged mesenteric glands and in- 
 testinal inflammation, though already stated by Broussais, has not, 
 however, been established by that author on authentic proofs. En- 
 largement of these glands is indeed, I have elsewhere said, a com- 
 mon effect of irritation at the organic extremities of their lympha- 
 tics. 
 
 § 6. Typhlitis, Perityphlitis. — The c(Bcum or blind bowel (typhlon 
 enteron) is often the seat of a peculiar disease, which, from slow and 
 almost imperceptible commencements, produces so much havoc as 
 to terminate the life of the individual. 
 
 This disease consists in inflammation and suppuration of the cel- 
 lular tissue connecting the cacum to the quadratus lumborum and 
 other parts, or in inflammation and ulceration of the mucous mem- 
 brane of the csecum, and often of the vermiform process, and which, 
 advancing by very gradual and insidious steps, destroys the mu- 
 cous membrane, aflPects the submucous cellular tissue and perito- 
 neal coat, and either causes inflammation of the latter with adhe- 
 sion to the muscular parietes of the abdomen, or perforation and 
 fatal peritonitis. The exact mode in which this disease commences 
 is not always perfectly known. But from the dissection of those 
 who have perished by it, we may infer that the following descrip- 
 tion makes a near approach to the facts. 
 
 At first the glands or follicles of the ccecum become enlarged 
 
intestinal mucous membrane — CJECAL DISEASE. 633 
 
 and thickened and elevated by inflammation. Then the summits 
 of these covered by the remains of purulent matter and adherent 
 mucus are separated ; and below are disclosed ulcerated surfaces 
 to the same extent as the glands of follicles originally aflfected. 
 This process extends and deepens, until the submucous tissue and 
 the peritoneum are affected. Lymph is effused over the surface 
 of the latter ; and this for some time either prevents the bowel 
 from being perforated, or it unites the peritoneal coat of the caecum 
 with the muscular peritoneum and the abdominal muscles. At 
 the same time the mucous membrane of the vermiform process is 
 affected by inflammation of its follicles and subsequent ulceration ; 
 so that when the body is inspected after death, this appendage pre- 
 sents numerous ulcers along its internal surface. 
 
 When the inflammatory action has caused the agglutination of 
 the caecal peritonaeum to the muscular peritonaeum and abdominal 
 muscles, the morbid process is not thereby stopped. Very com- 
 monly it is extended progressively to the cellular tissue outside 
 the peritonaeum, thence to the muscles in the right iliac region, and 
 it may even produce an external abscess in these muscles, the open- 
 ing of which on the surface will depend on the time during which 
 life is prolonged. 
 
 In one case of this kind, which I inspected in the body of a young 
 female of 11 or 12, the caecum itself was greatly distended; the 
 extra-caecal peritoneum was partly adherent to the muscular, and 
 partly destroyed by ulceration ; the round or convex part of the 
 bowel was perforated with 6 or 7 ragged apertures, various in size 
 and shape ; matter was found all round it and between them, and 
 also externally to the muscular peritoneum, and between the fibres 
 and layers of the abdominal muscles ; and the skin, though not de- 
 stroyed, was undermined. When the disease had reached this point 
 death had taken place. But had life been prolonged a few days 
 more, an opening in the skin of the right iliac region would have 
 taken place ; and a fistulous, cavernous abscess passing through the 
 abdominal muscles and into the cjecum must have ensued. In this 
 case also the colon was small, contracted, and almost empty, its 
 size being more like that of the ileum than the colon, while the 
 ileum was distended by feculent contents to about three or four 
 times its usual size, and presented at first sight the appearance of 
 the colon. This fact deserves, as we shall see, especial attention. 
 
 Another mode in which this disease shows itself is the following. 
 
634 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 After the disease in the mucous membrane of the caecum has sub- ' 
 sisted for some time, with or without ulceration of the caecum, it is 
 followed by inflammation taking place in the cellular tissue at the 
 posterior part of the caecum. The latter bowel, it must be remem- 
 bered, is tied down and fixed by cellular tissue to the right iliac 
 fossa immediately before the lumbar and iliacus internus muscles. 
 The inflammation passes to this cellular tissue ; and in it causes 
 effusion of lymph and purulent matter, forming a sort of abscess I 
 round and behind the caecum. In the right iliac region there is 
 then recognized a tumour compressible and doughy, and giving a ] 
 sense of deep-seated matter ; painful when pressed at certain points, J 
 and tending, as in the last case, to advance to the surface. The 
 disease then shows itself under the form of abscess of the right iliac 
 
 In this state after matter has been formed one of two results! 
 may take place. Either the inflammatory action continuing andj 
 the suppurative action advancing, a communication by ulceration^ 
 may be opened into the caecum, and through this the matter con-^ 
 tained in the tumour passes gradually but speedily into the colon, 
 and is thus discharged into the bowels. Then, if adhesive inflam- 
 mation and lymphy deposit take place, the tumour is emptied of J 
 its contents and recovery is accomplished, the inflammation and J 
 suppuration being confined to the immediate neighbourhood andf 
 attachments of the caecum. 
 
 Secondly, it may happen that either with or without the open-” 
 ing into the caecum the agglutinative or adhesive inflammation is:< 
 imperfect and inert. Lymph is not effused in sufficient quantity ' 
 to stop the spreading of the suppuration. Matter is effused or in- , 
 filtrated into the cellular tissue all round and downwards over the _ 
 surface of the iliacus internus muscle ; and after great ravages arel 
 committed, it appears forming an outlet at the margin of the anus. 
 This is an unfavourable result, because the matter in advancing 
 to the surface is attended with much destruction of parts ; and be- 
 cause the progressive advancement of the disease denotes a defi- 
 ciency of healthy agglutinative and reparative action. 
 
 In the third place, the suppurative process may advance to the 
 surface, causing superficial abscess in the right iliac region and 
 ulcerative openings to discharge the purulent contents of the deep- 
 seated abscess. This appears to be not very common ; but it oc- 
 curs in a certain number of cases. It is not very favourable. 
 
INTESTINAL MUCOUS MEMBRANE — C^CAL DISEASE. 635 
 
 Although I began the account of this affection by representing 
 it to originate in previous disease of the cacum and vermiform ap- 
 pendage, yet there occur cases in which the latter circumstance is 
 not always manifest. If the first movements of diseased action have 
 taken place in the caecum, it has been externally ; and hence they 
 have advanced to affect the bowel secondarily. This mode of pro- 
 cedure may best be illustrated by the following case. 
 
 A young female, in the rank and occupation of a servant, was 
 sent from Leith to the Royal Infirmary with symptoms believed to 
 indicate the presence of continued fever. The skin was hot, and 
 though not dry, was imperfectly transpiring ; the tongue was co- 
 vered with a whitish gray pasty fur ; there was some thirst ; the 
 expression of the countenance was languid and feeble, though the 
 face was flushed ; the pulse was between 86 and 90, rising to 100 ; 
 and the strength was impaired. The abdomen was a little distend- 
 ed and slightly painful ; yet pressure was borne tolerably well. 
 The sound emitted was clear and natural. But in the right iliac 
 region, where some fidness was manifest, the sound emitted was 
 dull ; and considerable pain was felt on pressing or handling this 
 region. This painful sensation also extended backwards to the 
 loins ; but was more complained of on the right than on the left 
 side. In the right iliac region also, but most towards the side of 
 the region and its posterior aspect, there was recognized a more 
 firm and resisting yet compressible and doughy state of the parts 
 than natural. Pain was aggravated by coughing. 
 
 Some blood was drawn from the arm ; twelve leeches were ap- 
 plied over the right iliac region ; and laxative medicine was given. 
 
 Next day the patient said she felt relieved and more easy. But 
 the state of parts in the right iliac region was not improved ; the ab- 
 domen was rather more distended, with some tympanitic resonance ; 
 the pulse was above 100, not full but hard ; the skin was dry; the 
 urine scanty and sedimentous ; and the bowels had been moved 
 scantily and imperfectly : the fur on the tongue was much as before. 
 
 Twelve leeches were ordered on the right iliac region, to be fol- 
 lowed by warm fomentations and a poultice ; and an enema was 
 directed to be administered. 
 
 Next morning the patient became suddenly very feeble and 
 died. 
 
 Inspection disclosed the following appearances. 
 
 A portion of bowel between 3^ and 4 feet long, which turned 
 out to be the lower part of the ileum, was greatly distended chiefly 
 
636 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 witli air ; of a dark brown-red colour, and with its peritoneal coat j 
 covered and penetrated by an infinite number of red vessels. This ; 
 piece of intestine formed in this state several turns or convolutions ; 
 and a considerable portion of it had been pushed over to the right 
 side. The ileum above this was distended but less reddened. 
 W hen cut open the contents were much as usual, but with more 
 air. The mucous membrane was greatly reddened, friable, rough, 
 and easily detached. The substance of the bowel was vascular and 
 reddened. But of the follicles there was neither elevation nor ul-' 
 ceration. The ileo-csecal valve was reddened. The interior of , 
 the caecum was also reddened and softened ; but no ulceration 3 
 had taken place. The appendix vermiformis presented a few 
 enlarged follicles along its interior. The ascending arch of the 
 colon was comparatively empty ; and the rest of the bowel was 
 pretty natural, and void of any thing except thin feculent matter 
 and mucus. The mucous membrane of the colon was not unna-^ 
 tural. 
 
 External to the caecum, on the lateral and posterior aspects of ^ 
 that bowel, were deposits of purulent matter and loose lymph, ex- 
 tending upwards and backwards for a good space. This purulent .1 
 matter occupied the place of the perityphlic cellular tissue ; was 
 not contained within a distinct or well-formed cyst, but appeared 
 to be loosely infiltrated into the space around the caecum. No 
 perforation of the caecum had taken place. But all round the 
 cellular tissue was reddened, softened, loaded with bloody serum 
 and specks of purulent matter ; and the parts wmre ash-coloured 
 and offensive smelling, as if proceeding to mortification. 
 
 In this case the cause of death was twofold. First, the general 
 inflammation of the lower portion of the ileum {enteritis ; ileitis)^ 
 caused apparently by obstruction and distension of the whole bowel, 
 in consequence of the pressure created by the inflammatory abscess 
 round the caecum ; and secondly, this suppurative inflammation of 
 the perityphlic cellular tissue itself, which, though operating chiefly 
 as a cause of pressure on the caecum and obstruction to the peristal- 
 tic motion of the bowel, yet did further mischief by the peculiar 
 effects of a bad suppuration on the system at large. 
 
 In this case also, there is every reason to believe that the pri- 
 mary morbid action was seated in the perityphlic cellular tissue ; 
 and that the inflammation and suppuration there established had 
 acted on the caecum by compressing it, and thus obstructing the 
 descent of the contents of the ileum, had caused over-distension of 
 
INTESTINAL MUCOUS MEMBRANE C^CAL DISEASE. 637 
 
 the latter and general inflammation much as a strangulated hernia. 
 Indeed, the appearance of the ileum was quite similar to that pre- 
 sented by intestines above a point of strangulated bowel. 
 
 The termination of this disease is, nevertheless, not necessarily or 
 inevitably fatal. If the tumor in the right iliac region be recog- 
 nized before suppuration has taken place, resolution may be accom- 
 plished under the use of local and general blood-letting, with very 
 gentle aperients. Several patients in this state I have treated and 
 seen get perfectly well; and there is always more chance of com- 
 plete recovery if the treatment be commenced in this stage, than if 
 it be delayed until suppuration has occurred. After this event the 
 favourable termination, though less likely, may be effected in the 
 mode already mentioned. 
 
 Though all the causes of this disorder may not be perfectly 
 understood, yet several are sufficiently obvious and intelligible. In 
 the first place, the peculiar situation and fixed attachment of the 
 ccecuin must be regarded as an important disposing cause. That 
 bowel being attached by its whole posterior surface, by means of 
 filamentous tissue, to the muscles of the right lumbar region, and 
 with its blind sac or receptacle below the level of the ileo-cascal 
 aperture, and in a dependent position, is liable to become distended 
 with excrementitial matter, which the bowel itself cannot easily ex- 
 pel and raise against gravity. Then the vermiform process itself, 
 by its dependent position, may encounter difficulty in evacuating 
 its contents. 
 
 Secondly, all articles taken with food, or otherwise swallowed 
 and not easily carried along the bowels, are here, from the position 
 of the ccBcum, more readily detained. The stones of the drupaceous 
 fruits, seeds, pieces of money or metal, fragments of bones, marbles, 
 and similar substances, are liable to be here stopped, and by their 
 presence to cause irritation. In fatal cases the caecum sometimes 
 contains hardened feces, concretions ; and in one case I found frag- 
 ments of glass. 
 
 Kaltschmidt records the case of an artisan of 25, who, about one 
 month after swallowing many walnuts and medlars, was attacked 
 with symptoms of ileus, which, after lasting for 15 days, terminated 
 in death. On inspecting the body Kaltschmidt found the whole 
 tract of the bowels presenting marks of inflammation, and the ileum 
 at its lower end near the valve of Bauhin perforated in three parts, 
 and contorted or twisted so as to form three separate cavities filled 
 with indurated feculent matter. The destruction was so complete 
 
638 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 that the ileum seemed detached from the ccecum, and adhered by aj 
 few shreds only. Feculent matter had escaped into the abdominal j 
 cavity near the lacerated portion of ileum ; and in this was found] 
 about half an ounce of the stones of the medlars eaten, and about] 
 as much in the faeces within the ileum.* 
 
 Similar instances of the stoppage of stones of the drupaceous fruits, 
 bones, pieces of money, and similar foreign bodies, are recorded by ‘ 
 Younge, Amyand, Fielding, Stoll, and other authors. In certain 
 instances intestinal concretions are formed either spontaneously or 
 around bodies of the kind now mentioned. In either case the stop- 
 page of such bodies in the cceeum is at once probable, and likely 
 to produce irritation and inflammation of that portion of the intes- 
 tinal tube. 
 
 These must be regarded as disposing causes. 
 
 As to age, it seems to take place most frequently in persons be-i 
 tween 20 and 30. 
 
 As to sex, MM. Husson and Dance say that it is more frequently! 
 seen in males than in females.! My own experience, nevertheless, '1 
 leads to the opposite conclusion. I have seen the disease in a greater, 
 number of females than males ; I have found it more unmanage- ’ 
 able in females than in males ; 1 have never seen a fatal case in a 
 man, but several in females. I infer that the class of females in] 
 whom it is most frequent is that of domestic servants and seam- 
 stresses. 
 
 As to the influence of articles of food, it has been said that the j 
 use of oatmeal, which favours the formation of intestinal concretions,] 
 is also liable to be followed by this disease. Yet it does not appear^ 
 that the disease is less frequent in France and England, where .j 
 wheaten bread is used, than in Scotland, where oatmeal is used as 
 part of food. It appears to me also very questionable, whether 
 among those who in Scotland use oatmeal much as food, it is more 
 frequent than among those who use it little or not at all. 
 
 Constipation is probably favourable to its formation ; and what- 
 ever tends to impede or interrupt the periodical evacuation of the 
 bowels must tend to produce this as it does other disorders.^ 
 
 ■* Caroli Fred Kaltschmidt de ileo a scrupulis Pyrorum Mespilaceorum eroso per- ^ 
 forato. dense, Imo Oct. 1747. Haller, Disput. Medico-Pract. iii. p. 510. 
 
 •f- Memoire sur quelques engorgemens inflammatoires qui se development dans la 
 fosse iliaque Droite. Repertoire d’Anatomie, &c. T. iv. p. 74. Paris, 1827. 
 
 $ Ferrall in Edin. Med. and Surg. Journal, Vol. xxxvi. p. 1. Edin. 18.31. And 
 Dr Burne in Medico-Chirurgical Transact, xx. p. 200, and xxii. ^ 
 
INTESTINAL MUCOUS MEMBRANE — DYSENTERY. 
 
 639 
 
 § 7. Colonia. Dysentery. Colonitis . — The opinion that dysen- 
 
 tery depends on inflammation of the howels is very ancient ; hut 
 the authority of Cullen succeeded for a time in throwing doubt and 
 obscurity on a doctrine, in favour of which various positive and un- 
 equivocal facts have since been collected. The state of the intes- 
 tines in this disease has been described by Pringle, Baker, Donald 
 Monro, Hunter, and Baillie, Cheyne, and O’Brien ; and their ac- 
 counts, with some trifling exceptions, in general correspond. In 
 four dissections made by Pringle in the Flanders campaign of 1744, 
 the villous coat of the colon was red or vascular, and abraded or 
 ulcerated ; the lower end of the colon, and generally the rectum., 
 was in a state termed mortification ; the ligamentous bands are 
 said to be relaxed, half corrupted, or entirely obliterated; and the 
 colon, sometimes the ileum and stomach, much distended by air.* * * § 
 In the inspections recorded by Baker of the London epidemic of 
 1762, the villous membrane of the rectum, colon, caecum, and 
 occasionally part of the ileum, was more or less reddened, vel-' 
 vety-granular, and occupied by numerous minute bodies like 
 small-pox pustules, but harder and solid when divided, and fun- 
 gous eminences. These h ard pustule s and fungous eminences 
 were manifestly seated in the Lqlated follicles. In one case four 
 or five perforations had taken place in the transverse arch of the 
 colon.f In persons cut off by old dysentery, Monro repre- 
 sents the villous membrane of the rectum and colon as inflam- 
 ed, with livid spots in the arch of the latter ; and in one seized 
 by violent pains of the bowels two days before death the ileum 
 was reddened.^ From a subsequent account by the same author, 
 it appears that the colic mucous membrane as high as the valve, 
 was occupied by livid or black spots of various size, occasioned by 
 black blood in the submucous filamentous tissue ; and that in the 
 centre of each spot there was more or less erosion of the viUous 
 membrane. Though no black spots or erosions were seen in the 
 mucous membrane of the ileum, in one or two minute red spots, 
 and slight traces of inflammation were recognized.§ The general 
 accuracy of these statements is briefly confirmed by F. L. Bang in 
 
 * Observations on the Diseases of the Army, by Sir John Pringle, AI. D. London, 
 1768. Chap. 6. 
 
 -f- De Catarrho et de Dysenteria Londinensi epidemicis utrisque, anno 1762, Libellus. 
 Auct. G. Baker, CoU. R. &c. Lond. 1764. 
 
 An account of the Diseases, &c. By Donald Monro, M. D. Lond. 1764. 
 
 § Essays and Observations, Physical and Literary, Vol. iii. article 25. 
 
640 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the following terms. ‘‘ Perlustrata interna facie intestini cseci 
 atque coli, vidimus tunicam villosam alibi adhserentem, et alibi 
 derasam, ibidemque tunicam vasculosam lividara quasi sanguine 
 plenam, niesenterium rubescens vasis distinctis plenissimum.”* 
 
 Dr John Hunter, on the contrary, who states that he never saw 
 abrasion or mortification of the villous coat, is inclined to think, 
 that in the dissections mentioned by Pringle, the black colour aris- 
 ing from extravasated blood was mistaken for gangrene. Though 
 it is impossible to doubt that this mistake has been often committed 
 in describing the necroscopic changes of the gastro-enteric mem- 
 brane, it must not be forgotten that inflammation occasionally ter- 
 minates in mortification, and that instances of this are not unusual 
 in the tropical form of the disease especially. The general fact of 
 inflammation is further confirmed by Maximilian Stoll, who de- 
 scribes the caecum, colon, especially its transverse arch, and rec- 
 tum, in persons cut off by acute dysentery, as swelled, thickened, 
 hard, and fleshy, of a leaden or dull red colour, the mucous mem- 
 brane of a foul or dingy red tint with blood, or of a deep rank 
 green tinge removable neither by water nor the sponge, — an ap- 
 pearance indicating the commencement of elementary decompo- 
 sition, f 
 
 Occasionally dysentery prevails during summer and autumn in 
 this country; and both in previous seasons and in the summer of 
 1 843, we had opportunities of observing its eflFects on the intestinal 
 coats. In several cases which I examined, the following were the 
 appearances. 
 
 The whole tract of the colon was thick, massive, and heavy, to- 
 tally different from the usual membranous appearance of that bowel. 
 This thickness was partly in the mucous membrane and partly in 
 the submucous cellular tissue. The mucous membrane was thick, 
 of a reddish colour, firm, and more solid than in the normal state, 
 which was shown by the peculiar mode in which it was cut. Its 
 surface was covered with much, viscid, thick^^ergntjnucus, which 
 was indeed partly albuminous. The section showed that it was 
 thickened, apparently from effusion of lymph into its interstitial 
 tissue, or from the great congestion of the vessels ; the colour was 
 also of a deeper fawn red here than natural. The calibre of the 
 bowel was much contracted, the size and capacity of the colon being 
 not so large as that of the ileum. 
 
 * Selecta Diarii Nosocomii Hafhiensis, Tom. ii. 178fi. P. 223. 
 
 t Ratio Mtdendi, Partis iii. Vol. iii. Sectionis 4. 
 
COLIC MUCOUS MEMBRANE — DYSENTERY. 
 
 641 
 
 When the mucous membrane was cleared of adherent mucus, 
 numerous patches, variable in size from that of a pea to that of a 
 sixpenny piece, or even larger, and irregular in figure, appeared 
 covered with a coating of albuminous mucus tinged with the co- 
 louring matter of the bile and excrement. When these coverings 
 were removed, they disclosed surfaces destroyed by irregular ul- 
 ceration of tbe mucous membrane. 
 
 These ulcers had originated in the follicles of the colon, which 
 had become softened at the commencement of the attack, and had 
 then proceeded to sloughing and ulceration. The state now de- 
 scribed extended along tbe whole colon, but was most remarkable 
 in the transverse arch and sigmoid flexure. 
 
 In some other cases the disease was confined to the lower part 
 of the sigmoid flexure and to the rectum. The mucous membrane 
 had become thickened, and similar patches of ulceration, very ir- 
 regular in shape, had been formed, covered in like manner by 
 lymph tinged with the colouring matter of the bile and excrement. 
 The coats of the bowel were in like manner thickened and indu- 
 rated, and the area of the bowel was contracted. 
 
 The necroscopic appearances of tropical dysentery have been 
 described more or less fully by Sir W. Farquhar, Sir George 
 Ballingall, Mr Bampfield, Mr Annesley, whose several testimonies 
 tend to establish the general conclusion, that this disease consists 
 in inflammation of the colic mucous membrane, spreading in gene- 
 ral, not always or necessarily, with ulceration, but advancing to this 
 process when not suitably or promptly opposed, and occasionally 
 ending in death of portions of the mucous membrane. Of this in- 
 flammation the peculiarities are, 1*’?, that it is confined with consi- 
 derable accuracy to the colon or large intestine, and the ileum be- 
 ing but rarely affected, and only at its lower or colic extremity ; 
 2rf, that this inflammatory action spreads continuously from the ileo- 
 coecal valve along the mucous membrane of the ccecum^ right branch 
 of the colon, transverse arch and sigmoid flexure, at various rates, 
 and with various effects, but at all times with that of producing fre- 
 quent copious discharges of mucous, muco-purulent, and blood-co- 
 loured stools; 3rf, that this process may continue for some time 
 without producing ulceration of the mucous corion, or inflamma- 
 tion of the submucous tissue ; that these phenomena may take 
 place, nevertheless, in certain circumstances, at an early period ; 
 and that in others they occur towards the conclusion of the disease ; 
 
 ss 
 
G42 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 and 4^/<, that though this inflammatory process in general com- 
 mences with disorder of the circulation, and increased number of 
 the cardiac pulse, it may commence without this, and almost always 
 goes on when once established, without the pulse being much quick- 
 ened, till the inflammatory process either affects the submucous 
 tissue, or, which is nearly the same thing, begins to effect mortifi- 
 cation of the mucous tissue. 
 
 The formation of numerous ulcers in the tract of the colon may 
 be said to indicate the chronic form of the disorder. This, from 
 the statements of Ballingall, Bampfield, and Annesley, appears to 
 be more common in the tropical variety of the disorder than in that 
 observed in more temperate climates. The same change, however, 
 was seen by Morgagni, Lieutaud, Baillie, Cooke, and others, in the 
 dysenteric affections of the latter description. In one instance of a 
 man of 65, who had for several weeks laboured under chronic 
 purging, and whose body I inspected for my friend Mr Caird, I 
 found the colic mucous membrane occupied by numerous ulcers, 
 irregular in shape, and varying in size from the area of a split pea 
 to that of a sixpence, and even of a shilling. The lower end of 
 the ileum presented a few small patches of ulceration scarcely pe- 
 netrating the mucous corion. In the caecum, on the other hand, 
 they were deeper, and had not only penetrated this membrane, but 
 were destroying the submucous tissue. In the ascending portion 
 and transverse arch they had effected equal destruction, and in one 
 or two the peritonjeixm only was left. The bottom or surface of 
 these ulcers varied according to the stage of destruction. In the 
 least advanced, in which the mucous tissue was not entirely de- 
 stroyed, the surface of the ulcer was a sort of pale-red or gray- 
 brown colour. When the surface was formed by exposed submu- 
 cous tissue it was more ashen-coloured, but with red streaks de- 
 pending on blood-vessels. The muscular layer gave it a red or 
 brown tint ; and where the peritonaeum was exposed, it was thick- 
 ened, reddened, and in general coated by a layer of lymph on its 
 free surface. The edges of these ulcers, if formed of mucous tis- 
 sue, were generally well-marked, sometimes thickened, and occa- 
 sionally slightly turned upwards from destruction of the submucous 
 filamentous layer. Selaom were they red ; and their most prevail- 
 ing tint was light or ash-coloured brown. The colic mucous mem- 
 brane was generally traversed by blood-vessels at variable distances 
 from each other. The villi w'ere obliterated and indistinct. The 
 
COLIC MUCOUS MEMBRANE — DYSENTERY. 
 
 643 
 
 valvular folds also were destroyed, and the cellular arrangement 
 of the bowel could no longer be recog-nized. 
 
 It is not unimportant to know that these ulcers of the intestinal 
 mucous membrane may, under certain circumstances, undergo a 
 process of reparation. The steps of this process, which was origi- 
 nally observed by Dr Donald Monro, have been well described by 
 Petit and Serres in their account of the entero-mesenteric disease 
 of Paris, and by Dr Latham in that of the epidemic of INIillbank 
 Penitentiary. From the observations of these authors it results, 
 that the first step towards repair consists in the loose margin of ul- 
 cerated mucous membrane becoming fastened down to the muscu- 
 lar layer or the peritoneal coat respectively, by deposition of lymph 
 all round. This lymphy deposition forms an elevated prominent 
 ring, inclosing a depressed space corresponding to the centre of the 
 sore, and which about the same time acquires a reticular appearance 
 from intersecting filaments of lymph, among which may be seen 
 minute red vessels. As the process advances, these filaments, by 
 acquiring solidity and strength, seem to draw the mucous membrane 
 forming the edges to the centre of the ulcer, while the elevated 
 ring becomes flattened. At length, the lymphy deposition being 
 covered by a thin pelhcle newly formed completes the cicatrix. 
 When the ulcerated spots are examined in this state, the ragged 
 edges of mucous membrane are found to be mutually approximated ; 
 and the peritonaeum at the same time to be puckered or drawn to- 
 gether, appearing as if a small portion of the intestine had been taken 
 by the forceps and tied by a ligature. This shows that the process 
 of repair consists not in the mucous corion being reproduced, but 
 in the opposite margins of its breach making as it were an effort to 
 approach by means of the lymphy exudation from the peritonaeum, 
 which was thus necessarily contracted. 
 
 § 8. Pustuh-tubercular eminences. Probable Tubercular depo- 
 sit in the isolated Follicles . — I am not aware that the circum- 
 stances on which the formation of hard pustules or tubercles of 
 the colic mucous membrane depends, have been investigated or 
 determined. Is this membrane bable to a peculiar pustular or 
 pustulo-tubercular inflam.mation ? That they do not occur in all 
 forms of colic inflammation is proved by the fact, that they were 
 not seen in the camp dysentery of 1743, and but rarely in the tro- 
 pical dysentery of the east, while they were observed in every case 
 of the London dysentery. Dr John Hunter, who saw them in all 
 
644 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the dysenteric inspections which he performed in Jamaica, describes : 
 them as true pustules^ though they contain no purulent matter, 
 and represents them as seated beneath the villous coat or in the sub- ij 
 
 mucous tissue. Each pustule, though at first small, round, and ! 
 
 reddish, not more than the one-tenth of an inch in diameter, gra- |i 
 
 dually enlarges till it attains the diameter of one-fourth of an inch, j 
 
 becoming at the same time paler. In this stage a minute crack or ' 
 
 fissure appears at the top, and gradually enlarges, when the con- ' 
 
 tents of the pustule are found to be cheese-like substance. As the j 
 
 opening enlarges, the edges become prominent, the base grows 
 rough, and matter sometimes tinged with blood oozes from it. 
 
 This is the progress of one pustule or tubercle ; but they are ge- 
 nerally in clusters, and may coalesce and form an unequal ulcer- ]■ 
 ated surface with a hard thickened base.* 9 
 
 It is impossible to doubt that these pustulo-tubercular bodies are 9 
 the isolated follicles either in a state of chronic inflammation and SI 
 enlargement, or infiltrated with tubercular matter, or degenerated 91 
 in consequence of the long continuance of chronic inflammation. 9 
 In general there are three forms under which this state presents 3 
 itself. One is when the subfollicular cellular tissue becomes thick- 9 
 ened, enlarged, and indurated. Another is when this tissue is infil- 9 
 trated with tubercular matter. This takes place in dysentery in 9 ■ 
 those of strumous habit, and in the phthisical. A third is when the X 
 follicular membrane is degenerated and converted into a hard warty 9 ■ 
 sort of matter, which usually splits or is fissured on the apex. In 9 ■ 
 either of these three cases the follicles are prone to undergo a spe- ^ 
 cies of bad and almost insanable ulceration, causing chronic diar- 9 
 rhoea with great weakness and wasting. 9 [ 
 
 Of much the same nature are the granulations of the intestinal w 
 mucous membrane, described in the persons of the phthisical by M 
 Louis. According to this observer, these granulations are of two 9 
 sorts, the semicartilaginous and the tubercular. The former, which 9 
 in the cases inspected were most frequent and most numerous, were 
 distributed equally round the bowel ; and though dispersed occa- f 
 sionally through its whole length with intervals of two or three I 
 square inches, they were generally largest and most numerous to- 
 wards the caecum. They were not seen in the colon. Generally 
 after attaining the size of a pea, the mucous membrane at top be- 
 
 * Observations on the Diseases of the Army in Jamaica, (Stc. By John Hunter, 
 
 M. D., F. R. S., &c. Lond. 1784. Chap. 4, Sect. 2, p. 230, 231. 
 
INTESTINAL MUCOUS MEMBRANE— INDURATION. 
 
 645 
 
 came thick, soft, and gave way; and the destructive process thus 
 begun advanced, forming an ulcer with hard, white, opaque edges. 
 The tubercular granulations, which were less frequent, were never 
 seen near the duodenum, and, always most numerous near the 
 coecum, occupied indiscriminately any point of the bowel. They 
 terminated by softening in minute ulcers. It does not appear that 
 the ulcers thus formed are ever cicatrized.* 
 
 When cicatrization either of the simple or the tubercular ulcer 
 does not take place, or takes place imperfectly, yet without causing 
 immediate death, it gives rise to the symptoms denominated lientery 
 (Xs/si/rsf/a, slippery bowels) ; and its natural termination is dropsy, 
 abdominal and general. 
 
 By these ulcers the colon is occasionally perforated with the 
 same effects as other parts of the canal. Haller records an instance 
 in which an ulcer of the transverse arch, by gradual absorption, 
 perforated the coats of the stomach ;f and Lowdell mentions one 
 in which an ulcer of the sigmoid flexure effected an opening into 
 the urinary bl adder. J 
 
 § 9. Infiammatory induration. Shleroma . — Another effect of in* 
 flammation common to the gastro-enteric mucous membrane with 
 others is more or less permanent thickening of its substance, or that 
 of the submucous tissue, inducing contraction of the capacity of the 
 canal. This takes place in the oesophagus, in the cystic and common 
 bile duc^s, and in the intestines, small and great. In the oesopha- 
 gus it constitutes one of the most manageable forms of stricture of 
 that tube, in so far as the swelling, under proper management, occa- 
 sionally disappears. (Grashuis, Bleuland, Monro, Howship.) Its 
 most usual seat is in the neighbourhood of the cricoid cartilage, and 
 occasionally at the cardia. A good example of the former is de- 
 lineated by Dr Armstrong. In the common biliary duct I have 
 seen this inflammatory thickening give rise to jaundice ; and I sus- 
 pect this, and not spasm of the tube, is the most frequent cause of 
 biliary obstruction. In the ileum this contraction is perhaps less 
 frequent than in the colon. Yet in the case above-mentioned the 
 diameter of the bowel was very much diminished, chiefly by inflam- 
 mation of the submucous and subserous filamentous tissue ; and Dr 
 Charles Combe records an interesting example of thickening of the 
 lower end of the ileum, in which the capacity of the bowel was di- 
 
 * Recherches Anatomico-Pathologiques sur la Phthisie. Paris, 1825. 
 
 -}■ Opuscula Patholog. 
 
 t Mem. Med. Society. 
 
646 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 minished to the size of a turkey’s quill.* In the colon this inflam- 
 matory induration is more frequent. It takes place chiefly in the 
 sigmoid flexure, and in the connection with the rectum. Of the 
 former instances are recorded by Haase, Christian Wincker, Lau- 
 bius, Portal, and Baillie, and delineated by Mr Annesley ; and in- 
 deed it is no uncommon consequence of tropical dysentery. Of its 
 occurrence in the latter situation, Willan records an excellent ex- 
 ample ; and I may add, that I have seen several cases of it in per- 
 sons who have returned to this country after severe or long-conti- 
 nued dysentery. 
 
 § 10. Membranous Exfoliation . — In some rare instances more or 
 less of the intestinal mucous membrane has become completely dead, 
 and been discharged like a foreign body. Of this mode of exfoliation 
 of the mucous membrane of the ileum, occasionally with the muscular 
 and peritoneal tunics, good examples are recorded by Monro second 
 from Cullen,t Mr William Dougall,J Dr T. Sanden,§ and Mr John 
 Bower. 11 Dr Baillie records a case in which a large portion of the 
 colic membrane was voided and Mr J. M. Bowman mentions one 
 in which a portion of the colon and cmcum with attached mesocolon 
 are said to have been discharged.** This subject has been most fully 
 examined by Dr William Thomson ; and to his Memoir I refer the 
 reader, tf 
 
 An effect of inflammation of the gastro-enteric membrane, as 
 well as the tracheo-bronchial, is albuminous or sero-albuminous 
 exudation. This was observed by M. Bretonneau in the oesopha- 
 gus; by Baillie, Andral, Howship, Godman, and Villerme in the 
 stomach; and by a considerable number of authors, in the colon. 
 In all cases the formation of these membranous substances has been 
 preceded and accompanied by marks of inflammatory action. In 
 the cases of M. Bretonneau they were connected with tracheal and 
 oesophageal inflammation. || In that of Howship it was the con- 
 sequence of swallowing boiling water ;§§ in the cases of Andral 
 
 ^ Transact. Coll. Phys. Vol. iv. p. 16. 
 
 t Essays, Physical and Literary, Vol. ii. p. 39S. 
 
 Medical Comment. Vol. ix. p. 278. 
 
 § Annals of Med. Vol. vi. p. 296. || Ib. Vol. vii. p. 346. 
 
 ^ Transactions of a Society, &c. Vol. ii. p. 144. 
 
 ** Med. and Surg. Journal, Vol. ix. p. 492. 
 
 ft Abstract of Cases in which a Portion of the Cylinder of the Intestinal Canal, 
 comprising all its coats, has been discharged by stool. Edin. Med. and Surg. Journ. 
 xliv. p. 296. Edin. 1835. 
 
 J J Des Phlegmasies des Membranes Muqueuses. 
 
 §§ Practical Remarks on Indigestion, &c. London, 1825. 
 
INTESTINAL MUCOUS MEMBRANE IN FEVER. 
 
 647 
 
 it occurred in connection with fever;* and in those of Godmanf 
 and VillermeJ it was connected with chronic inflammation of the 
 gastric mucous membrane. In the intestinal canal it is invariably 
 the consequence of some degree of inflammatory action. 
 
 § 1 Febrile Gastro-enteria. — Gastro-enteric inflammation has been 
 considered above chiefly as a primary and idiopathic disorder. It 
 is, however, not unfrequently observed as a concurrent symptom 
 or effect of many disorders reputed primarily febrile. This was 
 observed long ago in ague and remittent fevers by Baglivi, Sar- 
 cone, Roederer, and Wagler, Stoll, Selle, and others ; and more 
 recently by Pinel, Broussais, Petit, and Serres, Andral, Breton- 
 neau, and Trousseau. In continued fever it has also been seen by 
 Andral, Bretonneau, and Trousseau, Louis, and Chomel, and by 
 Cheyne, Reid, O’Brien, and Dr Bright in this country ; and it has 
 been more or less fully described in different parts of Germany by 
 Killiches, Frenzel, Grossheim, Ebel, Stannius, Kramer, and Les- 
 ser. 
 
 From the facts collected by these observers it results, that the 
 action of fever has a peculiar tendency to aflfect the mucous sur- 
 faces in general, and especially the tracheo-bronchial and gastro- 
 enteric membranes. In the former it may produce the anatomical 
 characters of unequivocal bronchial inflammation, proceeding not 
 unfrequently to the first stage of peripneumony. Of the latter it 
 affects more or less intensely diflFerent regions. In some it aflPects the 
 gastric, in others the duodenal, in others the ileal or csecal, and in a 
 few the colic mucous membrane. In most instances the membrane is 
 reddened and vascular, thickened, and occasionally softened. (An- 
 dral. ) In many it assumes the form of red or brown patches, with 
 or without ulceration. In many the mucous membrane is occu- 
 pied by white conical elevations half a line or a line high, as broad 
 as a lentil at base, but with depressed summits like the pustules of 
 small-pox. These are rare in the jejunum and colon, but are fre- 
 quent in the two lower fifths of the ileum. (Andral.) In the co- 
 lon this punctuate inflammation appears in the form of broad coni- 
 cal bodies, elevated, with pointed tops, of a cherry-red colour, and 
 injection of the surrounding membrane. In a large proportion of 
 cases, according to Bretonneau and Trousseau, the mucous follicles 
 
 * Clinique Medicate, &c. Paris, 1823. 
 
 t_The Philadelphia Journal, 1825. 
 
 Archives Generates, Tome xiv. 1827. P. 6T4. 
 
648 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 are enlarged, reddened, softened, and not unfrequently the seat of 
 
 Andral, who maintains, that, though these bodies are highly vascu- 
 lar, and pour forth an augmented secretion when the mucous mem- ' 
 hrane is inflamed, yet their affording the commencement of intesti- 
 nal ulcers is not an invariable circumstance. 
 
 I have already endeavoured to explain the circumstances under 
 which follicular inflammation is most likely to take place in fever. 
 It does not seem to be necessarily connected with typhous fever ; 
 and, therefore, the fever with which it is seen in connection has been 
 denominated typhoid fever. But it appears to be rather a remit- 
 tent disorder, to be endemic in certain regions and localities, and 
 epidemic in certain seasons. 
 
 Though the frequency of ulceration of the lower extremity of 
 the ileum is proportional to the number of follicles, ulceration is 
 exceedingly rare in the duodenum, in which they are more nume- 
 rous, larger, and more apparent than in any other part of the gas- 
 tro-enteric membrane. From the observations of Dr Bright, 
 nevertheless, and the facts collected by Frenzel, Stannius, Choinel, 
 Cruveilhier, and Lesser, no doubt can be entertained of the fact, 
 that inflammation and sloughing of the mucous follicles is a frequent 
 cause of ulcers. 
 
 The comparative frequency of ulcers in different regions of the 
 gastro-enteric surface during fever may be understood from the 
 following table, in which Andral gives the result of 71 necroscopic 
 inspections. 
 
 Ulcers of the Stomach in 
 
 Cases. 
 
 10 
 
 Caecum, 
 
 Cases. 
 
 15 
 
 Duodenum, 
 
 1 
 
 Ascending colon. 
 
 4 
 
 Jejunum, 
 
 9 
 
 Transverse arch. 
 
 11 
 
 Lower part of the 
 
 
 Descending colon, . 
 
 3 
 
 ileum, 
 
 38 
 
 Rectum, 
 
 1 
 
 According to this statement, which is on the whole accurate, 
 ulcers are most frequent in the lower end of the ileum, nearly in 
 the proportion of one-half of the cases, next to this in the caecum 
 in about one-fifth of the cases, then in the transverse arch, in the 
 stomach, and in the jejunum. In the ascending and descending 
 colon, they are not very common, and in the duodenum and rectum 
 extremely rare. Their progress and effects are the same as when 
 taking place idiopathically. 
 
 In some instances of fever, Andral remarked that portions of the 
 
INTESTINAL MUCOUS MEMBRANE IN SMALL-TOX. 
 
 649 
 
 intestinal mucous corlon appeared to be suddenly struck by morti- 
 fication, forming a species of mucous carbuncle, {ardhraMon^) and 
 like that requiring to be thrown off by a long process of ulceration. 
 The eschars thus discharged left ulcers extensive and irregular. 
 On this point I refer to what has been said above on the sloughs 
 of the muciparous follicles. 
 
 § 12. Variolous inflammation. — It has been an opinion not un- 
 common, that the variolous poison produces in the mucous surfaces, 
 and especially along the tract of the gastro-enteric mucous mem- 
 brane, pustules, similar to those of the skin ; and sundry instances 
 of papillcB, pustules, and similar bodies in the stomach or intestines, 
 recorded by Iheutaud, have been supposed to give countenance to 
 this idea. Upon this point, however, facts are something discor- 
 dant. 
 
 1. In Mr Heaviside’s museum is a preparation demonstrating 
 the appearance of numerous genuine pustules of the mucous mem- 
 brane of the pharynx, and half way down the oesophagus.* In 
 one subject, in like manner, Wrisberg counted 14 distinct pustules 
 on the palatine arch, on the posterior and inferior part of the velum 
 more than 12, and many in the neighbourhood of the epiglottis., 
 and in the upper part of the pharynx, but observed general red- 
 ness only in the rest of the oesophagus. In another subject he ob- 
 served on the mucous surface of the larynx and trachea a crop of 
 singular warty eminences, varying in size from a lentil to a grain 
 of hemp seed, round or oblong in shape. These bodies Wrisberg 
 states he took care to distinguish from inflamed mucous follicles.f 
 Sir Gilbert Blane, to tbe same effect, records an instance of fatal 
 confluent small pox, in which the whole mucous surface of the oeso- 
 phagus, stomach, duodenum, and intestines, to the rectum, was 
 found beset with small round ulcerated spots. These were most 
 crowded in the duodenum, and in the colon. They were dark- 
 coloured in the centre like cutaneous pustules. In the same sub- 
 ject, the mucous membrane of the trachea and bronchia was occu- 
 pied with similar ulcerated spots.| 
 
 2. Notwithstanding these facts, however, which are accui-ately 
 stated, it is not absolutely certain that genuine phlyctidia have even 
 
 * Howship, Observations, p. 253. 
 
 + Henrici Augusti Wrisbergii, D. M., &c. Commentationum, Medici, Physiolog. 
 &c. Argumenti. Vol. i. Gottingse, 1800. P. 52, &c. 
 
 t Some Facts and Observations, &c. by Gilbert Blane, M. D. Transactions of a 
 Society, Vol. iii. p. 425. 
 
650 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 been seen in the stomach or intestinal membrane. The papillae 
 and pustule-like eruptions which are supposed by some to be of 
 this nature are evidently enlargements of the mucous follicles. 
 
 3. The variolous poison certainly produces inflammation of the 
 gastro-enteric mucous membrane ; but this consists in diffuse red- 
 ness and injection, or red-brown patches, or both, generally with 
 some affection of the mucous follicles.* In several instances of 
 fatal confluent small-pox, I have seen the gastric mucous mem- 
 brane deep red, much loaded with vessels, and patches of extrava- 
 sated blood, and similar appearances with bloody mucus in vari- 
 ous parts of the ileum. In the same subjects, the tracheo-bron- 
 chial membrane was of a deep-brown colour, and highly vascular. 
 
 It is, indeed, always the tracheo-bronchial membrane that is 
 most affected in small-pox. But, excepting at the epiglottis and 
 larynx, it presents no variolous pustules. The larynx, indeed, usu- 
 ally presents the appearance of mere redness, roughness, and swell- 
 ing. In one case of fatal confluent small-pox, in which the pa- 
 tient was destroyed before the eruption came completely out, I 
 found the whole mucous membrane of the trachea and the large 
 bronchi covered by a thin filmy membrane like silver paper, and 
 the membrane of the small tubes much reddened. In other cases 
 in which the patients died with the eruption out, the whole tracheo- 
 bronchial membrane was red, rough, covered with viscid mucus ; 
 and the small bronchial tubes effused large quantities of frothy 
 sero- mucous fluid. 
 
 These phenomena explain the severity and fatality of this dis- 
 ease. 
 
 § 1 3. Tubercular Disease of the Ileum and Ileal Follicles. — Before 
 concluding this division, I think it right to mention here a peculiar 
 disorder of the ileum ; though I am not certain whether it ought to 
 be referred to the mucous membrane, the peritoneum, or the whole 
 intestinal tunics. To illustrate the nature of the lesion I give the 
 particulars of an instance of the disease extremely well marked. 
 
 A young woman, f of twenty years, had laboured for some time 
 under symptoms of disease of the abdomen ; and at length the ab- 
 
 * “ The pharynx and oesophagus were certainly much inflamed, as was the stomach, 
 and more or less the whole of the intestines ; but after the most diligent search, no 
 trace whatever of the pustular action was found either in the pharynx, oesophagus, 
 stomach, or intestines.” Howship, Observations. See also Cotwrmii syntagma, &c. 
 xliii. xUx. 
 
 ■f Under the care of Dr Paterson of Leith. 
 
 4 
 
INTESTINAL MUCOUS MEMBRANE. 
 
 651 
 
 doraen, which was swelled and painful at certain parts, became dis- 
 tended, and gave evident proofs of the presence of fluid. Dr Pa- 
 terson, under whose care the patient was, tried for some time all 
 means of producing the absorption of this fluid, and otherwise re- 
 moving the disease on which it depended. Little or no effect, how- 
 ever, was produced, either by aperients, diuretics, or local appli- 
 cations. Dr Paterson requested me to see her, to consider the 
 propriety of relieving the distension and other sufferings of the pa- 
 tient, by the operation of parakentesis. At this time the abdomen 
 was greatly enlarged, especially towards the infra-umbilical re- 
 gion, where it emitted a dull sound, and gave distinct evidence of 
 fluctuation. When the patient was placed in the supine position, 
 there was something peculiar in the abdomen, as if the intestinal 
 folds were more consistent than natm'al, and adhered in certain 
 points. When pressure was applied slowly and carried steadily 
 downwards, so as to urge the intestines towards the spine and pos- 
 terior region of the abdomen, the patient gave manifest indications 
 of pain. She also described her feelings as if something were tied 
 round the bowels. It was clear, nevertheless, that there was no 
 adhesion between the abdominal parietes and the intestinal perito- 
 naeum ; for there the abdominal fluid was interposed. 
 
 After careful consideration of the case, it was agreed, that, as no 
 medicinal agent had hitherto made any decided impression on the 
 abdominal swelling or the contained fluid, it was desirable to empty 
 the abdomen by operation, and then try the eflfect of remedies. 
 
 The operation was accordingly performed, and about nineteen 
 or twenty pints of serous and sero-purulent fluid withdrawn. The 
 operation was well borne ; and the patient was replaced in bed. 
 
 The wound healed in a few days, and the patient seemed to recover 
 from the immediate effects of the operation. But in the course of 
 a few days vomiting came on and death ensued. 
 
 Inspection disclosed the following appearances. 
 
 In the lumbar and iliac fossae and in the pelvis there was some 
 sero-purulent fluid, with a few albuminous flakes. A little accu- 
 mulation had taken place since the operation. 
 
 The omentum was drawn up and shrivelled, though thickened. 
 
 All the folds of the ileum, which came into view, adhered to each 
 other intimately by albuminous exudation, so that not one portion 
 of the ileum could be said to be in its natural free position. Even 
 some of the lower pai'ts of the jejunum adhered in this manner. 
 The tunics of the ileum were thickened, indurated, and in certain 
 
652 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 parts where the adhesions were most firm and intimate, they were 
 of cartilaginous consistence. 
 
 The ileum was cut open longitudinally, and the true state of the 
 disease was then seen. 
 
 At intervals of from six to eight or nine inches the mucous 
 membrane of the ileum presented large irregular ulcerated open- 
 ings, penetrating directly through all the coats to the perituncBum, 
 then from the peritonaeum of the corresponding adherent portion of 
 ileum, through the coats of that portion to the mucous membrane. 
 By these openings direct passages had been formed from one por- 
 tion of bowel through the coats into the attached portion. 
 
 These openings were in shape mostly elliptical or oval, with the 
 long diameter corresponding to the axis of the bowel. Their 
 edges were ragged and irregular ; and while the intestinal tissues 
 around them were thickened and cartilaginous, the capacity of the 
 bowel was much diminished. 
 
 In size the openings varied from half-an-inch to one inch or one 
 inch and a-half in the long diameter. Their breadth was from 
 half-an-inch to three-fourths. 
 
 The number of these openings was considerable. There were 
 at least 20, and probably more. 
 
 On examining the lines of adhesion by which they were con- 
 nected, tubercular matter was visible both at the peritoneal and 
 mucous surface, and in several parts of the peritonaeum small tu- 
 bercular bodies, white and opaque, were deposited. It was not easy 
 to say whether these bodies had commenced at the peritoneal or at 
 the mucous surface. They were in general covered by peritonaeum, 
 and they were as distinct at the mucous surface as at the serous. 
 
 A case similar to this is given by Dr George Gregory.* 
 
 An important inquiry suggested by cases of this class is to de- 
 termine where the ulceration originates ; whether at the mucous or 
 at the peritoneal surface of the bowel. The point is not one of 
 very easy determination. 
 
 It seems, on the one hand, most natural to think that the ulcera- 
 tion began at the mucous surface. To me these ulcerated open- 
 ings appear to be in the site of the agminated patches of Peyer. 
 These patches w'ere, I infer, originally penetrated or infiltrated with 
 tubercular matter. They had then proceeded to softening and ul- 
 ceration, destroying of course the mucous and other tissues slowly 
 
 * Observations on the Scrofulous Inflammation of tlie Peritonaeum, &c. Med. 
 Chir. Trans, xi. p. 258. 
 
GENITO-URINARY MUCOUS MEJIBRANE. 
 
 653 
 
 and progressively. When this destroying action arrived at the 
 peritoncEum, it caused first adhesion of that, or rather adhesive in- 
 flammation, connecting it to the peritoncBum of the corresponding 
 portion of ileum, and then proceeded by the same ulcerative action 
 to destroy the tunics of that portion of bowel, though in the oppo- 
 site direction ; that is, first, peritonaeum, then cellular and muscular 
 tissue, then cellular and mucous membrane. 
 
 This view of the course of the disorder is, nevertheless, not without 
 difficulty. It supposes the process of tubercular deposition and ul- 
 ceration to advance first from the mucous to the peritonmal surface 
 of a portion of ileum, and then from the peritonaeal to the mucous 
 surface ; or that the process was advancing simultaneously from 
 the mucous membranes of two applied portions of ileum to the peri- 
 tonaea! until they met in the latter point. 
 
 Notwithstanding these difficulties, this view appears more pro- 
 bable, than that the disease had commenced in the peritonceum, and 
 thence proceeded to affect the other intestinal tissues to the mucous 
 membrane. The ulcerated openings also corresponded in figure 
 and size with the patches of agminated glands. 
 
 Dr George Gregory takes the opposite view ; and his case I 
 therefore refer to the head of lesions of the peritonaeum. 
 
 D. THE GENITO-URESTARV MUCOUS MEMBRANE. 
 
 § 1. The genito-urinary mucous membrane in both sexes is the 
 seat of sundry forms of the inflammatory process. 
 
 The urethral membrane, though forming a part of this surface, 
 possesses, nevertheless, certain anatomical and sensible peculiari- 
 ties. Smooth, and even polished, moistened by a thin transparent 
 fluid, it is formed into the sinuosities named lacunae, which, like the 
 follicles of other membranes, secrete a fluid of a peculiar odour, 
 which, united with that of the general membrane, serves to lubri- 
 cate the surface. Examined from its opening to its cystic extre- 
 mity, it presents divisions which may be enumerated in the follow- 
 ing order, the spongy, the bulbous, the membranous, and the pro- 
 static or vesical portions, according to the parts of the canal to 
 which the membrane is attached. This membrane may be the seat 
 of inflammation of two sorts ; — one circumscribed and unsuppura- 
 tive, the other spreading, and accompanied with secretion of puri- 
 form or purulent matter, more or less abundant. 
 
 a. Urethria simplex . — Common inflammation of the urethra con- 
 
654 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 sists in redness, swelling, and pain of a certain part of the canal, 
 which thus is rendered very narrow, or even may undergo tempo- 
 rary and partial obliteration. This affection is attended with pain- 
 ful tension of part or the whole of the penis, suppression of urine, 
 sometimes priapism, and consitutional disturbance proceeding at 
 once from local irritation, and the distress occasioned by difficulty 
 of voiding the urine, or by its total suppression. This form of 
 urethral inflammation should be distinguished from stricture, with 
 which it is too often confounded. Instead of spreading along the 
 membrane, it has a tendency to pass to the submucous tissue, and 
 thicken it. It is probable that it may occur in any part of the 
 canal ; but its most ordinary site is the membranous portion. If 
 properly treated, it terminates in resolution with a gleety.discharge, 
 in effusion of lymph or suppuration, not unfrequently with fistulous 
 openings. 
 
 b. Urethria puriformis ; Gonorrhaa ; Medorrlio^a . — That the 
 fluid of gonorrhoea is of inflammatory origin is proved by the swell- 
 ing of the urethral orifice, the pain and tenderness of the canal, 
 and the sore or scalding sensation (ardor iirince) occasioned by the 
 transit of the urine over it. At an early period of the art, when 
 pathological knowledge was defective or erroneous, this discharge 
 from the urethra was believed to consist of seminal fluid, and to is- 
 sue from the organs by which that fluid is secreted. Afterwards, 
 when medical practitioners understood the nature of the discharge 
 as distinct from seminal fluid, it was believed to be purulent matter 
 issuing from ulcers in the canal. This opinion, which, indeed, was 
 more rational, was nevertheless completely disproved, first by Mor- 
 gagni,* and afterwards by John Hun ter, f who showed by dissection 
 of persons whose death had occurred while they were labouring 
 under urethral discharge, that though minute ulcers may occasion- 
 ally be found in the canal, they are totally unconnected with the 
 discharge, which in the greater number of cases is secreted by the 
 urethral membrane in a state of inflammation. According to the 
 most accurate observations several regions of the urethral mucous 
 membrane may without ulceration or erosion furnish puriform se- 
 cretion. 
 
 The first of these is the hollow named navicular fossa, about 1, 
 1^, or 2 inches from the orifice, or the anterior end of the spongy 
 
 * Adversaria Anatom. Epistola xliv. 1, 2. 
 
 -f- Treatise on the Venereal Disease, Part ii. Chap. 1. 
 
GENITO-URINARY MUCOUS MEMBRANE. 
 
 655 
 
 portion of the membrane. This region abounds with the canaliculi, 
 to which Morgagni traced the secretion ; and in the dissections of 
 John Hunter it was uniformly found redder, and more vascular 
 or blood-shot than usual, and the lacunas often filled with matter. 
 Secondly, in cases in which the inflammation is more extensive, the 
 membranous part of the canal, Cowper’s glands and their ducts, 
 are involved in the morbid process. This, however, is exceedingly 
 rare, according to Littre, Morgagni, and Baillie. The first, after 
 inspecting forty cases of urethral inflammation, found in one case 
 only the glands of Cowper morbid. Morgagni met with one or 
 two instances only ; and J ohn Hunter remarks, that if the matter 
 of clap were secreted and deposited either beyond or in the bulb, 
 it would be incessantly ejected by the muscles, as occurs in regard 
 to the urine and seminal fluid. In cases yet more extensive, the 
 prostatic part of the urethra has been known to be inflamed ; and 
 in very violent forms of clap, the inflammation has been found to 
 extend to the bladder itself. It thus appears that no portion of 
 the canal, from its orifice to the neck of the bladder, is exempt from 
 inflammation ; and every part of the membrane between these two 
 points has been found more or less reddened, slightly villous, vas- 
 cular, and more or less swelled, so as to diminish sensibly the cali- 
 bre of the canal. It is observed by Dr Baillie, that the inflamma- 
 tion may pass from the mucous to the submucous membrane, and 
 the surrounding tissue of the spongy body, which thus becomes 
 larger and harder, in consequence of loaded vessels and effused 
 lymph, than in the natural state. It is not improbable that this 
 morbid state of the spongy body, by irritating the ischio-cavernosi 
 muscles, and exciting them to action, gives rise to the painful af- 
 fection denominated cliordee. 
 
 The glands of Cowper have been seen indurated and like tuber- 
 cles, in consequence of inflammation ; occasionally their ducts are 
 rendered impervious, and in some instances ulcers take place. And 
 in some instances the effect of this process is to obliterate both the 
 longitudinal folds and the canaliculi of Morgagni. Ulceration, to 
 which Morgagni himself had recourse, is not requisite to explain 
 this occurrence, which may be affected by inflammatory thickening 
 of their membrane. When the inflammation terminates in effusion 
 of lymph into the submucous tissue, the swelling induces that con- 
 traction of the canal which constitutes stricture. 
 
 § 2. Cystidia. Cystirrhcea. — The cystic mucous membrane, like 
 
656 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the urethral, is liable to inflammation either over its whole extent 
 or at a single spot. The part most frequently affected is the neck 
 of the bladder and the space termed cystic triangle (la trigone vesi- 
 cate') ; a circumstance which has been ascribed to one of two causes. 
 The first is, that the neck is most usually affected by mechanical 
 obstructions to the passage of the urine, and is therefore most 
 likely to be the first seat of the irritation which connects injuiy 
 and inflammatory action. The other is, that its contiguity to the 
 urethra renders it liable to be first affected by inflammation of that 
 canal when disposed to spread, or when, in consequence of bad 
 treatment, chronicity, or other causes, urethral becomes an exciting 
 cause of cystic inflammation. 
 
 From either of these causes, inflammation may be developed in 
 the cystic mucous surface near the neck of the bladder, and may 
 thence be propagated over a considerable extent of the membrane, 
 which then becomes marked by red points, villous, highly vascular, 
 and diffusely swelled, with occasional spots of extravasated blood. 
 In general, the character of this inflammation is to spread ; and in 
 ordinary cases it does so without affecting the submucous or other 
 tissues. Instances, however, occur, in which it passes successively 
 to the submucous filamentous tissue, to the muscular, and thence 
 to the peritoneal coat. In the spreading form the inflammation is 
 attended with secretion of thick mucous or puriform fluid, which 
 falls to the bottom of the urine. 
 
 It may terminate in resolution, in suppuration, in destruction of the 
 coats or ulceration ; or lastly, it may pass into the chronic state. 
 The manner in which the two first terminations are effected, is in 
 every respect similar to these processes, as they take place in other 
 mucous surfaces. 
 
 The third, or ulceration of the mucous and other tissues of the 
 bladder, is not uncommon, and may occur under two forms. In 
 the first, which is most common, it may be superficial, and remove 
 the whole mucous membrane so as to expose tbe muscular layer as 
 if it bad been neatly dissected. In the second, which is more usual, 
 the ulcerative process advances in minute patches from the mucous 
 to the submucous and muscular tissues, and in some instances to 
 the subserous and peritoneal membrane. This process differs from 
 the other in this respect, that lymph is irregularly deposited, that 
 there is considerable swelling, and sometimes a true abscess is 
 formed. More frequently, however, small portions of the mucous 
 
 3 
 
MUCOUS MEMBRANE. 
 
 657 
 
 membrane are detached in isolated points by ulceration ; and though 
 the subjacent tissues are exposed, there is no regular cavity or 
 abscess, but merely an ulcerated depression, which secretes puru- 
 lent matter. (Walter.) In more severe cases, in which the suppu- 
 rative or ulcerative process penetrates the different coats, commu- 
 nications are formed between the bladder and the neighbouring 
 parts. The most ordinary of these modes of communication are 
 the general peritoneal cavities, or the rectum, in both sexes, and 
 the vagina in the female. In the first case, besides other symptoms* 
 the urine gives rise to fatal peritoneal inflammation ; in the second 
 and third, its escape by unnatural passages induces much local ir- 
 ritation and general distress, and eventually may terminate in death< 
 Sloughing of the cystic mucous membrane, has been known to oc- 
 cur, but is not common. 
 
 b. Cystidia Diuturna . — The termination of cystidia in the chro- 
 nic form is most frequent in those who have laboured under re- 
 peated attacks of acute cystic inflammation ; those who have had 
 urethral or prostatic inflammation, or other disease of these parts ; 
 those having urethral stricture ; those liable to sabulous or lithie 
 concretions, or wherever there is a permanent cause of irritation. 
 It is hence common in persons whose health is impaired, or who 
 are advanced in life. The cystic membrane becomes not only red- 
 dish, but brown, villous, flocculent, and considerably thickened. 
 In some instances it become granular and unusually hard. This 
 change was repeatedly seen by Hoffmann, Morgagni,* Lieutaudj 
 Portal, and others ; and it is important to remark, that it never 
 continues long without causing inordinate thickening of the mus- 
 cular layer, and occasionally irregular contraction of its constituent 
 fibres, so as to form sacculi^ or cavities in the walls of the organ. 
 In most instances it secretes puriform mucus, (Hoffmann, Chopart,) 
 but without destruction of the mucous membrane. The former au- 
 thor relates an instance in which the usual effects took place, while, 
 upon inspection, the cystic tissues were found thickened and condens- 
 ed, and the vessels of the mucous membrane large, numerous, and 
 loaded, yet without trace of ulceration. This disorder is said to 
 have been the cause of death to Voltaire, Buffon, D’Alembert, and 
 Spallanzani.! On the other hand, the mucous membrane may be 
 entirely removed, as in the acute form, by a process of ulceration 
 
 * Epist. xlii, 
 
 t Brera Storia della Malattia di P. Spallanzani. 
 
 T t 
 
658 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 or sloughing. In the case of Professor Barthez of Montpellier, 
 recorded by M. Double,* the cavity of the organ, which contained 
 a mulberry calculus nine lines in diameter, was diminished and 
 filled with purulent matter ; its walls were black and sphacelated ; 
 of mucous membrane not a trace was left, and the muscular coat 
 was thickened.! From a similar action results the villous, fun- 
 gating, and granular state of the bladder observed by Ruysch, 
 Walter, Baillie, and others-! 
 
 The anatomical characters, in short, of this disease in its exqui- 
 site form are the following. The walls of the organ, especially its 
 muscular coat, are thickened, hardened, and as if hypertrophied ; 
 and the muscular thickening, as well as the cellular, may be consi- 
 derable, that is to say, approaching to half an inch. The cavity of the 
 organ is much contracted, sometimes not larger than the capacity 
 of a small egg. The mucous membrane is very commonly red- 
 dened and Vciscular all over or in patches ; in some instances it is 
 partially removed by ulceration ; and in some instances it is entirely 
 removed, as if it bad been dissected away from the muscular coat. 
 This I have several times seen ; and in general the exposed surface 
 was covered with patches of calcareous matter, which was either 
 ammoniaco-magnesian phosphate, phosphate of lime, or carbonate 
 of lime. 
 
 The effects of this process is to alter considerably the ordinary 
 secretion of the cystic mucous membrane. The cystic mucus in the 
 healthy state is a thin fluid, easily miscible with the urine, and so 
 trifling in quantity, at least in the urine discharged, that it is rarely 
 observed. What is called cloudy urine generally contains a little 
 more of this mucous matter than usual. In the inflamed state it 
 appears in the form of thick, opaque, viscid fluid, which falls to the 
 bottom of the vessel, and in very severe cases it is puriform, or pu- 
 rulent fluid, opaque and milky, but not ropy, and is occasionally 
 reddish or streaked with blood. To account for the origin of this 
 morbid secretion, Fanton conceived that follicles or mucous glands 
 of the cystic membrane became inflamed, and increased their na- 
 tural action.§ The existence of such bodies in this membrane is 
 nevertheless questionable ; and it is unnecessary to look for any 
 
 ■* Hist. Anatom. Med. Obs. 1224, 1266, 1270, 1272, 1274. 
 
 t Journal Generate de Medecine. Nov. 1806. 
 
 J F. A. Walter, Einige Krankheiten der Nieren und Hamblase untersuclit u. s. w. 
 Berlin, 1800. P. 31. 
 
 § Dissert. Anatom. 174,5. 
 
 4 
 
MUCOUS MEMBRANE, 
 
 659 
 
 other tissue save the mucous surface to explain the origin of the 
 discharge. 
 
 The truth is, that, as soon as the mucous membrane of the bladder 
 begins to secrete puriform matter, this alters much the chemical pro- 
 perties of the urine. Ammonia is secreted ; or rather the urea is 
 decomposed and converted into ammonia or carbonate of ammonia ; 
 and either the urine contains ammoniaco-magnesian phosphates, or 
 some other aramoniacal salt. 
 
 The other effects of this disease are weight, uneasiness, and some- 
 times tension in the hypogastric region ; heat in voiding the urine ; 
 uneasy parched condition of the skin of the legs and feet, with burn- 
 ing of the soles ; thirst, quick pulse, impaired appetite, and general 
 wasting. The constitutional disturbance and wasting generally 
 prove fatal directly, or by inducing some fatal disease. 
 
 Membranous substances have been observed to be discharged 
 fi’om the bladder by Willis, Ruysch, Boerhaave, and Moi'gagni. 
 According to the account of the inspections, these are stated to be 
 portions of the mucous membrane of the bladder. Though I feel 
 difficulty in denying the testimony of observers so competent, I feel 
 equal difficulty in admitting this exfoliation, which is indeed ana- 
 logous to the exfoliations of the intestinal mucous membrane. It 
 is equally possible, and not altogether improbable, that these mem- 
 branous substances were albuminous concretions from the inflamed 
 cystic membrane. 
 
 § 3. The utero-vaginal mucous membrane of the female is not 
 less important as a seat of morbid action. 
 
 The labio-vaginal mucous membrane is often the seat of gonor- 
 rhcsal inflammation, which seems to produce in it much the same 
 effects as in the male urethra. In severe cases the nym-plia: swell 
 so m_uch that they make, with the external labia^ one shapeless mass. 
 The vaginal membrane I have seen the seat of a thick yellow puri- 
 form discharge, which was positively asserted to be unconnected 
 with gonorrhoeal infection. This, however, requires further confir- 
 mation. In all cases the membrane becomes so much swelled that 
 the rugce are to a certain extent obliterated. The lacuna are 
 stated to be the chief source of the discharge when thick and puri- 
 form. 
 
 The uterine mucous membrane is liable to various forms of the 
 inflammatory process, most of which, however, may be referred to 
 
G60 
 
 GEXERAL AND PATHOLOGICAL ANATOMY. 
 
 three heads, — the spreading sero-mucous or puriform, the limited or 
 suppurative, and the albuminous. 
 
 Of the spreading inflammation there are two varieties, one with 
 transparent mucous discharge, the other with opaque or white mu- 
 cous discharge. 
 
 In the first case, in which a transparent, gelatinous, imperfectly 
 coagulable fluid issues from the vagina, the uterine mucous mem- 
 brane is in a state of chronic congestion, and the organ itself becomes 
 slightly enlarged. This discharge, which issues from the mucous 
 surface of the womb, and, according to Leake, from the same vessels 
 which are subservient to menstruation, constitutes a large propor- 
 tion of the cases regarded as Jluor albus. It takes place as a symp- 
 tom of prolapse of the womb, bladder, or vagina, of inversion of 
 the womb, of cancer, polypus, and even warty growths of the or- 
 gan.* 
 
 In the second form, though the disease may affect the mucous 
 surface in general, its more particular seat is the cervix of the womb ’ 
 and its mucous glands. It was observed originally by Morgagni,f^ 
 and afterwards by Leake, that in certain forms of Jluor albus in- f 
 cident to young females of 8 or 10 years old, the discharge pro- ' 
 ceeds from the mucous glands of the womb. By observing pain -i 
 and tenderness uniformly in this part, Mr C. M. Clarke confirms'- 
 the accuracy of this observation. It causes to issue from the va- ’ 
 gina an opaque perfectly white fluid, resembling a mixture of ' 
 starch and water made in the cold, or thin cream, easily washed 
 from the finger, and diffusible in water, which it renders turbid, ' 
 sometimes tenacious, like melted glue. 
 
 3. When the raucous membrane of the womb or vagina is in- ? 
 flamed, it may secrete puriform or purulent fluid, which is not un- 
 frequently retained within the cavity of the organ. Collections of ^ 
 purulent matter in the former have been recorded by Lieutaud,J 
 Portal,§ Dr Clarke, || and others. Of these collections the pecu- i 
 liarity is that they are not discharged as they are formed, — a cir- I 
 cumstance which is in general to be ascribed to obstruction of the 
 uterine orifice by lymph. This, it is to be remarked, is accidental, 
 
 * Observations on those Diseases of Females which are attended by Discharges, &c. 
 &c., by Charles Mansfield Clarke. Part i. Lond. 1814, and Part ii. Lond. 1821. 
 
 + Epist. xlvii. 14, 15, 18. J Hist. Anatom. Med. 
 
 § Anatomie Meddcale, Tom. v. p. 519. 
 
 II Transactions of a Society, Vol. iii. p. 560. 
 
MUCOUS MEMBRANE. 
 
 661 
 
 and does not establish an essential or specific difference between such 
 purulent collections and those discharges which take place from 
 the orifice of the organ. It is nevertheless to be remarked, that 
 these collections partake in a more conspicuous degree of the cha- 
 racters of genuine active inflammation of the uterine mucous sur- 
 face. 
 
 Puriform inflammation of the utero-vaginal mucous membrane 
 is to be distinguished from abscess of the lahia^ or nymph(B^ from 
 suppuration of the submucous vaginal tissue, which I have seen take 
 place under circumstances that might lead them to be confounded 
 with each other, from gonorrhoeal inflammation, fi’om corroding 
 ulcer of the mouth of the womb, and from cancer of the womb or 
 of the rectum. 
 
 The second general form of uterine mucous inflammation is that 
 in which the product of the process is an albuminous membranous 
 concretion. Morgagni records a good instance of redness of the 
 uterine mucous membrane, part of which was at the same time 
 lined by a preternatural membranous substance. It has been 
 further long known, that many females discharge periodically shreds 
 and portions of membranous matter of various size and shape, and 
 some so large that they form almost complete moulds of the inner 
 uterine surface. These facts, which were observed by William 
 Hunter, Leake, Denman, and Hulme, are well known to acou- 
 cheurs and those conversant with the management of female dis- 
 orders. It may be stated as a wdl established fact, that these mem- 
 branous productions are analogous to those, which I have above 
 shown, are secreted by other mucous surfaces ; and that their for- 
 mation is connected with an inflammatory state of the uterine mu- 
 cous membrane. Independent of the fact, that their formation is 
 attended with pain of the uterine region and disturbed function, in 
 some favourable instances in which inspection has taken place, the 
 transition from fluid to solid state has been traced, and the congest- 
 ed state of the uterine vessels demonstrated. In sundry instances, 
 nevertheless, these membranous productions are formed by that ac- 
 tion of the vessels which constitutes menstruation, and they are 
 formed chiefly at the menstrual periods. In all cases, their forma- 
 tion implies a state of the uterus incompatible with impregnation ; 
 and sterility is the accompaniment of this disease. 
 
 § 4. Adhesive inflammation of the Vaginal Mucous Membrane. 
 — It has been observed by Baillie, that the vagina is liable to a vio- 
 
662 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 lent form of inflammation, which, by producing effusion of lymph, 
 causes mutual adhesion of the sides of the canal.* By Howship, 
 this is ascribed to excoriation between the labia^ causing at an early 
 age effusion of lymph, so as to resemble aphthce ; and he mentions 
 an instance in a child of two months, in which lymph had been se- 
 creted, and had become vascular, leaving a minute aperture for the | 
 urine at the inferior angle of the vagina.f If these two forms of 
 inflammation be different, the latter is probably of the same nature j 
 as that now to be mentioned. 
 
 § 5. Sloughing inflammation of mucous surfaces . — To this head 
 I refer two varieties of disease met with, particularly at the com- 
 munication of the two great mucous surfaces with the skin. 
 
 The first is the disease originally described by HoflPmann and 
 Van Swieten under the name of cancrum oris, the water canker of 
 Dr Robert Hamilton of Lynn Regis,:}: and more recently by Dr 
 M. Hall,§ Dr Thomas Gumming, || and various subsequent observ- 
 ers. In this disease the mucous membrane of the mouth, cheek, I 
 or gums, becomes hot, swelled, of a dark-red colour, and eventu- 
 ally black, hard, and dead. The mortified portion begins then to 
 be thrown off ; but in the meantime the original inflammatory pro- 
 cess advances ; and combined with that necessary for ejecting the ' 
 sloughs, is accompanied with extreme pain, and much constitutional 
 disturbance. Though this disorder has been thought to originate j 
 in the skin, in which it appears when presented to the practitioner, 
 it may always be traced to the mucous membrane of the mouth ; a | 
 fact which is properly verified by the observation of Dr Gumming. IF j 
 
 The second variety of this disease is seen in the pudendum of | 
 young girls, in whom the labial or valvular membrane is liable to j 
 a species of diffuse inflammation, which almost invariably terminates i 
 in mortification of the mucous corion, which is then cast in the 
 form of slough. According to the observations of Mr Kinder 
 Wood, to w'hom we are indebted for the most distinct account of 
 this disorder yet published, the labial mucous menlbrane becomes 
 of a dark red colour, swelled, and covered by numerous watery ve- 
 sicles or aphthcE, the cuticle of which dropping off discloses deep 
 
 * Morbid Anatom)', Chap. xxii. p. 415. 
 
 Practical Observations, &c. Chap. vi. p. 360. 
 
 J Apud On the Marsh Remittent Fever, &c. London, 1801. 
 
 § Bdin. Medical and Surgical Journal, Vol. xv. 
 
 II Dublin Hospital Reirorts, Vol. iv. p. 330. 
 
 Ibid. p. 335. 
 
MUCOUS MEMBRANE. 
 
 663 
 
 foul ulcers, surrounded with much redness, and secreting thin of- 
 fensive matter. Similar aphthae also appear on the skin of the 
 mans veneris, perinceum, and adjoining parts.* Though the disease 
 is often fatal by the severity of the constitutional disorder, in some 
 instances, after the sloughs are cast, effusion of lymph and granu- 
 lation may take place, and, unless much care is taken in dressing, 
 great part of the vaginal orifice and the labia are united perma- 
 nently, leaving only a small orifice for the escape of the urine. In 
 this manner the vagina is not unfrequently closed so as to simulate 
 congenital imperforation. It appears from the account of Mr 
 W ood, that this inflammation is confined chiefly to the labia, the 
 nymphcB, the clitoris, and hymen ; and it does not seem to affect 
 the vagina. 
 
 In a medico-legal point of view it is important to distinguish 
 this disease from the effects of violation, with which it has been 
 confounded. 
 
 III. Haemorrhage. — In the mucous membranes hemorrhage is 
 frequent ; and though none of them can be said to be exempt from 
 it, it is most common in the Schneiderian or nasal membrane, in the 
 pulmonic, intestinal, and uterine mucous surfaces. In the hemor- 
 rhagic form of land-scurvy, {purpura hasmorrhagica'), with the 
 bloody spots on the outer surface of the corion of simple purpura, 
 are combined spots and hemorrhage from almost all the mucous 
 surfaces. Of the hemorrhages of the mucous membranes the fol- 
 lowing table may be given: — 
 
 Nasal passages, 
 Mouth, 
 
 Bronchial membrane, 
 Stomach, 
 
 Ileum and colon. 
 Rectum, 
 
 Bladder, 
 
 Urethra, 
 
 Womb, 
 
 Epistaxis. 
 
 Stomacace, 
 
 Hcemoptysis, 
 
 Haimatemesis, 
 
 Meloena; DysenUnj, 
 
 Hcemorrhois, 
 
 Hcematuria, 
 
 Pneumonorvhajia. 
 
 Gastrorrhagia. 
 
 Enierorrhagia. 
 
 Pi'octorrhagia. 
 
 Cystirrhagia. 
 
 UrethrorrJiagia. 
 
 Menorrhagia. 
 
 In these several regions of the mucous surfaces, the pathology 
 of hemorrhage, which has been already partially considered, is 
 much the same. The discharge of blood or bloody fluid from any 
 of the mucous membranes is not so much a disease of itself as one 
 of the eflPects of some degree or variety of the inflammatory process. 
 Thus blood is discharged from the bronchial membrane during 
 bronchial inflammation ; from the gastric mucous membrane dur- 
 
 History of a very fatal aft'ection of the pudenda of female children, by Kinder 
 M ood, Esq. jVlecl.-Chir. Trans. V'ol. vii. p. o5, Ac. 
 
664 
 
 GENERAL AND RATHOLUGICAL ANATOMY, 
 
 ing vascular congestion of the stomach; from the intestinal during 
 the congestion of dysentery ; and from that of the rectum during 
 the vascular state attendant on hemorrhois. In these circumstances, 
 the hlood, whether pure or mingled, as it often is with mucous, mu- 
 co-purulent or puriform fluid, oozes from the mucous membranes 
 without destruction of tissue, or rupture of vessels, or, in the lan- 
 guage of the physiologist, is exhaled. ‘‘ I have often opened,” says 
 Bichat, “ persons who have died during hemorrhage, and have ex- 
 amined the bronchial, gastric, intestinal, and uterine surfaces, yet 
 have not perceived the slightest trace of erosion, notwithstanding 
 the precaution of washing ihem with care, allowing them to mace- 
 rate, and afterwards submitting them to examination by means of 
 a lens.”* In this manner, therefore, are to be explained those 
 slight hemorrhages which take place in pulmonary catarrh {hcemop- 
 toe), about the termination of peripneumony, and in young females 
 after the accidental suppression of the menstrual discharge. 
 
 From these the more copious and irresistible hemorrhages from 
 mucous surfaces differ chiefly in a previous serious lesion of the mu- 
 cous or submucous tissue. This lesion consists in vascular injec- 
 tion more or less extensive of the mucous corion, and injection oc- 
 casionally very complete, and amounting to extravasation, of the 
 submucous tissue, which is thus rendered red-brown, hard, and 
 void of its natural elasticity. Of the former instances are seen in 
 the gastro- enteric mucous membrane during luEmatemesis^ melcBna, 
 and bloody flux ; and the latter may be observed in the lungs du- 
 ring limmoptysis, and in the rectum in hcemorrhois. These princi- 
 ples are so well established by numerous facts, that it is unneces- 
 sary to strengthen them by any elaborate induction. I shall mere- 
 ly adduce the phenomena of a few of the hemorrhagic diseases in 
 illustration of the general doctrine that hemorrhage is an exhala-^ 
 tion from parts, the capillaries of which are previously inordinately 
 distended. 
 
 § 1. The G astro-enteric Membrane. Hcematemesis and Melcena. 
 — On the pathology of this disorder, so much misunderstood by the 
 ancients, it is unnecessary to dwell. Correct views were first given 
 by Hoffmann, who, from the fact of finding in dead bodies the me- 
 senteric vessels and those of the ileum much distended with black 
 blood, and the stomach filled with the same, taught that the bloody 
 discharge, whether from the upper or the lower end of the canal, 
 proceeds not immediately from the vessels of the stomach, or from 
 
 * Anatomie Generale, Tome i. p. 5b'3, 565. 
 
MUCOUS MEMBRANE. 
 
 665 
 
 blood extravasated into its cavity, but also from the vessels of the 
 small intestines, especially those of the ileum.* This inference is 
 confirmed by several dissections of Valsalva and Morgagni,! who 
 in hsematemesis and intestinal hemorrhage found the gastro-enteric 
 mucous membrane always entire, and its vessels more or less in- 
 jected. 
 
 From an extensive collection of cases, Portal derives conclusions 
 still more distinct. This anatomist shows, Is?, that the black mat- 
 ter discharged by vomit and by stool, or by vomiting only, is ge- 
 nuine blood, which is seen to ooze after death from the blood-ves- 
 sels of the stomach and intestines ; 2d, that this oozing or trans- 
 udation takes place from the gastric, duodenal, and mesenteric ar- 
 terial extremities into the cavity of the stomach or intestines, sepa- 
 rately or at once, more frequently into the stomach only, in conse- 
 quence of certain arterial branches receiving more blood than the 
 corresponding veins return ; and, 2>dly, though compression of the 
 branches of the portal vein may cause this extravasation, the blood 
 is not eflfused from the vasa brevia, in which it flows in an opposite 
 direction.! 
 
 Similar are the views of Abernethy, who states that in the bodies 
 of several persons who died under attacks of this disease, he found 
 ‘‘ the villous coat of the alimentary canal highly inflamed^ sioollen, 
 and pulpy. Bloody specks were observed in various parts ; and 
 sphacelation had actually taken place in one instance. The liver 
 was healthy in some cases and diseased in others.” He concludes, 
 therefore, that the diseases termed hcBmatemesis and melmia arise 
 from “ violent disorder, and consequent diseased secretion of the 
 internal coat of the bowels ; and that the blood discharged does 
 not flow from any single vessel, but from the various points of the 
 diseased surface. Ӥ From the same source originates the cocoa- 
 coloured fluid observed by Baillie in fatal cases of h(Bmatemesis.\\ 
 
 It may therefore be inferred, that the blood discharged in this 
 disease issues from the loaded capillary vessels of the gastric, duo- 
 denal, and ileal mucous membrane without breach of stu-face ; and 
 as it is anatomically impossible to distinguish these vessels into ar- 
 
 * Medicin® Rationalis Systematic®, pars ii. sect. i. chap. Hi. § 17. 
 
 Epist. xxix. 10 ; xxxi. 23 ; xxxvi. 11. 
 
 + Memoires sur la Nature et le Traitement de Phisieurs Maladies, Par Antoine 
 Portal, Tom. ii. Paris, 1800. P.108. 
 
 § On the Constitutional Origin and Treatment, &c. p. 30. London, 1811. 
 
 II Lectures and Observations on Medicine. 
 
 3 
 
666 
 
 GENERAL AND PATUOLOGICAL ANATOMY. 
 
 teries and veins, the dispute whether the blood issues from the one 
 or other order is fi’ivolous. The blood may acquire its dark colour 
 from two causes; 1st, admixture with the gastric juice in the sto- 
 mach and duodenum ; and 2d, from the action of the carbonic acid, 
 sulphuretted hydrogen, and other substances of acid properties con- 
 tained in the intestinal canal. 
 
 §2. Hcemoptysis ; Pneumonorrhagia ; Pulmonary Hemorrhage ; 
 Pulmonary Apoplexy . — For the first accurate description of the 
 anatomical characters of pulmonary hemorrhage, we are indebted 
 to the researches of the elaborate Stark, who ascertained the fol- 
 lowing facts. The air vesicles in some parts of the lungs are filled 
 with blood or bloody serum ; the parts do not collapse on opening 
 the chest, but are firm, dark or light red in colour, and can neither 
 be compressed nor distended by the usual inflation. When cut 
 into, thick blood or bloody matter issues from the cut surfaces ; 
 and portions of the diseased parts, after being macerated in water, 
 still sink as before maceration. He further showed, by blowing 
 air into the blood-vessels and air-tubes of the sound and diseased 
 portions respectively, that in the latter air passes from the branches 
 of the pulmonary artery and veins into the bronchial tubes ; in 
 other words, that the capillary vessels of the lungs communicate 
 freely with the bronchial tubes and air-cells.* 
 
 The general accuracy of this desciiption has since been verified 
 by the researches of Laennec, who has indeed rendered the patho- 
 logical anatomy of this disease more precise than formerly. From 
 these, it results that a portion of the pulmonic tissue becomes uni- 
 formly hard, of a dark red colour, and impermeable to air. The 
 indurated spot is always partial, from one to four cubic inches in 
 extent, circumscribed with sound or pale-coloured lung, and looks 
 not unlike a clot of venous blood ; circumstances by which it is to 
 be distinguished from pneumonic induration, which terminates gra- 
 dually in sound lung.j These changes, which consist in extreme 
 injection of the pulmonic capillaries, and in effusion of blood into 
 the submucous filamentous tissue, and into the pulmonic vesicles, 
 are confined, however, chiefly to the severe forms of pulmonary he- 
 morrhage. They are the effects of previous injection of the capil- 
 laries, which is to be considered as the uniform cause of hemor- 
 rhage. 
 
 * The Works of the late William Stark, M. D. Ac. London, 1788, p. 3L 
 
 f Traite de I’Auscultation Mediate, &c. 
 
MUCOUS MEMBEANE. 
 
 667 
 
 Much the same changes are observed in the rectum and its sub- 
 mucous tissue in hemorrhoidal disease. This is proved by the tes- 
 timony of Latta,* Benjamin Bell,f Callisen,+ Monteggia,§ Del- 
 pech,ll Chaussier, Larroque, and Calvert. H This disorder is to 
 be distinguished from varix of the veins of the bovpels. 
 
 I conclude this subject with a few remarks on hemorrhage from 
 the uterine mucous membrane in the state of impregnation. It is 
 generally supposed that hemorrhage taking place'at this period is 
 the effect of abortion ; and Denman and some other authors em- 
 ploy a good deal of not very intelligible argument to prove the 
 proposition. It may, however, be demonstrated, that hemorrhage, 
 or, to speak more to the fact, the abnormal state of the uterine ca- 
 pillaries, which leads to hemorrhage, is the cause of abortion ; and 
 that almost no instance of abortion takes place without previous 
 hemorrhagic distension of the uterine or utero-placental capillaries. 
 By Denman himself it is remarked, that “ when abortion is about 
 to happen, there is usually between this (the decidua rejlexa) and 
 the outer membrane of the ovum, an effusion of blood, which often 
 insinuates itself through the cellular membrane of the placenta, and 
 between the membranes, giving externally to the whole ovum a tu- 
 mid and unequal appearance, not unlike a lump of coagulated 
 blood, for which it has been frequently mistaken, and then it is 
 popularly called a false conception.”** I have had occasion to ob- 
 serve the phenomena of sevei'al abortions with some care ; and in 
 every one I have traced them to some degree of hemorrhage taking 
 place from the uterine or utero-placental vessels. The blood which 
 Denman remarks is found insinuated through the cellular mem- 
 brane of the placenta is derived from the vessels of that body. It 
 is not, therefore, the premature effort of the uterus to contract that 
 constitutes abortion ; but the inordinate distension of its vessels, 
 which terminates in hemorrhage, and the occurrence of which then 
 excites the uterus to premature contraction. The vessels of the 
 uterus and placenta, naturally full of blood, may, from a variety 
 of causes operating on the mother, become unusually distended, 
 
 * A Practical System of Surgery, Vol. ii. Chap. iv. p. 34. 
 f A System of Surgery, Vol. vi., 7. Edit. Chap. xxiv. p. 324. 
 t Systema Chii-urgise Hodiernise, Vol. ii. Edit. 4to. p. 12b'. 
 
 § Tnstituzione Chirurgiche, Vol. viii. Chap. xv. 389. 
 
 II Precis Elementaire, &c. Tome iiime. Sect. viii. Chap. I, § ii. p. 262. 
 
 'll A Practical Treatise on Hemorrhoids, &c. London, 1824. P.23,24. 
 
 ** Principles of Midwifery, V ol. ii. p. 280. 
 
668 
 
 GENEIUL AJMI) PATHOLOGICAL ANATOMY. 
 
 and discharge blood as in other hemorrhagic injections. This exu- 
 dation taking place either at the uterine surface, or in the substance 
 of the placenta, or in both at once, speedily detaches the placenta 
 from the womb ; the usual supply of blood is interrupted ; and the 
 foetus perishes in consequence. In this sense only can the remark 
 of Leake be well-founded. “ Whatever may be tbe cause of abor- 
 tion, the effect is produced by a separation of the after-burden from 
 the womb, and consequently, the child, being deprived of nourish- 
 ment, must soon perish and be expelled.”* The difficulty here re- 
 fers to the remote causes, which may be different in different cases. 
 The pathological cause is invariably the same. 
 
 Febrile yastro-enteric hemorrhage . — That the black or coffee- 
 ground vomit, {vomito prieto,') and dark-coloured, tar- like, or mo- 
 lasses-like stools, which take place in bad remittents, malignant 
 agues, and yellow fever, consist in hemorrhage from gastro- enteric 
 mucous membrane, is established by the researches of Physick, Dr 
 John Hunter, Bancroft, Jackson, and many other authors. In all 
 cases in which subjects dead of these diseases, under these symp- 
 toms, have been inspected, the same kind of coffee-ground matter 
 has been found in the stomach and intestines, but without breach 
 of the mucous surface. The matter, however, has been traced 
 almost in its formation, in the circumstance of dark blood oozing 
 insensibly from the capillaries of the mucous membrane. Its co- 
 lour is necessarily rendered more intense by the fluids of the gas- 
 tro-enteric surface. This peculiar exudation may be regarded as 
 the result of disorganization of the mucous capillaries, in conse- 
 quence of previous congestion during the febrile action. Not con- 
 fined, however, to the gastro-enteric mucous surface, it occurs in 
 the tracheo-bronchial and genito-urinary. It is observed also oc- 
 sionally in other tissues from the same cause. In short, febrile 
 action either consists in, or is the cause of capillary disorganization 
 in most of the textures. 
 
 The process of hemorrhagic injection, like that of inflammation,' 
 may terminate in suppuration, with or without breach of surface, 
 in induration, and thickening, dependent on chronic inflammation. 
 
 IV. Inflammatory Stricture. — To thickening as an eflPect of 
 the inflammatory process, I have already had frequent occasion to- 
 allude. This takes place to a small extent in the mucous corion, 
 and to a much greater degree in the submucous filamentous tissue, 
 
 * V'ol. i. p. 119. 
 
MUCOUS MEMBRANE. 
 
 669 
 
 in which it depends partly on the increased number of vessels, 
 partly on the effusion of lymph, which causes the mutual cohesion 
 of its component filaments. When this is considerable, and takes 
 place in a membrane lining a canal, it contracts its capacity, and 
 forms what is named stricture ; {constrictio) •, {arctatio.') Though 
 this may occur in any part of the mucous system, it is most com- 
 mon in the lacrymal canal, the Eustachian tube, the oesophagus, 
 near its upper or lower extremity, the rectum or lower part of the 
 colon, and in the male urethra. The constriction, in such circum- 
 stances, depends not unfrequently on the presence of some remain- 
 ing degree of inflammation ; and if this subside, the constriction 
 may also partially diminish.* * * § To its entire disappearance, how- 
 ever, the absorption of the effused lymph is essentially necessary ; 
 and in all probability this is never completely effected. In the in- 
 testinal canal especially, this induration may be so great that the 
 tissue of the tube becomes hard and firm like parchment or carti- 
 lage, and at the same time much thicker than natural. The calibre 
 of the canal then becomes so much contracted that nothing passes 
 through it ; and life is terminated, partly by inanition and deficient 
 nutrition, partly by irritation. I have already alluded to partial 
 contractions recorded by various authors, from Haase, Wincker, 
 and Laubius, to Dr Combe and Willan. The most perfect ex- 
 ample of total contraction with which I am acquainted is recorded 
 by M. Tartra in his Essay on Poisoning by Nitric Acid. In an 
 individual who died three months after swallowing this poison, the 
 alimentary canal was reduced to so small volume, that it might 
 have been held in the hollow of the hand. Its coats were shrivel- 
 led, crisp, and indurated ; and its calibre through its whole length 
 did not exceed that of a common quill. | Under such circumstances, 
 all the intestinal tissues suffer successively and simultaneously the 
 efiects of the inflammatory process ; and the contraction is aug- 
 mented by the violent and excessive stimulus which it applies to the 
 muscular layer. 
 
 That a similar change takes place in the mucous and submucous 
 tissues of the bladder is shown by the observations of Guarinonius, 
 Bonetus, Camerarius, Targioni, Morgagni,| Dr Barry,§ Dr Gil- 
 
 * Home. Howship, Practical Observations, p. 254. 
 
 t Essai sur I’empoissonnement, &c. 
 
 Epist. iv. 13, 19. X. i3. xxii. 4. xxxix. 33. xl. 22. xli. 13. xlii. 20, 33, 34. xliii. 24. 
 xliv. 15. xlviii. 32. xlix. 18. 
 
 § Edinburgh Med. Essays, Vol. i. p. 266. 
 
070 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Christ,* Dessault,t Baillie,f Fr. Aug. Walter, § Charles Bell,|| 
 Forster, H and other authors, who found the mucous coat thicken- 
 ed and indurated like cartilage, and the cavity much contracted. 
 It is at the same time generally sacculated. 
 
 Another form of inflammatory thickening, causing diminished 
 area of mucous canals, is that which takes place in chronic en- 
 largement of the mucous glands. The best example of this is ob- 
 served in the enlargement of the raucous follicles of the cardia, 
 which is no uncommon cause of stricture of the cardiac orifice of 
 the oesophagus. This inflammation is very difficult of resolution, 
 and too often terminates in ulceration of the membrane and the 
 glands. 
 
 4. Adhesion . — It was asserted by Bichat and others, that mucous 
 membrane does not effuse lymph or contract adhesions. The ac- 
 curacy of this conclusion, which evidently arose from opinions too 
 generalized on the properties of this tissue, the nature of lymph, 
 and the final causes or rather purposes of morbid action, is ques- 
 tionable, and the inference requires limitation. Independent of 
 the well known experiment of John Hunter, who, by the use of a 
 very irritating injection, produced a secretion of coagulable lymph 
 in the vagina of an ass ; — I have already shown that each of the 
 mucous surfaces, under certain states and forms of inflammatory 
 action, may effuse a fluid containing a large proportion of albumen, 
 and which, neither in chemical properties nor pathological relations, 
 can be distinguished from the albuminous exudation of serous 
 membranes. The question of adhesion, however, depends not s 
 
 much upon the fact of albuminous exudation as upon the anatc 
 
 mical disposition of the cavity or canal, whether it be sufficient! 
 small to favour the mutual approximation of opposite and cona 
 spending surfaces. Thus in the gastro-intestinal membrane, whic 
 is in general capacious and distended, either incessantly or fn 
 quently with foreign bodies, mutual approximation is too imperfei 
 to admit of adhesion. Yet by some observers this is asserted t 
 have happened. In situations, on the contrary, in which mucoi 
 surfaces line narrow tubes, as the lacrymal duct, the Eustachia 
 tube, the urethra, and perhaps the Fallopian tubes, obliteration c. 
 the canal by adhesion of its sides is more frequent. It is certain 
 
 * Essays, Physical and Literary, Vol. iii. -j- Journal de Chirurgie. 
 
 t Engravings, &c. 7th Fascicul. pi. I. fig. 2d. 
 
 § Einige Krankheiten der Nieren und Harnblase, u. s. w. p. 31. Tafel. ix. 
 
 II Engravings, &c. Med.-Chir. Trans. Vol. i. art. 9. 
 
]\rUCOUS JIEMBRANE. 
 
 671 
 
 that the surgeon has not unfrequently occasion to observe corre- 
 sponding points of narrow canals, as the urethra, adhering appa- 
 rently by concretion of its sides.* I have had occasion to ad- 
 vert above to a mode in wbicb the vaginal mucous membrane may 
 contract adhesions, and present the similitude of congenital imper- 
 foration. The assertion of Bichat regarding the inaptitude of mu- 
 cous surfaces to adhere requires, therefore, some limitation. Cer- 
 tain facts lead me to infer that one of the conditions necessary to 
 the albuminous exudation and the subsequent concretion of mutual 
 surfaces consists in the destruction of the mucous epidermis by 
 abrasion or ulceration, and the subsequent formation of granula- 
 tions, which in the course of healing unite the opposite edges of 
 the canal. 
 
 V. Induration and thickening ; Cartilaginous transfor- 
 mation OF MUCOUS MEMBRANE AND CANALS. ChONDROSIS. 
 Hypertrophy. — It is not easy to say to what head the change here 
 adverted to should be referred. For it is not by any means easy to 
 determine its exact nature ; or even whether it be an affection of 
 the mucous membrane solely, or of tbe muscular structure, or of 
 both taken together. My chief reason for referring it to the pre- 
 sent head is because there is a very considerable affection of the 
 mucous membrane, at its free surface. 
 
 The lesion consists in the conversion of a portion of mucous mem- 
 brane and its subjacent tissue, generally muscular or fibrous, into 
 a thick, bard, cartilaginous substance, sometimes with contraction 
 of the canal, sometimes with dilatation. The mucous surface is 
 irregular, honey-combed as it were, and rough, with numerous in- 
 tersecting ridges, fii’m and generally of a whitish gray colour. 
 
 It is liable to affect the mucous membrane of the oesophagus, 
 and forms there one species of stricture ; the mucous membrane of 
 the where it also forms a species of stricture ; and the mucous 
 
 membrane of the colon, where in like manner it generally causes 
 arctation of the calibre of the canal. 
 
 The region, however, in which this lesion is most distinctly seen, 
 and proceeds to its greatest extent, is that of the ureters and bladder. 
 Tbe former canals become thick to the diameter of half an inch and 
 more, their coats are hard, firm, of cartilaginous consistence, and a 
 gray-white colour ; the internal of mucous surface is rough and 
 
 * Smith Ward, Mem. Med. Society, Vol. iii. p. .536. Maclurc, Med. and Surg. 
 Journal. 
 
672 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 honey-comb like, with innumerable intersecting lines ; and the canal 
 of the ureters may be either natural, contracted, or dilated. 
 
 The bladder is always much contracted. Its coats are thickened 
 either to the extent of that of the ureters or more ; from half an 
 inch to three quarters. The thickening is seated both in the mucous 
 membrane and in the muscular coat, but often more in the former 
 than in the latter. The surface is, like that of the ureteric mem- 
 brane, irregular and honeycomb-like. The substance of the mucous 
 coat is as firm as cartilage ; and the same transformation appears to 
 affect the muscular coat. Occasionally the bladder is sacculated. 
 
 The causes and exact nature of this change are not well known. 
 
 It seems like a species of hypertrophy ; and from this, nevertheless, 
 it differs. The instances which have fallen under my own notice 
 occurred in persons under 35. But I daresay that it may appear 
 in old age. 
 
 VI. Morbid Growths. — § 1. Polypus . — Under this name va-^ 
 rious morbid growths are mentioned by authors. It is represented as ^ 
 a disease peculiar to the mucous tissue, and is generally observed 
 to take place in those regions at which it is not very remote from"|jJ 
 the skin. It occurs particularly in the nose, throat, Eustachian® 
 tube, the external earhole, and in the neck of the womb. In the® 
 stomach and bladder it is less frequent, and it very rarely occurs ® 
 in the intestinal tube. It appears under one of three forms. w 
 
 1. It may take place in the form of a soft ash-gray or bluish pro- ^ 
 duction, glistening on the surface, translucent, spongy, and com- 
 pressible, and attached to the membrane by one or more narrow || 
 necks, which render it pendulous. This, which is what is termed V 
 by practical authors the benign polypus.^ is proper to the mucous fj 
 tissue, of which it appears often to be merely a relaxed production x| 
 or growth. It is much under the influence of atmospheric pressure, S 
 increasing in size, and causing much uneasiness while the weather I 
 is moist and the mercurial column is low. In clear dry weather, on ^1 i 
 the contrary, and when the height of the barometer indicates vigo- 1 
 rous atmospheric pressure, it shrinks and contracts so much that the | ' 
 patient seems to forget its existence. This form of polypus is fre- 
 quent in the nasal mucous membrane, in which it causes much ] | 
 uneasiness during its distended state. It may grow also from the I 
 fibro-mucous membrane of the frontal, sphenoidal, and maxillary 
 sinuses.* When removed it presents, with a few blood-vessels, a 
 
 • G. F. Gruner de Polypis in cavo Navium obviis. I 
 
MUCOUS MEMBRANE. 
 
 073 
 
 flocculent tomentose structure, which is well seen by immersion in 
 water, in which it generally floats. It occurs also in the throat ; 
 and polypi of the same description I have removed from the 
 external auditory hole. Ruysch observed them growing in the 
 maxillary sinus, and proceeding through the passage below the 
 spongy bone into the nostril, — a fact which I find verified by an 
 observation of M. Giles.* The same sort of tumour is occasionally 
 found in the vagina ; and it is a remarkable proof of the general 
 tendency to the formation of these productions, that in some indi- 
 viduals I have seen them occur at the same time in the nasal and 
 vaginal mucous membrane. The formation of this variety of polypus 
 is ascribed by Morgagni to abnormal development of the mucous 
 glands ;t a theory in which he is followed by Plenck.| This, how- 
 ever, is too exclusive, and is not applicable to all cases. 
 
 2. The name of polypus is also given to a firm fleshy incompres- 
 sible mass, oval, spheroidal or pyriform, opaque, dark red or purple 
 in colour, sometimes with narrow, sometimes with broad and rnul- 
 tifid basis. This form of polypus, which is not influenced by the 
 weather, is observed to occur in the pharyngeal or oesophageal mu- 
 cous membrane, (Monro) , in that of the stomach, (Morgagni,§ 
 Monro,ll Granville ;1T) in the intestines, in the colon, and rectum, 
 (Rhodius, Fanton, Portal, hlonro.) In the case of M. Paulo, re- 
 corded by Portal, two fleshy concretions as large as the fist were 
 voided during life ; and after death, which was preceded by hectic 
 and wasting, in the ascending and transverse colon were found four 
 polypous tumours, each as large as a nut, and two smaller ones at- 
 tached to the mucous membrane.** A good example of polypus 
 of the rectum is recorded by Dr Monro, tertius.'\\ In the bladder 
 they are mentioned by Warner, Baillie, and Walter. Instances of 
 uterine polypus, (cercosis, Plenck,) are recorded by Mauriceau, 
 Lamotte, Morgagni, Lieutaud, Levret, Sabatier, Baudelocque, 
 Denman, and Clarke. From these it results, that though polypus 
 occasionally originates from the mucous membrane of the fundus, 
 it more frequently grows from the inside of the neck, or from the 
 os tmcce itself. Upon the nature or the mode of development of 
 this variety of polypus nothing satisfactory is known. It appears to 
 
 * Phil. Trans. No. 226, p. 472. t Epist. xvi. 36. 
 
 $ “ Causa polypi proxima est papill® pituitariae excrescentia seu yegetatio mor- 
 bosa.” Systeraa Tumorum, Classisiii. p. 173. 
 
 § Epist. xiv. 17, 18. II Morbid Anatomy, p. 189, pi. vi. 
 
 ^ Med. Rep. Aug. 1817. ** Anatomie Medicale, Tome v. p. 213. 
 
 -ff Morbid Anatomy of the Gullet, p. 192. 
 
 U U 
 
674 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 consist in deposition of matter entirely new, either in the mucous j| 
 corion, or in the submucous filamentous tissue. The tumour is j 
 almost invariably covered by a thin pelliele similar to mucous 
 membrane, but much more vascular. It appears, on the whole, to 
 be much of the nature of vascular sarcoma occurring in other tex- | 
 tures. It is generally vascular, often traversed by varicose veins, | 
 is liable to frequent hemorrhage, and occasionally degenerates into 
 destructive ulceration. It ought not, however, to be confounded 
 with cancer. 
 
 3. The name of polypus is also given to a broad, sometimes flat, 
 hard tumour, taking place in the nasal mucous membrane, and pe- 
 culiar apparently to this region. It is generally of a reddish or 
 brown colour, harder even than the fleshy polypus, smooth on the 5 
 surface, and presenting the appearance of mucous membrane. | 
 From several examples of this disease which I have had an oppor- 
 tunity of examining, I infer that it depends on some abnormal de- t 
 velopment of the fibro-mucous covering of the spongy or nasal ! 
 bones. It affects not the mucous membrane only, but the subja- 
 cent periosteum, and adheres firmly to the bones, fragments of i; 
 which are not unfrequently rent off in the attempt to extract this i 
 polypus. It has a tendency to induce inflammation and caries of | 
 the bones, but does not appear to possess much malignant tendency 
 of itself. Upon the whole, this variety, though commonly deno- 
 minated polypus, is in truth a tumour of the periosteum, partaking 
 of the polypous character. 
 
 § 2. Tyromatous deposition, commonly denominated tubercular, | 
 is not uncommon in the mucous tissue. It occurs chiefly in the 
 alimentary canal, and in the uterus in the persons of the strumous. 
 
 Its characters in the former situation are well described by Dr 
 Monro tertius* and have been already considered at length under 
 their proper head. In the uterus it has been observed by several. 
 
 § 3. Scirrho-carcinoma is a frequent organic change in mucous 
 tissue. It occurs under four forms, — fibro-cartilaginous deposi- 
 tion, tubercular deposition, colloid deposition, and lardaceous de- 1 
 generation. 
 
 a. Though fibro-eartilaginous deposition may affect any of the re- j 
 gions of these surfaces, it is more frequent in certain points than in 
 others. Thus it occurs very often in the oesophagus, in the cardia, in 
 the pyloric end of the stomach, in the sigmoid flexure of the colon, in 
 
 Morbid Anatomy, p. 217. 
 
:\IUCOUS MEMBRANE. 
 
 675 
 
 the rectum, and in the uterus, occasionally in the larynx and trachea. 
 In the oesophagus and stomach it has been seen by many observers, 
 among others, by Morgagni, Bleuland, Palletta, Baillie, Chardel, 
 Monro, Howship, Armstrong; intbe pylorus it has also been seen by 
 many: (Morgagni, Baillie, Pinel, Holmes, Louis, &c.)and tbe rec- 
 tum is perhaps the most frequent seat of scirrho-carcinoma of any of 
 the internal parts. In all these situations the anatomical characters 
 of the disease are much the same. In the mucous corion, or at its 
 attached surface, is formed a deposition of white or gray fibro-car- 
 tilaginous substance, the fibrous bands running transversely to the 
 direction of the bowel. This deposition is firm, of ligamentous con- 
 sistence, and undergoes a self- destroying process in the interior. 
 In general, however, the mucous pellicle forming its free surface 
 undergoes ulceration ; or contraction of the canal takes place to 
 such an extent as to interfere with the functions of the organ, and 
 terminate life. 
 
 b. Tubercular induration is another form in which scirrhus may 
 affect the mucous tissue. A portion becomes occupied by irregu- 
 lar nodulated masses, consisting of hard spheroidal bodies not un- 
 like cartilage, sometimes softer, like flesh interspersed with cartila- 
 ginous points. This is observed in the oesophagus (Bonetus, Bleu- 
 land, Palletta, Mr David Hay, &c.) in the cardiac and pyloric ori- 
 fices of the stomach, and in the rectum. In the latter it forms 
 many of the examples of scirrho-contraction of that organ. This 
 affection appears to consist in peculiar chronic induration with de- 
 generation of the mucous follicles, in situations abounding in which 
 it most usually occurs. It is observed to attack very often the neck 
 of the uterus. It is totally distinct from the tyromatous deposition 
 of strumous habits, with which it has been occasionally confounded 
 by some observers. The tyromatous deposition occurs chiefly in 
 the young, and has been seen even in infants. Tubercular indu- 
 ration is a disease of middle age and declining years. For some 
 judicious observations on the development and distinctions of these 
 two varieties of cancer, I refer to the writings of Bayle and Cru- 
 veilhier, and a Memoir of Scarpa in his Chirurgical Treatises.* 
 
 By several authorities, on the other hand, it is maintained, that 
 the fibro-cartilaginous and tubercular scirrhus are the same in 
 structure and characters, and differ only in the mode in which the 
 scirrhous matter is deposited. This view may be correct. It is 
 
 Opuscoli (li Chirurgia di Antonio Scarpa, &c. Vol. i. Pavia, 1825. 
 
676 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 perhaps of no great moment. It may be merely observed, that 
 while the fibro-cartilaginous form of scirrhus is common in the ex- 
 ternal glands, as the mamma, lacrymal gland, salivary glands, and 
 testicle, tubercular scirrhus is usually seen in the skin and in 
 certain parts of the mucous membranes, as the oesophagus, cardia, 
 pylorus, and rectum ; and, according to Scarpa, the uterine end 
 of the vagina and the os uteri itself. 
 
 c. Reticular, Areolar, Alveolar, and Colloid Cancer . — A third 
 form in which cancer may attack the mucous surfaces is that which is 
 named reticular and areolar, from its disposition, and colloid or 
 glue-like from its aspect. The general characters of this species 
 of degeneration are a tumour affecting a considerable portion of 
 the stomach, most commonly the anterior and posterior portions of 
 the large ai’ch of the organ ; and in some instances the cardiac 
 portion both anteriorly and posteriorly. It does not seem often to 
 commence in the pyloric portion ; but it may extend from the car- 
 diac or the middle region of the organ to ihapylorus. The tumour 
 is firm, of cartilaginous consistence, and when inspected at the 
 mucous surface of the stomach presents the aspect of a solution of 
 isinglass which has become coagulated, with a sort of honey-comb, 
 or reticular surface like network. The colour is generally light- 
 gray or pearl-like. The structure cuts firm. 
 
 The morbid structure affects primarily, and principally, it appears 
 to me, the mucous membrane of the stomach; and this areolar or 
 colloid form of cancer is more frequently observed in this organ 
 than in any other, or in any other texture. It consists apparently 
 in the infiltration of this colloid or gelatiniform matter into the in- 
 terstitial spaces of the mucous membrane. It renders the stomach 
 thick and hard. The thickness varies from one-fourth of an inch 
 to half air inch, and to three quarters. When divided, the morbid 
 structure appears like a hard or tough solution of firm jelly or 
 isinglass, with numerous communicating cells. 
 
 In general this deposit is confined to the mucous membrane ; and 
 the muscular coat is pale, hard, thicker than natural, with developed 
 fibres, and in a state of hypertrophy. Several authorities, and espe- 
 cially Cruveilhier, state that the muscular coat is also affected by 
 this deposit. But the statement appears not to be confirmed. 
 
 It is also said that this deposit affects primarily the cellular tissue 
 of the stomach. Such appears to be the opinion of Breschet, An- 
 dral, and Raikem. This appears to be still more doubtful than the 
 previous statement. The deposit, originating in the mucous coat 
 
 3 
 
MUCOUS MEMBRANE. 
 
 677 
 
 of the stomach, may extend to the cellular. But that it commences 
 in the cellular appears at present to be a questionable statement, 
 which requires the confirmation of further inquiries. 
 
 Scarpa, though not aware of the exact character of areolar or 
 colloid cancer, shows, nevertheless, that he had seen every reason, 
 from preparations and specimens of the disease, to infer, that it 
 commences in and affects the mucous membrane.* 
 
 In short, areolar, alveolar, or colloid cancer, is to be distinguish- 
 ed from the other forms of this morbid deposit, both by its physical 
 and anatomical characters, by its arrangement, and by the tissues 
 which it affects. In physical aspect it is semihard, elastic, like stiff 
 isinglass solution. In internal structure it is cellular. And lastly, 
 it is, if not exclusively confined to the stomach, much more common 
 in that than in any other organ. 
 
 d. A fourth form in which cancerous disease attacks the mucous 
 tissues is that of lardaceous degeneration. In certain regions, in- 
 deed, this is so rare that it is never seen. For example, though 
 not very frequent in the gastro-enteric mucous membrane, it has 
 been observed in the oesophagus and rectum. It is not known in 
 the tracheo-bronchial membrane. In the uterus, however, it is very 
 common ; and I have seen several instances in which the neck and 
 part of the body of this organ was converted into a ceromatous and 
 apparently inorganic mass. The decomposition of this morbid de- 
 position is peculiar. It terminates not in ulceration, but in a species 
 of softening and pulpy disorganization or liquefaction, rendering 
 the decomposing surface doughy or pasty like soft lard, traversed 
 by marks of erosion similar to those produced by the gnawing of 
 animals, 
 
 § 4. Warty excrescences are occasionally found in mucous mem- 
 branes, They consist of hard eminences often fissured, sometimes 
 sessile with broad base, occasionally peduncular, and occasionally 
 pass into bad ulceration. They are most frequent in the pharyn- 
 geal and oesophageal, and in the cystic and uterine membrane. 
 
 § 5. Fungous growths or excrescences are mentioned as occa- 
 sionally found in the mucous tissues ; but little accurate informa- 
 tion is given regarding them. They are frequent in the bladder 
 
 ■* “ Scirrhus and cancer of the stomach,” he says, “ always begins with induration of 
 the internal mucous membrane of the organ, which becomes thick, hard, cartila- 
 ginous, then ulcerates ; and from the inner coat the disease is propagated to the other 
 membranes of the stomach, which are converted into scirrhus, and cancerous hardness, 
 with ulceration.” Memoria Sullo Scirro et sul Cancro. Opuscoli di Chirurgia di An- 
 tonio Scarpa. Vol. i. Pa\'ia 1825. Folio minore. 
 
678 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 of the male (Lecat, Sandilort, Baillie, Walter, &c.) and the uterus 
 of the female, but appear to be more rare in other regions. It is 
 probable that these excrescences named fungous, are in truth the 
 products of an advanced stage of some organic change either al- 
 ready noticed or to be noticed. In the uterus, for instance, authors 
 mention the occurrence of reddish tumours not' unlike masses of 
 clotted blood, which are manifestly either molce., or fungus hcsma- 
 todes, or some of the products of cancerous ulceration. In other in- 
 stances, as in the bladder, these fungous growths actually issue from 
 the mucous membrane in a morbid state, sometimes the effect of 
 chronic inflammation, or are the result of enlarged prostate. Upon 
 the whole, accurate facts are wanting on this head. 
 
 § 6. Though hgdatids are enumerated by some authors among 
 the morbid products of mucous surfaces, it is not easy to understand, 
 without violation of certain pathological principles supposed to be 
 well-established, the reason of their development in these situations. 
 Thus, hydatids have been stated to be coughed up from the lungs, 
 to he voided from the intestines, and to have escaped from the ute- 
 rus. In the case of the lungs, they are formed originally in the 
 pleura or pulmonic tissue, from which they find their way to the 
 bronchial membrane ; or they may escape from the liver through | 
 the diaphragm ; (Dr Foart Simmons, Dr Monro.) In the case of ij 
 the intestines, they are also in all probability formed in the liver or [ 
 the peritoneum, and thence proceed by ulceration into the intestinal 
 cavity. The uterus, in short, is the only cavity with mucous sur- 
 face, in which inspection shows that they have been found.* Ty- 
 son, nevertheless, states that he found them in the bladder.f 
 § 7. Deposition of bony matter in certain of the mucous surfaces 
 is mentioned by various authorities. Thus Metzger records an in- 
 stance of ossification of the oesophagus Walter one of bony 
 deposition in the inner surface of the pharynx :§ De Haen 
 mentions an osseous degeneration of the stomach ;1| ShortIF and 
 others mention similar deposits in the colon and rectum ; and 
 Hody,** Lettsom,ft Baillie, Odier,and MackieJ^ mention examples 
 
 * Gregorini Dissert. Morgagni, Epist. xlviii. 13, 14. Porta), Anatomie Aledicale, 
 Tome V. p. 527, 528. Rudolphi gives the best account of Hydatids affecting the ute- 
 rus and other organs. Ueber die Hydatiden thierischer Korper, in Anatomisch-Physio- 
 logische Abhandlungen. Berlin, 1802. P. 190. 
 
 t Phil. Trans. No. 188. ^ Ed. Med. Essays, Vol. iv. 353. | 
 
 J Adversaria Medica, p. 176 and 177. ** Phil. Trans. No. 440. j 
 
 § Catalog! AIus. No. 1536. -fT Alem. Med. Society, Vol. v. 
 
 |] Rat. Med. Tom. iv, cap. i. ."I-'J Med. and Phys. Journal. 
 
MUCOUS MEMBRANE. 
 
 G79 
 
 of the same occurrence in the uterus. The history of the mode of 
 development of this deposition is not exactly known ; and it is not 
 quite certain whether the ossification originates invariably in the 
 mucous corion. This indeed appears to have taken place in the 
 instance mentioned by Walter, and in such cases of uterine ossifi- 
 cation as that recorded by Dr Caldwell. * In instances of osseous 
 deposition in the alimentary canal, it is justly suspected by Dr 
 Monro to originate in the muscular fibres. 
 
 § 8. Further, in certain regions of the mucous tissue are found 
 morbid growths which are proper to these regions, and to be found 
 in no other part of the mucous membranes. Thus the milt- like 
 tumour described by Dr Monro has been found chiefly in the sto- 
 mach and bowels ; and the fleshy tubercle of William Hunter and 
 Dr Clark, and the cauliflower excrescence of the latter, are found 
 only in the womb. 
 
 The former variety of tumour, for an accurate description of 
 which we are indebted to Dr Monro tertius, resembles in structure 
 and consistence the milt of fishes, is of a pale red. colour, with an 
 irregular surface, and is covered by a thin but vascular mem- 
 brane, adheres slightly to the organ from which it grows by a num- 
 ber of small vascular processes penetrating the mucous corion, which 
 is unnaturally thick, and presents a honey-comb appearance. The 
 portion of intestine to which such tumour is attached presents marks 
 of vascular injection. The substance of the tumour, though misci- 
 ble with water, which it renders turbid, is indurated by immersion 
 in alcohol, — a circumstance from which it may be inferred to con- 
 tain a proportion of albuminous matter. It emits a fetid oflFensive 
 smell, and communicates tbe same to the organ from which it grows. 
 It is chiefly a disease of advanced life, — a circumstance by which, 
 with others, it may be distinguished from hsematoid fungus. 
 
 The fleshy or sarcoid tubercle of the uterus, though apparently 
 not unknown to Morgagni, was first observed by William Hunter, 
 and has since been distinctly described by Dr John Clarke, Dr 
 Baillie,! and Sir C. M. Clarke. | According to the accounts of 
 these observers, it appears in the form of one or more tumours of 
 hard whitish substance, sometimes as firm as cartilage, projecting 
 from the mucous surface of the organ, but occasionally growing 
 
 * Med. and Surg. Journ. Vol. ii. 22. 
 
 t Morbid Anatomy, chap. xix. p. 37 i. 
 
 t Observations on the Diseases of Females, part i. chap, xviii. p. 243, 
 
680 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 between the peritonaeal coat and muscular layer. In'size they vary 
 from that of a pea to masses of several pounds ; and in shape, though 
 generally spheroidal, they are sometimes irregular. They cause a 
 copious mucous discharge and much local irritation, but without 
 much affecting the constitution. 
 
 The cauliflower excrescence was also first accurately described 
 by Dr John Clarke ; * and his description has been since verified 
 by his brother Sir C. Mansfield Clarke. From the observations of 
 these authors, it results that the cauliflower excrescence arises al- 
 ways from some part of the os uteri. When first recognised, it 
 forms an irregular prominence, with a broad base and a granulated 
 surface. As the tumour increases in size, the granulated structure 
 of its surface becomes more distinct, and begins to be parted into 
 numerous elongated granules, which give it the appearance of a 
 cauliflower when it begins to run to seed. In most instances these 
 granules are friable and brittle, and break off, if rudely handled, 
 in the form of minute white fragments ; and indeed such fragments 
 are occasionally or periodically discharged with the urine and other 
 fluids. Its surface, which is of a bright flesh colour, is covered by 
 a thin delicate membrane, from which oozes abundantly a sero-al- 
 buminous fluid, which mats the linen like starch, and occasionally 
 blood flows copiously. In married women who have had children 
 its growth is rapid ; in those not exposed to sexual intercourse it 
 is slow. The attempts made to inject this growth have been un- 
 successful. The injection escapes from its surface rapidly; and it 
 shrinks so much after death, that it is impossible to recognize any- 
 thing but a small loose flocculent membranous prolongation of the 
 part to which it is attached. These circumstances, with its hemor- 
 rhagic character, lead Sir C. Clarke to regard it as an assemblage 
 of minute arteries similar to the placental structure. It is probably 
 a morbid variety of erectile tissue.f 
 
 VII. Displacements. — The mucous merahranes, partly in con- 
 sequence of their loose connection in many instances with subjacent 
 tissues, partly in consequence of inordinate action in the muscular 
 fibres of their proper organs, sometimes in consequence of inflam- 
 mation, are liable to various unnatural changes of situation. Thus 
 the eyelids are liable to eversion, the rectum.! vagina, and the 
 
 * Transactions of a Society, Vol. iii. p. 298. 
 
 t Observations on those Diseases of Females, &c. Part ii. 
 
MUCOUS MEMBRANE. 
 
 681 
 
 uterus to prolapsus and procidentia, the uterus to inversion, and the 
 intestinal canal to invagination and hernial protrusion. 
 
 VIIT. Malforjmations. — § 1. Lastly, Malformations are fre- 
 quently observed in the mucous system ; hut it is often difficult to dis- 
 tinguish between those which are proper, and those which are com- 
 mon to it with collateral and subjacent tissues. Occasionally, for in- 
 stance, parts of the mucous system in common with the other con- 
 stituent tissues of an organ are wanting. Thus part of the alimen- 
 tary canal may be deficient, and the urinary bladder or the rectum 
 has been known to be wanting. In other instances, part of the 
 mucous tissue of one organ may be so incomplete, that a direct 
 communication with another is established. Thus the. velum may 
 be fissured and the palate may communicate directly with the na- 
 sal passages ; the vagina may open into the rectum, the bladder in 
 the hypogastric region, or communicate directly with the rectum ; 
 or the urethra may open into the perinseum. The mechanism of 
 malformations of this description is to be explained by the history 
 of the development of the mucous system during the early months 
 of foetal existence. The researches of Wollf, Oken, J. F. Meckel, 
 and Tiedemann, show that a slight interruption given to the pro- 
 cess of development at this period, while the cutaneous and mucous 
 surfaces are in direct continuation upon the mesial plane, is suffi- 
 cient to continue through life a peculiarity of structure, which be- 
 longs only to the embryo during formation. 
 
 § 2. Congenital Fistulaeoftheneck, — One of the most curious exam- 
 ples of this sort of malformation is furnished by the fistulce of the neck 
 described by Dzondi,* Ascherson,f and Meyer.;]; These fistulae are 
 in general known by a very minute, almost imperceptible aperture, 
 on the lateral surface of the neck, appearing in the angle formed 
 by the internal head of the sterno-raastoid muscle and the sternal 
 end of the collar-bone, or at the inner margin of that muscle. This 
 is the external aperture. An internal one is not in all cases ob- 
 
 * Carolus Henricus Dzondi, Phil.-Doct. et Chir.-Doct. De Fistulis Trachea Con- 
 genitis, Commentatio Pathologico-Therapeutica. Halae, 1829. 8vo. 
 
 -f- Ferdinandus Mauritius Ascherson, M. D., De Fistulis Colli Congenitis. Adjecta 
 Fissurarrim Branchialium in Mammalibus, Avibusque, Historia Succincta. BeroKni, 
 183-2. 4to. 
 
 t De Fissuris Hominis Mammaliumque Congenitis. Accedit Fissurse Buccalis Con- 
 genitae cum Fissur<e Tubs Eustachii et Tj-mpani Complicats Descriptio. Auctore 
 Conrado Meyer Tigurino ; Medicins utriusque Doctore. Cum quatuor tabulis sneis. 
 Berolini, 1835. Folio. 
 
682 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 served. The course of the fistula^ which is so small as often to ad- 
 mit only the lacrymal probe of Anel, is in general towards the 
 pharynx ; and in some cases water may be injected by the fistula 
 into the pharynx. 
 
 r rom the external aperture of these fistulce exudes, from time to 
 time, a thin white drop of transparent glutinous fluid, not unlike 
 white of egg, sometimes like purulent matter. The inner surface 
 of these fistulse is smooth, reddish, and like that of a mucous mem- 
 brane. 
 
 These fistulae, which are congenital, are the remains of the bran- 
 chial slits of the early intra-uterine period of the foetus, in conse- 
 quence of the process of closure of these slits being in some manner 
 stopped. They cannot be healed without inconvenience ; in one case 
 the attempt was followed by apoplectic death ; and there is reason 
 to believe that they must have been left open for some salutary pur- 
 pose. 
 
 They are more frequent in females than in males in the ratio of 
 about eight to three. 
 
 They are observed in certain families more commonly than in 
 others. 
 
 § 3. The sacs of the ileum and bladder, called diverticula, appear to 
 depend on deficiency of the muscular layer, in consequence of which 
 the mucous corion is protruded through the defective space. (Mor- 
 gagni ; Palletta.) 
 
 § 4. In other instances, deviations from the normal arrangement 
 consist in unnatural unions of mucous surfaces, rendering the canals 
 which they line impervious, and constituting varieties of imperfora- 
 tions. Thus the pyloric orifice of the stomach has been found 
 closed,* the rectum imperforate, and the vagina imperforate. These, 
 in all probability, are to be ascribed to deficiency of mucous mem- 
 brane, in consequence of which the contiguous parts contract ad- 
 hesion. 
 
 § 5. In other instances, again, malformations are the result of dis- 
 ease. Of this description are the enlarged or distended state of the 
 pulmonic vesicles, produced by several being hurst into one large 
 cavity ; the central contraction of the stomach ; the sacculated state 
 of the urinary bladder; the dilatations of the alimentary canal, in 
 consequence of the lodgement of foreign bodies or concretions ; 
 
 * Case bv Mr Crooks, Edin. Med.-Chirur. Transactions, Vol. ii. 589. 
 
 4 
 
SEROUS MEMBRANE. 
 
 . 683 
 
 and those of the gall-bladder or gall ducts, in consequence of the 
 presence of gall-stones. Another variety of the same description 
 of malformation consists in the fistulous openings occasionally 
 eflTected between the mucous membranes and the cutaneous sur- 
 face by the process of progressive ulceration. To this head be- 
 long the Jistulae of the stomach, of which many examples, from 
 wounds and similar injuries, as well as spontaneous abscesses, 
 are now recorded ; the Jistulae which result from the ulceration 
 caused by the discharge of gall-stones ; artificial anus so frequent 
 after intestinal inflammation, and especially that which attends 
 strangulated hernia ; urinary fistulse, whether taking place from 
 the bladder in the hypogastrium or rectum, or from the urethra ; 
 and destruction of the recto-vaginal septum in females, either by 
 laceration or ulceration. These fistulse are covered by a smooth 
 callous membrane so similar in its properties to mucous texture 
 that John Hunter, Meckel, and some other authors think it not an 
 extravagant or gratuitous hypothesis to regard them as examples of 
 the abnormal development of mucous texture. 
 
 CHAPTER HI. 
 
 Section I. 
 
 SEROUS MEMBRANE, TRANSPARENT MEMBRANE ; Membrann 
 
 pellucida, — M. serosa ; — Tiss?i Sereux. 
 
 The pleura and peritonaeum are the best examples of the tissue, 
 which has been named serous, from the fluid with which it is moist- 
 ened, and which may be termed transparent or diaphanous as its 
 distinctive character. 
 
 The distribution or mechanical arrangement of these membranes 
 is peculiar, and was not well understood by anatomists till Douglas, 
 in 1730,**^ by his description of the peritonaeum, rendered it clearer 
 
 A Description of the Peritoneum, and of that part of the Membrana Cellularis 
 which lies on its outside. With an Account of the true situation of all the Abdo- 
 minal Viscera in respect of these two Membranes. By Dr James Douglas, Physician 
 in ordinary to her Majesty, &c. London, 1730. 4to. 
 
684 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 and more intelligible. Since that time the distribution of these 
 membranes, individually and generally, has been elucidated by the 
 labours of Hunter, Carmichael Smyth, and Bichat, with a degree 
 of perspicuity and precision which leaves little to be done by sub- 
 sequent observers. Notwithstanding this, Valentin Hansen of 
 Triers, a learned student of the University of Berlin, thought it, 
 in 1834, a subject worthy of further inquiry and explanation ; and 
 his dissertation must be allowed to be a good memorial of industry 
 and intelligence.* 
 
 In this, nevertheless, there are certain peculiarities which may 
 perplex the beginner, and prevent him from obtaining at first a 
 clear idea of the distribution and configuration of the pellucid 
 membranes. Thus they have neither beginning nor termination ; 
 they have neither orifice nor egreclient canal ; and they are not 
 continuous with any other membrane or texture. 
 
 § 1. Every serous membrane consists of a hollow' sac everywhere 
 closed, and to the cavity or interior surface of which there is no 
 natural entrance, a circumstance from which they have been deno- 
 minated shut sacs, {sacci occlusi ; sacs sans ouverture.') In every 
 serous membrane one part is inverted or inflected, or reflected, as 
 is commonly said, within the other, so that the inner surface of the 
 former part is applied with more or less accuracy to the inner or 
 like surface of the latter. This mode of disposition has suggested 
 to anatomists the homely and trite, but not inappropriate compa- 
 rison of a serous membrane to a nightcap, one-half of which is 
 folded or doubled within the other, so that while one-half of the 
 inner surface is applied to the remaining half, no communication 
 exists between the inner and the outer surface. Every serous 
 membrane, in short, is a single sac, one-half of which is doubled 
 within the other. 
 
 In every serous membrane the outer surface of the unreflected 
 portion is applied over the walls of the region which the serous 
 membrane lines, while the outer surface of the inflected portion is 
 applied over the organ or organs contained in that region. From 
 this arrangement it results that each organ covered by serous mem- 
 brane is not contained in that membrane, but is on its exterior sur- 
 
 ’ Peritonaei Humani Anatomia et Physiologia, Dissertatio Inaug. Quam pro sum- 
 mis in Medicina et Chirui’gia Honoribus in Universitate Literaria Frederica Guilelma, 
 rite sibi conciliandis, die 21 Junii 1834, publice defendet Auctor Valentinus Hansen 
 Rhenano-Borussus. 4to. 
 
SEROUS MEMBRANE. 
 
 685 
 
 face, and that of every organ so situate, one part at least, viz. that 
 at which its vessels and nerves enter, is always uncovered. Thus 
 the lungs are on the outer surface of the pleura ; the heart is on 
 the outside of pericardium ; the stomach, intestines, liver, spleen, 
 and pancreas are on the outside of the peritonceum ; and the tes- 
 ticles are on the outside of the peridydimis. In the same manner 
 the lungs, though invested by pleura before and behind, at their 
 apex and their base, are uncovered at their roots, or the points 
 where the bronchial tubes and great blood-vessels enter their sub- 
 stance ; the heart is uncovered by pericardium at the upper part 
 of the auricular cavities ; and the intestinal canal is uncovered 
 along the whole of that longitudinal but tortuous line by which the 
 mesentery is attached, and at which its proper vessels and nerves 
 are transmitted. 
 
 To comprehend the arrangement of the pellucid membranes still 
 more distinctly, it is expedient, by an effort of abstraction, to trace 
 the course of any one of them, having previously thrown out of the 
 question the necessary means by which their interior or free sur- 
 face is exposed. In this mental process, also, it is requisite to re- 
 member that there is no initial point save what is arbitrarily made. 
 If, for example, the course of the pleura be traced, the membrane 
 presents no natural mark or boundary from which the anatomist is 
 to commence his demonstration ; and he must fix artificially on 
 any point which he finds most convenient for the purpose. Com- 
 mencing with this understanding, from the circumference of the 
 spot termed root of the lungs, the membrane may be traced first 
 along the internal surface of the chest formed by the ribs and in- 
 tercostal muscles, forwards to tbe sternum, upwards to the first rib 
 and apex of the thoracic cavity, and downwards to the diaphrag- 
 matic insertions, and over the surface of that muscle, and the outer 
 surface of the pericardium again, to the circumference of the root 
 or connection of the lungs. From this point again it may be traced 
 over the surface and between the lobes of these organs, both of 
 which, as already stated, are thus situate on the outside of the 
 pleura. The course first described is that of the unrejlected or ex- 
 terior division of the pleura. The second, or that over the organ 
 covered, is the course of the inflected or doubled portion of the mem- 
 brane, which is thus necessarily smaller and less extensive than the 
 former. 
 
 The arrangement thus sketched, which may be easily shown to 
 
686 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 be applicable to all the serous membranes, demonstrates their two- 
 fold character of lining the walls of a cavity and covering the organs 
 contained. From an idea of this property the older anatomists 
 applied to them the epithet of membranes succingentes. 
 
 In tracing the course of the serous membranes, the anatomist 
 observes, that they present productions which float with more or less 
 freedom in the cavity formed by the free surface, and which may be 
 generally shown to consist of two folds of the single membrane pro- 
 duced beyond the inclosed organ, but still maintaining the unity of 
 the membrane. Of these prolongations, the most distinct examples 
 are the epiploon and the appendices epiploicce of the peritonaeum. 
 Less manifest instances are the adipose folds of the pleura near the 
 mediastinum, and the bladder-like appearance at the base of the 
 heart, within the pericardium. The synovial fringes in the interior 
 of the synovial membranes, which belong to a subsequent head, are 
 nevertheless of the same general character. Between the folds of 
 these productions there is invariably more or less adipose substance, 
 which indeed is observed, in some quantity, in various parts of the 
 filamentous tissue on the outer surface of the serous membranes in 
 general. 
 
 Every serous membrane I have above represented as a hollow 
 sac everywhere continuous, and the outer surface of which has no 
 communication with the inner. To this character the only excep- 
 tion is the peritonasum in the female, which is perforated at two 
 points, corresponding to the upper extremity or orifice of the Fal- 
 lopian or oviferous tubes. This has been already mentioned as the 
 only spot at whieh the mucous and serous surfaces communicate 
 directly with each other. 
 
 Every serous membrane may be described as consisting of a very 
 thin, colourless, transparent web or pellicle, through which the 
 tissue of the subjacent organ or parts may be easily recognized ; and 
 every serous membrane presents two surfaces, an attached or ad- 
 herent, and a free or unadherent. 
 
 The attached surface, which is also termed its outer one, is that 
 by which it is connected to the tissue or organ which it covers ; it 
 is somewhat irregular, flocculent or tomentose, and is evidently con- 
 nected by fine filamentous tissue. The degree of attachment is very 
 variable in different membranes, and in different points of the same 
 membrane. In general serous membranes adhere much less firmly 
 to the walls of cavities than to the surface of the contained organs. 
 
SEROUS MEMBRANE. 
 
 687 
 
 Thus the abdominal peritonaeum and the costal pleura are more 
 easily removed than the intestinal peritonaeum and the pulmonic 
 pleura. The peritonaeum adheres feebly to the bladder, to the 
 liver, and to the pancreas, more intimately to the differenUregions 
 of the intestinal tube, and seems to be almost identified with the 
 substances of the female organs of generation. From the in- 
 terior of the capsular pericardium and from the vaginal coat 
 it is almost impossible to detach the serous pellicle. The former, 
 however, I shall have occasion to show, is peculiar in having between 
 the serous surface and the fibrous membrane no filamentous tissue, 
 upon the abundance or deficiency of which the degree of adhesion 
 depends. 
 
 The free or unadherent surface, which has been also named inner ^ 
 is very smooth or polished and uniform, moistened with a watery 
 fluid, fi’om which it derives in some degree its shining appearance, 
 and completely destitute of fibres or any other trace of organic 
 structure. From this smooth polished aspect, which is a peculiar 
 attribute of the free surface of serous membrane, all the organs 
 covered by it derive their glistening appearance. Thus the exte- 
 rior surface of the lungs derives its appearance from the pleura, the 
 heart from the pericardium, the liver and intestinal canal from the 
 peritonaeum. A successful injection of size or turpentine, colour- 
 ed with vermilion, brings into view so many capillary blood-vessels 
 in this membrane, that it might be supposed at first sight to con- 
 sist entirely of minute arteries and veins. F arther, by proper ma- 
 nagement, lymphatics may be injected in it with quicksilver to a 
 degree equally minute and delicate. From these experiments, 
 therefore, it may be concluded, that serous membrane is chiefly 
 composed of minute arteries and veins conveying colourless fluids, 
 and of vessels connected with the general trunks of the lymphatic 
 system. Whether it contain anything else but vessels of this kind, 
 or has a proper substance or tissue, remains to be ascertained. 
 Though nerves are often seen passing along their outer or attach- 
 ed surface to the neighbouring tissues, none have hitherto been 
 traced either into the pleura or peritonaeum. 
 
 By most of the older anatomists, and among others by Haller 
 and William Hunter, serous membrane is considered as of the na- 
 ture of filamentous tissue or cellular membrane, more or less closely 
 condensed, {tela cellulosa stipata ,•)* and this view is adopted and 
 * Elem. Physiolog. Lib. iv., sect. i. § i. xvi. Lib. xxii. 
 
688 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 maintained by Bordeu,* Bichat, f Meckel, | and Beclard,§ the last 
 of whom, however, thinks they partake of ligamentous characters. 
 Macerated they become soft, thick, and pulpy ; and are finally re- 
 solved into flocculent filamentous matter. In the course of decom- 
 position in the dead subject they first lose their glistening aspect, 
 then become covered by a foul dirty coating of viscid matter, which 
 appears to exude from their surface ; and eventually they are dis- 
 solved into shreds. Immersion in boiling water renders them thick, 
 firm, and somewhat crisp. When dried they become thin, clear, 
 and transparent, and, if preserved from humidity or the attacks of 
 animals, may remain long unchanged. The experiments of Hat- 
 chett, Fourcroy, and Vauquelin, show that they contain gelatin and 
 a little albumen ; but no precise information on their chemical com- 
 position has yet been given. 
 
 The principal character of the serous membranes is that of iso- 
 lating the organs which they cover, and to the structure of which 
 they are foreign or adventitious, and forming shut cavities, in which 
 there is an incessant process of exhalation and absorption. In some 
 instances they evidently contribute to facilitate the mutual motions 
 of contiguous and corresponding parts and surfaces. From their 
 free surfaces is secreted a fluid containing a very small portion of 
 albumen, (Hewson,|| Bostock,f) which is greatly augmented during 
 the state of disease. 
 
 The mode of development of the pellucid membranes is not very 
 well ascertained. The investigations regarding organogenesy by 
 Oken, Meckel, and Tiedemann, to which I have occasion so fre- 
 quently to allude, disclose facts which induce Meckel to hazard the 
 opinion that some of them are not at all times shut sacs. I have 
 some reason to doubt, however, whether the fact which he adduces 
 for this purpose necessarily implies the open condition of the peri- 
 cardium and the peritonaeum. In the case of the former the de- 
 velopment of the heart proceeds from the basis generally, without 
 affecting the integrity of the investing membrane. In the case of 
 the latter there is more reason to believe, that at the navel at least 
 the peritonaeum is either open, or is continuous with the vitellar 
 membrane. 
 
 * Recherches sur le Tissu Muqueux, sect. i. § i. 
 
 •j- Anat. Generale, Tome iv. p. S73. + Handbuch, B. i. 
 
 § Elemens d’Anat. Gen. p. 228. 
 
 II Experimental Inquiries, ii. chap. vii. 
 
 H Nicholson’s Journal, Vol. xiv. p. 147, and Medico-Chirurg. Tr. Vol. iv. 
 
SEROUS MEMBRANE. 
 
 689 
 
 In the foetus the serous membranes are so thin, that they are 
 much more transparent than in the adult. In small animals also, 
 they are more transparent than in lai’ge, and in cold-blooded ani- 
 mals than in the mammiferous. Of some also the disposition va- 
 ries at different periods. Thus the descent of the testicle, — a pro- 
 cess which has been so well explained by Albinus, Haller, Wris- 
 berg, and Langenbeck, — is necessarily attended with a remarkable 
 change in the arrangement of that portion of peritonaeum which 
 the gland impels before it. 
 
 The above description applies chiefly to the general characters 
 and properties of serous membranes. I have yet, however, to ad- 
 vert to certain forms of this tissue, which, though similar in gene- 
 ral characters, present too many peculiarities to be justly identified 
 with them. The first which I notice as least different is the -peri- 
 cardium, or capsule of the heart ; the second is the arachnoid mem- 
 brane, which shall be examined with the cerebral envelopes. 
 
 § 2. The capsule of the heart {pericardium) consists of two portions 
 or layers, an outer or proper capsular, and an inner or lining di- 
 vision. The outer or proper capsular part of the pericardium pos- 
 sesses the characters of a fibrous membrane, of some density and 
 considerable strength. When properly washed its colour is gray 
 or grayish-white, and it appears to consist of very minute fibrous 
 threads, which are arranged without any definite order. These 
 fibres are most distinct at its lower margin, where it is connected 
 to the circumference of the tendinous part of the diaphragm. In 
 the young subject it is generally thin and translucent ; in adult 
 age or advanced life it is thicker and more opaque. This part 
 of the pericardium is a mere investing membrane, which bounds the 
 region containing the heart, but which extends no further. It 
 embraces the origins of the large vessels above, adheres to the 
 margins of the tendinous centre below, and is on each side con- 
 nected with the pleura. 
 
 When the pericardium is slit open, its inner surface has the ap- 
 pearance of a transparent or serous membrane, through which the 
 fibres of the outer or capsular part may be seen, and which has the 
 usual glistening aspect of such membranes. It is difficult, however, 
 to insulate it from the outer layer, unless by boiling, when it may 
 be peeled off in minute shreds. 
 
 Like the transparent membranes, this inner layer has neither 
 beginning nor end, neither origin nor termination. After lining 
 
 X X 
 
690 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the inner surface of the proper capsule, it may he traced from the 
 angle at which this capsule a:clheres to the large arteries and veins, 
 over the auricles, and finally, over the outer surface of the ventricles 
 to the apex of the heart. 
 
 In this whole course, it preserves the characters of a thin trans- 
 parent membrane, with a free surface and an attached one. The 
 free surface is perfectly smooth, glistening, and moistened with a 
 watery fluid. The attached surface adheres, on the one hand, to 
 the inner surface of the capsule, and on the other, to the outer 
 surface of the heart, by means of fine filamentous tissue. 
 
 Injection shows that the pericardium consists chiefly of minute 
 arteries and veins. The substance of the capsular part is probably 
 a modification of the white fibrous system; but it requires to be 
 more carefully examined. No nerves have been traced into any 
 part of this membrane, nor is it quite certain that it contains lym- 
 phatics. 
 
 § 3. The cerebral membranes are not uniform in nature, and can- 
 not be conveniently referred to any head save that of compound 
 membranes. TYiedura mater is fibrous; the fia mo.ter is supposed to 
 be celluloso-vascular ; and Bichat has laboured to demonstrate that 
 the arachnoid is a serous membrane, — a view which is adopted by 
 Meckel and Bedard, but rejected by Gordon. By configuration 
 and disposition, I believe it is more easily referable to this than to 
 any other class ; and I therefore introduce its anatomical history 
 in this place. 
 
 The brain has been said to be surrounded by three membranous 
 envelopes, the hard membrane {meninx dura^ dura mater)^ the web- 
 like membrane {tunica arachnoidea)^ and the soft or thin membrane 
 {meninx tenuis, pia mater.') There is perhaps no great or just ob- 
 jection to this arrangement, which has been adopted by almost all 
 writers. But it simplifies the subject, without impairing the truth 
 of what is observed, to I’efer them to two only ; one of which, the 
 hard membrane {meninx dura, dura mater'), is com- 
 
 mon to the brain with the inner surface of the skull ; the other, 
 the thin membrane {meninx tenuis, Mvr/^ Xevrrt, pia mater'), is pro- 
 per to the brain only. They may be distinguished, therefore, by 
 the terms common membrane of the brain and proper membrane of 
 the brain. The arachnoid, again, is a pellucid web common to the 
 two cerebral membranes. 
 
 The first of these, the common or hai-d cerebral membrane {me- 
 3 
 
SEROUS JIEMBRANE. 
 
 691 
 
 ninx dura, dura mater), presents two surfaces, an outer or cranial, 
 and an inner or cerebral. The outer surface is irregular, filamen- 
 tous, and vascular ; and the substance of which it consists is dis- 
 tinctly fibrous. The fibres, however, do not follow any uniform 
 direction, hut are interwoven irregularly. Maceration causes this 
 membrane to swell and become separated into fibrous threads. It 
 is well known that it is liberally supplied with blood-vessels, and 
 that it is connected by these to the inner surface of the skull. No 
 nerves or absorbents have been discovered in it. This outer or 
 cranial surface of the dura mater is manifestly of the nature of pe- 
 riosteum. Its vessels may be ti’aced into the inner table ; it con- 
 tributes to the formation of the cranial bones in the foetus ; and 
 various facts show that it contributes to their nutrition during life. 
 
 The inner or cerebral surface of this membrane is very smooth, 
 uniformly polished, and shining ; and when examined in water, it 
 appears to be formed of a very thin, transparent membrane, through 
 which the cranial or outer surface and the fibrous structure of the 
 hard membrane may easily be recognized. This pellucid inner 
 membrane, which is termed by Baillie the inner lamina, I shall af- 
 terwards show, is the exterior division of the arachnoid membrane. 
 
 The dura mater is an extensive membrane, and lines not only 
 the interior surface of the skull, but that of the whole vertebral 
 column. Here indeed it undergoes some modification. The inner 
 surface of each vertebra has a proper periosteum continuous with 
 the periosteum of the outer surface ; and from this issues a quan- 
 tity of filamentous tissue, which penetrates directly a membranous 
 canal, evidently of fibrous^structure, (theca vertebralis,) tough and 
 firm, but more delicate than the cranial dura mater. The dura 
 mater in its course forms sundry prolongations ; for instance, the 
 large crescentic one named the falx, the horizontal otte termed 
 tentorium, and the small crescentic one named falx minor or cere- 
 belli. 
 
 The thin, soft, or immediate and proper cerebral membrane, 
 (jjia mater, meninx temds,) presents in like manner two surfaces, a 
 smooth or cranial, which is exterior, a filamentous or cerebral, 
 which is interior and central. 
 
 The outer or smooth surface of the thin membrane, {pia mater,) 
 has a glistening appearance; and if examined attentively it is 
 found to be formed by a very thin transparent membrane, exactly 
 similar to that which forms the cerebral surface of the dura mater. 
 
G92 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 It is possible to recognize through it the subjacent cerebral part of 
 the membrane, its vessels and the appearance of the brain itself. 
 This surface has been named in the ordinary 'woi’ks the web-like 
 membrane, {tunica arachnoidea). It is believed to be a separate 
 membrane from the pia mater ; but that which forms the inner or 
 cerebral surface of the dura mater has a claim equally strong to 
 this distinction. 
 
 The inner or cerebral surface of the proper or soft membrane, 
 
 I have already said, is filamentous, flocculent, and somewhat rough. 
 
 It indeed presents a surface which sends out many angular pro- 
 cesses of animal substance, which is filamentous and loose in ap- 
 pearance, and which evidently, by numerous minute vessels, arte- 
 ries, and veins, communicates with the convoluted surface of the 
 brain. These processes, which are the Tomenta of the ancient 
 anatomists, correspond to the furrows of the convoluted surface in 
 which they are lodged. In detaching the membrane from this 
 part of the brain, numerous vessels are observed to be drawn out 
 of its substance ; and when the membrane is injected these vessels 
 may be seen distinctly filled, and communicating with the gray 
 matter of the convoluted surface. The veins of this membrane 
 may be traced to the sinuses in those large longitudinal vessels 
 which are lodged in folds of the hard membrane. 
 
 After suitable injection, it is difficult to perceive any thing but 
 arteries and veins in the proper cerebral membrane. Neither 
 nerves nor absorbents have yet been recognized in it. Bichat con- 
 siders that it contains a notable quantity of cellular tissue. This, 
 however, is denied by Gordon, who could not recognize such tis- 
 sue. The difference, however, consists merely in name. The pia 
 mater, indeed, possesses no cellular tissue like the subcutaneous, 
 tbe submucous, or the subserous. If, however, a portion of the 
 arachnoid be peeled from it by careful management of the forceps 
 and blowpipe, there is found a quantity of loose filamentous or 
 flocculent matter, which evidently unites this tissue to the finer web 
 of the former. It is further remarkable that Dr Gordon himself 
 admits that the inner surface (he should have said the outer or 
 attached) of the arachnoid membrane is more or less thready or 
 flocculent, according to its connection with the pia mater, without 
 seeming to be aware that this thready appearance is occasioned by 
 filamentous tissue. Lastly, the existence of this tissue between the 
 
 4 
 
SEROUS MEMBRANE. 
 
 693 
 
 pia mater and arachnoid is unequivocally demonstrated by the phe- 
 nomena of serous infiltration. 
 
 The distribution and configuration of the pia mater is peculiar ; 
 and correct knowledge of these is requisite in order to understand 
 its pathological relations. The pia mater, or proper membrane of 
 the brain, consists of two parts, an outer, covering the convoluted 
 surface of the brain, and an inner or central, entering the cavities 
 formed by the inner, central, or figurate surface, and spread over this 
 surface in the form of what has been termed the vascular or choroid 
 web ; {plexus ctioroides ; tela clioroidea.') The arrangement of the 
 first or exterior division of the cerebral membrane is well known. 
 Its flocculent-vascular, or tomentose surface, is applied closely and 
 immediately to every part of the convoluted surface, both eminences 
 and depressions {gyri et sulci) ; to every part of the foliated surface 
 of the cerebellum in like manner ; and finally, though in a more 
 delicate form, to the surface of the spinal chord, transmitting those 
 vessels which enter and issue from the substance of each part. 
 
 The continuity of the pia mater or exterior division of the proper 
 cerebral membrane, with the choroid plexus or interior division, 
 may be demonstrated in the following manner. First, the pia ma- 
 ter may be traced behind and below the posterior extremity of the 
 mesolobe or middle band, {(Smixo, nXkoubii, corpus callosum, der bab 
 ken,) where it is continuous with the transverse web called velum 
 interpositum, and which may be regarded in this order of examina- 
 tion as the first part of the central division. Secondly, from this 
 point, the situation of the velum interpositum, it may be traced for- 
 wards on both sides of the mesial plane into the lateral ventricles, 
 spread over the surface of the optic thalamus and striated eminence 
 in the form of the vascular web called choroid plexus, the right half 
 of which communicates with the left by means of a similar slip of 
 vascular' membrane lying beneath the vault {fornix), and behind 
 the anterior pillars of that body at the spot termed Foramen Mon- 
 roianum. Thirdly, it may be traced over the geniculate bodies or 
 posterior eminences of each thalamus into the posterior-inferior cor- 
 nu, or sinuosity of the lateral ventricle, where it covers the great 
 hippocampus. Fourthly, it may be traced at the angle between the 
 cerebellum and medulla oblongata, or what is named the bottom of 
 the fourth ventricle, where it forms a very minute choroid plexus 
 seldom noticed by anatomists, but not less distinct, and which may 
 be traced up the fourth ventricle to be connected with the velum 
 
694 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 interpositum in the middle ventricle, and with the lateral portions 
 of the hippocampus on each side. 
 
 Each choroid plexus, or, to speak more accurately, each of the 
 divisions of the choroid plexus now enumerated, may be shown to 
 be mutually connected, and to form parts of one general membrane, 
 which again constitutes the inner or central division of the great 
 membrane of which the pia mater forms the exterior. Each divi- 
 sion of the choroid plexus, in like mannei*, is connected, by means 
 of minute blood-vessels, to the portion of the figurate cerebral sur- 
 face on which it rests, and it appears to perform the same function 
 of sustaining vessels as the pia mater does to the convoluted sur- 
 face. 
 
 The membranous nature and appearance of the choroid plexus 
 may be demonstrated by immersing it in clear water, when, by a 
 little management of the probe and foi’ceps, it may be spread out 
 exactly like the pia mater, which it closely resembles. It presents 
 the appearance of a thin semitransparent web, one surface of which 
 is smooth, the other somewhat flocculent, and the substance of which 
 appears with and without a glass to be traversed by numerous mi- 
 nute vessels. The transparent web, which forms the basis or ground- 
 work of this membrane, possesses the characters of very close fila- 
 mentous tissue ; and it may be regarded as a filamento-vascular 
 web. Its smooth surface, which is also the free one, is manifestly 
 a continuation of the arachnoid membrane. Like that it is smooth, 
 polished, thin as the finest silver paper, and it may be raised from 
 the more filamento-vascular basis of the membrane to which it ad- 
 heres. 
 
 I am now, by describing the characters and distribution of this 
 membrane, to show how far it resembles, and how far it is unlike, 
 the perfect serous membrane. 
 
 The fine inner lamina from which the cerebral surface of the 
 dura mater derives its glistening aspect, I have already stated, is to 
 be regarded as the outer or cranial division of the arachnoid mem- 
 brane. This is to be proved, first, by its anatomical characters, 
 and, secondly, by its distribution and transit. 
 
 The inner or free surface of the dura mater presents, it has been 
 already said, all the characters of the free surface of the pia mater, 
 except one, the facility with which the thin pellicle, which gives it 
 these characters, can be detached. This, however, is derived from 
 the want of filamentous tissue intermediate between the fibrous layer 
 
SEROUS MEMBRANE. 
 
 695 
 
 of the dura mater and the pellucid membrane; and the latter is 
 thus so intimately united with the former, that it is difficult, if not 
 impossible, by the ordinary means, to detach them. This, however, 
 is no more a reason for regarding this pellucid pellicle as the same 
 as the dura mater, than the intimate adhesion of the capsular peri- 
 cardium to its fibrous coat, or of the peritonaeum to the female 
 ovaries, is for regarding the membranes as part of these organs. 
 Immersion in boiling water and maceration produce on this surface 
 of the dura mater the same effects as on the free surface of \he, pia 
 mater. Lastly, the phenomena of morbid processes indicate that 
 these surfaces are in all respects similar ; and if the thin pellicle on 
 the free surface of the pia mater is entitled to separate existence, 
 that on the free surface of the dura mater is equally so. 
 
 The continuity of these two divisions, demonstrated by their con- 
 figuration, affords proofs of the same description. This is most 
 easily accomplished by tracing the dura mater from those points at 
 which it adheres to the inner surface of the cranium, to those at 
 which the several nerves issue from that cavity by the cranial holes. 
 If the optic nerves be attentively examined at the spot where they 
 enter the optic foramina, the dura mater, which covers the bone 
 around these holes, is found to go a very short distance into them, 
 to stop suddenly, and be reflected backwards, in anatomical lan- 
 guage, to cover the nervous trunks, and to extend along the pia 
 mater. This reflected portion is in truth the arachnoid membrane 
 which lines the dura mater, passing from it along the nervous chords 
 to form the free surface of the pia mater. In like manner, if the 
 third pair or oculo-muscular, or fifth or tergeminal nerves be exa- 
 mined at the openings at which they perforate the skull, the dura 
 mater is found adhering firmly round their several mai'gins to the 
 bone by its outer or attached surface, while its inner free surface 
 turns back on the nervous chords, and is thence continued over the 
 pia mater. In short, the continuity of this thin transparent mem- 
 brane from the dura mater to the pia mater may be traced at each 
 of the nervous trunks as they issue from the brain through the 
 cranial apertures. 
 
 Another proof of a similar description is derived from examin- 
 ing the free or lower margins of the falx major and minor, and of 
 the horizontal portion of the dura, mater, {tentorium cerebelli). 
 First, at the upper or convex margin of the great falx, where the 
 veins pass from the pia mater to the longitudinal sinus, it is not dif- 
 
696 
 
 GENERAL AND PATHOLOGICAL ANATOJIY. 
 
 ficult to trace the arachnoid ineinbrane from the pia mater along 
 their coats, to that portion of the dura mater which forms the sinns, 
 and conversely, from the falx along the veins to the free surface of 
 the pia mater. In the second place, the lower, or concave margin 
 of the falx, is connected at the bottom of the middle fissure between 
 the hemispheres to the pia mater on each side by thin transparent 
 filamentous membrane, which is in truth the arachnoid passing from 
 the falciform process of the dura mater to the free surface of the 
 pia mater, covering the commutual surfaces of the hemispheres ; 
 and the same may be seen at the lower margin of the small or ce- 
 rebellic falciform process. In the third place, at the inner mar- 
 gin of the transverse portion or tentorium, the transparent pellicle 
 of the dura mater maybe traced passing to ihepia mater of the brain 
 above, and of the cerebellum below. The same arrangement may 
 be demonstrated in the vertebral cavity, in which it further covers 
 the serrated membrane, {ligamentum denticulatum). In short, while 
 the dura mater is proper to the inner surface of the skull, and the 
 pin mater to the surfaces of the brain, the arachnoid membrane is 
 common to both, and invests not only the free surface of the pia 
 mater, as is usually stated, but the inner surface of the dura mater. 
 
 The arachnoid has a still more extended distribution. After co- 
 vering the free or inner surface of the pia mater., it follows the 
 course of that membrane into the central surface of the brain, and 
 covers the upper or unadherent surface of the several divisions of 
 the choroid plexus. This is demonstrated by the same process 
 by which the continuity of the plexus with the pia mater is esta- 
 blished. 
 
 From the foregoing description it results that the arachnoid 
 membrane possesses in arrangement and distribution a great re- 
 semblance to the serous membranes. It differs, nevertheless, in 
 its extreme tenuity, in the closeness with which it adheres to the 
 collateral tissues, and, as will afterwards appear, in its slight dis- 
 position, to albuminous exudation. It appears to contain in its 
 structure less filamentous tissue than the pure serous membranes. 
 
 I have elsewhere, in treating of the development of the brain, 
 had occasion to speak of the cerebral membranes. The pia mater 
 in the twofold form now described exists at an early period of the 
 ovum, before the formation of the brain is commenced. It is then 
 recognized in the form of a very vascular membrane, somewhat 
 confused, but still sufficiently distinct to show, that in the centre 
 
SEROUS MEMBRANE. — INFLAMMATION. 
 
 697 
 
 of each half, the cerebral matter afterwards to constitute the he- 
 mispheres is deposited from the vessels of its central or attached 
 surface. At this period the arachnoid pellicle cannot be distin- 
 guished. It is only when a considerable part of each hemisphere 
 is formed that the free surface of the pia mater can be shown to 
 be covered by arachnoid membrane. This may be stated in gene- 
 ral terms to be between the end of the fifth and the middle of the 
 seventh month,. The free surface of the dura mater begins to be 
 perceptible about the same time. 
 
 § 4. The tunica albuginea of the testicle may be here mentioned as 
 a membrane composed of fibrous- tissue, embracing the gland, and a 
 very thin pellucid layer outside, without intermediate filamentous 
 tissue, — a peculiarity in which it resembles the female ovary. 
 
 Section II. 
 
 The serous membranes are the seat of a considerable number of 
 morbid processes, which, according as they take place in one mem- 
 brane or another, give rise to several of those diseases which it is 
 the province of nosology to distinguish and of medicine to treat. 
 Most of these processes may be referred to inflammation or its ef- 
 fects, dropsy, hemorrhage, morbid deposits, and new growths. 
 
 I. Inflammation occurs in serous membrane under at least 
 two forms, acute and chronic. The anatomical characters of the 
 process vary according to its acute or chronic charactei*, and ac- 
 cording to the physiological peculiarities of the affected membrane. 
 These characters it is perhaps most convenient to examine, as they 
 appear in the pleura, pericardium, and peritonaeum, in which they 
 assume their most perfect form. 
 
 § 1. When inflammation commences in a serous or diaphanous 
 membrane, the first change which is observed to take place in it, is 
 diminution or loss of its transparent and glistening appearance.* It 
 becomes opaque, dull, and in some instances dry. This change is 
 very well seen, not only in the pleura, pericardium, and perito- 
 naeum, but in the arachnoid membrane, in which it is distinct when 
 
 * “ When inflammation,” says Hunter, “ takes place in parts that have a degree of 
 transparency, that transparency is lessened. This is probably best seen in membranes, 
 such as those membranes which line cavities or cover bodies in those cavities, such as 
 the pia mater, -where in a natural state we may observe the blood-vessels to be verv 
 distinct.” — 4to, p. 281. 
 
698 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 other traces of the process cannot be recognized. It is from this 
 circumstance that dulness of the arachnoid denotes, with great cer- 
 tainty, serous effusion within the cerebral cavities. 
 
 § 2. At the same time, red vessels may appear either in isolated 
 spots or over a considerable extent. They are generally arborescent 
 or parted into minute ramifications. Sometimes they consist of mi- 
 nute red lines, radiating from a point like stars ; and in other in- 
 stances they form a confused net-work of red vessels, interspersed 
 with bloody points and spots, amounting occasionally to extrava- 
 sation. These vessels, which, though placed in the substance of 
 the membranes, gradually approach the surface as the process ad- 
 vances, are not newly developed, but appear to be the colourless 
 capillaries of the sound state of the membranes injected with red 
 blood. These changes, which may be regarded as the essence of 
 the first stage of inflammation in serous membranes, are best ob- 
 served in the pleura, pericai’dium, and peritonaeum. In these they 
 are sometimes so intense and general, as to give the membranes a 
 red mottled appearance, and prevent the observer from distinguish- 
 ing the subjacent tissue. 
 
 § 3. After existing for some time, varying in different circumstances 
 (from 6 to 20 hours in the pleura and peritonoeum^) these changes 
 are follow'ed by others, which may be regarded as their effects. 
 The first and most important of these is the formation of a new 
 fluid at the free or unadherent surface of the membrane. The na- 
 ture of this fluid varies according to the stage, and perhaps the kind 
 of inflammation. I shall describe first that which takes place in 
 the commencement of the acute form. 
 
 a. The capillary injection of the inflammatory process is scarcely 
 well established when it begins to cause a semitransparent fluid to 
 ooze in small quantity from the affected points of the surface of 
 these membranes. In this state the characters of the fluid can 
 scarcely be determined. In a more advanced stage of the process, 
 when it is abundant, it is a straw-coloured, homogeneous, semi- 
 transparent fluid, which, as it is effused, undergoes spontaneous 
 coagulation. This consists in part of the fluid assuming a solid 
 form in the shape of a semifluid jelly-like layer of variable thick- 
 ness, with a rough honey-comb surface exteriorly, where it is in 
 contact with the membranes, and interiorly with thready filaments 
 mutually interlacing, and more or less consistent. A thin fluid 
 portion at the same time is found in the interstices of these fila- 
 
SEROUS MEMBRANE. — INFLAMMATORY PRODUCTS. 699 
 
 merits, and oozes from the surface of the coagulated part. These 
 facts are easily demonstrated, by examining the effused matter 
 while still recent, and while the process of coagulation is going on, 
 but not completed. It is then a soft, spongy, translucent matter, 
 of a straw-yellow' colour, and pulpy gelatinous consistence. When 
 removed from the membrane its surface is rough and irregular, 
 like honey-comb, and marked by blood spots more or less nume- 
 rous, which are occasioned by the forcible rupture of the minute 
 vessels of the membrane passing into the new product ; while se- 
 rous fluid trickles from it and falls to the most dependent part of 
 the cavity. When cut or torn in minute pieces, this serous fluid 
 oozes abundantly from the sections ; and the observer may then 
 remark the filamentous and cellular disposition of the solid coagu- 
 lated portions. The filaments varying in size cross each other mu- 
 tually, so as to form partitions and intermediate cells, but without 
 regular order. 
 
 The matter thus effused is what was named by Hunter coagulat- 
 ing or coagulahle lymph, in consequence of its property of sponta- 
 neous coagulation. It is often mentioned among some of the older 
 anatomists as masses of liquid fat found between the serous mem- 
 branes ; and even Dr Cleghorn speaks of it in this manner. Its 
 property of coagulation depends chiefly on the proportion of albu- 
 men which it contains. If a mass of coagulahle lymph in its re- 
 cent, straw-coloured, and translucent state, be immersed in alcohol, 
 it instantly becomes shrivelled, indurated, of a white colour, and 
 perfectly opaque ; and the same changes result from immersion in 
 dilute acids or in boiling fluids. It also becomes much tougher 
 and firmer. From this circumstance it has been denominated by 
 the foreign authors albuminous exudation. Of its soft state, when 
 recently effused, it is of the utmost importance for the physician to 
 be aware, in consequence of the fact which I have now verified se- 
 veral times, that in the pleura it communicates to the ear the same 
 stethoscopic and percussive phenomena which arise from the pre- 
 sence of fluid. 
 
 b. After its first coagulation this substance undergoes other changes 
 which are highly important in a pathological relation. As the dia- 
 phanous membranes are at all times mutually applied, a very com- 
 mon effect of this effused substance and its coagulation is to connect 
 the corresponding points more or less firmly. The process by 
 which this is accomplished was understood by Hunter and Balllie, 
 
700 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 and may be stated in the following terms. As the lymph is effused 
 and separated into clot or coagulable part and fluid, the former is 
 observed to be soon penetrated by minute red vessels, which may 
 be demonstrated by injection, and the existence of which is also 
 proved by the fact above-mentioned, that the surface of a piece of 
 detached lymph is marked by numerous blood-spots, occasioned by 
 the rupture of the elongated capillaries of the inflamed membrane. 
 These vessels may be traced from the latter into the extravasated 
 substance, in which they are observed to ramify. Red spots, like 
 effused blood, also appear through the substance of the lymph, and 
 in the course of a few hours these are discovered to be new vessels. 
 
 As this process, which constitutes the organization of the lymph, 
 advances, the penetrating vessels become more numerous, and the 
 lymph becomes more firmly attached to the inflamed surface of the 
 membrane. At the same time the fluid part of the exudation oozes 
 away and drops down to the most dependent points of the cavity, 
 or, if not abundant, it is absorbed. In the former case it forms the 
 serous or sero-purulent fluid, occasionally found in considerable 
 quantities within the pleura and peritoncEum. Meanwhile the al- 
 buminous portion becoming firmer and something opaque, the soft, 
 pulpy, gelatinous, translucent, straw-coloured substance is gradually 
 converted into a firm, white, opaque body, uniting more or less ex- 
 actly the corresponding surfaces of the membrane. The new ves- 
 sels of its interior substance at the same time contract, and ulti- 
 mately convey only colourless fluid. The substance thus rendered 
 organic and the seat of an incessant process of exhalation and ab- 
 sorption, is termed membrane of adhesion (^concretio, concrementum,') 
 or false membrane. The process by which it is formed is termed 
 union by adhesion, or simply adhesion. 
 
 These phenomena are most commonly observed in the pleura, 
 pericardium, and peritoncBum, in each of which they are modified 
 according to the local peculiarities of the membrane. 
 
 In the pleura it appears in the form of a broad layer, variable in 
 thickness, extending between the convex surface of the pulmonic h 
 and the concave surface of the costal pleura ; or it may occur in :j 
 the spaces between the lobes ; (interlobular pleurisy of Laennec) ; i 
 or it may be stretched between the j)leura of the inferior concave 
 surface of the lung and that of the thoracic or convex surface of 
 the diaphragm. When the lung is affected by tubercles or tuber- 
 cular excavations, it often occurs in the form of short membranous 
 
SEROUS MEMBRANE. INFLAMMATORY PRODUCTS. 701 
 
 slips, and very generally as a. membranous capsule covering the 
 apex of the lung, and connecting it to the thoracic pleura. 
 
 In the pericardium the constant motion of the heart modifies the 
 appearance of the albuminous exudation. As this motion prevents 
 during coagulation the exact apposition of the surfaces of the cap- 
 sular and cardiac divisions of the membrane, the most prominent 
 parts, or those which least change relation only adhere. This 
 forms the irregular laminated processes mentioned by Baillie as 
 giving the appearance of lace-work ; and if the capsule be separated 
 from the heart in this stage of the process, it gives the result no- 
 ticed by Laennec, who compares it to the appearance produced by 
 the sudden separation of two pieces of slab united by a thick layer 
 of butter. At a later period this disunion will afford the calf-sto- 
 mach surface {caillehottee ; honnet de veau'),* which may be regard- 
 ed as the link connecting the orgauizable state of the deposition 
 with that in which it forms an adherent tissue. 
 
 In the peritonaeum it takes place chiefly along the line of one 
 portion of ileum with another, and between the prominent points 
 of these and the omentum, or the muscular portion of the mem- 
 brane. In some instances every fold almost of ileum is connected 
 with some other, and the whole are matted together by long trian- 
 gular prisms of lymph, generally opaque, of a lemon-yellow-colour, 
 and of a pulpy or gelatiniform consistence. 
 
 Albuminous exudation or lymph is much less frequently found 
 between the surfaces of the arachnoid membrane. That it is ac- 
 tually secreted by tliis membrane, however, is well established. 
 Dr Stark records three cases in which coagulated lymph was found 
 between the dura and pia mater ^ and round the membranous co- 
 verings of the medulla oblongata awdi spinal chord.f ‘One example 
 of this exudation is delineated by. Baillie and Hooper represents 
 three in which he traces its progress from simple inflammation to 
 organized membrane. § Instances of albuminous exudation on the 
 surface of tne arachnoid are also mentioned by Tacheron, Andral, 
 and Dr Abercrombie. || In the body of a woman who died with 
 symptoms of intense coma, I found a thin but distinct albuminous 
 deposit on the free surface of the arachnoid, extending from the 
 
 * Laennec, Observ. 1, 2, 3, 4, and Art. u. Obs. 4. 
 
 t The Works of the late William Stark, M. D, Lond. 1788. Part iv. p.' 69. 
 
 + Plate iv. Fascic. X. g Plates i. and ii. 
 
 II Pathological and Practical Researches, &c. p. 51 56 60. 
 
702 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 optic commissure to the posterior margin of the annular protube- 
 rance. It was less firm and more translucent than in the pleura 
 01 ’ peritonaeum, hut presented in other respects the usual proper- 
 ties. This albuminous deposit I have seen take place over the su- 
 perior and lateral regions of the arachnoid in adults, though it is 
 much less frequent, spontaneously, than in consequence of external 
 injury.* Albuminous exudation I have likewise observed in the 
 arachnoid membrane of the base and lateral regions of the brain in 
 children who have died with symptoms of meningeal inflammation, 
 or water in the brain. Similar depositions have been remarked in 
 various regions of the arachnoid by Parent-Duchatelet, Martinet, 
 Bayle, and others. 
 
 c. Baillieand most other observers notice, besides coagulating lymph 
 or albuminous exudation, a serous fluid, limpid, yellowish, reddish, 
 or brownish, according to circumstances. Though this fluid has 
 been supposed to be derived immediately from the blood, there is 
 no doubt, that it is the serous or watery portion of the morbid ex- 
 udation, from the surface and interstices of which it may be seen 
 trickling. The red or brown tint it derives from blood issuing 
 from the newly formed capillaries opened by laceration of the lymph 
 from the membrane. Shreds of lymph are at the same time found 
 floating in it. This is most generally seen in the pleura and pe- 
 ricardium. 
 
 I have already stated that the exudation of inflamed serous mem- 
 brane owes its coagulability to the presence of albuminous matter ; 
 and indeed upon the proportion of this ingredient the process of 
 coagulation depends. In certain instances, in which the inflamma- 
 tory process is believed to be less genuine and energetic, this prin- 
 ciple is so scanty that coagulation is partial and imperfect; and in- 
 stead of a uniform layer of lymph between the mutual surfaces, 
 each presents a series of loose shreds and patches, with a conside- 
 rable quantity of reddish, or whitish, semi-opaque fluid in the de- 
 pendent part of the cavity. This constitutes the link between the 
 albuminous and the purulent, sero-purulent, or serous products of 
 inflammation in these membranes. 
 
 § 4. Examined more minutely we find that the fluid varies in its 
 proportion of albumen in different membranes, and according to the 
 
 * Clinical Report of Edinburgh Royal Infirmary for 1836-1837. Edinburgh Me- 
 dical and Surgical .Tournal, Vol. xlvii. p. 305. 
 
SEROUS MEMBRANE. — PURULENT SECRETION. 
 
 703 
 
 form of the inflammatory process. These variations may be refer- 
 red generally to two heads, puriform and serous secretions. 
 
 The varieties of puriform secretion may be classed under the 
 heads of sero-purulent, pm’iform, and purulent. 
 
 The sero-purulent is often connected with the albuminous, from 
 which it is separated during the process of coagulation. It consists 
 chiefly of serous fluid with minute granules of albuminous matter, 
 which subside to the bottom and leave the supernatant liquor like 
 whey or chalk- water. It always contains flakes of lymph. It takes 
 place in pleuritic and peritoneal inflammation, acute and chronic, 
 and is generally found in the dependent part of the cavity, e. g. in 
 the posterior part of the chest, and in the lumbar and hypogastric 
 fossce in the peritonaeum. 
 
 The puriform fluid of serous membranes consists of serons fluid, 
 with an opaque and thicker matter not coagulable in mass blended 
 with it more equably than in the last case. The granular matter 
 is less abundant or entirely wanting ; and the opaque milky fluid is 
 not so easily separable as in the sero-purulent fluid. Though it is 
 often associated with the albuminous, and contains flakes of lymph, 
 yet, as little lymph is found on the surface of the membranes, and 
 as the quantity of the latter is often in the inverse ratio of the quan- 
 tity of puriform fluid, it may be regarded as less nearly allied to the 
 pure albuminous inflammation than the sero-purulent. Both are 
 to be regarded as abortive efforts to eflfect albuminous exudation. 
 
 The puriform secretion occurs in all the serous membranes, but 
 is most frequent in the peritonaeum. It is in particular very com- 
 mon in that form of peritoneal inflammation which occurs in the 
 persons of women in childbed ; and Hunter, who was aware of the 
 fact, states it as an instance of the combination of the adhesive with 
 the suppurative inflammation, — a circumstance to which he ascribes 
 the unfavourable issue of such cases.* It is occasionally the com- 
 bination, and sometimes the substitution of the suppurative for the 
 adhesive process. This is amply confirmed by the necroscopic ap- 
 pearances of peritoneal inflammation in puerperal females, in which 
 every shade of morbid eflfusion is seen, from albuminous lymph, 
 with separation of proper serous fluid, to puriform or purulent col- 
 lection. 
 
 * “ This mixing of the suppurative with the adhesive, or the hurrjdng on of the sup- 
 purative, 1 have frequently seen in the abdomen of women who have been attacked 
 with the peritoneal inflammation after child-birth, and which, from these circumstances 
 became the cause of their death.” — On the Blood, &c. 
 
704 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Genuine purulent fluid, as it is represented by pathological au- 
 thors, — a white, or cream-coloured, opaque, and homogeneous fluid, 
 — is another product of inflammation of serous membranes. Though 
 always combined with more or less albuminous exudation, which is 
 found in loose irregular patches on the membrane, and in the form 
 of shreds and flakes in the fluid, it is more uniform in composition 
 than the puriform, being destitute of the granular matter, and not 
 separating, when allowed to rest, into thin and solid matter. It oc- 
 curs in chronic pleurisy, (^empyema,) in pericardial inflammation as 
 an effect of the acute, and in peritonitis, acute, subacute, and chro- 
 nic, especially the puerperal. 
 
 It was at one time believed that genuine purulent matter could 
 not be formed in these membranes, unless as an effect of the pre- 
 liminary process of ulceration. Instances of purulent collections 
 in the chest without ulceration of the pleura, and of purulent matter 
 in the abdomen without breach in the peritonseum, might have led 
 pathological writers to the inference, that suppuration may occur 
 in a serous membrane without ulceration, and that,secretion of puru- 
 lent matter is one of the effects of simple inflammation of serous 
 tissue. The truth of this fact, however, appears not to have been 
 established before the time of V/illiam and John Hunter, the last 
 of whom notices it as a point not previously ascertained. Speak- 
 ing of the transition or gradual change from coagulable lymph to 
 purulent fluid, he infers “ that suppuration takes place in serous 
 surfaces without a breach of solids or dissolution of parts,” men- 
 tions it as a circumstance “ not commonly allowed,” and considers 
 this suppuration as the effect of a more advanced stage of the pro- 
 cess than that which gives rise to effusion of lymph, and union by 
 adhesion. Of this fact, he informs us, he first became aware in 
 1749 and 1750, when, in the inspection of a young subject, the 
 left side of the chest was found to contain a considerable quantity 
 of purulent matter without breach of the pleura or surface of the 
 lungs ; and, at the same time, it was regarded by Dr Hunter and 
 Mr Samuel Sharpe as a new fact.* It has since been often ob- 
 served both in the pleura and peritonseum ; and as such is men- 
 tioned by William Hunter,f Baillie, Black, and Willan. It is, in 
 truth, seen almost daily by those conversant in morbid anatomy. 
 
 * Treatise on Inflammation, &c. p. 379. Note. 
 
 + “ Another kind of pui is that which is formed without any apparent breach or 
 dissolution of the solids, and therefore is only a sort of inspissated serum, or an inflam- 
 
SEROUS MEMBRANE. — SUBSEROUS DEPOSITS. 
 
 705 
 
 The purulent fluid in this case and many others is secreted partly 
 from the surface of the inflamed membrane, partly from the orga- 
 nized layer of lymph, partly from both. In the first case, the pu- 
 riform or purulent fluid is secreted directly by the capillaries of 
 the inflamed membrane. In the second, it is derived from those 
 of the organized false membranes, which assume tlie suppurative 
 action. In the third, both sets of vessels are concerned. These 
 facts are demonstrated in instances of chronic pleurisy, and of chro- 
 nic inflammation of the periton(Bum. 
 
 § 5. A second eflfect of inflammation of the diaphanous membranes 
 is efi’usion or secretion of fluid in the subserous filamentous tissue. 
 When the arachnoid membrane is inflamed the delicate filamentous 
 tissue which connects it to the pia mater is almost invariably dis- 
 tended with serous fluid, more or less transparent. This change 
 makes the arachnoid membrane look as if it were raised or detached 
 from the pia mater by the interposition of a transparent or slightly 
 opaque gelatinous matter uniformly spread between them. If a 
 puncture or incision, however, be made, a small portion only trickles 
 from it, being that which is exposed to the immediate incision. 
 The fluid of the contiguous parts does not escape, — a circumstance 
 which with inspection shows that it is contained in the interstices 
 formed by the mutual crossing of the filaments of the subserous 
 tissue. In this manner and in the same situation albuminous fluid 
 may be efiused, especially at the base of the brain. In pleurisy 
 this eflfusion is less common, unless the pulmonic tissue is at the 
 same time inflamed, — a peculiarity which appears to depend on the 
 intimate union between the pleura and lungs. It nevertheless takes 
 place and dissects the pleura from the substance of the lungs. In in- 
 flammation of the pericardium it takes place beneath the cardiac fold 
 of the membrane, and occasionally assumes the form of minute ab- 
 
 matory exudation. We occasionally meet mth collections of this kind in all the na- 
 tural internal canties of the body. I have seen it in great quantity in the carity of 
 the abdomen or of the peritonceum, in that of the thorax or of the pleura, and in the 
 pericardium, where there was no visible suppuration, ulceration, or dissolution of the 
 solids, or any part of the surface all round. This kind of pm is generally thinner than 
 that of an abscess ; and the containing surface is more or less covered with a glutinous 
 concretion, or slough of the same colour as the fluid, in some parts adhering very 
 loosely, in others so firmly, that it can hardly be rubbed off ; but still the surface 
 covered by these sloughs is without ulceration or loss of substance.” — Medical Obser- 
 vations and Inquiries, Vol. ii. p. 61. 
 
 BailUe, Morbid Anatomy, passim. 
 
 Black, Clinical and Pathological Reports. Newiy, 1819. 
 
 Willan, Reports on the Diseases of London, 1797. P. 186. 8vo Edition. 
 
TOG 
 
 GENERAL AND PATHOLOGICAL ANATOMV. 
 
 scesses in the subserous tissue and on the surface of the cardiac fibres. 
 In inflammation of tbe peritoneeum it is more common ; and careful 
 inspection may detect effusion below the intestinal, and more distinct- 
 ly in some instances below the muscular peritonaeum. In this situa- 
 tion, indeed, may be found patches and minute deposits of purulent 
 fluid, not only in the ordinary forms of peritonaea] inflammation, 
 but in that which takes place in the persons of puerperal women. 
 
 § 6. A third change mentioned as a consequence of inflammation in 
 serous membranes is inordinate thickness and some degree of pulpi- 
 ness.* On this point there is among pathologists some difference 
 of opinion. The occurrence of thickening is contradicted by Laen- 
 nec, who denies that inflammation produces thickening of the pleura, 
 and contends that observers have been misled by morbid deposits on 
 its surface, or the formation of new membranes. Without doubt- 
 ing the discernment or candour of this pathologist, I must remark, 
 that, as Baillie expressly mentions thickening as a consequence of 
 inflammation in the pleura, peritoneum, and mesentery, and as this 
 is confirmed in regard to the peritoneum by the testimony of Pem- 
 bertonf and Black,| the question resolves itself into one of indivi- 
 dual observation. If, in some instances of acute inflammation of 
 serous surfaces, thickening is not recognized, there are few in which 
 the chronic form of the process affects the pleura, pericardium, and 
 peritonaeum, without more or less thickening of the membrane. 
 The appearance of this, indeed, may arise from effusion into the 
 subserous filamentous tissue ; but in cases of chronic inflammation 
 the membrane itself appears to be not only thicker, but harder and 
 firmer than natural. Does this change depend on effusion of lymph 
 into its component tissue, or development of vessels which are loaded 
 with various fluids ? The thickening to which I allude is mostly 
 at the attached surface ; and I think that in that situation it de- 
 pends on the effusion of lymph into the subserous cellular tissue. 
 In chronic peritonitis I have observed the attached surface of the 
 membrane manifestly loaded with extravasated matter in the inter- 
 stices of the filamentous tissue. What are the cases in which the 
 serous membranes become pulpy or softer than natural, while they 
 are also thickened ? On these points accurate information is still 
 wanting. 
 
 On the other hand, it must be allowed, that the conditions usually 
 mentioned as examples of thickening of the serous membranes, are, 
 
 * Baillie’s Morbid Anatomy, p. 54, 127, and 200, in reference to the mesentery. 
 
 I On the Abdominal Viscera. + Clinical and Pathological Reports, &c. 
 
SEROUS MEMBRANE. — ULCERATION. 
 
 707 
 
 in truth, new deposits on their free surface. A deposit of lymph 
 which has become contracted and indurated, or even cartilaginous, 
 a deposit of tubercular matter, and patches of cartilage are formed 
 on the free surface of the membrane ; and though they appear to 
 render it thicker, yet are they adventitious and easy removable by 
 dissection, after which the free surface of the membrane comes into 
 view. 
 
 § 7. The next effect of the inflammatory process in serous membranes 
 is destruction of their tissue by ulceration. Though this may 
 happen in the acute form of the disease, it is not common. But 
 after it has subsisted for some time, one or more points of the mem- 
 brane begin to be affected by the ulcerative process, which at once 
 spreads superficially, and penetrates its substance. The manner in 
 which this takes place is invariably by the inflammatory process 
 affecting the subserous tissue, and causing their suppuration in a 
 circumscribed point. The serous membrane being no longer sup- 
 ported at this point, gives way sometimes in round irregular patches, 
 sometimes in ragged linear fissures. This process is not equally 
 common in all the serous membranes. It is most usual in the 
 pleura, pulmonic and costal, and in the muscular peritonaeum. 
 
 By some pathologists, and, if I do not misunderstand him, by 
 Hunter, ulceration is ascribed to pressure exercised by purulent 
 matter; and thus, indeed, this author explains the tendency which 
 collections of matter betray to proceed towards the surface. The 
 pressure of such agents, doubtless, operates as an irritating cause, 
 and may therefore produce what Hunter terms ulcerative inflamma- 
 tion. In several examples, however, ulceration may occur as a 
 direct effect of the inflammatory process, without the formation of 
 matter sufficient by pressure to cause destruction of the tissue ; and 
 in such circumstances I have in general traced it to previous sup- 
 puration of the subserous tissue, as already mentioned. In cases 
 of empyema and chronic peritonitis, especially the puerperal form, 
 in which this ulceration is not unfrequent, both causes may be in 
 operation. But even in the interesting case of peritoneal inflam- 
 mation given by Hunter to illustrate the nature of what he terms 
 the relaxing process, it is impossible to doubt, that, before the mus- 
 cular peritonaeum was detached in the shreds and fragments in 
 which it was found on inspection, inflammation and suppuration of 
 the subserous filamentous tissue had taken place.* In short, from 
 
 * Treatise on the Blood, &c. Part ii. Chap. vi. Sect. vi. p. 461. 4to. 
 
708 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the cases recorded, and from several which I have examined per- 
 sonally, I infer that ulceration of the serous tissue is always pre- 
 ceded by inflammation and suppuration of the subserous ; that the 
 attachment of the former being thus destroyed, its vitality is im- 
 paired, and its cohesion thereby weakened ; and that it gives way 
 rather in the manner of laceration than genuine ulceration. 
 
 § 8. Observation has not yet determined whether gangrene be an 
 effect of inflammation of the serous tissue. That it is occasionally in- 
 volved in this process I infer fi'om seeing the pleura in gangrene of 
 the lungs, and the pcritonaum. in that of the bowels, soft, black, or 
 greenish, shreddy, and lacerable. But it is still uncertain whether 
 primary inflammation of a serous tissue exclusively may terminate 
 in mortification of that membrane. With this process ulceration 
 with bloody effusion or blood-coloured patches must not be con- 
 founded. Bichat states, that in numerous bodies which he inspect- 
 ed, he met with gangrene of the peritoncEum only ; and that he 
 never witnessed an instance of this change either in the arachnoid 
 membrane, in the pleura^ in the pericardium, or in the perididymis* 
 
 On the surface of the lungs there is occasionally observed a spe- 
 cies of gangrene, circumscribed and limited in extent. A patch, 
 dark coloured and dead, of a shape nearly, sometimes exactly cir- 
 cular, is formed at the surface, that Is, the pleural surface of the 
 lung. The size of these patches varies from the size of a sixpenny 
 piece or a shilling to a crown piece. The patch is in certain cases 
 observed still adherent, though black and dead. In other in- 
 stances it has dropped off, leaving a cup-like cavity, pretty exactly 
 circular in outline, regularly hollowed out in the substance of the 
 lung, which is red but otherwise natural and free from appearance 
 of gangrene. 
 
 In this lesion, which I have described as circumscribed gangrene 
 of the lungs, the pleura is affected by gangrene ; but whether pri- 
 marily, or only in connection with the substance of the lung, it is 
 impossible to determine. The portions so affected appear exactly 
 as if they had been destroyed by the direct application of the hot 
 iron, or touched by a portion of caustic potass. 
 
 This circumscribed form of gangrene of the pleura and surface 
 of the lungs is sometimes associated with diffuse gangrene in the 
 deep-seated parenchyma of the oi’gan.j 
 
 * Anat. Generate, Tome iii. p. 517. 
 
 t Cases and Observations illustrative of the Nature of Gangrene of the Lungs. I?y 
 David Craigie, M. D., &c., Edinburgh Medical and Surgical Journal, Vol. Ivi. p. !■ 
 Edinburgh, 1841. 
 
SEROUS MEMBRANE. — SEROUS EFFUSIONS. 
 
 709 
 
 § 9. The second general head of secretions, or those termed se- 
 rous^ have been long received as the distinctive character of the dis- 
 orders named dropsies ; {Hyclropes.) 
 
 To the influence of inflammation or capillary injection in causing 
 efiusion, extravasation, or secretion of serum, I have already in 
 part alluded. In no texture is this more conspicuous than in the 
 serous or transparent. The mechanism of this process it is perhaps 
 not very easy to explain satisfactorily, unless by referring it to the 
 same principles to which I have already referred, the ordinary al- 
 buminous and purulent exudations. I shall attempt, however, to 
 state as briefly as possible the ascertained facts which tend to esta- 
 blish the general conclusion, — that inordinate accumulation of se- 
 rous fluid from the free surface of the diaphanous membranes is a 
 frequent result of a process of capillary congestion, or even of in- 
 flammation. 
 
 I have already stated that the serous membranes in general are 
 understood to be the seat of a process of incessant exhalation and 
 resorption. This may be regarded as demonstrated in the case of 
 the pleura, pericardium, peritonceum, and perididymis, by the ex- 
 periments of Haller, Bichat, and others ; and of the arachnoid, the 
 same as presumed from analogy. The fluid thus secreted, though 
 in the healthy state very scanty, is distinctly albuminous. This 
 may be regarded as demonstrated by the rude experiments even of 
 Hewson and Bichat. The difficulty in the healthy state of obtain- 
 ing a quantity sufficient for analysis led Berzelius to examine that 
 of hydrocephalus, which he supposes makes a nearer approach to 
 the normal condition than the others ; and of this he found 1000 
 parts to contain 1.66 of albuminous matter, with salts of potass and 
 soda, and some animal matter combined with lactate of soda.* 
 This result is confirmed by the researches of Bostock and Marcet, 
 which show that though some miico-extractive matter is present, 
 albumen forms tbe chief part of the solid contents of the serum of 
 the blood and the fluids of the serous membranes. Lastly, Mar- 
 cet, who examined all the dropsical fluids, found that they contain 
 coagulable matter ; but that those of the pleura, pericardium, and 
 peritonaeum, contain much more than the arachnoid, and that of 
 hydrocele most of all.f 
 
 The inordinate augmentation of these fluids varies in degree, 
 
 * General Views of the Composition of Animal Fluids. By J. Beizeliiis, M. D., 
 &c. Med.-Chir. Transactions, Vol. iii. 251. 
 
 •f- MediGO-Chirurg. Trans. Vol. ii. p. 381. 
 
710 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 from a few ounces to several pints ; and it varies according to the 
 site of the membrane from which it is effused. Thus the fluid se- 
 creted by the arachnoid membrane may not amount to above half 
 an ounce, or at most to two or three ounces, which is to be re- 
 garded as a great quantity. In some recorded instances it is said 
 ratber vaguely to amount to six. The fluid secreted by the peri- 
 cardium may not be above one ounce, rarely exceeds two or three, 
 and in a few instances only amounts to six, eight, or ten. In the 
 pleura, on the contrary, it may amount to three, four, or five pints 
 or quarts ; and in the peritoneum has been known to amount to 
 several gallons. 
 
 The quality of this fluid varies. That of the arachnoid is limpid 
 and colourless, like clear water, with a slight saline taste, and con- 
 tains traces of albumen. In the pericardium it is light coloured 
 and semitransparent. In the pleura it may be straw-yellow and 
 semitransparent, but is more frequently reddish, or brown and 
 something opaque. In the peritonaeum it is semitransparent, yel- 
 low, or greenish, sometimes with various shades of red or even 
 brownish, like chocolate or coffee. In each of the three last cases 
 it is invariably combined with albuminous matter. 
 
 The hypothesis of Cullen, who ascribes this inordinate accumu- 
 lation to any cause which increases exhalation or diminishes ab- 
 sorption, though plausible, is too general, and does not comprehend 
 all the facts of the case. One of the most uniform and powerful 
 agents in augmenting exhalation from serous surfaces is that state 
 of the capillaries in which they are injected, distended in such a 
 manner as to constitute congestion or even inflammation. The 
 influence of this cause appears to have been first well understood 
 by Cruikshank,* Baillie,t and Parry ,j: nor had escaped the obser- 
 
 * “ The second species of dropsy is very common, and is that which arises in conse- 
 quence of previous inflammation of a cavity, and may take place in any habit of body. 
 If an inflammation arise in a cavity, it may terminate in a number of different ways ; 
 one of these is by increased secretion of fluid of surfaces. A man receives a blow on 
 the testicle, inflammation takes place, and the consequence is frequently a hydrocele 
 or dropsy of the twiicd vagiTialis. A child’s brain inflames, and this inflammation 
 ends at last in hydrocephalus^ or collection of water in the brain. Pleurisy frequently 
 terminates in hydrothorax, or collection of water in the chest. I have often taken 
 away forty or sixty pints of w'ater, w^hich had accumulated in the cavity of the abdo- 
 men in the few days the periton;eal inflammation had lasted, during the usual species 
 of childbed fever. This is to be considered as the substituting a less dangerous disease 
 for another. Peritoneal inflammation kills often in three days, but acute may last 
 twenty years.” — Anatomy of the Absorbing Vessels. 
 
 Morbid Anatomy, p. 57. 4th edit. Lond. 1812. 
 
 J Collections from the unpublished Medical M ritings, &c. p. 205, 207> 20o. 
 
SEROUS MEMBRANE. — SERO-ALBUMINOUS EFFUSIONS. 7ll 
 
 ration of Pemberton. * Its reality, however, was first investigated 
 and formally maintained by Grrapengiesser of Gottingen, f by Rush 
 of Philadelphia,:!; and was subsequently made the subject of much re- 
 search and inquiry by Wells, § Blackall, jj Crampton,^ and Ayre. 
 The results of the inquiries thus instituted may be stated in the fol- 
 lowing manner. 
 
 Though accumulation of fluid in the cavities of serous mem- 
 branes depends on increased exhalation from the vessels of these 
 membranes, that exhalation is not to be regarded merely as an in- 
 creased form of the natural action, but is a process of morbid se- 
 cretion, depending on a state of the blood-vessels, either identical 
 with, or analogous to inflammation. The vessels of the membranes 
 are numei’ous, enlarged, and in general injected. When they are 
 not so, the stage of injection has passed,* and been succeeded by 
 that of exhalation. The presence of albuminous flakes in the ef- 
 fused fluid furnishes proofs of the same description. The mem- 
 branes are more or less opaque and dull, and covered by shreds 
 and patches of lymph in various spots ; and fluid is effused into 
 the subserous tissue. Thus, in several instances of dropsical infil- 
 tration, with effusion into the cavity of the pleura, 1 have found 
 that membrane not only vascular, but coloured of a red-brown tint, 
 opaque, void of its glistening aspect, and covered by patches of al- 
 buminous exudation. The same is observed in ascites. One of 
 the most decided examples is afforded by the inspection of Sir 
 James Craig, well described by Dr Somerville.** The perito- 
 naeum was found covered by lymph in various points, and lymphy 
 flakes were found abundantly in the fluid. On the same point the 
 dissections of Dr Crampton in the Transactions of the Dublin As- 
 sociation afford unequivocal and satisfactory evidence. 
 
 In most cases of this class, however, it will afterwards be shown, 
 the kidneys are affected with granular degeneration. 
 
 In the case of the cerebral membranes it is not quite so easy to 
 obtain evidence. The arachnoid is averse, if I may use the term, 
 
 * Abdominal Viscera, p. 12. “ Sometimes a resolution of the inflammation takes 
 place from the throwing out of a fluid, when ascites is produced.” 
 
 t De Hydrope. 
 
 X Medical Inquiries and Observations. By B. Rush, M. D. Philad. 1805. Vol. ii. 
 p. 159. 
 
 § Transactions of a Society, Vol. iii. p. 167, 183, and 194. 
 
 II Observations on the Natrue and Cure of Dropsies. 
 
 H Clinical Report on Dropsies. Transactions of Association, VoL ii. 
 
 ’* Medico-Chir. Tr. Vol. v. p. 340, &c. 
 
712 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 to albuminous exudation ; and though this occurs occasionally, 
 serous eflFusion is greatly more frequent. The inflammatory origin 
 of this effusion, however, is proved by several circumstances. 
 
 1st, The pia mater ax\di choroid plexus are more or less, sometimes 
 highly vascular. The arachnoid is always dry, opaque, dull, and 
 elevated by infiltration into the subjacent tissue. In some instances 
 this infiltrated fluid contains albuminous matter ; and in some patches 
 of lymph are deposited on the free surface of the arachnoid mem- 
 brane. In one of the most distinct cases of this disease which fell 
 under my personal observation, I found the free surface of the 
 cerebral arachnoid adhering to that of the falciform process in the 
 great fissure between the hemispheres by well marked filaments of 
 albuminous exudation. 
 
 2d, In the case of violence inflicted on the head, which it is well 
 known has a tendency to induce inflammation, when that inflamma- 
 tion proves fatal, almost invariably we find effusion from the mem- 
 branes, in some cases to a great extent. In proof of this, I prefer 
 referring to the cases of other observers than to such as I have in- 
 spected. In the fatal cases recorded by Pott and Dease the most 
 uniform appearance is water in the ventricles, which evidently pro- 
 ceeds from the choroid plexus, or inner division of the cerebral 
 membrane. In the numerous and well described cases of Schmucher 
 also, this eff'usion is always one of the changes recorded ; and vascu- 
 larity of the pia mater ^ and dulness of the arachnoid, with subarach- 
 noid infiltration, are frequently remarked. Similar results may be 
 derived from the cases given by Dr Thomson, and from those of 
 Dr Hennen. In short, it may be inferred that traumatic inflam- 
 mation of the cerebral membranes always Induces more or less 
 serous effusion. It is scarcely necessary to remark, that this explains 
 a fact observed by most practical physicians, ♦hat hydrocephalus is 
 very often ascribed to blows or falls on the head, the tendency of 
 which to induce congestion of the vessels cannot be denied. 
 
 3d, To the same purpose it may be said, that the effusion result- 
 ing from the operation of the process of fever, whether intermittent, 
 remittent, or continuous, demonstrates the influence of vascular con- 
 gestion in inducing it. Thus in ague, meningeal effusion is not 
 uncommon ; in remittent it is frequent ; and in continued fever it 
 is perhaps the most usual cause of the fatal termination of the disease. 
 The extensive body of evidence collected on this point of late years 
 by writers on remittent and yellow fever, and on the ordinary con- 
 
SEROUS MEMBRANE CHRONIC PLEURISY. 
 
 713 
 
 tinued fever of this country, renders it unnecessary to dwell longer 
 on this point. 
 
 In favour of the same inference, the connection so often remark- 
 ed between dropsy and hemorrhage might be adduced. My limits, 
 however, do not permit me to add more. 
 
 II. Peculiarities in Individual Inflammations. — The prin- 
 cipal pathological facts regarding the process of inflammation in 
 serous membrane have been so fully stated, that it is superfluous to 
 dwell on the individual diseases. I shall merely, after enumerating 
 them, make a few remarks on some peculiarities presented by the 
 chronic forms of these disorders. They may be arranged in the 
 following order, showing their transition into dropsies. 
 
 Acute form. 
 
 Cerebral envelopes, 
 
 Pleura, Phimtis, 
 Pericardium, Pericarditis, 
 Peritonaeum, Peritonitis, 
 Perididymis, Orchitis, 
 
 Chronic form. 
 Meningitis ; Arachnitis, 
 Eijipyema, 
 
 Pyocardia, 
 
 Chronic peritonitis, 
 Empyocele, 
 
 Dropsical form. 
 
 Hydrencephalus. 
 
 Hydrothorax. 
 
 Hydrocardia. 
 
 Ascites. 
 
 Hydrocele. 
 
 Visceral divisions of the peritonaeum. 
 
 Gastric peritonasum, 
 
 Gastritis. 
 
 Intestinal peritona 2 um, 
 
 Enteritis. 
 
 Colic peritonaum. 
 
 Colitw. 
 
 Mesenteric peritonaum, 
 
 Mesenteritis. 
 
 Omentum, 
 
 Epiploitis. 
 
 Cystic peritonaum. 
 
 Cystitis. 
 
 Hepatic peritonaum. 
 
 Hepatitis. 
 
 Splenic peritonaum. 
 
 Lienitis. 
 
 Uterine peritonaum, 
 
 Hysteritis. 
 
 § 1. Chronic pleurisy (e/wjot/ema) is remarkable for the effects which 
 it produces. First, the great accumulation of fluid forces the lung 
 towards the mediastinum and spine, and compresses it into so small 
 bulk that it appears to be destroyed. Inspection shows, however, that 
 it is merely compressed. Its vessels are crushed together ; its bron- 
 chial tubes and vesicles closed ; and the whole organ is rendered un- 
 fit for respiration. This is the condition mentioned by Broussais un- 
 der the name of atrophied lung.* Second, suppurative destruction 
 may take place in the pulmonic pleura and corresponding part of the 
 lung, and lay open one or more bronchial tubes, causing pulmonary 
 fistula pneumothorax. Sero-purulent or purulent fluid is then 
 discharged by coughing in a forcible and continuous stream. Of 
 this kind are many cases of pulmonary abscess reported to be cured. 
 
 * Phlegmasies Chroniques, Cases 19, 20, 24, 25, 27, 28, 30. 
 
714 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Thirdly, suppurative destruction may take place in one or more 
 points of the costal pleura, and discharge a considerable quantity 
 of puriform fluid through openings between the ribs, which are oc- 
 casionally carious.* When these two modes of opening are com- 
 bined, pneumothorax and emphysema take place.f Fourthly, the 
 inordinate accumulation of fluid in the left sac of the pleura may 
 be so great as to thrust the heart to the sternum, and eventually 
 into the side of the chest, in which its pulsations are then feltj 
 This change I have several times witnessed in chronic pleurisy. 
 
 § 2. Chronic peritoneal inflammation is distinguished by three cir- 
 cumstances : — Is?, Purulent or sero-purulent fluid may be secreted 
 in one or more distinct sacs, formed by the union, and secretion of 
 effused lymph. This, which was early noticed by Morgagni, (Epist, 
 xxxiv. 221,) is verified by J. Hunter, § and subsequently by Baillie, 
 Black, II Mr Cooke, and others. 
 
 2d, Purulent fluid may be secreted by the whole inflamed mem- 
 brane, without breach of surface. This proposition I should scarcely 
 have thought requisite, after what has been said above, to state for- 
 mally, did not the valuable remark of John Hunter, that “ the ca- 
 vity of the abdomen acquires all the properties of an abscess,” ap- 
 pear to he forgotten by Dr Black of Newry, who, in recording a 
 case in which the ‘‘ abdomen contained more than two quarts of 
 thin purulent fluid of a turbid appearance,” seems to think it extra- 
 ordinary that the matter was secreted by inflamed surfaces. In 
 other respects the case is a good confirmation of the general prin- 
 ciple now stated. I may add, that in several cases of peritonitis 
 lasting for several weeks, which have come under my own observa- 
 tion, 1 have seen many folds of small intestine connected by lymphy 
 exudation, and a considerable quantity of genuine purulent fluid 
 
 ■* Miscell. Curios. Dec. iii. An. v. Obs. 49. Mem. Med. Society, Vol. iii. p. 127. 
 Kirkland, Med. Surgery, Vol. ii. p. 178. Withering’s Remarks on Dropsy, &c. Works, 
 Vol. ii. p. 304, § 35. 
 
 + Treyer, in Annals of Thomann, V ol. i. Dr Duncan, in Trans. Med.-Chir. Society, 
 Edin. Vol. i. and Contributions to Morbid Anatomy, No. iv. Empyema and Hydro- 
 thorax. in Med. Surg. Journal, Vol. xxviii. p. 302. 
 
 $ Morgagni, Epist. xx. 6. .Barry, p. 405, 406. Abercrombie, in Med.-Chir. Trans- 
 actions. 
 
 § “ Inflammation attacks the external coat of an intestine. The first stage of this 
 inflammation produces adhesions between it and the peritonseum lining the abdominal 
 muscles. If the inflammation does not stop at this stage, an abscess is formed in the 
 middle of these adhesions.” — Treatise on the Blood. 
 
 II Clinical .and Pathological Reports, p. 133, 176. 
 
SEROUS MEMBRANE. — CHRONIC PLEURISY. 
 
 715 
 
 bathing the adherent masses, and filling the hollows of the lumbar, 
 iliac, and hypogastric regions. The omentum is sometimes glued 
 down at its corners to a fold of ileum ; in other instances it is drawn 
 up and shrivelled into a roundish or cylindrical mass. 
 
 ^d. Ulceration may take place at one or more points of the mus- 
 cular or intestinal peritonaeum, by a process, the mechanism of which 
 has been already explained. The first is most common, and may 
 be so extensive and complete as to destroy the whole membrane on 
 the fore part of the abdomen, and expose the transverse and straight 
 muscles as distinctly as if they were cleanly dissected, and leave the 
 tendons of the lateral muscles in rags, partly gone, partly in the 
 form of slough. At the same time, the intestines are covered with 
 a coat of lymph, which is believed by Hunter to prevent the matter 
 from irritating, and producing ulcerative inflammation of the bow- 
 els, and from diffusing itself over the abdominal cavity.* Its chief 
 use is to prevent inflammation of the subserous tissue. 
 
 The rarity of the latter, which is well established, is ascribed by 
 Hunter to the indisposition to ulceration manifested by the intestinal 
 peritonaeum.f It is the express testimony of Baillie, that he “ did 
 not recollect to have seen one instance in which the ulcer had begun 
 on the outer or peritonseal surface of the intestines, and had spread 
 inwards.” To show that this termination, though uncommon, is not 
 unknown, I mention, that of 16 cases of chronic peritonaeal inflam- 
 mation reported by Broussais, in one only did perforation of the in- 
 testines take place and that in the case of Willan above alluded 
 to, tbe colon was superficially ulcerated in several places. 
 
 In the sero-purulent and purulent collections, which are the re- 
 sult of peritoneal inflammation in puerperal females after it has 
 passed the acute stage, a peculiar mode of termination is not un- 
 frequently observed in an opening taking place spontaneously 
 generally at the navel, and allowing the issue of a large quantity of 
 fluid. This opening is effected first by distension, the pressure of 
 the matter separating the recti, and enlarging the umbilical aper- 
 ture afterwards by laceration, while the peritonaeum detached from 
 the supporting tissues, and sustained only by tbe skin, at length 
 gives way, and forms an opening. Examples of this are recorded 
 
 * On the Blood, &c. Part ii. Chap. vi. Sect. vi. p. 461, and Sect. ix. p. 467. 
 t “ If the disposition for ulceration was equal on every side of the abscess, it must 
 open into the intestine, which is seldom the case, although it sometimes does.” P. 236. 
 X Phlegmasies Chroniques, Section ii. Chap. iv. Obs. Iv. p. 480. 
 
716 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 by Hulme,* Leake, | Denman,:}; Mr John Burns, § Gordon, || Arm- 
 strong, IT and Hey.** Gordon and Denman mention cases in which 
 matter was discharged by the urethra with favourable issue. The 
 fluid of ascites in females has a peculiar exit, by which not unfre- 
 quently it escapes, the Fallopian tubes. 
 
 § 3. Puerperal Peritonitis . — That in the disease termed puerperal 
 fever, in a certain proportion of cases, peritoneal inflammation of 
 one or other of the forms above-mentioned takes place, is established 
 by the observation of the best authors, and by daily experience. In 
 every case in which the symptoms of the disease appear during life, 
 we find in the peritonaeum more or fewer of the marks of the in- 
 flammatory process above described. This variety of peritoneal in- 
 flammation, nevertheless, is peculiar in commencing almost invari- 
 ably in some part of the peritonaeum investing the organs of repro- 
 duction. Thus the first, the most abundant, and the most invari- 
 able traces of inflammatory action, are found either in the uterine, 
 or the ovarian peritonaeum, or in that of the Fallopian tubes, espe- 
 cially at their fimbriated extremities, and within these tubes, or all 
 three at once. 
 
 The most usual appearances which I have remarked in a large 
 proportion of cases, are opaque, dull, and lustreless aspect of the 
 uterine and ovarian peritonaeum ; blood-spots or vascular injection, 
 especially of the ovarian peritonaeum ; albuminous exudation of the 
 uterine and ovarian peritonaeum often agglutinating the latter to 
 that of the oviferous tubes ; and sero-purulent or purulent fluid, 
 with albuminous shreds, in the hypogastric, iliac, and occasionally 
 the lumbar ybssffi, and purulent or albuminous exudation between 
 the bladder and uterus, and the uterus and rectum. 
 
 In a certain proportion of cases, in which the disease is not at- 
 tended by well-marked symptoms, yet destroys the patient rapidly 
 and certainly, the appearances are not very distinctly presented. 
 The uterine peritonaeum is covered with a sort of unctuous looking 
 sero-albuminous fluid, or rather mere coating, which is liable to be 
 entirely overlooked by hasty observers. Yet it is seen all over the 
 anterior and posterior surface of the womb, and along the sides of 
 that organ, as a semifluid glutinous coating. In certain cases the 
 Fallopian tubes and ovaries are covered by the same coating ; and 
 
 * On the Puerperal Fever. f O'l Child-bed Fever. 
 
 t Introduction, &c. Fever. § Elements, &c. 
 
 11 Treatise on the Epidemic Puerperal Fever, 5th and 6th Cases. 
 
 Facts and Observations, p. 158. ** On Puerperal Fever. 
 
SEROUS MEMBRANE PUERPERAL PERITONITIS. 717 
 
 in one class of cases the principal circumstance is purulent matter 
 within the Fallopian tubes. 
 
 The difficulty of recognizing this peculiar unctuous looking coat- 
 ing has led several persons to deny the occurrence of peritoneal in- 
 flammation in this disease. There is, nevertheless, no doubt of the 
 fact, and it should further be remembered that this appearance takes 
 place in cases of the greatest rapidity, with the most obscure symp- 
 toms, and in which the disease is occasionally developed before 
 labour. Some females I have known die with the disease unde- 
 livered. 
 
 It must be observed, however, that puerperal fever is not a simple 
 but a complicated lesion ; and that it varies in diflferent seasons in 
 the same locality, and in different localities. Thus several forms 
 of the disease, to which the name of puerperal fever is ap- 
 plied, have been ascertained to affect the uterine, ovarian, and ab- 
 dominal peritoncRum, the womb, the ovaries, and Fallopian tubes, 
 the uterine veins, the uterine lymphatics, and the substance of the 
 womb itself. These different elementary tissues it may affect either 
 separately or conjointly ; either two or more of them simultane- 
 ously or successively. 
 
 Of these lesions some degree or form of inflammation of the pe- 
 ritonaeum is tlie most frequent. Among 222 cases inspected by 
 M. Tonnelle, in 193 traces of peritoneal inflammation were observ- 
 ed, consisting in more or less redness of the intestinal or the ute- 
 rine penYoKaeww?, or of the mesentery or omentum, sometimes with 
 thin albuminous exudation, sometimes with copious exudation of 
 opaque sero- albuminous fluid. 
 
 In puerperal females peritonitis appears to originate most com- 
 monly either in the uterine peritonceum^ or in that of the ovaries, or 
 in that of the Fallopian tubes, or in the mucous or inner lining of 
 these tubes. It is not easy to say to which of these points it shows 
 the preference. If we trust to the numerical results given by M. 
 Tonnelle, the disease commences most commonly in some point of 
 the uterine peritonaeum^ and next to that in the ovarian peritonaeum. 
 
 This observer foimd among 222 inspections of the bodies of fe- 
 males, destroyed by symptoms of puerperal fever, the following 
 proportions of the lesions now referred to, — 
 
 Cases. 
 
 Marks of peritoneal inflammation in . 193 
 
 Changes in the womb and its appendages in . 197 
 
 Difference in favour of affections of womb, . 4 
 
718 
 
 GENERAL ANI) PATHOLOGICAL ANA TOMY. 
 
 Cases. 
 
 Marks of inflammation of the peritonaeum and changes in the womb 
 or its appendages were variously associated in . 165 
 
 separated in 
 
 Viz. traces of peritonitis without affection of womb in 28 
 changes in womb, including those of ovaries and veins, 
 without affection of peritonreum, in . 29 
 
 In a considerable number of cases of this disease which I had oc- 
 casion to inspect, the peritoneal covering of each ovary was enclosed 
 in a layer of albuminous exudation. In this the fimbriated extre- 
 mities of the oviferous tubes were imbedded ; and in that of one 
 side in several cases the adhesion was tolerably firm. The usual 
 blood-spots indicating organization were distinct. Between the 
 uterus and rectum in several cases was an extensive albuminous exu- 
 dation, forming a cyst containing purulent fluid ; and a smaller one 
 of the same kind was found between the uterine and vesical perito- 
 naeum. In more severe cases the inflammatory process spreads over 
 the intestinal peritonaeum, and produces its usual effects. 
 
 The commencement of this disease in the uterine and ovarian 
 peritonaeum is not wonderful, when the extraordinary distension of 
 that membrane during the latter months of pregnancy is consider- 
 ed. Denman- remarks that there are not wanting instances in which 
 it has been evidently forming before delivery, or during labour ; 
 Joseph Clarke states that he saw reason to date the commencement 
 of several cases from before delivery, and refers to two in which 
 this conclusion was justified by the speedy extinction of life after 
 labour, and the appearances on inspection, (44) ; and Hey refers 
 to two cases, one fatal, in which symptoms appeared previous to de- 
 livery. These inferences I have now had occasion to verify more 
 than once. I had occasion in the summer of 1828 to detract in 
 two days fifty ounces of blood with corresponding antiphlogistic 
 measures, in order to check incipient symptoms of peritoneal in- 
 flammation in a lady during the latter part of pregnancy. 
 
 Though peritoneal inflammation in puerperal females, compli- 
 cated as it often is with inflammation of the ovaries, of the uterine 
 veins, or of the uterine lymphatics, often terminates fatally, and 
 that at an early period ; yet in certain cases it does not immedi- 
 ately end in this way, but causes so much destruction of parts, or 
 gives rise to such morbid products, that the patient, after lingering 
 for four or six weeks in a state of great feebleness, usually with 
 hectic fever, is suddenly or slowly cut ofli'. 
 
 4 
 
SEROUS MEMBRANE. PUERPERAL PERITONITIS. 719 
 
 The morbid products and changes which take place under these 
 circumstances, prove at once the destructive effects of the disease, 
 and the great eflPorts made by the system to counteract them. 
 
 Thus in one instance, in which the disease had been proceeding 
 for three weeks, the patient was brought to the hospital with the 
 symptoms still present, though in a milder form. Pain was much 
 abated though not gone ; swelling and tension were likewise di- 
 minished. But habitual fever w^as present ; and in the hypogastric 
 region, on the left side of the pubes, was a swelling, painful, elastic, 
 pointing, soft, and evidently containing some fluid. In the course 
 of a few days, a spontaneous opening took place, and much puru- 
 lent matter was discharged, apparently with relief to the symptoms. 
 The discharge continued, however, and the hectic symptoms and 
 wasting did not subside. Notwithstanding all means calculated to 
 abate the discharge and promote adhesion, the former continued, 
 and in the course of about four weeks more the patient expired. 
 
 It was then found that around the left ovary and Fallopian tube 
 had been deposited a great quantity of lymph which connected 
 these parts to the muscular peritonaeum of the left pubo-inguinal 
 region, and formed connections also with the fundus uteri ; that 
 within this mass of lymph had been contained a quantity of puru- 
 lent matter ; that the abscess which was found in the left pubic re- 
 gion at admission had communicated with this purulent cyst ; that 
 the ulcerated opening which had been formed through this abscess in 
 the left pubal region still communicated with the interior of this 
 cyst ; and that the latter extended downwards a little on the left 
 angle and side of the uterus. The left ovary was enlarged, and 
 contained various purulent collections of small size. The left Fal- 
 lopian tube contained purulent matter. Lymph and purulent 
 matter were deposited, though less abundantly, in the fundus 
 uteri, in the angle between the uterus and rectum, in that between 
 the uterus and bladder, and on the right side of the uterus. 
 
 In a similar case which occurred to Dr Lee the ovary was con- 
 verted into a large purulent cyst, which had, by coagulable lymph, 
 formed adhesions with the abdominal parietes, and discharged its 
 contents through an ulcerated opening. 
 
 This mode of involving the ovaries and Fallopian tubes in lymph 
 containing purulent matter and then forming adhesions with other 
 contiguous parts, as the muscular or the pelvic peritonaeum, or 
 the rectum, is by no means uncommon in that class of cases in 
 
720 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 which lymph is effused, and the tendency to limit inflammation is 
 strong. This tendency to limitation, in short, by effusion of coa- 
 gulahle lymph, is either connected w'ith the more favourable and 
 less violent form of the disease, or it is an indication that the dis- 
 ease is not so speedily and certainly fatal. 
 
 One of the most extraordinary terminations of cases of this kind 
 occurred in a patient under my own care, in the Royal Infirmary 
 of this place. A woman had been previously treated for fever 
 supposed to be typhoid, until the symptoms had proceeded so far 
 as to render the effect of active treatment questionable. Blood, 
 however, was drawn from the arm, and afterwards, by means of the 
 repeated application of leeches, from the right inguinal region, 
 where pain was felt, and dulness was recognized. About the fourth 
 week after she came under my care, a quantity of purulent matter 
 was discharged from the rectum, with some transitory relief to the 
 symptoms. Death, however, took place ; and on dissection I found 
 on the right side of the rectum, between that bowel and the uterus, 
 an ulcerated opening from the cavity of the peritonaeum, whence 
 the matter had escaped. The right ovary was found covered with 
 purulent lymph ; and the right Fallopian tube was filled with thick 
 purulent matter. 
 
 § 4. Tabes mesenterica; Marasmus. — A species oichromc peritonitis^ 
 giving rise in children to the symptoms of this disease, is described 
 by Dr George Gregory. Its anatomical characters are much the 
 same as in the ordinary instances of peritoneal inflammation ; but 
 it also tends to induce thickening of the peritonaeum, secretion of 
 matter termed scrofulous, {tubercular ? tyromaious 9) and finally 
 ulceration of the peritonaeum. In consequence of this ulceration, 
 the mucous and peritoneal surfaces of the bowel communicate di- 
 rectly, so that instead of forming a continuous canal, as in the 
 normal condition,, they constitute a mass of tubes communicating 
 freely with each other, and with thickened and ulcerated perito- 
 naeum, by numerous openings. From the early symptoms com- 
 bined with these changes. Dr Gregory considers this disorder as 
 primarily commencing in the peritonaeum.* The justice of this 
 view I have already attempted to consider.f I have only to observe, 
 that not only the symptoms, but even the appearances of peritoneal 
 inflammation may he explained, by supposing the ulcerative pro- 
 cess to originate in the mucous membrane, and proceed to the pe- 
 
 * Observations on the scrofulous inflammation of the Peritonaeum, &c. Med.-Chir. 
 Transact. Vol. xi. p. 258.' 
 
 •f See page 650, § 13. 
 
CEREBRAL SEROUS MEMBRANE MENINGITIS. 
 
 721 
 
 ritoneal, in which the effusion of the contents of the tube neces- 
 sarily produce inflammatory exudation. For a case illustrating 
 this mode of progress, I refer to Howship, p. 264. 
 
 § 5. Meningitis and Arachnitis. — These two affections are gene- 
 rally combined, — in other words, inflammation of the pia mater is 
 generally accompanied with that of the arachnoid membrane. It 
 assumes acute, subacute, and chronic forms. 
 
 The acute and subacute forms constitute the disease described 
 by practical authors under the name of water of the head, loater of 
 the brain, hydrocephalus, and hydrencephalus. This inference, 
 which was originally advanced by Quin, and adopted by Rush and 
 Garnet, was first verified by Cheyne, and has been since amply con- 
 firmed by the inspections of Golis, the inquiries of Dr Blackall, of 
 Dr Ayre, Dr Abercrombie, the dissections and researches of Pa- 
 rent-Duchatelet, Martinet, and Senff. The proofs collected by 
 these authors, it is unnecessary, after the general remarks already 
 submitted, to detail. From the account also of the distribution of 
 the proper cerebral membrane, it is easy to explain the necroscopic 
 phenomena of hydrocephalic brains. The natural result of this 
 distribution is, that when the membrane is inflamed, and its vessels 
 in consequence secrete watery fluid, while that from the outer divi- 
 sion is deposited beneath the arachnoid coat, that of the inner trickles 
 from the membrane, on the figurate surface of the brain, or in the 
 ventricles, in which its effects are in proportion to its quantity. If 
 small, it produces little change on the parts of the brain. If co- 
 pious, it raises the vault, pushes out the walls of the ventricles, en- 
 larges their capacity and dimensions, breaks down the median sep- 
 tum, forming a large communicating aperture, and may ultimately 
 extrude the substance of the organ, and render it so thin as to give 
 it the appearance of a mere bag, containing a considerable quantity 
 of water. 
 
 In some instances fluid is not found in the ventricles. The pia 
 mater and plexus, however, are highly injected ; the arachnoid is 
 opaque, dull, and dry-looking ; and the subarachnoid tissue is in- 
 filtrated. This demonstrates that the symptoms of the disease de- 
 pend not on the effusion, but on the previous vascular injection. 
 
 In addition to these proofs derived from inspection, that the fluid 
 proceeds not from the brain but its membranes, it may be added, 
 that in the foetal state, previous to the formation of brain, fluid may 
 be derived from the congested vascular membrane. The new ac- 
 
 z z 
 
722 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 tion thus established gives a sudden check to the normal action of 
 the vessels ; and as the formation of the brain is thus interrupted, 
 the individual is born aneneephalous. The same process taking 
 place in the vertebral portion of the membrane during the early 
 months of foetal life, causing at once serous effusion, interruption 
 to the growth of the chord, and arresting that of the spinal plates, 
 and their mutual union, constitutes s-pina bifida. 
 
 The influence of acute meningitis in deranging the mental facul- 
 ties, though questioned by Bayle, appears to me undoubted, for the 
 following reasons. 
 
 Is#, In several cases of the disease taking place in adults, and in 
 which its nature was confirmed by accurate inspection, I have re- 
 marked the same confusion of thought, incapacity of judgment, and 
 incoherence of speech as in the maniacal. In general, in this de- 
 lirium gay and pleasurable ideas predominate. In the most dis- 
 tinct of these cases, to which I have already alluded, the nature of 
 the disease was unequivocally demonstrated, not only by the fluid 
 of the ventricles, but by the vascularity of the pia muter and plexus, 
 subarachnoid infiltration, dulnessof the arachnoid, and albuminous 
 exudation from the free surface of that membrane. 2t/, In seve- 
 ral cases of the disease occurring in infants, without proving im- 
 mediately fatal, I have traced to this cause a degree of idiocy which 
 was supposed to be congenital. This idiocy is in many cases asso- 
 ciated with deafness, dumbness, or both, sometimes with squinting, 
 and sometimes with amaurotic blindness. Upon inquiry, it always 
 appeared that the infant had undergone soon after birth an anoma- 
 lous and little understood disorder, after which, hearing and sight 
 seemed much impaired, and the vivacity of the infantile age was 
 not observed. Inspection at a subsequent period demonstrated the 
 nature of the affection. 
 
 Symptomatic meningeal inflammation, or rather congestion, I 
 have formerly said, takes place in fever continued, intermittent, 
 and remittent, after injuries of the head, and occasionally in other 
 diseases. 
 
 From the appearances of a considerable number of cases of the 
 ordinary continued fever of this country, which since the beginning 
 of 1817 I have inspected personally, or have seen inspected, I in- 
 fer that suhacute congestion of the cerebral membranes is one of 
 the most frequent phenomena of that disease, and one which very 
 often contributes to its fatal termination. I have elsewhere at- 
 tempted to show, however, that this is not the cause of fever ; and 
 
 4 
 
CEREBKAL SEROUS JIEMBRANE — :PHTHISICAL DELIRIUM. 723 
 
 though the cause of many of its symptoms, especially the confused 
 thought and incoherent speech, that it is one only of an extensive 
 and general morbid state of the capillary system induced by the 
 action of fever. It may nevertheless occasionally amount to in- 
 flammation. 
 
 With the admission of the facts now stated, further, it must be 
 remembered, that the main cause of the symptoms of headach, de- 
 lirium, convulsions, and stupor during life, and of the appearances 
 after death, is the circulation in the vessels of the brain of blood 
 not oxygenated, blood containing much carbonaceous matter, and 
 several elements which in the state of health are expelled ; blood, 
 in short, poisoned by the operation of fever, of whatever type. 
 
 § 6. Delirium in the Phthisical not an instance of Metastasis . — 
 Subacute meningeal inflammation I have seen take place in the phthi- 
 sical during the last days or weeks of existence. Upon examining 
 the brains of persons of this description who have had delirium for 
 some time before death, the pia mater and choroid plexus are more 
 or less sometimes highly injected ; the arachnoid is dull, opaque, 
 and lustreless ; the subarachnoid tissue is infiltrated, especially in 
 the vicinity of the vessels ; and serum is effused in the ventricles. 
 In an extreme case of this nature, which occurred under the care 
 of Dr Renton, and in which the patient had cfcZzVfwwz amounting to 
 mania for three weeks previous to death, I found among other le- 
 sions, the whole pia mater most extensively injected, and its minute 
 vessels of a scarlet-red colour, while the large vessels were filled 
 with dark blood. The scarlet-coloured capillaries were distinct 
 and abundant at the convoluted surface, and in particular at the 
 base of the brain, and in the portion which covers the outer surface 
 of the hippocampus major. The arachnoid was dull, opaque, and 
 elevated by subserous infiltration. At the inner margins of the 
 hemisphere, in the neighbom’hood of the falx, the arachnoid of the 
 pia mater adhered to that of the dura mater with albuminous effu- 
 sion ; and pisiform or lenticular eminences like those described by 
 Greding and others were found proceeding from the pia mater. 
 The choroid plexus was also injected ; and serum to the amount 
 of about one ounce or ten drachms was found ‘in the ventricles. 
 The substance of the convoluted or gray matter of the brain was 
 extensively traversed by reddish vessels, in which the blood was 
 still fluid. 
 
 § 7. Inflammation of the Choroid Plexus or central Pia Mater. 
 — This lesion, though rai’e, is observed occasionally to take place. 
 
724 
 
 GENERAL AND PATHOLOGICAL ANATOM T. 
 
 The choroid plexus becomes thick, solid, and firm, and is matted 
 into a mass with lymph effused between its folds and interstices. 
 It may then be drawn from the ventricles and their divisions like 
 a thick solid mass. The ventricles, at the same time, contain tur- 
 bid sero-purulent fluid. 
 
 This change commmonly affects both choroid plexuses, in all 
 their divisions. 
 
 The external effects by which it is attended are variable and not 
 very distinctive. The patient, besides shivering and being hot and 
 uncomfortable, is feeble, tremulous, and has a sort of paraplegic 
 appearance in the lower extremities, and sometimes of the whole 
 person. The patient has a stupid look, complains little, except of 
 weight of the head, and weakness of vision or blindness. In some 
 instances he is at first affected by ringing in the ears, and is after- 
 wards deaf. At length speech is imperfect ; great weakness follows, 
 generally with coma ; and after some hours of this, death ensues. 
 
 § 8. Chronic Meningeal Inflammation. The pathological causes of 
 insanity . — However general be the opinion, that mental derange- 
 ment may exist independent of anatomical change in the state of 
 the brain or its coverings, we find in the writings of various au- 
 thors, and in the results of anatomical inspection, ample proof of 
 four facts ; that, though mental derangement m'ay, in first attacks 
 and in cases of short duration, depend on some dynamical change 
 in the circulation of the brain or its membranes, yet when long 
 continued, it is always connected with some change in the organi- 
 zation of these parts ; that mental derangement, as commonly 
 observed, is usually connected with a morbid state of the mem- 
 branes, or the brain, or both ; that most abnormal changes give 
 rise, sooner or later, to confusion of thought, incoherent ideas, and 
 insane actions ; and that deranged intellect is one only of several 
 symptoms which may occur in consequence. Already, when enu- 
 merating^ the morbid changes incident to the brain, I have alluded 
 occasionally to several of those which may induce insanity. I am 
 now to advert to states of the cerebral membranes, which, there is 
 every reason to believe, are a very uniform cause of that malady. 
 
 The elaborate inspections of Greding, to whom I have had occa- 
 sion formerly to allude, afford the first traces of comprehensive 
 views on the abnormal states of the brain and its coverings, in the 
 persons of the maniacal and epileptico-maniacal insane. Accord- 
 ing to the researches of this physician, the pia mater and arachnoid 
 membrane are rarely sound in those affected with insanity. In 
 
CEREBRAL SEROUS MEMBRANE — INSANITY. 
 
 725 
 
 120 cases inspected, though in a few (5) the pia mater is stated to 
 be pale, in more (9) it was reddish ; and in a number still greater 
 its vessels were injected with dark blood. The exterior surface 
 was in 29 cases white, thick, and mucous ; sometimes dry and lar* 
 daceous, like the buffy coat of inflamed blood, near the vertex, along 
 the mesial margins of the hemispheres. In 29 cases this alteration 
 extended more generally over the membrane. In 9 it was observed 
 over the convex and plane surfaces of the hemispheres ; and in 6 
 it extended round the cerebellum and medulla oblongata. The 
 white, thick, opaque appearance Greding ascribes to subarach- 
 noid effusion ; the dry lardaceous to albuminous exudation. In 
 37 cases he found minute, pisiform, or lenticular eminences, like a 
 mustard-seed, a hemp-seed, or a pea, soft or hard, disseminated 
 over the membrane ; in 27 cases more copious and thickly set ; and 
 in 14 cases accumulated abundantly. These bodies, which are to 
 be distinguished from the glandules of Pacchioni, by situation, soft 
 consistence, and milky colour, appear to be a product of the in- 
 flammatory process. I have occasionally seen them in subjects in 
 whom the traces of chronic inflammation were distinct.* 
 
 Similar changes in the cerebral membranes were recognised by 
 Joseph Wenzel of Mayence,f an 1 Chiarugi of Florence. The 
 latter especially, among 59 necroscopic inspections of insane per- 
 sons, found in 54 more or less thickening of the membranes, serous 
 infiltration of the subarachnoid tissue, with or without injection of 
 the capillaries, and serous flui i to greater or less amount within 
 the ventricles. J 
 
 Much the same results may be derived from <‘he necroscopic re- 
 ports of Haslam and Marshall. Of 37 cases of insane persons ex- 
 amined by the former, whatever was the state of the brain, the 
 membranes were unsound in all except one (the 33d); and in this 
 “ considerable determination of blood to the brain shows that the 
 capillaries of the pia mater were inordinately loaded. In 23 of 
 these cases, the pia mater was injected and loaded with blood, more 
 or less reddened or disordered in its capillary system. In 24 cases, 
 the arachnoid membrane was opaque ; in some instances of milky 
 
 * MelanchoHco-Maniacorum et Epilepticorum quomndam in Ptochotropheo Wald- 
 heimensi demortuorum sectiones tradit J. E. Greding, Continuatio 2da. Apud Ludwig 
 Adversaria, VoL ii. Part iii. p. 449. 
 
 t Observations sur le Cervelet et sur les diverses parties du cerveau dans les Epilep- 
 tiques, par Jos. Wenzel, D. M. &c. Traduit par M. Breton. Paris, 1811. 
 
 t Della Pazzia in genere e in specie, Trattato Medico- Analitico con una centuria 
 d’Osservazioni. 3 Tomi, 8vo. Firenze, 1793, 1794. 
 
726 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 opacity ; in several thickened ; and in one-half at least with infil- 
 tration into the subarachnoid tissue. Of these 24, 13 belong to 
 the first class in presenting traces of injection of the pia mater. In 
 21 cases, serous fluid varying in amount from two tea-spoonful to 
 four, six, or eight ounces was found in the ventricles ; and of these 
 also 10 corresponded with the first class in presenting traces of me- 
 ningeal inflammation more or less intense. The presence of this 
 fluid in the cerebral cavities, I have already shown, indicates pre- 
 vious vascular congestion of the choroid plexus ; and though this 
 membrane was not in all instances much or evidently affected, yet, 
 since in several it was vascular, thickened, vesicular, or indurated, 
 the appearance of fluid in the cavities is as unequivocal a mark of 
 previous inflammation as if it had been reddened, injected, or pe- 
 netrated by extravasated blood. The opacity, both macular and 
 diffuse. Dr Haslam regards as marks of inflammation ; and the sub- 
 arachnoid infiltration is of the same nature. In several cases, (5, 
 7, 8, 14, 15, 18,) the injection had proceeded to extravasated patches. 
 In one case, in which the patient died hemiplegic, the right lateral 
 ventricle was distended with dark-coloured blood which had issued 
 from the choroid plexus ; and in one, in which the patient dropped 
 dowm lifeless in a moment, much blood was extravasated between 
 the cerebral membranes.* 
 
 The cases dissected by Dr Marshall about the same time, but 
 published some years after, furnish similar results. Of 22 cases of 
 insane persons w hose brains were inspected by this anatomist, in 21 
 serous fluid, varying in amount from 1, 2, or 4, to 12 ounces, was 
 found in the cerebral cavities; and in 17 of these 21 cases similar 
 effusion was found in the subarachnoid tissue occasionally to the 
 extent of elevating the arachnoid membrane in minute vesicles or 
 cysts, (cases 6, 8, 9, 18, 22.) Though the pia mater is said to have 
 been injected in four cases only, and the arachnoid to have been 
 opaque in two, it results from the fluid effused into the ventricles 
 or between the membranes, from the vascularity of the substance 
 of the brain, and from the facility with which the pia mater was de- 
 tached from the convoluted surface, that the capillaries of the lat- 
 ter membrane were in a morbid state.f It is further to be remark- 
 ed, that in nine of these cases were the arteries of the brain opaque, 
 
 * Observations on Madness and Melancholy, &c. by John Haslam, 2d edition. 
 London, 1809. 
 
 T The Morbid Anatomy of the Brain in Mania and Hydrophobia, &c. &c. collected 
 from the Papers of the late Andrew Marshall, M. D. 1815. 
 
CEREBRAL SEROUS MEMBRANE INSANITY. 
 
 727 
 
 thickened, steatomatous, or ossified, — a condition highly favourable 
 for deranging the capillary circulation of the membranes or the in- 
 closed organ. 
 
 These results are important in enumerating the most uniform 
 morbid appearances found in the cerebral membranes of the mani- 
 acal. Their chief value, however, consists in the verification which 
 they have since received from the researches of Neumann of Ber- 
 lin, and Bayle and Calmeil of Paris. From the inquiries of the 
 second of these authors especially, it appears almost established that 
 a state of chronic inflammation of the cerebral membranes is inva- 
 riably the cause of insanity. My limits do not permit me to detail 
 the whole of the proofs on which this inference is founded ; nor is 
 it necessary, after collating the dissections of Greding, Chiarugi, 
 Haslam, and Marshall. A short statement of the principal mor- 
 bid changes recognized by M. Bayle will be sufficient to show how 
 far the inference is justified by facts. 
 
 Is^, The most constant anatomical character of this state of the 
 cerebral membranes is injection, more or less intense and extensive, 
 of the cellular vascular web of the pia mater. The vessels are 
 loaded ; the membrane is red or scarlet ; and blood trickles from 
 all parts on removing it from the brain. In other instances, its in- 
 terstices are distended with serous fluid, which gives it a pale gray 
 colour, and increases its volume and thickness. The arachnoid is 
 reddish scarcely once in 16 or 20 cases. 
 
 2J, The arachnoid becomes opaque and thickened, especially in 
 the convex centre of the hemispheres, at their mesial margin, and 
 on their mutual surface. This thickness, which may be so great as 
 to approach that of the pleura, the pericardium, the dura mater, or 
 macerated parchment, M. Bayle ascribes not to albuminous deposi- 
 tion on its surface, but to development of vessels, and extravasation 
 of matter in its substance. 
 
 Zd, The meningeal injection very generally terminates in serous 
 effusion, either from the free surface of the arachnoid membrane in- 
 to the subarachnoid tissue, or from the arachnoid of the choroid 
 plexus, constituting eflfusion into the ventricles. 
 
 ^th. Albuminous exudation occurred in ^th of the subjects at the 
 free surface of the arachnoid of the dura mater, covering its whole 
 extent, confined to the convexity of one or both hemispheres, to the 
 falx, or to the occipital region, — applied, but not adhering to the 
 cerebral arachnoid. 
 
728 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 5th, Adhesions of the two surfaces of the arachnoid occurred no 
 more than 8 or 10 times in 100 instances. They are most com- 
 mon in the great fissure, and once or twice were observed in the 
 ventricles. In one case, in which the disease was complicated, M. 
 Bayle found the two folds of the arachnoid intimately united by' the 
 interposition of an albuminous patch. 
 
 Qth, The membranes adhered to the convoluted surface with un- 
 usual firmness, so as to carry away portions of brain in one-half 
 of the cases. This took place in spaces varying in size from a 
 lentile or a beau to a five-franc piece or move. The connection of 
 this change with inflammation is denoted by the vascularity and 
 abnormal thickness of the membranes at the adhering points. 
 
 Itk, The pisiform granulations of Greding were found in not 
 more than of the subjects; a degree of rarity probably depen- 
 dent on the circumstance that they are in general a product of 
 long-continued inflammation. 
 
 Sth, Bloody extravasation in the arachnoid cavity, which belongs 
 to a subsequent head, was found in about |-th of the cases. 
 
 From these and similar facts, and from the cases of M. Calmeil, 
 it results that the cerebral membranes, more especially the tomen- 
 tose and vascular surface of the proper membrane, {pia mater and 
 choroid plexus,) are liable to assume a peculiar state of chronic in- 
 flammation, aflPecting more or less, sometimes very considerably, the 
 convoluted and central surfaces of the brain. Of this morbid 
 change the first effects are more or less weight, uneasiness, and pain 
 of the head ; sometimes partial convulsive motions ; sometimes te- 
 tanic motions or involuntary contractions, vertigo, double vision, 
 spectral delirium, and occasionally sudden loss of sensation and mo- 
 tion. In other instances, it induces gradually deficient memory, 
 disordered intellect, and some aflrection of the muscles of speech. 
 Finally, it induces palsy, fatuity, and stupor or coma, terminating 
 fatally. 
 
 Palsy occurring under these circumstances in the insane is dis- 
 tinguished by peculiar characters. At first the motions of the 
 tongue are constrained; the efforts to speak are unavailing; arti- 
 culation is impracticable ; and the individual struggles and stam- 
 mers to express his desires like a person under the influence of in- 
 toxication. As this becomes intense he is observed to totter, stagger, 
 or reel in walking, and is aware that he cannot direct the muscles 
 
 of the limbs to move as he wills. At this time the derangement 
 
 3 
 
CEREBRAL SEROUS MEMBRANE — HEMORRHAGE. 729 
 
 verges to fatuity. At a more advanced period, not only is speech 
 obliterated or converted into inarticulate muttering, but the patient 
 is unable to maintain himself erect ; and whenever he wills to make 
 any motion, neither arms nor legs are obedient to his desires. This 
 morbid action of the cerebral membranes, in short, impairs, but does 
 not annihilate the motions of all the voluntary muscles. It induces 
 a general but incomplete loss of power. 
 
 The senses are at the same time impaired but not obliterated. 
 The paralytic madman distinguishes light from darkness ; he hears 
 a loud sound made at the ears ; and he is sensible of pungent 
 odours. But if the skin be touched with two bodies, the one hot 
 and the other cold, he distinguishes no difference. Taste and ge- 
 neral sensation are equally obtuse. In this state death is not re- 
 mote. The duration of the affection varies according to the slow- 
 ness or rapidity of the meningo-encephalic disorder, from which 
 the palsy arises. Some paralytic maniacs live eight months, a 
 year, eighteen months, and others continue two or three years, 
 rarely longer. The average duration of life, after the commence- 
 ment of paralytic symptoms indicates affection of the cerebral sur- 
 faces extending to the substance, is about thirteen months. 
 
 II. Hemorrhage. — Discharges of blood from the serous mem- 
 branes have not attracted so much attention as those of the mu- 
 cous surfaces. They are nevertheless not uncommon ; and though 
 the inaccessible situation of the serous surfaces has made their he- 
 morrhages be overlooked or confounded with other diseases, they 
 constitute a form of morbid action too important to be omitted. 
 They occur in all the serous membranes, are preceded by injection, 
 and take place by exhalation, and may be arranged in the follow- 
 ing order. 
 
 Cerebral membranes, Mewingmfda. 
 
 Pleura, Pleurosmia, Hcemaihorax. 
 
 Pericardium, Hwmacardia. 
 
 Peritonaeum, Hcementeria. 
 
 PerididjTnis, Hceimatorchis. 
 
 § 1. MeningcBmia . — The nature of the subject compels me re- 
 luctantly to begin with hemorrhage of the tomentose or vascular 
 surface of the pia mater. In this variety of meningeal hemorrhage, 
 which has been greatly overlooked, the vessels of the attached sur- 
 face of the pia mater become inordinately injected and effuse blood, 
 which is deposited in the convoluted surface generally, and occa- 
 sionally in the ventricles. Omitting some obscure accounts of this 
 
730 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 affection in the older collections, the first good example is given 
 by Morgagni from Valsalvi, who found in the body of a man of 58 
 much coagulated blood between the pia mater and the convoluted 
 surface of the right hemisphere. (Epist ii. 19.) Two similar cases 
 Morgagni inspected himself. (Epist. iii. 2 and 4.) 
 
 The best instance of this hemorrhage, however, is given by Mr 
 Howship in his 11th case. It occurred in a young woman of 22, 
 who for two years had laboured under rheumatic ailments, and at 
 length, after paralytic and vertiginous symptoms, died lethargic. 
 Upon inspection the pia mater yms found vascular and red; its ves- 
 sels increased in number and size ; and blood was diffusely ex- 
 travasated all under the pia mater. ‘‘ The extravasated fluid had 
 formed superficial coagula, corresponding to the suki between the 
 convolutions.” — “ It had taken place very universally, and the ef- 
 fusion seemed to have arisen not only from the capillary arteries 
 upon the external surface of the pia mater but also from those 
 processes of the membrane which dip between the convolutions 
 forming the tomentum cerebri. Several of these deep-seated coa- 
 gula were divided by the knife in the course of the dissection.”* 
 
 Slighter examples of partial extravasation on the convoluted 
 surface I have seen myself, and mentioned many years ago,f when 
 I did not well understand the source of the hemorrhage. These 
 partial extravasations are the cause of the orange-coloured de- 
 pressed spots often seen on the convoluted surface of the brain. Dr 
 Abercrombie records two instances communicated by Dr Hunter 
 and Dr Barlow, in which the extravasation, he states, was from 
 the superficial vessels of the brain.| He does not specify, how- 
 ever, whether the blood was beneath the pia mater or above it. If 
 it was above, it belongs to the following head. 
 
 The lesion now described is to be regarded as a hemorrhage 
 taking place spontaneously. Much more frequently, however, blood 
 effused between the pia mater and surface of the brain is the effect 
 of blows, violence, and similar injuries. As such it has already 
 come under consideration ; and I have only to repeat what was 
 formerly stated, that in a medico-legal point of view the distinction 
 is most important, and the correct knowledge of it may often affect 
 
 * Practical Observations on Surgery and Morbid Anatomy, &c. Lond. 1816. Sec- 
 tion ii. Case xiv. See also cases xviii. and xx. 
 
 t On the Pathological Anatomy of the Brain and its Membranes, Med. and Surg. 
 .Journal, Vol. xviii. p. 487. 
 
 Researches, Pathological and Practical. 
 
" CEREBRAL SEROUS MEMBRANE — MENINGEAL HEMORRHAGE. 731 
 
 the life of a fellow-creature. In general, therefore, it is to be un- 
 derstood that when blood is effused between the pia mater and con- 
 voluted surface of the brain, or within the ventricles, it proceeds 
 from the membranes, and is most likely to be the result of external 
 violence. When, on the other hand, the effusion is found within 
 the substance of the brain, in fissures or lacerations, it is the result 
 of disease. 
 
 In the hemorrhage of the brains of new-born infants, tbe blood 
 is also situate between the pia mater and brain. To this subject, 
 however, I need not recur. 
 
 Hemorrhage from the free surface of the arachnoid mem- 
 brane is more common. It may take place either from that which 
 lines the dura mater, and covers the pia mater, w'hen it is found 
 between these two membranes ; or from the arachnoid of the choroid 
 plexus, when it is found in the ventricles. Of the former, a good 
 instance is given by Haslam, who found this the cause of sudden 
 death in the person of a maniac. The same change was found by 
 Bayle in about ^th of the cases of persons cut off by symptoms of 
 chronic meningitis. The cases of Drs Hunter and Barlow are 
 already mentioned. 
 
 Effusion from the interior or central arachnoid is more frequent ; 
 and cases may be found in the writings of most collectors. Of this 
 nature are the following. The case of the chamberlain of the mo- 
 nastery of Rheinau, near Schaffhausen, recorded by Wepfer;* 
 several described by Morgagni, e. g. the case of Cardinal Sanvitali ; 
 and those in the 13th, 15tb, 17th, 19th, and 22d sections of his 
 second epistle ; the cases of Antonio Tita, Pietro Facciolati, and 
 the Danish ambassador in his third epistle, and one or two in the 
 sixtieth ; the case related by Veratti in the Bologna Memoirs ;f the 
 case by De Haen, called rupture of the choroid plexus the 48th of 
 Rochoux ;§ the 4tb, 8th, and 12th cases of Cheyne;l| one or two 
 cases by Merat and tbe 20th and 21st cases of Serres.** 
 
 In all these cases, blood or bloody fluid was found in the ven- 
 tricles ; and since it was not connected, as in the ordinary instances 
 of this with rupture or injm-y of the cerebral substance, and conse- 
 quently had not penetrated, as I have formerly shown, from the 
 substance of the hemispheres, it is inferred that it must have issued 
 
 * Historia Apoplecticorum. f Comment. Bonon. Tom. ii. Chap. i. 
 
 t Rat. Med. Pars iv. cap. v. p. 189. § Recherches sur I’Apoplexie. 
 
 II Cases of Apoplexy and Lethargy. Lond. 1812. 
 
 H Memoires de la Societe Medicale d’Emulation, Tome vii. p. 61. 
 
 * * Annuaire Medico-Chirurgicale, &c. 
 
732 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 from the plexus. There is no reason to suppose that the vessels of 
 this web>re ruptured in this form of hemorrhage. The fluid is 
 rarely pure blood, generally sanguinolent ; but even if pure, the 
 observations of Bichat, Merat, and Serres, show that it may ooze 
 by exhalation from the plexus. It constitutes the meningeal apo- 
 plexy of Serres.* 
 
 The causes of this form of hemorrhage are often as obscure as 
 those of hemorrhage in the substance of the brain. Yet in certain 
 cases it is possible to trace a connection between these hemorrhages 
 and the state of the arteries, exactly as in hemorrhage into the 
 substance of the brain. For this reason, it is proper, in order to 
 complete the pathology of cerebral hemorrhage, to advert to the 
 state of the blood-vessels which are conveyed along the membranes 
 of the brain. 
 
 § 2. Effects of the Steatomatous and Osteo-steatomatous Degene 
 ration of the Cerebral Arteries on the Circulation of the Brain and 
 its Membranes . — Though to this change as a predisposing cause to 
 softening and hemorrhage I have already adverted, it may not be 
 improper to take in this place a general view of the transformation 
 and its several effects. 
 
 The tunics of the arteries of the brain are liable, in advanced 
 life, to become penetrated with steatomatous and osteo-steatomatous 
 matter to an extreme degree and a very general extent. They 
 then become rigid, unyielding, opaque, inelastic, and are no longer 
 capable of conveying the blood as pliant transmissile tubes. Though 
 this change affects most usually the internal carotid and its branches, 
 as the Sylvian artery, the anterior communicating arteries, and the 
 circle of Willis, and next to these the basilar artery, yet it may ex- 
 tend over all the arteries of the brain, great and small. In an ex- 
 treme and extensive example of the disease in my collection, the 
 whole of the trunks and branches of the internal carotid and basilar 
 arteries have become completely penetrated and transformed by 
 this cliange, and show its effects in various modes. In some parts 
 the arteries are enlarged in external circumference, without increas- 
 ing the internal capacity, and often diminishing it, in consequence 
 of the deposition between the middle and inner coats. In all parts, 
 the internal area of the arteries is more or less diminished ; in 
 some it is contracted so much, that the canal of the vessel appears 
 
 * On Extravasations of Blood into the cavity of the Arachnoid, and on the forma- 
 tion of the False Membrane which sometimes envelopes these extravasations. By 
 Prescott Hewett, Esq. Medico-Chirurgical Trans, vol. xxviii. p. 45. London, 1845. 
 
CEREBRAL SEROUS MEMBRANE — ARTERIAL DISEASE. 733 
 
 closed, and indeed may be closed. In some points the vessels be- 
 come tortuous and serpentine. Transverse sections also show an- 
 other change. The inner coat is separated from the middle by fis- 
 sures or chinks, caused apparently by the new deposition between 
 them ; and all over the tunics present specks of steatomatous or 
 osseous matter, sometimes rings of bone, and in short they are con- 
 verted into inelastic, brittle, and more or less rigid tubes. 
 
 The effects of this state of the cerebral arteries on the circulation 
 are considerable, though not permanent. The blood is liable to 
 irregularity in its movement, and sometimes to become entirely 
 stopped. In this state the obstructed motion induces an attack of 
 cataphora^ or stupor and insensibility, lasting for several hours, or 
 even for one or two days. In other cases it induces a degree of 
 confusion and inability to walk, or keep in the erect position, with 
 drowsiness, yet with the patient being capable of being roused, or 
 spontaneously rousing himself at intervals. After some hours of rest, 
 with the use of adequate means, the patient perfectly recovers, and 
 seems as well in intellect, memory, and observation, as ever. He 
 is liable, nevertheless, to recurrences of these fits of cataphora, and 
 in one of them death may take place. Fits of this kind, neverthe- 
 less, I have seen come and go in the same individuals for several 
 years, apparently without affecting the health or the intellect, and 
 with only a degree of impaired memory. These attacks of cata- 
 phora are often mistaken for attacks of apoplexy ; but they are not 
 so, and do not require the same treatment. Often, indeed, the pa- 
 tient recovers spontaneously after a sound sleep. An awkward 
 position of the head and neck occasionally precedes these attacks. 
 
 In other instances, the osteo-steatomatous state of the arteries 
 produces more permanent and more serious disorder. By obstruct- 
 ing the circulation, it induces the state formerly described as atro- 
 phy of the convolutions and brain, often with copious effusion into 
 the subarachnoid tissue and within the ventricles. In other cases 
 the individual speaks thick and inarticulately, is unsteady in his 
 motions, and, though not paralytic, the limbs totter and shake. 
 There is also more or less loss of memory. Such was the state of 
 the person whose cerebral arteries I have above described as ex- 
 tensively affected by this transformation. 
 
 Lastly, from this state of the arteries, evils still more consider- 
 able may result. It has been observed several times to give rise 
 to aneurism without or with rupture and hemorrhage. Thus Mr 
 
734 
 
 GENERAL AND PATHOLOGICAL ANATOMY, 
 
 E. A. Jennings records in a stout healthy man of 54, an instance 
 of aneurism of the hasilar artery suddenly giving way, and causing 
 speedy dissolution by hemorrhage. This aneurism, which was about 
 the size of a pea, was situate on the basilar artery, immediately 
 after the union of the two vertebral arteries. From this blood had 
 escaped and spread itself over the medulla oblongata* This per- 
 son was wont to suffer from pain in the head. Death took place 
 about eight hours after the appearance of the first symptoms. 
 
 In the course of inspections at the Royal Infirmary of this place, 
 I have observed three instances of aneurism of the cerebral arteries 
 within the space of about five years. Two of these were situate in 
 the anterior arteries of the brain in the fissure of Sylvius. The 
 arteries in both cases were diseased along their whole course. 
 The aneurismal swelling in one case was about the size of a pea ; 
 in the other it was a little larger. In both cases, rupture had 
 taken place, followed by apoplectic death. 
 
 A third case I observed in the basilar artery. The tumour here 
 was regularly spherical, and appeared like a small globular body 
 formed in the course of the artery. The preparation is preserved 
 in the museum of the university. A good example of aneurism in 
 the right vertebral artery is given by Cruveilhier. In this case 
 the swelling was almost exactly globular, and extended equally on 
 each side of the artery, being altogether from five to six lines in 
 diameter. The interior shows clots and steatomatous deposition. f 
 
 By some, as Mr Porter, it is maintained that aneurism in this si- 
 tuation must be true aneurism, that is, formed by dilatation of the 
 inner and middle tunics alone, as there is no cellular duct to form 
 an external covering, were the inner tunics lacerated. It is cer- 
 tainly remarkable that these aneurisms of the cerebral arteries pre- 
 sent examples of uniform and regular dilatation much more com- 
 plete, than are observed in the aneurisms of other regions. They 
 are in truth the only aneurisms which afford examples of what 
 Cruveilhier denominates peripheral, that is, spherical aneurisms, 
 embracing the entire periphery of the vessel in which they are 
 formed. Cruveilhier, nevertheless, maintains that the whole three 
 tunics are dilated ; and in supporting this proposition, he necessarily 
 maintains that the cerebral arteries possess a cellular tunic as well 
 as those of other regions. 
 
 * Case of Aneurism of the Basilar Artery suddenly giving way, &c. By E. A. Jen- 
 nings. Transactions of Provincial Association, Vol. i. p. 270. London, 1833, 
 
 f Anatomic Pathologique, Livraison xxviii. PI. iii. figs. 2, 3, 4. 
 
CEREBRAL SEROUS MEMBRANE n.UMATHORAX. 
 
 735 
 
 § 3. It is further an interesting confirmation of the view above given, 
 that hemorrhage of the same nature may take place from the arach- 
 noid of the membranes of the spinal chord, and give rise to similar 
 symptoms, though modified by the situation of the eflFusion. Of 
 this variety of arachnoid hemorrhage, an instance is quoted by 
 Sauvages from Duverney, under the title of asphyxia spinalis ; but 
 the best examples are those recorded by M. Chevalier in the 3d 
 volume of the Medico-Chirurgical Transactions, and that by Sir A. 
 Cooper in his work on Dislocation. In these cases blood, coagulated 
 and fluid, was found in the spinal canal between the membranes, and 
 the vessels of the membranes were inordinately loaded. 
 
 § 4. PleurcBmia ; hcemathorax . — On this form of hemorrhage, 
 instances of which are recorded by hlorgagni and Lieutaud, which 
 has been well described by Merat and Laennec, it is unnecessary to 
 say more. Merat informs us that this hemorrhage proved fatal to 
 Professor Mahon.* 
 
 § 5. Hcemacardia, or hemorrhage from the pericardium, has been 
 not less overlooked than the ether bloody discharges of the serous 
 membranes. In the few instances which have been recorded, it has 
 generally been ascribed to laceration or ruptm’e of the auricles, 
 venous sinuses, or organs of the large vessels, allowing the blood 
 contained to escape and distend the pericardium. In the instances 
 to which I now advert, the most minute and diligent search was in- 
 adequate to detect either rupture, laceration, or minute orifices by 
 which blood could escape ; and it must therefore be inferred, that 
 it issues from the membrane by the process of exhalation. 
 
 Of this singular hemorrhage, four distinct and authentic cases 
 are recorded. In the first, by Dr Alston, three pounds of coagu- 
 lated blood and bloody serum were taken from the pericardium. 
 When the inner surface of the pericardium, and the external sur- 
 face of the heart were carefully cleansed by sponges, no aperture of 
 any of the large vessels could be discovered ; “ but on pressing the 
 heart bloody serum oozed from many small orifices on its surface, 
 and principally near its basis. ”f The second case, by Dr Thomson 
 of Worcester, is similar in the quantity and kind of blood eflfused, 
 and in the impossibility of tracing it to rupture or open vessel. | In 
 the third case, by ]\Ir Joseph Hooper, about five pints of fluid 
 blood perfectly free from coagula^ were found in the pericardium, 
 in which no vestige of rupture could, after the most careful exami- 
 
 • Journal cle Medecine, Tome ix. p. 132. 
 
 t Medical Essays and Observations, Vol. vi. p. 111. Art. hi. 
 
 ?; Medical Observations and Inquiries, Vol. iv. p. 330, Art. xxvi. 
 
736 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 nation, be found.* Lastly, in a case by Herat, two ounces of pure 
 blood were found in the pericardium of a man of 53, who had la- 
 boured under organic lesion of the heart and consecutive dropsy.f 
 
 Baillie, to whom these effusions were known, was aware of the 
 difficulty of explaining them, and conjectures that the blood may 
 have oozed by transudation, or escaped from the extremities of the 
 minute vessels, which he supposes may be inordinately relaxed.^ 
 The last supposition, it may be remarked, virtually admits exhala- 
 tion. 
 
 It must be observed, nevertheless, that the arteries on the sur- 
 face of the heart are often diseased in this hemorrhage. 
 
 § 6. H(Bmenteria, PeritonoBmia . — Peritoneal hemorrhage is not 
 uncommon. It occurs under two forms, the sanguinolent and the 
 sanguine. A valuable instance of this hemorrhage, mentioned by 
 Morgagni, § is that of Laelio Laelii, a medical student, a native 
 of his own town of Imola, in whose abdomen was found about lA 
 pound of fluid blood, with black spots of the peritonaeum. The 
 best examples, however, are those recorded by Herat. In the first, 
 there were three pints of bloody serum in the cavity, with evident 
 marks of peritoneal inflammation. In a second, there were between 
 two and three pints, and the membrane was covered with numerous 
 granulations. It is reasonable to infer that this was tubercular 
 disease of the peritoneum causing hemorrhage. In a third case, 
 in which death took place 47 days after the first symptoms, upon 
 inspection there were found about twenty pints of a fluid, first 
 sanguinolent, then like pure blood, and lastly some clots. The 
 marks of inflammation were so intense as to leave few traces of the 
 original form of the abdominal viscera. || 
 
 § 7. Hcematorchis . — Of hemorrhage from the vaginal coat, Bichat 
 states that he met with two instances only ; and Herat acknowledges 
 that he has not yet seen any example. On some occasions this 
 hemorrhage lays the foundation of the bloody tumour (Ji(Bmatoma^) 
 occasionally found in the vaginal coat. 
 
 From the facts recorded it results that these hemorrhages, like 
 those of the mucous tissue, are the result of exhalation. Bichat 
 states, that after scrupulous examination of the inner surface of the 
 pleura, pericardium, and peritoncBum, under these hemorrhages, he 
 found the surface entire, and the vessels unbroken. There is every 
 
 * Memoirs of the Medical Society, Vol. i. p. 238, Art. xviii. 
 
 t Memoires de la Societe Medicale d’Emulation, Vol. vii. p. 63. 
 
 X Morbid Anatomy. § Epist. xxxv. 2. Case of Laelio Laelii. 
 
 II Memoires de la Societe Medicale d’Emulation, Tom. vii. p. 6H. 
 
SEROUS MEMBRANE — TUBERCLES, 
 
 737 
 
 reason to believe that they are in all cases preceded hy congestion 
 of the capillaries ; for most of those which are hitherto accurately 
 recorded were connected with marks of inflammation, and some with 
 organic lesion. 
 
 I have yet to observe, that the serous membranes are liable to 
 become simultaneously the seat of hemorrhage in land-scurvy and 
 in sea-scurvy. In the former disease, these membranes have been 
 found occupied not only by petechial spots and dark or livid blotches, 
 but with considerable effusion of fluid blood. Of this, the cases of 
 Dr Duncan Junior and Mr William Wood are the best examples. 
 In extreme cases of scurvy the same extravasation takes place. 
 
 III. Dropsies. — Of abnormal accumulation of serous fluid within 
 the serous membranes I have nothing to add to what is already said 
 in the chapter on the exhalants. These accumulations may almost 
 invariably be traced to disease of the contained organs, or of other 
 organs, as the heart, liver, kidneys, or tubercular deposit in the 
 membranes. 
 
 IV. Air is not unfrequently effused into cavities formed by serous 
 tissue. Besides the form of pneumothorax^ which results from fistu- 
 lous opening of the lung, another may take place from laceration 
 or wound of the lung. In the peritonaeum it is the result either of 
 inflammation, of gangrene and decomposition of serum, of ulcera- 
 tive perforation, or of organic disease producing the same effect. 
 
 V. Tubercles. — Tubercular deposition of different kinds is fre- 
 quent in the serous membranes. The exact nature of the deposi- 
 tion, however, is not well defined. The tubercular diseases occur- 
 ring in serous membranes are of two sorts, the genuine tyromatous^ 
 or that in which tyromatous matter is deposited, in irregular or 
 amorphous masses in the membrane, — and the cenchroid or miliary, 
 in which minute lenticular bodies hard as cartilage, but opaque or 
 semi-transparent, are developed in these membranes. 
 
 § 1. The tyromatous deposition occurs in these membranes, but 
 most frequently in the peritonaeum, in which it was originally ob- 
 served by Morgagni, Lieutaud, and Baillie, afterwards well described 
 by Dr Baron, and Scoutetten, and observed by Dr MoncrieflT. 
 They are round bodies, varying in size from a vetch or garden-pea 
 to a bean, not always regular in shape, of caseous consistence, and 
 generally softened in the centre. They cause inflammation of the 
 membrane. In the pleura tubercles are noticed by Morgagni, Lieu- 
 
 3 A 
 
738 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 taud, and Baillie. To this head, perhaps, we may refer a variety of 
 tyromatous tumour of the pleura observed by Mr Howship. It con- 
 sisted in a great number of bulbous processes variable in shape and 
 size, but, apparently from the description, oblong, spheroidal, and 
 attached by narrow stalks or peduncles. The substance of these 
 bodies, which was semitransparent and very firm, of a dull-yellow 
 colour, partly fluid and partly solid, is ascribed by Mr Howship to 
 effusion of lymph. The opacity and increase of density resulting 
 from immersion in alcohol showed that they contained albuminous 
 matter.* 
 
 In the membranes of the brain they seem to be also not uncom- 
 mon, though their origin from the arachnoid is not quite established. 
 
 Tubercles or tyromatous depositions in the tubercular form are 
 often found in the pia mater ^ and especially its cerebral prolonga- 
 tions. They occur not only in the exterior division of the mem- 
 brane, but in that which penetrates the ventricles ; and from this 
 circumstance it often happens that tyromatous bodies, which are 
 found in the cerebral substance, have originated in the membranes. 
 Thus of the figures given by Baillie in the 7th pi. of his 10th fasci- 
 culus, two tubercular bodies are found actually attached to the cho- 
 roid plexus ; one found in the lower part of the fourth ventricle ; 
 and that represented by Dr Hooper in the same situation (12th 
 pi.) appears to have had the same origin ; and those said to be found 
 in the brain were very probably originally formed at the filamentous 
 surface of the pia mater, between which and the bodies, in most in- 
 stances, vascular connections are distinct and immediate. 
 
 § 2. The cenchroid tubercles are very frequent in serous tissue. 
 In the pleura they wei’e seen by Wrisberg, Baillie, Bayle, Laennec, 
 and Andral ; in the peritonaeum by Scoutetten. 
 
 These miliary or cartilaginous tubercles are not unfrequently 
 found to occupy all the serous membranes at once, more especi- 
 ally in the bodies of the lower animals. Thus I have often seen 
 them in the pleura, pericardium, and peritonaeum in the sheep ; 
 and in a specimen of the Paca dissected by my friend Dr Grant, 
 every serous membrane was thickly set with them. They occur 
 chiefly in men and animals long excluded from air and exercise. 
 In the early stage they do not exercise much influence on the state 
 of these membranes. But at a more advanced period they cause 
 inordinate exhalation, opacity, dulness, and other marks of morbid 
 circulation of the tissue. 
 
 ■* Practical Observations on Surgery and Morbid Anatomy, p. 204. 
 
SEROUS MEMBRANE — TUBERCLES. 
 
 739 
 
 In the human body cenchroid tubercles occur in the pleura and 
 peritoneum in two forms. 
 
 In one, very small bodies like the heads of needles or pins, and 
 generally of a white colour, are disseminated over the whole pleu- 
 ral or peritoneal surface. These are very closely set, and com- 
 municate to the membrane a perceptible degree of roughness. 
 After some time they cause, at least in the peritonaeum, adhesion 
 of the folds of the ileum, so that the whole bowels are united in one 
 general adherent mass. These tubercles are seated in the substance 
 of the peritonaeum. They do not appear to increase much in size, 
 but they tend simply to induce chronic inflammation of the mem- 
 brane and union of Its parts by efiusion of lymph and adhesion. 
 
 They likewise tend to cause the efiusion of serous fluid from the 
 surface of the peritoneum. 
 
 In the second variety, small bodies, a little larger than those 
 last mentioned, are most minutely and extensively disseminated 
 over the pleura or peritoneum. These resemble gunpowder grains, 
 are generally of a light blue colour, and are always extremely hard. 
 They are less liable to cause adhesive inflammation than the small 
 white tubercles. Yet occasionally the intestinal peritonaeum is ob- 
 served adhering extensively, in consequence of their development 
 in that membrane. 
 
 They alw'ays derange the circulation and secretion of the mem- 
 brane ; and much serous fluid is accumulated within the cavities in 
 consequence. They may take place in one serous membrane only ; 
 but they often take place in the pleura and peritoneum at once, 
 causing in the former hydrothorax, and in the latter ascites. 
 
 They affect in the abdomen, the mesentery and omentum ; and 
 the latter is doubled or folded up like an oblong tumour across the 
 abdomen between the stomach and colon.* 
 
 In the brain they are mostly seen in the pia mater towards the 
 base ; and they in that situation resemble neither the first nor the 
 second variety of tubercles ; being larger than the former, and less 
 hard than the latter. 
 
 They may take place at any region of the pia mater. But they 
 are more common at the base of the brain and around the cerebel- 
 lum than in any other situation. 
 
 Wherever they are found, they induce chronic hydrocephalic 
 
 * Report of the Cases treated during the Course of Clinical Lectures delivered at 
 the Royal Infirmary in 1832-1833. By Uavid Craigie, M. 1). Edin. Med. and Surg. 
 Journal, xli. 122. Edinburgh, 1834. 
 
740 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 effusion, with symptoms of stupor, coma, and sometimes convul- 
 sions, which terminate fatally in about six or seven weeks, sometimes 
 earlier. 
 
 The opinion of Laennec, that miliary tubercles are the incipient 
 form of the tyromatous tubercle, is, in reference to the serous mem- 
 branes, destitute of proof. The miliary eminences of these mem- 
 branes have not yet been shown to pass into the tyromatous. 
 
 VI. Chondroma. — Cartilaginous degeneration is not uncommon 
 in the serous tissue. It appears in the form of patches varying in 
 size and shape, attached to the free surface of the membranes. By 
 some authors this is regarded as a preliminary step to ossification. 
 But this is not established. 
 
 New development of cartilage is most commonly seen in the 
 pleura and pericardium in the form of bluish-white patches, highly 
 polished on the free surface, varying from the size of a fourpenny 
 piece to the diameter of one shilling and more. The margins of 
 these patches is irregular and sometimes indented and sending out 
 other thin patches. 
 
 In general the formation of these patches is preceded by inflam- 
 mation, subacute or chronic, in the course of which the spot is 
 covered by lymph, which afterwards undergoes the cartilaginous 
 transformation. Sometimes the part is puckered and shrivelled, 
 as if previously the pulmonic tissue had been affected by inflamma- 
 tion. In old cases of chronic pleurisy and emphysema^ it is usual 
 for the false membrane to be converted into a fibrous layer of im- 
 perfect cartilage, uniting the two pleurae. 
 
 Similar patches are observed in the hepatic and splenic perito- 
 nceum ; the spleen may be entirely enclosed in a cartilaginous tu- 
 nic ; and often the peritonaeum covering the ovaries is entirely 
 transformed into a firm though not very thick cartilaginous covering. 
 
 VII. Ossification. — In no texture, perhaps, is osseous deposi- 
 tion more frequent than in the serous. It occurs in every one of 
 these membranes without exception. In the arachnoid it is not 
 unfrequently seen in the form of osseous plates at the inner surface 
 of the dura mater and the free surface of the pia mater. Often, 
 also, numerous thin scales of bony matter with pearly aspect are 
 observed in the arachnoid of the spinal canal. In the pleura and 
 pericardium it is exceedingly common, instances of it being no- 
 ticed by most authors, and numerous specimens of it contained 
 
SEROUS MEMBRANE — MORBID GROATTHS. 
 
 741 
 
 in museums. In the pleura it is most common in the costal divi- 
 sion, large portions of which are sometimes found converted in- 
 to broad flat patches of bone. The instances of ossification of the 
 diaphragm are of the same nature. In the pericardium it is pro- 
 bably most frequent in the cardiac division, and constitutes those 
 cases vaguely denominated ossified hearts. In the peritonaeum it 
 is less frequent ; but is remarked in particular portions of this mem- 
 brane. Thus it is common in the muscular, diaphragmatic, splenic, 
 and uterine peritonaeum, less frequent in the hepatic and colic, and 
 scarcely seen in the ileal. These patches, though hard, firm, and 
 apparently solid like bone, never present the organization peculiar 
 to that substance. Their presence is generally connected with 
 traces of inflammation or at least injection of the membrane ; and 
 Rayer, in an elaborate essay, attempted to prove that osseous 
 deposition is a result of that process.* Indeed, many circumstances 
 render it highly probable that chronic inflammation of serous tis- 
 sue causes effusion of lymph, which is eventually converted into 
 osseous matter. One of the most satisfactory proofs of this principle 
 is, that osseous induration of the peritonaeum is very common in 
 hernial protrusions of the intestine, in which the membrane is sub- 
 jected to slow inflammation ; and that the vaginal coat of the tes- 
 ticle is often cartilaginous, or even bony in cases of old hydrocele. 
 
 VIII. Morbid Gtrowths and Parasitical Animals.- — § 1. 
 Hygroma. — The serous cyst is not uncommon in the diaphanous 
 membranes. It appears, however, from various observations, to be 
 most frequent in the attached surface, or in the subserous tissue. 
 
 § 2. Hydatids., Acephalo-cysts. — These globular sacs are believed 
 to be almost proper to tbe serous membranes. It is certain that in 
 these they are more frequently observed than elsewhere. Thus 
 they are found attached to the pleura, to the pericardium, to the 
 peritonaeum, and to the vaginal coat ; and in some rare cases they 
 have been seen in the choroid plexus. Thus Pischer found the 
 taenia hydatigena of Pallas, or the cysticercus pyriformis of Zeder, 
 attached to this membrane by a peduncle, and vesicular bodies, sup- 
 posed to be of the same genus, attached to the arachnoid surface of 
 the dura mater. The writings of Bonetus, Morgagni, and other 
 collectors, contain frequent examples of pulmonary hydatids, seve- 
 ral of which were originally hydatids of the pleura, and several of 
 
 * Archives Generales, Tom. vii. 
 
742 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the subserous tissue. In the peritonaeum they are still more fre- 
 quent ; and Dr Monro tertius gives a valuable collection of cases, 
 in which these bodies were found connected with various regions of 
 that membrane. Though the cysticercus or solitary hydatid is oc- 
 casionally found, those more usually seen in this membrane are the 
 ccBnuri and echinococci, or the gregarious form of the animal. Of 
 this description, I have several times observed good examples. In 
 the body of a man of about 45, who died with the usual symptoms 
 of dropsy, tvvo globular cysts, one as large as a child’s head, were 
 found attached to the hepatic peritonaeum. In each of these were 
 contained an immense number of globular cysts containing trans- 
 parent fluid, about half an inch or eight lines in diameter, and sur- 
 rounded in like manner by a transparent fluid. Two similar cysts, 
 each containing many small ones, were found attached to part of 
 the ileum. These were unequivocal examples of the acephalo-cyst, 
 which is indeed very commonly developed within and in connection 
 with the peritonaeum. These bodies caused during life irregular 
 prominent tumours of the belly. Hydatids are also common in the 
 vaginal coat, 
 
 § 3. Fungus Hoimatodes is observed to take place in this tissue, 
 I have seen it affect the pleura in the form of numerous pendulous 
 and sessile tumours. It is, however, more common in the perito- 
 ncBum, both at its free and at its attached surface. One example, 
 in which it originated in the hepatic peritonaeum, and thence pro- 
 ceeded to affect the greater part of the abdominal cavity, and af- 
 terwards presented at the groin, where it destroyed the bones of 
 the pelvis, and the upper end of the thigh-bone, some years ago 
 fell under my observation. The tumour had attained an enormous 
 size, and consisted chiefly of cerebriform matter contained in seve- 
 ral cysts, and in some instances softened into a dark-coloured pulpy 
 semifluid mass. 
 
 § 4. Scirrhous induration is said to take place in serous tissue. 
 There is no doubt that it often affects this tissue from the conti- 
 guous ones, especially the mucous and submucous ; but it is not 
 ascertained, that it originates in the serous membrane. It is not 
 necessary to confound under this name various indurations, which 
 seem to be the result of the inflammatory process, or the lardaceous 
 state observed in the omentum and mesentery in old dysenteries, 
 which by some have been represented as examples of this morbid 
 degeneration. 
 
 4 
 
FIBRO-SEROUS MEMBRANE — CHRONIC THICKENING. 743 
 
 IX. Accidental Development. — No tissue perhaps is so liable 
 to be accidentally repeated as the serous. The cysts already men- 
 tioned are generally regarded as examples of this repetition ; and, 
 indeed, they possess all the characters of serous tissue. These 
 cysts are found in many parts of the body ; but they are most fre- 
 quently observed in the kidneys, sometimes in connection with 
 granular disease of those glands; and they are very common in 
 the female ovary, in which they often constitute the anatomical 
 character of dropsy of that organ. They are also seen in the 
 testicle of the male. The mode of their development is not 
 well ascertained. The hypothesis of dilatation or expansion by 
 mechanical compression was successfully refuted by Bichat; but 
 the one, which he attempts to establish in its place, has not been 
 generally adopted. 
 
 Certain of the minute clustered bodies denominated by Laennec 
 acephalo-cysts, and the animal nature of which, though admitted 
 by that author, is denied by Cuvier and Rudolphi, belong to the 
 same head. Their formation is equally little understood. 
 
 X. Morbid States of the Fibro-serous Membranes. — Be- 
 fore concluding this chapter, I must notice certain morbid states 
 incident to the fibro-serous membranes. 
 
 § 1. The dm-a mater, as a compound membrane, partaking at once 
 of the structure of periosteum and arachnoid, is liable to affections 
 which bear this twofold character. Its outer or cranial lamina is 
 liable to all the morbid processes incident to periosteum. Its in- 
 ner or arachnoid, it has been already shown, is liable to those pe- 
 culiar to this membranous pellicle. 
 
 I have already shown that the latter surface of the dura mater is 
 occasionally covered by albuminous exudation, the result of the in- 
 flammatory process. This same substance is occasionally deposited 
 between its laminae, and causes thickening and some induration. 
 
 § 2. Thickening of the Dura Mater . — This membrane is liable, 
 under the influence of various causes, to become greatly thickened. 
 In several instances I have seen it as thick as ordinary leather, very 
 firm, yet otherwise unchanged in structure. This thickening is 
 always connected with symptoms of chronic inflammation, which 
 may take place either spontaneously or in consequence of external 
 violence on the head. Yet the thickening is usually confined to 
 the dura mater of one hemisphere, and that the superior part of the 
 
744 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 brain ; and it terminates gradually in the membrane, presenting its 
 wonted character at the base of the organ. The dura mater of the 
 opposite hemisphere is in general natural. 
 
 In one spontaneous case, in which I found this thickening, the 
 person during life was so addicted to the use of spirits, that he was 
 rarely sober, or at least quite correct. He was in the practice of 
 speaking aloud to himself in the streets, and had a habit of jerking 
 his head to the side from time to time as he walked. He died at 
 last of symptoms of injury of the back and posteriors from a fall, 
 and with them were mingled symptoms of delirium tremens. 
 
 Most commonly, nevertheless, this lesion is the result of external 
 violence. In one well-marked case which fell under my own no- 
 tice, and in which I carefully inspected the parts after death, the 
 first exciting cause was a fall down stairs in a state of intoxication, 
 in which the individual struck the head on the steps. He was car- 
 ried home in a state of insensibility, and in that he continued for 
 nine days. He then began to show signs of returning conscious- 
 ness ; and began to take food and drink, and live a sort of vege- 
 table existence. This state improved a little. But memory, judg- 
 ment, and all the mental faculties were entirely gone. The patient 
 recovered consciousness and a degree of sensibility, only to remain 
 a paralytic idiot for life. This state continued between two and 
 three years, when death ensued. 
 
 The dura mater of the left hemisphere was then found very much 
 thickened. The sub-arachnoid tissue was infiltrated with serous 
 fluid to a very great amount. The convolutions were very much 
 atrophied. About four ounces of serous fluid were contained with- 
 in the ventricles, the cavities of which were dilated, and the walls 
 extruded. 
 
 The fornix was softened ; the septum lucidum entirely destroyed; 
 and in its place was a large elliptical aperture, by which the ven- 
 tricles communicated freely and directly with each other. 
 
 Such are the eflPects of chronic inflammation continued through 
 a long period before they prove fatal. 
 
 § 3. Tyroraatous deposition in round nodules also occurs in this 
 membrane, and has been well represented by Dr Hooper in his 6th 
 and 7 th engravings. They possess all the characters of the usual 
 tyromatous matter, and consist of whitish or gray opaque substance 
 of the consistence of cheese, of different degrees of firmness, inclosed 
 in a vascular capsule. Generally they grow from the arachnoid 
 
 5 
 
FIBRO-SEROUS MEMBRANE. 
 
 745 
 
 surface of the membrane, but sometimes they seem to arise from 
 its substance. 
 
 § 4. The dura mater oiiQU becomes the seat of a firm tumour, which, 
 as it grows, produces absorption of the cranial bones. In the ex- 
 cellent collection of cases by M. Louis, we find that it invariably 
 proceeded to bad ulceration ; but that death in general took place 
 in consequence of interruption to the functions of the brain. 
 
 § 5. In the testicle I have seen a peculiar disease which I refer to 
 the albuginea and its serous covering. The testicle seems much 
 enlarged and irregular; but shortly ulceration takes place, and 
 discloses an extensive mass of dead matter evidently exterior to the 
 gland. The sloughing process alternating with ulceration and gra- 
 nulation proceeds till the whole exterior coat of the testicle is ex- 
 pelled. This process, which occurred in a scrofulous subject, and 
 never showed any tendency to malignant ulceration, I ascribe to 
 death of the fibro-serous covering of the testicle, and perhaps of 
 the gland itself. 
 
 XL Fibrous and Fibro-cartilaginous Tumours. — Cartilagi- 
 nous and bony matter of different degrees of firmness and perfection 
 are often observed in the cerebral membranes, more especially the 
 dura mater. Of this change manifold instances are given byBonetus, 
 Morgagni, Lieutaud, Sandifort, and other collectors ; and they are 
 delineated by Baillie and Hooper. These cases are vaguely men- 
 tioned under the general title of ossification of the brain ; but few 
 of them are entitled to this character, for all of these originate in 
 the membranes. The only authentic instance apparently of bony 
 matter found in the substance of the brain unconnected with the 
 membranes, is that delineated by Dr Hooper in his 12th engraving. 
 The description, nevertheless, is not sufficiently minute to justify 
 positive assertion. 
 
746 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 CHAPTER IV. 
 
 SYNOVIAL MEMBRANE. — Memhrana Si/novialis, — Bursa: Mucosa. 
 
 Section I, 
 
 Bichat enumerates several circumstances in which he conceives 
 that serous and synovial membrane differ from each other. Gror- 
 don, who doubts how far the distinctions are well founded as the 
 basis of anatomical arrangement, admits^ however, peculiarities 
 which shall afterwards be mentioned. 
 
 Synovial membrane resembles serous membrane in so far as it 
 is a thin, transparent substance, having one smooth free surface 
 turned towards certain cavities of the body, and another connected 
 by delicate cellular substance to the sides of these cavities, or to 
 the parts contained in them. But it differs from serous membrane 
 in the following circumstances, l.s?. It possesses little vascularity 
 in the healthy state ; no blood-vessels are almost ever seen in it 
 after death, nor can they be made to receive the finest injection. 2(7, 
 Its lymphatics are quite incapable of demonstration. Zd, Very de- 
 licate fibres, like those of cellular substance, or like the finest fila- 
 ments of tendon, are distinctly seen in it after slight maceration. 
 47A, It is considerably less strong than serous membrane. On these 
 grounds, therefore, synovial membrane is to be anatomically dis- 
 tinguished from serous membrane. 
 
 The synovial membrane, as described above, is found not only in 
 each of the moveable articulations, but in those sheaths in which 
 tendons are lodged, and in which they undergo a considerable ex- 
 tent of motion, and in certain situations in the subcutaneous filamen- 
 tous tissue. 
 
 The distribution of the synovial membranes is much the same in 
 all these situations. They are known to line the ligamentous appa- 
 ratus of each joint, capsular and funicular ; and they are also con- 
 tinued over the cartilaginous extremities of the bones of which the 
 articulation consists. This continuation, which was originally main- 
 tained by Nesbitt, Bonn, and William Hunter, and was demonstrat- 
 ed by various facts by Bichat, was afterwards questioned by Gordon 
 and Magendie, the former of whom especially thinks it unsuscep- 
 
SYNOVIAL MEMBRANE. 
 
 747 
 
 tible of anatomical proof. The cartilaginous synovial membrane 
 is certainly not so easily demonstrable as the capsular, for the same 
 reason which I have already assigned regarding the difficulty of 
 isolating the arachnoid of the dura mater, the capsular pericardium, 
 the ovarian peritonaeum, and the serous covering of the tunica al- 
 buginea , — the want of filamentous tissue. 
 
 The presence of synovial membrane in the articular cartilage is 
 nevertheless established by sundry facts. Is?, If a portion of arti- 
 cular cartilage be divided obliquely, and examined by a good glass, 
 it is not diflBcult to recognize at one extremity of the section a thin 
 pellicle, differing widely in aspect, colour, and structure, from the 
 bluish-white appearance of the cartilage. 2d, If the free surface 
 of the cartilage be scraped gently, it is possible to detach thin shav- 
 ings, which are also distinct from cartilage in their appearance. 
 Zd, The free surface of the cartilage is totally different from the 
 attached surface, or from a section of its substance, and derives its 
 peculiar smooth polished appearance from a very thin transparent 
 pellicle uniformly spread over it Ath, If ai’ticular cartilage be 
 immersed in boiling water, this thin pellicle becomes opaque, while 
 the cartilage is little changed. 5t1i, Immersion in nitric or muri- 
 atic acid, which detaches the cartilage from the bone, gives this sur- 
 face a cracked appearance, which is not seen in the attached surface, 
 and which is probably to be ascribed to irregular contraction of 
 two diflPerent animal substances. Zth, The existence of this carti- 
 laginous synovial membrane is demonstrated by the morbid process 
 with Mdiich the tissue is liable to be aflTected. Upon the whole, 
 therefore, I believe little doubt can be entertained, that the repre- 
 sentation of their course, as given originally by Nesbitt, Bonn, and 
 Hunter, is well founded. 
 
 The same views may be applied to the synovial linings of the 
 tendinous sheaths, which are equally to be viewed as shut sacs. 
 
 Attached to the free surface of each synovial membrane is a pe- 
 culiar fringe-like substance, which was long supposed to be an ap- 
 paratus of glands (glands of Havers) for secreting synovial fluid. 
 It is now known that these fringes are merely puckered folds of 
 synovial membrane, and that, although synovia is abundantly se- 
 creted by them, this depends merely on the great extent of surface 
 which their puckered arrangement necessarily presents. This ar- 
 rangement is easily demonstrated by immersing an articulation con- 
 taining the fringed processes in clear water, when they are unfolded 
 
748 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 and made to float, and show their connections, figure, and termina- 
 tions. They are analogous to the free processes of serous mem- 
 branes, and like them are double, and contain adipose matter. 
 
 The synovial sheaths (hursce mucoscB) are very numerous, and 
 are generally found in every tendon which is exposed to frequent 
 or extensive motion. 
 
 Though the fluid prepared by these membranes has been exa- 
 mined by Margueron, Fourcroy, John Davy, Orfila, Berzelius, 
 .John, and other chemists, it cannot be said that very accurate re- 
 sults have been yet given of its chemical composition. It is said 
 to contain water, albumen, incoagulable matter, regarded as muci- 
 laginous gelatine, a ropy matter, and salts of soda, lime, and some 
 uric acid. 
 
 Section II. 
 
 The diseases of synovial membrane are important. 
 
 § 1. Hymenarthritis . — Inflammation is an occurrence not unfre- 
 quent in the synovial tissue, and produces effects in many respects j 
 similar to those which are observed in the serous membranes. 
 Every example of diseased joint, there is reason to believe, com- 
 mences with inflammation, acute or chronic, of the synovial mem- 
 brane. Of this process the anatomical characters are, injection of 
 the membrane, which sometimes becomes very red with numerous 
 vessels, and occasionally traversed by crimson or brown spots and 
 patches, dulness of its surface, opacity, thickening to a considerable 
 extent, and some degree of pulpiness. The effects of the process 
 are effusion of fluid, sometimes serous, sometimes ichorous or vi- 
 tiated synovia^ more especially tinged with blood, occasionally sero- 
 albuminous fluid, which undergoes partial coagulation, and leaves 
 the cavity distended with a thin sero-purulent liquid. In other 
 instances, complete purulent matter, with curdy or albuminous 
 flakes, are the result of synovial inflammation. 
 
 If it fail to terminate in resolution, the fluid effusion in the syno- 
 vial sac constitutes the simplest of those multiform affections known 
 under the name of white swelling ; (hydarthrus.) When this is not 
 abundant, the fluid part is absorbed, and the coagulable matter 
 may contract adhesion to the free surface of the membrane. This 
 is the origin of that species of ankylosis, sometimes general and 
 complete, sometimes partial and imperfect, in which the articular 
 
SYNOVIAL MEMBRANE — INFLAMMATION AND ULCERATION. 749 
 
 synovial membrane is found united by bridles or ligaments of false 
 membrane. 
 
 When sero-purulent or purulent matter is effused into a synovial 
 cavity, especially -where the inflammation fails to be resolved, or 
 passes into the chronic state, ulceration of the capsule and the in- 
 terligamentous tissue is liable to take place, and the ichorous or 
 sero-purulent fluid is discharged by one or more openings through 
 the skin. 
 
 In more advanced and chronic states, the synovial membrane 
 often becomes thick, pulpy, and vascular, granular or villous on 
 its surface, and is at length destroyed by ulceration. In some 
 joints, this process is an immediate effect of inflammation, the syno- 
 vial covering being gradually perforated in numerous points at 
 which the subjacent cartilage is exposed, and then undergoes ero- 
 sion. Though this process may occur in any joint, the researches 
 of Sir B. Brodie show that it is most frequent in the knee, in which 
 the destruction it occasions is often very great. A disease of this 
 kind I have several times seen remove every particle of cartilage 
 from the articulating extremities, and expose the cancellated struc- 
 ture of the bone. This process is attended with extreme pain and 
 sufiering to the patient, more particularly aggravated during the 
 night. The same process takes place in the elbow-joint, but here 
 it often forms fistulous abscesses of the extra-capsular cellular tissue. 
 In the articular processes of the vertebrae, I have seen it often give 
 rise to disease of these bones, and finally terminate in ankylosis, 
 with destruction of the processes, and considerable lateral curvature 
 of the spine. 
 
 Inflammation of the articular synovial sacs affects not only the 
 cartilages and bones, but the ligaments, capsular and funicular. 
 Its transition to these textures, which is easy and direct, induces 
 thickening and induration of the ligament, in consequence of effu- 
 sion of lymph between its fibres and interstices. After some time 
 the action extends to the extra-articular filamentous tissue, which 
 is then injected by jelly-like fluid, sometimes colourless or pale red> 
 at other times reddish or brown. At the same time, this filamen- 
 tous tissue acquires a granular character and some induration. 
 These several changes, which give rise to swelling round the joint 
 more or less diffuse, constitute one of the most frequent forms of 
 white-swelling. Suppuration may take place, as in the last in- 
 stance, followed by fistulous openings. 
 
,( 
 
 750 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 § 2. Velvet-like Degeneration. — I have already mentioned the gra- 
 nular and villous state of the synovial membrane. It is not easy to 
 say whether the change next to be noticed is a more advanced stage 
 of this state, or is to he viewed as a separate organic affection. 
 
 Synovial membrane is liable to a peculiar form of degenera- 
 tion, in which the membrane becomes thick, soft, and villous, not 
 unlike a piece of coarse velvet. The change is evidently in the 
 organization of the membrane, which is entirely destroyed. The 
 surface is red or brown, and no trace of the original structure is 
 left. 
 
 This is one of the most unmanageable forms of diseased joint. 
 It may take place in any joint, but is most common in the knee- 
 joint, the hip-joint, and the elbow-joint. 
 
 It appears to be attended with chronic inflammation of the sy- 
 novial membrane, and may probably be the eflfect of a peculiar 
 form of that process. It seems, nevertheless, by its characters and 
 tendency, to arrange itself rather with the class of organic changes. 
 
 Its approach is generally slow but steady, and it is attended with 
 deep-seated pain in the joint, aggravated hy motion. It gives rise 
 to general swelling, often with the effusion of some fluid within the 
 synovial cavity. The cellular tissue outside the capsule also be- 
 comes diseased, swelling, and being sometimes affected by second- 
 ary inflammation and the formation of abscesses. 
 
 This disease takes place principally in those reputed of strumous 
 habit ; and its presence causes hectic fever, wasting, and debility. 
 
 § 3. Thecal Inflammation. — In the synovial sheaths of tendons, 
 inflammation produces effects not dissimilar. The most marked in- 
 stance of this process is observed in synovial or thecal whitloe, pa- 
 ronychia thecalis, in which inflammation of the synovial membrane, 
 I have elsewhere shown, from the anatomical peculiarities of these 
 sacs, not only causes death of the contained tendon, hut, by passing 
 to the periosteum, may induce caries of the phalanges.* In other 
 parts of the body, these sheaths are not very liable to inflame, un- 
 less in consequence of external injury. From this cause I have 
 more than once witnessed severe inflammation terminating in effu- 
 sion of purulent fluid in the synovial sheath, between the tendon 
 of the glutceus maximus and the head of the trochanter. After in- 
 cision, however, it terminated favourably, without appearing to im- 
 pair the motions of the tendon. 
 
 * Observations, Pathological and Practical, on Whitloe. By David Craigie, M. D. 
 Edinburgh Medical and Surgical Journal, Vol. xxix. p. 255. Edinburgh, 1828. 
 
SYNOVIAL MEMBRANE SYNOVIAL RHEUMATISM. 751 
 
 § 4. Ganglia . — A milder form of inflammation is occasionally seen 
 in these sheaths, terminating in eflPusion of semitransparent, viscid> 
 glairy fluid, like white of egg. This eflPusion causes an oblong pro- 
 minent hemispheroidal swelling, tense, elastic, and communicating 
 a sense of fluctuation, which has been long distinguished by the 
 names of hygroma and ganglion, according to the degree in which 
 it takes place. As I restrict the former appellation to the serous 
 cyst, there is no occasion for using two names to varieties of an 
 affection the same in anatomical characters. Ganglion is subcu- 
 taneous or tendinous, according to its situation in the subcutane- 
 ous or tendinous synovial sacs. 
 
 § 5. Arthragra . — During gout the synovial sacs, both articular and 
 tendinous, are the seat of an inflammatory process which terminates 
 in the secretion of synovial fluid loaded with urate of soda. 
 
 § 6. The Synovial Membranes in Rheumatism . — Though rheuma- 
 tism, as affecting the aponeurotic sheaths and membranes, has already 
 been under consideration, it does not, however, confine its action to 
 these tissues. From them it may either spread by contiguity, as al- 
 ready explained, to the articular capsules and the synovial mem- 
 branes, or it may affect the latter tissues at once. It is then usually 
 denominated articular rheumatism. This takes place both in the 
 acute, in the subacute, and in the chronic forms of the disease. In 
 the two latter, however, rheumatic action produces eflfects of a serious 
 and unmanageable character. 
 
 Tlie mode of the approach of this affection is in general the fol- 
 lowing. 
 
 Sometimes after a slight attack of fascial rheumatism, in the loins, 
 the back of the neck, or one or more of the joints, sometimes with- 
 ; out this preliminary circumstance, one joint is attacked with a feel- 
 I ing of stiffness, fulness, as if there were something within it, and dull 
 obtuse uneasiness. These sensations are relieved while the joint is 
 ; in motion, but become worse when it is at rest ; and, always after 
 resting, the sense of fulness and stiffness is aggravated, until it 
 i amounts to difficult mobility of the joint. 
 
 Swelling does not appear at first, but always comes on after 
 I some time. The joint is then enlarged, elastic, full, and rounded; 
 
 1 the articular angles being lost in the swelling ; and when examined 
 1 it is manifest that a fluid is contained within the synovial raem- 
 I brane. 
 
 ' At the same time, it must be observed, that in ' articular rheuma- 
 i tism, the seat of swelling may be twofold. It may affect the peri- 
 
752 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 artliric or extra-capsular cellular tissue, which is infiltrated with 
 sero-albuminous fluid ; or it may cause effusion within the capsule 
 and synovial membrane. The former is the most favourable and 
 least injurious. The latter, if chronic, is always a troublesome and 
 sometimes a hurtful lesion. 
 
 As the disease proceeds, the stiffness and swelling increase, im- 
 peding greatly the mobility of the joint ; preventing it either from 
 being fully extended or easily inflected. Pain is also superadded, 
 especially when the joint is moved ; and if the joint be one used 
 in supporting the person, as the knee-joint, the individual can no 
 longer support himself without pain. 
 
 Pain, however, is not the worst symptom of this disorder. Stiff- 
 ness, swelling, immovableness, and consequent lameness, are the 
 usual results. 
 
 This disease may affect any joint; but it is most commonly seen 
 in the elbow-joints, the knee-joints, the wrists, and the articula- 
 tions of the fingers. 
 
 The pulse is not accelerated, nor are there always indications of 
 fever. After some time, however, the urine evinces alkaline pro- 
 perties, and may deposit or contain ammoniaco-magiiesian phosphate. 
 
 As stiffness and swelling increase, there is felt on moving the 
 joint a grating sensation, and a rough grating sound may be heard, 
 as if two rough surfaces were moving on each other. In this con- 
 dition the disease may continue for months and even years. 
 
 Death does not often take place in the early stage, or in the 
 course of this disease. In one case, nevertheless, a female who pre- 
 sented symptoms of it in one knee-joint, which had been lasting for 
 many weeks, if not two months or more, was attacked with symp- 
 toms of delirium tremens and died. The affected knee-joint, which 
 was semibent, was examined, and the synovial membrane was found 
 of a bright scarlet-red colour, with numerous blood-vessels, a 
 little roughened with deposits of blood and lymph, thickened, and 
 at one part it appeared to be wearing away by a species of absorp- 
 tion. This, however, was not ulceration. 
 
 The state of the articular cavity and surfaces in cases of long 
 duration, is the following. 
 
 At first when the joint is stiff and slightly swelled, sero-albu- 
 minous fluid is moderately effused. Afterwards, as the joint is 
 moved, it is effused more copiously. This fluid contains much urate 
 of soda, which is separated and coats the membrane. According 
 to some it also contains lime, which is deposited as a carbonate on 
 
SYNOVIAL MEMBRANE — SYNOVIAL RHEUMATISM. 
 
 753 
 
 the membrane. But whatever be the matter which it contains, the 
 lymph so deposited renders the surface of the membrane rough ; 
 limits and circumscribes the mobility of the joint ; and, in conse- 
 quence of the motion to which it is subjected, it becomes hard and 
 polished like porcelain or ground ivory ; and in this state forms a 
 sort of imperfect substitute for the synovial membrane. 
 
 Some have asserted that in this disease the synovial membrane 
 is removed by absorption and ulceration, and the cartilages are ul- 
 cerated. This may occur in extreme cases. But it is not neces- 
 sary to the disease or its effects ; and the most common result is li- 
 mited mobility of the joint with the ehurneoid deposit or degenera- 
 tion. It is for this reason that the joint so incrusted has been said 
 by foreign authors to be affected with usure or friction wearing. 
 
 The margins of the articular surfaces, at the attachment of the 
 membranes, present deposits of earthy matter irregularly nodulated, 
 or tuberculated, which are usually termed exostoses. They are com- 
 monly swellings consisting of phosphate and carbonate of lime. 
 Occasionally the periosteum, near the articular extremities in this 
 disease becomes thickened and penetrated with the same material. 
 
 On the tendency of this form of rheumatism to affect internal 
 organs, and thereby to influence the duration of life, different opi- 
 nions are entertained by different authors. In some instances, in- 
 dividuals have lived long with it ; in other instances it has suddenly 
 proved fatal by affecting the brain. In all instances it impairs 
 health, and is an indication of feeble digestion, imperfect assimila- 
 tion, and an unsound state of the circulating fluid. 
 
 The nature of this malady is not well known. Some call it arti- 
 cular, capsular, and synovial rheumatism ; others refer it to the head 
 of gout ; others again term it rheumatic gout. In extreme cases, 
 it has been known to produce ankylosis of all the joints ; and in the 
 Museum of the College of Surgeons of Dublin is preserved the 
 skeleton of a person, who was in this manner transformed into an 
 inflexible body. 
 
 On the circumstances acting as causes of this disease, the opin- 
 ions and testimony of physicians are not less discordant than on its 
 nature. By some it is represented as taking place chiefly in those 
 in whom the brain is overworked, and who are much exposed to 
 causes of mental anxiety. This may be the fact in a certain class of 
 cases. But the disease is observed in those, in whom the brain is little 
 or not at all subjected to exertion ; and conversely it does not take 
 
 3 B 
 
754 
 
 GENERAL AND PATHOLOGICAL ANATOMY, 
 
 place in all persons, in whom the brain is much exerted, or in pro- 
 portion to that exertion. It is observed as much in the temperate 
 and regular as in those of opposite habits ; indeed it almost never 
 appears in persons who live freely. It is greatly more common in 
 females than in males ; and at Buxton and Bath especially, to which 
 patients affected with it resort, the proportion of females to males 
 varies from 5 to 1 to 5 to 2. On the other hand, however, the 
 disease is generally more severe and obstinate in males than in fe- 
 males. It seems to affect the labouring classes and those engaged 
 in corporeal exertion rather in a greater degree than the sedentary. 
 
 This disease, when affecting the joints of the hands and fingers, is 
 liable to produce not only ankylosis of the joints, but great deformity. 
 The ends of the bones are enlarged, and irregularly tuberculated 
 and knotty. Some of the phalanges are bent forcibly and immovably 
 into the palm of the hand. Others stand out equally immovably, 
 and do not admit of inflection. Others are twisted and contorted ; 
 so that the hand and fingers are of little use. The whole hand then 
 not unfrequently is so deformed as to resemble the root of the 
 parsnip. This is the disease described by Heberden, and after- 
 wards by Haygarth, under the name of Nodosity of the joints. 
 
 § 7. Purulent collections within the synovial membranes. Arthropy- 
 ema after phlebitis . — Though purulent matter maybe collected with- 
 in any of the synovial membranes, in consequence of common in- 
 flammation of these membranes, the species of suppuration or puru- 
 lent collection to which I here advert, is peculiar in taking place 
 after inflammation of the inner coat of a vein or veins. I have 
 already shown that, though venous inflammation often proves im- 
 mediately fatal, yet instances occur in which the mere venous in- 
 flammation does hot terminate in death. In this class of cases 
 other processes take place which must be regarded as the conse- 
 quences of venous inflammation. To several of these, as purulent 
 collections within the serous membranes and extensive suppurations 
 in the cellular and adipose tissue, I have already adverted. Be- 
 sides these, however, purulent matter is liable to be formed within 
 the synovial membrane of a joint, and to be followed by all the de- 
 structive consequences attending suppuration within such a cavity. 
 
 This lesion has been supposed to be confined to females with ut^ 
 r'mQ phlebitis ; and in them it is perhaps more frequent than in others. 
 
 veins, succeeding to the operation of venesection ; and give rise to 
 
 3 
 
SYNOVIAL MEMBRANE — PHLEBITIC ARTHROPYEMA. 
 
 755 
 
 all the exquisite effects of this destroying process. In a patient under 
 my care, in whom this accident was followed by secondary effects, the 
 right shoulder -joint first and the knee-joint afterwards, became affect- 
 ed with pain, heat, swelling, and finally, indications of the presence 
 of fluid. The shoulder-joint got better, under the use of various 
 means. But the knee continued swelled, immovable, with much pain, 
 and giving indications of matter in its interior. Death took place 
 soon after. The interior of the synovial membrane of the knee- 
 joint was filled with purulent matter and coagulable lymph, the 
 latter adhering to the membrane in masses, and connecting the 
 opposing and corresponding parts of the membrane. The purulent 
 matter was thick, opaque, yellow well formed matter. After re- 
 moving most of it, the synovial membrane was brought into view, 
 much reddened and vascular, especially at the marginal connections 
 to the bones and enclosing capsule, where also it was thickened. 
 Over the head of the tibia and the corresponding parts of the fe- 
 moral condyles, it had begun to be destroyed by ulceration ; and in 
 several points the cartilage was exposed. At the attached margins 
 also were irregular tubercular bony masses ; but it was doubtful 
 whether these were the effects of the recent disease or of some pre- 
 vious orgasm. 
 
 It has been maintained by some, that these purulent collections 
 within the joints after venous inflammation are the results of the 
 transport or conveyance of purulent matter by the veins into the 
 interior of the joint. Such they may be in certain cases. But iu 
 the present instance, and in others of the same kind, which I have 
 observed, tbe collection was preceded and followed by all tbe usual 
 symptoms and effects of inflammation ; and I regard the lesion as an 
 instance of inflammation affecting the synovial membrane of the 
 knee-joint, in consequence of previous inflammation of a venous 
 trunk. 
 
 § 8. Hemorrhage of the synovial membranes is not very common, 
 but has nevertheless been observed. M. Pitet, in particular, saw 
 in the knee-joint a collection of blood, which he thinks was exhaled 
 from the articular synovial membrane.* When this effusion does 
 take place, it is an effect of previous injection of the capillaries of 
 the sac. I have often thought that some of the bloody abscesses 
 met with occasionally in the cellular tissue and in the neighbour- 
 hood of tendons, depended on synovial sacs in which hemorrhage 
 had followed chronic inflammation. This probably is the origin of 
 
 * Bulletin de la Societe de Med. p. 222. 
 
756 
 
 GENERAL AND PATHOLOGICAL ANATOMT. 
 
 the 17th case of Palletta, in which a bloody tumour, containing 
 pure blood, was found in the left ham.* The incision of these tu- 
 mours is always followed by extensive and malignant, often fatal 
 inflammation of the interior surface of the cyst. 
 
 § 9. Tyroma . — Synovial membrane is said to be liable to tuber- 
 cular deposition. No doubt can be entertained of the frequency 
 of albuminous deposits ; and I believe tubercles have been seen in 
 the coxo-femoral synovial membrane in disease of that joint. This, 
 however, I have not had an opportunity of verifying. 
 
 § 10. Cartilage . — In some instances, cartilaginous bodies are ob- 
 served to adhere by a narrow peduncle to the free surface of the 
 synovial membranes. This, though most frequently observed in 
 the femoro-tibial articulation, is certainly not peculiar to it. These 
 bodies may be either generated by morbid action of the synovial 
 tissue, or may be portions of cartilage or fibro- cartilage broken 
 accidentally from some part of the articular apparatus, and suffered 
 again to contract adhesion to the synovial membrane by the inflam- 
 mation which their presence induces. 
 
 § 11. Hematoid fungus, or cerebriform degeneration, is a disease 
 which often originates in the Interior of joints. The circumstances 
 under which this begins render it difficult to ascertain the tex- 
 ture primarily affected. It is, nevertheless, most probable that 
 it is chiefly the synovial membrane in which this tumour commences. 
 In the cases of the disease which have been inspected before much 
 destruction has taken place, the articular extremities of one or both 
 bones have presented large fungous spongy masses of matter like 
 brain, and well supplied with blood-vessels ; and it has been im- 
 practicable to recognize any trace of synovial membrane or carti- 
 lage. The analogy between the serous and synovial sacs in this 
 respect is obvious. 
 
 The degeneration may take place in any joint, but affects com- 
 monly the shoulder-joint, the hip-joint, and the knee-joint. 
 
 § 12. Scirrho-carcinoma appears not to originate in this tissue, 
 but certainly affects it from collateral tissues. Some authors have, 
 indeed, with singular vagueness, spoken of certain forms of white 
 swelling or fungus articidi, as being a sort of cancerous disease. 
 This, however, is only one of many errors which originate in the 
 practice of applying a vague general ej)ithet to many different 
 morbid states. 
 
 * Exercilaiiones Patliologicee, p. 207. 
 
BOOK V. 
 
 CHAPTER I. 
 
 GLANDULAR TISSUE. THE GLANDS. THE GLANDULAR SYSTEM. 
 
 GLANDULE. DRUSEN. 
 
 Section I. 
 
 GENERAL CHARACTER OE GLANDS. 
 
 A gland may be defined to be an organ, or organized texture, 
 consisting of blood-vessels and nerves ; tbe blood-vessels very nume- 
 rous, arranged in a particular manner, and communicating with a 
 series of sacculated cavities, vesicles, or hollow tubes ; intended for 
 the purpose of receiving or preparing from the blood, or secreting, 
 a substance of peculiar properties, either to be applied to some pur- 
 pose within or without the economy, or to be conveyed entirely out 
 of the system. 
 
 According to the terms of this definition, the denomination gland 
 comprehends only the secreting or conglomerate glands, or those 
 organs which are known to secrete some substance, generally liquid, 
 and to deposit the same in cavities communicating with an emissary 
 duct or ducts. 
 
 These are by various authors denominated perfect glands. 
 
 By imperfect glands the same authors understand organs with 
 apparent glandular structure, but without visible secreting appa- 
 ratus, secreted product, or excretory duct, as the thymus gland in the 
 infant, the thyroid gland, and according to some the spleen. It is 
 evident that the term imperfect gland is equivalent to thatof no gland. 
 
 Some anatomists, guided by physiological and in a certain sense 
 transcendental considerations, have proposed to add to the order of 
 glands, the lungs, because they separate or secrete carbonaceous 
 matter from the blood ; and many have in this manner classed the 
 lungs with the liver and the kidneys under the head of emunctory 
 or excreting organs. 
 
758 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Others again have proposed to refer to the order of glands the 
 ovaries of the female, because they are analogous to the testes of 
 the male ; and they have regarded the ova as secreted or excreted 
 products ; and the Fallopian tubes as excretory ducts. This view 
 rests, it must be admitted, upon some analogy both anatomical and 
 physiological. But it is enough to mention it here ; nor do 1 think 
 it proper, in a work of this kind, to introduce views which may re- 
 quire further confirmation. 
 
 Under the glandular system I include the following organs ; the 
 lacrymal gland ; the salivary glands, viz. the parotid, the sublin- 
 gual, and the sabmaxillary glands ; the liver and the pancreas ; the 
 kidneys ; the testes, the prostate gland, and Cowper’s glands in the 
 mate ; and the mammae in the female ; the sebaceous follicles of 
 the skin, and the muciparous follicles of the mucous membranes. 
 
 On no subject in general anatomy has information been so void 
 of precision and accuracy as on the structure of the glands. By 
 several anatomists the structure has been believed to be the same 
 in all ; and consequently, what was supposed to be ascertained as 
 to one has been applied indiscriminately to all. Little, indeed, was 
 ascertained ; and few accurate facts were recorded. Sylvius and 
 Steno, Glisson* and Wharton, t were the principal inquirers previous 
 to the time of Malpighi ; and both the two latter did communicate 
 some information. These anatomical results, however, were much 
 influenced by various physiological notions on the nature of secre- 
 tion ; and as the latter were often erroneous, the former were rarely 
 in all points correct. 
 
 Malpighi, in 1661, taught that all glands consisted of an aggre- 
 gation or collection of minute saccular organs, {utriculi), in which 
 the blood-vessels were distributed, and which saccular organs he 
 denominated sometimes small glands, {glandules), sometimes acini. 
 Acini in the liver he represents to consist of simple glandules col- 
 lected in clusters, which glandules are hollow membranous cavities. 
 These acini are in shape hexagonal or polyhedral. The glandular 
 bodies in the kidneys, on the other hand, are round or spherical like 
 the ova of fishes ; but these glandules are in like manner hollow.J 
 
 * Francisci Glissonii Anatomia Hepatis. 12mo. Londini, 1654. 
 
 -f- Thomas Wharton Adenogi-aphia, seu Glandulamm totius Corporis Descriptio. 8vo. 
 Londini, 1656. 
 
 + Marcelli Malpighii Exercitationes Anatomicae de Structura Viscerum ; nomina- 
 tim, Hepatis, Cerebri Corticis, Renum, Lienis. cum Dissertatione de Polypo Cordis ct 
 Epistolis Duabus cle Puimonibus. apud Opera Omnia. Tomum Secundum. Folio, 
 Londini, 1687. 
 
GLANDULAR TISSUE. 
 
 759 
 
 Ruysch was confident that the final structure of all glandular 
 organs consists in fasciculi of blood-vessels ramified to an infi- 
 nite degree of minuteness. He admitted, indeed, in 1722, when 
 eighty-five years of age, that sixty years previously he had taught 
 the existence of acini or little glands with membranous cavities, ac- 
 cording to the received opinion. Afterwards, how'ever, by much 
 observation in injection, he became convinced, that these acini are 
 composed of blood-vessels only, and not of little hollow membranes 
 with an outlet* * * § He allows, nevertheless, that the liver contains 
 acini or acinuli ; but repeats bis doctrine, that these are not small 
 glands or hollow sacs, but very delicate pulpy vessels.! 
 
 Ferrein, in the middle of the 18 th century, called in question 
 both of these doctrines. He maintained that the liver and the cor- 
 tical part of the kidney consist neither of blood-vessels nor of small 
 glands, but of a peculiar substance formed by a wonderful collection 
 of white cylindrical tubes variously folded, which, he contended, he 
 demonstrated manifestly in the kidneys, — which he had seen in the 
 liver and renal capsules, and which he believed he could make 
 known in other glandular organs.^ 
 
 Plaller has collected under the several heads of the pancreas, the 
 liver, the kidneys, the testes, the mamma, and other glands, the re- 
 sults of the inquiries of different anatomists to his own time (1777.) 
 In the liver he admits the existence of acini, and he adopts the view 
 of Malpighi, representing them to consist of simple hollow glan- 
 dules collected in clusters ; that these acini are hexagonal ; and are 
 not an element but a mass of elements ; or, in short, that they are 
 the lobules of the liver enclosed in cellular tissue. § 
 
 Each kidney he represents to consist of several little kidneys (re«- 
 culus ') ; each of which, again, consists of cortical or vascular and 
 medullary or striated matter. || 
 
 * Opusculum Anatomicum de FabricaGlandularum in Corpore Humano, Continens 
 Binas Epistolas, Quarum Prior est H. Boerhaave, super hac re, ad Friedericum Ruys- 
 chium; Altera F. Ruyschii ad H. Boerhaave, Qua priori respondetur. Amstelsedami, 
 1721 et 1722. Apud Ruyschii Opera Omnia, Tomum iv. p. 71- Amstelsedami, 1733, 4to 
 
 -f- “ Acini ibi (in hepate) manifesti semper sunt agniti a me ; sed ego tan turn dixi 
 quod non sunt folliculi membranacei cavi cum emissario, sed quod sint vascula pulposa 
 tenerrima. Epistola, p. 75. 
 
 J Observations sm- la Structure des Glandes, et part, des Reins, et du Foi. Me- 
 moirea de PAcademie Royale des Sciences. Paris, a. 1749. Hist. p. 92. Mem. p 
 489. 
 
 § Elementa Pbysiologiae, Lib. xxvi. Sect. I. § xxvi. xxvii. 
 
 !| Elementa, Lib. xxvi. Sect. I. § vii. and viii. 
 
760 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 In 1788 Schumlanskl published his dissertation on the structure 
 of the kidney, and thereby directed attention to the arrangement both 
 of the cortical or vascular part of these glands, and to that of the 
 tubuli Belliniani or excreting ducts. He did not, however, eluci- 
 date much the intimate structure of the organ.* 
 
 The facts and statements given by Haller were very generally 
 repeated by Soemmering and other anatomists. Bichat alone re- 
 jected many without substituting others in their place, and main- 
 tained that whatever could not be sensibly demonstrated was to be 
 regarded as Tincertain and undeserving attention. 
 
 Various inquirers continued to investigate this department of 
 anatomy, with different degrees of success, during the first third of 
 the 19th century. In 1818 Eysenhardt published his dissertation 
 on the structure of the kidneys, in which, with various errors, he 
 gave correct views of the corpora Malpighiaria.\ In 1819 Doel- 
 linger, in a dissertation on secretion, adduced several curious facts 
 regarding the arrangement of arteries in several glands.:}: These 
 
 were followed by the essays of Rathke and Huschke on the struc- 
 ture of the kidneys, the observations of Weber on the salivary 
 glands, and those of Baer on the liver. The researches of all 
 these inquirers, however, though most valuable, have been in a 
 great degree eclipsed by the elaborate commentary on the glands, 
 published in 1830, by John Muller, first of Bonn and afterwards 
 of Berlin, who has, with great skill and much personal research, elu- 
 cidated the structure of all the glands in a systematic manner, com- 
 bining the researches of all his predecessors. Since the date of the 
 monograph of Muller, various facts of considerable value, chiefly 
 microscopical, have been added by subsequent observers. 
 
 In the following account I shall study to combine the results ob- 
 tained by all these inquirers. 
 
 Muller distinguishes all the glands of the animal body into nine 
 orders, in the following manner. — 
 
 I. Glands of the first and most simple order. 
 
 1. Crypts or cells, a. Solitary crypts of the mucous mem- 
 branes. b. Aggregated, agminated, or agglutinated crypts, 
 as the glands of Peyer in the intestines. 
 
 ^ F. Schumlansky Dissertatio de Stnictura Renum. 8vo. Argentorati, 1788. 
 
 d* Carol. Guilelm. Eysenhardt de structura Renum, Observation es microscopicae 
 cum Tab. aen. 4 Maj. BeroMni, 1818. 
 
 + Wa.s ist Absonderung und wie gescbieht sie. Wurzburg, 1819. 
 
GLANDULAR TISSUE. 
 
 761 
 
 2. Follicles or pedunculated vesicles, a. Solitary, as those 
 of the skin. b. Associated, as the aggregated follicles in the 
 auricular glands of amphibious animals. 
 
 3. Elongated bladders, (utricui.i elongati,) sacs, or c^ca. 
 This glandular apparatus consists in the eversion of a simple 
 membrane, which is prolonged without contraction or terminal 
 enlargement. 
 
 These are either, a. simple intestinula, occurring in the mucous 
 membranes, or b. aggregated intestinula^ like the Meibomian 
 glands of mammalia, and the glands of the stomach of birds. 
 
 4. Tubuli or BLIND sacs; (c^ca.) 
 
 These are either, a. solitary tubules, as the secretory organs 
 of several insects ; or b. Aggregated tubules, as the glands 
 of the oviducts of the ray and shark, consisting of parallel tu- 
 buli, the oesophageal glands in certain birds, and the pyloric 
 appendages of some fishes. 
 
 II. Glands of the second order. Compound Crypts. Fol- 
 
 licles. Intestinules. Compound tubules. 
 
 1. Compound crypts, or compound cells, in which several 
 crypts are united. 
 
 a. Berry-like crypts, as in the anal glands of the hyena. 
 
 b. Bladders with cells, (crypto loculat^,) as in the prae- 
 putial glands of the dormouse. 
 
 c. Tubules with internal cells, as the salivary glands of some 
 insects. 
 
 d. Flower-like crypts, or crypts united as flowers, as in the 
 testicles of insects. 
 
 2. Compound follicles, or compound pedunculated vesi- 
 cles. Follicles united in various modes. 
 
 3. Compound c^ca. Intestinal c<Eca united in various modes. 
 
 4. Tubuli compositi. Tubules or hollow cylinders united in 
 various modes. 
 
 III. Glands of the third order ; compound cells, follicles, 
 Intestinules. Compound Tubules united so as to form one 
 glandular sac. 
 
 IV. Glands of the fourth order. Glands composed of 
 SPONGY CELLULAR TEXTURE, variously arranged ; sometimes in 
 
762 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the form of tubules, sometimes of cells, sometimes of glandular 
 cells inclosed within membranous partitions {septa.) 
 
 V. Glands of the fifth order. Lobulated glands com- 
 
 posed OF aggregations of small intestinal c^ca. 
 
 1. A gland composed of clusters of small intestinal caeca arranged 
 in lobules, as the pancreas of the tunny. 
 
 2. A gland composed of blind branching intestinula., arranged like 
 leaves in lobules ; for instance, the prostatic glands and Cowper’s 
 glands in the hedgehog. 
 
 3. A gland composed of branched intestinula caeca irregularly ar- 
 ranged. 
 
 VI. Glands of the sixth order. Branched excretory 
 
 DUCTS INCLOSED FROM THEIR ORIGIN TO THEIR TERMINATION BY 
 ELEMENTARY PARTICLES. 
 
 This arrangement, which resembles efflorescence, is not terminal, 
 but is similar to the protracted efflorescence of botanical terminology. 
 Of this examples are found in the liver of the crustacea, the lacry- 
 mal gland of the tortoise, and the lacryraal gland of birds. 
 
 VII. Glands of the seventh order. Compound ramifica- 
 tion IN A LOBULATED GLAND, WITH TRUNKS OF EXCRETORY 
 DUCTS CONTINUOUS AND ENTIRE AMONG LATERAL BRANCHES 
 AND VESICULAR ENDS OF ULTIMATE DUCTS. 
 
 The trunk of the excretory duct, entire and continuous, is not 
 divided into branches, but sends out laterally small branches, which 
 are also continued entire and without interruption by lateral rami- 
 fication. The result of this arrangement is great, small, and very 
 small lobules ; because each trunk with lateral branches makes a 
 large lobe ; branches with lateral shoots make small lobes of the 
 second order ; and from the twigs, and their attached portions the 
 smallest lobules arise. This origin of the lobules is shown from 
 the history of the development of the embryo. 
 
 To this mode of arrangement belong the salivary glands, the 
 pancreas, the ynammoi, and the lacryraal gland of many mammalia. 
 
 VIII. Glands of the eighth order. Compound ramifica- 
 tions IN GLANDS NOT LOBULATED WITH DIVISION OF TRUNKS 
 INTO IRREGULAR BRANCHES, WITH SHORT OR TERMINAL VESI- 
 
GLANDULAR TISSUE. 
 
 763 
 
 CULAR TWIGS, (as in the pancreas of birds ; and in the liver of 
 the embryo of birds and mammalia.) 
 
 IX. Glands of the ninth order. Consisting of short 
 
 TUBULES AND VESSELS, NOT RAMIFIED. 
 
 The elements of the glands in this order are tubules long and 
 
 very long ; of equal diameter to their short ends ; either straight 
 
 or serpentine. At the origin they are often furcated ; after that 
 
 simple without giving branches. They appear under six forms. 
 
 1. From a lateral excretory duct arise bundles of tubules, as in 
 the kidneys of many fishes, and batrachoid animals, and in the 
 testes of fishes. The tubules proceed either parallel towards the 
 opposite margin, as in the kidneys of the petromyzon and frogs, 
 and the testes of fishes ; or they wind tortuous and serpentine, as 
 in the kidneys of the ray family and serpents. 
 
 2. Bundles of parallel tubules everywhere issue from branching 
 excretory ducts. Such are the kidneys of the crocodile and tor- 
 toise. 
 
 3. An excretory duct divided into very long uniform serpentine 
 vessels; as the seminiferous canals of the higher animals, and 
 the prostate glands of the hedgehog. 
 
 4. Tubules forked and fasciculated like rays or wheel-spokes, pro- 
 ceeding from an excretory duct ; as in the testes of frogs and 
 cuttle-fish. 
 
 5. Very long vessels ; pinnatifid at apex ; closed; rising in bundles 
 from a branched excretory duct ; as in the kidneys of birds. 
 
 6. Very long vessels rising in bundles, at first bifurcated, then pur- 
 suing a serpentine course, without branches. The kidneys of 
 the mammalia and man. The proportion between the ureter 
 and the uriniferous ducts varies in three modes. 
 
 a. The ureter is continued to branches; from, these arise 
 bundles of uriniferous ducts arranged in separate lobules, 
 externally serpentine, as is seen in the kidneys of the cetacea. 
 
 b. One single ureter passes into a pelvis and calyces^ which 
 receive the bundles of the uriniferous ducts. These bundles 
 are evolved in the lobated kidney, externally serpentine ; 
 but the lobules are not altogether separated, as in the kid- 
 neys of several mammalia. 
 
 c. In the kidneys of the rest, even the superficial lobes of the 
 kidneys disappear. 
 
764 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 To explain this numerous list of the different forms of glandular 
 structure, it is necessary first to premise certain general facts illus- 
 trating the essential characters of glandular organs, and then to at- 
 tend to the following statements, in which a summary is given of the 
 result of all the inquiries. 
 
 The simplest idea of a gland is to be found in such organs as 
 the pyloric appendages of fishes, the pancreas of certain fishes, as 
 the sturgeon, and the kidneys of several of the fishes. 
 
 In the first case, that of the pyloi’ic appendages, {appendices py- 
 loriecB), which are well seen in the cod and haddock, a great num- 
 ber of cylindrical canals or tubes with closed ends hanging free in 
 the abdominal cavity, and with open ends communicating with the 
 bowel are attached to the pylorus or duodenum. The number of 
 these canals or tubes varies from 50 to 80, 150, or 200 in different 
 genera. They are membranous, and open, as already stated, into 
 the interior either of the pylorus or duodenum. 
 
 These bodies are understood to perform the function of secreting 
 glands. Their inner surface, which is continuous with the raucous 
 surface of the intestine, is believed to secrete a fluid necessary to 
 the proper performance of digestion and solution of the alimentary 
 mass. Part of the food seems to enter them, and after being subject- 
 ed to the action of this fluid, to be returned into the intestine ; proba- 
 bly allowing other portions in succession to undergo the same action. 
 
 This arrangement may be regarded as presenting that of a tu- 
 bular gland. 
 
 The pancreas or pancreatoid organ of the sturgeon is an or- 
 gan in external appearance and consistence somewhat different, 
 but in internal arrangement similar. 
 
 Externally it is a thick fleshy firm mass, triangular, or pentahe- 
 dral rather, in shape, with one apex hanging free into the abdominal 
 cavity, and with tbe base attached to the duodenum. The colour 
 of the pancreatoid organ is greenish-black, with pansy purple, in- 
 terspersed with whitish or whitish-gray spots. Its parietes vary in 
 thickness, according to the size of the animal, from half an inch to 
 one inch or one inch and a half. 
 
 This organ is attached to the duodenum near its pyloric end ; 
 and with this its cavities communicate by means of a large oi’ifice 
 placed in a recess opposite to the pyloric opening. This orifice is 
 circular or slightly elliptical, sufficiently large to admit the tip of 
 the finger, and even more in large animals. 
 
 4 
 
GLAND ULxVR TISSUE. 
 
 765 
 
 This large orifice speedily diverges into several similar orifices ; 
 and, when these are exposed by sections, they are observed to ter- 
 minate in spherical and spheroidal cavities, in which are similar 
 orifices leading to similar cavities, — all communicating in the same 
 manner with each other. The size and capacity of these cavities 
 varies according to the size of the animal. Thus in a sturgeon six 
 feet long they are in general about one inch or more in diameter. 
 In smaller animals they are not more than half an inch : and in 
 large individuals they are larger. These dimensions, nevertheless, 
 it is difficult to specify ; as their accuracy depends much on the 
 shape of the cavities, which is not exactly spherical, but only irre- 
 gularly so. 
 
 The pancreatoid organ, therefore, of the sturgeon consists of a 
 series of rounded cavities communicating with each other, and with 
 the duodenum by one general large orifice. The whole of these 
 cavities are lined by a. membrane quite similar to that which forms 
 the inner lining of the duodenum ; and for a particular description 
 of which I refer to another work.* 
 
 The surface of this inner membrane evidently secretes a liquid 
 which is applied to the alimentary mass in a peculiar manner. 
 The liquid does not flow by the outlet into the duodenum. But 
 the alimentary mass, after it has been received from the stomach, 
 is conveyed in successive portions into the communicating cells 
 of the pancreas ; there the secreted liquid is effused on them ; and 
 after they have undergone its proper action they are expelled ; and 
 other portions of the alimentary mass are introduced in order that 
 they may be impregnated with pancreatic fluid in like manner. 
 
 In all the specimens of the sturgeon which I have examined, I 
 have always found the pancreatoid cells quite filled with chyme or 
 alimentary pulpy matter, evidently in a more advanced stage of 
 digestion, than that contained in the stomach and pyloric end of the 
 duodenum. 
 
 The arrangement is singular in this respect, that the chyme is 
 conveyed into an organ to be subjected to the operation of its se- 
 creted product ; and after this, is not conveyed through the organ, 
 for which there is no provision, but is withdrawn from its cells, 
 
 * On the Anatomical Peculiarities of the Sturgeon. {Aciperiser Sturio.) By DaUd 
 Craigie, M. D., &c., Memoirs of the Wernerian Natural History Society, Vol. vi. p. 
 364. Edin. 1831. 
 
766 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 and urged on its onward course through the rest of the intestinal 
 canal. The chyme may nevertheless be said to make the circuit 
 of the pancreatoid chambers. 
 
 Notwithstanding this arrangement, the pancreatoid organ is re- 
 garded by most anatomists as an example of a gland ; and except- 
 ing the circumstance of the chyme being conveyed to its interior, 
 instead of its secreted product being conveyed to the chyme, it may 
 be regarded as presenting on the large scale, the structure and in- 
 ternal arrangement, which in other glands is so minute and delicate 
 as to elude observation. 
 
 In short, the pancreatoid organ of the sturgeon may be regard- 
 ed as an aggregation of glandular sacs or cells, communicating 
 with each other, and the interior of which furnishes a liquid secret- 
 ed from its blood-vessels, which are large and numerous. 
 
 There is, however, still one point on which information is want- 
 ing. This is, how do the blood-vessels terminate and communicate 
 with this secreting surface ? On this point no accurate information 
 has been obtained. 
 
 The kidneys, or rather the urinary organs, of the sturgeon in 
 like manner may be taken as organs illustrating what may be re- 
 garded as the most simple form of glandular structure. 
 
 The urinary organs of the sturgeon consist of two long tubular 
 canals, placed on each side of the intestine with the spiral valve, 
 and resting on the spinal column and its muscles, to which they 
 are attached by cellular membrane. These organs resemble neither 
 the kidneys, nor the ureters, nor the bladder of the Mammalia and 
 Birds, but combine the characters of all these. Their parietes are 
 thin and membranous, so as to seem like elongated bladders or utri- 
 culi. Their inner surface, which is red, smooth, and mucous, but not 
 distinctly villous, presents a series of minute orifices not larger than 
 pin heads. These orifices or pores correspond partly to the infun- 
 dibula, partly to the uriniferous tubes of mammiferous animals. 
 The lower extremities of these canals widen ; and, suddenly con- 
 tracting, terminate in one common outlet or vent, which opens on 
 the surface behind that of the intestine at the anal fin. 
 
 These urinary organs, which in this manner represent at once^ 
 kidneys, ureter, and bladder, and even urethra, are membranous ' 
 sacculi or utriculi, which in this manner act as glandular surfaces, 
 or secreting and excreting surfaces. The small pores are the out- 
 lets of the secreting portion ; but around them the parts are so 
 
GLANDULAR TISSUE. 
 
 767 
 
 thin and membranous, that they may be justly regarded as the ru- 
 diraental or essential portions of the kidneys. 
 
 Of the mode in which the blood-vessels communicate with these 
 pores and their membranes, nothing is accurately known, except 
 that the vessels ramified to an infinite degree of delicacy and mi- 
 nuteness terminate in the membrane. 
 
 Thus it appears that the most simple and elementary form of a 
 gland is a hollow cylinder or tube communicating either directly 
 with the surface of the body, or indirectly by opening on a mucous 
 membrane ; that the superior, internal, or upper end of this tube 
 presents the form of a closed sac; that the shut end, nevertheless, 
 communicates in different modes with the vascular system ; or 
 that branches and ramifications of the vascular system terminate 
 on this closed end. It further will afterwards appear, that the 
 forms which this arrangement and connection with the vascular 
 system presents, may be very much varied. 
 
 Meanwhile, it is necessary to state here the general characters 
 of every form of gland. 
 
 I. All glands, however much they may depart from the confor- 
 mation of secreting vessels, nevertheless follow one common fixed 
 law of formation, and present an uninterrupted series from the 
 most simple unramified follicle, to the most complicated structure. 
 
 II. Between the secreting organs of Aspondylous animals and 
 the glands of the higher classes no fixed distinction in truth exists. 
 But simple follicles, and tubuliform secreting organs, and closed 
 intestinula are repeated not only in animals of the higher classes, 
 but pass by an unbroken series through the different classes of ani- 
 mals, gradually into conglomerate glands. Thus the mammcB of 
 the Cetacea and Ornithorhyncus, the simple salivary glands of 
 birds, the prostatic glands of several mammalia, and the pancreas 
 of several fishes are formed after the manner of small cocca or 
 closed intestinula, as observation shows regarding the secreting or- 
 gans of the CRUSTACEA and insects. 
 
 III. All glands with a system of secreting ducts present inter- 
 nally a very large secreting surface. But the variety of forms in 
 which the secreting surface is increased within small space, is innu- 
 merable. There is indeed boundless diversity and profuseness ; yet 
 there are in all glands certain common characters. The variety 
 in the testes or seminiferous canals in insects is so great, as to re- 
 semble the profuseness of the forms presented by the vegetable 
 
768 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 kingdom. Yet of all glands it is a common character, that from 
 the more full evolution of an excreting duct, they increase, in pro- 
 portion as the canals terminated by closed ends are increased. The 
 hypothesis of Malpighi, accordingly, on the structure of the glands, 
 makes a nearer approach to the truth than that of other anato- 
 mists ; and its correctness is confirmed beyond doubt, in all the 
 forms of glands. Malpighi, however, was little acquainted with 
 the elementary forms of glands, which he represented in all cases 
 to be follicles and acini. 
 
 The objects which Malpighi considered to be follicles in the vis- 
 cera, were bodies consisting of masses of much smaller particles, 
 in which terminate the final twigs of the efferent ducts. Then, 
 besides follicles, the variety of forms of closed sacs in which the se- 
 creting canals terminate is great ; for they are either utriculi, or 
 elongated tubular-shaped intestimda^ or pinnatifid and paniculate 
 canals ending in closed sacs, or canals evei’ywhere equal in diame- 
 ter, very long, serpentine, and not branched. This point, however, 
 in which is placed the force of the hypothesis of Malpighi, is 
 certain, that the small twigs of the efferent and secreting ducts are 
 closed at their blind or shut ends in the cellular tissue of the 
 glands. 
 
 This is the case with the mamma; of the mammalia, the salivary 
 glands in various classes of animals, the pyloric appendages, and 
 the parenchymatous pancreas of fishes, the biliferous ducts of the 
 liver, the tubuli of the kidney, and the testicles. 
 
 IV. Acini., considered as glandular grains or hypothetical balls 
 of blood-vessels, from which secreting vessels are supposed to pro- 
 ceed, are fictitious. There is no immediate and continuous pas- 
 sage of blood-vessels into efferent vessels either in acini or any- 
 where else. The system of secreting vessels is peculiar, distinct 
 from the blood-vessels, terminating in closed extremities in all 
 forms of glands. 
 
 V. Acini, therefore, are merely closed ends of secreting canals, 
 or a branchy group of the same parts, that is vesicles, which may be 
 perfectly filled with mercury, and in some glands inflated. Truly 
 solid granules are seen only in the testes of a few fishes, the testes 
 of which, without excretory duct, send granules into the abdominal 
 cavity, from which they are conveyed by a proper orifice in the ab- 
 doun n. 
 
 VI. The term acinos has been employed in different senses, at 
 
GLANDULAR TISSUE — ACINI. 
 
 769 
 
 different periods, by different authors. The word akinos, acinus, and 
 acinum, from the Greek ayuwg and anovog, was used by ancient writ- 
 ers to signify a grape-stone, the kernel of a pomegranate, or the 
 grain or stone of any stone-fruit. By Glisson, Wharton, and Mal- 
 pighi it was adopted to designate certain hypothetical parts of glan- 
 dular structure, into which they thought that glandular structure 
 might be finally resolved. This Malpighi studied to render more 
 definite by saying, that in the liver acini were small elementary 
 bodies, hexahedral or polyhedral, or even spherical in shape ex- 
 ternally, but with an inner cavity, and thickish parenchymatous 
 walls. These acini are further called, both by Malpighi and Boer- 
 haave, one of his great defenders, utriculi, or membranous sacculi. 
 These bodies Malpighi represents to be round and hollow in the 
 kidneys. 
 
 To this view Malpighi probably, and Boerhaave certainly, was 
 led by analogy between crypts and the ultimate elements of large 
 conglomerate glands. 
 
 Ruysch, on the other hand, who admitted the existence of acini 
 or acinuli in glands, maintained that they presented nothing in 
 common with crypts, because they appear not like hollow mem- 
 branes, and because they have no emissary canal. He further 
 maintained that these acini are composed of the final extremities of 
 blood-vessels, united so as to form globular or spherical bodies,* 
 and he altogether denies cavity and emissary tube. 
 
 After the time of these anatomists, the word appears to have 
 been used either without definite meaning, or in different senses. 
 At one time and with one set of writers it means a clustered struc- 
 ture ; istructura racemosa) ; with another it is used to designate a 
 granular structure, or a substance composed of minute granules. 
 
 As, however, many glands contain none of this acinated or gra- 
 nular structure, Muller in a great degree renounces the term ; 
 and preferably employs the name of elementary particles of 
 
 GLANDS, or ENDS OR ROOTS OF SECRETING DUCTS ; bccause Under 
 these names may be included the several denominations of vesicles, 
 utriculi, tubules, follicles, cells, and canals, straight and serpentine, 
 of which glands consist. 
 
 Weber applies the term acini to the shut ends of the excretory 
 
 ■" F. Ruyschii Epistola Anatomica de Structuia Glandularum, ad H. Boerhaave, 
 p. 69, 70, Op. Om. Tom. IV. 
 
770 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 ducts, which are arranged according to their cellular projection ; 
 and also to the primary lobules or their apices. 
 
 Henle, like Muller, avoids the use of this terra acini., by which 
 he thinks Malpighi meant the closed ends of excretory ducts, and 
 which probably were primary lobules.* 
 
 The most recent authorities withhold the term for the glandular 
 vesiculce. Further, the solid lobules of the liver, and especially the 
 cells of which they consist, are named acini. 
 
 VII. Tlie smallest blood-vessels pass not directly into glandular 
 parts and ends of secreting ducts ; but the blood-vessels are distri- 
 buted to the parietes of secreting canals exactly as to any other se- 
 creting membrane. They do not enter by open ends into the cells 
 of these canals ; but they pass between the elementary particles of 
 the glands, and upon these terminate by delicate networks into the 
 small veins. This passage of blood between the elongated acini of 
 the liver from one order of blood-vessels into another, may be dis- 
 tinctly seen in the living larvae of the triton. 
 
 VIII. The system of blood-vessels, therefore, in every glandular 
 organ is confined within certain definite limits, by means of an in- 
 termediate reticular connection of minute vessels interposed between 
 the arteries and veins. 
 
 IX. Of the connection between lymphatic vessels with the ex- 
 cretory ducts in some glands, which has been already noticed un- 
 der its proper head, Muller is of opinion that it is not proved by 
 the alleged injection ; and that it is entirely accidental. 
 
 X. Every system of secreting ducts, without any continuous 
 communication with blood-vessels, bounded and closed by certain 
 shut ends, is to be viewed as an efflorescence or ramification of the 
 excretory duct ; because it is proved, that in the embryo it grows 
 or sprouts, as it were, from an excretory duct, at first unbranched. 
 
 XL The ramifications of the blood-vessels accompany the efflo- 
 rescence of the secreting canals, and with peripheral reticular ves- 
 sels wind on the elementary parts, and terminations of the secret- 
 ing canals. As a follicle or intestinula rise from the uniform mem- 
 brane, and send out repeatedly several utriculi and canals, so on 
 the efflorescing canals the vascular network advances, itself rising 
 from the uniform membrane. These facts are shown in the phe- 
 nomena of the incubated egg. 
 
 * Allgemeine Anatomie. Lehre von den Mischnngs-und P’ormbestandtheilen des 
 Menschlichen Korpers. Von J. Henle. Leipzig, 1841. Seite 922. 
 
 4 
 
GLANDULAR TISSUE — DIAMETER OF SECRETING TUBES. 771 
 
 XII. While canals, which always in insects and sometimes in 
 the higher animals are observed free, are progressively increased 
 by the new efflorescence, and mutually approximated, connected 
 by blood-vessels, — from these free canals gradually a species of 
 parenchyma arises. 
 
 XIII. The most delicate reticulate blood-vessels are still much 
 smaller than the most slender branches of the secreting canals, and 
 their terminations in the largest glandular viscera. The elemen- 
 tary parts of glands, therefore, though small, are nevertheless al- 
 ways so capacious that they are enclosed and connected by the 
 smallest reticulated blood-vessels. The cortical uriniferous canals 
 
 are much larger than the smallest blood-vessels in all classes of 
 animals. In the salivary glands of the mammalia and man, the 
 most delicate blood-vessels are many times smaller than the acini 
 of the salivary terminal vesicuM. The same is true of the pancreas. 
 The free ends of the salivary ducts in the hamster differ greatly 
 from the very smallest blood-vessels. The closed ends of the bili- 
 ferous ducts in the embryos of birds, amphibia, and mammalia are 
 much larger than the smallest blood-vessels. 
 
 To show the amount of this relation of majority of the secreting 
 ducts to the blood-vessels, and that of the relation of minority of 
 the blood-vessels to the secreting ducts, Muller gives the respective 
 diameters of these two orders of tubes as determined by himself by 
 the micrometer. From these measurements a few examples are 
 here selected. 
 
 The smallest capillary blood-vessels, (Weber,) 
 
 The same in kidney, (Muller,) 
 
 The same in human iris. 
 
 The same in human ciliary processes. 
 
 Smallest pulmonary cells in man, (Weber,) 
 
 CyUndriform mtestinula in the lungs of embryo birds, 
 
 Elementary vesicles of mammae of suckling hedgehog. 
 
 Terminal cells in salivary ducts of goose filled with mercurj'. 
 Terminal cells of salivary ducts of parotid in man filled with mer- 
 cury. 
 
 Cells of lacrymal gland of goose filled with mercury. 
 
 Cells of pancreas of goose filled with mercury. 
 
 Elements of lacrymal gland of Testvdo mydas 
 Cells of Harderian gland of hare filled rvith mercury, 
 
 Terminal vesicles of biliferous ducts of snail, {Helix pomatia) 
 
 Free terminal twigs of bile-ducts in embryos of birds, 
 
 Intestinula of Wolffian body in embryo of bird. 
 
 The same from another embryo. 
 
 Paris inch. 
 0.00025 — 0.00050 
 0.00037 — 0.00058 
 0.00037 — 0.00057 
 0.00053 
 
 0.00441 — 0.01333 
 0.00474 
 
 0.00712 — 0.00928 
 0.00260 
 
 0.00082 
 
 0.00327 
 
 0.00137 — 0.00297 
 
 0.00194 
 
 0.00776 
 
 0.00565 
 
 0.00172 
 
 0.00377 
 
 0.00300 
 
772 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Uriniferous ducts of Petromyzon, 
 
 Paris inch. 
 0.00324 
 
 Uriniferous ducts from kidney of Torpedo Marmorala, 
 
 0.004G.9 
 
 Uriniferous ducts from kidney of owl injected from ureter i 
 
 (under 
 
 air-pumj),) 
 
 0.00174 
 
 Cortical uriniferous ducts from kidney of squirrel, 
 
 0.00174 
 
 Serpentine cortical uriniferous ducts from kidney of horse injected 
 
 from ureter, (under air-pump,) 
 
 0.00137 — 0.20182 
 
 Medullary uriniferous ducts from kidney of horse injected 
 
 from 
 
 ureter, the largest near the papilla;, 
 
 0.01803 
 
 The same from the central medullary matter, 
 
 0.00489 
 
 The same cortical seen in section of kidney. 
 
 0.00140 — 0.00188 
 
 Corpmcula Malpighiana from human kidney, (Muller,) 
 
 0.00700 
 
 The same, (Weber,) 
 
 0.00666 — 0.00883 
 
 Seminal canals of young cock. 
 
 0.00528 
 
 squirrel, 
 
 0.01453 
 
 hedgehog, 
 
 0.00970 
 
 • man. 
 
 0.00470 
 
 Tuhuli in anal glands of goose, 
 
 0.00990 
 
 Clustered tubuU in Cowper’s glands in hedgehog, 
 
 0.01022 
 
 Cells in Meibomian glands in man, (Weber,) 
 
 0.00258 — 0.00633 
 
 XIV. In simple glands, which are composed of intestinules and 
 large follicles, the smallest blood-vessels wind along the walls of 
 these intestinules and follicles, exactly as in any other animal 
 membrane ; for instance, the pulmonic mucous membrane. In 
 these walls the transition of arteries into veins by reticular arches 
 takes place in the usual manner. In compound glands, however, 
 the ducts of which are small and very small, as in the kidneys, 
 liver, and testicle, the uriniferous, biliferous, and seminiferous 
 ducts are connected only externally with the most delicate vascu- 
 lar networks, without the vessels winding on the thin walls of these 
 ducts. 
 
 XV. The ultimate distribution of the blood-vessels does not al- 
 ways follow the formation of the secreting canals. In the liver of 
 the embryo, indeed, where the paniculate and pinnatifid ends of 
 the biliferous ducts spring from the surface, so as to be seen by 
 the microscope, the blood-vessels, though smaller, imitate a similar 
 disti’ibution ; for they run in the middle of a panicula ovfolwlus, 
 and with their final smallest capillary twigs descend between the 
 closed ends of the ducts or acini. But in glands which are formed 
 of serpentine unbranched ducts, everywhere equal in diameter, the 
 blood-vessels are not serpentine, but with very small branches, creep 
 among the gpri or turns of the serpentine ducts. 
 
 XVI. That the smallest currents of blood run freely between 
 the acini of a compound gland, as the liver, and that the blood is 
 
GLMDULAK TISSUE — VARIETIES IN SECRETING TUBES. 773 
 
 in immediate contact with the acini, has been inferred by Gruit- 
 huisen, on the faith of microscopical observations on the liver of 
 the frog. This inference Muller thinks unfounded. He allows 
 that at first on investigating the development of the liver and kid- 
 neys in the embryo, such appears to be the fact. The blood-in- 
 terstices of the canals appear without certain trace of parietes of 
 vessels ; and the same appearance is presented by the microscopical 
 e.xaniination of the liver in live larvEe of Tritons. But Muller is 
 satisfied from microscopical observations on the kidneys of adults, 
 both after injection and recent, that vestiges of the most minute 
 blood-vessels are formed in the tissue which unites the uriniferous 
 canals. Muller allows, nevertheless, that at first new currents, 
 without proper walls, are formed in an amorphous web ; but imme- 
 diately walls, however thin, as more fixed boundaries to these cur- 
 rents, are formed by increased thickness of the substance round the 
 currents. 
 
 XVII. The development of the glands in the embryos of the 
 higher animals takes place in the same manner as the glands in the 
 series of animals generally. That is the most complex glands in 
 the embryo of the higher animals consist at first of excretory ducts 
 alone, similar to the secreting vessels of the lower animals. 
 
 XVIII. The intimate structure of the glands presents very many 
 varieties, chiefly with the object of increasing the extent of secret- 
 ing surface. Tet no species of structure is peculiar to any indivi- 
 dual gland. In the most difierent glands the structure may be the 
 same, as in the cortical substance of the kidney, and in the testicle. 
 Conversely the same gland presents a ditferent structure in differ- 
 ent animals. For instance the lacrymal gland in the tortoise con- 
 sists of fasciculated utriculi^ forming a cortex or rind around the 
 excretory ducts. In birds the same gland is cellulated ; in the 
 mammalia it consists of pedunculated vesicles, with ducts appended 
 in the form of clusters. The minute structure of the liver and 
 testicles in like manner presents great variations. The kidneys 
 alone, in all classes, observe one common model of formation, from 
 uniform canals unbranched, either straight or tortuous, though the 
 disposition and walls of the canals undergo the greatest diversity in 
 different classes. 
 
 XIX, The structure of glands increases in complication in the 
 series of animals up to man ; yet tliis increase in complication is not 
 always in the same ratio. The rule seems to be that in every class 
 
774 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the gland which appears first presents the most simple formation. 
 Thus the pancreas is the most simple in fishes, the liver in the lower 
 classes of animals, and the kidneys in fishes and amphibia. And 
 when any gland appears first in any order of animals, it is formed 
 either of intestinules or follicles, or tubules. 
 
 XX. The substance of the canals in the glandular tissue is either 
 whitish, or whitish-gray, or whitish-orange, however different be the 
 colour of the secreted products. There is, therefore, no perfect re- 
 semblance between the glandular substance and the secreted pro- 
 duct, as has been erroneously staled by several writers. 
 
 XXL The elementary parts of glands, viz. cells, vesicles, utri- 
 culi, follicles, tubules, &c., always consist of one single tissue. The 
 excreting duct only consists sometimes of several, sometimes of two 
 membranes, the inner of which, being usually continuous with the 
 mucous membrane, is generally of the same nature, while the ex- 
 ternal passes in the substance of the gland into the proper substance 
 of the canals. The other external membranes of the excretory 
 ducts, fibrous, or adventitious cellular, terminate in the beginning 
 of the gland, are sometimes continued in the fibrous investment of 
 the gland, as in the poison-gland of serpents. In certain cases the 
 fibrous investment of a gland transmits processes between the seg- 
 ments and lobules, as in the poison-glands of the Trigonocephalus, 
 in the salivary glands of serpents and Birds, and in the anal glands 
 of the mole. The gland is then divided into compartments, and 
 the lobules. are contained within septa or partitions, though exter- 
 nally it appears, and is erroneously considered to be, uniformly 
 parenchymatous. More frequently, however, the lobules of a gland 
 are united by loose cellular tissue and vessels. 
 
 XXII. The nerves of glands accompany the arteries and veins 
 in general regularly, and form slender plexuses over the large 
 branches ; and nowhere do the nerves separate from the blood-ves- 
 sels ; so that they may be regarded as rather foreign to the glandu- 
 lar structure. 
 
 XXIII. These ducts, canals, or intestinula, are all lined or form- 
 ed internally or at the free surface by a membrane continuous with 
 some mucous membrane. This membrane has been called epithe- 
 lium by the revival of a name formerly in use. It consists of cells, 
 mostly nucleated, mingled with granules irregularly dispersed. 
 These cells are clear and colourless, but often scattered with small 
 punctvlu. The nucleus is round or oval, from ,550 to ^555 of a 
 I'aris inch in diameter, more or less flat, generally colourless or 
 
STKUCTURE OF INDIVIDUAL GLANDS — SALIY.UIY GLANDS. 775 
 
 pale-red, like blood-globules. These epithelial cells are believed 
 to be detached from time to time in the form of scales. 
 
 Section II. 
 
 THE STRUCTURE OF INDIVIDUAL GLANDS. 
 
 The previous observations are general. It is requisite now to 
 advert shortly to the structure of individual glands. This struc- 
 ture is best understood by tracing it in the embryo. 
 
 § I. THE SALIVARY GLANDS. 
 
 As an example we may take the parotid. 
 
 When the parotid gland is examined in the embryo of the sheep 
 or the ox, it appears that it is developed or formed by a species of 
 progressive ramification from the mucous membrane of the mouth. 
 The excretory duct, in short, which is first formed, is a prolonga- 
 tion of the mucous membrane of the mouth. It appears at an early 
 period in the form of a whitish semitranslucent canal, extending in 
 an arched curvature towards the ear, dividing into several very 
 short branches scarcely smaller than the trunk. These branches ter- 
 minate in a blind or vesicular close cavity, slightly swelling ; and this 
 disposition is retained throughout the whole period of the formation 
 of the gland. This branchy arrangement is well distinguished in 
 the midst of a pellucid jelly-like matter, which was regarded by 
 Rathke as primordial, or the blastema. Afterwards tbis jelly-like 
 matter becomes opaque, and is divided into roundish flattened lo- 
 bules. These dilated vesiculoe or ampullulce form the ultimate gra- 
 nules or elementary parts of the gland. 
 
 The arrangement of the twigs and branches is the following. 
 The excretory duct is divided into long whitish canals. From these 
 proceed long lateral branches scarcely smaller than the trunks. 
 Each of these goes to a lobule and sends branches into it ; in such 
 manner, however, that the twigs then arising are scarcely smaller 
 than the trunks. These twigs again send out new stalks, which all 
 terminate in large rounded bladders or vesiculcB. 
 
 All the canals are white, even to the extreme tips of the twigs, 
 and they wind about in the same plane of flattened lobules, pre- 
 senting under the microscope an interesting object. 
 
 It is further to be remembered that this ramification is only 
 lateral, that is from each side or margin of the duct and branches. 
 
776 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 and not all round or peripheral. It appears that the same lateral 
 ramification, with the same arrangement of lobules, takes place in 
 the lacrymal gland, and in the mammae. 
 
 The blood-vessels do not follow these ramifications so much as 
 the blastema, or primordial matter, to which they are nutrient 
 canals. 
 
 As the ooum or embryo grows, this growth of ramification or 
 branching like a plant proceeds ; and as this advances in producing 
 shoots and pedunculated vesicles, the blastema or primordial mat- 
 ter of the lobules is consumed ; the internal ramification towards 
 the margin of the lobules, originally spacious, advances ; and 
 branches formerly dispersed in the place of the lobules are accumu- 
 lated over each other. 
 
 The vegetation of the ducts of the submaxillary gland differs a 
 little from that of the parotid, according to Rathke, and approaches 
 that of the pancreas. 
 
 § II. THE PANCUEAS. 
 
 The arrangement representing this gland in fishes has already 
 lieen noticed. 
 
 In the Mammalia, this organ having passed through different 
 stages in reptiles and birds, presents the following characters. — 
 
 In the foetus of the sheep of four inches, the elementary particles 
 of the ]>ancreas have already consumed almost their whole blastema, 
 so that scarcely a trace of the common amorphous primordial sub- 
 stance remains. The elementary particles are everywhere freely 
 lirominent. These consist of elongated cylindrical acini or bunchy 
 idriciili, which are larger than the pedunculated vesicles of the sa- 
 livary glands, and are so generally conjoined, that they constitute 
 poniculce everywhere scattered on the surface. These cylindrical 
 acini, or elementary utriculi, proceed alternately from the middle 
 twig, form elsewhere pinnatifid paniculce, as in the pancreas of 
 birds. In other respects they are all very white, equal, not pedun- 
 culated, gently expanding in a shut end. In each set of three, four, 
 or five panicidce, Muller observed prominent shoots ; the rest, if 
 there were more, were covered by the neighbouring paniculce. The 
 shoots composing one single panicula are unfolded in the same 
 jilace ; and in this respect they manifestly differ in structure from 
 the parotid gland. The intimate union of the puniculcE Muller was 
 unable to unravel. 
 
STRUCTURE OF INDIVIDUAL GLANDS — LIVER. 
 
 777 
 
 In the Hamster ( Cricetus vulgari&\ the pancreas consists of very 
 small lobules, which are almost entirely separate from each other, 
 and adhere only loosely by the different ducts, forming large lobules. 
 The elementary particles are the same almost as in the salivary glands, 
 but half more slender ; nor does the middle part of the canal appear 
 white as in the salivary glands. Each lobule divided into small 
 fasciculi, or clusters, or elementary parts, receives in the middle a 
 blood- vessel, which is distributed in twigs among the smaller/ascfcM?f. 
 
 The summary of the structure of the pancreas is the following. 
 In Amphibia, Birds, and IMammalia, in the foetal state, there is 
 observed a paniculated vegetation of acini, or elongated cylindrical 
 utriculi or bladders ; the cylindrical acini in the paniculcB, proceed 
 from a middle twig like the nerves of leaves ; .and all terminate in 
 free, shut, and slightly swelling ends. In adult birds, the secreting 
 canals begin in cellular roots or very crowded small vesicles. 
 
 * § III. THE LIVER. 
 
 In the surface of the liver of the sturgeon, Muller observed with 
 the microscope small pinnatifid paniculm variously dispersed, so 
 that the acini or roots of the biliferous canals were united in the 
 pinnatifid manner. The sprouts were otherwise free, slightly 
 swelled at the tip. 
 
 In the toad the formation is the following ; — 
 
 The proliferous membrane, after surrounding the yelk by 
 growths in all directions, forms a saccated appendix, pendulous from 
 the keel of the embryon, containing the substance of the yelk. 
 That sac is divided into an external very thin pellucid layer, and 
 an internal vascular layer, one of which belongs to the integu- 
 ments, and the other to the intestines. The inner sac is soon pro- 
 longed towards the vertebral column, into an anterior and posterior 
 lacinia, which indicate respectively the anterior and posterior ends 
 of the intestinal canal. When the anterior prolongation issues 
 from the common sac, on the right side, in the continuation of the 
 sac of the yelk, is seen conspicuously a whitish swelling, consisting 
 of globules, with slender peduncles, as it were, attached. Observed 
 casually granules appear, and these are the first vestige of the 
 liver. The sac of the yelk is distinguished by innumerable reti- 
 cular blood-vessels, in which the blood is observed moving dis- 
 tinctly. 
 
 After one or two days, the beginning and end of the intestinal 
 
GENERAL AND PATHOLOGICAL ANATOMY. 
 
 sac are more elongated; and the circular motion of the blood 
 most fully evolved in the intestinal sac, is distinguished by innu- 
 merable arches of reticulated vessels. A trunk of veins bends to 
 tbe right, and seems to proceed under the liver, where it sends se- 
 veral small vessels into the liver. The liver itself, situate in the 
 anterior prolongation of the intestinal sac, is known by its whiten- 
 ing, elongated, almost pedunculated acini. These might be called 
 vesiculcB., if it could be proved that they are already hollow. 
 
 In grown animals, the principal difference is in the greater dis- 
 tinctness with which the vessels and the contained blood are seen. 
 
 The substance of the liver is very tender, is turned from tawny 
 into white, not unlike the substance of the yelk : it consists of 
 elongated acini., variously disposed, similar almost to the elongated 
 bundles of acini in the embryo of birds ; only these are in Birds 
 more distinct and freely prominent. 
 
 As to the liver of Birds, the observations of Baer deserve notice. 
 He states, that from the swelled vascular fayer of the alimentary 
 canal are developed, in the course of the third day after impregna- 
 tion, the lungs, the liver, the pancreas, the cmcum, and the urinary 
 bladder. All these parts are developed from the closed, not the 
 open end of the alimentary canal, while the mucous membrane of 
 that canal is covered with the proportional tubes in the vascular 
 layer. 
 
 The liver appears, about the middle of the fourth day, as two 
 pyraraid-like hollow limbs of the intestinal canal, which enclose the 
 common venous trunk, and pass with their broad basis into the ali- 
 mentary canal. Scarcely have these pyramids clasped the veins, 
 when they are prolonged into the next containing part of the vas- 
 cular layer, and are ran)itied in it, a covering from the vascular 
 membrane at the same time urging them forward. The protruded 
 portions appear, with increasing prolongation and contraction of 
 the alimentary canal, leaf-like, and closely embracing the veins. 
 In these leaves appear the tips of the advancing quills, while their 
 basis is progressively narrowed, and assumes the form of a cylinder. 
 The ramification appears under the microscope as a branching dark 
 figure in the inside of each leaf. 
 
 As soon as the quill-like prolongations, which form the future 
 hepatic ducts, begin to take the cylindrical form, there appears among 
 them a retraction which increases gradually, so that at the end of 
 the third day they scarcely reach the middle of the substance of 
 the vascular layer, and externally they form nowhere any projec- 
 
STRUCTURE OF INDIVIDUAL GLANDS LIVER. 
 
 779 
 
 tion. The granular inner layer presents at the apex some ramifi- 
 cation ; which evidently has the aspect of mucous cavities. 
 
 On the fourth day, the vascular layer is still farther removed, 
 and resembles semitransparent jelly ; the liver is divided into two 
 flat bodies, which surround like plates the portal vein. In these 
 plates both hepatic ducts undergo further ramification, but at the 
 same time at a greater distance from the bowel, so that most com- 
 monly they are united at the bases, and at the end of the fourth 
 day are wont to form one common canal. 
 
 After this the progress is similar, only to render the vascular and 
 secreting parts more distinct. On the eighth, ninth, and tenth day, 
 the gall-bladder appears. 
 
 In short, the liver is formed in the following manner : by ever- 
 sion of the internal tunic of the intestinal canal into the vascular 
 layer, whence a double excavated cone arises. These two excavated 
 cones are then ramified internally, though united at the base, the 
 common basis being, as it w'ere, prolonged from the intestinal wall, 
 until the two orifices open in one common orifice. 
 
 In the Mammalia, the terminations of the biliferous ducts end 
 exactly as in birds, free and in shut extremities ; but in their in- 
 ternal union they seem to diflFer in each, so that in some the elon- 
 gated acini are joined in the pinnatifid manner, in others like 
 leaves, and in others irregularly. 
 
 Next to the arrangement, disposition, and form of the secreting 
 ducts comes that of the blood-vessels. 
 
 The branches and twigs of the portal vein everywhere rise to the 
 surface of the liver, and follow chiefly the distribution of the bili- 
 ferous ducts ; while the branches of the hepatic artery traverse the 
 surface in a peculiar manner. Of the twigs of the portal vein it is 
 a peculiar character, that they are more conical ; while the arterial 
 twigs diminish their diameter very gradually, and are distributed in 
 a sinuous course so irregularly, that it is difficult to distinguish 
 trunks from branches. 
 
 The smallest blood-vessels are much more minute than the elon- 
 gated ends of the biliferous ducts. 
 
 The smallest blood-vessels in the embryo of Birds, and the larvcR 
 of tritons and frogs, are not distributed on the walls of the bilife- 
 rous ducts ; but run in the intervals between their bundles and 
 sprouts. 
 
 There is no direct communication between afferent vessels, whe- 
 
780 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 ther portal or arterial, and revehent vessels. In all cases tliere is 
 an intermediate network of very minute capillaries, that is, vessels 
 all of the same diameter, and all frequently and freely communi- 
 cating with each other. It is therefore a mistake to say that a 
 blood-vessel terminates in a biliferous duct. If this be the case, no 
 one has ever seen it, even by the microscope ; and the phenomena 
 which are supposed to prove it, are irregular, or the result of certain 
 fallacies. 
 
 In 1833, Mr Kiernan published a description of the minute 
 anatorny of the liver. He arrived at the conclusion that each lobule 
 is composed of numerous minute bodies of a yellowish colour, im- 
 parted to them by contained bile, and of various forms, connected 
 with each other by vessels. These bodies he regards as the acini 
 of Malpighi. Each of these lobules consists of a plexus of biliary 
 ducts, of a venous plexus formed by branches of the portal vein, 
 of a branch of an hepatic vein, and of minute arteries. Nerves and 
 absorbents he did not trace into them. He showed also that the 
 hepatic veins do not communicate with the branches of the portal 
 vein ; that the interlobular branches of the latter form one conti- 
 nuous plexus through the whole liver ; that the portal veins have 
 no direct communication with each other, but anastomose by 
 means of interlobular branches only ; and that the portal vein, 
 accompanied by an artery, resembles an artery in its ramifications.* 
 
 According to Henle, the microscope shows that the acini of the 
 liver are formed in a quite different way from all other glandular 
 lobules. They are heaps of closely-crowded, and everywhere closed 
 nucleated cells, which entirely fill up the meshes or intervals be- 
 tween the blood-vessels. 
 
 In a fine section of a hepatic lobule, these nucleated cells are 
 seated without the walls of the blood-vessels, sometimes in irregular 
 heaps, sometimes in irregular short rows close to each other, which, 
 if these transverse divisions be examined, appear like minute blood 
 intestinula. The medium diameter of these cells is about 
 parts of a Paris line ; the nucleus is usually round, compressed, 
 somewhat flat, from idVoo to -joilo parts of a Paris line in diame- 
 ter, with one or two nucleated granules. By the mutual pressure 
 of the cells on each other they become polygonal, tetrahedral, or 
 
 * Tlie Anatomy and Physiology of the Liver. By Francis Kiernan, Esq. 4to. 
 London, 1834. Philosojihical Transactions of the Royal Society of London for 1833^ 
 Part II. 
 
STPJICTURE OF INDIVIDUAL GLANDS — KIDNEYS. 
 
 781 
 
 pentahedral. Their colour is yellowish. They contain a quantity 
 of fine punctuated corpuscula, which appear to be seated on their 
 walls, and frequently in man and mamraiferous animals, small and 
 large fat globules, which are never seen in perfectly sound livers. 
 Not unfrequently there are small cells which inclose the narrow 
 nucleus and large cells with two nuclei; and some there are, the 
 cavities of which communicate with each other, or between which 
 certainly no partition is visible. Hallmann found cells without 
 nuclei ; that is, non-nucleated cells. 
 
 Besides these cells, we see only fat in the intervals of the lobules, 
 fibres in the walls of the strong vessels and biliferous ducts, and 
 cylindrical epithelial cells detached from the last. Henle could 
 not observe on the surface of the lobes or between them any peculiar 
 ligamentous tissue ; and Vogel says that it appears doubtful.* 
 
 These cells, there is every reason to believe, perform an import- 
 ant part in tbe formation of bile. 
 
 § IV. — THE KIDNEYS. 
 
 The kidneys and testes are referred by Henle to the head of Re- 
 ticulated or Net-like glands. 
 
 The substance of the kidneys in fishes consists of long canals of 
 equal diameter, which arise from branches of the ureter, or pa- 
 rallely in bundles from the lateral ureter, and proceed sometimes 
 straight, sometimes in a sinuous course variously contorted, without 
 being divided into branches, which are not attenuated towards the 
 extremities, but terminate uniformly in short ends. 
 
 In' reptiles, the vesiculcE or bladders of tbe secreting apparatus, 
 or ends of the uriniferous ducts, arise before the ureter itself is dis- 
 tinctly seen. This seems to show that the development of the kid- 
 neys begins from the peripheral vesicles. The stalks of these ve- 
 sicles are prolonged daily, by which the tubules terminated by ve- 
 sicular rounded apices arise, while the vesiculcB themselves are more 
 and more attenuated, until the uriniferous ducts observe the same 
 diameter to their shut end. In short, in this order of animals, the 
 substance of the kidneys consists of equal cylindrical tubules rising 
 from the ureter and ascending to the outer margin of the kidney, 
 where they terminate in short extremities. 
 
 * Allgem eine Anatomic. Lehre von cler Mischungs-und Formbestandstheilen des 
 Menschbchen Kdrpers. Von J. Henle. Leipzig, 1841. 8vo. See also Ueber der 
 Feineren Ban der Leber. Von C. Krause in Hanover. Muller’s Archiv, 1845. No. V. 
 seite 524. 
 
782 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 In adult serpents, the kidneys consist of many lobules, which are 
 connected in order by the ureter, which passes along the internal 
 margin. The lobules on the flat surface of the kidney are less 
 distinct than those on its convex surface. All the lobules, however 
 are very closely connected. The lobulated appearance, indeed, is 
 the result of the undulated flexures of the renal mass. When the 
 substance, inflected in the undulated fashion, is confined and con- 
 tracted by the ureter, each lobule consists of a convoluted tract, or 
 of a sort of arch, with a median furrow left. Into these median 
 turrows on the one side enter the bundles of the uriniferous ducts ; 
 and on the other the blood-vessels. And as the lobules arise by 
 alternating flexures, the bundles of the uriniferous ducts being on 
 the one margin, and the vascular trunks on the opposite one, the 
 former are mostly distributed on the convex surface, and the latter 
 on the plane surface of the kidneys. 
 
 The kidneys of the crocodile are also lobulated ; but the lobules 
 are not attached in order to the ureter, as in serpents, but are 
 united into an irregular mass, and receive the ureter internally. 
 All the lobules are contorted, and surround the surface with wind- 
 ing gyri. When a kidney is divided transversely on the surface, 
 through the gyri of the lobules, the section of the lobule or gyrus 
 is pyramidal. This shows that the gyri of the lobules project with 
 an external acute border, and are united internally at their bases, 
 where they receive the branches of the ureter. The ureter itself 
 appears to be ramified on the deep substance of the kidney, so that 
 the branches pass everywhere into internal gyri^ according to the 
 arrangement of the lobules. 
 
 In Birds at the first period of development, when, besides the 
 heart and the first rudiment of intestine, the other bowels of the 
 trunk are not yet visible, on each side near the vertebral column 
 appears an elongated body, extending from the site of the heart, 
 almost along the whole keel of the embryo. This body observers 
 first mistook for the kidney. Rathke showed, however, that this 
 body is peculiar to the embryon ; that it precedes and prepares for 
 the formation of the testes and ovaries, and then, as the foetus ad- 
 vances in maturity, it becomes shorter, and at the close of foetal life 
 vanishes entirely. These bodies, which were first described by 
 Wolff, and therefore received the name of Wolffian bodies ( Corpora 
 Wolffiana), and by Burdach, were called spurious kidneys, consist ^ 
 at first of elongated pedunculated vesicles, which being arranged 
 transversely, issue from one common marginal excretory duct, which 
 
STRUCTURE OF INDIVIDUAL GLANDS — KIDNEYS. 
 
 783 
 
 are gradually elongated into very small intestinula caca or tubules, 
 also transversely placed. These tubules, at first straight, are gra- 
 dually curved, until their course becomes serpentine. They are, 
 however, at all times separated from each other, and without trace 
 of ramification. 
 
 Rathke observed the first rudiment of kidneys on the sixth day, 
 and the ureter in the form of a slender filament on the seventh 
 day ; while the Wolffian bodies are still of considerable size, and 
 have extended the whole length of the keel on the fourth day.* It 
 is further ascertained, that the Wolffian bodies already present the 
 characteristic structure, namely, transverse tortuous intestinula, 
 when the first traces of kidneys, like a mass of very tender grey 
 substance, appears close to and behind the Wolffian bodies. 
 
 It is the opinion of Rathke, that the substance of the kidneys is 
 formed from the Wolffian bodies, because, on the sixth and seventh 
 day of incubation, when these bodies are detached from the keel, 
 the kidneys adhere, not to the keel, but to the Wolffian bodies. 
 The view of Muller is different. The Wolffian bodies, according 
 to him, however, similar to the kidneys in Batrachoid reptiles, yet 
 diflfer entirely in texture from the kidneys in other Amphibia and 
 in Birds ; the first trace of uriniferous ducts being widely different 
 from the intestinules of the Wolffian bodies. Muller further^never 
 could recognise, after very frequent observation, any internal and 
 organic communication between these organs ; the closed intesti- 
 nules of the Wolffian bodies being at one part, and at another the 
 uriniferous ducts, arranged in brilliant convolutions, also closed and 
 whitish. Another circumstance which places this question out of 
 all doubt is, that in Batrachoid Amphibia, the Wolffian bodies, 
 though at first sought in vain, Muller found in the upper part of 
 the abdomen, where, at a great distance from the kidneys, they are 
 provided with their excretory duct, and. consist also of minute cffica. 
 From these facts Muller infers, that the Wolffian bodies have an 
 intimate connection with the development of the organs of genera- 
 tion, as Rathke first suspected. 
 
 The substance of the kidneys, on the other hand, is formed from 
 its own proper blastema or primordial matter, by an innate effort. 
 
 When the mass of gray substance, situate at the margin and be- 
 hind the upper part of the Wolffian body, is examined at its first ap- 
 pearance by the microscope, the surface is distinguished by a ver- 
 
 ■* By the Carina or keel is meant the vertebral column, or what represents it. 
 
784 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 micular eruption and varied appearance of gyri or convoluted lines, 
 which are in different parts convex and concave ; and these gyri 
 again converge everywhere into the foliated form, like the leaves 
 of the oak, fig tree, or cauliflower, variously arranged with undu- 
 lated margin. The whole kidney at this period consists of mere 
 leaf-like convoluted gyri. These gyri form the uppermost part of 
 the substance ; but they are continued inwards, as if they were 
 held together in the deep-seated substance by one common mesen- 
 tery. When the small masses deep in the middle, undulated at 
 margin, and also beyond the margin, are aiTanged like leaves, the 
 observer thinks he sees the elementary particles of the renal sub- 
 stance in the prominent lobules of the gyri. 
 
 At first the gyri of the masses appear everywhere with unequal 
 margin. Soon, however, by the aid of the microscope, there is 
 seen on the tortuous border a vesicular eruption like pearls ; that 
 is, in the tender substance of the tortuous border, round cor- 
 puscles are contained one after the other ; but when these are 
 carefully examined, they are found to he round on the margin 
 only ; and below, where the gyri penetrate into the interior sub- 
 stance, these corpuscula also descend, and in their course become 
 smaller, as the pedunculi proceed from the deep seated substance, 
 and are unfolded variously on the tortuous and curled border of 
 the gyri. These pedunculated corpuscles are whiter than the rest 
 of the very tender substance, and are arranged one beside the other 
 in very regular order, held together, as it were, by one common 
 mesentery, which, folded and contracted inwardly, but outwardly 
 unfolded by innumerable gyri and a tortuous margin, produces a 
 remarkable resemblance to the arrangement of leaves and lobules. 
 In the same manner the pedunculi meet in various points in the 
 deep-seated substance, and outwardly are unfolded in the undulat- 
 ing fashion, terminating in a vesicular or headed end. These pe- 
 dunculi, though approximated internally, are not really united, but 
 merely approximated in the contracted membranous substance. 
 This may be regarded as tbe earliest conformation in most embryos. 
 
 The arrangement therefore is, that the appearance of granules 
 takes place first on the margin of the gyri ; while the vesicles with 
 peduncles are in the deep-seated substance. 
 
 The further development consists in this, that the gyri of the ^ 
 uriniferous ducts increase daily, and the undulated margin is con- 
 tracted into several contorted lobules, whence a more profuse leaf- | 
 
 I 
 
STRUCTURE OF INDIVIDUAL GLANDS — THE KIDNEY. 785 
 
 like vegetation results, so as to fill the intervals between the gyri ; 
 and the leaf-like shape of the lobules is gradually obscured. The 
 kidneys now are parted into several distinct masses united by the 
 ureter. 
 
 At length all the uriniferous ducts send out near their ends se- 
 veral lateral knots, from which arise short branches scarcely smaller 
 than the tru’-k, and terminate in short ends. This causes the pin- 
 natifid shape in the apex of each uriniferous duct. These ducts, 
 pinnatifid at end, are quite separate from each other, and, though 
 arranged in regular order, have no mutual communication. 
 
 About the close of foetal life, the uriniferous ducts, at first white, 
 are now everywhere filled with a secretion which from being tawny 
 becomes bright white, which fills the canals almost to their ends, 
 and is best seen in the first days after hatching ; and in the young 
 of large birds shows beautifully the structure of the uriniferous 
 ducts on the surface of the gyri and lobules. 
 
 The kidneys of the adult bird are not only divided into several 
 masses, but these present a surface composed of innumerable minute 
 lobules. These lobules arise from continuous gyri variously ar- 
 ranged ; the margins of these gyri only project, whence the multi- 
 form surface, viewed through the microscope, seems to imitate nearly 
 the gyri of the convolutions of the brain. 
 
 The kidneys of the bird, after being hatched, require no injection 
 to demonstrate the disposition of the uriniferous ducts. Being na- 
 turally filled with white solid urine (urate of ammonia), they may 
 be observed in large birds, especially ravens, by the naked eye, in 
 the first, second, third, and fourth day after hatching. All the 
 uriniferous ducts, to their most remote pinnatifid extremities, are 
 swelled with whitish-yellow matter, their proper secretion, consist- 
 ing of uric acid. 
 
 It is difficult to convey a distinct and correct idea of the arrange- 
 ment now described without figures. But it may appear to be 
 compared to that produced by a long frill or ruffle of muslin or 
 cambric which is doubled up and folded on itself six, eight, or ten 
 times, with the frilled edges allowed to project, and all within an 
 oval or elliptical space of half an inch or less. 
 
 By micrometrical measm’ement, the terminations of the m'inife- 
 rous ducts are about *00174, that is, loselo of one Paris inch in 
 diameter. This is much larger than the diameter of the blood- 
 vessels. Supposing the diameter of the smallest blood-vessels to 
 
 3 D 
 
786 
 
 GENERAL AND EATHOLUGICAL ANATOMY. 
 
 be 0'00025, or ioIboo of one Paris inch, then they are seven times 
 smaller, or the ducts are seven times larger. 
 
 In Mammalia, the following are the most important facts to be I 
 known in the development and structure of the kidneys. 
 
 In the embryo of Mammalia as well as of Birds, Wolffian bo- 
 dies are observed ; and as they are largest in the earliest period of 
 embryal life, they have by Dzondi and others been mistaken for 
 kidneys. They consist, as in birds, of very slender closed intesti- |i 
 mda. In the younger embryos they are larger than the kidneys, 
 and then chiefly simulate these organs ; afterwards they are con- , 
 founded with the testicles, being lower in situation and of the same 
 size as the kidneys, so that it is difficult to distinguish between the 
 three organs. They differ from the kidneys in Mammalia in being 
 covered by an external envelope, on removing which the intestinula 
 protrude, arranged transversely. 
 
 The kidneys are rounded. In the sheep they present vessels 
 shooting from the notch or umbilicus (Jiilus) towards the circumfe- 
 rence in bundles, which are divaricated in arch-like folds and retort- 
 ed, yet all terminate in large vesiculcB pedunculated and hollowed. 
 
 In almost all embryos of Mammalia, the kidneys consist of mul- 
 tiplied lobules in which the same arrangement of pedunculated and 
 closed tubes is presented and repeated in various forms. In some 
 animals this multiplied division or lobulated form of the kidney is 
 retained through life. In others, certainly the greater number, 
 the kidney appears in the shape of one general organ ; but this is 
 caused merely by its external appearance, or, to speak more accu- 
 rately, by the arrangement of the cortical matter outside. In the 
 human foetus the lobulated arrangement is manifest, and is in cer- 
 tain instances continued after birtb ; but in most instances the kid- 
 ney appears like one undivided organ. 
 
 This difference further is of use in illustrating the anatomy of 
 glandular organs in general. The lobulated or divided state is 
 continued thi’ough life in certain animals, as the ox, the bear, the 
 badger, and several of the cetacea, especially the porpoise. In 
 these animals the kidneys consist not of one united mass, but of a 
 number, more or less considerable, of separate bodies, each pre- 
 senting and repeating the same internal structure. 
 
 Thus in the ox the kidney consists of a series of sixteen or se- i[ 
 
 venteen lobules or separate parts, each of which presents the fol- If 
 
 lowing arrangement from the pelvis or common excretory cavity. 
 
 4 
 
STRUCTURE OF INDIVIDUAL GLANDS — THE KIDNEY. 787 
 
 First is a large but short duct or canal lined by a membrane con- 
 tinuous with that of the pelvis ; this terminates in a shut or closed 
 cavity called cup^ {calyx^ or funnel (infundibulum). Into this cavity 
 projects a small conical eminence, {papilla)., with an aperture in 
 its apex. From this, urine may be made by pressure to exude ; and 
 when the papilla is divided by a longitudinal section, it is observed 
 that one short duct from which the urine issues, is the termination 
 of a great number of small capillary tubes which are disposed lon- 
 gitudinally, yet radiating or converging towards the small papillary 
 duct. These are the uriniferous ducts of Bellini ; {tuhuli Belliniani). 
 
 At these upper or peripheral ends is placed a species of structure 
 which is parenchymatous and granular in aspect but vascular in 
 arrangement, that is, it consists mostly of blood-vessels ramified to 
 an infinite degree of minuteness and delicacy. On the mode in 
 which these vessels are arranged at their terminations, ‘Muller states 
 that the arteries terminate in a very minute and delicate vascular 
 or capillary network, which lies between the closed ends of these 
 tubes, and that from this network again veins arise as in other 
 textures of the body. 
 
 The papillary cone, which is about half an inch from base to 
 apex, and rather less than half an inch at base, consists of firm 
 solid matter, the colour of which is white or pale gray. Its exte- 
 rior structure is formed of numerous tubes uniting and converging 
 from the base to the papilla or apex. 
 
 Beyond this the substance of the tubular part is of a bright pink 
 colour, less firm, but more distinctly consisting of multiplied tubes 
 placed close to each other, and converging from the base to the 
 segment of the frustum, on which the papillary portion rests. 
 
 In the bear and badger, these separate lobules or diminutive 
 kidneys are still more numerous ; but the internal arrangement is 
 quite the same. 
 
 In the dolphin and porpoise the same multiplied division is car- 
 ried to a very great length. The masses called kidneys in these 
 animals consist of an immense number of tetrahedral, trapezoidal, 
 or hexadral small bodies, connected to each other by cellular tis- 
 sue and blood-vessels not very firmly, and in such manner that they 
 may be easily separated. The number of these renculi it is difficult 
 in the Cetacea to fix. I am sure I have numbered more than 
 200, yet have not exhausted them. Each renculus presents the 
 internal tubular or medullary portion, consisting of multiplied tu- 
 
GENERAL AND PATHOLOGICAL ANATOMY. 
 
 
 bnles placed along over each other, and the external cortical or 
 vascular portion consisting of blood-vessels most minutely ramified, 
 
 When in any of these simple or integral kidneys the aperture of 
 the papilla is examined, it is found to be continued into a short 
 thickish tube not larger than one line or one line and a-half, which 
 then is divided into two small cylindrical trunks. These again, 
 after a short space, are divided into two others of the same diameter 
 almost, very different from, and much larger than blood-vessels. 
 Thence they advance dichotomous, cylindrical, straight, or deviat- 
 ing little from the straight direction, and in their course constantly 
 double and multiply themselves to the base of the papilla^ being 
 conjoined by tender cellular substance. When increased in number, 
 without being diminished in diameter, they are collected into one 
 or two bundles separate from each other by blood-vessels. Each 
 of the bundles enters then its own meatus formed by the vascular 
 plexus of the vault or arch. After this, the small ducts contained 
 in their respective fasciculi, and connected with each other, are no 
 longer dichotomous, but proceed singly in the same direction 
 through the substance of the cortex, whence they diverge laterally, 
 and in a serpentine course, contorted in numerous convolutions, and 
 wandering far from the branches. One single serpentine duct, 
 continued from the straight duct, not inserted into the same, de- 
 ffected laterally, preserves almost always the same diameter and 
 whiteness. 
 
 These uriniferous ducts further are continued into the cortical 
 part of the kidney, a fact first ascertained by Schumlansky, and 
 afterwards by Huschke, by injecting them under the receiver of 
 the air-pump. According to Schumlansky, as the straight ducts or 
 Bellinian tubes advance to the pei’iphery of the kidney they dimi- 
 nish in number, or rather they terminate in serpentine ducts, which, 
 with many windings and convolutions, proceed between the few and 
 diminishing straight ducts onwards to the periphery or extreme 
 edge of the cortical matter. Before the straight ducts reach this 
 point or line, all of them have terminated in serpentine ducts which 
 communicate by multiplied arches, so that at the peripheral edge of 
 the cortical matter no straight ducts exist. 
 
 Not essentially different is the account given by Huschke. Ac- 
 cording to his account, when the tubes reach the utmost limits of 
 the medullary matter of the organ, they proceed progressively, se- 
 parating from each other, until in the surface of the kidney they 
 
STRUCTURE OF INDIVIDUAL GLANDS — MALPIGHIAN BODIES. 789 
 
 begin to wind in serpentine directions, forming arches with each 
 other, and again turn backwards and are insensibly lost, becoming 
 still more minute, yet without entering the Malpighian bodies. 
 
 The mention of these objects renders it necessary to explain what 
 they are. 
 
 Though Eustachi appears to have maintained the existence of a 
 sort of minute glandular grains in the kidney, Malpighi was the 
 first who spoke of them distinctly and confidently. He states that 
 in all the kidneys examined by him, in quadrupeds, the tortoise, 
 and in man, he observed a cluster of minute glandules by the fol- 
 lowing means. A black fluid, mixed with spirit of wine, was in- 
 jected into the renal artery, so as to cause the whole kidney to be 
 swelled and of a black colour externally. Then on stripping off 
 the external membrane, there appeared attached here and there to 
 the dividing arteries small glandules stained of a black colour ; and 
 on making a longitudinal section of the kidney, it was possible to 
 observe between the bundles of the urinary vessels, {i. e. the ducts,) 
 and in the spaces thereby formed, the same glands, almost without 
 number, attached to the blood-vessels, distended with the black 
 fluid, like apples suspended to the branches of a tree.^ He after- 
 wards adds that these bodies are placed in the utmost region of the 
 kidney in almost countless numbers ; that he thinks it likely that 
 they correspond to the urinary vessels of which the mass of the 
 kidneys consists ; that as to shape, by reason of their minuteness 
 and remarkable translucency, though they cannot be said to be 
 distinctly circumscribed, yet they appear round like the ova of 
 fishes ; they are blackened when a dark-coloured fluid is injected into 
 the arteries ; and they are placed among the extreme branches of the 
 arteries, which wind round them like tendrils, so that they appear 
 surrounded by the former, with this exception, however, that the 
 portion attached to the arterial branch is black, while the rest re- 
 tains its own colour.f 
 
 In these injections, Malpighi explicitly states, that he never saw 
 the liquor thrown into the artery, though it blackened the nearest 
 portion, get into the urinary ducts, or the round masses which he 
 considered as the glandules of the kidney. This agrees with what 
 is long afterwards maintained by Muller. 
 
 The round or globular bodies thus described by Malpighi were 
 
 * De Renibus, Caput II. apud Opera Omnia, pag. 6'0. Folio. Londini, 1680'. 
 t De Renibus, Cap. III. p. 92. 
 
790 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 seen afterwards by Winslow, Ferrein, Schumlansky,* Eysenhardt, 
 Huscklie, Muller, Henle, Bowman, Gerlacb, Bidder, and in short 
 all those who have studied the minute anatomy of the kidney. They 
 have been denominated from the anatomist who first directed at- 
 tention to them Corpora Malpighiana. \ 
 
 At the same time it must be observed, that, whether from some 
 confusion of ideas, or from presuming that these bodies must be 
 well known, almost all those who have spoken of them have given 
 them different names at different times, so that it is difficult to know 
 whether all understood the same objects. Ruysch, for example, 
 regards these round or globular bodies as balls of the extremities of ! 
 blood-vessels {glomeres vasculorum) convoluted on themselves, and 
 not as glands ; nor does he allow that they are surrounded by any 
 membrane. Similar opinions were entertained by Berger and Vieus- t 
 sens, and especially Peyer, who contended decidedly for their being 
 winding and contorted vessels. Schumlansky long afterwards calls i 
 them glandulcB auctorum, and while he in one passage represents the 
 clustering terminations of the arterial capillaries as the glandules of 
 Malpighi, in another he distinguishes these glandules from the glo- 
 meres and glomeruli^ or vascular balls of Ruysch. This anatomist, 
 after injecting kidneys, and examining them, concludes that, though 
 the appearances favour at once the doctrine of Malpighi and that of 
 Ruysch, there are, amidst the blood-vessels of the cortical portion 
 of the kidney, granules or globular, polyhedral or polymorphous 
 bodies, which may be injected from the arteries ; yet he doubts 
 whether these are hollow like follicles. He allows that they are 
 connected by cellular tissue ; and he says further, that they are the 
 terminations of the serpentine uriniferous ducts, f 
 
 According to Muller, the Malpighian bodies are vesiculos^ or 
 spherical, or spheroidal bladders, which contain glomeruli or glo- 
 bular clusters of minute blood-vessels, and which may be extracted 
 or removed from the vesicular coverings. He thinks also, that 
 another matter besides these blood-vessels is contained in the vesi- 
 
 * Arteriarum rami dant vieissim ramulos laterales, capillares, brevissimos, magis 
 minus copiosos, quibus tanquam pedicillis appenduntur grana, cuique unum, seminum 
 papaveris similia, nunc materie turgida. Totus ramus cum suis pedunculis et mole- 
 culis subrotundis lustratus, refert fere ribium racemum. En famosas glandulas Mal- 
 piGHii, earumque acinos. D. Alex. Schumlansky De Structura Renum Tractatus Phy- 
 siologico-Anatomicus. Edente G. C. Wurtz, M. D., &c. Cum II. Tabuhs jEneis. ' 
 Argentorati, 1788. 8vo. § xxix. p. 77. 
 
 f T). Alex. Schumlansky, &c. § xxxvii., xxxix., xl., et xlii. ■ 
 
STRUCTURE OF INDIVIDUAL GLANDS — MALPIGHIAN BODIES. 791 
 
 culcB, and that this adheres at one point only. When these glome- 
 ruli or spherical balls of capillaries are extracted, there are left 
 smooth hollow hemispheres, through the wall of which blood-vessels 
 adjacent appear. This vesicula forms the capsule of the Malpighian 
 bodies. 
 
 The diameter of a Malpighian body, at an average, is about 
 Togo of 000 Paris inch. The blood-vessels vary in diameter from 
 rgVoo to of one Paris inch. Consequently, the former are 
 
 from thirteen to eighteen times larger than the latter. 
 
 Huschke allows that the Malpighian bodies are filled from the 
 arteries, and are attached to these vessels ; in short, that they are, 
 as Ruysch maintained, glomeruli of blood-vessels. 
 
 Upon the whole, the Malpighian bodies may be described as 
 globular or ovoidal vesicles, situate amidst or appended to the mi- 
 nute capillary divisions of the arteries, which are curled round them 
 as tendrils of the vine or hop-plant. When the kidney is macerated 
 in water, the Malpighian bodies may also be separately distinguished, 
 lying in all directions between the serpentine uriniferous ducts. 
 There they resemble vesicles, according to Muller ; and, while they 
 are attached to the arteries, there is no communication between them 
 and the urinary ducts.* 
 
 The accuracy of this last statement is partly controverted by Mr 
 Bowman, who has examined these bodies with much care. He found 
 them to be a rounded mass of minute vessels invested by a cyst of 
 similar appearance to the basement membrane of the tubes. He 
 ascertained also that the investing capsule is the basement mem- 
 brane of the uriniferous tubes expanded over the tuft of blood-ves- 
 sels. 
 
 It appears further that the terminal twigs of the artery corre- 
 spond in number with the Malpighian bodies. Arrived at them, 
 the twig perforates the capsule, and dilating suddenly breaks up 
 into two, three, four, or even eight branches, which diverge in all 
 directions like petals from the stalk of a flower, and usually run, 
 in a more or less tortuous manner, subdividing again once or twice 
 as they advance, over the surface of the ball, they are about to 
 form. The vessels resulting from these subdivisions are very small, 
 and consist of one simple, homogeneous, transparent membrane. 
 They plunge into its interior at different points, and after further 
 
 * De Glandularum Secernentiuni Structura Penitiori. Commentatio Anatomica. 
 Scripsit Joannes Mueller. Lipsiae, 1830. Folio. 
 
792 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 convolutions reunite in one single small vessel, varying in size, be- 
 ing generally smaller, butjn some situations larger, than the ter- 
 minal twig of the artery. This vessel emerges between two of the 
 primary divisions of the terminal twig of the artery, perforating 
 the capsule close to that vessel, and, like it, adhering to this mem- 
 brane in its transition. It then enters the capillary plexus which 
 surrounds the tortuous uriniferous tubes. 
 
 The tuft of vessels thus formed is a compact ball, the parts of 
 which are held together by their mutual interlacement ; there be- 
 ing no other tissue, according to Mr Bowman, forming the capsule 
 except blood-vessels. It is lobulated, at least in certain animals, 
 as man and the horse. 
 
 The basement membrane of the uriniferous tube, expanded ovei’ 
 the Malpighian body so as to form its capsule, is a simple, homo- 
 geneous, and perfectly transparent membrane, in which no struc- 
 ture can be recognized. It is perforated, as before stated, by the 
 afferent and efferent vessels, and not reflected over them. They 
 are united to it at the point of transit. Opposite to this point is 
 the orifice of the tube, the cavity of which is continuous with that 
 of the capsule, generally by a contracted neck. This continuity 
 Mr Bowman observed in mammalia, birds, reptiles, and fishes. 
 When a thin section of a Malpighian body parallel to the neck of 
 the tube is made, the capsule is observed to pass off into the base- 
 ment membrane of the tube, as the body of a Florence flask into its 
 neck. The basement membrane of the tube is lined by a nucleated 
 epithelium of fine-granular opaque aspect ; while the neck of the 
 tube and its orifice are abruptly covered with a layer of cells much 
 more transparent, and clothed with vibratile cilia. Within the 
 capsule these cilia cease ; and the epithelium beyond is very deli- 
 cate and translucent. The cavity existing in the natural state be- 
 tween tbe epithelium and the tuft, is filled with fluid in which the 
 vessels are bathed, and which is continually impelled onwards by 
 the movement of the cilia. 
 
 The tubules on quitting the Malpighian bodies become greatly 
 contorted ; and this, Mr Bowman infers, is their constant disposi- 
 tion. The tortuous tubes unite again and again in twos, and 
 in their course centrad become straight, forming the pyramids of 
 Ferrein, and the medullary cones of Malpighi. Among these con- 
 volutions the Malpighian bodies are imbedded, and are in contact 
 on all sides with the surrounding tubes. 
 
 r( 
 
STRUCTURE OF INDIVIDUAL GLANDS — ^SIALPIGHIAN BODIES. 793 
 
 The blood leaving the Malpighian bodies is conveyed by their 
 efferent vessels to the capillary plexus surrounding the uriniferous 
 tubes. The vessels of this plexus lie in the interstices of the tubes, 
 anastomosing everywhere freely, and forming one continuous net- 
 work lying outside the tubes, in contact with the basement mem- 
 brane. This capillary plexus is interposed between the efferent 
 vessels of the Malpighian bodies and the veins. 
 
 The efferent vessels of the Malpighian bodies never inosculate 
 with each other, each being an isolated channel between its Mal- 
 pighian tuft and the plexus surrounding the tubes. They are 
 formed by the union of the capillary vessels of the tuft, and, after 
 a course variable in length, they open into the plexus. They vary 
 in size. In general they are smaller than the terminal twig of the 
 artery, and scarce larger than the vessels of the plexus into which 
 they empty their contents. They are larger in large Malpighian tufts. 
 
 From the plexus now mentioned, the veins arise and form the 
 set of venous plexus, situate in the nipple-shaped extremities of the 
 cones, round the orifices of the tubes, and pursuing a retrograde 
 course to empty their contents into veins situate at the base of the 
 cones. Another set of venous radiculse are dispersed through 
 the cortical part of the kidney, and each receives blood on all sides 
 from the plexus surrounding the convoluted tubes. 
 
 From tbe account now given of the arrangement of the vessels 
 connected with the Malpighian bodies, hlr Bowman infers that in 
 the kidney there are two ■perfectly distinct systems of capillary ves- 
 sels, through both of which the blood in its course from the arteries 
 into the veins passes. The first is that system of vessels proceeding 
 immediately from the arteries, and inserted into the dilated extre- 
 mities of the uriniferous tubes, (the Malpighian bodies,) the Mal- 
 pighian capillary system ; the second that enveloping the convolu- 
 tions of the tubes, and communicating directly with the veins. 
 The efferent vessels of the Malpighian bodies, which convey the 
 blood between these two systems, Mr Bowman regards as perform- 
 ing to the kidney the same function which the portal veins per- 
 form to the liver, and these he accordingly regards as collected 
 in the portal system of the kidney. The only difference is the ab- 
 sence of one general single portal trunk. 
 
 In short, Mr Bowman thinks that he has established the follow- 
 ing facts. 
 
 15 ^, That each Mal])ighian body consists of the dilated extremity 
 
794 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 of a uriniferous tube, with a small mass of blood-vessels inserted 
 into it. 
 
 2(i, That the Malpighian bodies may be easily injected from the 
 arteries, and that the capillaries surrounding the uriniferous tubes 
 may be injected though less easily. When the tubes are injected, 
 it is by extravasation from the Malpighian tufts. 
 
 2)d, By the veins, the capillaries surrounding the tubes may be 
 injected ; but neither the Malpighian bodies, nor the arteries, nor, 
 without extravasation, the tubes. The main cause of this impediment 
 to injection and the movement of fluids from the veins into the ar- 
 teries is the position and small size of the efferent vessels of the 
 Malpighian bodies, which stand in the way of any fluids being 
 transmitted to the Malpighian vessels. 
 
 4#^, The Malpighian bodies cannot be injected from the tubes, 
 neither can the plexus surrounding the tubes or the veins be in- 
 jected without extravasation. 
 
 5th, There is only one Malpighian body to each serpentine tube. 
 
 Qth, The epithelium of the tube, when it enters the expanded por- 
 tion which forms the Malpighian body, becomes transparent, and is 
 covered with vibrating cilia.* Within the capsule, however, of the 
 Malpighian body, the cilia cease. 
 
 The accuracy of several of the representations of Mr Bowman 
 has been doubted, and more or less decidedly controverted by 
 Huschke, Reichert, Gerlach, and Bidder. Reichert states, that 
 whatever means be adopted, by making minute sections of recent 
 kidneys, and using high magnifying powers, he never was able to 
 observe any transition of the uriniferous ducts into the capsule of 
 the Malpighian bodies.! 
 
 On the other band, some confirmation of the correctness of this 
 part of Mr Bowman’s representation is furnished by the structure 
 of the kidney in the Myxinoid fishes by Muller. In these animals, 
 which present the simplest type of renal structure, this connection 
 is undoubted. 
 
 Gerlach made trials of the same kind as those by Reichert, yet 
 without tracing any connection between the uriniferous tubes and 
 
 * On the Structure and Use of the Malpighian Bodies of the Kidney, with Obser- 
 vations on the Circulation through that Gland. By W. Bowman, F.R.S., &c. Read 
 February 17, 1842. Philosophical Transactions of the Royal Society of London for 
 1842. London, 1843. Part i. p. 57. 
 
 t Bericht iiber die Fortschritte der Microscopischen Anatomiein dem Jahre 1842. j 
 Von Reichert, Prof, in Dorpat. in Muller’s Archiv, Jahrgang 1843. ' 
 
STRUCTURE OE INDIVIDUAL GLANDS — MALPIGHIAN BODIES. 795 
 
 the capsule. He further denies that the uriniferous ducts terminate 
 in shut ends in the capsule. These ducts or tubules form collars, 
 and what has been taken for shut ends of ducts, are nothing but 
 the capsules, which communicate with the same by means of a short 
 neck, which is evidently thinner than the uriniferous duct. The 
 capsule is not a blind termination of a uriniferous duct, but a re- 
 traction or introversion, — a diverticulum of the same structureless 
 membrane which forms the uriniferous tubes. 
 
 Gerlach admits that the account given by Mr Bowman of the 
 perforation of the capsule by the arteries is correct. 
 
 As to the point at which the capsule is perforated by tbe affer- 
 ent and efferent vessels, Gerlach thinks that the statement of Mr 
 Bowman is too exclusive, when he represents this point to be al- 
 ways opposite to the opening of the uriniferous tube into the capsule. 
 He gives a figure, (fig. 12,) which shows that the point, at which 
 the afferent and efferent vessels perforate the capsule does not 
 always correspond to the point of communication between tbe uri- 
 niferous ducts and tbe capsule. 
 
 The point in Mr Bowman’s statements, which has been most 
 strongly controverted both by Reicher and Huscbke, is that as 
 to the free entrance of the Malpighian capillary net-work into 
 the cavity of the capsule ; and both justly remark that such an as- 
 sumption is at variance with all experience hitherto collected on 
 the laws of histological organization ; there being no example yet 
 known of vessels lying immediately in the cavity of a secreting tis- 
 sue. In truth, the representation of Mr Bowman, that the water 
 of the urine is separated from the blood flowing in the Malpighian 
 capillary vessels by simple transudation alone, while the peculiar 
 constituents of the urine are separated through cells at the inner 
 surface of the uriniferous ducts, Gerlach regards as in every respect 
 a rash statement, and to be corroborated by no other fact. On the 
 other hand, all investigations on glands prove, that in the process 
 of secretion, cells are the essential element ; and in the present 
 state of science, it is impossible to think of secretion without 
 cells. 
 
 He further adds, that wRen the Malpighian capillary net-work 
 is closely examined, after the capsule has been entirely detached 
 from it, we see it in its whole extent covered by a thick layer of nu- 
 cleated cells, which are continued from the inner wall of the capsule 
 upon the Malpighian vessels ; and the latter lies introverted within a 
 
796 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 layer of cells, like the intestine within the peritonaeum. The Mal- 
 pighian capillary net-work further possesses the essential element 
 of secretion, in which the blood undergoes those chemical changes, 
 which the metabolic force of the gland-cells imparts to the secreted 
 product. The secretion in the Malpighian vessels differs from the 
 usual secretions, only in so far as between vessels and secreting 
 cells there is no structureless membrane ; which last, however, ap- 
 pears not to be an essential condition to the process of secretion. 
 
 On the existence of ciliary motions at the point of transition of 
 the uriniferous tubes to the capsule, evidence is contradictory. 
 Huschke and Keichert could observe no ciliary motion in the places 
 indicated by Mr Bowman ; and the latter denies even any layer of 
 cells at the inner surface of the capsule. On the other hand, Bis- 
 choff is convinced of the presence of cilia in the kidneys of the frog. 
 Valentin observed ciliary motions not only in the spots indicated by 
 Mr Bowman, but even within the capsule ; and Pappenheim gave a 
 verbal communication on the^ame fact. The result of the inquiries 
 of Gerlach is as follows. In mammalia he could never, unless he 
 examined perfectly recent kidneys, observe ciliary motions either at 
 the cervix or in the capsule. On the other hand, he found the inner 
 wall of the capsule lined with a very slender layer of cells, which 
 is seen very distinctly at the edge of the capsule. Between these 
 cells lining the inner wall of the capsule and those which cover the 
 Malpighian net-work, normally there is found a small interval. 
 
 In examining the recent kidneys of the frog, on the other hand, 
 Gerlach convinced himself of the presence of ciliary motions not 
 only in the cervix or collar, but also in the whole inner surface of 
 the capsule ; and he thinks it probable that ciliary motion is a phe- 
 nomenon not peculiar to the renal capsule of the frog, but gene- 
 rally diffused over the animal kingdom.* 
 
 The results obtained by Bidder are not less at variance with 
 those given by Mr Bowman. 
 
 Bidder states, first, that in no circumstances, and by no means 
 which he could devise, could he obtain any certain evidence of con- 
 nection of the glomeruli with the uriniferous ducts. The vascular 
 bundles were always found below and between the uriniferous ducts, 
 without interior relation to themselves, either uncovered or sur- 
 
 * Bcitrage ;jiu' Stnikturlehre der Niere von Dr Joseph Gerlach, prakt. Aerzte in 
 Mainz. Archiv fur Anatoniie, Physiologic, uud Wissenschaftliche Medicin, von Dr 
 Johannes Muller. 1845, No. IV. Seite 878. / 
 
STRUCTURE OF INDIVIDUAL GLANDS — MALPIGHIAN BODIES. 797 
 
 rounded by the capsule seen by Muller. Never is there seen on 
 the glomerulus an unequivocal trace of an aj)pended canal, and 
 never at the inner surface of the capsule, or any where else in the 
 uriniferous ducts, ciliary epithelium. From these facts, Bidder 
 thinks it results, that the representations by Mr Bowman contain 
 one fact which is incorrect. This is, that as stated by Gerlach, the 
 circumstance of vessels being exposed uncovered is quite at va- 
 riance with all hitherto known as to the laws of organization. He 
 finds, however, from examining the kidneys of the water salamander, 
 that while the representation of phenomena, as seen by Mr Bow- 
 man, is essentially correct, the explanation of these phenomena 
 requires in many parts to be rectified. 
 
 For the investigation in question, the anterior part of the kidney 
 of the male triton, ( Triton taeniatus,) is particularly well adapted, 
 because it is by nature expanded in such manner, that for mi- 
 croscopical examination no further artificial preparation is required. 
 Indeed, if one of the leaf-like masses of serpentine canals, of which 
 the part of the kidney specified consists, is simply cut out and 
 placed under the microscope, this is all that is requisite in order 
 to exhibit completely, without exception, the whole of the texture 
 under consideration. Bidder further found that any attempt to 
 improve such a preparation by artificial means, as pulling and tear- 
 ing with needles, to expand fully the convoluted ducts, usually 
 obliterates the characteristic texture, removes the connectio’n of the 
 glomeruli with the uriniferous ducts, destroys the flask-like dilated 
 terminations of the latter, removes the aspect of ciliary epithelium, 
 and otherwise renders the part unfit for examination, so as to give 
 correct results. 
 
 In the fact now stated lies the explanation of the negative re- 
 sults always obtained from examining tbe kidneys of the frog, be- 
 cause the microscope cannot be employed until fine sections of the 
 renal substance have been spread out by mechanical means. He 
 allows, also, that as these parts are not so easily found in the fi’og, 
 it is no small proof of the perseverance of Mr Bowman, and the 
 solidity of his inquiries, that notwithstanding these unfavourable 
 circumstances in the higher animals, he has been able correctly to 
 give the essential circumstances of the renal structure. In the ser- 
 pent family and in lizards, the connection of the glomeruli with the 
 uriniferous tubes is seen with comparative ease. But never in the 
 higher animals did Bidder find, notwithstanding numerous trials, 
 
798 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 any fact which could suggest or establish the direct connection of 
 these parts of the kidneys. 
 
 In the triton, on the other hand, there are observed in the parts 
 of the kidney specified, at pretty regular distances from each other, 
 shut terminations of the uriniferous tubes, which become dilated in 
 the flask-like shape, and make themselves distinguished from the cy- 
 lindrical tubes by greater transparency. Before the transition into 
 these dilated parts, the uriniferous tube appears to he sometimes 
 contracted ; yet this is by no means uniform. Normally only one 
 uriniferous tube passes into this sort of dilated portion ; sometimes, 
 however, two uriniferous tubes are connected with the same dilated 
 portion, by which the objection of an illusion taking place thereby 
 is completely set aside, viz. that by pressure the contents of one 
 canal may be forced, without impediment, through the dilated por- 
 tion into the second canal, and impelled onwards in it. In such 
 circumstances also, the designation may he, instead of a closed ter- 
 mination of the uriniferous tube, rather a general dilatation in the 
 course of such a tube. 
 
 Of the presence of an epithelium with actively vibrating cilia^ 
 immediately before the transition of the uriniferous tube into the"' 
 flask-shaped expansion, and in the cervix or collar of the latter, as 
 also in a considerable space of the inner wall of the same. Bidder 
 states that he has completely convinced himself. The representa- 
 tion of Mr Bowman, that the vibratory epithelium layer of the uri- 
 niferous canals is prolonged into the expanded portion, progres- 
 sively diminishing in thickness, he finds to be quite correct ; but 
 he observes, that not in every instance can we expect, even in the 
 triton, to be able to recognise this circumstance with the desired / 
 certainty. He had inspected many preparations before he was able 
 for the first time to be satisfied of the accuracy of the observation 
 of Mr Bowman. The third part, or even the half of the circum- 
 ference of the flask-shaped expansion presents this ciliated epithe- 
 lium. If the same appears sometimes to be still more expanded, 
 this depends only on the circumstance, that higher up detached ci- 
 liated cells are thrust deeper into the cavity. 
 
 On the other hand, the statement which Mr Bowman makes in 
 denying any epithelium to the rest of the walls of the cavity. Bid- 
 der finds to be inaccurate. He finds here a simple thin plate-form- 
 ed epithelium, which appears in pretty regular polygonal forms ; 
 and if this do not appear equally evident in every case, the defi- 
 
 4 
 
 
 
STRUCTURE OF INDIVIDUAL GLANDS — MALPIGHIAN BODIES. 799 
 
 ciency appears to depend on this circumstance, that from the con- 
 tiguous uriniferous tubes entire epithelium cells or their fragments 
 are thrust by the pressure of the covering glass plates into the ca- 
 vity, and the correct view in the same is destroyed. The original 
 transparency of these cells is frequently lost before the eyes of the 
 observer ; and there is thus sufficient opportunity to observe imme- 
 diately the cause here specified. 
 
 Opposite the entrance-spot of the uriniferous tube into that ex- 
 pansion, or on one side of the latter when it is connected with two 
 tubes, the Malpighian vascular tuft enters the uriniferous tube, 
 and advances to a greater or less depth in the expanded portion 
 itself ; so that sometimes it fills the half of the cavity, sometimes 
 it occupies a much smaller part of it. As to the statement that 
 the glomerulus perforates the wall of the uriniferous tube, lies un- 
 covered and free in this cavity, and is immersed in the fiuid of the 
 same, it must be indeed admitted, that the microscopical image on 
 superficial examination appears frequently to agree with this ; but 
 that this is nothing but an illusive appearance any one, by more 
 careful examination of all the circumstances taking place, may be 
 convinced in the most positive manner. F or, when the preparation 
 has not lost its original translucency by the causes mentioned, it 
 is at once easy to observe, sometimes directly, a partition separating 
 the cavity of the expanded uriniferous tube from the vascular 
 bundle. This partition appears like a fine arch-shaped border de- 
 noted by one single line, the convexity of which is directed towards 
 the cavity, and the concavity towards the vascular bundle, which 
 is usually most difficult to be distinguished on the most prominent 
 points of the vascular network, and is most manifest in the distri- 
 butions on the delicate interstices of the same, the periphery of which 
 is in uninterrupted connection with the proper tunic or basement 
 membrane of the uriniferous tubes. But even if this partition did 
 not present itself to the eye with the desired distinctness, which 
 from its delicacy cannot be wonderful, several convincing circum- 
 stances indicate its presence. 
 
 Isf, The already mentioned entrance of the epithelial fragments 
 in the expanded portions; for, while the latter thereby lose their 
 translucency, that of the Malpighian bodies is little or not at 
 all impaired, and remain clear and transparent, while the resi- 
 dual blood globules or their nuclei are from the first not in any 
 way diminished in transparency. 
 
800 
 
 CxENERAL AND PATHOLOGICAL ANATOMY. 
 
 2d, The phenomena of compression of the prepai’ation prove the 
 existence of such a partition. The fluid granular content of the ex- 
 panded portions is thus impelled hither and thither without any 
 entrance of the same ever being effected between network of the 
 vascular bundle, and any mutual yielding of the last ; and by such 
 pressure the glomerulus itself, yet always only in one mass, and not 
 in individual vascular clusters. This proves unequivocally the 
 presence of a medium, by which the network of the vascular mass 
 is held together ; and that this connecting bond must be a mem- 
 brane enclosing the whole vascular bundle, and cannot be a cement 
 holding one of the separate networks to another, is shown by this 
 circumstance, that after drawing the glomerulus from the urinife- 
 rous tubes, the vascular convolutions drop from each other, and 
 present at the circumference of the mass disproportionately larger 
 furrows than in the natural disposition of these parts. 
 
 Lastly, by continued pressure the glomerulus is forced back from 
 the uriniferous tubes, nay, may be expelled from them entirely ; and 
 in such circumstances it may be again evidently perceived, that the 
 whole flask-shaped expansion is surrounded by one uninterrupted 
 outline, on the outside of which the glomerulus is placed. 
 
 Assuredly the uncovered disposition of the glomerulus in the ca- 
 vity of the uriniferous tube would be contradicted, were it possible 
 to prove that the plate-formed epithelium, which, as observed, covers 
 part -of the cavity, covers also the vascular mass. Though he al- 
 lows that he cannot prove this unequivocally, yet he maintains that 
 the rectiflcation here suggested is probable. This he does in the 
 following manner. 
 
 The relation of the glomerulus to the expanded portion of the 
 uriniferous canal appears to him most properly to be referable to 
 the series of those formations which it is usual to designate as intro- 
 versions ; by which nothing is stated as to their origin, but merely 
 a certain form and kind of position of organic structures within 
 each other is meant. In the case here treated, of such introver- 
 sions, the same appears to take place at the thinnest and feeble&t 
 point of the wall of the shut end of the uriniferous tube. This is 
 proved by the fact, that when, in consequence of strong pressure, the 
 expanded portion bursts, this bursting regularly happens at the 
 point where the proper tunic (basement membrane) of the urinife- 
 rous duct coalesces with the glovxerulus. The outline of the partition 
 mentioned appears also unequally feebler than at the other points 
 
STRUCTURE OF INDIVIDUAL GLANDS — MALPIGHIAN BODIES. 801 
 
 of the circumference of the expanded portion. But this undoubt- 
 edly has great influence, that the ligamentous substance which lies 
 on the outside of the uriniferous tubes and strengthens their walls, 
 passes in uninterrupted succession, usually upon the vessels going 
 to the glomerulus, but never enters the glomerulus itself, so that the 
 vascular net-work of the same is actually held together only by the 
 enclosing slender proper tunic of the uriniferous ducts. 
 
 In Mr Bowman’s representation of the renal texture, a misconcep- 
 tion has accordingly happened by this, that the capsule of the glo- 
 merulus and the expanded portion of the uriniferous duct are fully 
 identified, while both are to be easily distinguished, though, as be- 
 longing to one and the same organic part, they pass insensibly into 
 each other. In the agreement in the anatomical basement of the 
 tunica propria of the uriniferous ducts and the capsule of the glo- 
 merulus, it is intelligible, that if the glomerulus and uriniferous ducts 
 are separate from each other, in the first no trace of the early con- 
 nection may be found, while the only available means thereto, viz. the 
 position relation of both, are removed. So it is intelligible, how the 
 glomerulus, after artificial spreading out sections of kidney and 
 detachment from the uriniferous ducts, sometimes lies free, some- 
 times appears surrounded by a capsule. Because this capsule is 
 not the covering belonging originally to the glomerulus, but only 
 touches at the neighbouring connecting tissue, which, after sepa- 
 rating the glomerulus from the uriniferous ducts, sometimes sur- 
 rounds the same. Hence proceeds the statement made under these 
 circumstances, that the glomerulus lies free within its capsule. In- 
 deed there is here between the vascular packet, the net-work of 
 which is more expanded, and the connecting tissue accidentally 
 lying on the same, a free space ; while the natural capsule of the 
 glomerulus, that is, the introverted part of the uriniferous duct, lies 
 close to the same. 
 
 The term capsule of the glomerulus has also been applied, on the 
 one hand, to the flask-shaped dilated uriniferous duct itself, because 
 it is supposed that the glomerulus lies free in the same ; and, on 
 the other hand, the connecting substance surrounding the glome- 
 rulus after preparation of sections of renal tissue might be view- 
 ed as the natural capsule ; in both cases the true capsule would be 
 misunderstood.* 
 
 ■ Ueber die Malpighischen Korper der Niere ; von F. Bidder in Dorpat, Archiv 
 fur Anatomie, Physiologie, und Wissensehaftlichen Medicin, Von Dr Johannes Mul- 
 ler. 1845. Heft V. Seite 508. 
 
 3 E 
 
802 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Lastly, A. Kiilliker of Zurich maintains with Mr Bowman not 
 only the connection of the renal ducts with the capsule of the Mal- 
 pighian bodies, but also at the entrance of the capsule and the con- 
 tiguous portions of the renal ducts, or in the neck and orifice of 
 the uriniferous tube, the existence of a ciliated epithelium with 
 vigorous acting cilia. 
 
 According to this observer, whose observations were made on 
 the kidneys of the embryo lizard, uriniferous ducts, measuring from 
 Tofl to -,55 in diameter, consist of two layers. The outer is formed 
 of a slender structureless membrane, which is easily distinguished 
 by the addition of water, and is altogether a repetition of the outer 
 coat of the renal ducts. The inner is a stratified epithelium, from 
 10^0 0 to ^o5o parts of one inch thick. The cells of which it con- 
 sists are roundish, flat, ]|sob of one inch thick, broad, with * 
 nuclei in two, three, or more layers arranged over each other. 
 The inner layer is remarkable for distinctly developed ciliary pro- 
 cesses, from io®oo to fSBo of one inch long, which, by their vigo- ' 
 rous action, attract the attention of the most superficial observer, 
 and furnish an interesting sight in transverse sections of the canal. 
 The ciliated epithelium, so far as Kblliker saw, covers the whole 
 length of the canal ; but it is wanting in the common excretory 
 duct of the gland, and in the ends of the canals. These are the 
 Malpighian bodies, the existence of which, in the primordial renal 
 matter, has been established by Rathke’s observations on the de- 
 velopment of the viper. Every Malpighian body which has a dia- 
 meter of from 150 fo iSo of one inch, is a bladder or vesicula, 
 which is placed immediately at the end of the renal duct, and is in 
 free communication with the same. The structureless membrane | 
 of the ducts is peculiar to it ; so also is the epithelium, only more 
 slender, and is formed of one single layer, and is void of cilia. 
 Within the Malpighian body is a cluster of capillary vessels, which , 
 enter and emerge at the origin of opposite sides of the canal, and*, 
 as it appears, are separated from the cavity of the renal duct or 
 tubule by a layer of cells.* 
 
 M. Kolliker further thinks that it may be owing to the mode of ' 
 preparing the parts, that Reichert and Bidder did not observe the ^ 
 ciliary motions. If these parts are copiously sprinkled with water, 
 
 t 
 
 * It does not very clearly appear, from this mode of expression, vhether M. Kol- 
 liker describes this partition from his omi observation or from that of Bidder, by 
 whom I have shown this partition was discovered. 
 
STRUCTURE OF INDIVIDUAL GLANDS — MALPIGHIAN BODIES. 803 
 
 the nucleated cells swell so much, that it is impossible to distin- 
 guish the nucleus and contents ; and they appear only as pale, ap 
 parently homogeneous transparent globules. This renders the 
 ciliated movements indistinct, or annihilates them. But, at all 
 events, M. Kolliker has more frequently seen them in preparations 
 moistened with serum, albumen, or frogs’ urine, than in those 
 sprinkled with water ; and he has found them most certainly in 
 preparations entirely unmoistened. 
 
 In one point only he thinks Mr Bowman’s statements not quite 
 correct, viz. regarding the epithelium of the Malpighian bodies. 
 He observed within the capsule a complete epithelium ; but the 
 cilia he traced no further than the entrance of the capsule. He 
 has satisfied himself, by preparations made with the greatest care, 
 that within the capsule of the Malpighian bodies there is normally 
 no free cavity.* 
 
 Such is an abstract of the present state of information on the 
 microscopical anatomy of the kidney and the Malpighian bodies. 
 It will be seen, that, notwithstanding the skill and dexterity of the 
 observers, the facts are contradictory and not easily reconciled. 
 I have nevertheless given them for various reasons ; first, to show 
 the great difficulty of the subject ; secondly, to prove what is ad- 
 mitted by Henle, that microscopical anatomy is still in a transition 
 and imperfect state ; and also, thirdly, to enable readers to form 
 some idea of the minute structure of the glands. Though the 
 kidney is in some respects peculiar in its minute structure, yet it 
 agrees with other glandular organs in certain general and leading 
 characters ; and the exposition of these, however incomplete, may 
 serve to communicate an idea of the peculiar characters of glandu- 
 lar structure in general. 
 
 Before quitting the subject, however, it is proper to observe that 
 one, if not two of the points on which Reichert, Gerlach, and Bid- 
 der differ from Mr Bowman, depend on optical illusions only ; 
 that he has described correctly what he saw by the microscope ; but 
 that, from some cause not easily understood, he has not given the 
 explanations of the phenomena which they conceive to be correct. 
 
 On the uses of the Malpighian bodies we have no positive correct 
 information. All is supposition and conjecture ; and those who 
 have most studied these bodies, have been least willing to speak with 
 
 • Ueber Flimmerbewegungen in den Primordial Nieren ; von A. Kolliker, Archiv 
 for Anatomie, Physiologie, und Wissenschaftliche Medicin. Heft V. S. 518. 1845. 
 
804 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 confidence. The fact that they are placed among the serpentine re- 
 nal ducts, and that they are furnished with a peculiar arrangement of 
 capillary arteries, may favour the inference that they are in some way 
 connected with the secretion of urine. If the fact contended for by 
 Mr Bowman, that the Malpighian bodies are connected with the 
 serpentine ducts, were established, this inference would be rendered 
 almost certain. This communication, however, is denied by Muller 
 and others; and Muller accordingly maintains that the Malpighian 
 bodies have no concern in the secretion of urine. 
 
 Mr Bowman, on the other hand, who thinks he has shown that each 
 Malpighian body is situate at the remote or superior extremity of a 
 uriniferous tube, and that the tufts of vessels are a distinct system 
 of capillaries inserted into the interior of the tube, infers that, as the 
 arrangement of the vessels in the Malpighian tufts is evidently de- 
 signed to retard the motion of blood through them, the insertion of 
 the tuft in the extremity of the tube indicates that this retardation 
 is connected with the secreting process. He concludes, therefore, 
 that it is highly probable that the use of the Malpighian tufts is to 
 afifuse water abundantly and uniformly over the urine as it is se- 
 creted, so as to ensure the perfect solution of all its constituents. 
 Along with this, he thinks that these bodies, by contributing tore- 
 move aqueous matter from the blood, act as a self-adjusting valve 
 or sluice to the circulation. The use of the Malpighian bodies, in 
 short, according to Mr Bowman, is to separate from the blood the 
 watery portion, according to the necessities of the system. 
 
 I have only to add, in order to complete the description of the 
 renal serpentine ducts, that while they advance through the cortical 
 portion of the kidney to its periphery, they are not always, properly 
 speaking, serpentine. 
 
 In the horse, for instance, in which they are so large that they 
 may be perceived by the eye, at least after injection, without the 
 microscope, they do not run in the serpentine and tortuous course, 
 which they observe in man and most other animals. They are con- 
 tinued from the straight ducts, very slightly bending or undulating, 
 but still almost straight, for at least one inch or one inch and a- 
 half. As they approach the surface of the cortical portion, these 
 undulating flexures increase, and at the very surface they are com- 
 pletely converted into serpentine or tortuous tubes. 
 
 In the squirrel also, the serpentine ducts are large, and united 
 by little cellular tissue. In that animal they are seen without in- 
 
STRUCTURE OF INDIVIDUAL GLANDS — TESTES. 805 
 
 jectioD, by the microscope. The Bellinian ducts advance straight 
 through the medullary cones, and then passing into the cortical 
 matter, become bent. They appear a little larger than the medul- 
 lary ducts upon entering the cortical portion. 
 
 § V. THE TESTIS. 
 
 In the Insect tribes and Articulate animals, the iesfes assume 
 an endless variety of forms. All, indeed, consist of tubules mostly 
 simple ; but these are arranged in so great a variety of forms, that 
 it is extremely difficult to give a short, and at the same time accu- 
 rate view of these forms. 
 
 In Fishes, the organs corresponding to Testes appear to be con- 
 structed in two different modes. 1. For the most part, the testes 
 are composed of multiplied seminiferous canals or ducts. 2. Less 
 frequently the testes are entirely solid, and are composed of globules 
 without internal canals, and without deferent duct ; the substance of 
 which passes from the external surface into the cavity of the abdo- 
 men, from which it is conveyed outwards by one single orifice, ex- 
 actly as the ova. The best examples of these structures are seen 
 in the eel and •petromyzon. In such animals the ova and the testes, 
 or matter com'posing the testes, are so similar, that they are often 
 confounded. 
 
 In the herrinar and shad the structure is the following. From 
 the eflferent duct, running by the side or margin of the milt ( Tes- 
 tis), the largest tubules proceed close to each other, approaching to 
 the lobes attached to the common duct. But the further division 
 is efiected, not only by ramification, but also by numberless reticu- 
 lar anastomoses, so that almost the whole substance of the testis 
 or milt consists, in the month of May, of anastomoses of large 
 ducts filled with seminal fluid, which are distinctly seen by the 
 naked eye. From the reticulated anscB, however, proceed also 
 other branching canals, variously separated, which terminate here 
 and there in free but closed ends. Towards the outer margin and 
 at the opposite side of the lobes, the branchy divisions are most 
 abundant, while the anastomoses are less frequent; so that the 
 margin itself is almost composed of straight twig-like tubules, which, 
 little diminished, terminate in the extreme margin and at the sur- 
 face with closed ends. The internal branches are dispersed in va- 
 rious directions ; all the external and marginal ones proceed in a 
 straight course to the surface, so that on the surface of one side of 
 
806 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the testis, the closed ends of the tubules project like rounded cor- 
 puscnla. The disposition of the tubules is mostly known from the 
 white seminal matter contained, which renders it more distinct than 
 the other grey matter. 
 
 The most singular is the conformation of the male genitals in 
 the rays and sharks. The glandular organs are of two sorts ; one, 
 corresponding to what has been hitherto described as testes, con- 
 sisting of globules, and not of seminal ducts ; the other generally 
 regarded as the epididymis, composed of serpentine canals, yet not 
 at all joined with the globulose testes. On this account Muller 
 thinks that these bodies are not epididymides, but peculiar glands. 
 
 In man the essential part of the testis consists of tubuli semini- 
 feri, or very minute tubules, which are very numerous, and radiate 
 from all parts of the circumference of the organ to the centre, or 
 mediastinum testis, making numberless convolutions, which pro- 
 gressively diminish as they approach the rete testis. Two or more 
 of the tubuli being collected together, and invested by a common 
 cellular tunic, form a lobule of a conical shape, with its apex ter- 
 minating in the corpus Highmorianum. The lobules thus formed 
 are not entirely distinct, but communicate with neighbouring lo- 
 bules, the process investing them being incomplete. Krause esti- 
 mates their number between 404 and 484. 
 
 The tubuli of which they are composed are of a white colour, 
 and uniform in size ; but their calibre varies in different subjects, 
 and in different periods of life, and different states of tbe systetn.^j 
 They are larger in young adults, and when distended with semenj^ 
 than in aged persons, and when the gland is in a state of rest.^ 
 From a table of measurements'made by Mr Gulliver, and publish^ 
 ed in tbe proceedings of the Zoological Society, their diameter ap- 
 pears to have varied from the 1-1 12th to the l-77th part of an 
 English inch, and from the l-160th to the 1-lOOth part of an inch 
 in adults; and in children and infants, from the l-400th to the 
 l-230th part of an English inch. Observers, however, vary as to 
 the diameter of these tubuli. The average diameter of the unin- 
 jected canal is estimated by Muller at l-18th of a line, = l-180th 
 of an inch, and by Lauth, l-185th of an inch. Krause found the 
 tubrdi when filled with semen to measure about one-twelfth of one 
 line, = l-120th of an inch, and in old men and youths about l-16di 
 of a line, or 1-I60tb part of an inch. 
 
 As to their number and their length little seems ascertained. 
 
STRUCTURE OF INDITIDUAL GLANDS — TESTES. 
 
 807 
 
 Monro estimated the number of seminiferous tubes at 300 ; while 
 Lauth made their average number 840. The latter author esti- 
 mated the mean length of all the ducts united at 1750 feet. The 
 individual ducts he found to vary in length, the mean being 25 
 inches. Krause estimated their entire length at 1015 feet. 
 
 That the membrane composing the tubuli is of a mucous charac- 
 ter has been proved by microscopic examination ; and it is further 
 continuous with the mucous surface of the genito-urinary system. 
 There is no appearance of interlobular substance. The ducts are 
 connected by a loose network of vessels, and consequently may be 
 easily separated and unravelled. The tubes are usually injected 
 with mercury, and in this state are shown in most anatomical col- 
 lections. Sir Astley Cooper injected the tubes with size ; but of 
 the method which he followed no account is given. 
 
 When the tubuli are unravelled, they are found to divide and to 
 form numerous anastomotic unions, which increase in frequency as 
 they approach the circumference of the gland. The tubuli thus 
 form one large communicating network, in which it is impossible 
 to isolate completely either one duct or one lobule. In one in- 
 stance only did Lauth, who discovered these anastomoses of the se- 
 miniferous tubuli, find a duct terminating in a blind sac ; and this 
 he regards as an exception. Blind sacs have been more frequently 
 found, however, by Krause. 
 
 The convolutions of the seminiferous tubes diminish in number 
 as they approach the mediastinum and cease at a distance of from 
 one to two lines, where two or more unite to form one single, 
 straight duct termed vas rectum, whith joins the rete testis at a 
 right angle. The vasa recta are very slender, and easily give way 
 when injected. Their calibre, which is greater than that of the se- 
 minal tubes, is estimated by Lauth at l-108th of an inch. Their 
 number Haller reckoned at 20 ; but it is believed that they are 
 more numerous. 
 
 The rete testis is formed of a plexus of seminal tubes, which oc- 
 cupies the Corpus Highmorianum or mediastinum testis. The vasa 
 recta, after penetrating the walls of the corpus, terminate in from 
 seven to thirteen vessels, which, running parallel to each other in a , 
 waving course, and frequently dividing and anastomosing, form the 
 rete testis. The mean diameter of these vessels Lauth found in in- 
 jected preparations to be l-72d of an inch. 
 
 From the upper part of the rete thus formed issue vessels in nuin- 
 
808 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 ber about twelve or fourteen, but sometimes rising to thirty, which 
 are named vasa efferentia. These ducts, which are arranged in co- 
 nical shape, and hence named coni vasculosi, run straight for the 
 space of one or two lines, forming convolutions which become nu- 
 merous and close as the vessels recede from the testis. Lauth, es- 
 timating the average length at 7 inches 4 lines, and their number 
 at thirteen, makes the united length to be nearly 8 feet. After form- 
 ing the vascular tubes, already mentioned, they successively join 
 one single duct, the canal of the epididymis, at irregular intervals, 
 the intermediate spaces of the duct varying in length from half-an- 
 inch to 6 inches. These efferent ducts are more slender than the 
 canal of the epididymis, and frequently give way under the pres- 
 sure of the column of mercury. 
 
 While the vascular cones form a round bulky mass, which has 
 been named the head, or (jlobus major ^ of the epididymis, the con- 
 volutions made by the efferent ducts form the body and tail, to 
 which also the name oi globus minor has been applied. 
 
 A shut canal or duct, usually attached to the tail of the epidi- 
 dymis, and with a blind appendage or termination, constitutes what 
 has been named the vasculum aberrans. The length of this duct 
 varies from 1 to 12 or 14 inches, and it is always more or less con- 
 voluted. It is not constant ; nor is its use perfectly known. Mr 
 Curling infers that it serves no particular purpose, and that it is a 
 mere diverticulum, or process similar to those observed in the in- 
 testinal canal. 
 
 The canal of the epididymis as it approaches the level of that 
 body becomes larger, and forms then the vas deferens or excretory 
 duct of the testicle. The course, direction, and termination of this 
 tube are well known. 
 
 The spermatic artery or arteries, or those which supply the testis, 
 arise either from the aorta immediately below the renal artery, or 
 come off in one trunk, common to it and the renal artery, a mode 
 of origin connected with the site of the organ in the foetus, when it 
 is placed near the kidney on each side of the spinal column. From 
 the point now specified they descend behind the peritoneum, form- 
 ing many convolutions and tortuous windings, obliquely across the 
 psoas muscle and ureter, to which each artery gives branches, and, 
 entering the inguinal canal by the internal ring, they are joined 
 with the chord and reach the gland. Their subsequent distribu- 
 tion is described by Sir Astley Cooper in the following manner. 
 
STRUCTUEE OF INDIVIDUAL GLANDS TESTES. 
 
 809 
 
 “ When the artery reaches from one to three inches from the 
 epididymis it divides into two branches, which descend to the tes- 
 ticle, and its inner side, opposite to that on which the epididymis is 
 placed ; one passing on the anterior and upper, the other to the 
 posterior and lower part of the testis. From the anterior branch 
 the vessels of the epididymis arise. First, one passes to its head ; 
 secondly, another to its body ; and thirdly, one to the tail and the 
 first convolutions of the vas deferens^ communicating freely with 
 the deferential artery. The spermatic artery, after giving off 
 branches to the epididymis, enters the testis by penetrating the outer 
 layer of the tunica rdbuginea ; and, dividing upon its vascular layer, 
 they form an arch by tbeir junction at the lower part of the testis, 
 from which numerous vessels pass upwards ; and then descending, 
 they supply the lobes of the tuhidi seminiferi. Besides this lower 
 arch there is another passing in the direction of the rete, extremely 
 convoluted in its course, and forming an anastomosis between the 
 principal branches. The testis receives a further supply of blood 
 from another vessel, the artery of the vas deferens, or posterior 
 spermatic artery, which arises from one of the vesical arteries, 
 branches of their internal iliac. This artery divides into two sets 
 of branches, one set descending to the vesicula seminalis and to the 
 termination of the vas deferens ; the other ascending upon the vas 
 deferens, runs in a serpentine direction upon the coat of that vessel, 
 passing through the whole length of the spermatic chord; and 
 when it reaches the tail of the epididymis, it divides into two sets of 
 branches, one advancing to unite with the spermatic artery to supply 
 the testis and epididymis, the other passing backwards to the tunica 
 vaginalis and cremaster.” 
 
 The spermatic veins issue from the testis in three sets ; one from 
 the rete and tubuli ; another from the vascular layer of the tunica 
 albuginea ; and a third from the lower extremity of the vas deferens. 
 The veins of the testis pass in three courses into the beginning of 
 the spermatic chord. Of these, two quit the back of the testis, one 
 at its anterior and upper part; and a second at its centre, and 
 thereafter from two to three inches are united into one. The other 
 column accompanies the vas deferens. The veins of the epididymis, 
 issuing from the head, body, and tail, with some from the vas defe- 
 rens, terminate in the veins of the spermatic chord. The veins, af- 
 ter quitting the testis, become very tortuous, and forming frequent 
 divisions and inosculations, constitute the plexus named vasa pam- 
 
810 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 piniformia. After entering the pelvis they form one or two veins 
 which terminate on the right side of the vena cava inferior, and on 
 the left in the renal vein, though this is liable to some variety. 
 The left spermatic vein passes under the sigmoid flexure of the co- 
 lon, — a circumstance important to be remembered, in certain mor- 
 bid states of the gland and its vessels. 
 
 Several anatomists represent the spermatic veins to be void of 
 valves ; and to this circumstance ascribe the occurrence of va- 
 ricocele. Mr Curling states, that he has several times injected 
 these veins with alcohol, and on laying them open, he observed 
 valves in the larger veins, and found the passage of the alcohol ar- 
 rested by the valves. Valves are not seen near the testis, or in the 
 small veins forming the plexus, nor did Mr Curling observe them 
 within the abdomen. 
 
 § VI. THE MAMMA. 
 
 The Mammalia are the only class of vertebrated animals which 
 possess the glands called Mammae or Breasts ; Birds, Reptiles, 
 and Fishes, being destitute of these ; and in this order the confor- 
 mation of these glands appears under two forms. 
 
 1. In the higher Mammalia and in man the elementary particles 
 of the Mamm^, or the ends of the lactiferous tubes, are small vesi- 
 culse, joined to stalks by small branches of lactiferous tubules 
 in the manner of cluster of grapes or berries, and enclosed 
 by a very delicate cellular tissue. These acini of vesicles constitute 
 the smallest lobules. Several clustering acini united to the twigs 
 of a larger branch form a large tubule or one of the second order ; 
 and when several of these are conjoined they form a tubule of the 
 third order. These lactiferous tubes then uniting form trunks of 
 lactiferous ducts, which, either united open into the nipple, as in 
 the udder of the Ruminants, or separately perforate the nipple, 
 as in the human female and various other mammalia. 
 
 2. The second form of mamma is more rarely met with, and is 
 observed in families of the mammalia, which may be regarded as 
 the lowest in that class ; namely, in the Cetacea, and in the duck- 
 bill {ornithorhyncus paradoxus), and probably in the echidna. In these 
 animals the structure is reduced to that of a glandular organ, sucli 
 as first presents itself in the lowest mammalia, or in the most simple 
 form, that is in the shape of closed intestinula, collected in one mass. 
 
GLANDULAR ORGANS. 
 
 811 
 
 CHAPTER II. 
 
 MORBID STATES OF THE GLANDULAR ORGANS. 
 
 The morbid states of the glandular organs are very numerous 
 and varied ; and if we remember how often their function is dis- 
 ordered, to how many morbid changes their secreted products are 
 liable, how many changes may take place in their circulation, in- 
 dependent of changes in their structure, we must allow that 
 there is scarcely a texture in the whole frame which presents so 
 many forms of diseased action as the glands. 
 
 It would lead me into a field too extensive to consider all the 
 varieties of disorder and diseased action to which I have now ad- 
 verted. It must also be admitted, that the subject is in many re- 
 spects imperfectly known ; and that the consideration of various 
 changes incident to glandular action would lead me into inquiries 
 inconsistent with the nature of the present work. I propose, there- 
 fore, to confine the present sketch very much, if not entirely, to the 
 morbid states most frequently taking place in the system of the se- 
 creting glands. 
 
 Section I. 
 
 general observations on disorders of the secreting 
 
 GLANDS. 
 
 The glands, from being liberally supplied with blood-vessels, are 
 liable to he affected by all the changes which take place in the vas- 
 cular system. The blood, indeed, may be regarded as the first 
 great agent which affects the state of the functions of the secreting 
 glands. All substances taken into the blood are circulated to the 
 glands, and in a degree greater or less affect their secretions. 
 Thus, mercury and its preparations, which have been erroneously 
 supposed to act on the salivary glands only, act at the same time 
 on the pancreas, the liver, and the kidneys. In the same manner 
 also, spirituous liquors or articles containing them are absorbed by 
 the veins, circulated and conveyed to the different glands, and in 
 
812 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 this manner always cause unnatural excitement and irritation in 
 their vessels and elementary particles. Saline substances also 
 reach the glands and act on them sometimes favourably, sometimes 
 detrimentally. 
 
 Glands are liable to inflammation, acute and chronic, and all 
 their usual effects and consequences ; to hemorrhage ; to indura- 
 tion ; to hypertrophy ; to atrophy ; to interstitial deposits of new 
 matter ; to the obstruction of their ducts by blood, lymph, and the 
 products of secretion ; to various changes in structure in the ele- 
 mentary or ultimate particles ; and to several of the heterologous 
 depths. 
 
 When glandular organs are affected by inflammation, that pro- 
 cess may affect either the component tubes or the delicate filamen- 
 tous tissue by which these tubes are united ; or both at the same 
 time. When the process affects the tubes, if it do not terminate in 
 resolution, that is, if the orgasm, after subsisting for some time, does 
 not subside without giving rise to inflammatory products, it causes 
 effusion of plasma, or of blood within the tubes, which are then for 
 the time obliterated. In this case the gland is enlarged and indu- 
 rated, sometimes irregular, is the seat of dull pain and weight, and 
 secretion is almost impracticable. 
 
 In certain favourable cases, in which the plasma or blood is ef- 
 fused in small quantity, it does not undergo coagulation ; and the 
 tubes may remain more or less pervious ; or even, after a time, may 
 recover entirely their permeability. Instances of this undoubtedly 
 take place both in inflammation of the liver and in that of the kid- 
 neys. 
 
 In other instances, however, in which the effusion is abundant, 
 the gland remains hard and enlarged for a long time, sometimes 
 for life. 
 
 When inflammation affects the outside of the tubes and acini, or 
 elementary particles, and the connecting tissue, it more commonly 
 causes the effusion of purulent matter, in one or more distinct cysts 
 or abscesses. 
 
 Lastly, inflammation often attacks first and principally the ex- 
 cretory duct and its divisions, and terminates in effusion of matter ^ J 
 more or less copious. This either escapes by the general duct; or, 
 if i do not readily escape, or is entirely confined, the duct and all the 
 communicating parts become greatly distended, containing conside-;',^ 
 rable quantities of purulent matter, and their lining membrane co- 
 vered with a coating of lymph ; and in this case the gland appears ^ - 
 
GLANDULAR ORGANS — LACRYMAL GLAND. 
 
 813 
 
 to contain a number of separate abscesses. If, however, these be 
 carefully examined, it is seen that neither the gland nor the tex- 
 ture of the ducts is destroyed ; that the former is enlarged and ex- 
 tenuated by the distension of the ducts ; while the apparent ab- 
 scesses are formed by the latter. This takes place in the kidneys 
 and prostate gland. 
 
 Inflammation of strumous character is liable to affect the secret- 
 ing glands, more especially the female breast, the testes and pros- 
 tate gland of the male, and the kidneys and parotids in both sexes. 
 The effects of this process, which is chronic in duration, and insidi- 
 ous and not well-marked in symptoms, are denoted by the deposit, 
 in general, within the tubules of the glands of semifluid or fluid ty- 
 romatous matter, that is to say, an albuminous animal product, 
 which, though it undergoes coagulation, is nevertheless remarkable 
 for showing little or no tendency to become organized. This sub- 
 stance, found in tbe shape of putty-like matter, caseous matter, or 
 caseous mixed with calcareous matter, presents few or no blood- 
 vessels, bas no independent circulation, and, in short, gives evidence 
 of possessing a very low degree of vitality, or rather nothing of that 
 property at all. As already stated, it is found in the ducts of the 
 testes and prostate gland, in which its presence gives rise to consi- 
 derable irregular swelling and pain by pressure on adjoining parts ; 
 it is also seen in the mamma, where it likewise causes considerable 
 irregular swelling ; and it may affect either the serpentine ducts of 
 the kidney, or the calyces of that gland. 
 
 Section II. 
 
 § I. THE LACRYMAL AND SALIVARY GLANDS. 
 
 These glands are liable to inflammation, acute and chronic ; 
 the latter most usual. 
 
 Inflammation of the lacrymal gland is certainly rare, unless as 
 the effect of injury or the extension of inflammation of the conjunc- 
 tiva into its ducts. Most usually it is chronic. An instance is 
 mentioned by Beer ;* and the disease is described by Reil and Be- 
 nedict. Hemorrhage takes place from it sometimes as vicarious of 
 menstruation, sometimes without any obvious connection with this 
 cause. Hemorrhage appearing at the eyes in purpura is most 
 probably from the conjunctiva. 
 
 * Georg. Jos. Beer Auswahl aus dem Tagebuch eines practrischen Augenarztes, n. 2. 
 Wien, 1800. 
 
814 
 
 GENEIIAL AND PATHOLOGICAL ANATOMY. 
 
 The lacryinal gland may be enlarged from strumous disorder to 
 the size of a nut. It then makes a distinct tumour at the exterior 
 and superior angle of the eye beneath the orbital plates. 
 
 Schmidt admitted that inflammation of the lacrymal gland alone 
 can scarcely be said to take place ; because, the disease thus desig- 
 nated is rather inflammation of the entire orbit, that is of the or- 
 bital cellular tissue, embracing also the gland.* This view is 
 adopted by Benedict, who devotes a whole chapter to the descrip- 
 tion of the disease and its eflects. As described by this author, it 
 is manifestly an acute inflammation of the ophthalmic cellular tis- 
 sue, with some symptoms indicative of extension to the cerebral 
 membranes. Thus, not only is there pain in the eyeball and orbit, 
 but pain of the head, delirium, want of sleep, and great suflfering. 
 The characteristic symptoms are the sense of something in the or- 
 bit above the eye, the feeling of the orbit being too small for the 
 eye, as if the eyeball were thrust out of it ; then swelling of the up- 
 per eyelid, proceeding generally to a great degree ; and at last the 
 formation of matter, which points in this situation, or immediately 
 beneath it.f A similar account is given by Weller. 
 
 It is manifest that this is the account of general inflammation 
 of the orbital celluloso-adipose tissue ; and not of the lacrymal 
 gland alone. The gland, however, may be affected ; but that is 
 only in a slight degree. 
 
 This disorder may terminate in one of three modes. First, un- 
 der symptoms of complete phrenitis, the patient dies ; secondly, it 
 may terminate in abscess of the orbital tissue ; or, thirdly, complete 
 ophthalmitis is associated with inflammation of the eyeball, and sup- 
 puration of the latter is superadded to abscess of the orbit. 
 
 Next to resolution abscess of the orbital tissue is the most favour- 
 able result. Benedict states that when this does not take place, 
 or an opening is neglected, death has been the result, by the tran- 
 sit of the disease to the brain ; and on inspecting the parts, the an- 
 terior lobe has been found inflamed, and a collection of purulent 
 matter, both on the surface of the cranium, frontal bone, and in 
 the orbit. 
 
 When the lacrymal gland is affected by chronic inflammation, 
 the eye is protruded, the optic nerve suffers from pressure, and 
 
 * Johann. Adam Schmidt, iiber die Krankheiten des Thranenorgans, mit 4 Kup- 
 fertaf, gr. 8vo. Wien, 1803. 
 
 f Traugott Guilelmi Gustavi Benedict, de Morbis Oculi Humani Inflammatoriis. 
 Lib. xxiii. Lipsije, 1811. Liber 7imus, § 153, p. 82. 
 
GLANDULAR ORGANS — LACRYMAL GLAND. 
 
 815 
 
 amaurosis follows ;* or the vitreous humor and lens are so much 
 compressed, that sight is greatly impaired. 
 
 Even without this compression the sight may be lost. 
 
 This is probably owing to the nervous connection between the 
 divisions of the first part of the fifth nerve, — one of which supplies 
 the lacrymal gland, — and the branches of the same nerve, which are 
 distributed to the ciliary processes. 
 
 Portal states, that he found it affected with scirrhus, and even 
 proceeding to ulceration in dead bodies ; especially in the body of 
 one female who had cancer in both mammae, and who some time 
 before death had an attack of chronic ophthalmia. 
 
 It is often difficult to distinguish between mere induration, the 
 effect of chronic inflammation and scirrhus of the gland. In both ^ 
 the gland is hard and enlarged, and causes a prominent swelling, 
 more or less distinct, at the superior outer angle of the orbit. The 
 eye is pressed downwards ; and more or less ophthalmia affects the 
 palpebral and ocular conjunctiva. At first the secretion of tears 
 is augmented ; but after the disease has continued some time it is 
 diminished ; and the peculiar symptom called xerophthalmia or 
 preternatural dryness of the eye is induced. 
 
 The disease named cancer of the e}'^eball often originates either 
 in the lacrymal gland, or in the caruncula lacrymalis. Conversely, 
 if scirrhus affect the eyeball, it may spread to the lacrymal gland. 
 
 Guerin states that he extirpated a lacrymal gland affected with scir- 
 rhus, while the eye appears to have been unaffected. This he did with 
 so great dexterity, that the rectus externus muscle was not touched. 
 The gland formed a swelling so considerable, that it covered com- 
 pletely the globe of the eye. The eye, however, was found quite 
 sound behind the tumour of the lacrymal gland. Richerand, who 
 knew no other instance of extirpation of the gland alone, is inclined 
 to believe the case solitary. It is certainly much more common to 
 remove the gland, sound or diseased, in removing the eye, than to 
 remove the diseased gland alone without the eye. 
 
 The lacrymal gland has, nevertheless, been repeatedly removed 
 since that time. Thus it was removed by Duval de Rennes,t by 
 Mr Travers,! by Mr O’Beirne in 1820,§ by Mr Todd in 1821,H 
 
 * Reil, Memorabilia Clinica. Vol. i. Fascicul. i p. 118. 
 
 t J. L. Duval sur quelques Affections Douloureuses de la Face. Paris, 1814. 8vo. 
 
 t Synopsis of Diseases of the Eye and their Treatment. London, 1820 and 1824, 
 p. 233. 
 
 § On Diseases of the Lacrymal Gland, by Charles H. Todd. Dublin Hospital Re- 
 ports, Vol. iii. p. 407. 
 
 II Ibid. 
 
816 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 by Daviel in 1829, by Lawrence in 1826 and 1828,* and by M. 
 Jules Cloquet in 1835.f 
 
 It is not perfectly certain, whether in all these cases the gland 
 was affected by genuine scirrhus. It is certain that in its site was 
 a hard firm body, generally much swelled, and forcing the eyeball 
 downwards. In each of the cases almost the structure of the gland 
 was different. In two cases, in which Mr Lawrence operated, he 
 allows that the gland in respect of hardness might have been called 
 scirrhus ; but he adds, that he saw no reason for suspecting the 
 disease to be malignant. If this latter conclusion be admitted, 
 then it follow^s that these are examples of simple induration (sklc- 
 roma) of glands. In all these cases, however, the gland is more 
 or less enlarged, sometimes very much so. 
 
 In those cases in which the lacrymal gland has been examined 
 after extirpation, it has been observed that the elementary particles 
 or granules were hard and enlarged, chiefly by the effusion of 
 lymph. But the appearances vary in different instances. 
 
 Schmidt, and afterwards Beer, describe the formation of true 
 hydatids as occurring in the lacrymal gland. Their pressure 
 causes a tumour at the upper part of the orbit, and some degree 
 of exophthalmia. 
 
 Among the salivary glands, the morbid states of the parotid have 
 attracted most attention. 
 
 It is known that the parotid and soda parotidis are liable to 
 acute inflammation, forming the disease known by the popular name 
 of Mumps and Branks, and also to various chronic disorders. Of 
 the former I need scarcely speak in this place ; because, though a 
 disease not unimportant, yet it is rarely the object of attention to 
 the pathological inquirer ; and the accounts given in the ordinary 
 treatises contain all the information which it is necessary to possess 
 on the affection! and the diseases in conjunction with which it ap- 
 pears either as an effect or a part. 
 
 One or two points only require to be here noticed. The swelling 
 which takes place in the parotid region in remittent fever, typhous 
 
 * A Treatise on the Diseases of the Eye, by William Lawrence, P. R. S. London, 
 1833. Chapter xxix. sect. i. 
 
 -f- Du Squirrhe de la Glande Lacrymale et de I’Ablation de cette Glande, par G. 
 E. Maslieurat-I.agemard. Archives Generales, iiie. et Nouvelle Serie. T. vii. ou T. 
 lii. Paris, 1840. P. 90. 
 
 J Elements of Practice of Medicine. Vol. ii. Book ii. Chapter v. § iv. p. 410. 
 
PAROTID GLAI^D. — DISEASES. 
 
 817 
 
 fever, synochus^ scarlet fever, and similar diseases, appeal's to be 
 seated rather in the surrounding cellular and adipose tissue than 
 in the parotid gland. It occasionally proceeds to suppuration ; and 
 this I have seen it do, notwithstanding the use of means calculated 
 to obviate this termination. This result is supposed not to be un- 
 favourable ; and many physicians prefer promoting it by the use of 
 stimulating applications. At the same time, it must be observed 
 that suppuration in this region is not always a favourable result. 
 The following case given by Monteggia is in point. 
 
 In a man of 60 years a swelling took place, in the course of 
 fever, in the right parotid region. This speedily subsided, and 
 was followed by a similar swelling in the left parotid region, which 
 terminated in abscess. This being evacuated by an incision made 
 below the ear, the opening continued for one month discharging 
 much matter, and a little coming away daily by the ear-hole. The 
 patient, in the meantime, though the original disease was gone, did 
 not recover properly, continued long languishing, and at length, 
 becoming worse, died comatose. 
 
 Inspection of the body disclosed the following facts. The whole 
 cellular tissue on the left side of the head was loaded with fluid. 
 The parotid gland, contracted, rigid, and hardish, was marked in 
 various places with red points. Trom the external site of the in- 
 cision an ulcerated passage or sinus led to the meatus auditorius, 
 the eroded cartilage of which was partly seen. The adjoining part 
 of the bony canal, with the root of the zygomatic process, were 
 struck with caries. In the meatus itself were some loose osseous 
 fragments, along with some testaceous remains of some insect dead 
 in this situation. The temporal muscle presented unequivocal traces 
 of previous inflammation ; and beneath it were some drops of pu- 
 rulent matter on the surface of skull. The intermeningeal space, 
 when the skull was opened, effused a large quantity of fluid on the 
 left side, the veins here being, besides, unusually turgid. When 
 the dura mater was detached from the inner surface of the skull on 
 this side, there appeared a purulent space half an inch broad on the 
 surface of the petrous process, where foramina of Valsalva lead 
 to cavity of the tympanum. 
 
 The purulent matter, nevertheless, did not proceed from that 
 cavity, in which there was no disease. But the suppuration which 
 had taken place between the temporal muscle and the skull, had 
 transmitted many drops into the cavity of the skull by a small 
 
 3 F 
 
818 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 aperture conspicuous in the temporal bone, from which then the 
 fluid proceeding backwards by a linear path had dropped into the 
 space mentioned in the petrous portion of the temporal bone.* 
 
 This case, however, merely shows, that when extensive suppura- 
 tions take place in certain situations and in particular constitutions, 
 the matter may find its way into or among important and essential 
 organs. 
 
 In almost all these cases of suppuration in the parotid region, 
 the gland does not itself suppurate, but remains as described by 
 Monteggia, shrunk, dry, hard, and apparently atrophied. 
 
 § 2. The parotid gland and its companion are liable to strumous 
 transformation and infiltration, to chronic induration, to hypertro- 
 phy, to scirrho-carcinoma, and to melanosis. 
 
 In ordinary circumstances enlargement of the parotid is most 
 commonly strumous or dependent on chronic inflammation. In 
 either case, a tumour variable in size is formed at the auriculo- 
 temporal region, a little above the angle of the jaw. When this 
 swelling is of strumous origin, it usually causes secondary inflam- 
 mation and suppuration of the surrounding cellular tissue and the 
 incumbent skin ; one opening or two may take place ; and for a 
 considerable time a thin serous or sero-purulent discharge conti- 
 nues. Usually the gland is not itself much or seriously affected be- 
 yond the swelling caused by infiltration of its ducts and acini. In 
 certain cases, however, the gland or its ducts seem to pass into the 
 ulcerative stage ; and a long continued sore with a salivary fistula 
 is the result. In other cases the ulcerative communication appears 
 to be established between Steno’s duct only and the surface. Ul- 
 cers and fistulse of this kind were seen by Hildanus and Chesel- 
 den states, that he saw patients with the gland ulcerated, and caus- 
 ing a constant effusion of saliva, till, he adds, the greatest part of 
 the gland was consumed by the use of red precipitate. | It is not 
 easy to imagine the gland, that is the substance of the gland, to be 
 much consumed in this manner or by this agent, without more 
 serious effects. But we may admit that the remedy, by inducing 
 a new and more decided action, and enabling the most healthy 
 
 * Joannis Baptistae Monteggia Fasciculi Pathologici. Turici Helvetiorum, 1793. 
 8 VO, p. 17. 
 
 -f- One in a young man of 12. Observat. Chirurgic. Centuria V. Obs. Ixxx. Op. 
 Omnia Francofurti ad Moeniun, 1646. Folio. P. 471. 
 
 i The Anatomy of the Human Body. Book iii. Chapter iii. p. 142. London, 
 1784, the 12th edition. 
 
PAKOTID GLAND — STRUMOUS ENLARGEMENT. 
 
 819 
 
 part of the gland to assume proper action, had effected cicatriza- 
 tion. 
 
 Tenon speaks of a tumour of the parotid gland which attains 
 a large size, yet he says without change in structure. The instance 
 which he describes took place in a child, on the left cheek of whom 
 appeared a tumour almost as large as the fist, extending from the 
 ear to the angle of the lip. This tumour, which had grown gra- 
 dually from the birth of the child, was soft, white, indolent, move- 
 able, and composed apparently of glandular grains. It appeared 
 also traversed by large vessels, which formed in various parts of 
 the skin networks of spiral form or reddish whorls. The child 
 died not from the tumour, but from a different cause. Tenon found 
 that the tumour was formed by the parotid gland, which had ac- 
 quired great size, and exceeded its usual limits. Large arteries 
 proceeding from the external carotid and external maxillary enter- 
 ed the lower part of the gland.* 
 
 This seems to have been an example of simple strumous enlarge- 
 ment, or at most of hypertrophy occurring in the strumous. If 
 there was no perceptible change in structure, that must be ascribed 
 to the short duration of the affection ; for the enlarged state of the 
 arteries shows that they were conveying much blood into the gland ; 
 and though this seemed only to be giving rise to simple enlarge- 
 ment, it is impossible to doubt, that the characteristic deposition of 
 strumous disorganization would soon follow. A case similar is 
 recorded by Dr Duke.f 
 
 The same species of changes may take place in the submaxillary 
 and sublingual glands, though in these they have probably attract- 
 ed less attention. A peculiar cause of enlargement of the sub- 
 maxillary gland is the irritation of teething, and especially the 
 presence of carious molar teeth ; and both these and the sublingual 
 glands may become enlarged from the irritation of the gastro-in- 
 testinal mucous membrane in disorders of the alimentary canal. 
 These disorders cause sour offensive exhalations to arise, indicating 
 the bad sort of chyle prepared. The blood is consequently in an 
 unhealthy state ; and this, again, appears to irritate the glands, and 
 to excite their vessels to increased and disordered action. 
 
 In adults, a common cause of enlargement of the parotid and 
 the other salivary glands is the use of mercury in strumous habits. 
 Whether it be that mercury operates always hurtfully in the stru- 
 
 * Memoii-es de I’Academie des Sciences, 1760. 
 
 t Provincial Medical and Surgical Journal, No. XXI, Feb. 19, 1842. 
 
820 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 mous, or whether it be, that while it is taken, the individuals are 
 incautious, and expose themselves to cold, or commit errors in 
 diet, certain it is, that in the great majority of cases, the first en- 
 largement of the parotid and other salivary glands takes place 
 either during a course of mercury, or soon after it is completed. 
 All these glands are more or less swelled, sometimes very much ; 
 and the parotid being placed in a situation so conspicuous, forms a 
 large bulging tumour on one or both sides of the jaw. These tu- 
 mours are manifestly of the strumous character, and occur princi- 
 pally in strumous subjects. Often they cause suppuration of the 
 surrounding cellular tissue and skin, forming sinuous ulcers, and 
 leaving ugly scars. * 
 
 § 3. The sublingual glands are liable to a peculiar enlargement, 
 generally of a chronic character, immediately beneath the tongue, 
 where its pressure on the sublingual veins causes great dis- 
 tension of these vessels. To this appearance a peculiar name, 
 that of Ranula, has been applied, from some fancied resemblance 
 to a small frog. The matter causing this tumour varies. Some- 
 times it is a simple enlargement of the gland. More frequently, 
 however, it arises from one or more concretions in the excretory 
 duct of one or other of these glands. 
 
 § 4. Chronic induration is liable to affect either or all of the sa- 
 livary glands. The change has, however, been most commonly ob- 
 served in the parotid gland. The gland is enlarged, hard, indo- 
 lent, resistent ; and constrains the motions of the jaw. Sometimes 
 the tumour is irregular on the surface; in other instances it is 
 smooth. As to pain, evidence varies a good deal ; for in some in- 
 stances there is much deep-seated lancinating or darting pain ; in 
 others no pain is felt, except that resulting from pressure and dis- 
 tension of the parts. 
 
 Almost all these tumours in the site of the parotid, if a little 
 hard, have been comprehended under the general and comprehen- 
 sive name of scirrhus ; and at present it cannot be said that there 
 is any good diagnosis between simple chronic induration and scir- 
 rhus, before at least the tumour has been removed and subjected to 
 proper microscopic examination. Boyer himself admits the diffi- 
 culty of the diagnosis, and allows that many cases of enlargement 
 in this region, which were strumous, were ascribed to scirrhus. T 
 think it scarcely possible to mistake for scirrhus, as he seems to be- 
 lieve was done, mere strumous swellings, whether of the parotid 
 
PAROTID GLAND — CHRONIC INDURATION. 
 
 821 
 
 gland or of the lymphatic glands, when taking place in young per- 
 sons ; and the age of the patient, as well as the appearance of the 
 tumour and aspect of the patient, ought to be taken into account. 
 Neither does mobility avail so much as M. Boyer seems to imagine. 
 A mere indurated parotid gland may, from its position, contract 
 very firm adhesions with the contiguous parts. 
 
 The circumstance of age, however, must not be taken alone. 
 Sabatier records a case of considerable enlargement in the site of 
 the right parotid, in a person above 60 years. The tumour extend- 
 ed in the vertical direction from the infra-zygomatic fossa to 5 or 6 
 centimetres below the angle of the jaw ; and in the horizontal, from 
 the lobe of the ear to the anterior margin of the temporal muscle. 
 In shape it was irregular. It was free from pain. To this tumour, 
 which Sabatier removed by operation, he applies the name of Exu- 
 berance. Upon its inner structure he gives no details. But it 
 must have been an instance either of hypertrophy, or some change 
 difierent from scirrhus. 
 
 What, then, is to be said of the cases, now numerous, in which 
 the parotid gland is recorded to have been removed by operation ? 
 For a long series of years, surgical authors have been in the habit 
 of speaking familiarly of scirrhus of the parotid gland, and of the 
 removal of the gland for this distemper. It appears, indeed, at one 
 time, if we form a judgment from the frequency of instances of exci- 
 sion, to have been imagined to be a common disease. Thus Heister, 
 Von Siebold, Souscrampes, Orth, Burgras, Hezel, and Alix, all 
 record cases, which, they say, are examples of excision of the parotid 
 gland. 
 
 To the question here suggested two answers must be given. First, 
 it appears certain that scirrhus is by no means so frequent as has 
 been supposed; and, secondly, the alleged instances of scirrhus, 
 from which the gland is stated to have been removed, were cer- 
 tainly either strumous indurations and enlargements of other parts, 
 or affections of the gland not scirrhous. 
 
 In several instances these operations could not have been per- 
 formed on the gland, and must have taken place on enlarged lym- 
 phatic glands ; and, in other respects, it is more than doubtful that 
 the parotid was affected by scirrhus. Richter and John Bell first ; 
 and afterwards Murat, Richerand, Boyer, Velpeau, and the majo- 
 rity of well-informed surgeons, maintain that it is impossible to ex- 
 tirpate the gland without tying the carotid. 
 
822 
 
 GENERAL AND PATHOLOGICAL ANATOIIY. 
 
 In the museum of the College of Surgeons of Dublin, are seve- 
 ral preparations of tumours removed either from the site or the 
 substance of the parotid. A. a 80 is one from the substance of 
 the parotid gland. It is about the size of a turkey’s egg ; and it 
 was contained in a fibrous cyst, which adhered to the substance of 
 the gland. Its texture is in some parts fibrous and dense ; in others 
 it presents patches of gelatinous consistence ; and in one, in spots 
 near the surface, these patches are soft and bloody. This had not 
 recurred 12 years after operation. This tumour was not in the 
 parotid, but only touching it. 
 
 A. a 81 is the section of a tumour, about 3 inches long, lobu- 
 lated, firm, and pale in colour, which was contained within a cyst, 
 and was imbedded in the parotid gland. 
 
 A. a 82 is a tumour of the parotid, in an aged female, supposed 
 to be scirrhous. The texture of the gland is involved. This ap- 
 pears to have been removed after death. 
 
 A. a 83 is a tumour removed by Mr R. Power from the parotid 
 region of a married female, aged 40. The disease had commenced 
 nine years previously, by a hard swelling about the size of a pea, 
 near the left angle of the jaw. 
 
 At the time of admission to hospital the tumour was large ; oc- 
 cupying the external part of the parotid gland, displacing the lobe 
 of the ear, extending upwards as high as the zygoma, and back- 
 wards to the sterno-mastoid muscle. It was hard and resisting to 
 the touch, and in the fixed condition of the jaw, slightly moveable. 
 The tumour was the seat of sharp tingling pain, and caused conside- 
 rable difficulty in mastication. Other symptoms were pain in the left 
 eye-ball, with dimness in vision and internal squinting; numbness 
 and soreness of the left side of the face ; impairment of articula- 
 tion and of the sense of taste, with atrophy of the left half of the 
 tongue, which, when protruded, was drawn to that side.* The tu- 
 mour was easily removed by operation. 
 
 The tumour consists of two globular masses, unequal in size. 
 The large portion is firm and heavy, presenting on section the 
 compact hard texture of scirrhus with radiating fibrous bands, 
 with slight softening at one or two points. The small tumour con- 
 
 * This statement is not quite intelligible. If the tong-ue were drawn to the left 
 side, in which the tumour was situate, it shows that the right side was paralysed. It 
 ought, according to all that is known, to have been the left side that was paralysed ; 
 and the tongue would then have been drawn to the right side. The mistake may be 
 clerical. 
 
PAEOTID GLAND — TUMOURS INYOLVING. 
 
 823 
 
 tains softer substance, not unlike medullary matter, which seems 
 deposited in cells, with hard points interspersed, which had not yet 
 lost their original scirrhous character. A portion, only of the pa- 
 rotid gland was removed, and that portion is incorporated with the 
 anterior edge of the tumour, and most intimately connected with 
 it. The disease is supposed to have commenced in the lymphatic 
 gland always situate in this position, and to have secondarily affect- 
 ed the parotid gland.* 
 
 In 1805, Dr John M'Lellan of Green Castle, Franklin County, 
 Pa., removed from the parotid region, in a female of 50, a tumour 
 large and ulcerated, believed to be affected with carcinoma. He 
 tied the maxillary and temporal arteries.f 
 
 The gland, moreover, has been, when affected hy melanosis^ re- 
 moved entirely by Dr Mott of New York.J 
 
 M. Larrey is stated to have extirpated the parotid gland in a 
 young man of 19 for scirrhus. I have no doubt that this was 
 mere strnmous induration.§ 
 
 In 1842, M. Jobert stated to the Royal Academy of Medicine 
 that an American physician extirpated, in a man of 62, a large 
 tumour in the parotid region, believed to be affected with scirrhus. 
 The carotid artery was in this case tied.|| 
 
 In 1842, Dr Wheeler of Dundaff, Susquehanna, removed from 
 the parotid region of a man, age not mentioned, a tumour of con- 
 siderable size, stated very confidently to be scirrhous in texture, 
 and to affect the whole parotid gland. The external carotid artery 
 was tied. IF 
 
 Professor Vanzetti of Karahoff (Russia) removed from the paro- 
 tid region of a man aged 40, a tumour weighing three pounds and 
 a-half.** j 
 
 From the facts now recorded, it can by no means be confidently 
 inferred that in all these cases the parotid gland was affected with 
 
 * Descriptive Catalogue of Preparations of the Museum of the College of Surgeons 
 in Ireland. Vol. ii. Dublin, 1840. P.537. 
 
 + Case of Extirpation of Parotid Gland. American Journal of Medical Sciences, 
 April 1844. No. XIV. New Series, p. 499. 
 
 J Case of Extirpation of the Parotid Gland, by Valentine Mott, M. D. American 
 Journal of Medical Sciences, Vol. x. p. 17. 1832. 
 
 § Examinateur Medicale, 15th Aug. 1841. 
 
 II Archives Generates, Illieme Serie. Tome LX. p. 232. Oct. 1842. 
 
 IT Extirpation of a Scirrhous Parotid Gland. By H. H. Wheeler, M. D. Ameri- 
 can Journal of Medical Sciences, No. XVIII. April 1845, 520. 
 
 ** Annales de Chirurgie. Aout 1844. 
 
824 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 scirrhus. Two inferences seem to be established by the cases now 
 noticed. The first is, that these tumours are not in all cases seated 
 in the parotid gland. In the majority of cases they do not at first 
 affect the gland, which is involved only secondarily. Most com- 
 monly they are seated in lymphatic glands or cellular tissue. The 
 second inference is, that the tumours of the kind now noticed cannot 
 in all cases be regarded as scirrhous. It is quite impossible to ad- 
 mit that the tumour in the young person of 19 w^as scirrhus; and 
 as to the others, there is no very certain evidence that these tu- 
 mours are any thing but strumous glands or swellings. 
 
 It appears, nevertheless, that these glands are liable to be in- 
 volved in the morbid changes and growths so frequently observed 
 in this region. 
 
 Lastly, it must be allowed that the most frequent change ob- 
 served in the salivary glands, and perhaps in all glands, is that 
 of induration, {sMeroma\ in consequence of the eflPusion of plastic 
 matter during chronic and strumous inflammation, either around 
 their component granules or within these granules. 
 
 §5. The parotid gland is liable to the formation of other structures 
 besides induration and scirrhus. Mr Pole records, in the person 
 of a woman of 47, an instance in which a tumour began to be form- 
 ed in the site of the left parotid gland about 1 1 years previously. 
 This tumour steadily and progressively increased in size, aflfecting 
 also the submaxillary glands, until it caused death by suffocation, 
 by compressing the trachea, oesophagus, and blood-vessels. After 
 death, when it was removed, it weighed ten pounds and a half; 
 and contained every kind of substance which usually fills steatoma, 
 meliceris, atheroma, lipoma, and even carcinoma, enclosed in 
 cysts.* 
 
 Similar to this, though observing an inverted order in succession, 
 is the case given by Cheselden, who shortly states, that he was pre- 
 sent at the inspection of a woman who was suffocated by a tumour 
 which began in the submaxillary gland, and extended itself from 
 the sternum to the parotid gland in six weeks time, and in nine 
 weeks killed her. It was a true scirrhus, he adds, and weighed 
 twenty-six ounces.f 
 
 * A Case of Extraordinary Diseased Enlargement of the Parotid and SubmaxilJary 
 Glands. By T. Pole, Surgeon. Memoirs of Medical Society, Vol. iii. p. 546. Lon- 
 don, 1792. 
 
 t The Anatomy of the Human Body. London, 1784, p. 143. 
 
 3 
 
PAROTID GLAND — TUMOURS INVOLVING. 
 
 825 
 
 It does not impugn much the judgment of this excellent surgeon, 
 if we doubt whether this tumour were a true scirrhus. If it were 
 not malignant, it might have been a mere strumous enlargement. 
 If it were malignant, it was much more likely to be encephaloid 
 disease than scirrhoma. 
 
 But even this point it is very difficult to determine. In most 
 cases of tumours affecting the neck, the enlargement consists either 
 in strumous disorder of the lymphatic glands, affecting probably 
 also the salivary glands ; or in encephaloma^ affecting these glands 
 and the cellular tissue. 
 
 A woman of about 40, with a tumour on the right side of the 
 neck, extending from the parotid region downwards to the collar 
 bone and larynx, was admitted into the Royal Infirmary. The 
 tumour was lobulated, and consisted of seven or eight spheroidal 
 masses. It might have affected the parotid gland, the site of which 
 it covered ; and, as it dipped under the angle of the jaw, it might 
 also have involved the submaxillary. It was, nevertheless, ob- 
 vious from its lobulated encysted appearance, and the short time 
 which had elapsed since its commencement, that it was probably 
 encephaloid. It was removed with great dexterity and success by 
 an able surgeon ; though it was found requisite to enclose in a li- 
 gature a portion which descended deep near the articulation of the 
 lower jaw. 
 
 The tumour consisted of about 12 or 13 spherical masses, each 
 enclosed in a separate cyst. The matter contained in these cysts 
 was of a whitish-gray colour, of the consistence between fat and gra- 
 nular cheese, and in all respects resembling the encephaloid growth. 
 It was impossible to detect the substance of the parotid gland, 
 which seemed to be involved in this growth, and was otherwise 
 rendered indistinct by the last incisions. 
 
 The wound healed up well. But about three months after, the 
 disease returned and destroyed the patient. 
 
 This must be regarded as either a case of encephaloma, affecting 
 first the lymphatic glands and cellular tissue of the neck, and after- 
 wards, perhaps, the parotid gland, or as an instance of the tumour 
 called cystic sarcoma. 
 
 The salivary glands are liable to the formation of encysted tu- 
 mours. Sandifort mentions one being found in the parotid gland. 
 
 The observations hitherto made are applicable to the submaxil- 
 lary and sublingual glands, as well as to the parotid. Both the 
 
826 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 submaxillary and sublingual glands are liable to be affected by in- 
 flammation, more frequently chronic than acute. This process 
 causes hard swellings, with more or less pain, in the site of these 
 glands. 
 
 § 6. Occlusion of Ducts. — More or less obstruction of the excre- 
 tory ducts is a disorder common to all glands. This may be occa- 
 sioned either by the ducts being contracted and narrowed by in- 
 flammatory thickening or its products, or by some of the products 
 of secretion sticking in the ducts. 
 
 The ducts in which changes of this kind are most usually ob- 
 served are Steno’s ducts in the parotid, and Wharton’s in the suh- 
 maxillary and the sublingual ducts. There is no doubt, neverthe- 
 less, that the lacrymal excretory ducts are liable to the same in- 
 convenience. 
 
 When the duct of Steno is obstructed by any cause of the kind 
 now referred to, a swelling more or less considerable, and more or 
 less firm, is formed in its course, in the cheek ; and unless the ob- 
 structing cause is removed, it sometimes produces ulceration of the 
 walls of the duct, and salivary fistula. 
 
 The same accident may happen to the duct of Wharton. Of this 
 sort of swelling, Boyer saw an instance. The gland swelled, and 
 the swelling subsided alternately, as the saliva was retained or was 
 allowed to flow into the mouth. By pressing the tumour whenever 
 the pain allowed pressure to be made, the saliva was urged along 
 the duct into the mouth, and the volume of the gland diminished. 
 This condition continued for months. Boyer recommended the 
 patient to make frequent and long-continued use of mallow water 
 in the mouth. The swelling of the walls of the canal subsided ; 
 the saliva resumed its free course ; and the gland no longer swell- 
 ed. 
 
 § 7. Concretions. — The most usual causes, however, probably, of 
 obstructions are the'presence of concretions in the excretory ducts. 
 This cause is common to all glands ; for the secreted product may 
 be prevented from descending along the ducts, either hy its own 
 viscidity and morbid consistence, or by some arctation in the ducts. 
 
 All excreting ducts are liable to have their channels contracted 
 by tbickening of the walls. But independent of this cause, which 
 has been already noticed, the secretions of all glands, though ori- 
 ginally and normally fluid, are liable to vary in chemical and me- 
 chanical properties, and thereby to favour the formation of various 
 
LACRYMAL AND SALIVARY GLANDS — CONCRETIONS. 827 
 
 solid masses. Thus concretions are found to affect the lacrymal 
 and salivary glands, as well as the hepatic and renal ducts. 
 
 § 8. Lacryjial Concretions. Dacryolitha. — Concretions or 
 hard bodies formed in the lacrymal gland, or its ducts, have been 
 noticed and recorded by many authors. Schurig relates from Paul- 
 lin the fact, that, in a young peasant, along with the tears small 
 stones were discharged, with heat, itching, and pain.* Lachmund 
 relates, that in 1661, in a girl of 13, there arose a painful swelling 
 on the left temple, from which, as well as from the angle of the eye, 
 were discharged small stones at intervals for the space of three weeks. f 
 Similar cases are mentioned as having occurred to d’Emery,^ Schafer,§ 
 and Plot. II An important case is given by Walther. In a healthy 
 young woman, from the left upper eyelid in whom, two years pre- 
 viously a portion of chalky matter had been removed, without leav- 
 ing any bad effect, there were formed, amidst evident marks of in- 
 flammation, recurring from time to time, in the fold between the 
 eye-ball and the lower eye-lid, opposite the external angle of the 
 eye, white angular stones of thfi size of a pea, which, in the subse- 
 quent course of the disease, became more numerous and larger. 
 After some time the left eye was first delivered from the evil. But 
 a similar formation of concretions began in the right eye at the 
 same place. The phenomena progressively diminished, and at 
 length ceased; yet returned after some years in a milder form. 
 At length the patient got quite well.lf Guillie mentions that, in a 
 young person of 15, after marks of violent inflammation, with red- 
 ness and swelling of the eye-lids, the lower fold of the conjunctiva 
 was filled on the 6th day with chalky deposit like fine sand ; and 
 on the 9th day there appeared at the outer angle a small co- 
 nical-shaped body, as thick as a vetch, reddish yellow, and irregu- 
 lar on the surface, which was loosely attached to the conjunctiva, 
 and was easily removed by forceps.** 
 
 Dr Kersten,ft who writes an elaborate paper on these concretions, 
 
 * Schurig Lithologia, p. 100. f De Fossilibus, Sect. iii. Cap. 22, p. 72. 
 
 J Journal des Sfavans, 1679, 1 May, p. 66-68. 
 
 § Ephemerid. Cent. iii. iv. Obs. clxxvii. p. 421. 
 
 II Natural History of Oxfordshire. London, 1677. Folio. 
 
 f Graefe und Walther’s Journal, Band i. Heft i. S. 163. 
 
 ** Bibliotheque Ophthalmologique, Tome i. p. 1 33. 
 
 Ueber Steinerzeugung aus der Thranenflussigheit, Von Dr Kersten in Mag- 
 deburg. C. W. Hufeland’s J ournal der Practischen 'Heilkunde. Fortgesetzte von Dr 
 Fr. Busse. 1843. iv. u. v. Stuck April u Alay, xcv. Band 4 u 5 St. S. 26-63. 
 
828 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 thinks, that they may be formed in the caruncula lacryrnalis ; and 
 he believes that they are formed also in the puncta, the canal, and 
 sac. This seems very doubtful as a general inference. These con- 
 cretions appear generally at the outer angle of the orbit ; and it is 
 most likely, that they are most commonly formed in the ducts and 
 orifices of the lacrymal gland, or near this situation. 
 
 Sandifort, however, found concretions in the lacrymal canal ; 
 and Desmarres records the circumstances of a case in which, in a 
 gouty female of 66, he found a lacrymal concretion impacted in 
 the lacrymal sac of the right side. Manifest swelling was formed 
 over the inner angle of the right eye. The patient had suffered 
 for two years from lacrymation, and latterly a discharge of matter 
 from the eye. The lower punctum was enlarged to three times its 
 normal size. In the course of the lower lacrymal duct there was 
 a small, prominent, circumscribed, indolent, and colourless swell- 
 ing. By means of a probe, Desmarres recognized the presence of 
 a solid body. He then introduced a grooved probe, and, dividing 
 the integuments down to the canal, he extracted a hard, yellowish, 
 pea-like body. The wound was healed in 24 days.* 
 
 On the frequency of the occurrence of concretions in the lacry- 
 mal sac evidence is divided. While some authors, as Nicolai and 
 Waldeck, consider the lacrymal sac as the most usual place for the 
 formation of lacrymal concretions, others, viz. Walther, maintain 
 that they are never found in this receptacle. That this is a mis- 
 take is evident from cases recorded by Le Dran, Schmucker, Kri- 
 mer, Cunier, Stievenart, Thibou, and Maunoir. 
 
 Cunier, in particular, gives the details of two cases, one in a man, 
 of 58, another in one of 63, in which concretions were found in 
 this situation,! and which seem to leave no doubt of the fact. 
 
 Lacrymal concretions of the largest size are observed in the 
 nasal duct ; because in the cavity of this canal there is most space 
 for their growth and enlargement with least inconvenience. Of 
 this three examples are recorded ; two in the observations of Dr 
 Kersten, and one by Horn in Schmucker ’s Miscellaneous Writ- 
 ings. 
 
 It may be observed that though these concretions occur some- 
 times in young persons, yet in general their subjects are of middle 
 age or up in years, and persons who have suffered from gout and 
 Aimales d’Oculiste. Paris, 1842. 
 
 t Observations pour servir a I’histoire cles Calculs Lacrymales. Bruxelles, 1842. 
 
LACRYMAL AND SALIVARY GLANDS — CONCRETIONS. 829 
 
 rheumatic symptoms. In one of the instances given by Cunier, 
 the patient had, six years previously, viz. in 1831, been cut for 
 stone in the bladder by Dupuytren. 
 
 Lacrymal concretions have been analyzed at different times by 
 different persons, uchs found in the concretions given him by 
 Walther carbonate of lime, forming the largest part of the weight, 
 and traces of phosphate of lime and albumen. The concretions 
 met with by Cunier consisted chiefly, according to Pasquier, of car- 
 bonate of lime, with traces of phosphate of lime and muriate of 
 soda ; and in one there was some phosphate of magnesia. Lastly, 
 the concretion removed by Desmarres was analysed by Bouchar- 
 dat and gave the following results ; — solid albuminous matter, 25 
 parts; mucus, 18 parts; carbonate of lime, 48 parts; phosphate of 
 lime and magnesia, 9 parts ; with traces of fat and muriate of soda.* 
 
 These facts seem to justify the views taken by Walther, Cunier, 
 and Desmarres, that the formation of lacrymal concretions, like 
 that of other concretions, depends on general causes. 
 
 Lacrymal concretions are perhaps disposed to be formed more 
 readily from the complexity and tortuosity of the lacrymal pas- 
 sages, and also from their narrowness and liability to inflammatory 
 thickening and obstruction. 
 
 Salivary concretions have not quite so frequently been observed 
 as lacrymal concretions. They are nevertheless by no means un- 
 common. 
 
 The most usual situation for salivary concretions to be present- 
 ed are either beneath the tongue in the ducts of the sublingual 
 glands, or in the duct of Wharton leading from the submaxillary 
 gland. 
 
 In the former situation the cases are so numerous, that it is im- 
 possible in this place to enumerate the twentieth part of them. I 
 shall merely mention that instances of salivary concretions have 
 been recorded by Lister, Freeman, Scherer, (1737); Bacciocchi, 
 (1749); Hamberger, (1754) ; Handtwig, (1754) ; Hartmann, 
 (1762 and 1784) ; Heilman (apud von Siebold,) Titius, and seve- 
 ral others. 
 
 Most of these are from the ducts of the sublingual gland. Fla- 
 jani gives a case of calculus from Steno’s duct, which is the least 
 frequent. Since the time of Flajani cases have been recorded by 
 * Annales d'Oculiste. Paris, 1842. 
 
830 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Muller (1811) and Seguignol. In the cases by Scherer, Acrel, 
 Heilman, in one by Sabatier, and in one by Boyer, the concretions 
 were from the duct of Wharton. 
 
 In the first case, these concretions give rise to an irregular swell- 
 ing beneath the tongue, and form one variety of the disease named 
 ranula. The size of this swelling varies according to the size of 
 the stone, and may be from that of a pea to the size of a filbert, or 
 even a walnut. In some rare instances they give rise to inflamma- 
 tion and ulceration, and thus extricate themselves from the position 
 in which they are confined. More frequently, however, they re- 
 quire the aid of operation. In the case given by Sabatier, it ap- 
 pears that the presence of the concretion in the duct of Wharton 
 caused painful swelling of the suhmaxillary gland, and this seems 
 to have given rise to more suffering and inconvenience than the 
 immediate swelling caused by the tumour. Two concretions were 
 in this case removed by two separate and successive operations.* 
 Boyer tells us that in a similar case in which the suhmaxillary 
 gland was likewise swelled, he cured the swelling of the gland by 
 extracting an oblong stony concretion, one extremity of which 
 projected a little beyond the orifice of the duct of Wharton. 
 
 I may here mention that salivary concretions are occasionally found 
 in the lower animals. Grognier records two cases of this lesion. 
 In one a concretion weighing 6 drachms was found in the Steno- 
 nian duct of a mule ; in another a concretion weighing 1 3 drachms 
 was found in the Stenonian duct of an ass.f 
 
 The chemical constitution of these concretions has been several 
 times examined. They consist of carbonate and phosphate of lime 
 coated with animal matter, with traces of muriate of soda, 
 
 § 9. Ranula. — Of this disease it would be unnecessary to say any 
 more, were the terms not employed to designate more than one 
 morbid affection. To every tumour, in short, appearing beneath 
 the tongue, the denomination of ranula is given. Munnicks, Louis, 
 and after him Boyer, espoused the opinion that the swelling de- 
 pended on an accumulation of saliva in the duct of Wharton. 
 But the main point was, why did the saliva accumulate ? Boyer 
 was of opinion that this was caused by obstruction at the outlet of 
 the ducts, or obliteration of those outlets. In point of fact, there 
 
 * Sabatier, Medecine Operatoire. 
 
 -j- Grognier in Sceance de I’Ecole Veterinaire. Journal de Medecine continue, 
 1810, Dec. p. 504. 
 
INFLAMMATION OF THE PANCREAS. 
 
 831 
 
 is no doubt that, from various causes, most frequently inflammatory 
 thickening, the duct is narrowed, and its outlet is either obstructed 
 or temporarily obliterated. Even inflammation of the mucous 
 membrane of the mouth, by causing obliteration of the outlets of 
 the duct, may be followed by such accumulation. In other in- 
 stances, again, the presence of a calculus within any of the ducts 
 has the same efiect. 
 
 Ranula is said to appear in the form of a tumour, in some de- 
 gree transparent, soft, and fluctuating, and in some instances in the 
 form of one quite hard and firm. At first small, it gradually en- 
 larges, projecting into the mouth, and interfering much with mas- 
 tication, speech, and even deglutition. It is even said that the 
 eflFect on speech is so considerable, as to make the voice of the pa- 
 tient resemble the croaking of frogs, and that from this circum- 
 stance the disease receives its name. This is probably an idle 
 fancy. 
 
 Section III. 
 
 DISEASES OF THE PANCREAS. 
 
 The diseases of the pancreas may be enumerated in the follow- 
 ing order. 1. Inflammation and its effects, adhesion, and suppu- 
 ration ; 2. simple induration ; 3. chronic induration ; 4. hypertro- 
 phy ; 5. softening ; 6. atrophy ; 7. concretions in the ducts or duct ; 
 8. chronic ulceration ; and 9. the heterologous deposits. 
 
 § I. INFLAMMATION OF THE SWEATBREAD OR PANCREAS. 
 
 AVNCREATIA, PANCREATITIS. 
 
 That the pancreas is liable to inflammation has been admitted 
 by most morbid anatomists ; but it has been also ascertained, that 
 it is very difficult, if not impracticable, to recognize the inflamed 
 state of the gland by symptoms during life, Morgagni believed 
 that he found it twice in a state of inflammation, that is, redder and 
 more vascular than usual; and Wedekind and Daniel have since 
 his time mentioned the circumstance as taking place occasionally. 
 Portal states in general terms that, when inflamed, it is redder 
 than natural not only at its external surface, but in its interior 
 substance ; and that it had been found in this state in persons who 
 had undergone an attack of continued fever of more or less inten- 
 
832 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 sity, with pains in the abdomen, especially at the navel, frequent 
 fits of violent vomiting, in some instances jaundice, and diminished 
 secretion of urine. Baillie was led by experience to regard in- 
 flammation as not very liable to attack the pancreas. 
 
 The only inference that can be deduced from these several facts, 
 is, that inflammatory action, if it do take place in the pancreas, does 
 not in all cases evince its presence by well-marked or unequivocal 
 symptoms. Does the inflammatory process, it may be asked, leave 
 distinct effects of its presence ? 
 
 Of the presence of inflammation in this gland several proofs may 
 be adduced. One is redness of the pancreatic substance with 
 vascularity and more or less softness, generally with effusion of 
 bloody serum in the glandular substance and surrounding cellular 
 tissue. Another is either the effusion of albuminous matter in the 
 neighbourhood, or preternatural adhesion to the adjoining organs. 
 A third effect is suppuration or abscess of the gland, sometimes with, 
 more frequently without, pain and other external symptoms. And 
 a fourth consists in different degrees of induration of the gland, 
 usually with pain in the epigastric region, and occasional vomiting. 
 
 § 1. Redness and vascularity are occasionally observed in the pan- 
 creas. But they are most frequently the effect of transudation after 
 death, or some similar pseudo-morbid process. In cases in which 
 they are associated either with effusion of plastic exudation, or 
 purulent matter, or induration or softening, they must be allowed 
 to depend o» inflammation. This, however, is not common ; chiefly 
 because inflammation of the pancreas is not usually an acute dis- 
 ease, and death does not take place in the early stage of the dis- 
 order. 
 
 One of the best and least equivocal examples of inflammation of 
 the pancreas is given by Mr Lawrence ; and as the appearances 
 observed by Mr Lawrence illustrate well the effects of inflamma- 
 tion, it is proper to mention them. 
 
 The case occurred in a married lady of 21, partly during preg- 
 nancy, and partly after delivery. During the three latter months of 
 pregnancy, the patient suffered unusually from thirst, and drank 
 large quantities of water. She had also suffered much from pain 
 in the epigastric region, particularly over the site of the pancreas. 
 She became pale, anaemic, feeble, and breathless. She made no 
 good recovery after delivery, but presented symptoms of great 
 weakness and exhaustion ; and died exactly five weeks after delivery. 
 
 I 
 
INFL.^MMATION OF THE PANCREAS. 
 
 833 
 
 Upon inspecting the body, the cellular texture round the pan- 
 creas and duodenum, the great and small omentum, the root of 
 the mesentery, the mesocolon, and the appendices epiploicce of the 
 arch of the colon, was loaded with serous fluid, transparent, bright 
 yellow, and of watery consistence, which escaped abundantly from 
 incisions. The pancreas was throughout of a deep dull red colour, 
 which contrasted very remarkably with the bloodless condition of 
 other parts. It was firm to the feeling externally ; and when an 
 incision was made into it, the divided lobules felt particularly firm 
 and crisp. The texture was otherwise healthy. The part was left 
 wrapped in a cloth for nearly forty-eight hours after its removal 
 from the body, when the weather was very cold. At the end of this 
 time the hardness was gone, and the gland appeared rather soft.* 
 
 From this it results that redness, and vascularity, and slight 
 hardness followed by softening, with infiltration of serous or sero- 
 albuminous fluid, constitute the anatomical characters of pancreatic 
 inflammation. This case also illustrates a principle formerly men- 
 tioned as to the effects of inflammation, namely, that the process 
 renders the tissues friable and easily lacerable. 
 
 § 2. Adhesion of the pancreas to the adjoining organs may he the 
 effect either of suppurative or common inflammation. In general, 
 when suppurative inflammation takes place, more or less albumi- 
 nous deposition is formed, and connects the gland to the adjoining- 
 organs, either to prevent the farther progress of the destructive 
 efiects of the suppuration, or to prevent the purulent matter from 
 being absorbed by the veins and transported into the circulating 
 system. 
 
 § 3. Purulent Inflammation of the Pancreas . — Collections of pu- 
 rulent matter in the pancreas have been observed by many anato- 
 mists. Tulpius mentions the case of a young man who, after an 
 intermittent fever, was attacked with pain in the belly and loins, 
 so violent, that he was unable to lie on any side. After death, 
 besides inflammation of the liver, the pancreas was found suppu- 
 rated.f Thomas Bartholin found, in a man who had previously 
 fever with pains in the back and in the loins, the pancreas alto- 
 gether destroyed by an enormous abscess full of foetid greenish 
 
 * History of a Case in which, on Examination after Death, the Pancreas was found 
 in a state of active Inflammation. By William La^vrence, F. R. S. Medico-Chirur- 
 gical Transactions, Vol. xvi. p. 366. London, 1830. 
 
 t Ohs. Med.'Lib. iv. cap. xxxiii. p. 3’27. Amst. 16.52 and 1672. 
 
834 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 matter ;* and Blancard records a similar history ;f and Lieutaud 
 mentions instances which had occurred to various observers.! Bonz 
 describes in a man of thirty-eight, an abscess in the right extremity 
 of the pancreas, the purulent matter of which implicated the sto- 
 mach and the liver, and established a communication between the 
 liver and the abdomen.§ Gautier states that, in the body of a 
 woman who had been afflicted with long-continued cardialgia, he 
 saw an abscess of the pancreas which opened into the postei'ior w^all 
 of the stomach. II Portal states that he found the pancreas in a 
 state of complete suppuration in a person who, after having expe- 
 rienced violent paroxysms of gout in the feet, upon their disap- 
 pearance had two or three fits of vomiting, followed by syncope 
 and death.^ Baillie informs us, that he only once met with an ab- 
 scess in the pancreas in the case of a young man of little beyond 
 the age of twenty, and in whom the gland was enlarged in size, 
 and contained a good deal of thin purulent fluid without peculiar 
 characters, unattended by fixed pain in the region of the gland, 
 but with a good deal of pain in different parts of the belly.** 
 
 Dr Playgarth records the case of a gentleman who laboured un- 
 der jaundice, bilious vomiting, and disordered urinary secretion 
 with epigastric pain and swelling, and at length the discharge of 
 blood and purulent matter from the intestines. After three months 
 death took place. The pancreas was found greatly enlarged, oc- 
 cupying the site of the tumour felt during life in the epigastric re- 
 gion. The common biliary duct was obliterated where the pres- 
 sure had been greatest. The gall-bladder was full and the cystic 
 duct pervious. The substance of the pancreas was indurated, and 
 when divided it contained a considerable abscess.ft 
 
 In cases of this nature the suppuration may he either limited 
 and partial, or extensive and destroying the greater part or the 
 whole of the gland. The matter is usually of a gray-white colour, 
 
 * Centuria ii. Hist, xxxix. Tom. i. p. 333. Hafniae, 1654-1657. 
 
 f Anatom. Pract. Cent. ii. Obs. Iv. p. 271. 
 
 J Hist. Anatom. Med. Tom. i. Obs. 1046 and 1060. 
 
 § Nov. Acta. N. C. T. viii. p. 51. 
 
 II J. L. Gautier de Irritabilitatis Notione, Natura, et Morbis. Halse, 1793, § 13, p. 
 129. 
 
 H Anatomic Medicale, Tom. v. p. 352. Paris, 1803. 
 
 •»* Morbid Anatomy in Works by Wardrop, Vol. ii. p. 238 and 240. London, 1825. 
 
 i-f Two Cases of Inflammation and Enlargement of the Pancreas, &c. Transac- 
 tions of Association, Vol. II. p. 132. Dublin, 1818. 
 
SUPPURATION OF THE PANCREAS. 
 
 835 
 
 similar to that of other abscesses ; in a few cases it is greenish. 
 It may be either inodorous or exhale a faint mawkish odour like 
 ordinary matter ; and it has in a few instances been found ex- 
 tremely fetid. In some cases it consists of thin serous fluid with 
 curdly clots ; and it is then conceived to indicate the presence of 
 the strumous diathesis. 
 
 The matter of these pancreatic abscesses is often enclosed with- 
 in a sac or membranous pouch, formed by the cellular tissue either 
 of the pancreas or covering the gland. Portal states that he has 
 seen two pounds of purulent matter contained within the gland. 
 It may open a passage to itself either through the posterior wall of 
 the stomach, through part of the duodenum^ through the colon into 
 its cavity, or into the general cavity of the peritoncsum. 
 
 Portal allows that suppuration is in many cases the immediate 
 eflfect of inflammation of the pancreas. It may be admitted that, 
 in all cases where suppuration has taken place, it is the effect of 
 inflammation ; and the only circumstance of difference is the ques- 
 tion, whether the inflammation is attended with pain and other 
 feelings of uneasiness, or is unattended by these symptoms ? Sup- 
 puration seems always to be a process occupying a considerable 
 time ; and in this point of view it may be said to be chronic. But 
 it appears from the cases recorded, that suppuration or suppurative 
 inflammation is of three kinds at least ; the ordinary, the strumous, 
 and the metastatic. In the two former instances, it must be ad- 
 mitted to be preceded by inflammatory action, however obscure 
 that may be, and however indistinct be the symptoms to which the 
 process gives rise. 
 
 It is chiefly important to observe that inflammatory suppuration 
 of the pancreas does not give rise to well marked symptoms at first. 
 But after some time, that is, when probably the purulent collection 
 has become considerable, and begun by mechanical pressure and 
 distension to affect the physiological properties of the gland and 
 the contiguous parts, fits of vomiting, more or less violent and con- 
 tinued, especially after taking food, take place ; pains of the loins, 
 which have been often mistaken for nephritic or rheumatic pains, 
 and which prevent the patient from lying on his back, ensue ; 
 sometimes pains of the belly, like spasmodic pains (Baillie), are ob- 
 served ; after some time the pulse, which at first was unaflPected, 
 becomes a little quick, — from 80 to 86 ; dyspeptic symptoms, as fla- 
 tulence, cardialgia, and gastrodynia^ are observed, in some in- 
 
836 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 stances with occasional diarrhoea ; the patient appears to derive no 
 nutriment from his food ; and he dies tabid. 
 
 The name of metastatic suppurative inflammation I have applied 
 to denote suppuration of the pancreas occurring under peculiar 
 circumstances, that is, connected with inflammation of veins, usually 
 the hemorrhoidal or spermatic. It was observed long ago, that in 
 the operation of extirpation of a testicle or testicles, and subsequent 
 ligature of the cord to prevent hemorrhage, among other accidents 
 it occasionally happened that a collection of matter was formed 
 within the substance of the pancreas or around the gland, and the 
 same result was observed to take place in the course of various dis- 
 eases of the testicle or its vessels. Antony Petit, especially, who 
 had witnessed several examples of the suppurative destruction of 
 the pancreas, adduces them as arguments against the propriety of 
 practising the operation of ligature of the cord after castration. 
 Portal also informs us that he found in a man dead after extirpa- 
 tion of a testicle and ligature of the spermatic cord, a large quan- 
 tity of purulent matter witliin the cord and round the pancreas. 
 
 The explanation of this singular occurrence is to be found in the 
 fact, that in the old method of inclosing the cord within a ligature, 
 the veins were included, and very often became inflamed and un- 
 derwent the suppurative inflammation. When this took place, the 
 matter formed in the interior of the spermatic veins was transported 
 to various internal organs, sometimes to the kidneys or their ves- 
 sels, sometimes to the lungs, and sometimes to the pancreas, and 
 there deposited. According to this view, it is scarcely requisite to 
 regard inflammation as the necessary preliminary of this suppura- 
 tive deposit, and probably the purulent matter found around or 
 within the pancreas is to be considered as transported from the in- 
 flamed part of the tied vein to the other parts of the venous system, 
 and among others to the pancreas. 
 
 Suppuration of the pancreas has been observed in persons dead 
 of ague, continued fever, fever after the suppression of some ha- 
 bitual evacuation, diarrhoea, hemorrhoids, the catamenia, dropsy, 
 marasmus, convulsions, epilepsy, and hysterid. Regarding the 
 four latter conditions, it is proper to observe, that the state called 
 marasmus is undoubtedly the tabid condition with hectic already 
 noticed, as consequent on the purulent collection within the pan- 
 creas ; and convulsive symptoms are so often observed to ensue on 
 any of the disorganized states of the thoracic or abdominal viscera. 
 
INDURATION OF THE PANCREAS. 
 
 837 
 
 that they are doubtless to be regarded as symptoms rather than 
 preliminary conditions. 
 
 § 4. Scleroma or Indurating Inflammation of the Pan- 
 creas ; SciRRHUS OF RhAN AND MANY OTHER AUTHORS, IMPRO- 
 PERLY. — The pancreas is subject to slow chronic inflammation, which, 
 without tending to suppuration, renders the gland much harder than 
 natural, without, it is said, otherwise changing its structure. All 
 that is meant by this, I presume, is, that the structure is not sen- 
 sibly changed ; for if minutely examined and compared with the 
 sound pancreas, it will be found to be considerably altered. This 
 chronic inflammation, though mistaken for scirrhus, and as such 
 described by Tissot, Storck, Morgagni, Haller, Baader, Rahn, 
 Portal, and others, is quite distinct from it, in so far as it does not 
 present the true scirrho-carcinomatous transformation. It appears 
 to be the same change which has been described by Pemberton 
 under the vague name of Disease of the Pancreas. 
 
 Instances of preternatural hardness of the pancreas have been 
 noticed by Riolan, Charles Le Poix, De Paw, Harder, Cheselden, 
 Haller, Morgagni, Tissot, Baader, and Rahn ; but all have con- 
 founded, under the general name of scirrhus, a change which was 
 evidently the eflFect of inflammation, probably of a chronic cha- 
 racter, acting on the glandular tissue. The observations of these 
 authors appear to have been totally overlooked, at least by Eng- 
 lish physicians. Cheselden had early observed what has often 
 since been confirmed, namely, the effect of the indurated pancreas 
 in compressing, the common biliary duct, and thereby causing fatal 
 jaundice.* But from the time of this author downwards, no at- 
 tempt is made to explain the anatomical characters of these in- 
 stances of scirrhus or induration. Dr Latham had the merit of 
 directing the attention of the profession in 1806 to the symptoms 
 of the disorder, as distinct from disease of the liver and other ab- 
 dominal organs.! 1816, Mr Bedingfield, in speaking of cases 
 of disease of the pancreas, stated, that in a certain class of cases, 
 all attended with dyspeptic symptoms, and often with jaundice, it 
 was found on inspection that the pancreas was always more or less 
 
 * The Anatomy of the Human Body. By Wilham Cheselden. Twelfth Edition.' 
 London, 1784. Book iii. chap. v. p. 166. 
 
 -j- Remarks on Tumours which have occasionally been mistaken for Diseases of the 
 Liver. By J. Latham, M. D., F. R. S., &c. Read 11th Dec 1806. Medical Trans. 
 Vol. iv. p. 47. London, 1813. 
 
838 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 hardened, and sometimes increased in size to the extent of six times 
 its natural hulk.* Mr Todd also described, in 1817, an instance 
 of induration and enlargement, or what must now be called hy- 
 pertrophy of the pancreas, pressing the common gall-duct ;f and 
 Dr Percival and Dr Crampton recorded, in 1818, examples of the 
 disorder attended with unusual compression of the same duct and 
 the symptoms of jaundice.| 
 
 From the dissection recorded by Dr Crampton, it may be in- 
 ferred that inflammation attacking the pancreas renders that gland 
 harder, and larger or more tumid than usual, and that, either in 
 consequence of this tumefaction, it compresses and obstructs the 
 common gall-duct, or the inflammatory action extending to the 
 surrounding parts produces a morbid effusion, which gives rise to 
 the same result. 
 
 Since the time of Dr Crampton, many instances of different de- 
 grees of induration of the pancreas, sometimes alone, more com- 
 monly along with affections of the duodenum or other abdominal 
 organs, have been recorded by Dr Heineken, Dr Bright, Dr Wil- 
 son, Dr Holscher, Dr Ritter, Dr Landsberg, and other observers, 
 all of which tend to show that induration of the pancreas is not a 
 very uncommon disease ; and that this induration, though usually 
 denominated scirrhus, is either the effect of inflammation or accom- 
 panies that process. 
 
 From the cases recorded by these authors, it results that, though 
 induration may affect any part of the pancreas, or the whole of 
 that gland, yet most usually it is the head of the organ, that is in- 
 durated ; and at the same time it may be enlarged. 
 
 The pancreatic substance is then hard and cuts firm, grating on 
 the knife. 
 
 In some cases it is stated to be like cartilage ; in others like the 
 boiled udder of the cow. Usually there are adhesions or recent 
 lymph connecting the pancreas to other adjoining parts. The lo- 
 bulated acinoid structure is not always very manifest. Ritter 
 
 * Compendium of Medical Practice. 
 
 + History of a Remarkable Case of Enlargement of the Biliary Ducts. By Charles 
 H. Todd, M. R. C. S. Dublin Hospital Reports and Communications, Vol. i. p. 325. 
 Dublin, 1817. 
 
 J Two Cases of Inflammation and Enlargement of the Pancreas. By Edward Per- 
 cival, M. B., M. R. I. A., Bath. Read 1st June 1818. Transactions of the Associa- 
 tion of the Fellows and Licentiates of King and Queen College of Physicians in Ireland, 
 Vol. ii. p. 128. Dublin, 1818. Additional Cases, by John Ciampton, M. D., &c. 
 Ibid. p. 134. 
 
INDUEATION OF THE PANCREAS. 
 
 839 
 
 states, that in a case observed by him it was no longer cognizable. 
 In other instances, however, I am satisfied, from what I have my- 
 self seen, that these bodies are certainly not less distinct than be- 
 fore. The change, of which they are the seat, is effusion of lymph, 
 which becomes coagulated. This effusion takes place both into 
 their interior, and externally between the acini and lobules ; and 
 when the exudation becomes consolidated, the whole is converted 
 into a hard, firm cartilage-like mass. 
 
 In some instances the head or duodenal end of the pancreas is 
 thus indurated and enlarged, and at the same time the left or sple- 
 nic end may be hardened, while the middle portion is comparatively 
 healthy and natural in structure. 
 
 The duodenum is very generally rough, irregular, and compres- 
 sed ; its interior capacity is diminished ; and its mucous membrane 
 is vascular. 
 
 With this induration of the pancreas, not unfrequently are asso- 
 ciated more or less disease in the duodenum, as chronic ulceration,* 
 thickening, and similar changes in the beginning of the jejunum. 
 
 The following instance, given by Cruveilhier, from an infant born 
 at full time, shows that the disease may take place in the foetus. 
 The pancreas presented a lardaceous appearance, like the structm-e 
 of a scirrhous mamma, without distinction of glandular grains. The 
 antero-posterior diameter was as great as the vertical diameter. 
 The size of the splenic or left end was as great as that of the right 
 or head. The pancreas adhered to the supra-renal capsule and the 
 right kidney. 
 
 I think it is hardly possible to doubt that the whole of the cases 
 now referred to are instances of chronic inflammation of the pan- 
 creas. It is quite clear that they cannot in all instances be regard- 
 ed as scirrhus ; for several of the cases mentioned are stated to have 
 been instances of bad health, with symptoms of pancreatic disease, 
 from which the patients recovered. Thus Dr Percival gives one 
 case of this kind, in which recovery took place under the employ- 
 ment of local blood-letting, blistering, restrained diet, and the use 
 of aperients. Dr Crampton gives one case, in which recovery was 
 effected under the same measures. Dr Landsberg gives an instance 
 of what he calls Tabes Pancreatis, in which, after about rather 
 more than three months, the patient got well under the succes- 
 sive use of mercury, and mercurial and iodine ointment, and 
 the foot-bath of nitro-muriatic acid. In other two cases, to which 
 
 * Two of the eases given by Dr Bright. 
 
840 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 lie applies the name of Pancreatitis chronica, recovery took place in 
 like manner, under the use of foot-baths of mineral acid, (appa- 
 rently the hydrochloric,) which were followed after a short time by 
 critical diarrhoea.* 
 
 Another circumstance, showing that these must have been in- 
 stances of chronic congestion or inflammation, is that most of them 
 took place in persons comparatively young. The patient of Dr 
 Haygarth was middle-aged. In one of the fatal cases of Dr 
 Crampton, the age was 35. In another favourable case it was 32. 
 In Dr Landsberg’s first case the age was 42, in the second 30, in 
 the third 22. 
 
 The effects of this change of structure are of two kinds ; one 
 order in the adjoining organs ; another in the function of digestion 
 and the general health. 
 
 Those in the contiguous organs are anatomico-pathological, and 
 have been in some degree referred to already. The most common 
 are adhesions with the duodenum, the right kidney, the jejunum, 
 and in some instances with the gall-ducts and gall-bladder. 
 
 Next to these come compression of the gall-ducts, and usually 
 jaundice. 
 
 The aorta may be compressed; but the vena cava and vena jjor- 
 tae are most frequently so. The result is ascites. 
 
 The duodenum, however, is the organ that suffers most in all this 
 mischief. Its calibre is contracted ; the inner surface is excited and 
 injected ; and its first curvature is so much obstructed, that a sense 
 of painful distension, fiatulence, and acid eructations are common 
 and almost constant results. 
 
 There seems no doubt that this induration may proceed to ulce- 
 ration ; and in this way ulceration usually takes place at the head 
 of the gland, and finds its way into the duodenum. Though in 
 strict pathological language this ulceration is not properly malig- 
 nant, yet to all practical purposes it is sufficiently so to he regarded 
 incurable. It almost never heals when it has once begun. It pro- 
 ceeds destroying the gland, very much like chronic ulceration of 
 the stomach. The havoc then found after death has made most of 
 the cases be denominated scirrhus of the pancreas. 
 
 The effects on the digestive function are very serious. It is 
 
 * Einige Bemerkungeii iiber Krankheiteii lies untcni Magcnnuindes unci cler Baiicli- 
 speicheklriise. Vem Dr Landsberg ijract. Arzte zu Alunsterberg in Schlesien. C. 
 Ilufelaud’s .Journal dor Practisdieii Heilkunde. Fcrtgesetzte von Dr E. Osaiin. 
 lolO. Siebonter Stuck .Tali, (xci. Bud.) 
 
INFLAMMATION OF THE PANCREAS. 
 
 841 
 
 unfortunate that Rahn, who has given the fullest collection of 
 cases of induration of the pancreas, has not distinguished the 
 disorder from scirrhus, properly so named, and has even given as 
 instances of the latter, cases in which tumours, more or less ex- 
 tensive, were formed from the mesenteric and meso-colic glands, 
 and had then implicated the pancreas. It hence results, that it is 
 impossible to attach to his history of symptoms that importance 
 which a correct critical semiographical account deserves. It is im- 
 portant to know, however, that he mentions the following as pre- 
 sent in most of the cases. 
 
 1. Pains between the ensiform cartilage and navel, at one time 
 occupying the middle region of the belly and stretching to the 
 spine, and at another the right or left hypochondriac region. 2. 
 Tumour in the same region, easily palpable by the finger, hard, 
 moveable, causing a sense of weight while the patient stands or 
 walks, most painful above the lumbar vertebras, with great precor- 
 dial anxiety, especially after taking food or drink. 3. A sense of 
 burning in the stomach, not temporary but constant, with a painful 
 sense of soreness and heartburn spreading into the oesophagus, with 
 frequent eructation of a watery, tasteless, or acid fluid which re- 
 sembles saliva. 4. Constipation. 5. Anorexia, squeamishness ; 
 and, 6. Eventually vomiting occurring at uncertain intervals, 
 bringing up ingesta and ropy phlegm ; and at length, 7. wasting 
 ( tabes J and hectic fever with all their attendant symptoms. 
 
 The chief objections to this history are, that the same series of 
 symptoms is liable to take place in various disorders of the stomach, 
 the duodenum, and the liver ; that the pancreas is sometimes found 
 indurated without any of these symptoms having taken place ex- 
 cepting the pain and occasional vomiting ; and that the circum- 
 stance of palpable tumour is often wanting, and when present is 
 not pathognomonic. 
 
 The principal symptoms, judging from the cases recorded by 
 the best observers, are deep-seated pain in the region of the 
 stomach, more or less sickness, sometimes vomiting, with ema- 
 ciation, general languor, fever especially in the night, and in gene- 
 ral a yellow or jaundiced colour of the skin. The urine is in ge- 
 neral scanty and high-coloured ; and though the bowels are gene- 
 rally confined, and dyspeptic symptoms are common, sometimes 
 diarrhoea takes place and proceeds to a considerable degree, appa- 
 rently with salutai'y effect. Wedekind, who observed this symptom. 
 
842 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 absurdly ascribed it to a milder degree of pancreatic inflammation, 
 or, as Gautier expresses it, to increased irritability of the pancreas. 
 It may, however, be regarded as a law of inflammation of glandu- 
 lar tissue, that, in the early stage, the secretion is diminished or 
 suppressed, and that, if it seem to be augmented in the latter stage, 
 this is rather the effect and the proof of the. subsidence of the in- 
 flammation and its final disappearance than of increased action. 
 
 In one case of this disorder, in which I had an opportunity of in- 
 specting the parts after death, I observed the progress of the disease 
 for months. The patient, a female of about 48, continued ill for seven 
 or eight years, with pain in the epigastric region, and more urgently 
 unwell for about two years, with pain and tenderness in the same 
 part, frequent attacks of sickness and vomiting, occasional diarrhoea, 
 constant headach, a pulse varying from 88 to 96, most usually at 
 92, rather full, and hot dry skin, though pale, blanched, and at 
 length leucophlegmatic complexion. The pain, which was most 
 felt in the epigastric, and towards the right hypochondriac region, 
 was so urgent, that the slightest and gentlest pressure could not be 
 borne ; it was constant, and underwent no remission ; was distinctly 
 i-eferred to the region specified by the patient herself ; and was 
 always relieved by local bleeding, and occasionally by general 
 blood-letting. The effect of opiates was immediate but temporary, 
 that of counter-irritation by blister or tartar-emetic ointment more 
 permanent. As the disease proceeded, the fits of vomiting became 
 more frequent and urgent, and were accompanied with distressing 
 hiccup ; nothing was retained ; the patient wasted, and became 
 waxy-coloured and leucophlegmatic ; and life was maintained for 
 some time by nutritious enemata with opiates. Though the ema- 
 ciation was not visibly extreme, yet the pale waxy appearance of 
 the surface and transparency of the skin, showed the imperfect and 
 scanty degree of nutrition. Death took place apparently by ex- 
 haustion and inanition. 
 
 It was then found that the pancreas was exceedingly hard, al- 
 most like a stone, a little enlarged, but not positively altered in 
 structure. It resisted the knife like firm cheese or cartilage. The 
 acini, which were the parts mostly altered, were of a reddish-gray 
 colour, very close in texture, and extremely firm. It seemed. ra- 
 ther less vascular than usual. This body was felt during life, and 
 it never could be pressed or handled without causing much pain. 
 
 The gall-bladder w'as greatly distended, — a circumstance which 
 
 1 
 
INDURATION OF THE PANCREAS. 
 
 843 
 
 showed that the pancreatic induration had compressed the common 
 biliary duct. 
 
 In general, when wasting is far advanced, the gland may be felt 
 more or less distinctly by slight pressure on the belly, which is also 
 attended either with pain or tenderness. In earlier stages of the dis- 
 ease the most eflFectual mode of ascertaining the state of the pancreas 
 is to make the patient lie prone on the belly, getting him supported 
 so as to allow the hand of the physician to examine the abdomen. 
 If in this position the patient be examined carefully, in general it 
 is possible to recognize not only a painful region, but some swell- 
 ing. 
 
 Induration of the pancreas is attended, after some continuance, 
 either with a leucophlegmatic appearance and anasarca, or with 
 dropsy of the belly, which, though not an invariable consequence, 
 may supervene ; and in every case of ascites^ in which the liver does 
 not appear to be indurated or enlarged, or affected with cirrhosis, 
 or the kidneys are known not to be diseased, it may be apprehend- 
 ed that the pancreas is indurated and compressing some of the veins, 
 either the vena cava or some of its branches. 
 
 In some individuals induration of the pancreas appears to give 
 rise to that anomalous assemblage of symptoms called hypochon- 
 driasis ; and probably in this manner we are to explain the fact 
 mentioned by Baillie, that in one instance there were pain in the 
 hips and a sense of numbness in one thigh or leg. Difficulty and 
 pain in stooping are also not unfrequent symptoms. It must not 
 be omitted that this disease is sometimes one of the lesions found 
 in the bodies of the insane. 
 
 These statements are, it must be admitted, not satisfactory ; and 
 their chief use is to show the extreme difficulty of recognizing the 
 presence of this disease during life, at a period sufficiently early 
 to enable us to form a correct and useful diagnosis. This 
 difficulty led Pemberton to conclude, that it is chiefly by nega- 
 tive reasoning that the physician must infer the existence of dis- 
 ease of the pancreas ; that is, if in a case in which there is deep- 
 seated pain in the epigastric region, and more or less sickness and 
 emaciation, the patient does not at the same time present the other 
 symptoms denoting the presence of primary disease of the stomach, 
 of the posterior part of the liver, of the gall-bladder or ducts, or of 
 the small intestines, he may infer the evidence of disease, that is 
 chronic inflammation, of the pancreas. 
 
844 
 
 GENERAL AND RATHOLOGICAL ANATOMY. 
 
 To one symptom, which, if constant, must he important. Dr 
 Bright, in 1832, directed attention. This consists in the discharge 
 of oily or fatty matters from the howels in certain affections of the 
 pancreas. In three cases in which the pancreas was considerably 
 indurated, and had contracted 6rm adhesions with the adjoining 
 parts, with ulceration in the duodenum, there were diseharged from 
 the howels, with the usual matters, a quantity of material like 
 melted grease or tallow, and whieh was ascertained, hy chemical 
 examination, to be either adipocire or stearine. Dr Bright has 
 been led, from various facts, to connect this symptom with disease, 
 probably malignant, of that part of the pancreas which is near to 
 the duodenum, and ulceration of the duodenum itself.* There is 
 no doubt that the suspension of the pancreatic secretion must exert 
 great influence on the process of duodenal digestion ; but it has 
 not been proved by subsequent cases that this oily or fatty dis- 
 charge never takes place without disease of the pancreas.! In 
 other cases the pancreas was merely indurated. 
 
 § 5. Hypertrophy. — Enlargement of the pancreas as an effect 
 either of chronic inflammation or of over-nutrition, is often associated 
 with induration ; but may take place with a natural state of the con- 
 sistence of the gland. When the gland does become enlarged in this 
 manner, it is almost superfluous to say that the lesion causes more 
 or less of a firm, solid, tumid mass in the epigastric region. The 
 hulk which the hypertrophied gland attains varies in dift’erent cir- 
 cumstances, chiefly according to the duration of the disorder. 
 Riolan mentions a case in which it was as large as the liver, (Rio- 
 lani Anthropographia) ; in a person tnentioned by Tissot, its size 
 was three times the natural size, (De Melaena et Morbo Nigro); 
 and in a woman seen by Storck, it is said to have been so large as 
 to weigh thirteen pounds. In the case of a woman of forty years, 
 detailed by Rahn, the gland measured nine inches long and seven 
 broad, and weighed a little above four pounds, and its internal 
 structure was like lard. Westenberg describes a case in which the 
 
 * Cases and Observations connected with Disease of the Pancreas and Duodenum. 
 By Richard Bright, M. D., &c. Medico-Chirurgical Transactions, Vol. xviii. p. 1. 
 London, 1833. 
 
 Case of Jaundice with Discharge of Fatty Matter from the Bowels, &c. By E. 
 A. Lloyd, Esq. Ibid. p. 57. 
 
 On the Discharge of Fatty Matters from the Alimentary Canal and Urinary Pas- 
 sages. By John Elliotson, M. D., &c. Medico-Chirurgical Transactions, Vol. xviii. 
 p. 117. London, 1833. 
 
SOFTEN^JG OF THE PANCREAS. 
 
 845 
 
 gland weighed six pounds. The natural weight varies from one 
 ounce and a half to six ounces. 
 
 In some instances the hypertrophy is only partial, and it then 
 affects chiefly the right side of the pancreas, which may attain the 
 size of the fist, while the left side is natural. (Rahn, cases 4th, 
 5th, 6th, 11th, 12th.) A common result, then, is pressure upon 
 and obstruction of the common biliary duct, and consequent dis- 
 tension of tbe gall-bladder, and, if the obstruction be complete, a 
 jaundiced colour of the surface. 
 
 Dr Holscher records an instance, in a man of 48, otherwise 
 stout and healthy, in whom the enlargement, by compressing the 
 duodenum^ caused contraction or stricture of that bowel, and fatal 
 ileus. The duration of the symptoms of epigastric pain was eight 
 months ; but the symptoms of ileus continued not longer than six 
 days. Dissection presented no marks of inflammation. But the pan- 
 creas was void of its normal granular condition, soft, succulent, and 
 fleshy ; its sections presented neither tubercular matter, nor any 
 formation like scirrbus, or encepbaloma ; but it was enlarged to the 
 size of a foetal head of four months ; and it had so closed the duo- 
 denum for the space of three inches, that the contracted portion 
 did not admit a goose-quilh* 
 
 This enlargement appears to be of the same nature as that which 
 is observed to affect other secreting glands, as the mamma, the tes- 
 ticle, and the liver. In general the individual lobes and acini may 
 be observed to be perceptibly enlarged ; and usually large and nu- 
 merous blood-vessels are observed entering tbe gland. The en- 
 largement seems to depend on additional matter deposited in the 
 interstitial spaces of the acini^ and perhaps into their substance. 
 
 The case mentioned by De Haen, in which he represents the 
 pancreas to have degenerated into numerous scirrhous tumours of 
 various size, closely cohering to each other, may belong to this 
 head. Does the change bear any analogy to the early stage of 
 cirrhosis of the liver ? 
 
 In some cases the gland is enlarged and resembles lard or suet. 
 In such circumstances the change probably belongs to encepha- 
 loma. 
 
 § 6. Malakosis. Softening. — Softening or diminution of con- 
 
 * IMedizinische, Chinirgische und Ophthalmologische tVahrnehmungen. I'on Dr 
 Holscher. Haimoversche Annalen fur die ges. Heilkunde v. Band 2. Heft, 1841. 
 
846 
 
 GENERAL AND PATHOLOGlft^L ANATOMY. 
 
 sistence is observed under certain circumstances to take place in 
 the pancreas. If attended with increase of size, this may be regard- 
 ed as the eflPect of inflammation. In other instances, for example, 
 in persons labouring under scurvy, in cachectic persons, and after 
 several eruptive disorders, especially small-pox and scarlet fever, 
 it seems doubtful whether the diminished consistence can be as- 
 cribed to inflammatory orgasm. Portal states that he found it 
 much softened without being reddened or swollen, in two children 
 cut off by measles ; and in the body of a young man between fif- 
 teen and eighteen years, who died on the tenth day of confluent 
 small-pox. 
 
 When the pancreas is softened, its texture is loose, soft, easily 
 lacerable, of a yellowish gray or yellowish green colour, and seems 
 permeated by dirty purulent matter. 
 
 When the tissue is reduced to a soft, greenish-coloured foetid 
 pulpy mass, it is believed to constitute gangrene of the pancreas, — 
 a very rare affection. A case is mentioned by Portal.* I have 
 seen the pancreas in this state, of a pale brick-red colour, the acini 
 still a little firm, but softened all round their margins, and with 
 purulent matter oozing from the interstices of the gland. It seems 
 difficult, therefore, to say, whether the change described as soften- 
 ing of the pancreas is to be regarded as a species of diffuse suppu- 
 ration, or as gangrene. 
 
 Dr Holscher gives a case, in which a person who had been dys- 
 peptic from his 30th year, began in his 39 th to suffer extremely 
 from violent constriction in the region of the transverse arch of 
 the colon, and afterwards from squeamishness, acidity, and sore 
 aphthae in the mouth and tongue, with great emaciation. In the 
 course of twelve months more, after various oscillations, these 
 symptoms terminated fatally. There was then found, one inch 
 and a-half beyond the pylorus, in the duodenum, an ulcer larger 
 than a shilling, with slightly everted edges, surrounded with many 
 blood-vessels, and which had proceeded to perforation about the 
 size of a pea. The pancreas, void of its usual granular structure, 
 seemed partially fleshy, bore some resemblance to the thymus 
 gland of a three months’ infant ; was softened and very abundant 
 in blood-vessels, which, when divided, effused blood copiously. 
 
 In this case the pancreas appears to have been softened, and to 
 
 * Anatomie Medicale, Tome v. p. 354. 
 
ATROPHY ; — CONCRETIONS OE THE PANCREAS. 
 
 847 
 
 have lost its characteristic lobulo-graiiular structure, in consequence 
 of, or along with increased vascular distension.* 
 
 § 7. Atrophy of the pancreas or diminution of its size, sometimes 
 with, sometimes without, condensation and induration of its sub- 
 stance, may be regarded as one of the effects of enlargement and 
 hypertrophy of some one of the other abdominal viscera, for in- 
 stance the stomach, the liver, spleen, or the right kidney. The pan- 
 creas is also in general diminished in size, in chronic inflammation 
 and ulceration of the intestines. It is not so much an effect of in- 
 flammation, as of the opposite state of diminished supply of blood 
 for nutrition. By some, however, it is regarded as a remote eflPect 
 of inflammation, which has either been partially cured, or has pro- 
 ceeded to suppuration, and the matter of which has been discharged. 
 
 This is the most convenient place to mention, that the arteries of 
 the pancreas have been found ossified. This takes place chiefly 
 when the abdominal aorta and the coeliac and mesenteric arteries 
 are aflPected by osteo-steatomatous deposition. The most characte- 
 ristic case is the following. A shipmaster, aged 59, and who had 
 been 37 years at sea, had always enjoyed good health. All at 
 once, however, he began to suffer from headach, anorexia, squeam- 
 ishness, thirst, a sense of burning heat, following the course of the 
 oesophagus, and constipation. Emaciation speedily followed ; and 
 at the end of six weeks, death. Upon inspection the pancreas was 
 found small, shrivelled, dense, of a deep gray colour. Its excretory 
 duct was obliterated ; and all the arteries, viz. the small branches 
 of the splenic, the pancreatico-duodenal, and those from the supe- 
 rior mesenteric were ossified.! 
 
 It is not improbable that the morbid condition of the arteries was 
 in this case the cause of the atrophy. 
 
 It will be seen from the subsequent head, that the pancreas may 
 be shrunk and rigid when the ducts are filled with calcareous mat- 
 ter. It would be wrong to consider these two circumstances in the 
 relation of cause and effect. But we may infer that there are two 
 conditions or forms of atrophy of this gland ; one in which it is 
 shrunk, shrivelled, and indurated, and another in which it is small, 
 yet softened. 
 
 * Medizinische, Chirurgische und Ophthalmologische AYahrnehmungen. Von Dr 
 Holscher. Hannoversche Annalen fiir die Gesammte Heilkunde v. Band ii. Heft 5 
 Falle. S. 328-369. 
 
 ! Lancet, Vol. ii. No. 680. ■ 1835-36, 10th September, p. 82.5. 
 
 / 
 
848 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 § 8. Concretions. — Concretions are said by Baillie, who had 
 known only one example, to be a rare lesion. Yet they have been 
 observed in the pancreas or its ducts by several. Instances are given 
 by Van der Wiel, Panaroli, Matani, Ten Rhyne, Eller, Sandifort, 
 Portal, Cowley, and lastly by Dr Arthur Wilson and Dr Adam 
 Schupmann. Dr Wilson found the pancreatic ducts in a man of 
 41, universally filled with compact white earthy matter, which, 
 examined chemically, was found to contain almost pure carbonate 
 of lime on a nucleus of animal matter. The pancreas itself was 
 hard and shrunk, in short atrophied.* Dr Schupmann found in 
 the main duct of the tail of the pancreas, in a man of 57, a concre- 
 tion one inch and six lines long, weighing three drachms and one 
 scruple. In the lateral ducts were two smaller concretions. These 
 consisted of carbonate of lime, with animal mucus, and traces of 
 phosphoric acid.f 
 
 This fact as to chemical constitution corresponds with the result 
 of other analyses. 
 
 § 9. Heterologous Growths, a. Scirrhus. — Of these the 
 most common in the pancreas, if we can trust the statements of 
 authors, is indubitably scirrhus, or the common fibro-cartilaginous 
 cancer. An immense number of instances under this denomination 
 are recorded by authors. But when we consider these cases, we 
 find no details as to the facts, on which they were referred to that 
 head ; and all that we learn is, that either the pancreas is said to be 
 affected with scirrhus, on the testimony of the observer, — or it is 
 stated that the gland is very hard. 
 
 It is impossible, therefore, to avail ourselves of the cases record- 
 ed by old observers in this matter ; and it seems to me doubtful 
 whether we can ascend to a more remote period than the last twelve 
 or thirteen years for evidence as to the pancreas being affected 
 with scirrhus. 
 
 From various cases recorded by Mondiere, Holscher, Ritter, 
 Battersby, and other authors, excluding those cases which are doubt- 
 ful or referable to the head of induration, I think the following 
 inferences may be established. 
 
 Scirrhus does not very frequently attack the pancreas primarily. 
 Much more frequently it appears rather to extend from the stomach t 
 
 * An account of a Case of Extensive Disease of the Pancreas. By Janies Arthur f 
 Wilson, M. D., &c. Medico-Chirurgical Transactions, Vol. xxv. p. 42. Iiondon, 1842. 
 
 -}• C. W. Ilufeland’s Journal. 1841, April, xcii. Bd. 
 
HETEROLOGOUS GROWTHS — SCIRRHUS OF THE PANCREAS, 849 
 
 or duodenum to that gland, or it involves that gland in common 
 with other organs. Holscher gives two cases, one of which he calls 
 scirrhus of the pancreas, the other cancerous degeneration of the 
 pancreas. In the former he describes the gland as greatly ex- 
 panded and developed, and so cartilaginous that it could scarcely 
 he cut by the knife. It retained, nevertheless, its granular struc- 
 ture. This case, therefore, is doubtful. In the second, he states 
 that however much the pancreas may be disposed to scirrhous de- 
 generation, it nevertheless resists the operation of the carcinoma- 
 tous process in the neighbouring organs ; and among 60 cases of 
 cancer of the stomach, in two only did the pancreas partake of the 
 morbid action. One of these was in a man of 80 years, in whose 
 body the pancreas was found little enlarged, but containing, dis- 
 persed through its substance, knotty tuberosities, which, when di- 
 vided, showed a fibro-cartilaginous structure, with intermixture of 
 dull streaks, and several of which had proceeded to softening. 
 The softened portion was like dissolved cheese, and exhaled a pe- 
 culiarly disagreeable odour. One of these tubercular elevations 
 was opened by an ulcerative process advancing from within, and 
 had elevated bloody edges covered with some thin fetid ichor. It 
 had not proceeded to the formation of fungi. The carcinomatous 
 pancreas had contracted adhesions with the neighbouring organs.* 
 This bears much more the character of a heterologous growth, and 
 appears to have been an instance of tubercular scirrhus. 
 
 In the case of a married female of 40 years old, and who, after 
 suffering for months under pain in the epigastric region, anxiety, 
 squeamishness, and vomiting, with great emaciation, died, inspection 
 presented the following state of parts ; — the stomach normal as far 
 as the indurated portion of the pylorus ; but the pancreas indu- 
 rated, enlarged to twice its proper size ; its lobular structure obli- 
 terated ; the parenchyma hard and solid, yellowish-white in colour ; 
 the duct of Wirsung and the hepatic vessels pervious ; the former 
 filled with a viscid liquid. The pancreas was morbidly adherent 
 before and behind.f 
 
 Dr Engel found in the body of a female who died in her 65th 
 year, after vomiting and intestinal discharges of dark-coloured 
 matters with emaciation, besides an ulcer in the stomach and one 
 in the duodenum, immediately beyond the pylorus, which was 
 
 * Medizinische, Chirurgische und Ophtlialmologische Wahrnehmungen. Hanno- 
 versche Annalen, v. Band. 2 Heft. 1841. 
 
 t Scirrhosc Verhartung des Pancreas. Von Ritter, Medizinische Zeitung. 1. 1840. 
 
 3 H 
 
850 
 
 GENERAL AND rATIlOLOGlCAL ANATOMY. 
 
 covered by the pancreas, the pancreas as large as a fowl’s egg, 
 with an uneven, solid fibrous covering, pale, bloodless, with an ir- 
 regular fibrous structure, with many eminences larger than peas 
 at the surface, in which was found a jelly-like brain-like matter. 
 The acini were completely compressed. Right in the middle of 
 the largest eminences were roundish bands, which might be traced 
 to the pancreatic duct. The latter, normal in diameter, was buried 
 deep in the mass, had thick, rigid, resisting walls like those of ar- 
 teries ; but upon quitting the mass now mentioned became suddenly 
 large, flaccid, and with thin walls. 
 
 If these bodies were of medullary structure, as Dr Engel seems 
 to think, then this was rather an example of encephaloid than scir- 
 rhous pancreas. He allows that the ulcers in the stomach and 
 duodenum were not cancerous but simple. 
 
 The same observer found in the body of a female dead with 
 symptoms of intense jaundice in her 76th yeai’, the pancreas small, 
 very firm and solid ; the excretory fluct more than a goose quill in 
 calibre, with many prominent valve-like processes in the interior, 
 and filled with a gray coarse frothy fluid; at the head, however, 
 directed outwards, of normal calibre and condition.* 
 
 A case given by Dr Battersby is entitled to attention from the 
 correctness of its details. In a widow lady, aged 60, who, after 
 suffering for twelve months from pains regarded as rheumatic, be- 
 came much emaciated, a tumour about the size of an orange ap- 
 peared in the epigastric region, and which was the seat of pulsation. 
 
 In the course of one or two months the tumour subsided ; but ema- 
 ciation proceeded ; dropsy followed ; and death took place. 
 
 The gastro-hepatic epiploon, especially that part in front of the ^ 
 foramen of Winslow^, was very dense, hard, and thickened ; and 
 the vessels and ducts were intimately cemented together. This 
 thickening and hardening affected the cellular tissue surrounding 
 the cardiac orifice of the stomach, which resisted the introduction 
 of the little finger. The stomach was universally connected with 
 the left extremity of the pancreas, which was hard and enlarged, 
 and had lost every trace of its natural structure. Near the centre 
 of this gland was a thin translucent horny cyst, which was slightly 
 prominent, about the size of a walnut, and lay directly over the 
 
 * Nachti'iig zu den Krankheiten des Pancreas und seines Ausfahrungsganges ; 
 von Dr Joseph Engel. Medizinische Jahrbucher des K. K. Osterreich. Staates. xxxiii.’'S 
 Band oder xxiv. Band N. Folge, 1842. 
 
HETEROLOGOUS GROWTHS — SCIRRHUS OF THE PA^^CREAS. 851 
 
 aorta. Its base was surrounded by a hard cartilaginous scirrhous 
 structure partly projecting into it. The rest of the gland consist- 
 ed of less solid yet unyielding heavy substance, composed of dense 
 closely interwoven membranous bands. 
 
 The pancreatic duct was pervious for about one inch only from 
 the duodenum. The ductus choledockus and hepatic ducts were 
 pervious.* 
 
 The pancreas is liable to be involved in the heterologous struc- 
 tures of other parts. Thus it may be involved in new heterologous 
 structure, arising either in the interperitoneal cellular tissue, or in 
 the mesenteric glands, or in the pylorus, or in the duodenum. In 
 the 7 th case given by Dr Bright the pancreas was involved for a great 
 portion of its space in a new growth which had atfected the liver 
 and the whole of the abdominal absorbent glands.f And in a case 
 given by Schupmann, in which cancer affected the pylorus and 
 pancreas, the head of the latter gland was enlarged to three times 
 its usual size, while the gland 'itself consisted of separate masses 
 mutually connected, longish, from the size of a hazelnut to that of 
 a walnut, and the interior structure of which was hard and gristly- 
 like.| No ulceration had yet taken place. But the mesenteric 
 glands had partaken in the disease, and were firmly united to the 
 pancreas. 
 
 In all cases of scirrhus affecting the pancreas, the lobulo-granu- 
 lar structure of the gland is either greatly or entirely obliterated. 
 The acini are so much changed, that the granular character can- 
 not be recognized. In the place of this there is substituted more 
 or less of the following structure. First, there may be deposited 
 a hard homogeneous matter of whitish gray colour, and as firm as 
 cartilage, which is diffused in amorphous portions varying in size 
 through the gland. These masses are traversed by bluish-white 
 lines of firmer matter, which look like fibrous bands. Secondly, 
 there may be deposited the same substance in the form of tubercles 
 or nodules, varying in size from a small pea to a bean. Both of 
 these forms of new deposit tend to softening. 
 
 § 10. Encephaloid Disease. — On this point information is not 
 
 * Two Cases of Scirrhus of the Pancreas, &c. by Francis Battershy, M. B. Dublin 
 Journal, vol. sxv. p. 219. Dublin, 1844. 
 
 t Cases and Observations connected with Disease of the Pancreas and Duodenum, 
 Medico-Chirurg. Transact., vol. xviii. p. 36. London, 1833. 
 
 + Pfdrtner und Pancreas-Krebs, von Dr Ad. Schupmann, W. C. Hufeland, Journal 
 der Practischen Heilkunde Sechsfes Stuck. Juni 1840. 
 
852 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 more precise than on that of common scirrlms. Ihave already allud- 
 ed to one case which probably is to be referred to this head ; and 
 hitherto almost all have been considered as belonging to one cate- 
 gory. The instances of adipification, or rather lardaceous degene- 
 ration, mentioned by Lobstein and Dupuytren, appear to belong to 
 the present head. Bang records in his reports the case of a soldier 
 of 40, in whom, for at least half a year, much pain had been felt in 
 the middle of the abdomen, followed by loss of appetite, constipation, 
 and wasting, and for two months considerable swelling in the loft 
 hypochondre. In the course of six weeks more, after great ema- 
 ciation, death took place ; when, besides much bloody serum con- 
 tained in the abdomen, the liver was found occupied by white stea- 
 tomatous tumours, (manifestly encephaloid) ; and the pancreas, 
 which was enlarged to the size of the head of a child, consisted of 
 large glandular tumours, in various parts suppurated and emitting 
 an offensive odour, with extravasated dark putrid blood. This 
 Bang denominates cancer of the ‘pancreas. It appears to have 
 been either encephaloma or chronic strumous suppuration.* 
 
 It seems doubtful, indeed, if encephaloid disease frequently ori- 
 ginates in the pancreas. It often arises in the liver, and thence 
 spreads to the stomach, duodenum, and pancreas ; and it often also 
 arises in the interperitoneal cellular tissue. In this manner I have 
 more than once seen encephaloid tumours developed in the abdo- 
 men and affecting successively many different organs. In cases 
 of this description globular masses of whitish semihard matter like 
 granular suet or cheese, varying in size from a walnut to an orange, 
 appear involving and penetrating the mesentery, the intestines, the 
 pancreas, the liver, and not uncommonly the ovaries in the female. 
 It must, nevertheless, be observed, that, amidst these masses of new 
 (leposite, it is usually possible to find the substance of several or- 
 gans less injured than might be expected. Amidst this new struc- 
 ture, the pancreas is in general found, compressed and concealed, 
 but retaining its characteristic granular structure. 
 
 Of the changes and combination of changes now mentioned, ex- 
 amples are given in almost all pathological collections. Thus, both 
 in the museum of Mr Langstaff, and in that of St Bartholomew’s 
 Hospital, when the pancreas presents medullary or encephaloid tu- 
 mours, the same are found in the brain, in the kidneys, in the liver, 
 or in the interperitoneal tissue. 
 
 * Selecta Diarii Nosocomii Regii Fridericiani Haviiiensis. Auctore F. Lud. Bang. 
 Hafniae, 1709, ii. p. 409. 
 
TYROMA. — MELANOSIS. 
 
 853 
 
 § 1 1. Tyroma. — D oes tubercular structure affect this gland? In 
 some instances it is possible to recognize in it small bodies with the 
 aspect of tubercles, when the spleen and the peritonaeum are affect- 
 ed by these growths. At the same time, that the lesion is not very 
 frequent may be inferred from this fact, that in tubercular disease 
 of the lungs, when the intestines are also much affected, the pan- 
 creas is most rarely affected by the same or any similar deposit. 
 It is necessary, however, to distinguish between strumous and scir- 
 rhous tubercles. The latter, that is, scirrhus in the tubercular form, 
 are seen occasionally ; the former very seldom, 
 
 § 12. Melanosis seems to be more frequent than tubercle in the 
 pancreas ; yet much less so than either scirrhus or encephalorna. A 
 good example of the deposite is given by Langstaff in the third vo- 
 lume of the Medico-Chirurgical Transactions, and the original of 
 which is preserved in his museum, (now in the College of Surgeons.) 
 In this instance the disease affected the brain, liver, intestines, ster- 
 num, and ribs ; and it projected externally in the axilla. 
 
 From a similar instance preserved in the museum at St Bartho- 
 lomew’s Hospital, it may be inferred that melanosis is often com- 
 bined with encephalorna,* 
 
 Section IV, 
 
 MORBID STATES OF THE LIVER, 
 
 The morbid conditions, to which the liver is liable, may be dis- 
 tinguished into two orders ; first, those proper to the liver ; and 
 secondly, those affecting the gall-bladder and gall-ducts. 
 
 Tbe morbid changes proper to the liver may be enumerated in 
 the following order ; Inflammation of different kinds and its effects, 
 such as adhesion, suppuration, induration, and softening; hyper- 
 trophy ; atrophy ; cirrhosis ; fatty degeneration ; concretions in the 
 ducts ; entozoa, or parasitical animals ; and the heterologous de- 
 posits. 
 
 Among those belonging to the gall-bladder and gall-ducts must 
 be placed inflammation of these parts, and their effects ; contraction 
 and obstruction of the ducts ; biliary concretions and their effects ; 
 and entozoa or parasitical animals. 
 
 § 1. Inflammation — When inflammation attacks the liver, it 
 may affect either the peritoneum, or the hepatic substance, or both. 
 
 * A Descriptive Catalogue of the Anatomical Museum of St Bartholomew’s Hospi- 
 tal. Published by order of the Governors. Vol. i. Pathological Anatomy. Lou- 
 don, 184(). ovo. Serie.s p. 317. 
 
854 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 In the former case the disease constitutes hepatic peritonitis, a dis- 
 order already noticed generally under the head of the peritoneum. 
 One or two points only deserve particular attention. 
 
 1 . It is usually supposed that hepatic peritonitis is always an acute 
 disease^ or rather, that acute inflammation of the liver always afiects 
 the peritoneum. This is a mistake. The disease may, like other 
 inflammations of serous tissue, assume either the acute or the chro- 
 nic form ; and it is not easy to say, from what is seen in the in- 
 spection of bodies, which is the most frequent. 
 
 Hepatic peritonitis is a disease not uncommon, especially when 
 the substance of the liver is either congested, indurated, or affected 
 with cirrhosis. In cases of this kind, almost uniformly, the whole 
 convex upper surface of the liver is found adhering to the dia- 
 phragm. 
 
 Hepatic peritonitis is liable to take place in the concave surface 
 of the gland, when the stomach is inflamed or affected by chronic 
 ulcer. This ulcer, it has been shown, most commonly is seated in 
 the small arch of the stomach ; and, if it destroy the gastric tissues 
 down to the peritoneum, peritonitis then follows, with effusion of al- 
 bumen, which may be in various states of consistence, from soft and 
 semifluid up to orga.nized membrane, according to the duration of 
 the disease. 
 
 Occasionally inflammation attacks the peritoneum covering the 
 concave surface of the liver, in the site of the capsule of Glisson, 
 and is mostly confined to that region. This is most commonly, nay, 
 very generally, attended with yellowness of the surface. The in- 
 flammation extends over the hepatic ducts and vessels in the cap- 
 sule, and causes more or less constriction of the ducts. 
 
 2. Inflammation may attack the hepatic peritoneum at the ante- 
 rior-inferior margin of the right lobe, either along with, or in con- 
 sequence of, inflammation of the peritoneal coat of the colon, or 
 even the pyloric end of the stomach. The former is the most com- 
 mon. A good specimen of this I had occasion, on the 10th of Janu- 
 ary 1839, to observe, in inspecting the body of a man destroyed by 
 continued fever. A band of firm false membrane, about two inches 
 broad, and from three to four inches long, extended from the an- 
 terior margin of the liver and the fundus of the gall-bladder to the 
 transverse arch of the colon, about one inch to the left of its angle, 
 and connected that bowel firmly to the liver and gall-bladder. In- 
 stances even are recorded, in which, in consequence of biliary calculi 
 
 (i 
 
ACUTE INFLA3IMATI0N OF THE LIVER. 
 
 855 
 
 ulcerating a passage out of the gall-bladder into the intestines, si- 
 milar adhesions had been previously formed between the peritoneal 
 coat of that organ and the peritoneal covering of the bowels. Si- 
 milar inflammation and adhesion take place in India in consequence 
 of disease of the colon and caecum. 
 
 3. Inflammation of the hepatic peritoneum of the inferior surface 
 of the liver may arise either spontaneously, or from some cause of 
 irritation in that region, as biliary calculi sticking in the gall-ducts, 
 or inflammation of the duodenum or jejunum, spreading to the cap- 
 sule of Glisson. In all these cases the same eflFects are produced. 
 The membrane becomes Injected, vascular, and rough, and after- 
 wards efliises albuminous exudation, which unites the contiguous 
 organs by adhesion. 
 
 In all the cases now mentioned, hepatic peritonitis arises from 
 some morbific cause applied to or seated in the membrane. But it 
 may be also the result of another cause seated in the hepatic sub- 
 stance. When the substance of the liver is inflamed, whether it 
 proceed to suppuration or not, it is a very common consequence for 
 the peritoneal covering over the inflamed or suppurating portion to 
 become red, injected, and at length covered on its free surface with# 
 albuminous exudation, which more or less quickly unites the mem- 
 brane with the organs to which it is applied. It may hence be said 
 that though hepatic peritonitis may often take place without inflam- 
 mation of the hepatic substance, the latter is almost never inflamed 
 without being followed or accompanied by hepatic peritoneal in- 
 flammation. 
 
 § 2. Scar-like Marks on the surface of the Liver. — 
 In examining dead bodies, it is not uncommon to observe on the 
 surface of the liver marks like the remains of scars or cicatrices. 
 The peritoneum at these marks seems drawn or depressed into the 
 substance of the liver at one point ; and, radiating from this point, 
 are lines gradually lost in the space of about from half an inch to 
 three-quarters of an inch. At these parts, the peritoneum adheres 
 very firmly ; and there is often a sort of contraction or drawing to- 
 gether of all the parts. 
 
 The cause of these appearances is in all probability inflammation 
 of the hepatic peritoneum, taking place at a particular point, and 
 connected with inflammation either of the liver or of the sub-serous 
 cellular tissue. 
 
 § 3. Cartilage-like Patches. — The hepatic peritoneum is often 
 found covered with patches of cartilage-like matter. The con- 
 
856 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 vex surface is the most usual seat of this deposition and transfor- 
 mation ; and it is most common in females. There are evidently 
 layers of albuminous effusion, the result of chronic inflammation. 
 
 § 4. Tubercles. — The hepatic peritoneum is, like other parts of 
 that membrane, liable to be affected with osseous degeneration ; 
 and it may be occupied with minute hard seraitranslucent tuber- 
 cles, when the peritoneum is affected by these bodies. All these 
 conditions are liable to be attended with inflammation of the mem- 
 brane, that is redness, congestion, roughness, and exudation of 
 coagulating lymph, but which is slow in progress, and in other 
 respects of a chronic character. 
 
 It then usually happens that the hepatic peritoneum adheres 
 more or less extensively and firmly to the diaphragmatic, the gas- 
 tric, or the muscular peritoneum. This disorder is most usual when 
 the abdominal peritoneum generally is affected by tubercles. 
 
 It has been formerly mentioned that in one order of tubercles 
 adhesion is most common ; and in another ascites. 
 
 § 1. Inflammation of the Hepatic Substance. — Inflamnia- 
 4 |tion of the substance of the liver has been generally, since the time 
 of Cullen at least, believed to be of a chronic nature ; and doubtless 
 the trifling or obscure symptoms which appear in cases, in which 
 dissection discloses a considerable abscess of the organ, are highly 
 favourable to this opinion. For, independent of the avowed diffi- 
 culty of ascertaining the existence of what has been termed chronic 
 hepatitis during life, almost all authors abound with examples of 
 abscess of the organ discovered on dissection, yet in which no de- 
 cisive symptom had led to the suspicion of such an event. The 
 truth of this I can verify by personal testimony. Various reasons, 
 however, lead me to doubt whether hepatic inflammation is invari- 
 ably chronic ; and several facts prove that it assumes, under cer- 
 tain circumstances, a sufficiently acute form. 
 
 ]. In the tropical regions, inflammation of the hepatic substance 
 is often attended with acute pain, quick pulse, and all the marks 
 of a violent disease ; and unless remedies be seasonably and ener- 
 getically employed, suppuration takes place in a period sufficiently 
 short to warrant the opinion of the inflammation being acute, 
 (Clark, (Med. Com. xiv. p. 322,) Ballingall, Marshall). 2. In tro- 
 pical countries, also, there arc two forms of hepatic inflammation, — 
 one, acute, rapid, and with well-marked symptoms; the other slow, 
 long-continued, and with indistinct symptoms. 3. Though, in 
 
INFLAMMATION OF THE LIVEE. 
 
 857 
 
 temperate climates, this disease is undoubtedly milder, slower, and 
 less violent than in countries where the atmospheric heat is exces- 
 sive, yet instances are not wanting in which the disease appears 
 with distinct symptoms, runs a rapid course, and terminates in more 
 or less extensive suppuration. It is true that the distinction, ac- 
 cording to duration or severity of symptoms, is liable to be vague 
 and undefined ; but it is the only one which is pretty obvious, and 
 which may be useful in diagnosis. 4. Lastly, both in temperate and 
 hot climates one form of inflammation of the liver consists in a 
 slow and gradual enlargement of the gland, which appears to de- 
 pend on chronic congestion, if not inflammation, without tending 
 to suppuration, but mere hardening. 
 
 From these facts, it may be inferred that hepatic inflammation is 
 of two kinds, suppurative and unsuppurative ; that the former, 
 which is analogous with the phlegmonous inflammation of Cullen, 
 Smyth, and others of the same school, may be acute or chronic, 
 severe in character, and rapid in progress, or moderate in action, 
 and slow in progress ; that the latter is always chronic, unless, 
 when, under certain circumstances, it may suddenly pass into the 
 acute form ; and that, though all forms of the disease may occur 
 in temperate countries, yet warm or tropical regions are the situa- 
 tions most common for the several forms of hepatic inflammation. 
 I enumerate, according to these principles, the following varieties. 
 
 A. Acute suppurative ; B. Chronic suppurative ; C. Acute con- 
 gestive or enlarging ; D. Chronic congestive or indurating. 
 
 A. Of the first the best examples are afforded in the cases of Dr 
 John Clark, occurring in the East Indies, Dr James Clark, oc- 
 curring in Dominica, those of Sir G. Ballingall, Mr Annesley, and 
 Mr Geddes, in the East Indies, and those of Mr Marshall in the 
 Island of Ceylon. Its most common symptoms are more or less 
 pain in the right hypochondriac or epigastric region, tenderness in 
 some part of the side, difficulty or pain in lying on the right, some- 
 times on the left side, sickness, vomiting, heat, thirst, quick strong 
 full pulse, and constipation, with scanty high-coloured urine. The 
 pain is generally increased on pressure ; but, in some instances, 
 there is merely an undefined sense of soreness or of weight, or of 
 gnawing emptiness, deep in the right hypochondriac and towards 
 the epigastric region. These sensations are generally aggravated 
 by lying on the left side, in some instances by lying on the right 
 side; and occasionally no ease is procured unless when the patient 
 
858 
 
 GENERAL AND PATHOLOGICAL ANATOJIY. 
 
 is on his back. It is probable that this variety of complaint de- 
 pends on the part of the organ most severely affected. The ag- 
 gravation caused by lying on the left side appears to denote that 
 the left lobe is inflamed ; that resulting from lying on the right 
 side denotes inflammation of the right lobe, each being respectively 
 pressed by the weight over a tender and inflamed part; while the 
 ease derived from the supine position indicates a deep-seated inflam- 
 mation verging towards the upper obtuse margin, and the concave 
 surface of the organ. The sickness, vomiting, and constipation are 
 not constant symptoms ; but if present with local pain and quick 
 pulse, denote the disease, with considerable certainty, as extending to 
 the concave surface. The heat, thirst, quick strong pulse, and scanty 
 high-coloured urine are merely connected with the general feverish 
 state of the system. It rarely happens that, in this form of hepatic 
 inflammation, there is sufficient enlargement or hardening of the 
 organ to cause a sensible increase in the bulging of the hypochon- 
 driac region. This only occurs towards the latter end of the dis- 
 ease, when it threatens to terminate in suppuration, or to pass in- 
 to the chronic form. Clark of Dominica considers inability to 
 sneeze as a certain sign of the malady. 
 
 The acute hepatic inflammation terminates, Is^, in resolution ; 
 2d, in suppuration ; 3c?, in induration or chronic inflammation. 
 
 Termination by resolution is when the symptoms gradually de- 
 cline either spontaneously or by the use of suitable remedies, and 
 the patient is restored to health without further complaint. If the 
 resolution be spontaneous, it is generally accompanied by some eva- 
 cuation, for instance, hemorrhage from the nose or from the intestines, 
 diarrhoea, critical sweating, or a copious sediment in the urine. Saun- 
 ders states that he has seen a great increase of bronchial secretion at- 
 tend the resolution of this disease ; and perhaps this is an instance 
 of transfer of morbid action.* Termination in suppuration is more 
 common, and is fatal either speedily or more slowly. In the for- 
 mer case the right or left lobe is converted into a large abscess or 
 collection of matter, purulent, sero-purulent, or purulent with mas- 
 ses of flaky lymph. If the whole hepatic tissue be not destroyed 
 in this manner, the inner surface of the abscess is somewhat irre- 
 gular, having the appearance of an ulcer thickly covered with pu- 
 rulent matter, or flaky lymph. The substance of the organ for 
 about a third of an inch from the ulcerated surface appears unus- 
 
 ■* A Treatise on the Structure, &c. p. 208. 
 
INFLAMMATION OF THE LIVER. 
 
 859 
 
 ually red, and may be hardened a little, but beyond this the glan- 
 dular substance is healthy. In some instances the hepatic sub- 
 stance is destroyed or entirely removed at one spot or over a great 
 extent, and the purulent fluid is contained in a sac formed by the 
 peritoneal coat. The quantity of purulent fluid varies from one to 
 seven pounds, the most usual quantity being about two or three 
 pounds. At the same the contiguous hepatic substance is denser, 
 larger, and heavier, and weighs, exclusive of the purulent matter, 
 from one to three pounds more than in the healthy state it would 
 do. This increase in bulk and weight is occasioned partly by 
 blood in its capillary system, partly by new products from the 
 blood, causing swelling or enlargement of the organ. 
 
 When a considerable abscess of one or both lobes bas formed, 
 death generally takes place very quickly, apparently in conse- 
 quence of the feebleness and waste of vital power induced by a 
 violent disease. If, however, life is protracted a little, the pur- 
 ulent collection increases in size, and flnds its way to the surface 
 of the organ. Ulceration of the peritoneal covering takes place 
 at one or more points, and the contents escape by the openings. 
 An abscess may in this manner be discharged ; Is?, into the abdo- 
 minal cavity ; 2d, through the diaphragm into the air-cells and 
 bronchi ; 3d, by the adhesive process into some part of the intestinal 
 canal, the stomach, transverse arch of the colon, or even the duo- 
 denum ; 4ith, by the same process to the outer surface of the body. 
 
 1. When the matter escapes into the abdominal cavity, it pro- 
 duces immediate peritoneal inflammation, generally terminating 
 fatally. This termination is most usual when the abscess is seated 
 about the posterior inferior surface, and the acute margin of the 
 gland. This is believed to be a rare termination.* 
 
 2. If the collection be seated about the upper surface and right 
 lobe of the organ, the liver, diaphragm, and lungs become united 
 by adhesive inflammation, and the matter passes into the air-cells, 
 from which it is discharged by expectoration with frequent cough- 
 ing. In fatal cases the hepatic portion of such an abscess presents 
 a wide hollow, to the margin of which the lungs and diaphragm 
 are firmly attached ; the muscular structure of the latter is destroy- 
 ed to the extent of the ulcerated surface, and the lungs are harden- 
 ed, and void of crepitation. This termination is generally fatal in 
 a short time. The symptoms becotne complicated with those of 
 
 * Vide Bang Selecta Diarii Havnieusis, Tom. ii. p. 65, where a case with dissection 
 is given. A case by Mr Macmillan Jameson in Mem. Med. Society, vol. iii. p. 579. 
 
860 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 pulmonary consumption, and the patient is worn out by incessant 
 irritation, difficult breathing, coughing, and hectic emaciation.* 
 Yet, according to Marshall, recoveries from this state have occur- 
 red ; they are indeed rare, and perhaps occur only when the ab- 
 scess is small, and the consequent inflammation of the lungs not 
 extensive. (Vide John Clark, pp. 405, 407.) 
 
 3. Mr Marshall mentions a case in which the left lobe adhered 
 to the stomach, and part of the contents of an abscess had passed 
 through a large opening into its cavity. Sir G. Ballingall states, 
 that, in many instances, extensive adhesion takes place between the 
 liver and transverse arch of the colon ; and though he never met 
 with a case in which an opening was effected, yet he infers that it has 
 taken place, so as to discharge matter and effect a cure. Mr 
 Marshall adheres to the mere fact of no communication ever being 
 formed, and is not aware of a cure having been accomplished. 
 Dr John Clark, however, records a case, which he considers, from 
 the discharge of purulent matter, to have been of this nature, (p. 
 416). Two examples of this communication are given by M. Petit.f 
 
 4. Among the cases of hepatic abscess related by Valsalva, in 
 one the biliary duct communicated with the abscess by a large ori- 
 fice, and was considerably dilated. Morgagni infers, that there is 
 no reason to doubt that this duct frequently conveys blood and 
 purulent matter from the substance of the liver into the duodenum ; 
 and he mentions that, in one case in which many pounds of purulent 
 fluid were voided at different periods during life, much matter was 
 found after death in the intestines, biliary ducts, and liver, and the 
 ducts were much dilated, the intestinal extremity being large 
 enough to admit the little finger, (xxxvi. 10.) The probability of 
 this mode of outlet in consequence of purulent matter being form- 
 ed either in the vicinity of the ducts, or in the concave part of the 
 liver, is noticed by Petit, and afterwards by Saunders ; but he ap- 
 pears to have been misled by speculative views, and to have inferred 
 that, because adhesion generally attends suppuration and ulceration, 
 it was difficult to explain the mode in which the hepatic abscess 
 made its way into the duodenum, and falls into some philosophical 
 inconsistencies. (See Chap. iv. Sect. i. 7-13.) 
 
 5. The passage of an hepatic abscess to the surface of the body 
 
 * See cases by E. Barry, Ed. Med. Essays ; Ur Ludlow, Mem. Med. Society, vol. 
 iii. p. 145 ; and Larrey, Exj)edition en Egypte, p. 191. 
 
 T Des Apostemes du Foie, Memoires de I’Academie de Chirurgie, tome ii. p. Cl, 
 cases 2 and 8. Paris, 1753. 
 
INFLAMH^VTIOJ^ OF THE LIYER, 861 
 
 appears to be uncomntion ; and its spontaneous opening by ulcera- 
 tion of the integuments almost unknown. Clark of Dominica re- 
 cords several cases in which, by an external incision, he discharged 
 considerable quantities of matter, (I, 2, 3, quarts, half a gallon, a 
 pint, &c.) sometimes so as to effect a permanent cure. Marshall, 
 however, states that no case occurred in the Kandyan country 
 among any of the classes of troops in which it was deemed advis- 
 able to make an incision through the abdominal parietes into an 
 hepatic abscess ; and in those cases in which bulging of the false 
 ribs appeared to indicate the performance of this measure, it was 
 found on dissection that adhesion was not sufficiently intimate to 
 render it successful. In three cases in which the abscesses were 
 small, the operation was performed with good result. 
 
 The termination of acute hepatic inflammation in hardening or 
 chronic disease shall be noticed afterwards. 
 
 Acute suppurative inflammation of the liver may be said to be 
 endemial in tropical climates. It is so in the West Indies; in 
 India, but particularly the Coromandel Coast, (John Clark) ; in 
 the Mysore, especially at Bengalore, (Mouat) ; and in the whole 
 of the Presidency of Madras ; in Ceylon, (Marshall) ; and on the 
 coast of Africa, (Winterbottom). It may occur, however, in tem- 
 perate or cold climates. Morgagni mentions examples in Italy, 
 Portal in France, and Bang in Denmark. (See Selecta Diarii, pp. 
 62, 224, 285, 315). Two cases have fallen under my observation 
 in this country. 
 
 It attacks indiscriminately natives and Europeans, but especially 
 the latter, in the East Indies. In Dominica, the’ negi’oes were as 
 frequently attacked as the whites. Not unfrequently it succeeds 
 ague or remittent fever, or may be complicated with them. Ex- 
 posure to cold, moisture, or extreme heat appears equally to favour 
 its production. 
 
 B. Chronic suppurative hepatic inflammation differs from the 
 acute in its mode of attack, the degree of severity, and its effects 
 on the substance of the organ. It generally comes on slowly and 
 insidiously, either originally in constitutions previously exhausted 
 by long residence in hot climates, and repeated attacks of acute 
 disease, or it follows remittent fever or ague. The patient is lan- 
 guid, listless, averse to exertion either bodily or mental, and some- 
 times apprehensive. Yet he does not complain of pain, or that 
 distressing uneasiness which attends the acute disease. The hypo- 
 chondriac region, on the contrary, may be insensible, or the seat 
 
862 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 of a gnawing sense of emptiness. At the commencement it is not 
 enlarged or prominent, but becomes so as the disease advances. 
 The pulse, at first slow and natural, becomes afterwards quicker, 
 varying from 90 to 100, and sharpish ; the skin is cold, and dry or 
 unctuous ; the tongue furred ; the complexion sallow, and the look 
 anxious. The appetite is variable, at one time apparently good, 
 at others completely gone, while squeamishness and even vomiting 
 may succeed. The matters discharged are chiefly tough phlegm, 
 with disordered bile and the portions of food eaten. At the same 
 time, the patient is hot, thirsty, and restless. The bowels are ge- 
 nerally bound ; the stools darker or lighter than natural ; after- 
 wards they are loose, frequent, and lienteric. The urine is scanty, 
 depositing a copious red flaky sediment. 
 
 But the most distinguishing character of this disease is, that 
 whatever variation these symptoms may present, and however ob- 
 scure they may be, there is a distinct accession of fever during the 
 night. The pulse may be calm and of natural frequency, the skin 
 may be cool, and the sensations of thirst and hunger may be na- 
 tural during the day ; — in the course of the night the skin becomes 
 hot, the face reddish, the pulse strong and frequent, the mouth dry 
 and parched, and the patient is restless, or enjoys only disturbed 
 slumber ; as morning advances slight sweating comes on, with 
 abatement of his sufferings and tolerable sleep. If the disease is 
 not arrested, all the symptoms, and especially those of night fever, 
 become more severe and distressing ; the patient tosses about in 
 bed with a dry burning skin, and scalding palms, constant and in- 
 satiable thirst, and, in some instances, a severe husky cough ; his 
 nights become sleepless, and it is only in the morning, after the 
 urgent complaints are relieved by partial sweating, that he falls in- 
 to a laboured, interrupted, and unrefreshing slumber. His strength 
 and flesh waste, his appetite decays, and he at length sinks into hec- 
 tic, which shortly terminates in death. 
 
 Dissection shows, instead of an abscess of considerable size, se- 
 veral small distinct collections of purulent matter similar to the 
 small abscesses {iwmicae) of the lungs. They may be very nume- 
 rous, and not larger than peas, or fewer in number, and as large 
 as a hen’s egg. The whole mass of the liver is altered in colour; 
 it appears as if parboiled, and its texture is firmer than natural, 
 giving when cut the sensation of the knife passing through a soft 
 cartilaginous mass. Very little blood issues from the incision. In 
 some instances the surfltce of the organ is sprinkled with white spots 
 
IXFLA3IMIHI0N OF THE LIVER. 
 
 863 
 
 of various dimensions, or tubercles are interspersed through its sub- 
 stance. These appearances may be conjoined with hydatids ; but 
 these are rarely met in the disease as it occurs in India. The bile 
 differs from healthy bile in a slight change of colour or consistence ; 
 but it has not been chemically examined. The gall-bladder seldom 
 presents any change of structure, or is merely thickened in its coats. 
 
 This form of hepatic inflammation is very common in India, es- 
 pecially in those who have resided long in the country, who have 
 been exposed to the causes of ague and fever, or whose habits have 
 been rather intemperate. It is not unknown, however, in European 
 countries ; for Bang describes an instance of it in his Copenhagen 
 Reports, occurring in the month of April 1783, and with symptoms 
 somewhat acute. (Tome i. p. 88, Selecta Diarii Havniensis.) Two 
 instances have come under my own notice in this country. 
 
 In various instances of the disease, a single large abscess is form- 
 ed in the liver without acute symptoms, or with the usual train of 
 chronic complaints. I had occasion in 1827 to examine the body 
 of an aged person who had been labouring for about five or six 
 weeks under symptoms of inflammation of the intestinal mucous 
 membrane, and in whom, besides the usual traces of disease in the 
 colon, I found a large abscess in the right lobe of the liver, con- 
 taining fully four pounds of purulent matter, mixed with lymphy 
 flakes. To this head Mr Andree’s case in the Transactions of the 
 Medical Society appears to belong. “The formation,” says Mr 
 Marshall, “ of a large abscess in the liver sometimes takes place 
 without much indication of disease, in as far as the feelings of the 
 patient are concerned. So little obvious occasionally are the symp- 
 toms which indicate a large accumulation of pus in that organ, that 
 the pointing of the abscess outwards has been mistaken for a super- 
 ficial collection, and an opening made into it by means of a lancet. 
 The issue of three or four pounds of purulent matter undeceived 
 the operator. (P. 155.) Are such collections to be regarded as 
 the result of chronic inflammation, or of a scrofulous disease of the 
 liver, as they are in other organs? or are they the result of secondary 
 deposition through the medium of the veins, as takes place in cer- 
 tain cases of intestinal ulceration ? A peculiar modification of he- 
 patic suppuration is described by Sandifort in the eighth chapter 
 of the second book of his Academical Researches. 
 
 C. I have made a distinct head of acute congestive infiammation, 
 for the purpose of referring to it an affection of the liver, which is 
 described by Dr Chisholm, as prevailing epidemically in some parts 
 
864 
 
 GENERAL AND PATHOLOGieAL ANATOMY. 
 
 of the West Indies. The disease began with headach, pain at the 
 pit of the stomach, general languor, and a sense of tightness and 
 oppression at the breast, with difficult breathing. The skin was 
 dry, harsh, and cool ; the tongue moist and foul, without thirst ; 
 the helly natural ; the urine freely secreted ; and the pulse was 
 soft, about 70 or 80 in the minute, and of natural fulness. In 
 some cases the pulse was quick and hard from the first, the skin 
 hot and dry, and some swelling of the belly, especially at the um- 
 bilical region, was remarked. The pain varied in situation, being 
 some time confined to the right hypochondriac and epigastric re- 
 gions, in other instances extending from these to the shoulder, es- 
 pecially the right, across the belly to the navel, or from the navel 
 through to the spine. It was remarkable, that, when the pain was 
 fixed, it was felt in the left side, under the false ribs. 
 
 In about two days the headach increased much, but without 
 giddiness ; the pain at the pit of the stomach became more excru- 
 ciating; and shivering came on, with chilness of the skin to the 
 touch, but an intense burning sensation when pressed strongly. 
 The tongue was covered with a thick moist fur, purplish at the 
 edges ; the cheeks, nose, and eyebrow’s assumed a copper hue, ex- 
 uding large drops of sweat, while the skin, in general, was cover- 
 ed with an unctuous moisture ; the pulse rose from 80 to 120 or 
 140 ; dry cough, or rather a sudden catching mode of expiration, 
 with a sense of compression of the lungs, came on ; and about the 
 sixth day, all the symptoms increasing, the skin became cold and 
 clammy, the pulse exceedingly quick and small, deglutition became 
 difficult, and coma came on, terminating in death. 
 
 On dissection the liver was found greatly enlarged ; its surface, 
 especially the convex, was clouded irregularly with red, purple, 
 and tallow-coloured spots ; the peritonaeum sound and transparent. 
 The hepatic substance was of natural consistence, without any ap- 
 pearance of suppuration, but so much enlarged as to occupy in 
 eight of ten cases not only the right hypochondriac and epigastric 
 region, but the left hypochondre. Its vessels were enlarged, butj 
 empty. These appearances seem to arise from an unusual accu-? 
 mulation or congestion of blood in the liver. It appears to be the^ 
 same described by Marshall at p. 146, and which he regards as a 
 passive engorgement of the vascular system of the gland. 
 
 This sort of hepatic inflammation prevails occasionally as an epi- 
 demic in Grenada, Dominica, and others of the later settled islands. 
 Although persons of all colours, ages, and of both sexes may be 
 
SKLEROMA OF THE LIVER. 
 
 865 
 
 attacked, yet blacks and young people from eight to twenty-five 
 years are most liable. 
 
 D. Skleroma. — To the fourth head, or that of chronic conges- 
 tive inflammation, may be referred those examples of liver disease, 
 in which the organ becomes slowly indurated, generally with, some- 
 times without, enlargement, but always with obscure symptoms of 
 ill health, until the structure of the organ is so generally changed, 
 that it is no longer fit for its functions of receiving the venous cir- 
 culation, or performing the secretion of bile. The symptoms of 
 this disease are so similar to those of suppurative inflammation, 
 that it is impossible in the present state of knowledge to attempt 
 a complete history. The principal, according to Pemberton, are 
 a sense of weight and dull pain in the right side, weary heaviness 
 of the right arm, and frequently pain at the top of the shoulder. 
 The tongue is usually whitish, the appetite impaired, the counte- 
 nance sallow, and the bowels slow, and stools clay- coloured. The 
 pulse is about 90, almost invariably intermitting, and there is a 
 sensation of fluttering at the pit of the stomach, — symptoms which 
 Pemberton ascribes to the impeded motion of the arterial and ve- 
 nous blood through the hardened gland. T hese symptoms, how- 
 ever, it may be remarked, appear only when the disease is far ad- 
 vanced, when the natural structure is much injured. 
 
 The organ is harder than natural, and when cut gives a gristly 
 sensation. Its surface is mottled, irregular, and marked with de- 
 pressions not unlike cicatrices. Its substance is also generally 
 paler than natural, sometimes of a wood-brown colour ; and some- 
 times like a recent section of nutmeg in tint ; and, if immersed in 
 clear water, appears quite different from the sound state. It is 
 traversed with gray or light-coloured particles, which seem to be 
 infiltrated between the acini, or glandular granules. In some in- 
 stances it is possible to distinguish between the acini a bluish- gray 
 firm sort of substance, which is indurated cellular tissue. 
 
 Not unlike, perhaps, is the hard state of liver observed in 
 drunkards. Dr Marshall describes them as yellowish, containing 
 little blood, and communicating a gristly sensation, when divided, 
 sometimes loose and granular, at others solid and tenacious, weigh- 
 ing generally five pounds. 
 
 Such a state of the liver gives rise to all the symptoms of imper- 
 fect digestion and impaired nourishment, and eventually terminates 
 in dropsical effusion within the peritonceum (^ascites,') or uncon- 
 
 3 I 
 
866 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 trollable hemorrhage from the mucous surface of the intestinal 
 canal. This is the early stage of that change, which is afterwards 
 to he described as kirrhosis. 
 
 This disease may succeed the acute form, or may be developed 
 slowly and insensibly after ague, remittent fever, or in the persons 
 of those accustomed to the use of spirituous liquors. It is certainly 
 a common disease in tropical climates, but is by no means unknown 
 in more temperate latitudes. It is much seldomer found in females 
 than in males. 
 
 § 2. Anatomico-pathological causes of suppuration and 
 
 ABSCESS OF THE LIVER. INFLUENCE OF SUPPURATIVE DISEASE 
 IN OTHER TISSUES. INFLUENCE OF PHLEBITIS. ThoUgh the 
 
 inquiry into the circumstances acting as precedents or antegre- 
 dients, and esteemed causes of suppuration of the liver, involves 
 the consideration of causes of inflammation in general, yet the 
 formation of purulent collections within the substance of the liver, 
 is attended by circumstances so peculiar, that, in order to render 
 the pathological history of these collections complete, it is necessary 
 to consider these circumstances a little in detail. Abscess of the 
 liver, indeed, is a lesion so frequent, and in a certain number of 
 cases takes place so steadily and regularly, yet so insidiously, and 
 often in connection with injuries of the head, that the subject is en- 
 titled to particular consideration. 
 
 The circumstances usually observed to precede suppurative 
 inflammation of the liver are ; 1st, external violence or injury ; 
 2d, internal irritation, as from the presence of bones, concretions, 
 or other objects which may irritate the gland ; 3d, suppurative 
 inflammation of bones, especially of their veins ; 4th, inflammation 
 of a vein or veins, whether purulent or lymphy ; 5th, the presence 
 of ulcers in the intestinal or colic mucous membrane, or ulcers in 
 the stomach, duodenum, gall-bladder, or gall-ducts, or ulcers or 
 abscesses in the pancreas ; 6th, previous congestive states of the 
 liver ensuing on the operation of excessive solar or atmospherical 
 heat ; and 7 th, the operation of the poison or miasma producing 
 intermittent and remittent fever. 
 
 Of all these causes, though it be difficult to appreciate the com- 
 parative influence of each, yet little doubt can be entertained that 
 the most common and the most potential are venous inflammation, 
 or the presence of purulent matter in certain veins, and ulceration 
 of the intestines, either small or great. 
 
 1. External violence is rarely the cause of hepatic abscess. 
 
PATHOLOGY OF METASTATIC ABSCESS OF THE LIVER. 867 
 
 More commonly this produces either laceration, with hemorrhage, 
 or it gives rise to inflammation of the hepatic peritoneum, which 
 is then found to have formed adhesive connection with the 
 diaphragm, with the internal surface of the hypochondriac region, 
 or with the stomach, colon, duodenum, or kidney. Lentin re- 
 cords one case from external violence.* * * § Bretin mentions another 
 which he ascribes to this cause.f And two cases are recorded by 
 M. Petit the younger, (Case 3d, the kick of a horse ; Case 4th, a 
 contusion on the epigastric region).^ Yet it is evidently not frequent. 
 Among sixty cases, collected in tabular form from different 
 sources by Dr Budd, in one only, a case recorded by Andral, 
 could the disease be traced to a blow. In this case were two 
 abscesses on the convex surface ; and in all probability they were 
 collections of purulent matter between the hepatic and hypochon- 
 driac peritoneum. 
 
 2. From the irritation of internal objects the disease is more 
 common. Thus cases are recorded from the presence of biliary 
 concretions. § In general, the presence of these bodies causes, first, 
 inflammation and ulceration of the gall-bladder and gall-ducts, 
 and then of the hepatic substance. One of the most pointed cases 
 is given by Mr George Mallet, of Bolton-le-Moors. A clergy- 
 man who had been ill with general bad health, accompanied with 
 fits of excruciating pain in the epigastric region, died after the course 
 of eight years. Inspection disclosed an ulcerated opening through 
 the coats of the gall-bladder, communicating with an abscess beneath 
 the concave surface of the liver, containing about six ounces of puru- 
 lent matter. The ulceration was caused by the irritation of a mo- 
 derately-sized gall-stone which was found near the opening, but still 
 within the gall-bladder. The pancreas contained in a cyst a gall- 
 stone about three-quarters of one inch in diameter, and which must 
 have ulcerated its way into that gland at some period anterior, as 
 no recent traces of inflammation or suppuration were observed. || 
 
 3 and 4. Hepatic abscess after venous inflammation is much 
 more frequent. In 16 cases which fell under the observation of 
 
 * Beobachtungen Eineger Kranken, p. 94. 
 
 -j- Journal de Medecine, Tom. Ixv. p. 546. 
 
 $ Memoires de I’Academie de Chirurgie. Tome ii. p. 59. 
 
 § Ephemerides Naturae Curios. Dec. I. Ann. I. Obs. 66. Obs. 105. 
 
 Fournier in Journal de Medecine, Tome xlv. 
 
 Lombart in Recueil Periodique de la Societe de Medecine a Paris, No. 32. 
 
 1| Transactions of the Provincial Medical and Surgical Association. Vol. ix. 
 art. ix. London, 1841. 
 
868 
 
 GENERAL AND rATHOLOGICAL ANATOMY. 
 
 Louis and Andral, four may be traced to this source. In 15 
 cases seen by Dr Budd in the Dreadnought hospital ship, only one 
 belongs to tins head. 
 
 Inflammation of any vein may be followed by the formation of 
 purulent matter in one or more collections in the liver ; but the 
 veins, in which inflammation is most generally followed by this 
 result, are the veins of hones, often very minute, and the veins of 
 the intestinal viscera, from the stomach to the rectum. 
 
 The influence of inflammation in the veins of bones in producing 
 hepatic abscess appears in different modes. One of the most com- 
 mon is after injuries of the skull. 
 
 It had been observed by Pare, Pigray, (1658,) De Marchettis, 
 (1665,) a Meek’ren, (1682,) and other surgeons of the seventeenth 
 century, that after wounds of the head and fractures of the skull, 
 abscess of the liver was an occurrence so common, as always to be 
 apprehended. Various attempts, some odd enough, were made 
 to explain this combination of pathological phenomena, which 
 was too regular to be regarded as accidental. Little regard was 
 given to the modes of explanation, however, till the middle of the 
 following century, when, within the lapse of some years, the sub- 
 ject exercised the ingenuity of Petit, Bertrandi, Andouille, Pou- 
 teau, and other members of the French Academy, and Richter, 
 Bianchi, Morgagni, Cheston, (1766,) and other observers in dif- 
 ferent countries of Europe, 
 
 Previous to the time of Bertrandi, two opinions appear to have 
 been entertained regarding the cause of hepatic suppuration after 
 injuries of the head. Pare, a Meek’ren, and the cotemporaries of the « 
 latter merely note the conjunction of the two phenomena, and "3 
 suppose the suppuration first formed within the brain, and thence ^ 
 absorbed and deposited in the liver. By another party, among 
 whom may be placed Goursaud, it was ascribed to sympathetic af-^jB 
 fection of the nerves, or the reflux of purulent matter. This author,' 
 in a memoir presented to the Academy in 1751, gives two cases, in 3 
 one of which hepatic abscess followed a wound of the finger, and in 5 
 another a blow on the tihia^ and ascribes them generally to nervous A 
 influence.* ^ 
 
 This phenomenon Bertrandi ascribed to derangement in the 
 motion of the blood in the brain. He supposed that, after every 
 violent concussion of the brain, the blood flows in greater abun- 
 
 * Recueil cles Pieces qui ont concouru pour la Prix de PAcademie de Chirurgie, 
 Tome iii. Paris, 1759. Sur la Metastase, p. 3. 
 
PATHOLOGY OF METASTATIC ABSCESS OP THE LIVER. 869 
 
 dance to this organ, and returns in greater quantity by the jugidar 
 veins ; so that while a large stream is brought downwards by these 
 veins, and a considerable quantity of blood is conveyed by the 
 superior vena cava against the inferior, the blood of the latter is 
 made to regurgitate and accordingly pass into the vena cava 
 hepatica and its tributaries ; and in this manner, more blood than 
 the liver is capable of admitting being thrown on the vessels of that 
 organ, inflammation follows, and terminates in suppuration and 
 gangrene, the former most commonly.* 
 
 This theory was favourably received by the French academicians, 
 especially David ; and was illustrated and commended by M. An- 
 douille.f 
 
 The justice of this hypothesis was questioned in this country by 
 Cheston, and in France by Pouteau. 
 
 Cheston expresses his general belief of the improbability of the 
 disturbance in the circulation assumed by Bertrandi, and has re- 
 course to three suppositions in order to explain the occurrence of 
 hepatic suppurations after injuries of the head. Is?, Abscesses may 
 exist in the liver after an injury received on the head, without be- 
 ing derived or occasioned by falling, from the head to that abdomi- ^ 
 nal viscus. 2d, Abscess in the liver may be the result of transla- 
 tions of matter from one part to another, as are frequently observed 
 after amputation of the larger limbs. 3d, In severe injuries of the 
 head, the functions of the liver are injured by sympathetic irritation 
 of its vessels and neighbouring parts from the diseased state of the 
 brain ; and this disorder may cause obstruction, terminating in 
 suppuration. 
 
 To these Cheston adds as an accessory circumstance, that, in 
 those accidents in which the brain suffers, as by falls from some 
 height, being thrown violently from a horse, the body must re- 
 ceive a severe shock, which may not only aggravate the injury 
 inflicted on the head, but, from the size and soft pulpy texture of 
 the liver, affect the functions of that viscus in particular, and thereby 
 not a little assist in confirming those obstructions which afterwards 
 could not be terminated but by suppuration. j; 
 
 * Sur les Absces du Foie qui se forment a J’occcision des playes de la tete. Par 
 M. Bertrandi. Memoires de I’Academie de Chirurgie, Tome iii. p. 484. Paris, 1757. 
 
 t Observations sur les Absces du Foie, par M. Andouille. Memoires de I’Acade- 
 mie de Chirurgie, Tome iii. p. 506. Paris, 1757. 
 
 X Pathological Inquiries and Observations in Surgery from the Dissection of Mor- 
 bid Bodies, Ac. By Richard Biwvne Cheston. Gloucester, 1766. 4to, chapter iii, 
 p. 32—42. 
 
870 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 The doctrine of Cheston was long afterwards espoused in a di- 
 vided form by Desault and Richerand. 
 
 According to Pouteau, on the other hand, who maintained that 
 it was not proved that either the quantity or the velocity of the 
 blood in the superior cava was increased, the impediment to the cir- 
 culation takes place in the arteries. Admitting that after a blow on 
 the head the blood is accumulated in the arteries of the brain, this 
 accumulation extends, he maintains, to the carotid and vertebral arte- 
 I’ies; and consequently, the blood being resisted in the upper divisions 
 of the arterial system, is accumulated in the abdominal aorta and the 
 rest of the blood-vessels ; while the substance of tbe liver being soft, 
 and its vessels large and numerous, readily gives way to this new 
 orgasm, and becomes affected by inflammation and suppuration.* 
 Desault rejected both explanations, and confined bimself to ad- 
 mitting tbe fact of a relation unknown, but real, between the brain 
 and the liver, more intimate than between other organs ; and the 
 proof of this relation shown by the living body by sickness and vo- 
 miting ; and in the dead body by the formation of abscesses in the 
 gland.f This explanation, or rather statement, of the two facts 
 % was long received in the French schools, apparently in consequence 
 of the high reputation of its author, and his commentator Bichat. 
 
 Curtet, a military surgeon at Brussels, appears first, in 1800, 
 to have doubted the sufficiency of all those hypotheses. Regarding 
 these hepatic collections as secondary or consecutive, he looked for 
 some other cause than any hitherto assigned ; and this cause, he 
 believed, he found in the absorbing function of tbe lymphatic sys- 
 tem. Goursaud, we have seen, had shown that hepatic suppu- ^4 
 ration may follow ordinary suppurating wounds of the extre-^i 
 mities. Roose, a surgeon at Antwerp, had communicated to the 
 Society of Medicine and Surgery at Brussels, a memoir containing - ■ 
 cases of whitloe, in consequence of which abscesses were found in 
 the liver. Rejecting the explanation of this sym-phenomenon given 
 by Roose, but receiving the fact, which he confirms by other two 
 cases, Curtet ascribes the suppuration in the liver to absorption of 
 matter by the lymphatics, and the transport of the same by these 
 vessels to the liver, first, into the thoracic duct, and thence, both by 
 the hepatic artery and portal vein to the gland. He invokes also 
 
 * Melanges de Chimi-gie par M. Claude Pouteau, D. M. et C. A Lyon, 1760. P. 
 123 ; et Oeuvres Posthumes de M. Pouteau, Tome ii. Paris, 1783. P. 111. 
 
 Oeuvres Chirurgicales, 2 tomes. Paris, 1801. 
 
 
PATHOLOGY OF METASTATIC ABSCESS OF THE LIVER. 871 
 
 the aid of various accessory causes ; viz. the size of the liver, the 
 softness and vascularity of its structure, and the slowness with 
 which its blood moves through the organ.* 
 
 It is impossible to deny, that the single fact of proving suppura- 
 tion of the liver in other circumstances besides those after injuries 
 of the head, was one great step in the inquiry ; and to refer the 
 process to the absorbing powers of the lymphatic vessels was an- 
 other. It showed at once that hepatic suppuration might take place 
 in the course of suppurative processes in other parts of the body. 
 
 It is singular, that, in this respect, the memoir of Curtet has been 
 so much neglected. 
 
 Dissatisfied with the whole of these accounts of the connection of 
 these two phenomena, Richerand brought forward a difierent view, 
 first, in 1803, and afterwards in 1815. According to this author, 
 the large size and the weight of the liver are the main cause of its 
 becoming the seat of suppuration in consequence of injuries of the 
 head. The weight of this gland, between three and four pounds, is so 
 considerable, that it exercises on the diaphragm great tension, which 
 causes inconvenience and pain unless counteracted. The liver also, 
 from its size, weight, and the looseness of its tissue, void of fibres ^ 
 or plates, is easily lacerated by slight violence ; and, of all the or- 
 gans, is next to the brain most exposed to the eflfects of concussions 
 and shocks, as in falls from some height. 
 
 In illustration, he gives two cases ; and conversely one, in which, 
 after a blow on the head, causing fracture and fatal inflammation 
 of the brain, the liver was quite sound.f 
 
 Not satisfied with this evidence, Richerand tried experimentally 
 the effect of throwing dead bodies from a height of eighteen feet 
 above the ground on the pavement below. By precipitating in this 
 manner more than forty dead bodies, he found that the brain and 
 the liver were always more or less injured ; that in some cases the 
 latter presented deep lacerations ; that heavy bodies presented the 
 most severe injuries ; and that while fractures of all kinds and dif- 
 
 * Observations et Reflexions sur les Depots Consecutifs qui ont lieu au Foie, 
 particulierement a la suite des Lesions traumatiques. Par le Cn. Curtet, officier 
 de Sante a I’Hopital Militaire de Bruxelles, &c. &c. Actes de la Societe de Medecine, 
 Chirurgie, et Pharmacie etablie a Bruxelles, Tome i. 2ieme partie. A Bruxelles, An. 
 
 8. 1 800. P. 93. 
 
 t Nosographie et Therapeutique Chirurgicales. Par M. Le Chevalier Richerand, 
 
 Prof. d’Operations de Chirurgie, &c. Cinquieme edition, Tome iiiieme, p. 70 75. 
 
 Paris, 1821. 
 
872 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 ferent luxations were observed, no viscus, not even the brain, suf- 
 fered more than the liver from these violent concussions produced 
 artificially by falls. 
 
 It is easy to see that this explanation is the same, in one circum- 
 stance, as that given in 1766 by Cheston. 
 
 The explanation of Richerand was very generally received, both 
 in France and in various countries of Europe. 
 
 That the explanation, nevertheless, was unsatisfactory and ina- 
 dequate, appears from the fact, that hepatic abscesses are observed 
 in the case of injuries of the head, in which the individual had sus- 
 tained no fall, and his person had received no shock, except the blow 
 on the skull, and in injuries and especially compound fractures of 
 the extremities. 
 
 Though Curtet had, at the end of last century, made a consi- 
 derable advance in tbe right line of inquiry on this subject, it was 
 not till near thirty years after, that the explanation, which may be 
 regarded as the correct one, was given. Mr Arnott showed, in a 
 paper read to the Medico-Chirurgical Society in 1828, that, when 
 the phenomena of injuries of the skull or other external parts are 
 # followed by suppuration or abscess witbin the liver, there is every 
 reason to believe that the veins of the former part are inflamed, and 
 that, in consequence of this venous inflammation, secondary deposits 
 take place in the liver. Mr Arnott showed, in short, that second- 
 ary deposits take place in this way both in the abdominal and tbe 
 thoracic viscera, and sometimes in both sets of organs at once. He 
 further showed, that the injury which the head had sustained con- 
 sisted, in two-thirds of the cases, of fracture or fissure of the skull, 
 in all compound ; and though, in one-third, the skull was neither 
 fractured nor fissured, yet with wound of the soft parts, in several, 
 part of the outer table and diploe had been sliced off, while in all 
 the bone was exposed. As inflammation of the osseous substance 
 must, in all these cases, have existed, Mr Arnott infers that this 
 process taking place in the numerous veins ramifying between the 
 two tables of the skull, and in those distributed to the soft parts 
 externally, may be attended with similar consequences to those 
 which follow phlebitis in other parts; that is, collections of matter 
 in internal organs.* '' ' 
 
 Cruveilhier subsequently showed, that injuries affecting bones, 
 
 * A Patliolngical Inquiry into the Secondary Effects of Inflammation of the Veins ’ 
 by James Arnott, surgeon. Medico-Chirurgical Transac. Vol. xv. p. i. London, 1829. 
 
PATHOLOGY OF METASTATIC ABSCESS OF THE LIVER. 873 
 
 causing inflammation of the osseous tissue, and involving the veins 
 of that tissue, are very commonly followed by abscess in the liver. 
 The veins so aflPected may be so minute as to escape notice ; and 
 hence the errors and misconceptions that have so long prevailed on 
 this subject. The experience of the three days of July 1830, which 
 furnished many cases of gun-shot wounds and injuries of bones, con- 
 tributed to throw light on this mystery. It was then found, that, 
 in some cases, injuries and fractures of the cranium, in other in- 
 stances, compound fractures of the bones of the extremities, were 
 followed by purulent collections within the liver ; and always almost 
 was it found, that the veins of the fractured and subsequently in- 
 flamed bone were inflamed, and contained purulent matter. 
 
 The veins of bones, it must be observed, allow this species of 
 suppuration and deposit within the liver more easily than the veins 
 of other tissues; because, being contained within incompressible 
 canals, they do not collapse, and remaining open, they are more 
 likely to become inflamed than the veins of other textures. 
 
 Though inflammation and suppuration in the minute veins of 
 bones may be generally requisite, in order to be followed by second- 
 ary purulent collections, yet probably it is not requisite that this 
 inflammation extend far up within the venous trunks arising from 
 these minute veins. Even it may happen, that inflammation and 
 suppuration of the inner venous coat may not be requisite ; and that 
 the veins act as the mere carriers from the inflamed tissue. 
 
 It has been from a very remote period observed that suppura- 
 tion within the liver after injuries of the head is a most insidious 
 affection, and takes place with very imperceptible external indica- 
 tions of its presence ; and most probably this is to be ascribed to the 
 circumstance, either that it is a peculiarly chronic and insidious 
 process, or that it consists merely in the successive transport of 
 purulent matter by the veins from the parts suppurating as the 
 matter is formed. The testimony of Pigray, given in the middle 
 of the seventeenth century, is remarkable; and its accuracy has 
 been confirmed by all subsequent observers. “Wounds of the 
 head,” he says, “are of great importance, from the variety of 
 symptoms and accidents which follow them, which it is good to 
 foresee and consider. In certain years, almost all these wounds, 
 both small and great, are mortal ; and this may be ascribed to the 
 constitution of the air, of which it is difficult to form a judgment. 
 I remarked one year in which wounds of the head, almost all, 
 
874 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 were followed by gangrene of two or three fingers’ breadth, with 
 little fever; and nevertheless few died. Several others I have 
 seen, in which no manifest accidents followed ; and nevertheless 
 there died, namely, of the smallest wounds, principally those in 
 whom fever began the third day after the infliction of the wound ; 
 but in almost all those who so died, we found a purulent abscess 
 in the substance of the liver.”* 
 
 This insidiousness led Bertrandi to observe, that the writers by 
 whom these instances of hepatic suppuration after injuries of the 
 head are recorded, were unaware of the existence of such collec- 
 tions in the liver before the body was inspected. 
 
 Without dwelling longer on this subject, I only add, that it is 
 not impossible that in several cases the operation of trepanning 
 itself, by inducing inflammation of the bone, may have been a 
 cause of hepatic suppuration. 
 
 5. Instances of purulent collection or collections within the 
 liver, in consequence either of inflammation of the veins of the 
 intestines, or of these veins opening at purulent surfaces, are often 
 observed. Cruveilhier mentions a case in which a man of 60 had 
 a protruded rectum replaced, after repeated and violent attempts, 
 which caused much pain. He speedily became ill, with the usual 
 symptoms indicating disease of the veins, and on the fifth day 
 expired. Several small abscesses, superficial and deep-seated, were 
 found within the liver. In other instances, the puriform collec- 
 tions were formed after operations on the rectum, where the actual 
 cautery was employed ; after the operation for the cure of fistula 
 ani ; and after that for strangulated hernia, in which a portion of 
 irreducible omentum underwent suppuration,, 
 
 It is not easy to say whether in these instances suppuration 
 within the veins is always necessary ; or whether the veins merely 
 transport the purulent matter to the liver. Inflammation is sel- 
 dom found to extend far from the spot ; and almost never into the 
 interior of the large veins. It is probable that when hepatic 
 abscess takes place after ulceration of the intestinal canal, it is 
 rather to the transporting power of the veins than to their actual 
 inflammation, that this sym-phenomenon is to be ascribed. 
 
 Of twenty-nine instances of this conjunction given by Annesley, ' 
 in twenty-one, or nearly three-fourths, were these ulcers more or 
 
 * Epitome des Pieceptes de Medecine et Chirurgie. Par Pierre Pigray. A Rouen, 
 1658. 12mo. Liv. iv. chap. ix. p. 368. 
 
PATHOLOGY OF METASTATIC ABSCESS OF THE LIVER. 875 
 
 less extensive in the large intestine ; and in other two cases the 
 colon was contracted with stricture, showing the presence of dy- 
 sentery at some former period. Among fifteen fatal cases which 
 fell under the observation of Dr Budd in the Dreadnought, in eight 
 cases there were ulcers in the large intestines ; in one case, two 
 ulcers were observed in the stomach ; and in two cases the state of 
 the intestines was not observed ; so that in nine among thirteen cases 
 hepatic abscess was conjoined with ulcers in the colon or stomach. 
 Among sixteen cases collected by Andral and Louis, in two cases 
 ulcers in the large intestine and lower end of the ileum are noticed ; 
 in one case, ulcers were observed in the lower end of the ileum 
 only ; in four cases, ulcers were seen in the stomach ; and in one 
 case, in the gall-bladder. In one of these cases of ulcer of the 
 stomach, the ulcer was caused by the abscess opening into the sto- 
 mach ; and this case may therefore be excluded. With this de- 
 duction, however, there are, among fifteen cases, seven in which the 
 existence of abscess of the liver was preceded by ulceration of some 
 part of that extensive mucous membrane, from which the capillary 
 veins arise and proceed to unite in the vena portae. 
 
 I have already, in page 863, mentioned that, in 1827, I met 
 with a remarkable example of the conjunction of large hepatic 
 abscess, with extensive ulceration of the colon; and in which 
 the formation of the former was so insidious, that its existence was 
 not suspected during life. It appeared to me at this time that 
 some connection between the two phenomena subsists ; and that this 
 connection is not accidental. Of this connection I had little doubt, 
 after reading the Memoir of Mr Arnott, already referred to ; and 
 if I had, that doubt must have been removed by the facts given in 
 1833 by Cruveilhier.* 
 
 On the other hand, it is agreed, that, in the case of this sym- 
 phenomenon, in various instances hepatic suppuration precedes the 
 formation of ulcers of the intestinal canal. This, however, merely 
 shows, that the same general causes which produce hepatic abscess, 
 that is, excessive solar heat, terrestrial miasmata, and full living, 
 may be followed by inflammatory processes in two sets of organs 
 much exposed to the hurtful influence of these physical causes. 
 
 It must also be observed, that, for aught that is hitherto known, 
 mere inflammation, or even vascular congestion of the mucous 
 membrane of the alimentary, may, considering the direct relation 
 
 * Anatomie Pathologique, Livraison xi. pi. 1,2, 3. Paris, 1833. 
 
876 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 of its venous system with that of the liver, give rise, in the latter ‘ 
 organ, tojrritation, which might readily terminate in suppuration. ^ 
 
 Physicians in India, where this union is most commonly seen, 
 ascribe the dysenteric disorder to the passage of irritating hile. i 
 
 Were this always the case, then it ought to be expected that the * 
 
 small intestine should be diseased before the large intestine. This, 
 however, is so far from being the case, that most commonly the 
 colon is first diseased ; and, in many cases, the colon alone is ulce- 
 rated, while the ileum remains sound. The bile, if it irritate, must 
 irritate most the membrane which it touches first ; and, before it 
 reaches the colon, its irritative properties ought to be abated, if not 
 extinguished. Yet the effects of this irritation are presented in no 
 degree almost by the small intestine, and in a most remarkable de- 
 gree by the large intestine. From these facts, it seems natural to 
 infer, that whatever be the cause of ulceration in the colon, it is not 
 irritating bile ; that the blood sent from the diseased intestinal mu- 
 cous membrane irritates through the branches of the portal vein the 
 substance of the liver. 
 
 § 3. Sphakelus — Gangrene of the Liver. — Gangrene of the 
 liver is a rare affection ; and we must be cautious in admitting, as 
 examples of the lesion, all the instances given by authors. In the 
 majority of cases, from Morgagni downwards, the descri[)tions are 
 too vague, and merely represent portions of the liver to be in a state 
 of sphakelus. The lesion nevertheless may take place ; first, either 
 by gangrene attacking an abscess of the liver, generally with more 
 or less inflammation of the veins ; and, secondly, in consequence of, , - 
 or in connection with, gangrene of some part of the surface, for in-'^ji 
 stance, the toes or the sacrum, and the gangrenous inflammation ^Tfll 
 passing thence, apparently by the veins, either to the liver or the^Bl 
 lungs, or to both simultaneously. jH j 
 
 In the former case, a large portion or the whole of the walls of^y] 
 an abscess are soft, flaccid, and filamentous, exhaling an offen- S 
 sive odour, while the adjoining portion of liver is also more or less 
 softened, dark coloured, and lacerated. In the latter case, the ^ 
 lesion appears in the form either of one gangrenous abscess, that is, ‘ 
 an abscess with soft, ragged, dark brown fetid-smelling walls; or * , 
 in the shape of several collections, of the same characters, while the 
 neighbouring veins contain fetid purulent matter. Y, 
 
 Gangrene of the liver is occasionally associated also with gan- 
 grene of the lungs. 
 
 4 
 
877 
 
 GANGRENE OF THE LIVER. 
 
 The cause of this lesion is not well understood. Are we to be^ 
 lieve that it is an affection originally gangrenous ? or are we to 
 believe that the gangrenous termination is an effect of inflamma- 
 tion ? To me, it appears to be the result rather of inflammation of 
 peculiar intensity, in persons of a certain kind of constitution, than 
 of a gangrenous form of inflammation. The course of phenomena, 
 or rather of the process, seems, in general, in cases of this nature, 
 to be as follows. First, inflammatory action or vascular congestion 
 distends and overloads the vessels of the part, and causes interstitial 
 extravasation of blood, of lymph, and of serum ; secondly, by this 
 the tenacity, pliancy, and elasticity of the texture are destroyed ; 
 it becomes friable, lacerable, and easily softened ; its physical pro- 
 perties are altered and impaired ; and its vital properties are en- 
 feebled ; thirdly, as this action or inaction continues, the texture of 
 the part is still more completely changed from its normal state ; 
 and at length, on any slight increase in the morbid distension, the 
 parts, already deprived, in a great degree, of their vital pro- 
 perties, give way ; vessels are broken open, and expose their con- 
 tents ; parts lose their cohesion ; and the process of gangrene, 
 which is a mixture of the mechanical with the weak vital, is esta- 
 blished. 
 
 On the other hand, gangrenous suppuration of the liver may 
 follow the formation of an external gangrenous sore. 
 
 In the collection of pathological drawings made by the late Dr 
 Thomson, is an instance in several respects important. A person 
 attempted to destroy himself, first, by cutting his throat, and after- 
 wards by discharging a pistol at his forehead. Death did not ensue 
 immediately. The wound of the throat mortified ; and exfoliation 
 from the frontal bone took place. After death, which took place 
 in about ten days, a large abscess, with ragged, dark-coloured, 
 softened walls, was found in the upper part of the right lobe of 
 the liver.* 
 
 In this remarkable case, we observe the illustration of two pa- 
 thological principles, which I have attempted to establish. First, the 
 abscess in the liver was evidently secondary, and consecutive either 
 on the wound in the frontal bone, or on that in the throat, most 
 likely the former. The suppurating process in the medullary mem- 
 brane of the frontal bone, rendered necessary to eject the dead 
 
 * A Practical Treatise on Diseases of the Liver and Biliary Passages. By William 
 Thomson, M.D., and the private collection of that gentleman. 
 
878 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 bone and lieal the living one, gave rise to the formation of matter, j 
 which was conveyed by the vessels of the bone by the veins to the 
 liver.’ Secondly^ as this purulent collection was then forming 
 within the liver, it was struck with sphakelus, most likely in conse- 
 quence of the previous mortified and sloughing state of the wound 
 in the throat. 
 
 Tt is necessary to distinguish gangrene of the liver from those 
 changes in colour, — blue, black, dark-green, dark-brown, mottled 
 dark-green and brown, which are so common in this organ. These 
 colours are effects of mere death changes. No change in colour, 
 without an evident change in consistence and demolition of struc- 
 ture, can be received as indicating the presence of gangrene. 
 
 It has been supposed that hemorrhage may be the cause of gan- 
 grene. It seems rather the effect in the majority of cases. 
 
 § 4. Malakosis. — Softening of the Liver has been observed, 
 in certain circumstances, to take place. The substance of the liver 
 is then soft, friable, easily torn and broken down between the fin- 
 gers ; and, in some instances, the change in cohesion is so great, 
 that the hepatic substance resembles softened spleen. 
 
 Dr Marshall met in Ceylon with instances of softening of the 
 liver without other remarkable change. In other instances the 
 parenchyma was granular, and broke down between the fingers, 
 while the peritoneal coat came away with unusual facility. He 
 mentions one case in which the liver was softened in such a man- 
 ner in a patient with dysentery, that the pulpy substance resembled 
 hasty pudding. The liver weighed in this case pounds — more 
 
 than double the average. In all such cases the softening is the 
 effect of a species of vascular congestion or orgasm. 
 
 Of this lesion, Andral distinguishes two varieties, — one indi- 
 cated by the red colour of the hepatic substance ; the other by a 
 pale or whitish colour. In the former, the substance presented th^„ , 
 appearance of softened spleen ; in the latter, of a species of gray^ 
 coloured pap, and with little blood in the tissue. In the former 
 case, the softening appeared to be the effect of inflammation of the [ 
 peritoneum, general and hepatic. In the latter case, it appeared 
 to be the result of lesion of nutrition ; as the gall-bladder contained 
 not bile, but colourless and insipid serum. The latter also appears 
 to be more chronic in its progress and duration than the former.* 
 
 § 5. Hepatic Phlebitis Inflammation of the veins of the liverijtf 
 
 is not very frequent ; and when abscesses and purulent collectionsj* 
 
 * Case by M. Snetiwy. Oesterreich. Med. Wochenschrift. 1842. N. 32. 8S,' 
 
 
HEPATIC PHLEBITIS. 
 
 879 
 
 are found within the gland, these are the result either of inflamma- 
 tion of the parenchyma or of the transporting property of the veins, 
 which, however, themselves remain unafiected. Inflammation may 
 nevertheless aflFect veins either spontaneously or from the irritation 
 of foreign bodies. 
 
 M. Lambron records the case of a man of 69 who was attacked 
 with squeamishness, sickness, uneasiness in the right hypochondre, 
 and irregular shiverings. In the course of four days, jaundice ap- 
 peared slightly, and increased in the subsequent three days. At 
 the end of one week, the shiverings, which had not been very dis- 
 tinct, were present in the evening, generally with hiccup, and imi- 
 tated the rigors of ague. The symptoms continued with great 
 and increasing weakness ; and the patient expired on the 25th day 
 from the appearance of well-marked symptoms. 
 
 Inspection revealed the following state of parts. The portal vein 
 was filled with wine-lee matter and purulent matter ; in the trunk 
 of the superior mesenteric vein a fish-bone, which, implanted in 
 the head of the pancreas, had entered the anterior wall of this vein 
 from before backwards, and was fixed in the posterior wall of the 
 same vein. This bone was about 3 centimetres, or one inch and a 
 little more than a line long ; as thick as a stout pin ; yellowish, hard, 
 and resisting ; and the extremity was twisted like a cork-screw. The 
 cavity of the mesenteric vein was obliterated by slate-gray false mem- 
 brane. Below this obliteration the divisions of the superior mesente- 
 ric were sound, but contained fibrinous clots of blood. The splenic 
 vein was in size, colour, and consistence normal ; but it contained 
 a quantity of wine-lee coloured matter ; and the same matter was 
 found in the divisions of the portal vein, while its sinus was filled 
 with purulent matter mixed with blood. The liver presented no 
 metastatic abscess ; but its tissue at the level of the portal sinus 
 was very much softened. The sub-hepatic veins were sound.* 
 
 The same observer gives the case of a man of 48, who had been 
 ill for eight days with debility, slight fever, and was incoherent 
 at admission. Four days after he had violent and distinct rigors ; 
 while it was observed that the size of the spleen was palpably 
 enlarged. The rigors underwent temporary abatement; but 
 
 * Observations d’Inflammation de Veines du Foie. Imo, de la Veine-Porte pro- 
 duite par une arete de poisson ; 2do, des veines sus-hepatiques, due au voisinage d’un 
 abces metastatique. Par Ernest Lambron. Archives Generates. Juin 1842. Tom. 
 lix. p. 129. 
 
880 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 without improving the condition of the patient ; and in rather more 
 than three weeks they returned, accompanied with delirium, fol- 
 lowed by profuse sweatings and diarrhoea. In ten days more 
 death followed, the whole duration of the illness having been 
 about 73 days. 
 
 At the pyloric end of the stomach was an ulcerated cancer, 
 which had destroyed the mucous membrane to the extent of more 
 than a shilling. The liver was in size normal, but yellowish, and as 
 if fatty ; and part of it was dotted with red points, which were traced 
 to the inter-lobular veins. Disseminated in the hepatic substance 
 were seven or eight purulent collections, which looked like metas- 
 tatic abscesses. The largest of these was the size of a hen’s egg. 
 One of these abscesses was situate near one of the trunks of the 
 sub-hepatic veins, as they enter the vena cava, where that vessel is 
 attached to the base of the lobule of Spigelius. This abscess had 
 caused inflammation in the venous trunk, so that the latter showed, 
 at some lines from its opening into the vena cava, an ulceration about 
 eight millimetres (/g of one inch) in diameter, while matter easily 
 flowed from the abscess into the cavity of the vessel. The portion 
 of the vein between the ulceration and the vena cava was quite 
 covered with lymph sufiiciently thick to protect the interior of the 
 vein from the entrance of the purulent matter. Above the ulcera- 
 tion the vessel was intensely inflamed ; and its area was obliterated 
 by lymph and fibrinous clots. The circulation was thus completely 
 interrupted.* 
 
 This disease is generally fatal. Yet I have stated in a former 
 part of this work, (p. 127,) that I have met with a case in which 
 the trunk of the portal vein, together with those of the splenic 
 and superior mesenteric veins, were completely filled and obstructed 
 by a solid coagulum of lymph apparently, or lymph with fibrin of 
 blood. 
 
 In this case it is probable that the obstruction or closure 
 of the vein in this manner must have arisen from one of two 
 causes ; either inflammation within the vein, or pressure exter- 
 nally. If the former were the cause, then the closure was perhaps 
 
 * These cases have since been quoted in a German journal, in order to prove that 
 splenic inflammation and enlargement is the primary cause of intermittent fever, not 
 the effect ; and in order to accomplish this, the speculator has added to the report of 
 the first case, that the spleen was strongly developed and distinctly circumscribed, and 
 in the second, that its volume was evidently increased. 
 
HEPATIC HEMORRHAGE, 
 
 881 
 
 one means of averting the immediate fatal termination. In this 
 person further, the right lohe of the liver was so much shrunk 
 and diminished, that the whole organ weighed only about one- 
 fourth of its usual amount ; while its shape was greatly altered, 
 being rounded and drawn from the sides and circumference to the 
 centre ; so that the whole gland was represented by a small shrunk 
 left lobe. The effect of this lesion, which is one species of atrophy, 
 was obstinate and incurable ascites. 
 
 § 6. Hepatorrhagia. — I am quite satisfied that occasionally 
 the biliary ducts and the liver pour out blood, which is discharged 
 into the intestinal canal. I have more than once seen in patients 
 large quantities of blood-coloured bile, and even blood discharged 
 in this manner, which I am satisfied came from the biliary ducts 
 and the port biliarii^ in which this liquid had been poured out 
 abundantly. This is a species of hepatic haemorrhage. 
 
 Another variety, however, of hepatic haemorrhage takes place, 
 one in which blood is poured into the substance of the liver, which 
 is rent and lacerated, much as is the brain in apoplexy. Sir G. 
 Blane gives, in a boy of eight, a case in which, after eight days of 
 illness, ending fatally, several fissures were found in the left lobe of 
 the liver, and much blood was effused within the abdomen.* M. 
 Andral mentions the case of a person who, without any previous 
 complaint or indication of illness, felt one morning on awaking, 
 pains in the abdomen, and accordingly remained in bed. In the 
 course of a few hours he was found dead. The peritoneal cavity 
 was filled with a large quantity of dark-coloured blood partly 
 coagulated ; and several clots were found between the diaphragm 
 and the convex surface of the liver. Near the centre of the right 
 lobe, on the convex surface, was an opening of sufficient size to 
 admit the tip of the little finger, and which was the orifice of a 
 cavity in the hepatic substance as large as a pippin, and filled 
 with blood. A large vessel which had been rent opened on a 
 point in this cavity ; and this vessel was found to be a branch of 
 the portal vein. The surrounding parenchyma was healthy.f 
 
 Dr Honore presented, in 1 834, to the Academy a liver, in which 
 were several cavities containing blood. It was uncertain, however, 
 whether this proceeded from torn vessels or was the effect of exha- 
 lation. 
 
 M. Louis mentions one case in which, along with an abscess, 
 
 * Transactions of a Society, Vol. ii. p. 18. London, 1800. 
 
 t Medecine Clinique. Partie Vieme. Livre Ilieme. Set. 1. chap. iii. 
 
 3 K 
 
882 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 there was in the liver a cavity as large as a nut, containing blood 
 coagulated in concentric layers. No laceration in any of the blood- 
 vessels was recognized. 
 
 Instances of this lesion have been given also by Dr Heyfelder 
 and Dr James Abercrombie. In the former case, which took place 
 in a man of 60, the heart was affected with hypertrophy of the 
 right ventricle, and the rent, which was in the right lobe of the 
 liver, communicated with the laceration in the portal vein.* In the 
 latter, which occurred in a lady of 35, who had been several years 
 in India, the liver presented, at its anterior and upper surface, a 
 large sac, containing two pounds of blood. This sac was the peri- 
 toneum. The blood had escaped from a branch of the portal vein. 
 The accident occurred in the eighth month of pregnancy. The 
 liver was softened, lacerable, and pulpy.f 
 
 The causes of this lesion and its external effects are equally un- 
 known. 
 
 In those affected with scurvy, the liver, as other organs, is liable 
 to present effusions of blood, which, *in this case, undergoes imper- 
 fect coagulation. 
 
 § 7. Traumatic Laceration and Hepatorrhagia. — In falls 
 from a considerable height, especially on hard ground, and after 
 death by heavy bodies which have passed over the trunk, laceration 
 and hemorrhage of the liver is by no means uncommon. On the 
 1st of January 1824, three soldiers, in attempting to get out of 
 Edinburgh Castle, mistook their way in the dark, and fell over the 
 perpendicular side of the rock. They were found dead next morn- 
 ing ; and in all the liver was lacerated. 
 
 Cases of rent either from violence or falls are given by Morgagni 
 and Dr Pearson and instances of the same accident from the 
 transit of a carriage or waggon over the trunk or abdomen are 
 given by various authors. 
 
 In all these cases, hemorrhage to a greater or less extent takes 
 place ; and as the blood flows into the cavity of the perito- 
 neum, if life be not immediately or speedily extinguished, the quan- 
 tity may be estimated by the degree of swelling which takes place,' 
 with the dull sound always emitted on percussion, when blood is 
 contained within the abdominal cavity. 
 
 * Memoire sur plusieurs Maladies du Foie. Par Dr Heyfelder. Archives Gene- 
 rales, t. li. p. 468. Paris, 1839. 
 
 ■f London Medical Gazette, September, 1844, Vol. xxxiv. p. 507 and p. 792. One 
 case twice given. 
 
 + Transactions of College of Physicians, vol. in. art. xxiv. p. 377. London, 1785. 
 
HYPERTROPHY OF THE LIVER. 
 
 883 
 
 Death is, in these cases, generally immediate, or at most follows 
 in no long time. A young boy of five or six was crossing the street 
 at the South Bridge, about two o’clock in the day. He was 
 knocked down some way by a carriage passing, and one if not both 
 wheels passed over the trunk before the coachman could stop his 
 horses. The boy was taken up immediately and brought to the 
 Infirmary, where I was at the time. He was quite dead ; and it 
 was manifest, from the appearance of the abdomen, which was al- 
 ready enlarged, that blood was copiously escaping into its cavity. 
 When the body was examined next day, it was found that the liver 
 had been much crushed, and had not only been rent across the 
 right lobe, but as if broke down. About four or four pounds and a 
 half of blood in clots and fluid were found in the abdominal cavity. 
 
 My limits do not, however, allow me to say more of these cases, 
 nor of the important order of wounds of the liver, for information 
 on which I refer to the writings of military surgeons. 
 
 § 8. Hypertrophy By hypertrophy is meant increase of the 
 
 liver in size and weight, without any palpable change in structure. 
 The normal weight of the liver varies at different ages, in the two 
 sexes, and according to the size and stature of the individual. In 
 general, in an adult of between 25 and 35 years of age, and of the 
 height of 5 feet 8 inches, the liver will weigh about three lbs., anA 
 from two to six ounces imperial weight, or about 53 ounces. In 
 general, it may be stated that the weight of the liver is between the 
 29th and 30th part of the weight of the whole person.* 
 
 * Facts and Inferences relative to the Condition of the Vital Organs and Viscera in 
 general, as to their Nutrition in certain Chronic Diseases. By John Clendinning, 
 M. D., &c. Medico-Chirurgical Transactions, vol. xxi. p. 33. London, 1838. 
 
 Mr Marshall gives several important facts regarding the weight of the liver in the 
 troops in Ceylon. Of 55 livers belonging to Europeans that died of fever, 25 were 
 deemed sound. The average weight of these livers was 4 pounds 6 ounces. The ex- 
 tremes were 6 pounds and 3 pounds 7 ounces. 27 appeared unusually soft. The 
 average weight of this division was 4 pounds IS ounces. The largest weighed 6 pounds 
 8 ounces ; the smallest 3 pounds 1 3 ounces. Two were found indurated. One weigh- 
 ed 2 pounds 10 ounces ; the other 10 pounds. Mr Marshall states afterwards, that 
 of two examples of indurated liver, in which the gland cut hard and gritty under the 
 knife, and in both of which the liver was rounded or drawn together like a ball, 
 without any of the usual distinctions into lobes, one weighed 3 pounds, the other 4 
 pounds. [This is hi'irhosis.'] He adds, that “ the livers of European soldiers were 
 found to vary in weight from 2J pounds to 5 pounds, without any satisfactory trace 
 of pre-existing disease.” — Notes on the Medical Topography of the Interior of Ceylon. 
 By Henry Marshall, Surgeon to the Forces. London, 1821. P. 141, and 151 and 152. 
 
 These numbers are higher, on the whole, than those which we have been accustom- 
 ed to observe in this country. I have weighed a great number of livers at the Royal 
 
884 
 
 GENERAL AND PATHOLOGICAL ANATOMY, 
 
 Above this standard the weight of the liver may rise greatly ; 
 for instance, to G, 8, 9, or even 10 pounds; and its volume is pro- 
 portionally increased. At the same time, the organ is in a high 
 degree vascular, firmer than natural, and cuts hard under the knife. 
 The intimate structure is generally understood not to be impaired, or 
 in any way changed ; and in one sense this is correct. The structure 
 resembles, except in increased firmness and greater vascularity, the 
 usual structure of the liver; yet, when examined carefullyand closely, 
 the granular tissue of the organ appears more fleshy than in the nor- 
 mal state, and occasionally portions of the liver are harder than the 
 surrounding texture. In certain periods of the disease, which I 
 supposed must be more advanced, the vascularity of the organ ap- 
 ])ears diminished ; at least less blood escapes from incisions. 
 
 The increase in volume which the liver acquires, when enlarged 
 hy hypertrophy, may be very considerable, and with its increase in 
 weight, produces great uneasiness and derangement in some of the 
 thoracic and all the abdominal visce^’a. The gland is enlarged in 
 all its dimensions, and may press up the right side of the diaphragm 
 and right lung, wliile it prevents the diaphragm from descending 
 freely. It also thrusts upward the tendinous centre and the heart a 
 little. These effects, nevertheless, vary according to the posture of 
 the patient. Thus, in the horizontal position, the hypertrophied 
 liver is decidedly higher up in the right side of the chest than in 
 the erect. In the latter, while its bulk prevents the free descent 
 of tlie diaphragm, its weight draws that muscle downward. In the 
 abdomen it may come down as low as the crest of the os ilium^ 
 while at the same time it extends beyond the median line into the left 
 hypochondriac region, and makes usually a decided bulging pro- 
 minence in the right hypochondriac and epigastric regions. From, 
 the circumstance of the liver lying transversely below the diaphragm, 
 this bulging is generally more marked above than below, the gland* 
 being tied closely to the diaphragm by its ligaments. ' 
 
 The hypertrophied liver usually has contracted preternatural ad- 
 hesions with the neighbouring organs; the stomach; the transverse 
 
 Infirmary, and generally found those supposed to be free from disease to be from ?j 
 jiounds to d pounds 5 or 6 ounces. Very rarely did they ascend to 4 pounds, 
 unless in conjunction with jialpable marks of disease. In females, the weight was 
 usually about 2 pounds 10 ounces to 3 pounds. One fatty liver in a young female 
 (lead of consumption I found to weigh 8 pounds and 7 or 8 ounces. The low weight 
 of the liver given by Mr Marshall is less astoni.shing than the high weight within tlie 
 limits of healthy structure. These weighty livers were probably hypertrophied. 
 
HYPERTROPHY OP THE LIVER. 
 
 885 
 
 arch of the colon; the duodenum, or the pancreas, or cdl these at 
 the same time. 
 
 Instances of hypertrophy of the liver have been long observed. 
 They were seen by Morgagni, Bianchi, Bang, Stoll, Portal, Fo- 
 dere, Baillie, Bailly, and all who have observed the morbid changes 
 incident to this gland. The lesion is at present common in differ- 
 ent forms and degrees. 
 
 Hypertrophy may be the effect of the third variety of inflamma- 
 tion, the acute, congestive, or enlarging. But more commonly it 
 advances slowly and steadily, until the size of the organ and its 
 projection under the right hypochondriac margin and the epigas- 
 tric region renders the enlargement no longer doubtful. As it 
 advances, it gives rise to effusion of serous fluid within the abdo- 
 men. 
 
 Hypertrophy, both in moderate and extreme degrees, arises in 
 this country from the intemperate and long continued use of spirits. 
 One of the most marked instances of the disease which have come 
 under my notice, in which th^ liver projected fully four inches be- 
 low the margin of the right hypochondre, arose in this manner. 
 When first seen, it was in the early stage, with symptoms of inflam- 
 matory and vascular congestion. Under the use of remedies 
 chiefly depleting, the size of the organ was reduced, and the drop- 
 sical effusion within the peritoneum disappeared. But when the 
 patient left the hospital, he returned to his previous habits, and in 
 no long time came back, with the liver as large, heavy, and pro- 
 minent as before. He soon sunk under the disease. The liver 
 was found to weigh upwards of 10 pounds. 
 
 Instances of the disease I have seen come from Norfolk, in some 
 parts of which county it is the effect either of ague or the physical 
 causes of that disease. The change has also been observed in all 
 aguish and marshy districts ; in Lincolnshire and some parts of 
 Essex in England ; in the department of the Maritime Alps, ac- 
 cording to Fodere; in the island of Walcheren and many parts 
 of Holland ; in the Maremma in Italy ; in the marshy and low coasts 
 of the W est India Islands ; and in various parts of the East Indies. 
 In these situations, hypertrophy of the liver may either follow one 
 or more attacks of ague, most usually quartan ague, or it may be 
 established slowly and steadily without being preceded by any dis- 
 tinct attack of this disease. In these circumstances, it is clear that 
 the hypertrophied state of the gland arises from a previous long 
 continued vascular orgasm or congestion. This congested state of 
 
886 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the liver, however, is always preceded and accompanied with a 
 greatly deranged condition of the vascular system of the stomach, 
 duodenum, and whole intestinal canal. 
 
 In this disease the gall-hladder usually contains thin watery hile ; 
 the surface is more or less tinged yellow ; and the intestinal dis- 
 charges are' light coloured. A state of anaemia with ascites follows. 
 
 § 9. Atrophy. — The term Atrophy of the Liver has been ap- 
 plied" to more than one state of that organ ; certainly to two at 
 least. The first is a state of diminished size, with contraction, as it 
 were, of the parenchyma in all directions, from the periphery to the 
 sinus of the vessels, and often mostly in the left lohe, sometimes 
 with persistence of its parenchyma, though diminished in volume, 
 sometimes with the disappearance of the red, vascular, or acinoid 
 tissue of the gland, and the substitution of a whitish dense tissue, 
 which is manifestly the cellular substance of the gland. The second 
 consists in diminished volume also of the organ, but with more or 
 less induration, and a granular or tubercular appearance of the 
 liver; in short, one of the forms of kirrhosis. Thirdly, I have 
 mentioned an instance in which the whole gland, but especially the 
 right lobe, was shrunk and contracted to about one-third, or be- 
 tween that and one-fourth of its usual size, in connection with an 
 obstructed state of the portal vein. 
 
 It is not easy to say, in the present state of our knowledge, to 
 which of these states the term Atrophy ought to he confined. One 
 point is clear, that the name includes, according to present usage, 
 several morbid states of the liver, which are in all probability dif- 
 ferent, and proceed from different causes. It is clear that the con- 
 tracted state of the liver in kirrhosis ought not to he regarded as an 
 instance of atrophy, though part of the hepatic tissue in that dis- 
 ease is atrophied. The shrunk and contracted state of the gland 
 in that affection is secondary and consecutive. 
 
 That there are cases in which the glandular matter of the liver 
 is diminished or atrophied must be allowed, from such cases as that 
 given by Andral, part v. livr. ii. chap. iii. section ii. obs. 12. 
 
 § 10. Moschatismus Jecoris In certain circumstances, the 
 
 liver, when divided, presents on the surface of the sections a mot- 
 tled or party-coloured aspect of brown-coloured spots, set in a 
 lighter coloured basis, so as to resemble the section of the nutmeg. 
 It is very doubtful whether this appearance indicates any change in 
 structure. The dark-coloured spots appear to be merely sections 
 of granules or lobules which have been largely injected with blood. 
 
GRANULATED LIVER. KIRRHOSIS. 
 
 887 
 
 while the light-coloured basis retains its normal colour. This nut- 
 meg aspect of the liver- is connected with certain states of the vas- 
 cular system of the chest and abdomen, in which some impediment 
 is presented to the circulation of the blood. Thus it takes place 
 in various affections of the heart, hypertrophy, valvular contraction, 
 and similar affections, in which the blood of the vena cava does not 
 easily return to the heart, and in which consequently the vena cava 
 hepatica is inordinately distended. It may also take place in con- 
 sequence of some morbid states of the abdominal circulation. 
 
 § 11. Jecur Granulatum. — Jecur Tuberculatum, — Kir- 
 
 RHOSis. It has been already mentioned, that, in consequence of , 
 
 inflammatory congestion, the liver is liable to become hardened, 
 and as if tuberculated or granulated. It may be that this is the 
 early stage of the state which is to be described under this head by 
 the name of Granulated Liver, Tuberculated Liver, and to which 
 Laennec applied the epithet of Kirrhosis. To English observers, 
 it was known partly under the name given by Baillie of Tubercu- 
 lated liver, and more frequently in its exquisite form under the 
 name of hob-nailed liver. 
 
 Kirrhosis appears under two forms, one an early, another a 
 more advanced and perfect. 
 
 In the early form of the disease the substance of the liver is 
 firm, doughy, yet not irregular. The surface is coloured with 
 patches of yellow, variable in size. The whole organ is in gene- 
 ral somewhat enlarged, and usually weighs between four and five 
 pounds or more. When divided it appears of an orange red co- 
 lour, or between that and orange brown ; sometimes with patches 
 of this colour diffused through the natural colour of the gland ; 
 and when a slice is immersed in water it soon imparts to the water 
 a green colour, which is repeated after several immersions. Closely 
 examined, the section shows innumerable small bodies like millet 
 seed or grains of barley, of an orange colour, dispersed through its 
 substance. Such livers are vascular in the red granular portion 
 mostly. 
 
 This lesion does not usually prove fatal of itself at this stage ; 
 but persons occasionally die with the liver in this state, from dis- 
 ease of the heart, granular disease of the kidneys, fever, or disease 
 of the intestinal canal. 
 
 In a more advanced stage the surface of the liver preseuts at 
 various parts small irregular shaped elevations like the heads of 
 vetches or peas, separated by irregular linear furrows. These ele- 
 
888 
 
 / 
 
 y 
 
 GENEPwVL AND rAT>f6L0GlCAL ANATOMY. 
 
 .r' 
 
 vations may not extend over the whole liver, but occupy at first 
 only one part, viz. gene/ally the convex surface. When the peri- 
 toneum is stripped, M'hich is always difficult to be done, it is ob- 
 served that the .elevations are the prominent parts of roundish or 
 irregular-shapdd bodies about the size of tares or small peas, and 
 some as large as peas. The colour of these bodies is orange-brown 
 or wood-brown, sometimes a shade lighter than the colour of the 
 sound liver. A section of such presents an aggregation of bodies 
 varying in size, affecting a roundish irregular outline, united or 
 separated by whitish fibrous or filamentous lines. The liver in 
 these parts is decidedly firmer and harder than in the last describ- 
 ed case. Other parts of the liver are firm, doughy, and generally 
 of the orange-yellow or orange-brown tint. 
 
 The liver in this state may not be larger than usual, and if it be, 
 it is only in a slight degree larger. 
 
 Sections of this sort of liver, when macerated in water repeatedly 
 changed, continue long to impart a green colour to the liquid. 
 
 In the most complete form of the disease the appearance of the 
 liver is the following. The liver is seldom larger than natural. 
 It either retains its normal size, or it is smaller, and apparently 
 shrunk and contracted. The whole surface of the liver presents the 
 appearance of numerous irregularly round bodies, elevated so as 
 to give the organ an irregular tuberculated or knotty look. These 
 eminences are as large as peas or small beans, a few larger. Their 
 colour externally is of that light brown usually designated wood- 
 brown. They are separated by well-marked linear furrows, which 
 seem all continuous, so that the surface of the liver presents a re- 
 semblance to a shoe covered with hobnails. This appearance ex- 
 tends over the whole surface of the liver ; but in general it is most 
 distinct and conspicuous on the convex surface. 
 
 The shape of the liver is at the same time in general more or 
 less altered. The convex surface is more decidedly convex ; the 
 anterior edge is obtuse, thick, and as it were bent downwards ; all 
 the sharp edges are rounded or obtuse : and in general, by the 
 bending downwards of the right and left margins, and the anterior 
 margin, the lower surface is more concave than in the natural 
 state. The last character, however, may be wanting ; and the 
 lower surface either remaining even, though irregularly granulated, 
 or partaking in the general elevation, the whole gland appears 
 thick, but rounded, and contracted aj)parently towards the sinus 
 of the vessels. 
 
GRANULATED LIVER. KIRRHOSIS. 
 
 889 
 
 When sections of a liver in this state are made, these sections 
 present the same appearance of irregularly rounded bodies aggre- 
 gated together, as is seen at the surface. The colour is in general 
 more of the orange-yellow tint, or that combined with wood-brown. 
 These bodies are united by a species of gray filamentous or liga- 
 mentous tissue ; and both structures become more distinct on im- 
 mersion in water, and after boiling. 
 
 These bodies, though affecting the globular figure, vary much. 
 Many are ovoidal or spheroidal ; many are irregularly angular ; not a 
 few are elongated with rounded or angular ends ; and some look like 
 the small stony fragments set in porphyry, or a small grained breccia. 
 
 In size also they vary. Some are, as already stated, as large as 
 good sized garden peas ; and this volume they do not often exceed. 
 Others are smaller, of the magnitude of dried peas ; others, again, 
 like tares or vetches ; and some not larger than millet seed. All 
 are mixed confusedly together without any order. 
 
 The peritoneum may be stripped from these bodies ; and they 
 then present the appearance of an aggregation of orange-brown or 
 wood-brown looking bodies, all closely united and packed. This 
 close conjunction is evidently the cause of their variation in size 
 and shape ; for it is manifest, that if all were round, they could 
 neither touch each other nor be of the same size; whereas, beino- 
 diflPerent in size, the small bodies are interspersed between the large 
 ones ; and the shape of all is modified by tbe contiguous bodies. 
 
 In general, I tbink in the cases examined by me, the bodies at 
 tbe surface are both larger and more regularly rounded than those 
 in the substance of the liver. 
 
 I have several times macerated sections of kirrhotic liver; and 
 I always found that they required a long time, months at least, to 
 part even with a portion of their greenish colouring matter. In 
 several cases I kept slices of granulated liver, for spaces of from 20 
 to 24 months, in water periodically changed, before attempting to 
 put them in spirits ; and even then, in the course of a few weeks, 
 the spirits were completely coloured green, and required to be 
 changed ; and the spirit in which the section so prepared was im- 
 mersed, was again tinged green. This fact shows the tenacity with 
 which the colouring matter adheres to these granules. 
 
 This green colouring matter is precipitated by the addition of 
 hydrochloric acid. A fatty matter is taken up by ether. 
 
 From the prominent characters now described, Morgagni applies 
 to this state of the change the name of jecur granulatum ; Baillie 
 
890 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 terms it tuberculated liver ; many physicians, both in this country 
 and abroad, term it granulated liver ; and Laennec applied to it 
 the name of kirrhosis, or yellow degeneration of the liver, from the 
 colour which the liver so changed often presents. 
 
 Besides the forms now described, the disease in certain instances 
 appears in the form of yellow matter dispersed through the sub- 
 stance of the liver like peas ; or presents an appearance similar to 
 the vitellarium of the common fowl. 
 
 In some instances small empty cavities are found in the interior 
 of the granulated liver ; and in others are small cavities containing 
 a greenish jelly-like liquid of little consistence. This, which 
 appears to have been observed by Portal, is made the ground of 
 another stage of the disease more advanced than the one last men- 
 tioned. The distinction I think entirely useless, as the state men- 
 tioned is found, though not very often, in the state already describ- 
 ed as the third stage. 
 
 Laennec, who considered this yellow matter a new formation, 
 characteristic of the lesion, admitted three forms of hirrhosis ; one 
 in masses, a second in patches, and a third in cysts. This idea of 
 the separate new morbid formation has not been generally recog- 
 nized ; and it is probable that these distinctions, which apply rather 
 to the external form than the essential character of the lesion, are 
 fanciful. 
 
 A liver in the exquisite and perfect form of granulation presents 
 in its snbstance appearances so characteristic, that, though not 
 easily described, they have attracted general attention. The 
 orange-coloured matter has been sometimes described as like sole- 
 leather, when attempted to be cut by the knife ; and in other in- 
 stances the section has been compared to impure bees wax. Both 
 of these statements are either inaccurate or exaggerations. The' 
 granulated liver is certainly not so tough and inflexible as sole lea-' 
 ther ; neither does it present the hard yet friable property of yel- 
 low bees wax. It resembles a solid, close, dense, fleshy mass, con- 
 sisting apparently of numerous small bodies irregularly aggregated 
 together, which, when closely inspected, are of an orange or orange- 
 brown colour. 
 
 This disease tends certainly and invariably to the formation of 
 incurable abdominal dropsy. At first the liver is larger than usual ; 
 but afterwards it returns to its normal size, though not to the 
 normal shape, or it becomes smaller and shrunk, as already de- 
 
GRANULATED LIVER. KIRRHOSIS. 
 
 891 
 
 scribed. I have seen three persons among about 32 cases die with 
 intestinal hemorrhage. Becquerel observed this five times in 42 
 cases. 
 
 It is not uncommon for the granulated liver to he affected with 
 superficial or peritoneal inflammation, and thus to contract adhe- 
 sions to adjoining parts. In two cases I found the convex surface 
 adhering extensively by false membrane to the diaphragm. This 
 might have taken place previous to the granular transformation. 
 I have seen the liver also adhering in this state to the stomach, and 
 to the duodenum. 
 
 Sometimes the gall-hladder is found thickened, and adhering 
 preternaturally to adjoining parts. 
 
 The capsule of Glisson is usually thickened, and appears to have 
 been the seat of chronic inflammation. 
 
 The state of the bile varies. In some cases it appears not per- 
 ceptibly changed. In others it is dark-coloured, viscid, ropy. In 
 a few it is liquid, light-coloured, and manifestly serous. In these 
 states there appears to be nothing regular. 
 
 Attenda^jt lesions. — Kirrhosis may take place alone, that is, 
 without lesion of other organs, or at most with a morhid state of 
 the alimentary canal and its mucous membrane. But it is more 
 common for it to be conjoined with lesions of other organs. The 
 most common morbid accompaniment in this country is granular 
 disease of the kidney ; and I have seen a great number of instances 
 in which the latter lesion was conjoined with kirrhosis either in the 
 early or in the advanced stage. Becquerel, who has studied the 
 lesion particularly in this view, found among 42 cases only 7 which 
 could be said to be simple or unconnected with lesion of other or- 
 gans. Among these were 19 in which the granulated state of the 
 liver was complicated or associated with the granular state of the 
 kidney ; in 2 1 kirrhosis was complicated with disease of the heart 
 in different stages, and in two with pericarditis. The most usual 
 cardiac lesion was hypertrophy of the left chambers ; hypertrophy 
 of the right chambers ; and changes in the valves of the left cham- 
 bers in the order now observed. In 9 cases he found pulmonary 
 emphysema ; and in one case pulmonary tubercles. 
 
 In this country the disease is not so frequently associated with 
 well-marked disease of the heart ; but in almost all the cases which 
 I have examined, there were traces of chronic bronchitis and em- 
 physema. 
 
802 
 
 GENERAL AND PATHOLOGICAL ANATOMY, 
 
 Though abdominal dropsy is the constant and invariable effect 
 of this lesion, so much so, that in every case of abdominal dropsy 
 which is unattended by manifest enlargement of the liver, it may 
 be inferred that this gland is in the granulated state, yet the dis- 
 ease may be followed or associated with other lesions which precede 
 the fatal event. Thus it may cause chronic peritonitis ; pleurisy, 
 especially the chronic form ; less frequently pericardial inflamma- 
 tion ; pneumonia occasionally ; pulmonary apoplexy ; and if not, 
 expectoration tinged with blood. 
 
 From the observations of Dr Eichholtz of Konigsberg, I infer 
 that the conjunction of granulated liver with granular kidney is 
 also frequent in Germany.* 
 
 The nature and cause of this degeneration has given rise to 
 much inquiry and considerable difference of opinion. We have 
 seen that Laennec imagined that it consisted in the formation of a 
 
 new morbid product, which was infiltrated into the substance of the 
 liver, which was liable to be formed in the same manner in the pa- 
 renchyma of other organs, and which appearing at first in an in- 
 cipient or nascent state, proceeded eventually to softening. It was 
 further the idea of Laennec, that as the kirrhotic bodies were 
 developed, the substance of the liver disappeared and was ab- 
 sorbed. 
 
 The correctness of this idea was first questioned by M. Boulland, 
 who denies the fact of a new' formation, and maintains that hirrhosis 
 consists in what he calls a dissociation of the elements of the liver, 
 viz. the glandular yellow portion and the red vascular portion. In 
 the early stage, he conceives that the vascular network is enlarged 
 and much loaded with blood. In the second stage, this vascular 
 netw'ork, which is interposed between the granules of the yellow' 
 portion, becomes impermeable, but large ; it assumes a colour va^ 
 rying from gray rose to pale green, and allows turbid serum to 
 escape. This idea implies that the granulated state of the liver is 
 owing to congestion.! 
 
 Andral ascribes kirrhosis to hypertrophy of the yellow or gra- 
 nular matter of the liver, while the red or vascular matter remains 
 either the same, or may be changed in colour to an olive-green, 
 
 * Ueber die Granulirte Leber und Niere, und ihr Verhaltnis zur Tuberciildsen 
 und Krebsigen Dyscrasie. Von Dr H, Eichholtz zu Konigsberg. Muller’s Archiv 
 fur Anatomic und Physiologie. Jahrgang, 1845. Berlin. Seite 320. 
 
 -f- Memoires de la Societe Medicale d’Bmulation. Tome ix. 
 
NATURE OF KIRRHOSIS, 
 
 893 
 
 witli increase or duninution in its volume ; the latter being the 
 cause of the shrivelling. * * * § 
 
 Cruveilhier, as well as Andral, denies the formation of a new 
 substance ; and considering the appearance and relation of the mi- 
 nute bodies constituting this change, he infers that they are part of 
 the acini or glandular granules of the liver in a state of hypertrophy, 
 while, in consequence of these hypertrophied granules, the others 
 are atrophied or wasted, f 
 
 In 1837, Dr Carsewell brought forward, on the nature and for- 
 mation of this disease, an hypothesis which has had in several points 
 several followers. Rejecting the idea of Laennec, that kirrliosis 
 depends on the formation of a new tissue. Dr Carsewell regards 
 the change as consisting in atrophy of the lobular, that is the glan- 
 dular structure of the organ, produced by the presence of a con- 
 tractile fibrous tissue formed in the capsule of Glisson. | This 
 idea has been more or less decidedly adopted by Mr O’Ferrall, 
 Mr R. W. Smyth,§ and some others : while part of the hypothesis, 
 that relating to the induration of the substance of the capsule of 
 Glisson, corresponds with an hypothesis presently to be mentioned. 
 
 In 1839, Dr Hallmann of Berlin announced formally in his 
 dissertation an hypothesis which had been in various modes and 
 quarters occasionally produced. This is, 1st, that in kirrhosis, 
 hypertrophy of the cellular or ligamentous tissue of the liver takes 
 
 * Clinique Medicale, Partie Vieme, Liv. Ilieme, Section I. Chapitre III. Paris, 
 1834. 
 
 The ideas of M. Andral regarding the granular liver are founded on his notions of 
 its natural anatomical structure. This is perfectly correct were these notions well 
 founded. But either these are not accurate, or they do not accord with the idea of the 
 majority of anatomical observers. He states that in the liver two substances exist na- 
 turally, so arranged as to represent the form of a sponge. One more or less white re- 
 ])i-esents the solid part of the sponge, contains large vessels which traverse without ra- 
 mifying in it, and consequently contains little blood. The other is a red substance, 
 extremely vascular, in appearance cavernous, and is deposited in the areola of this 
 white substance. 
 
 The white substance of which M. Andral here speaks appears to be the interlobular 
 and intergranular cellular tissue. The red substance is indeed vascular, and is con- 
 tained in its areola; ; but besides this, there is an orange or yellow substance, which 
 is the granular or acinoid, and which consists of the ends of gall-ducts throughout the 
 whole gland. 
 
 •f Anatomie Pathologique, LirTaison xii. Paris, 1837. 
 
 i Illustrations of the Elementary Forms of Disease. By Robert Carsewell, M. D. 
 London. Folio. 1838. Atrophy 2, Plate ii. 
 
 § Dublin Journal, Volume xxv. p. S21-.524. Dublin, 1844. 
 
894 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 place ; 2d, that in this hypertrophy of the hepatic cellular tissue 
 consists the essential character of the pathological change called 
 kirrhosis. These propositions he maintains that he proved, by 
 showing microscopically the increased quantity of cellular tissue 
 which the kirrhotic liver presents ; and chemically, by the quantity 
 of gelatin which he obtained by boiling from the kirrhotic liver, 
 and which is to that of the sound liver, by taking like weights, as 
 five to one. He obtained from three ounces of kirrhotic liver 66 
 grains of dry gelatin, and from the same quantity of healthy liver 
 only 13 grains. 
 
 Dr Hallmann further observes that the yellow bodies (granula- 
 tions, kirrhotic nodules) consist partly of cells filled with more or 
 fewer fat globules, and thereby often expanded beyond their 
 proper volume, and partly of large free fat globules. Their me- 
 dium diameter is about 106 thousandth parts of one Paris inch. 
 The fat may be forced from them by pressure ; but seldom do 
 they show a distinct nucleus. By maceration in solution of caustic 
 alkali, the fat is dissolved. The accumulation of fat within and 
 without the cells is not peculiar to the kirrhotic liver, but is 
 observed in the drunkard’s liver, and occasionally in livers reputed 
 sound. The basement tissue which surrounds the yellow granules, 
 consists partly of closely compressed cells, partly of thin compact 
 fibres, which are much more abundant here than in the sound 
 liver. From the several facts now specified, he concludes that the 
 toughness and hardness of the granular liver proceeds from an 
 augmentation of the cellular tissue of the capsule of Glisson, 
 caused by chronic inflammation.* 
 
 Imperfect as this hypothesis is, it is supported by Muller of 
 Berlin, who closes some interesting observations on the structure 
 of the liver with the following remarks. “ According to my 
 observations, kirrhosis consists principally in hypertrophy of the 
 interlobular ligamentous tissue', at the expense of the glandular 
 or lobular substance of the liver, by which individual lobules and 
 separate masses of lobules are removed and as if extruded from 
 the others in a striking manner. In a remarkable specimen of 
 kirrhosis in the Anatomical Museum, this is so palpable, that it 
 may be seen in the section of the liver by the naked eye. I con- 
 
 * Bemerkung uber die Lebercirrhose von Dr E. Hallmann. A Berlin. Muller’s 
 Archiv fur Anatomie, Physiologie, un Wissenchaftliche Medicin. Jahrgang. 1843. 
 Berlin. 475 . 
 
 4 
 
NATURE OF KIRRHOSIS. 
 
 895 
 
 jecture that kirrhosis depends on local dissimilar hypertrophy of 
 the interlobular or interacinous connecting tissue.”* 
 
 I mention the hypothesis of Muller in this place, because, though 
 not published till 1843, it appears that it had been taught by the 
 author previously. 
 
 Meanwhile Becquerel adduced in April 1840, a view which has 
 always appeared to me more consonant with the facts, and which, 
 in truth, I had myself maintained before the appearance of the 
 essay of that author. 
 
 Becquerel maintains that in kirrhosis the only tissue primarily 
 affected is the yellow substance of the liver ; that this yellow sub- 
 stance, which he should have called the glandular tissue, is infil- 
 trated with plastic or albumino-fibrous yellow matter, quite similar 
 to the false membranes of the serous tissues ; that from this results 
 hypertrophy of the yellow substance of the liver ; and that from 
 this hypertrophy arises at first compression, and subsequently 
 atrophy of the greatest part of the red or interlobular substance. 
 He further thinks, that, though it is difficult to speak positively on 
 the cause of the infiltration of this yellow matter in the glandular 
 . tissue of the liver, yet most probably it is the result of repeated 
 vascular congestions.! 
 
 It is impossible to doubt that this makes the nearest approach to 
 the correct explanation of the phenomena ; and as it is that which 
 I have for several years been in the habit of teaching in demon- 
 strations and lectures,! I do not hesitate to add a few words in 
 further explanation. 
 
 It has been formerly shown, that the hepatic substance consists 
 of three separate elementary tissues ; a red, or vascular ; an orange 
 or glandular ; and a gray or filamentous. 
 
 The vascular tissue consists of the capillary or minute vessels of 
 the hepatic artery, portal vein, and the origins of the hepatic 
 veins. This constitutes, in the healthy liver, and especially in 
 early life, the largest proportion of the gland. 
 
 Disseminated through this capillary network, which forms the 
 
 * Uber den Ban der Leber. Anmerkung zui Vorstehenden Abhandlung von Heraus- 
 geber. Archiv fur Anatomie. Jahrgang. 1843. Berlin. P. 343. 
 
 -|- B,echerches Anatomico-Pathologiques sur la Cirrhose du Foie. Par Alfred 
 Becquerel. Archives Generales de Medecine. Tomelii. Aral 1840. P. 398 et 407. 
 
 J Report on the Cases treated during the Course of Clinical Lectures delivered at 
 the Royal Infirmary in Session 1832-1833. By David Craigie, M. D. F. R. S. E. &c. 
 Edinburgh Medical and Surgical Journal, Voh xli. p. 112 — 118. Edinburgh, 1834. 
 
89(5 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 basis of the gland, is the second tissue, generally of an orange co- 
 lour, in the form of minute granules or atoms, which consist of the 
 terminal ends of biliary ducts, or what have been named acini. It 
 is not easy to say whether single acini, or groups and clusters of 
 acini., thus form these orange-coloured interposed granules. The 
 question is of little moment. The main fact, which it is important 
 to know and remember, is that this orange-coloured matter is sur- 
 rounded by or enclosed in the vascular network, as it were ; that 
 it is the proper ’granular or secreting part of the liver; and that it 
 is formed by the superior or terminal ends of the biliary pori. This 
 matter is much less abundant, and occupies much less space of the 
 gland, though disseminated through its entire substance. 
 
 The third substance is white or gray, and consists of filamentous 
 tissue, which encloses the vessels on the one hand, and the bile- 
 ducts on the other, throughout the whole gland, connecting all to- 
 gether in one body. This is supposed by some to be a prolonga- 
 tion or process from the capsule of Glisson, and thence to be con- 
 tinued along the vessels through the parenchyma of the gland. 
 There is no doubt that this hepatic cellular tissue is connected with 
 the capsule of Glisson, and may be traced from it; but it is of little 
 moment whether we admit that it is a prolongation of that capsule 
 or not. This third substance is easily known by the gray or whit- 
 ish intersecting lines which it forms all through the liver. 
 
 Now, of the three elementary tissues thus constituting the liver, 
 it is the second, viz. the orange-coloured granular substance, which 
 is primarily affected in kirrhosis. This affection consists in en- 
 largement and induration of the granular bodies, until they attain 
 the size, shape, and general appearance of kirrhotic granulations 
 or nodules ; in short, are hypertrophied. That this is the fact, I 
 conceive is proved, first by their appearance in complete states of 
 kirrhosis ; and, secondly, by the other phenomena which have been 
 mentioned in the general description. The appearance of granu- 
 lations of different sizes, from pin-heads up to the volume of peas 
 or hazel-nuts, can be produced only by the growth and enlarge- 
 ment of the original granular bodies of the liver. These bodies 
 are of different sizes, because necessarily the morbid process com- 
 mences in some granules, before others are affected ; and those in 
 which it first commences, must be, and are largest. Secondly, these 
 bodies contain the colouring matter and fatty matter of the bile, 
 indeed the parts that cannot escape by filtration ; and this circum- 
 
NATURE OF KIRRHOSIS. 
 
 897 
 
 stance alone is sufficient to show that the glandular or granular 
 portion of the liver is the part affected by kirrhosis. 
 
 It must not be forgotten therefore, that though the hypertrophy 
 affects the whole of the granular or orange-matter of the liver, it 
 affects it unequally ; some being more, others less affected. 
 
 As to the exact change induced in these bodies, it is most pro- 
 bable that the bile-tubes are first contracted, and eventually oblite- 
 rated by adhesive inflammation ; for little genuine bile ever reaches 
 the hepatic ducts, in the established form of the disease ; and in all 
 the largest tubercles, it is reasonable to tbink that the ducts are 
 either much contracted or completely closed. 
 
 The red or vascular portion of the gland is, at the same time, 
 ati’ophied ; and its waste or diminution appears in some instances 
 to proceed to a very great extreme. Baillie observed that the gra- 
 nulated liver contains little blood ; a fact which is confirmed by 
 daily observation. The granulated liver cannot be injected to any 
 extent. The small vessels are obliterated evidently by the pressure 
 of the granulated bodies on them. 
 
 It is, therefore, not hypertrophy of one set of granules, and 
 atrophy of another, as imagined by Cruveilhier, that is the essential 
 circumstance in kirrhosis, but hypertrophy of the whole of the 
 orange-coloured tissue, and atrophy of the vascular portion. 
 
 The reason why it has appeared to many that the granular part 
 could not be hypertrophied, when the whole liver was actually 
 smaller, is the circumstance, that they overlook the anatomical fact, 
 that, in the sound state, the granular portion of the li\ er makes but 
 a small proportion of the gland, while the vascular portion forms 
 the most considerable ; whereas, when hypertrophied as in kirrhosis, 
 the granular portion constitutes almost the whole. 
 
 Along with these changes, the interlobular, cellular, or filamen- 
 tous tissue is hardened, apparently by inflammatory adhesion. This 
 has been assumed to be the cause of the other changes ; but it is 
 manifestly merely a concomitant effect. It is always most remark- 
 able in the concave portion of the liver, and much less so in the 
 convex. Conversely the granular degeneration is usually most 
 complete and furthest advanced at the convex surface of the liver, 
 and least so in the neighbourhood of the capsule of Glisson and 
 the sinus. 
 
 The remote causes of kirrhosis are not very accurately known ; 
 and all the information which has been given on this subject is ra- 
 ther conjectural than positive. During the years 1817 and 1818, 
 
 3 n 
 
898 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 when my attention was first directed to the granular or tubercu- 
 lated liver, I inspected a considerable number of cases, several of 
 the subjects of which I had opportunities of seeing during life. A 
 good proportion of these cases, at least two-thirds, occurred in per- 
 sons who had been as soldiers in the expedition to Walcheren; 
 and after becoming acquainted with this fact, I inferred that it is 
 one of the states of liver disease induced by miasmatic poison. 
 Subsequent observation, however, satisfied me that this conclusion 
 is too limited. I afterwards met with instances of granular liver 
 in all its stages in persons who had not been in aguish districts. 
 Between 1831 and 1845, I saw cases of the disease arising appa- 
 rently under every variety of different circumstances ; residence in 
 cold countries, residence in hot and tropical climates, in persons 
 who had never been out of Great Britain. At the same time, 
 while a considerable proportion of cases was found in the persons 
 of Irish who had migrated to Scotland, it was not always ascer- 
 tained that these persons had been in the bog districts of Ireland. 
 The cause which seems most usually and generally to be followed 
 by the development of this degeneration is the habitual use of spi- 
 rits ; and to this cause, both in London and in Edinburgh, great 
 numbers of granulated liver may be traced. 
 
 While the influence of this agent is admitted by Becquerel, he 
 adds various other circumstances ; gloomy and distressing mental 
 emotions, bad and innutritions food, and residence in damp situa- 
 tions and dwellings. 
 
 The influence of sex and age it is not easy to determine. Among 
 18 cases of simple kirrhosis, Becquerel found 12 to be in males 
 and 6 in females. Among 45 cases of complicated kirrhosis, 28 
 were in males and 17 in females. Among the cases seen by my- 
 self in 1817 and 1818, all occurred in males. Among those seen 
 afterwards, 3 among females were observed to 5 among males. 
 
 Among 1 8 cases noted by Becquerel, 7 took place between the 
 ages of 30 and 40, and 5 between 50 and 60. Among those in 
 which the age was noted by myself, two cases took place in young 
 females of 20, two in females between 35 and 40, one in a man of 
 35, and other three in men between 35 and 50. The disease, 
 therefore, seems to be most prevalent between 30 and 50, or 30 
 and 45. 
 
 As to exciting pathological causes, Becquerel maintains that dis- 
 ease of the heart is a frequent antecedent, and must be considered 
 as a cause of eranular deareneration of the liver. This inference he 
 
NATURE OF KIRRHOSIS. 
 
 899 
 
 adopts, because he found 21 instances of kirrhosis among a series 
 of 55 instances of disease of the heart. Granulated liver is doubt- 
 less found often associated with disease of the heart ; but often also 
 the latter disease is without the former, while the nutmeg state of 
 the liver is present Again, it is not doubtful that kirrhosis is often 
 associated with vascular congestion and irritation of the stomach, 
 duodenum, and jejunum ; and it is almost certain, that the mode 
 in which the habitual use of spirituous drinks operates in causing 
 kirrhosis, is partly owing to this irritation, partly to absorption into 
 the abdominal venous system. 
 
 When kirrhosis is associated with renal granulation, it seems less 
 reasonable to ascribe the one of these affections to the presence of 
 the other, than to ascribe both to the same cause. They also ap- 
 pear to be similar forms of degeneration of the glandular tissue in 
 different glands. 
 
 It is not doubtful that kirrhosis is quite adequate of itself to cause 
 death. It must nevertheless be allowed, that it is often found 
 associated with other lesions which are usually fatal ; for instance, 
 chronic bronchitis, hypertrophy and valvular disease of the heart, 
 and disease of the kidney, occasionally continued fever, and, in a 
 few instances, pulmonary consumption. When fatal without these 
 diseases, it is invariably found terminating in incurable ascites. 
 
 It could not be expected that so great a change in the structure 
 of the liver should be without effects on the health and general sys- 
 tem. Yet, in the early stage, it rarely produces conspicuous symp- 
 toms. Kirrhosis is, indeed, an insidious disease, causing little dis- 
 turbance until the liver is altogether changed in structure. The 
 liver is seldom so much enlarged in the early stage as to give rise 
 to manifest and palpable swelling ; and there is at this time also 
 little or no serous fluid within the abdomen. Pain is not felt, at 
 least not mentioned by patients ; and all that can be observed is a 
 feeble and irregular state of the digestive function, denoted by want 
 of appetite, thirst, constipation, a sense of heat at times in the palms 
 of the hands, and general feebleness and languor. Nutrition is 
 manifestly impaired. As the disease advances the liver is enlarged, 
 and continues so for some time. Then it is diminished ; and no 
 tumour may be felt in the hypochondriac region. 
 
 Bile is evidently not secreted ; for the motions are usually paler 
 than in their normal state. Yet jaundice is an occurrence so rare 
 that I have never seen it in a distinct and well-marked form. 
 All that is observed is a peculiar dingy brownish' or sallow 
 
900 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 colour of the face and skin generally, wliieh is so characte- 
 ristic, that, though not strongly marked, if once or twice seen, it 
 can rarely be mistaken. It has often appeared to me also, that the 
 perspiration of patients with this disease has a peculiar odour. All 
 perspire during the night or towards morning with a peculiar 
 unctuous discharge. The urine contains no bile ; but it is scanty, 
 deep-coloured, contains a large proportion of urea, and deposits a 
 sediment of urate of ammonia. 
 
 At length fluid is accumulated within the abdomen ; and the 
 strength is still more completely impaired. 
 
 Death occasionally takes place by coma, the bile not being elimi- 
 nated, and acting as a poison. 
 
 Kirrhosis may be complicated with abscess of the liver.* 
 
 § 12. Steatosis. Pimelosis. Fatty Degeneration. — Though 
 the liver even in the human body, in its healthy state, contains in 
 its cells some oily matter, which may be obtained from it by various 
 means, yet in ordinary circumstances this is so small, that it has 
 been generally overlooked. 
 
 On the other hand this element, if element it be, is liable to be 
 augmented to so great an extent, that it is infiltrated interstitially 
 into the acini and around them, and constitutes a peculiar morbid 
 state, to which the name of fatty liver has been applied. 
 
 A liver in this state is very generally larger and heavier than in 
 the healthy state, sometimes amounting to double the weight, or 
 7, 8, or 9 pounds. It may, nevertheless, he not above 4^ or 5 
 pounds. When large, it may be felt during life in the form of a 
 large, prominent, but smooth tumour, under the margin of the right 
 hypochondre, which it raises, filling the epigastric region, which is 
 rendered prominent and full, and extending somewhat into the left 
 hypochondriac region. All over this space the tumour emits a 
 dull sound on percussion, but feels not unusually hard. 
 
 The fatty liver generally covers the stomach and transverse arch 
 of the colon, and descending about three inches below the margin 
 of the hypochondre, and spreading beyond the median line, appears 
 prominent and conspicuous, concealing all the viscera in the epi- 
 gastric region. The enlargement usually affects the whole gland. 
 
 A liver in this state, when first exposed, is of a pale orange, or 
 reddish yellow colour, or yellowish marbled, some parts being 
 deeper and others lighter coloured. These colours are dispersed 
 in patches, various in size, over the liver. The surface is smooth, 
 
 * Case by Dr H. Beer in Oesterreichische Mediz. Wochenschrift. 1843. N. 22. 
 
FATTY DEGENEEATION OF THE LIVER. 
 
 901 
 
 and something doughy, or compressible-inelastic to feeling; less 
 solid and dense than the natural liver. When divided, the sec- 
 tions are yellowish red, or with the tint of the fat of old oxen 
 mixed with the red colour of the liver. lu advanced stages, the 
 colour is _still more highly yellow, approaching to gold yellow. 
 The substance is soft, doughy, and sometimes lacerable. These 
 sections leave on the knife a distinct dirty, greasy mark ; and even 
 paper applied over the cut surface receives an oily stain, while 
 fresh particles of dirty grease ooze from the surface. 
 
 This fatty matter is deposited or infiltrated partly within the 
 acini and granules, partly at their exterior ; while the acini in the 
 advanced stage of the disease, though present, are compressed. 
 Under the microscope, a bit of yellow or orange-coloured fatty 
 liver appears, according to Albers, like a pale-white sponge, which 
 contains individual bladders of clearer colour with viscid fluid, and 
 there are dispersed in various points remote from each other indi- 
 vidual dark-brown punctula. These he regards as the atrophied 
 acini of the liver. In the portions of the liver retaining their red- 
 dish-shaded colour, these acini are large, and more in the normal 
 state, while the morbid intermediate tissue is neither so yellow nor 
 so abundant. From this circumstance he infers that the inter- 
 mediate or cellular tissue is over-nourished and enlarged, or 
 hypertrophied ; and that by this hypertrophy of the cellular tissue 
 the acini are atrophied. 
 
 The fatty state of the liver is said to be commonly confined to 
 that gland alone ; while all the other parts of the system are atro- 
 phied. It is observed most usually in pulmonary consumption ; 
 and has been by some supposed to denote the most advanced stage 
 of this disease. This inference must nevertheless be regarded as 
 erroneous ; since, on the one hand, in many cases of advanced 
 consumption, it is not observed ; and, on tbe other, the adipescent 
 liver is observed in persons who have not died of consumption. 
 
 Analysis shows that the adipescent liver contains matter which 
 is something a little different from pure animal fat. Andral found 
 that it was almost entirely cholesterine ; and, according to Vau- 
 quelin, in 100 parts, 45 consist of oil, 19 of parenchyma, and 36 of 
 water. 
 
 The size and weight which the adipescent liver may acquire va- 
 ries fi’om five to eight or nine pounds, lu one remarkable case, in 
 which I recognized the disease during life in a young female la- 
 
902 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 bouring under consumption, the liver descended fully three inches 
 below the margin of the right hypochondre, approaching close on 
 the crest of the os ileum^ extended into the epigastric region, which 
 it might be said to fill, and a little into the left hypochondriac re- 
 gion. Its weight was nearly eight pounds. 
 
 On the pathological causes of this transformation, nothing is cer- 
 tainly known. Pathological speculations have appealed to the fat- 
 tened liver of the goose, to show that it is produced by overfeed- 
 ing and too little corporeal exertion ; and unquestionably this may 
 give rise to the transformation. But the change has been observed 
 in the bodies of persons who, if well fed, have not been under- 
 woi’ked. Again, it is seen in those who are corpulent, and who 
 are addicted to the use of nutritious food and spirituous and fer- 
 mented liquors. Its occurrence in consumption is supposed to de- 
 ])end on the obstructed state of the circulation through the lungs, 
 on the diminished power of decarbonization thus induced, and on 
 the greater quantity of blood believed to be sent to the liver, and 
 the greater amount of duty thrown upon that organ. 
 
 The liver in its sound state is said always in the adult to show 
 that its acini contain oil and fat globules, which are further said to 
 be most abundant in those who use fat and oleaginous articles of 
 food. It is possible that this may be one of the sources of the adi- 
 pose infiltration. Another is more evident. The bile certainly 
 is liable by some means to have its elements converted into cho- 
 lesterine ; and it is reasonable to suppose, that, in the transition to 
 this decomposition, its elements may be converted into fat. 
 
 Another illustration of this subject I add from comparative ana- 
 tomy. The livers of all the finny tribes abound in oil to so greati 
 extent, that it is one of the products of spontaneous decomposition. 
 It is most likely that the separation and deposition of oil in this] 
 organ is connected with the mode of respiration presented by this] 
 class. Gills are evidently less favourable to the elimination ofj 
 much carbonaceous matter than lungs ; and while a small part of J 
 the carbonaceous matter is separated by the gills, part may also, in 
 union with hydrogen, be separated by the liver. 
 
 As this disease is generally associated with others, as pulmonary 
 consumption, its external effects are not well known. Various 
 symptoms indicative of indigestion are said to denote its first for- 
 mation. But as upon these no reliance can be placed, I do not 
 mention them. It is known in its advanced stage by the swelling 
 
 6 
 
CONCRETIONS OF THE DUCTS. 
 
 903 
 
 in the right hypochondi’iac and epigastric region, which is uniform, 
 smooth, and emits a dull sound on percussion, while pain is often 
 considerable in the epigastric region.* 
 
 § 13. Concretions in the Ducts. — Under certain circum- 
 stances the ducts of the liver are filled more or less completely with 
 concretions, which appear to be either bile, or that product in a 
 state passing to the formation of biliary concretions. Concretions 
 may be formed in any part of the course of the secreting and 
 excreting apparatus of the liver ; 1st, in the upper or terminal 
 ends of the pori or small ducts ; 2d, in the middle sized ducts 
 which form the hepatic duct ; 3rf, in the hepatic duct ; 4f/i, in the 
 gall-bladder ; 5th, in the cystic duct ; and, Qth, in the common 
 duct. 
 
 In the first-mentioned situation, these concretions are, so far as 
 is known, less common than in the others. Cruveilhier gives a 
 very good instance of them in the fourth plate, book xii. of his col- 
 lection.! These concretions appear under the aspect of grains of 
 a deep gi-een colour, irregular in shape and size, disseminated 
 through the sound structure of the gland, the yellow colour of 
 which forms a strong contrast with that of the grass-green colour of 
 these bodies. No information is given as to the chemical nature 
 of these bodies ; but from their colour, it may be inferred that they 
 are nearly pure bile. The glandular substance of the liver ap- 
 pears of a deeper yellow colour than natural ; a condition probably 
 to be ascribed to the obstruction in the ducts preventing the bile 
 from descending. 
 
 In some livers, especially in those of children, tubercular bodies 
 are occasionally found disseminated in minute grains through the 
 substance of the liver. These grains are deposited in the terminal 
 portions of the ducts ; and it is the opinion of Cruveilhier that they 
 are the result of the formation now mentioned, namely, biliary 
 concretions. The ducts in which these bodies are thus formed are 
 usually dilated into cysts ; while the ducts below these dilated 
 portions may be entirely obliterated. It seems not unlikely that 
 this obliteration of these ducts may have been caused by inflamma- 
 tion at some previous period, and that this obliteration may thus 
 
 * Einiges zur Pathologie unci Pathologischen Anatomie der Leber. Von J. F. H. 
 Albers, Professor der Medizin in Bonn. Riist’s Magazin fur die Gesammte Heil- 
 kunde, S3 Band, 3 Heft, Seite Sll. Berlin, 1839. 
 
 t Anatomie Pathologique, Livi-aison xii. Planch 4. Paris, 1828-1833. 
 
904 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 be the cause of the formation of the concretions and the cysts in 
 which they are inclosed. 
 
 § 14. Akinopyesis. Suppuration of the Acini, — These ter- 
 minal ends are nevertheless subject to inflammation, so as to form 
 an immense number of minute abscesses in the substance of the 
 liver. Cruveilhier gives an instance in a female of 45, who had 
 jaundice with febrile symptoms for 10 days previous to admission to 
 hospital. The symptoms proceeded, notwithstanding the use of re- 
 medies ; and at the end of 55 days she died, that is, 65 days after 
 the appearance of the jaundice. 
 
 It was then found, besides two pounds of greenish serum in 
 the abdominal cavity, that the liver, though natural in size, was of 
 an olive colour, and adhered intimately to the diaphragm, the 
 duodenum, and the transverse arch of the colon ; that the whole 
 surface of the liver presented a yellowish-white marbling ; that the 
 lower surface presented two small abscesses, which were on the 
 point of bursting into the peritoneal cavity ; and that the substance 
 of the gland, when divided by the knife, brought into view nume- 
 rous small abscesses, containing purulent mucus thickened, orange- 
 yellow, deep-green, and greenish. These small abscesses had no 
 determinate shape. Some were formed by an enlarged biliary ter- 
 minal duct ; others by a duct dilated and perforated ; others by 
 sevei'al dilated and perforated terminal ducts, communicating mu- 
 tually so as to form multilocular abscesses. The adjoining sub- 
 stance of the liver was, he states, not sensibly inflamed. Yet these 
 abscesses were in thousands, not throughout uniformly, but mostly 
 in the right lobe of the liver. 
 
 The ductus clioledochus^ narrow at its duodenal end, was dilated 
 immediately above, and contained a concretion which imperfectly 
 filled its cavity ; and at this point a slough in the walls of the duct 
 had been formed. 
 
 This appears to be an example of inflammation of the terminal 
 ends of the biliary ducts, confined mostly to these bodies, and not 
 extending beyond them. The inflammation Cruveilhier ascribes to 
 irritation, partly from distension of the ducts by the bile not per-, 
 mitted to descend ; and which, there detained, is liable to form 
 miliary hepatic concretions.* 
 
 § 15. Entozoa. — a. Parasitical animals have been observed in the 
 liver by many anatomists. In the livers of the lower animals 
 * Analomie Pathologique, Livraison xL Plate 1. 1839. 
 
PARASITICAL ANIMALS IN THE LIVER. HYDATIDS. 905 
 
 these entozoa are very frequent ; and the fluke, {Distoma hepati- 
 cum^) especially, is seen often in the bile ducts of the liver. This is 
 a broad, flat, lancet-shaped animal, from one to four lines long, and 
 half a line to one line broad, which generally is found within the 
 hepatic ducts and their branches. This animal has been found 
 in the liver of the ox, the pig, the hare, and in that of man. 
 In the last, however, it is greatly more rare. It was seen by Mal- 
 pighi, Bauhin, Wepfer, Pallas, Chabert, Bucholz, and Brera. 
 
 The presence of these animals causes some enlargement of the 
 hepatic tubes, and consequent irregularity on the surface of the 
 liver. In the lower animals, the walls of the tubes become ossified, 
 and after some time the parasites die. 
 
 b. The hydatid, {acephalocystis\ is by far the most common para- 
 site in the human liver ; and while numerous instances of it are 
 recorded, it is of no unfrequent occurrence. The liver, also, is 
 the most common locality of these animals in the human body. 
 
 Of the acephalocyst there are two sorts or species ; one the 
 manifold acephalocyst, (yicephalocystis socialis ;) the other the soli- 
 tary, (acephalocysiis eremita vel solitaria.') 
 
 In the former case numbers of hydatids are found in one or 
 more cysts in the liver. In the latter in general only one or two 
 large hydatids are found. 
 
 The acephalocyst appears in the shape of a globular or roundish 
 bladder, or a cubical shaped bladder with truncated and round- 
 ed corners. 
 
 In the manifold or social hydatid, the figure is in gene- 
 ral round or globular ; but by pressure on each other the figure 
 is often irregular. One large hydatid globule may contain twenty 
 or thirty small-sized hydatids ; or fifty or sixty hydatids of the 
 diameter of half an inch or three quarters may be contained with- 
 in one large cyst. 
 
 In size hydatids vary from the volume of a heinpseed to that of 
 an orange, or even larger. In the liver their most usual size is 
 that of a middle-sized gooseberry ; but of course this must depend 
 on the length of time elapsed from their original development. 
 
 These bodies, whether large or small, consist of a thin, semi- 
 ti'ansparent, or transparent, homogeneous membrane, in which, by 
 the naked eye, it is not possible to trace either fibrillar or vascular 
 arrangement, and which, externally, is smooth and uniform. In- 
 ternally there are often eminences or inequalities, to which, in all 
 
906 
 
 GENERAL AND TATHOLOGICAL ANATOMY, 
 
 probability, the small hydatids are or were attached. As it is not 
 possible in these spherical bladders to recognize either head or tail, 
 it is from this circumstance that Laennec applied to them the name 
 of acephalocyst. 
 
 Of the internal eminences some are irregular, white, more or 
 less extended in surface ; others are spherical, white, opaque, united 
 in greater or smaller number, and showing the transparence of the 
 enveloping cyst in their intervals. The smallest of these bodies have 
 no cavity. The largest have a small cavity, which enlarges as the 
 granulation itself increases. In other instances these granulations 
 are not opaque, but colourless and transparent, like the walls of the 
 acephalocyst itself. Lastly, there are some in which colourless 
 granules present not rounded but varied forms ; some elongated, 
 others cuboidal, others flattened. The largest, which approach 
 the globular figure, when punctured, discharge a little serous 
 fluid. 
 
 These bodies, indeed, are the prolific gemmules by which the ani- 
 mals are propagated. The cyst appears to be a general envelope. 
 
 The cavity of the acephalocyst as seen in the liver is filled by a 
 liquid, most commonly quite limpid, and which has all the proper- 
 ties of pure or slightly albuminous water. 
 
 The acephalocyst, it has been stated, contains others within it. 
 In general one large acephalocyst contains many of smaller size. 
 These again contain others still smaller ; and it has been inferred 
 that in this succession they may pi'oceed to a great extent. This 
 arrangement is probably the strongest proof of their living charac- 
 ter ; for it appears to show that one hydatid may produce many. 
 
 Of the animal nature of these bodies, the best authorities enter- 
 tain little doubt.* 
 
 * Neither Rudolphi nor Bremser appear willing to admit as a distinct species of 
 hydatid the cysts described as the acephalocyst. That distinction was first made by 
 Laennec in 1805 and 1814, and afterwards illustrated by Liidersen and H. Cloquet, 
 and adopted by most of the French authors. Laennec, Rudolphi mentions hastily, 
 giving no opinion of the merits of the distinction. And Bremser states that he lost 
 the notes which he had made in Paris on Laennec ’s dissertation. 
 
 Laennec distinguishes these cysts, regarding them as animals, into three species ; 
 1st, The acephalocyst rvith ova or true eggs ; A. pyriformis, simplex, vesicular is, cor- 
 porihus ovatis praeclita intus ; 2d, The acephalocyst with sprouts or gemmulae : A. 
 surculigera, A. pyriformis, simplex, vesicularis, surculis praedita intus ; and 3d, The 
 acephalocyst with granules ; A . rjranidosa, A. pyriformis, simplex, vesicularis, yranulis 
 intus praedita. Thus it appears that these three species differ ; — in the first presenting in 
 its walls small spherical white opaque bodies, little adherent and often hollow in the cen- 
 
PARASITICAL AI^IMALS IN THE LIVER. HYDATIDS. 907 
 
 The mode in which hydatids are formed in the liver appears to 
 be twofold. First, they may be formed in the peritoneum, and 
 are attached to the peritoneal covering of the liver, forming round 
 tumours, attached either to the upper or lower surface of the liver. 
 In this case it is not unusual for Acephalocysts to be attached to 
 the intestinal peritoneum at various points. Secondly, the hydatids 
 may be developed within the substance of the liver ; and gradually 
 enlarging by the prolific multiplication of their numbers, they may 
 form irregular elevations or tumours of considerable size at the sur- 
 face of the gland. They are said to be more common in the right 
 lobe than in the left ; but in this there seems to be nothing regular. 
 They may occupy both lobes at once. 
 
 Hydatids when thus formed may undergo changes in themselves, 
 or they may induce changes in the surrounding tissue of the liver. 
 
 In certain circumstances, the fluid which the membranous cysts 
 contain becomes thick and jellydike. The hydatids may die, and 
 then the membranous coverings usually become opaque, thick, and 
 indurated, sometimes almost horny. In both cases apparently they 
 induce inflammatory irritation in the substance of the liver, fol- 
 lowed by suppuration ; and they may in this manner ulcerate their 
 way outward, either into the mucous surface of the alimentary canal, 
 the duodenum, or the transverse arch or ascending portion of the 
 
 tre ; the second presenting at its two surfaces small geranvudae or buds, very irregular 
 and varied in shape, scarcely visible, and of the size of a hemp seed ; and in the third 
 being covered interiorly with transparent granulations of the size of a millet seed. 
 Though in appearance little different, these three sorts of acephalocyst are never found 
 i'.i the same cyst. (Bulletins de I’Ecole de Medecine, a Paris, an 13.) 
 
 Rudolphi had read the dissertation of Liidersen and formed an opinion of it. Lii- 
 dersen had found in the interior of hydatid cysts, as others have done, innumerable ve- 
 sicular granules, which could not be referred to the head of Echinococci ; and these, 
 therefore, after Laennec, he denominates human acephalocysts ; which, Rudolphi adds, 
 perhaps may be admitted. (Henrici Caroli Ludovici Liidersen Dissertatio de Hydatidi- 
 bus. GottingiE, 1808.) But if these hydatids are taken for animals, says Rudolphi, it is 
 a mistake ; for they are void of certain organs, proper motion, and therefore of life. 
 The acephalocyst of the hog Rudolphi refers to the head of Echinococcus. And the 
 same, he adds, is either always or sometimes true of the human acephalocyst. “ De 
 acephalocystide humana idem forsan semper aut quandoque valet ; ipse saltern hyda- 
 tidibus compluribus hepati debitis, ab aegro deorsum dejectis, solicite examinatis, ver- 
 miculos sed rarius in iisdem offendi.” (Entozoorimr sive Vermium Intestinalium His- 
 toria Naturalis. Auctore Carolo Asmundo Rudolphi, Vol. I. and II. Amstela;dami, 
 1808 et 1810. Vol. II. part ii. 3G7.) 
 
 De Blainville is of opinion that acephalocysts ought to be arranged neither with the 
 Taenia hydatigcna, or with the Cocnurm or Echinococcas, but that they should be pla- 
 ced near the Monadarire in the type of Amorphozoa. 
 
908 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 colon, or to the surface of the body. When they cause progressive 
 ulceration into any part of the intestinal canal, they are generally 
 discharged through the rectum. Sometimes there is reason to be- 
 lieve, "if situate near the upper surface of the liver, they may cause 
 inflammation and ulceration through the diaphragm into the lungs, 
 and be thence expelled by cough and expectoration. Lastly, in se- 
 veral instances, they have come to the surface of the body, and 
 formed a pointing fluctuating tumour, on puncturing which the 
 escape of purulent matter containing the debris of hydatids, has 
 shown the true nature of the case. Of this latter termination, va- 
 rious cases are recorded by Heuerman, Rebentisch, Yeats, Sher- 
 win,* Placido Portal,! and other observers. 
 
 c. Echinococcus. — Another of this family of parasitical animals, 
 much more rare, is found in the liver. The Echinococcus is a ve- 
 sicular parasite with a pyriform body, globular, or round at head, 
 and with the caudal extremity much narrower, but also rounded. 
 The head is furnished with a circlet or ring, surmounted by a row 
 of booklets or prominent spikes, slightly incurvated at the extre- 
 mity, — the whole apparatus forming a sort of diadem or coronet. 
 
 Of the occurrence of this animal in the liver only three cases are 
 recorded. One is contained in the Museum of the College of Sur- 
 geons, London, and was originally in the possession of John Hunter. 
 The second occurred to Mr Rose of Swaffham, who observed them 
 in the purulent discharge from an abscess in the liver, which be had 
 opened.! instance, the Echinococci were associated with ace- 
 
 phalocysts. The third is recorded by Mr Curling, who found them 
 in a cyst in the left lobe of the liver, in the body of a man aged 71 , 
 who had died in the London Hospital of disease of the urinary 
 organs. § 
 
 As the cyst in this last case, when first opened, presented the 
 usual appearances of the acejihalocyst, and the peculiar characters 
 of the inhabitants of the cyst were only ascertained by microscopi- 
 cal examination, it comes to be a question, whether, in many other 
 
 * Case of a very large Abscess containing Hydatids connected with the Liver ter- 
 minating favom-ably. By H. C. Shenvin. Edin. Med. and Surg. Journal, Vol. xix. 
 p. 223. Edinburgh, 1823. 
 
 •f- Annali Universal! di Medicina, Vol. xcvii. 1841. 
 
 J On the Vesicular Entozoa, and particularly Hydatids. By C. B. Rose, Swaffham, 
 Norfolk. London Medical Gazette, Vol. xiii. p. 204. London, 1834. 
 
 § A case of a rare species of Hydatid ( Echinococcus Hominis ), found in the Human 
 Liver By T. B. Cmding, Esq. Medico-Chirurgical Transactions, Vol. xxiii. p. 385. 
 London, 1840. 
 
HETEROLOGOUS GROWTHS. 
 
 909 
 
 instances of large cysts like those of the acephalocyst, they may not 
 belong to the same animal. 
 
 In this instance the mode of generation is different. In the 
 echinococcus, the yonng animal is formed between the layers of the 
 parent cyst, and is detached from the external surface of the inner 
 layer. 
 
 § 16. Hygroma. — It is doubtful whether serous cysts are formed 
 in the liver ; and it may be argued that any instances of this kind 
 are to be referred to the head of Hydatids, especially that named 
 the solitary acephalocyst. The circumstance is certainly not com- 
 mon, and not very well authenticated. Cases referable to the 
 head of Cysts are nevertheless recorded by Dr Todd,* and Dr 
 Stocker.f An instance is believed to be given by Dr Hesse, in 
 Horn’s Archiv, in which a female of 42, unmarried, was affected, 
 some years after a fall on the right hypochondre, with a fluctuating 
 swelling as large as the head of an infant. This tumour was punc- 
 tured ; and large quantities (five pounds) of serous fluid escaped 
 without any trace of relics of hydatids. The patient did not recover, 
 but died one year after the operation. It was then found that the 
 liver was very much enlarged ; and that the right lobe contained a 
 large cyst, which, when divided, allowed to escape twelve pounds of 
 serum, at first watery, then turbid and flocculent.t 
 
 Mr Caesar Hawkins describes certain encysted tumours as form- 
 ing on the margin and at the surface of the liver, and occasionally 
 sinking into its substance, and seldom exceeding the size of a Al- 
 bert, or, at most, a walnut. These tumours contain clear semi- 
 transparent or pellucid liquid, scarcely coagulable by heat, and in 
 which there is found a peculiar animal matter, named by Dr IMar- 
 cet muco-extractive.§ 
 
 According to Mr Hawkins, these cysts rarely secrete purulent 
 matter ; and when this fluid is formed in them, it is not of a healthy 
 character. 
 
 § 17. Heterologous Growths. — A. Of these it has been ob- 
 served, that occasionally one or other of the encysted tumonrs, 
 
 * Dublin Hospital Reports, VoL L p. 325. 
 
 -j- Transactions of the College of Physicians in Ireland, Vol. i. p. 11. 
 
 •]- Horn’s Archiv, Septembre und Octobre 1839. 
 
 § Cases of Sloughing Abscess connected with the Liver, with some remarks on En- 
 cysted Tumours of that Organ. By Casar Hawkins, Esq. Medico-Chirurgical Trans- 
 actions, Vol. xviii. p. 98. London, 1833. 
 
910 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Meliceris* Athermna^-\ and Steatoma,% were formed in the liver, ' J 
 
 The instances nevertheless are not well authenticated, and were 
 recorded at periods, when accurate distinctions had not been intro- 
 
 informed authorities to he degenerated acephalocysts ; and those of 
 the last belong mostly to the encephaloid deposit. 
 
 B. Struma. — Whether struma be always regarded as a hetero- 
 logous product or not, tubercle is usually considered as such. 
 Struma, however, does not appear, in all instances, in the form of 
 tubercle in the liver. It may take place in that of a sort of infil- 
 tration of strumous deposition in the interstitial matter of the gland. 
 Its appearances are then the following. The liver is enlarged, mostly 
 in the transverse direction, with some flattening of the two surfaces. 
 It is also heavier, i. e. from five to six or eight pounds. The peri- 
 toneum is smooth and tensely stretched. The liver is doughy; 
 generally of a pale yellow or grayish-red colour, sometimes a little 
 variegated, and not vascular. The section is smooth, homogeneous,* 
 a little lardaceous looking, but not leaving greasy traces on the 
 knife ; and little blood escapes, while a serous muddy liquor oozes 
 from points of the section. The substance is in general friable, 
 flaccid, and lacerable. 
 
 pathological causes of this change ; and, when its physical charac- 
 ters are stated, it is almost all that can be predicated regarding the '/ 
 lesion without committing errors. A new matter is infiltrated into 
 the interstitial tissue of the gland ; but what that new matter is, is 
 not known. 
 
 This lesion takes place in persons wasted by disease, and with 
 other marks of strumous disposition. It is observed in children 
 and young persons who have enlarged mesenteric glands ; and in 
 those who are phthisical. It occasionally proceeds to abdominal 
 dropsy. Yet life may be prolonged for a considerable time with 
 this disorder. Many years ago, I performed several times the ope- 
 ration of paracentesis on a young man labouring under this disease, 
 which had, at the time referred to, been of some duration. In ge- 
 
 * Bianclii, Hist. Hepatica. p. ID 7. 
 
 t Columbus, Glisson, and Bianchi, Hist. Hepat. Guettard, Baader. 
 
 + Columbus de Re Anatomica. Bianchi, Hist. Hepat. Biumi apud Sandifort, Dis- 
 sertat. Enaux. 
 
 duced. Instances of the first and second are believed by the best 
 
 Nothing positive or certain is known regarding the anatomico- 
 
STRUMOUS TUBERCLES. ENKEPHALOBIA. 
 
 911 
 
 neral, however, it proves fatal, partly by the imperfect digestion 
 from want of proper bile, and partly by the abdominal dropsy. 
 
 C. Tubercles. — Bodies quite similar to the tubercular masses 
 of the lung have been observed in the liver ; and these are then to 
 be viewed as the tubercular form of struma. In other instances 
 strumous abscesses, like those already described, may be regarded as 
 the softening or liquefying stage of the tyromatous deposit. Baillie, 
 however, admits that tubercle is a rare disease of the liver. They 
 appear to have been observed by Portal who, however, has spoken of 
 them as gelatiniform mucous and albuminous formations within the 
 liver. A case in a person of 19 is given by Dr Bramer of Cassel.* 
 
 The soft brown tubercles of the liver, mentioned by Baillie as bo- 
 dies situate at or near the surface of the liver, and consisting of 
 smooth soft brownish-coloured matter, appear to have been either 
 clots of blood, the effects of hemorrhage, or instances of melanosis. 
 
 D. SciRRHUS AND Enkephaloma. — Though instances of scir- 
 rhus are represented by many writers to have been found in the 
 liver, yet if we apply the elucidations and distinctions of accurate 
 observation and pathology, scarcely one of these can be recognized 
 as genuine examples of that species of structure. I have already 
 shown that skleroma or simple induration and kirrbosis have been 
 referred to the head of skirrhus of the liver ; and 1 think it not 
 doubtful that any kind of hard structure of unusual characters has 
 been considered as instances of scirrhus. On the whole, genuine 
 skirrhus is a rare formation in the liver ; and probably only ap- 
 pears in it by extension from other organs, especially the stomach. 
 From the observations in the next article, however, it must be al- 
 lowed that if genuine skirrhus be not observed in the liver, it has 
 its representative in the kindred form of morbid structure called 
 Enheplialoma, 
 
 , Enkephaloma must be regarded as the true form in which skir- 
 rhus appears in the liver ; and in this organ it is extremely common. 
 
 It appears in three forms, which are probably only different stages 
 of the same morbid change. 
 
 First, there are formed in the liver irregularly rounded nodules, of 
 whitish or whitish-gray matter, varying from the size of a filbert to 
 that of a walnut, or larger. When these bodies are divided, they 
 have a consistence between that of cream cheese and the unboiled po- 
 tato. The section is quite homogeneous, and totally void of any 
 * Pabst’s Allgemeine medizin. Zeitung, 1838. N. 15-19. 
 
912 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 arrangement like vascularity or proofs of organization. Examined 
 very minutely they present the appearance of infinitely minute 
 granules aggregated together. The sections occasionally present 
 an appearance of fibrons radiation very much like that of the ra- 
 diated zeolite; the fibrous lines diverging and radiating either 
 from one or two points towards the periphery of the tumour, or 
 from a line passing through the middle or centre of the tumour. 
 
 In some instances the colour of these tumours internally is of a 
 drah-gray, or fawn, or giraflFe tint. But the consistence and phy- 
 sical characters are the same. 
 
 In general these moderately sized masses are pretty firm, softer 
 than the unboiled potato, but firmer than lard, something like new 
 cheese of moderate firmness, but less tough and more friable. 
 
 In another variety this deposit may appear in the form of irre- 
 gularly spherical, spheroidal, or ovoidal masses, varying from the 
 size of a filbert to that of a walnut or small egg, yet softer and 
 more elastic than those last described, and presenting at the surface 
 more or less vascularity, and not unfrequently with some vessels 
 ramified through their substance. The aspect of these is in some 
 instances like a smooth strawberry or raspberry. 
 
 Tumours of this character proceed early to the formation of fun- 
 gous growths, which discharge blood freely and often. Some ob- 
 servers deny that this is a softening process. 
 
 The consistence of these tumours is generally about that of brain, 
 pulpy, soft, and compressible ; and in several parts they may be 
 more pulpy than in others. 
 
 Cruveilhier distinguishes this variety into two subspecies accord- 
 ing to their less or greater degree of vascularity. For this dis- 
 tinction there may be some foundation ; but, if we consider that a 
 degree of vascularity is the general attribute of this form, it seems 
 unnecessarily to multiply subdivision, to derive the characters fro|i 
 differences in degree only. 
 
 If a stream of water be directed on tumours of this species, the 
 soft pulpy matter is washed away, and nothing is left but a cellulo- 
 vascular frame-work. 
 
 These reddish rasp-like bodies are found both at the surface and 
 in the substance of the liver. They are in general formed in a 
 short time, like all the varieties of encephaloid disease ; but they 
 are peculiar in proceeding rapidly to the formation of bleeding 
 fungi. 
 
ENKEPHALOMA OF THE LIVER. 
 
 913 
 
 These two forms of enkephaloma appear to correspond with the 
 TtJBERA Circumscripta first well described by Dr Farre, 
 
 Though I describe these two forms of enkephaloid disease as 
 appearing usually in small masses of definite size, yet it does not 
 follow that they may not be larger. Two or more masses may be 
 growing, and extending, may coalesce, and thus form, instead of 
 twenty or thirty small tuberosities, five or six large irregular-shaped 
 masses. In short, I have strong reason to believe that neither 
 colour nor size are essential and invariable characters ; and that 
 the same structure may appear sometimes in small nodules, some- 
 times in large masses, and that its colour may vary from tallow- 
 white to light fawn. 
 
 A third form which the disease assumes is the following. 
 
 Large irregularly rounded masses, generally of a whitish colour, 
 are formed in the substance of the liver, projecting from its surface, 
 and rendering that surface irregular and firm. These masses vary 
 in volume from the bulk of a middle-sized potato to that of a large 
 orange. They are never exactly spherical, but only irregularly 
 rounded, oblong, or quite incapable of being referred to any ordi- 
 nary known figure. 
 
 These masses are so large as not only to alter very much the 
 shape of the liver, but to encroach extremely on the original struc- 
 ture of the organ. When the liver is divided, the sections show 
 that the morbid deposition has extended throughout the whole gland. 
 
 These masses are whitish, or whitish gray in colour, firm, of a con- 
 sistence between tallow and cheese ; and the section has some re- 
 semblance to that of the unboiled potato or yam. The section is 
 not quite so homogeneous and uniform as that of the small tube- 
 rosities, and it presents more or fewer minute cavities containing 
 a sero-gelatinous liquid which readily oozes from them. Traces 
 of organic arrangement cannot be distinctly recognized; yet, in 
 some instances, one or two large varicose-like vessels may be seen 
 passing through the mass. In some instances the appearance of 
 radiating fibres, like that of zeolite, may be seen as in the small- 
 sized tuberosities. But this is less frequent than in the latter. The 
 radiating appearance also is greatly less regular, and often ap- 
 pears in the form of irregular lines or fibres. 
 
 The shape and outline of these masses is irregularly round, or 
 globular, or spheroidal, and often so irregular that it is impossible 
 to compare them to any known figure. In some instances two or 
 three masses appear to have coalesced into one continuous mass, 
 
 3 M 
 
914 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 and in this manner to have rendered the figure of the whole still 
 more irregular. 
 
 In size, the masses now described are generally large ; that is 
 from the size of an apple or orange, to three or four times that 
 magnitude. 
 
 The masses now described form the tuhera circumscripta, and the 
 tuber a diffusa of Dr Farre, who first after Baillie gave, in 1812 , a 
 particular account of these growths. Those first described, or the 
 small-sized tumours, are the tuhera circumscripta ; those last de- 
 scribed are the tuhera diffusa. For this distinction the reasons ap- 
 pear not satisfactory. The tuhera circumscripta,Y)x Farre believed 
 to be confined chiefly to the liver, while the tuhera diffusa might 
 affect not only the liver, but all other organs. We now know that 
 though the former growth appears most commonly in the liver, yet | 
 it is not confined to that organ ; and we know also that both are ^ 
 mere varieties of the same morbid deposition. ?! 
 
 The disease has been regarded and described as the same as the 
 medullary sarkoma or fungus, and the hematoid fungus; and^ 
 probably it is. But though it bears a close resemblance to this in 
 the great rapidity of its growth, and its mode of invading the sub- 
 stance of organs, it is in some respects different from this. The 
 most probable view is, that the medullary fungus is the advanced 
 stage of the enkephaloid tumour. 
 
 The microscopical structure of enkephaloma has been examined 
 by Muller and Vogel, under the name of the medullary fungus. 
 According to both, the tumour consists of nucleated cells, round, 
 oval, caudate, varying in magnitude from part of a line tOj^Q.' 
 Some contained a nucleolus within a nucleus. By addition of vine-^ 
 gar these cells become pale, and the nuclei and nucleoli are more 
 distinctly brought into view.* Gluge states that enkephaloma con- 
 sists of clear serum, and very numerous white spherical globules, 
 which show no nucleus, but a ragged undulating surface, or they are 
 colourless and even. These globules are larger than pus-globules. | 
 The fluid contains crystals. 
 
 From the circumstance of enkephaloid tumours presenting these ^ 
 nucleated cells as other tissues, Muller infers that they are not?, 
 heterologous growths. But this does not touch the question. The J 
 
 * Ueber den feinem Ban und der Fonnen der Krankhaften Geschwiilste von Dr Jo- 
 hannes Miiller in Zwei Lieferungen. Erste Lieferung. Berlin, 1838. 
 
 Julli Vogel leones Histologiae Pathologicae. Tabula, vi. Histologiam Pathologicam 
 Illustrantes. Lipsias, 1843. 
 
 t Atlas des Pathologischen Anatomie. Erste Lieferung. Jena, 1843. 
 
ENKEPHALOMA OF THE LIVER. 
 
 915 
 
 cells may be the same ; yet the structure, that is, the arrangement 
 and contents of the cells, may be totally different. The question is 
 further one which, it is clear, the microscope is not adequate to deter- 
 mine, Careful comparison of the enkephaloid structure shows that 
 it resembles neither cellular tissue, nor fat, nor lard, nor brain, nor 
 gland, nor cartilage, nor bone, but is peculiar in resembling itself 
 alone, and in undergoing peculiar changes. 
 
 Enkephaloma appears in the liver in several different modes. 
 
 First^ It may appear in that gland and in no other tissue ; and 
 the masses may gradually enlarge until they coalesce and occupy 
 the largest portion of the hepatic structure. They may attain a 
 considerable size before the fatal event takes place. 
 
 Secondly^ Encephaloma may appear in the liver along with or after 
 the development of enkephaloid tumours in one or more of the abdo- 
 minal viscera, or in the interperitoneal and mesenteric cellular tissue. 
 
 Thirdly^ A mode not unusual in which it appears is the follow- 
 ing. A tumour of suspicious character appears in the breast of a 
 female, and after some time it is removed by the surgeon. The 
 wound is healed ; but in the course of eight, ten, or twelve months, 
 the patient complains of tightness and fulness in the right hypochon- 
 driac region, and in the abdomen generally. In the former there 
 is irregular swelling; fluid is effused within the abdomen; and 
 after two or three months more, death ensues. The liver is found 
 quite occupied with large enkephaloid, whitish, or whitish gray 
 masses. The same structure affects the diaphragm, and spreads 
 into the lower lobe of the right lung. This I have seen take place 
 more than once. The tumour removed from the breast is not al- 
 ways quite the same. Sometimes it presents the whitish lard-like 
 structure of enkephaloma; sometimes it presents^ the characters of 
 pancreatic sarkoma; and in various instances it has presented 
 those of alveolar or areolar cancer. 
 
 Fourthly^ Dr Alder son gives several examples of disease of the 
 stomach and liver, in which the former organ presented the areolar 
 and colloid cancer, and the latter presented distinct and unequivo- 
 cal masses of enkephaloid structure. 
 
 If all the facts now adduced be well ascertained and constant, 
 and I can vouch for the truth of the three first, it follows that en- 
 kephaloma is allied to other forms of cancerous disease, and that it 
 may be regarded as the form which pancreatic or alveolar cancer 
 of the external organs assumes in the liver. The same morbid 
 action which produces the pancreatic and alveolar deposit in the 
 
916 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 mamma, and that which produces the colloid structure in the sto-r^^ 
 mach, may produce the encephaloid deposit in the liver. 
 
 the neck, those of the female breast, among the muscles of an ex- 
 tremity, or in a bone or joint, and also, either at the same time or 
 soon after, in the liver, 
 
 Enkephaloid deposit may affect the liver at any period of life. But 
 it appears most usually between the ages of 30 and 45 or 50. I have 
 seen an instance beyond 60 ; but this must be regarded as unusual. 
 
 Death is produced, not so much by the mere nature of the dis 
 ease as by its mechanical pressure and pathological irritation o 
 the chylopoietic and assistant chylopoietic viscera. The enlarge 
 liver compresses the stomach, duodenum, and blood-vessels ; in 
 pedes the function of digestion ; and causes intra-abdominal effusioi 
 
 Dr Carsewell shows that in many if not all instances, the enk< 
 phaloid matter is previously found in the blood and blood-vessels 
 and that from the blood it is conveyed by the vessels to various oi 
 gans, and especially to the liver. He thinks that in the liver tl 
 enkephaloid matter is infiltrated or deposited within the acini, c 
 glandular elements ; and as the form and size of these bodies 
 not altered, he infers that this new matter is introduced in the sani 
 order and manner as the normal element' of nutrition,* 
 
 right hypochondre and epigastric region, sometimes extending dowr 
 wards to the space of two or three inches, with an irregular nodulate 
 surface, with the peculiar complexion and expression indicating th 
 presence of heterologous disease, are the marks which it presents. 
 
 E. Melanoma. Melanosis. — This, which consists in a depc 
 sition of black ink-looking or umber-brown matter, semifluid, solid,*' 
 like black paste, or liquid, sometimes in points, sometimes in masses 
 contained in cysts, sometimes in layers, is an affection of the liver 
 not very uncommon. Yet it rarely takes place in the liver unless 
 at the same time or previously it has taken place in other tissues. 
 The most usual situation for the melanotic matter to he deposited 
 when it is found in the liver, is in the adipose tissue between the 
 folds of the mesentery, the mesocolon, in that round the rectutn,v 
 and in the lumbar glands and loins in general. It seems to be not 
 
 * Illustrations of the Elementary Forms of Disease. By Robert Carsewell, M. D„ 
 &c. London, 1838. 
 
 Fifthly, It occasionally happens that the enkephaloid structure ? 
 appears both in several external parts, for instance in the glands of 
 
 nized during life with little difficulty. A tumour in the site of th 
 
 The presence of enkephaloma in the liver is in general reco^ 
 
MELANOIIA MELANOSIS OF THE LIVER. 
 
 1)17 
 
 doubtful that in these parts it is deposited before it is formed in the 
 liver. The melanotic deposit may, when forming in the liver, have 
 been also previously deposited in organs still more remote, for in- 
 stance, in the adipose tissue of the eyeball. Melanoma is in short 
 a deposit which is first formed in some of the divisions of the adi- 
 pose tissue, and then may be formed, to all appearance, in a secon- 
 dary way, in one or more of the internal organs, most commonly 
 the liver or the lungs. 
 
 When melanosis takes place in the liver, it affects one of two 
 forms ; first, either the form of black points which are deposited in 
 the acini, or black semifluid or consistent masses, which may be tu- 
 beriform, and may be or not contained within cysts. 
 
 Melanosis, viewed as a morbid deposit, consists of a sort of 
 frame-work, and a colouring matter or pigment. The frame-work 
 or tissue is a fibrous structure arranged in the areolar manner, that 
 is, forming areolae or interstices, of a pearly aspect, and which is 
 probably allied to the fundamental structure of areolar cancer, only 
 much softer. 
 
 The pigment or colouring matter is of two sorts. It may be 
 either as black as the ink of the cuttle-fish, or it may he of an um- 
 ber or bistre-brown tint. The former is the most frequent. This 
 Thenard regards as charcoal, and Barruel and Breschet as the 
 colouring matter of the blood. According to the best analyses, 
 those of Barruel, and Clarion, and Lassaigne, this colouring matter 
 consists of albumen 15 per cent., fibrin 6 per cent, carbonaceous 
 matter 31 per cent, oxide of iron If per cent, and the usual salts 
 of the blood. These facts give a high degree of probability to the 
 opinion promulgated by 'Breschet, that melanotic matter is blood 
 extravasated and changed, with a large proportion of colouring 
 matter. If this be correct, it seems that it is a mistake to regard 
 melanosis as always a malignant or heterologous growth. The 
 deposit, nevertheless, takes place under circumstances which scarcely 
 permit us to call this in question. It may be that there is a simple 
 or innocuous form of melanosis, and one associated with the carci- 
 nomatous structure. 
 
 When melanotic matter is deposited in the liver so as to present 
 the solid form, it is usually in the acini ; and then it gives the gland 
 the aspect of a piece of syenite, or rather black micaceous rock, 
 from the peculiar glistening aspect of the fundamental tissue. 
 
 § 15. d. Dr John Gairdner and Mr Thomas M. Lee described 
 in 1844 a species of hydatid, which, though perhaps noticed by 
 
918 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 previous observers, had not been accurately distinguished or care- 
 fully described. Though the morbid condition connected with the ’’ | 
 presence of this parasite was not confined to the liver, and affected , [ 
 not merely the right lobe of that organ, but the omentum, part of j;.: 
 the pancreas and spleen, part of the intestinal canal, and the sur-^ j 
 face of the peritoneum in general, yet it may he well to notice^ 
 shortly the characters of the animal. 
 
 In the case given by Dr Gairdner, the hydatids consisted of glo- H;| 
 bular or rounded bodies aggregated in masses or groups, not un- tiii 
 like the egg-bed of the common fowl. Each hydatid consisted of ■ . 
 gelatinous matter contained within striae or fibres ; and each had an 
 external membrane provided with stomata, or orifices which lead S 
 into tuhvli. Each group consisted of many hydatids attached or 
 covered by one common membrane, which further dipped between^ U 
 them. This membrane presented numerous disks varying in size,^,, 
 and round which the orifices or stomata were arranged. This it 
 has been proposed to denominate, from the circumstance now spe-^^" 
 cified, Diskostoma acephalocystis. 
 
 In the case which occurred to Mr Lee, the hydatid had a gela-^i 
 tinous body like the last noticed, and membranous investments pmII 
 but the animal itself, which varied in size from a millet seed to the^ ' 
 bulk of an orange. This animal is without aperture or apparent^ 
 organ of nutrition ; and hence it has been proposed to term it^‘ 
 Astoma acephalocystis. ^ 
 
 Those under the size of a filbert were globular. As soon as 
 they advance beyond this size, they assume on the surface a nodu- 
 lated appearance, which increases with the size of the animal, and 
 which is owing to the simultaneous growth and enlargement of tlie c 
 young cysts contained within it. 
 
 The Astoma acephalocystis forms a sort of intermediate link be-,. '3 
 tween the common acephalocyst {Acephalocystis simplex) and th^ 
 Dishosloma acephalocystis.* 
 
 Some observers have called in question the independent animal ,• 
 existence of these two species of parasite, as others have doubted 
 that of the common acephalocyst. So far as it is possible to forin:,^ 
 an inference from appearance and characters, they seem entitled to 
 be regarded as animals, though of a low and imperfect type ; and 
 it seems most convenient to notice them in this place. 
 
 * Cases and Observations illustrating the History of two kinds of Hydatids, hitherto | 
 midescribed. By John Gairdner, M. D. and Thomas M, Lee. Edin. Medical and j 
 Surgical Journal, Vol. Ixi. p. 269. Edinburgh, 1844. 
 
DISEASES OF THE GALL-BLADDER AND GALL-DUCT. 919 
 
 The Gall-Bladder and Ducts. The Bh.e. — § 1. The gall- 
 bladder, and cystic duct, and common duct are all liable to inflam- 
 mation, sometimes of a spreading and catarrhal character, or phleg- 
 monous and limited. In either case the process may cause a tem- 
 porary attack of jaundice. 
 
 § 2. Hydatids have been found in the gall-bladder.* 
 
 Parasitical animals, as the Fasciola hepatica^ it has been already • 
 stated, may take place in the biliary ducts. 
 
 § 3. The most usual and important disorder of the biliary excretory 
 system consists in the formation of gall-stones, which may be form- 
 ed in any part of these ducts, and in the gall-bladder, but most 
 commonly in the latter. 
 
 Gall-stones occur of all sizes, from that of a pin-head up to the 
 magnitude of one inch in diameter. When small, they are gene- 
 rally numerous, and may occur to the amount of sixty or seventy 
 in the gall-bladder at one time. Their figure in that case is poly- 
 hedral or tetrahedral, with rounded edges and angles, from mutual 
 attrition and polishing. When there are only two or one, then the 
 size may be considerable, that is, from half an inch to three-quar- 
 ters of an inch, or a whole inch and more in diameter. Their 
 figure is then spherical, oblong spheroidal, or pyriform, more or 
 less regular. In this state they may be contained either within the 
 gall-bladder, or in certain dilated portions of the biliary ducts. 
 
 These bodies are lighter than water. Soemmering states he has 
 seen them sink; yet his facts show that they are lighter. They are in- 
 flammable, and, when burned, are slowly reduced to charcoal almost 
 pure. Their interior structure presents a resinous glistening frac- 
 ture, and a yellow or yellowish-brown colour, and, when closely 
 inspected, the broken part exhibits numerous minute brilliant, crys- 
 talline scales, which resemble mica or scales of spermaceti. These 
 scales are almost pure cholesterine, which, indeed, constitutes the 
 larger portion of almost all gall-stones. Some gall-stones consist 
 of pure cholesterine ; others consist of cholesterine with the colour- 
 ing matter of the bile ; and a very small proportion contain the 
 matter of bile inspissated and altered. 
 
 Cruveilhier states, that in most calculi of cholesterine, the nu- 
 cleus consists of concretions of thickened bile. This does not cor- 
 respond with what is observed in this country. In general, the 
 nucleus or central portion consists of cholesterine in more or less 
 purity, and round this are lamellae or strata, still of cholesterine 
 
 * Museum Anatomicum, a Johanne Gottlieb Walter. Berolini, 1805. 4to, p. xix. 
 
920 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 in scales, but with colouring matter of bile ; and the only part 
 which, in a small proportion of cases, is inspissated bile, is the outer 
 portion of the concretion.* 
 
 These facts regarding the chemical composition of biliary cal- 
 culi show that, previous to their formation, a great and decided 
 change takes place in the bile. Bile does not in the normal state 
 contain cholesterine ; but there is no doubt that the cholesterine is 
 formed from the bile. A new arrangement, therefore, of the ele- 
 ments of bile must take place. Cholesterine consists principally of 
 carbon and hydrogen, and the ingredients of the bile must so alter 
 their relations as to form in this manner cholesterine. 
 
 The presence of gall-stones in the tubuli, the gall-ducts, or in the 
 gall-bladder, gives rise to various effects in these parts. The liiost 
 common is believed to be jaundice ; and eertainly in the case of gall- 
 stones of moderate size becoming fixed in either the tubuli^ the pori^ 
 the hepatic duct, the cystic duct, or the common duct, more or less 
 jaundice, continuing for a longer or shorter time, usually takes 
 place. On the other hand, numerous instances have been recorded 
 of gall-stones being discharged either by the bowels, or by ulcera- 
 tion through the parietes of the abdomen, in which no jaundice 
 had at any time appeared. 
 
 When gall-stones are small, their presence probably gives rise 
 to few or no symptoms. But when they are large, there is strong 
 reason to believe that they induce symptoms of considerable seve- 
 rity. These symptoms may be of two sorts. In one set of cases they 
 are supposed to be those of excruciating pain, and that of a spasmodic 
 character. In another set of cases they induce well-marked symp- 
 toms of either peritoneal inflammation, or of intestinal obstruction, 
 or ileus, or of both combined. 
 
 When gall-stones are small and numerous, and are contained in 
 the gall-bladder, they cause little uneasiness ; and numerous ex- 
 amples show that they may remain in that situation to the end of a 
 long life without giving rise to prominent symptoms. 
 
 When, on the other hand, they are large, and either are con- 
 tained in any of the ducts or get into these canals, they cause very 
 serious evils. Pain in the epigastric region, often of an excruciat- 
 ing character, relieved only by incurvating the trunk, vomiting, 
 jaundice, constipation, are all effects which have been observed to 
 result from the presence of gall-stones in the ducts. These symp- 
 
 * An Account of an unusually large Biliary Calculus voided from the Rectum. 
 By James A. Wilson, M. D. Med.-Chirurg. Trans., vol. xxvi. p. 80. London, 1843. 
 
GALL-STONES AND THEIR EFFECTS. 
 
 921 
 
 toms are caused either by the presence of a large distending body 
 in the ducts, or by the efforts made by the ducts and other textures 
 to expel that body. 
 
 When gall-stones are unusually large, they may be discharged 
 either by vomiting from the stomach ; or by the intestinal canal ; 
 the whole of which, as well as the cystic and common ducts, they 
 must traverse ; or they procure for themselves a route to the sur- 
 face of the body by means of ulceration, most commonly through 
 the parietes of the intestinal canal and abdominal muscles. Indeed 
 it is not unlikely that, in various instances, they cause ulceration 
 through the hepatic ducts or gall-bladder, in both the previous 
 cases ; and instances are recorded in which ulceration must have 
 been previously effected in the gall-bladder or hepatic and cystic 
 ducts, before the gall-stone could get either into the intestinal 
 canal, or come to the surface. 
 
 1. It is not very usual for gall-stones to be expelled from the 
 stomach by vomiting. Schurig, nevertheless, mentions not fewer 
 than eight instances in which gall-stones had been ejected in this 
 manner.* Orteschi records one case in his Diary.f One is given 
 in the Gazette Salutaire ; and one is given by Biondi.j; 
 
 2. Through the intestinal canal it is greatly more common to ob- 
 serve gall-stones expelled ; and while numerous cases are record- 
 ed, many must have taken place without being noticed. The fol- 
 lowing are the best authenticated. 
 
 F. Ruysch, Thesaurus Anatoraicus Quintus, n. 32. 
 
 Dr Musgrave records an instance of an oval gall-stone nearly 
 one inch long, and weighing 59 grains, being voided by a gentleman, 
 after an attack of jaundice, with much pain in the epigastric region.§ 
 
 Bezold records the case of a woman of 52, who, after much suf- 
 fering, passed a wedge-shaped hard biliary concretion, weighing, 
 immediately after discharge, one ounce two drachms and half a 
 scruple, which measured in its long circumference from two inches 
 and a half to three inches and a half, and in the middle was about 
 four inches and a half.|| 
 
 Mr J, Yonge, in a letter to Hooke, informs him that he had 
 lately seen a gentlewoman almost dead in jaundice relieved by the 
 
 * Lithologia. f In Diario, p. 283. t Giornale di Medicina, i. p. 282. 
 
 § A Letter from Dr William Musgrave to Dr Hans Sloane concerning Jaundice oc- 
 casioned by a stone obstructing the Ductus Commvmis Biliarius. Phil. Transact. No. 
 306, p. 227. London, 1706-1708. 
 
 II Georgii Bezold Dissertatio de Cholelitho. Argentorati, 24th May 1725. Apud 
 Haller, Dissert. Medico-Practicas, Tom. iii. p. 605. 
 
922 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 evacuation of a gall-stone as large as a pullet’s egg ; and another 
 from a man as big as a nutmeg ; both followed with a lask (loose- 
 ness) discharging prodigious quantities of choler. * 
 
 John Baptist Bianchi relates the case of a lady of rank who had 
 been subject to periodical jaundice from twelve to fifteen days at a 
 time ; and from whom a gall-stone larger than a walnut was brought 
 away by the operation of a strong purge, f 
 
 Dr James Johnstone records a case in which a corpulent old 
 lady, after suffering for two days severe pain in the epigastric re- 
 gion with vomiting, voided an oblong pyriform biliary concretion, 
 about one inch and a quarter long, and fully one inch in diameter, 
 and weighing 126 grains. She had no jaundice, but seven hours 
 of most excruciating pain.j: 
 
 Lavernet relates a case in which a large biliary concretion 
 weighing three drachms was voided. 
 
 Petit mentions the case of a lady who had jaundice with colicky 
 pains. After the use of the warm-bath three times, she discharged 
 with much blood a gall-stone, rough like the skin of the shark, 
 weighing four drachms and two scruples, and measuring two inches 
 and a half long, one inch and a half in diameter, and three inches 
 and a half in circumference. (| 
 
 Walter mentions shortly the case of a female of about 70 years 
 who voided two gall-stones, weighing together two drachms two 
 scruples = 160 grains. The largest was oblong spheroidal, a little 
 more than one inch long, and a little less than one inch in trans- 
 verse diameter.lf 
 
 M. Gosse records in a married lady during pregnancy the escape 
 of two concretions of a burnt umber colour, which had been origi- 
 nally one, at an interval of ten hours, weighing together about four 
 drachms (3 gros,) and the first of which was 14 lines long and 23 
 in circumference. She suffered much previously from colic pains ; 
 but had no jaundice.** 
 
 * Philosophical Experiments and Observations of the late Dr Robert Hooke, F. R. S. 
 &c. published by Wilbam Derham, F. R. S. London, 1726, p. 79. 
 
 + Historia Hepatica Joannis B. Bianchi, M. D. Tom. i. p. 189. Genevae, 1725. 
 
 An account of two extraordinary Cases of Gall-stones. By James Johnstone, 
 M. D. of Kidderminster. Phil. Trans, vol. 1. p. 543. London, 1758 ; and Medical 
 Essays and Observations, &c. Evesham, 1795, 8vo, p. 200. 
 
 § Jom-nal de Medecine Continue, vol. xv. p. 404. 
 
 II Traite des Maladies Chirurgicales, Tome i. p. 325. Paris, 1774 and 1790. 
 
 •H Henkel’s Neuen Medizinische und Chirurgischen Anmerkungen. 1769. And Wal- 
 ter Anatomisches Museum, T. 112, 213. Taf. 2. 
 
 ** Observation d’un Calcul Biliare expulse par les selles ; par M. Gosse. Jom-nal 
 de Medecine et Chirurgie, &c. T. xxxiv. p. 45. Paris, 1770. 
 
GALL-STONES AND THEIR EFFECTS. 
 
 923 
 
 M. Brillouet gives, in a lady of 68, a case in which, after colic 
 pains, vomiting, and constipation, lasting apparently about a month, 
 there was voided first a gall-stone, five lines long and eighteen in 
 circumference, and weighing forty-three grains ; and fourteen days 
 after a similar concretion, six lines long, and weighing fifty grains ; 
 both fragments of one gall-stone weighing together one drachm 
 thirty- three grains.* * * § 
 
 Dr Lettsom records the case of a military gentleman of Jamaica, 
 who had laboured for years under severe pain of the epigastric re- 
 gion, which was ascribed to gout. As he had intervals of ease for 
 eight or ten days. Dr Lettsom suggested that his complaints de- 
 pended on the presence of gall-stones. At length, in one of the 
 fits, he voided an oblong spheroidal concretion 2 inches long, with 
 a contraction or collar in the middle, weighing 1 ounce 2 drachms 
 and 23 grains. No jaundice took place in this case.f 
 
 F. G. in Meyer Epist. ad Zimmermannum Hannoverae, 1789, 
 Editio secunda, 1790. 
 
 John Gottlieb Walter notices the case of a man of 71 who voided 
 an oblong spheroidal gall-stone, weighing two drachms, two scruples, 
 ten grains =170 grains, about one inch and a half in the greatest 
 diameter, and nearly one inch in the small diameter. The patient 
 suffered violent spasmodic pains in the abdomen ; but all ceased on 
 the discharge of the concretion, j; 
 
 Heberden mentions a case, in which a female, who had suffered 
 from jaundice for many years, at length voided a concretion, of 
 which the smaller circumference was two inches. § 
 
 Mr H. L. Thomas records in a woman of 63 an instance of a 
 globular gall-stone being evacuated, 1.6 inch largest diameter, 1,1 
 inch small diameter, weighing 228 grains. || 
 
 Mr T. Brayne records in a woman of 55 an instance of a gall- 
 stone of the shape of a pigeon's egg being expelled from the 
 bowels, measuring If greatest diameter, 1| shortest diameter, and 
 
 * Observation sur un Calcul Biliare expulse par les selles, par M. Brillouet. Jour- 
 nal de Medecine, T. xxxvi. p. 233. Paris, 1771. 
 
 f Case of a Biliary Calculus. By J. C. Lettsom, M. D. Read 4th September 1786. 
 Memoirs of Medical Society, Vol. i. art. xxx. p. 373. London, 1787. 
 
 t Anatomisches Museum Gesammelt von Johann Gottlieb Walter, S. 96, Taf. iv. 
 Berlin, 1796. 4to. 
 
 § Commentarii de Morborum Historia et Curatione. Lond. 1797. 8vo. Cap. 50, p. 209. 
 II Case of Obstruction of the Large Intestines occasioned by a Biliary Calculus of 
 extraordinary size. By H. L. Thomas, Esq. Medico-Chinu-g. Transactions, vol. vi, 
 p. 99. London, 1815. 
 
924 
 
 GENERAL AND PATHOLOGICAL ANATOMY, 
 
 weighing 162 grains. Occasional slight jaundice. Symptoms of 
 ileus.* 
 
 The same gentleman records, in a female of 65, an instance 
 in which, after much suffering, a flat cubical concretion, with 
 rounded angles and concave depressed sides, weighing 176 grains, 
 and one inch in diameter, was voided ; and another, six days after, 
 hemispherical in shape, and 159 grains, was expelled. ^No jaundice. 
 
 I met, in March 1824, with a case in an elderly lady, who, after 
 being very ill for eight days with symptoms of obstinate ileus, voided 
 a large spherical biliary concretion, weighing, when dried, 160 
 grains, and measuring one inch two lines in diameter. In this case 
 no yellowness ever was observed.! 
 
 Dr Robert Paterson of Leith presented to me, in 1842, the half 
 of a spherical gall-stone, fully one inch in diameter, which had 
 been voided some time previously by a patient of his, after pre- 
 senting symptoms of obstinate obstruction, without jaundice. 
 
 Dr James Arthur Wilson records a case in which a gentleman 
 of 73, after suffering from constipation, with jaundice and hiccup, 
 and vomiting for many days, voided a large biliary concretion, con- 
 sisting of cholesterine in the centre, and inspissated bile with choles- 
 terine externally. ! 
 
 The question has often occurred to my mind since I witnessed 
 the violent and obstinate symptoms both of inflammation and 
 intestinal obstruction, with which the case now referred to was 
 attended, whether these large calculi merely distend the ducts 
 before getting into the intestinal canal, or pave to themselves a 
 passage by inflammation and ulceration. It appears to me that 
 though, in some instances, dilatation of the ducts may take place, 
 and be sufficient for the transport of the concretion, yet in several 
 inflammation and ulceration had taken place. Though I distinguish 
 this class of cases from those which are to come next, yet we must 
 remember that nature knows no distinction of this kind. When a 
 gall-stone is fixed either in one part of any of the three ducts, or 
 in the gall-bladder, it may there give rise to inflammation and suppu- 
 ration of the surrounding textures ; and it will depend on several 
 
 * An Account of two Cases of Biliary Calculi of extraordinary Dimensions. By 
 T. Brayne, Esq. Medico-Chirurg. Transactions, Vol. xii. p. 255. London, 1823. 
 
 4 History of a case in which the symptoms of Ihac Passion arose fi'oni the transit of 
 an unusually large gall-stone, terminating favourably. By David Craigie, M. D. Edin- 
 burgh Medical and Surgical Journal, vol. xxii. p. 235. Edinburgh, 1824, 
 
 + An Account, &c. Medico-Chirurg. Transactions, vol. xxvi. London, 1843. 
 
GALL-STONES AND THEIR EFFECTS. 
 
 925 
 
 circumstances what course this inflammation is to take, what textures 
 it will affect, and by what channel the concretion will finally proceed. 
 The suppurative process may then be either confined more or less 
 strictly to the tissues immediately concerned, as the gall-bladder, 
 the cystic duct, the hepatic duct, or common duct, or two of these 
 at once according to the position of the concretion, and the cellular 
 substance of the capsule of Griisson and the duodenum ; or it may 
 extend to a larger portion of the intestines, and even by ulceration 
 and adhesion to the parietes of the abdomen themselves. The 
 latter result is most likely to happen when the concretion is in the 
 gall-bladder, fundus or base of which is very near the abdomi- 
 nal muscles. Yet there is no assurance that the same course may 
 not be followed when the concretion is in the cystic or common 
 duct, or even in the hepatic duct. In the first case, the concretion 
 is discharged into the cavity of the intestines, — viz. the duode- 
 num^ the ileum, or the transverse arch of the colon. In the latter, 
 it is almost uniformly expelled by an ulcerated opening through 
 the abdominal parietes. 
 
 The reason which induces me to think that these concretions may 
 pass into the intestinal canal by means of ulceration, is found in 
 such cases as that given by Tyson of an abscess in the liver, in 
 which gall-stones were found in the gall-bladder, the ductus cysticus, 
 common duct and in the porus hiliarius, or hepatic duct •,* a case 
 mentioned by Walter (at page 126), in which he infers that the 
 gall-bladder must have been inflamed and suppurated, forming 
 around it a pouch or sac, connected with the transverse arch of the 
 colon that already mentioned at page 867 of this work ; and that 
 given by Dr Scott, in which the patient died during inflammation 
 of the gall-bladder, caused by the presence of a concretion as large 
 as an olive ; and which, had life been prolonged, must have found 
 its way by ulceration into the intestines or to the surface of the 
 body,+ 
 
 3. The latter appears to be the mode of exit most common in 
 
 * Anatomical observations of an abscess in the liver, a great number of stones in 
 the gall-bag and bilious vessels, &c., by Edward Tyson, A. M., &c. Oxon. Phil. 
 Trans., No. 142, p. 1035. London, 1678, voL xi. 
 
 •f- Anatomisches Museum Gesammelt von Johan Gottlieb Walter. Berlin, 1796, 
 4to. 
 
 + Case of Death from Inflammation of the Gall-bladder, occasioned by the irrita- 
 tion of a Stone. By Da^dd Scott, M. D. Edin. Med. and Surg. Journal, Vol, xxiii. 
 p. 297. Edin. 1825. 
 
926 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the case of large concretions ; yet it is not confined to them, but 
 serves as the channel for evacuation of moderate-sized gall-stones 
 also. Of this mode of expulsion, many instances are recorded ; but 
 I mention only the following in illustration of the circumstance. 
 
 In the Ephemerides Naturae Curiosorum cases by many authors. 
 
 Tolet states that he saw a gall-stone as large as a pigeon’s egg 
 discharged by an ulcer at the navel.* * * § 
 
 The editor of the Bologna Commentaries gives, from the prac- 
 tice of Tacconi, in 1739, the following case. A married woman 
 of 27 suffered for some time under pain at the epigastric region, 
 squeamishness, occasional vomiting, and at length a suppurating 
 swelling near the site of the right lobe of the liver. Into this an 
 incision was made ; when four ounces of matter and seven biliary 
 concretions came away. In the course of fourteen days, other con- 
 cretions came away, varying in shape, size, and weight, one as large 
 as a nutmeg. After this, recovery took place. No jaundice was 
 observed.! 
 
 Cheselden mentions a case in which two gall-stones, six lines in 
 diameter, were discharged through the abdominal integuments-! 
 
 Hoffmann mentions a case in which eighty gall-stones were dis- 
 charged by an ulcer in the abdomen. § 
 
 Wislicen records the case of a man who, after suffering for one 
 year much pain in the abdomen, had a tumour in the right groin, 
 which was opened by caustic, and discharged at length upwards of 
 fifty concretions of the size of beans and peas-H 
 
 Petit mentions three instances. The first was that of a lady who 
 had a pointing tumour in the right hypochondre, which, on being 
 opened, discharged at first pure bile ; and from which, seven or 
 eight months afterwards, there escaped a gall- stone. IF The second 
 one, from Lapeyronie, in a woman of 37, in whom a tumour ap- 
 peared in the epigastric region, which, on being opened, discharged 
 purulent matter with bile, and five or six concretions of the size of 
 
 * Traite de la Lithotomie. 8 vo, 4trieme edition, Utrecht. Chap. iv. p. 24. 1693. 
 
 + De Bononiensi Scientiarum et Artium Institute atque Academia Commentarii, T. 
 2di, Pars prima. Bononiae, 1745. 4to, p. 212. 
 
 ^ Anatomy, Book iii. chap. v. p. 166. 12th edit. London, 1784. 
 
 § Crell Chemische Annalen 1789. viii. St. Seite 128. 
 
 II J. Andreae Wislicen Lapides per Abdomen ulceratione exclusi. Lipsiae, 1742. 
 Apud Haller Dissertationes Medico-Practicas, T. iii. p. 629. 
 
 ^ Traite des Maladies Chirurgicales, Oeuvrage Posthume de J. L. Petit. Tome i. p. 
 313. Mis au jour, par M. Lesne. Paris, 1790. 
 
 4 
 
GALL-STONES ESCAPING BY ULCERATION. 
 
 927 
 
 peas.* * * § In a third, a female of 74, he extracted from a fistulous 
 opening in the right hypochondre first one concretion four inches 
 long and three in circumference, and afterwards another smaller 
 concretion. 
 
 A case in the Commerdum Norimberg. 1743, p. 81. 
 
 Dr James Johnstone mentions the case of a woman of upwards 
 of 30 labouring, in 1752, under jaundice and excruciating pain, 
 striking from the right hypochondre to the back, with frequent fits 
 of vomiting. At this time, hardness was felt at the pit of the sto- 
 mach. About three months after this time, the tumour suppurated, 
 and discharged with matter several gall-stones. She recovered, 
 and died in 1763.f 
 
 M. Marechal and Guerin, in attending a lady of rank, who had 
 a suppurating tumour at the margin of the right hypochondre, 
 opened it by incision, and removed a gall-stone as large as the 
 largest acorn, j; 
 
 Haller mentions the instance of a woman in whom, from an ulcer 
 in the epigastric region, several biliary calculi were discharged, an- 
 gular, trihedral ; the patient surviving. § 
 
 Bloch saw several concretions come away from an ulcer under 
 the false ribs ;1| and Buttner saw thirty-eight gall-stones discharged 
 from an aperture near the navel.1T 
 
 Civadier saw several gall-stones come away from an ulcer in the 
 right groin.** * * §§ 
 
 Acrell published in 1788 atUpsal a dissertation on gall-stones 
 escaping by ulceration through the abdominal parietes ; and Sand- 
 torff published at Helmstadtlf a dissertation on the same subject, 
 containing accounts of various cases. Vogler gives an instance of 
 the occurrence and Bruckmann observed several gall-stones 
 escape successively through an abscess in the abdomen. §§ 
 
 * Lapeyronie, Memoires de I’Academie de la Chirurgie, T. i. p. 185. Paris, 1743 ; 
 and Petit, Oeuvres Posthumes, Tome i. p. 320 and 325. Paris, 1774 and 1790. 
 
 t Philosophical Transactions, Vol. 1. p. 543, and Essays, p. 207. 
 
 t Observations par M. Morand, Memoires de I’Academie Royale de Chirurgie, 
 Tome ui. p. 470. Paris, 1757. 
 
 § Opuscula Pathologica, Lausannae, 1767 et 1768. Ohs. 38, Hist. 8. 
 
 II Medicinische Bemerkungen. Berlin, 1774. 
 
 ^ Funf Besondere Wahmehmungen. Koenigsberg, 1774. 
 
 ** Nouvelles Economiques et Litteraires, Tom. xx. 
 
 •)"t" Hissertatio de Cholelithis ex ulcere abdominis elapsis. Helmstadii, 1810. 
 
 Museum der Heilkunde, iv. Band, p. 91. 
 
 §§ Horn’s Archiv, 1810, p. 231, 144. 
 
928 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Mr George White, formerly a practitioner in this city, Informed 
 me, in May 1825, some time after I had published the account of 
 the large gall-stone voided, as already mentioned, from the bowels, 
 of an instance in which first inflammation, and suppuration, and 
 then ulceration of the abdominal parietes took place, and through 
 the aperture thus made a gall-stone of considerable size was dis. 
 charged, with recovery of the patient. 
 
 I may add also, that, in the Museum of Guy’s Hospital, there 
 are preserved two biliary concretions, which made their escape 
 through an abscess at the navel in a female patient of Mr T. Cal- 
 loway, one of the surgeons to that institution. 
 
 Dr Macnish gives an interesting case, in which, some months af- 
 ter an attack of acute hepatitis, an abscess was formed below the 
 margin of the ribs, which was at length laid open by incision. About 
 twenty-five days after this, a gall-stone as large as a nutmeg was 
 discharged from the wound ; and four days after another concre- 
 tion and some fragments were discharged. A good deal of bile 
 was afterwards mixed with the discharge. But the patient made a 
 good recovery, the wound having completely cicatrized about twelve 
 months after the date of incision.* 
 
 In short, there is no lack of evidence to show, that biliary con- 
 cretions of all sizes may find their way to the surface of the body 
 by a process of progressive inflammation and suppuration, the parts 
 behind and around being united by the eflPusion of lymph, so as to 
 prevent the concretion from getting into the peritoneum. It is, 
 indeed, important to observe, that while numerous cases of this 
 mode of exit are recorded, in all of which the movement of the con- 
 cretion must have been attended with ulceration, and not less nu- 
 merous cases of their transit into the intestinal canal, in several of 
 which, probably, the same process took place, no instance is recorded 
 of a gall-stone dropping into the cavity of the peritoneum, except 
 in one doubtful instance, f 
 
 After the foregoing detail, it is superfluous to say that the gall- 
 bladder and biliary ducts are liable to be afiected by inflammation 
 and ulceration. The ducts are liable to become obliterated in the 
 course of the process. 
 
 * Case of Tumour in the Region of the Liver, with discharge of Biliary Calculi 
 through the abdominal parietes. By William Macnish, M.D. &c. Edinburgh Me- 
 dical and Surgical Journal, Vol. xli. p. 169. 1834. 
 
 + Andree, 
 
 3 
 
INFLAMIATION OF THE KIDNEY. 
 
 929 
 
 One cause of tumour and eventually abscess has been pointed 
 out by Petit in France, and Amyand in this country. This con- 
 sists in an accumulation of bile, too thick apparently to flow through 
 the duct, attended probably with some obstruction either in the 
 cystic or common duct, by which the bile is prevented from getting 
 into the duodenum, and consequently distends the gall-bladder, 
 which then is inflamed. 
 
 § 4. The gall-bladder is liable to be involved in the heterolo- 
 gous deposits by which the liver is affected. 
 
 § 5. The gall-bladder has been found altogether wanting by Mar- 
 cellus Donatus, Schenke, Huber,f Targioni Tozzetti,| Sandifort,§ 
 and Wiedemann. II 
 
 § 6. It is liable to be ruptured, to be wounded or lacerated, and 
 to be ossified. 
 
 Section V. 
 
 Morbid States of tue Kidney. 
 
 The kidney is liable to be the seat of inflammation of various 
 sorts, and its effects, especially suppuration within the calyces ; to 
 the formation and presence of calculi within the calyces and pelvis ; 
 to enlargement and dilatation, and hemorrhage ; to granular dege- 
 neration {steatosis) ; to the formation of serous cysts ; to atrophy ; 
 to hypertrophy ; and to the heterologous growths. 
 
 § 1. Nephritis. Inflammation and its Effects. — The kid- 
 ney is, like other glands, liable to inflammation ; but this is more 
 particularly the consequence of certain circumstances residing either 
 in the general system of the individual ; or in the organ itself ; or 
 in the relation of the organ to the stomach, and the function of 
 digestion and assimilation. It is said that idiopathic inflammation 
 of the kidney is a rare affection ; and that most commonly the dis- 
 ease is symptomatic, that is, is supposed to indicate the presence 
 and operation of some irritant agent. This may he correct as to 
 acute attacks ; but it is not applicable to chronic affections, which 
 come on and are established either without perceptible cause, or 
 depend on the state of the blood and of the organs of digestion. 
 The idiopathic form is liable to take place in the gouty, as a symp- 
 tom of the gouty diathesis aud internal gout, being one form in 
 
 * Philosoph. Transact. 492. T Journal de Medecine, Tome iv. p. 283. 
 
 J Tabulae Anatomicae, Fasciculus iiL 
 
 § Reil Archiv fiu: die Physiologic, v. Band, p. 145. 
 
 3 N 
 
980 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 which gout affects the kidney ; and it is known by the individual 
 having presented more or fewer of the symptoms of gout, and by 
 the disease terminating in or being associated with a paroxysm of 
 regular gout. 
 
 Renal inflammation may ensue on blows or contusions on the 
 loins; falls in which the kidney, with other organs, suffers concus- 
 sion ; carrying heavy loads on the back, or wrenches in conse- 
 quence of falling in cari’ying loads ; riding on horseback ; riding 
 in a carriage over a rough road ; the presence of renal concretions 
 or sabulous matter in the infundibula or pelvis, especially if the 
 former be rough, or angular; various irritants taken into the 
 stomach, which either induce acidity, or being absorbed by the 
 blood-vessels, are enabled to irritate the tissue of the kidney, as 
 some of the vegetable acids and fruits, acid wines ; the application 
 of cantharides externally, or their use internally ; the terebinthinate, 
 resinous, and balsamic substances ; cold applied to the lumbar re- 
 gion, especially when overheated ; inflammation of the adjoining or- 
 gans, as the liver, spleen, duodenum, colon, psoas muscle, the dor- 
 sal or lumbar vertebrae ; and in some instances inflammation of the 
 bladder, extending upwards through the ureters, either resulting 
 from excessive distension of these organs, or without distension. 
 
 Of the whole of these circumstances which may be regarded as 
 exciting causes, the operation is very much favoured by the presence 
 of the gouty or calculous diathesis already mentioned. 
 
 Inflammation may attack either the pelvic and calycine membrane 
 of the kidney ; or the substance of the gland ; or the external sur- 
 face of the gland, with or without its investing membrane. 
 
 The most common is inflammation of the calycine membrane, or 
 that part of the mucous epithelial membrane of the kidney, which 
 extends upwards from the pelvis into the calyces and papilloe. This 
 membrane is then injected into blood, covered by a coating of 
 lymph more or less thick, and the free surface of which is formed 
 into a multitude of minute ]>rocesses or scales, while purulent mat- 
 ter is eventually deposited within this. The subsequent course of 
 this process shall be noticed presently. 
 
 When the substance of the kidney is inflamed, it becomes of a 
 deep red or reddish brown colour, abounds in blood-vessels, much 
 loaded with blood ; the whole organ is enlarged in all its dimen- 
 sions ; and its substance is copiously infiltrated with bloody serum. 
 As to consistence, nothing is certain ; the inflamed kidney being 
 
 3 
 
INFLAMMATION OF THE KIDNEY. 
 
 931 
 
 sometimes softer than natural, sometimes harder. This difference 
 depends prohahly on the duration of the inflammatory process. 
 Blood may be expressed from the papillae. In some instances small 
 points and drops of purulent matter, or purulent matter and fluid 
 lymph, are infiltrated into the substance of the gland. 
 
 The terminations vary according to the causes on which the 
 disease depends, the method of treatment, and the nature of the 
 affection. 
 
 Idiopathic renal inflammation may terminate in resolution, in an 
 attack of gout, in the deposition of sand or sabulous concretions 
 (lithiasis), in suppuration, in suppuration with extenuation of the 
 kidney, in induration or softening of the kidney, and perhaps in 
 granular deposition and transformation, or in death. 
 
 Idiopathic nephritis may, under the prompt use of remedies, ter- 
 minate in resolution on the third, fifth, or seventh day. In this case 
 the pain gradually or speedily abates and finally disappears ; the 
 vomiting ceases, the heat and thirst are diminished, the patient be- 
 comes less restless, and at length falls asleep ; and the skin becoming 
 moist, he awakes in general without any feeling of his former suf- 
 ferings, with the pulse down at 80 or even lower, and begins to dis- 
 charge without pain or uneasiness a considerable quantity of urine, 
 usually dark-coloured, like brown dirty water or coffee, which de- 
 posits on cooling a sediment dark-coloured, and sometimes slightly 
 bloody. In the course of a day or two, if this amendment con- 
 tinue, the urine returns to its natural standard in quantity, quality, 
 and appearance. 
 
 In cases of gouty diathesis, the pain of the renal region subsides 
 or disappears, and at the same time pain, redness, and swelling 
 appear on the foot or hand, and pass through their usual course. 
 
 If neither of these results take place on or before the fifth or 
 the seventh day, it may be apprehended that the disease is to ter- 
 minate either fatally, or in suppuration or abscess, or distension 
 and attenuation of the kidney, or one or other of the events already- 
 specified. 
 
 When the fatal termination takes place, it is generally preceded 
 by complete suppression of the urinary secretion, slow full pulse, 
 stupor proceeding to coma, and a urinous exhalation from the sur- 
 face of the body. 
 
 When nephritis terminates neither in resolution nor in death, it 
 may he apprehended that it is to end in suppuration or some 
 
932 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 similar disorganizing process in the kidney ; and though this may 
 take place in the spontaneous or idiopathic form of the disorder, 
 it is much more likely to ensue in cases in which the disease is in- 
 duced by the mechanical irritation of an urinary concretion. 
 
 It is requisite here, therefore, to specify the circumstances under 
 which suppuration is most likely to take place, and the usual forms 
 under which it appears. 
 
 § 2. Though suppuration of the kidney may take place either in 
 its cortical or secreting part, or in its tubular or excreting portion, 
 yet, so far as the evidence of morbid anatomy goes, the most usual 
 mode in which suppuration, or rather the secretion of purulent 
 matter takes place, is the following. 
 
 1. An attack of renal inflammation may, if it affect mostly the 
 tubular part of the kidney and the infundibula, terminate in the 
 secretion of puriform mucus, plastic lymph and blood from the 
 calycine membrane, that is the delicate mucous surface of these 
 cavities, and the •papilla, and from the mucous surface of the pelvis ; 
 and these morbid secretions may either escape through the ureter 
 into the bladder, and be expelled, or they may remain and produce 
 obstruction of the pelvis, secondary inflammation, and distension 
 of the pelvis and infundibula. 
 
 In the former case, the matter escapes by the ureters into 
 the bladder, partially or entirely, and is discharged in the 
 form of purulent matter, mixed with urine or purulent urine 
 {pyuria) ; but it is liable again to accumulate, unless the in- 
 flammatory action is totally subdued. If it do accumulate, it 
 then becomes, in all respects, similar to the latter case, and 
 a peculiar state of the kidney is presented, (Nephrotasia ; Ne- 
 phropyema). The matter retained within the pelvis and infun- 
 dibula, or at least not permitted to escape by tbe ureter, either 
 mixed with urine, or by itself, gradually accumulates and increases 
 in quantity, and causes more or less distension of the pelvis and 
 infundibula. If this be moderate, and if death take place, the 
 kidney, when divided, presents as many cavities containing puru- 
 lent matter as there are infundibula ; and while the substance of 
 the kidney is rendered much thinner than usual, these cavities are 
 sometimes supposed to be purulent cysts into which the kidney has 
 been con verted. This is the true explanation of such cases as that 
 mentioned by Cbeston, who states that in a boy of seven, “ the 
 substance of the kidneys was so dissolved into matter, that they ap- 
 
THE KIDNEYS NEPHROPYEMA. 
 
 933 
 
 peared little more than cysts full of pus, the one weighing four 
 ounces and the other three.”* I have seen several cases in which 
 observers otherwise able were deceived by his appearance, and were 
 led to imagine that the kidney was converted into purulent cysts. 
 The mistake is rectified by removing the purulent matter cauti- 
 ously, and washing the cavities in pure water, when it is observed 
 that the fine membrane covering the papillce and lining the infun- 
 dibula (membrana calycina) is a little rough and thickened, very 
 generally covered with lymph, but not destroyed or marked by any 
 breach of continuity ; that the papillse may be recognized also en- 
 tire ; and that the only change which has taken place is consider- 
 able distension by purulent matter, and consequent attenuation of 
 the tubular and cortical part of the kidney. 
 
 The quantity of matter accumulated, however, may be consider- 
 able, the distension great, and the consequent attenuation of the 
 renal substance may be carried to a great extreme. The first eflTect 
 of this increased accumulation is, by the distension, to force two or 
 more infundibula, into one common and considerable cavity or sac ; 
 the next eflFect is gradually to force several infundibula into one 
 considerable sac ; and if the accumulation continue and the disten- 
 sion proceed, the infundibula and pelvis are converted into one 
 general extensive sac, containing purulent matter. In cases of 
 this description, the cortical and tubular substance of the kidney 
 are so much stretched and attenuated, that not unfrequently they 
 are not thicker than a crown or a half-crown piece ; and it might 
 be imagined that these tissues were almost or altogether destroyed 
 by suppuration, and that nothing is left but the external capsule. 
 When, however, a proper section is made, the purulent matter 
 evacuated, and the parts washed with pure water, the calycine 
 membrane and the papillm may be recognized, — the former rough 
 with lymph and thickened mucus, the latter much compressed ; the 
 individual tubular cones may be traced, though much stretched and 
 separated ; and the cortical structure may be perceived in the form 
 of a thin exterior coating. 
 
 The size which the expanded and attenuated kidney may in these 
 circumstances attain, is often very great, and the quantity of mat- 
 ter with or without urine very considerable. The older authors, 
 as Blasius and Ott, have not distinguished the disease with accu- 
 racy or precision ; and consequently I can make little use of these 
 
 Pathological Inquiries, Chap. ii. p. 9. Gloucester, 1766. 
 
934 
 
 GENERAL AND rATlIOLOGICAL ANATOMY. 
 
 cases. But the kidney has been in this state found to be as large 
 as the head of a child, and to contain almost two pounds or more 
 of purulent, sero-purulent, or urino-purulent fluid ; and in one 
 case which was known to me, the left kidney was so much enlarged 
 and distended, that it occupied the whole left side of the abdomen 
 and extended into the pelvis. An excellent case is given by Cor- 
 visart in his journal.* 
 
 This disease has been described by Frederic Augustus Walter 
 in one stage, under the name of expansion of the kidneys, {expan- 
 sio renum,) and in another under the title of dropsy of the kidneys, 
 (Nierenwasserseuche,) {hydrops renalis.')] Neither of these names 
 are appropriate ; and the latter is particularly improper, in so far 
 as it conveys a just idea neither of the origin of the disorder, nor 
 its nature, and is liable, in the present state •of pathological know- 
 ledge, to be confounded with the secondary dropsical efiusions which 
 take place in consequence of granular degeneration of the kidney. 
 The expansion is the efibct of inflammation, which, by giving rise 
 to morbid products, causes distension of the kidney, and dilatation 
 of its infundibula and pelvis, much as sero-purulent fluid within the 
 pleura separates the lungs from the pleura costalis and ribs, and 
 extrudes the walls of the chest. The sero-purulent, purulent, or 
 urino-purulent fluid contained within the expanded infundibula and 
 pelvis of the kidney, constitutes no resemblance or analogy between 
 the fluid and those of dropsical effusions ; and the name should 
 therefore be discarded. If a particular denomination be wished 
 for the disease, the terra Nephropyema or Pyonephria is the proper 
 one, and the term Nephrotasia may be used to signify the disten- 
 sion. It may be observed, however, that the latter is a mere efiect 
 of the accumulation of purulent fluid. 
 
 I think that Mr Howship has been misled by the same circum- 
 stance, when, in speaking of this change under the head of disten- 
 sion of the kidneys, he observes, that “ by this means a degree of 
 pressure is established, which, as it increases, induces by degrees a 
 total resolution of the whole of the natural structure of the gland, 
 which is ultimately found converted into an assemblage of large 
 and small cysts, or thin membranous capsules.”| 
 
 * Journal de Medecine, Tom. vii. p. 387. 
 
 •j* Einige Krankheiten der Nieren und Harnblase. Berlin, 1800. 4to. 
 
 J A Practical Treatise on the Symptoms, Causes, Discrimination, and Treatment of 
 some of the most important Complaints that affect the Secretion and Excretion of the 
 Urine, &c. By John Howship, Member of the R. C. of Surgeons in London. Lon- 
 don, 1823. Section vi. p. 13. 
 
SUPPURATION OF THE KIDNEY. 
 
 935 
 
 That the great distension which in some cases takes place may 
 be suflficient to separate and detach forcibly from each the indivi- 
 dual component cones of the kidney, is a circumstance which 1 will 
 not deny. But I must say that everything known regarding the 
 effect of suppuration in this part of the kidney shows, that this is 
 not a common result ; and that the most frequent consequence by 
 far is that which I have here represented it to be. It is quite im- 
 possible to imagine the great changes produced by mere pressure 
 and distension in the human body, without absolute destruction of 
 the organization of parts, were it not the subject of daily observa- 
 tion, aided by accurate inspection of the state of the parts. 
 
 In some instances this purulent distension is confined to one or 
 two infundibula, which do not readily communicate with the others ; 
 and in consequence the purulent matter contained within them 
 does not escape into the other, but, being incessantly increased, 
 causes expansion and enlargement at one part of the gland. In 
 other cases it is confined to the pelvis, and produces on that the 
 same effect which it would elsewhere, but leaving the kidney for 
 some time comparatively uninjured. 
 
 The fluid contained may be purulent, sero-purulent, or sero- 
 purulent mixed with urine, that is urino-purulent. In some of the 
 cases described by Walter, the fluid is represented to have been 
 clear and diaphanous. 
 
 It is proper, however, to say, that Walter, who had seen several 
 examples of this disorder from obstruction of the ureter by con- 
 cretions, represents the whole kidney as so changed, that nothing 
 seemed to be left except the exterior membrane or capsule, which 
 was so much extenuated by the pressure of the contained fluid, 
 that the part which was previously a kidney, presented the appear- 
 ance of an expanded bladder. This distension he ascribes solely to 
 the accumulation of urine, which, not being allowed to pass by the 
 ureter, stagnates in the pelvis and infundibula^ and by compression 
 upon their excreting and secreting parts and vessels, first impedes 
 and then suspends the secretion and excretion of the gland. 
 
 In instances of great distension he mentions, that not only is all 
 the perinephral fat absorbed, but the exterior membrane itself may 
 be transformed into an osseous capsule, as was exemplified in various 
 preparations preserved in the collection of his father. The de- 
 scription now mentioned is most applicable to that obstruction which 
 arises from the presence of a concretion in the pelvis or ureter. 
 
936 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 § 3. Nephropsammia ; Lithiasis Nephritica. — An attack of 
 renal inflammation may terminate in the secretion of a considerable 
 quantity of sabulous matter, with or without puriform or morbid 
 mucus and blood ; and if this escape not by the ureter into the 
 bladder, and be thence expelled in the usual manner, the sabulous 
 matters are aggregated by the viscid mucus and other morbid 
 secretions into masses moulded in one or more of the infundibula 
 or the pelvis ; and there they remain constituting urinary renal 
 calculi ; in which case they may, either with or without inflamma- 
 tion, cause obstruction in the excretion of the urine, and consequent 
 expansion of the renal infundibula. 
 
 § 4. Nephropyema Calculosa. — Though it is well ascertained 
 that calculi if round do not always give rise to symptoms of un- 
 easiness or pain in the dorso-lumbar region, or to symptoms of 
 renal inflammation, yet they are very liable to do so during the 
 operation of any of the ordinary exciting causes of inflammation, 
 as external violence, exposure to cold, or a long and fatiguing 
 journey on horseback, or the operation of the particular causes of 
 renal irritation, as the use of acidulous articles of food or drink, 
 the absorption or the internal use of cantharides, or the use of the 
 turpentine, or resinous, or balsamic articles. 
 
 Either after or without the operation of one or other of these 
 causes, the patient is attacked with the symptoms of pain in the 
 dorso-lumbar region, shivering, squeamishness, numbness of the 
 thigh, pain or soreness or retraction of the testicle of the same side, 
 scanty urine or total suppression, or bloody sedimentous urine and 
 constipation. In some cases the severity of these symptoms under- 
 goes, either in consequence of remedies or spontaneously, tempo- 
 rary alleviation ; urine tinged brown with blood is expelled ; and 
 shortly after, quantities of sabulous matter or minute concretions 
 are discharged. 
 
 In some instances purulent matter is voided more or less co- 
 piously with the urine, and is observed to fall to the bottom of the 
 vessel, presenting its usual appearance and characters. Such a 
 circumstance is generally conceived to indicate suppuration of the 
 kidney. In one sense it certainly does denote the presence of this 
 process, but not in the sense commonly understood. Though it 
 be generally said that the kidney then suppurates, yet this is not 
 necessary either to the termination of the disease, or the appearance 
 of purulent matter in the iirine. A more common result is puru- 
 
SUPPURATION OF THE KIDNEY. 
 
 937 
 
 lent or suppurative inflammation of the fine mucous membrane of 
 the pelvis and infundibula, and consequent distension of the renal 
 tubular cones, but without destruction of their substance. It should 
 never be forgotten, that the presence of a urinary concretion in the 
 pelvis or ureter may cause inflammation and suppuration without 
 that suppuration affecting the proper substance of the kidney ; and 
 that suppuration of the kidney may take place without the presence 
 of a concretion in the pelvis, or ureter, or any of the infundibula. 
 If the stone be by any means expelled and carried into the bladder, 
 the purulent matter may also escape, and after being discharged, 
 the kidney may contract, and the morhid secretion may cease. 
 Hence it is found that discharges of purulent mine may take place 
 for some time, and eventually cease, without preventing the patient 
 from recovering temporarily. 
 
 More frequently, however, the reverse is the case. Though the 
 calculus may be discharged, the purulent matter may not be eva- 
 cuated, or the purulent inflammation continues ; and even the stone 
 itself, forming a sort of cyst of the pelvis or ureter, may remain 
 firmly impacted, and prevent the issue either of urine or purulent 
 matter. In either case, the expansion of the kidney (Nephrotasia) 
 continues and increases ; the tubular cones are distended, com- 
 pressed, and extruded ; the papillcB are compressed, flattened, and 
 almost obliterated ; the cortical covering is also distended and ex- 
 tenuated ; and the exquisite stage of the lesion already described 
 as Nephropyema {Pyonephria) is fully established. Even ulcera- 
 tion of the parts around the concretion, wherever it happens to be 
 fixed, may take place, and give rise to great and irreparable ra- 
 vages in the renal tissue, and that of the contiguous organs. 
 
 § 5. It is not uninteresting to trace the subsequent progress of this 
 disorder, and to observe what singular and extraordinary efibrts 
 are sometimes made to counteract the mischief in the kidneys, and 
 its effects on the constitution, and to prevent the immediately fatal 
 effects of the disorder. 
 
 Eight different terminations may in this state of the disorder be 
 mentioned. 
 
 a. The first termination requiring notice is, that the disease may 
 pass into the chronic state, in which the inflammatory process in 
 the infundibula and pelvis continues, causing the secretion of puru- 
 lent matter, which is voided with the urine, {pyuria), and attended 
 with quick pulse, nocturnal sweatings, wasting, and all the symp- 
 
038 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 toms of hectic fever. It is further requisite to observe, that this 
 state is liable to alternate with, or terminate in, an acute attack of 
 the disease, in which the purulent secretion is suddenly suspended 
 or stopped, pain in the renal region is induced or augmented, with 
 the other symptoms of renal inflammation, and terminate not un- 
 usually, if not checked, in sopor and fatal coma, with urinous ex- 
 halation from the surface of the body. 
 
 In those instances in which a calculus remains impacted in the 
 pelvis or ureter, these attacks are several times repeated, until the 
 kidney is very much enlarged, distended, and attenuated by the 
 large quantity of purulent or sero-purulent fluid, which never be- 
 ing allowed to escape, is progressively augmented by the addition 
 of that which is secreted at each new attack. Death seems then 
 to be the united result of the repeated inflammatory attacks, and 
 the lesion inflicted on the structure of the kidney. Of this mode 
 of termination instances are given by Tulpius,* and Job a Meek’- 
 ren,t and a melancholy and remarkable example occurred, in 1821, 
 in the person of a medical practitioner of this city, in whose body 
 the left kidney was found dilated so much, as to contain nearly 
 three pounds of sero-purulent fluid, which had been the product of 
 several attacks of renal inflammation, occasioned by the presence 
 of a small mulberry calculus, weighing only 1^ grain, impacted in 
 the upper end of the ureter.| 
 
 In such circumstances, there is reason to believe that the dis- 
 eased kidney ceases to secrete urine ; since its texture is so much 
 injured, and its circulation is employed in the maintenance of a 
 morbid secretion ; and that the functions of both are performed by 
 the sound one. 
 
 b. In the second place, ulceration may take place through the 
 pelvis or ureter, and purulent matter escape into the lumbar and 
 pelvic adipo-cellular tissue. Such a termination is necessarily fatal, 
 as it induces a sloughy mortified state of the lumbar and pelvic 
 adipose membrane, the effect of which on the system at large is 
 speedily fatal. Of this mode of termination a good case is given 
 
 ’ Nicolai Tulpii Observationes Medicse, 8vo. Amstelod. 1652 and 1672. Lib. ii. 
 cap. 45. 
 
 + Jobi A Meek’ren, Chirurgi Amstelodamensis Observationes Medico-Chirurgicaj 
 Amstelodami 1682, cap. xlv. The Memoirs of the Royal Society of Medicine (1780-8 1 
 Paris, p. 272) ; Fourcroy, Medecine Eclairee par les Sciences Physique, ii. p. 253. 
 
 X Edinburgh Medical and Surgical Journal, vol. xviii. p. 557 and 561. 
 
TERMINATIONS OF SUPPURATION OF THE KIDNEY. 939 
 
 by Mr Howship, in case 7, (p. 43), in a person between 60 and 
 70 years of age, in whom the matter eventually passed by a small 
 round ulcerated aperture of the peritonasum into the general ab- 
 dominal cavity. A similar case is recorded by Chomel.* 
 
 c. In the third place, the matter may pass directly through the 
 ■peritonaum into the cavity of the abdomen, establishing a direct 
 communication between the infundibula and pelvis of the kidney 
 and the latter cavity. This is mentioned by Chopart ; but it seems 
 to be questioned by Chomel, because no cases are specified by the 
 former. It is proper to mention, therefore, that an instance of this 
 mode of suppurative destruction is afforded in the sixth case by Mr 
 Howship, (p. 49,) taking place in the person of a boy of 7, who 
 had laboured under symptoms of urinary disorder from the age of 
 18 months, and in whom both kidneys, but especially the left, pre- 
 sented marks of suppurative inflammation, and a communication 
 had been established between the surface of the left kidney and the 
 cavity of the peritonaeum, and the matter had thereby escaped into 
 the interior of the latter. 
 
 d. A fourth mode in which the purulent matter may escape, is 
 into the transverse arch of the colon, especially if it be the left 
 kidney. Of this mode of issue Fantoni records an instance ; and 
 in the year 1832, in inspecting the body of a woman destroyed by 
 cholera, I found a state of parts which shows that the same issue 
 must have taken place in that case. In the transverse arch of the 
 colon was a fistulous opening leading into the pelvis of the right 
 kidney, in which and the expanded renal substance was contained 
 a large calculus. 
 
 e. In the fifth place, the communication may open, and the mat- 
 ter be evacuated into the sigmoid flexure or rectum. Of this an 
 instance is recorded by Bonnetf in the person of a young woman. 
 
 f. A sixth mode in which renal abscess has been observed to pro- 
 cure an outlet for itself is by producing ulcerative destruction of 
 the diaphragm and pleura^ and evacuating its contents into the 
 lungs and bronchi. Of this De Haen gives an instance, in which, 
 in the person of a young man of 15, after symptoms of renal in- 
 flammation, purulent matter was first voided with the urine, and, 
 
 * Archives Gen. xliii. p. 12. 
 
 t Journal Hebclomadaire, Tome vii, p. 397. Archives Generales, Tome xxiv. p. 
 278. 
 
940 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 after the interval of three or four years, during which the indivi- 
 dual recovered his health so far as to be able to marry, he was at- 
 tacked with symptoms of intense inflammation of the chest, he ex- 
 pectorated fetid sanious reddish purulent mattei’, and had most la- 
 borious breathing ; and eventually he died hectic. It was then 
 found that the left kidney was dilated into a large sac or cyst with- 
 out any trace of the original gland ; the ureter was distended to 
 the size of the small intestine, and was filled with purulent matter ; 
 a large aperture was found in the diaphragm, forming a direct 
 communication between the left kidney and the lower lobe of the 
 left lung, which was destroyed, with the lower part of the upper 
 lobe.* 
 
 g. A seventh mode in which the renal abscess may procure an 
 issue for its contents is into and through the liver or spleen, the 
 right kidney by the former, the left by the latter, towards the sur- 
 face. This mode of termination, which is assigned by Peter Frank, 
 is received with doubt by Chomel. It may be observed, however, 
 that Mr Howship gives in his eighth case, (p. 47), the history of an 
 attack of inflammation of the right kidney, in which a large abscess 
 of the right kidney pointed over the region of the liver, and was 
 there opened, and discharged five pints and a half of matter ; and 
 though after death, w'hich took place forty-two days after the ope- 
 ration, the substance of the liver was found healthy, its inferior sur- 
 face was united by adhesion to the superior extremity of the right 
 kidney. 
 
 li. In the eighth place, the matter of the renal abscess may open 
 a path for itself posteriorly through the back part of the pelvis or 
 ureter or kidney, and the dorso-lumbar cellular tissue, muscles, 
 and fasciae, so as to point on one or other side of the spine. Of 
 all the modes of proceeding outward, this is the one which has been 
 most frequently observed ; and as it has often suggested to surgeons 
 the expediency of making an incision in suspected cases of renal 
 concretion, it is chiefly in the writings of surgeons that accounts of 
 it are given. 
 
 Of this mode of issue, instances are recorded by Fantoni, Tulpius,f 
 Job a Meek’ren,J Cheselden,§ Petit.|| 
 
 The concretion giving rise to ulceration, first of the kidney or its 
 
 * Ratio Medendi, Tom. x. p. 103. 
 
 f IV. chap. 27. J Cap. xliv. § Anatomy, Book iv. chap. 1. 
 
 II Oeuvres Po.sthumes, iii. p. 73, and in the Memoirs of the Academy of Chirurgery, 
 ii. p. 233. 
 
GANGRENE OF THE KIDNEY. 
 
 941 
 
 pelvis, or the top of the ureter, causes at the same time suppurative 
 and adhesive inflammation, proceeding gradually to the surface, 
 where it forms a prominent tumour, red, painful, soft, and fluctu- 
 ating, and, either a spontaneous opening taking place or after an 
 incision, matter is discharged, and not unusually with that one or 
 more urinary calculi, or sabulous matter and urine. The swelling 
 subsides after the first discharge of matter ; but the aperture evinces 
 no disposition to close, and matter continues to be discharged for 
 months or years, while a long sinus or fistula leading to the kidney 
 is maintained. It is then a renal fistula, discharging matter, and 
 sometimes urine and sand, or urinary concretions. If the opening 
 happen to become closed, much pain is produced, and all the for- 
 mer symptoms of nephritis ensue, until fresh suppuration takes place, 
 and the aperture is reopened. Hence Lassus,* * * § Monteggia,f Boyer,| 
 and other surgeons, recommend that the fistula he kept open by a 
 bougie, a cannula, prepared sponge, or a bit of charpie, in short, by 
 some dilating body. 
 
 As in most of the cases now specified, the local disorder of the 
 kidney, if it do not prove immediately fatal, gives rise to more or 
 less hectic fever, with wasting and loss of strength. The condition 
 of the system thus induced was, early designated by the name of 
 renal consumption, {^phthisis renalis)^. This name, though retain- 
 ed by Hildenbrand and several moderns, is not proper, because it 
 is liable to lead to confusion ; since the term phthisis is no longer 
 general, but has been by most modern nosologists restricted to the 
 particular form of wasting which depends on tubercular destruc- 
 tion of the lungs. A more convenient appellation would be tabes 
 renalis, 
 
 § 6. Gangrene. — The question whether renal inflammation ever 
 terminates in gangrene has been proposed by Chomel. Fabricius 
 Hildanus mentions that in his own son, a boy of 9, he found the 
 kidneys and neighbouring parts inflamed and degenerated into 
 gangrene ; and Chopart records the case of a person of 62, who 
 died on the ninth day of symptoms of nephritis, in whose body he 
 found the kidneys bulky, livid, mottled with blackish spots, and 
 easily lacerable. In neither of these cases does the pathologist re~ 
 
 * Pathologie Chirurgicale, i. xxvii. p. 163. 
 
 t Istituzione Chirurgiche. 
 
 + Traite des Maladies Chirurgicales, T. viii. p. SOS, SOS. 
 
 § Jac. Fabricii, Disputatio de Phthisi RenaU. Giessse, 1699. 
 
942 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 cognize positive evidence of gangrene ; and Chomel is therefore 
 inclined to doubt the termination ; but he allows that, in cases of 
 persons who have died after long continued suppuration of the 
 kidney, some parts of the suppurating surface presenting the dark 
 colour, or grayish, the peculiar odour, the softness, and the absence 
 of apparent organization observed in mortified sloughs. 
 
 As an instance of this lesion, Walter records a curious case 
 which took place in the person of a young woman who had labour- 
 ed for many years under violent pains in the region of the kidneys ; 
 and who was at length attacked with inability to void urine, in 
 place of which she had a continual discharge of purulent matter, 
 mixed with blood and fine sand. The belly swelled so much that 
 she was imagined to be pregnant ; but she suddenly fell down dead. 
 Upon inspecting the body, Walter found the right kidney enlarged 
 into a great spheroidal swelling, ten inches in the long diameter, 
 six in the transverse, its substance of a brownish-red colour, very 
 soft, and so easily lacerable, that on the slightest touch an opening 
 was made. Internally it was altogether consumed, and its cavity 
 was filled with an astonishing quantity of coagulated blood, puru- 
 lent matter, and dissolved renal substance. This mixture, which 
 resembled a sort of soup, enclosed two concretions, one weighing 
 two drachms, the other two scruples, which could not be discovered 
 till some of the mixture was emptied. On further investigation, 
 Walter found that some of the large renal vessels had been eroded 
 and laid open, and to this he ascribed the sudden death of the wo- 
 man, and the quantity of blood found in the kidney.* 
 
 This, I think, must be regarded as a pretty unequivocal case of 
 gangrene of the kidney. The termination must, nevertheless, he 
 regarded as rare. 
 
 Vogel gives, in a man affected with jaundice, an example of the 
 kidney labouring under gangrene. The chief characters are masses 
 of clotted and decomposed blood disseminated through the paren- 
 chyma of the gland.f 
 
 Mortification of the perinephral adipose membrane is a common 
 consequence of infiammation of that tissue. But it belongs to 
 another head. 
 
 § 7. a. Suppurative inflammation of the Kidney. — Though 
 
 * Einige Krankheiten dcr Nieren und Harnblase. 4to. Berlin, 1800. § 11, 
 
 seite 0 . 
 
 •f Tabula xxiii. 
 
SUPPURATION OF THE KIDNEY. — CHONDROSIS. 
 
 943 
 
 1 have represented suppuration of the kidney to commence, in or- 
 dinary circumstances, in the interior of the calyces and pelvis, and 
 rather to produce a sort of expansion and distension of the gland 
 than an actual purulent destruction, it is, nevertheless, necessary 
 to say, that purulent destruction does take place in the substance of 
 the kidney. Of this I have seen several instances. In these cases, 
 the whole kidney was completely converted into a quantity of thick 
 purulent matter, partly like thin putty, partly more fluid, all of 
 which was contained within the renal capsule, like atheromatous 
 matter in a hag or cyst. 
 
 In all the cases of this disorder, excepting one, the patients pre- 
 sented no evident or prominent symptoms which could lead to the 
 suspicion that the kidney was in a state of inflammatory disease. 
 In one case, death took place after an obscure illness of a few days. 
 In the case which I have mentioned as an exception, the patient 
 was hectic, and had uneasiness in the bladder and along the ureters ; 
 but, as it was plai« that the lungs were tuberculated and presented 
 open vomicae, the hectic symptoms were justly ascribed to the pre- 
 sence of the pulmonary disorganization. If we say that this lesion 
 is of strumous origin, we merely give another answer, without com- 
 ing more closely to the explanation. It seems as if the whole re- 
 nal tissue, cortical and tubular, were liquefied or dissolved in pu- 
 rulent matter. 
 
 b. Small patches of purulent matter are occasionally observed 
 in the cortical or in the tubular part of the kidney, without appa- 
 rent connection with inflammation of the calyces. These, I think, 
 must be admitted to be of strumous origin. In one instance, in 
 which I witnessed this state of the kidneys, it took place in the body 
 of a sickly strumous boy of fifteen years, who died of lobular 
 'pneumonia ; and it is usually seen in young subjects. 
 
 c. In some instances of inflamed vein, purulent matter has been 
 found in the substance of the kidney. This has been regarded as 
 metastatic ; but it is most correct to look on it as transported from 
 the vein inflamed to this in common with other internal organs. 
 
 § 8. Cartilaginous induration of the Ureters and Pelvis, 'produc- 
 ing or accompanied with Renal Inflammation . — It is proper to men- 
 tion here, that the ureters and pelvis are liable to a particular kind 
 of chronic inflammation, inducing great thickening and induration 
 of the mucous membrane, with roughness of its inner surface. In 
 the most marked case of the disorder which I have seen, this state 
 
944 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 extended from the bladder upwards, through the ureters on both 
 sides into the pelvis and calyces of the kidneys. The ureters were 
 rendered thick and firm like cartilage ; their size was increased to 
 about five or six times the usual dimensions ; their canal was also en- 
 larged ; and their firmness prevented them from collapsing, as in the 
 healthy state. The morbid state now mentioned appeared to have 
 originated in the mucous membrane, but eventually to have affected 
 the other tissues. It was difficult to say whether it had commenced 
 in the membrane of the calyces or in that of the ureter, and extended 
 to the former ; for both were affected in nearly equal degrees. 
 
 This change was accompanied with painful and difficult micturi- 
 tion, the urine containing puriform mucus and sand ; with quick pulse, 
 much thirst, hot dry skin, alternating with shiverings and sweat- 
 ings, wasting, loss of strength, a most anxious miserable expression 
 of the countenance, and slight incurvation of the person, as if un- 
 der the suffering of much pain. The disease had been of long 
 duration, at least several months. 
 
 § 9. Disease of the Kidneys simulating disease of the Spinal 
 Chord; and inflammation of the Calycine Membrane from injury or 
 disease of the Spinal Chord . — A singular effect of renal inflamma- 
 tion and suppuration is to induce paraplegia and symptoms of dis- 
 eased spine. It has been long known that injuries and diseases 
 chiefly of an inflammatory character in the spine or spinal cord, are 
 liable to be followed by various morbid states of the urinary secre- 
 tion, which is generally rendered alkalescent or ammoniacal, some- 
 times deposits the ammoniaco-magnesian phosphate, sometimes the 
 carbonate of ammonia. Bellingeri had observed, that in animals, 
 after experiments on the spinal chord, inflammation was liable to 
 attack the kidneys and the peritoneum, and render the former red 
 and vascular, and cover them with lymph. Mr Stanley has shown, 
 by a judicious selection of cases, that when the spinal chord is sup- 
 posed to be diseased or injured, either directly or in consequence of 
 disease or injury of the vertebrae, causing pain in the back and 
 paraplegia, the symptoms so produced do not originate from dis- 
 ease of either the vertebra, the chord, or the membranes, all of 
 which are sound, but from inflammation or suppuration of the 
 kidneys, in which in general are found collections of purulent 
 matter. From such cases it must be inferred, as Mr Stanley has 
 done, that disease originating in the kidneys simulates, and may 
 give rise to disease in the spinal chord, probably by a reflected in- 
 
 4 
 
INFLUENCE OF DISEASE OF SPINAL CHORD, 
 
 945 
 
 fluence from the diseased gland through its nerves to those con- 
 nected with the spinal chord. It may conversely be inferred, that 
 in any morbid state of the spinal chord, the impaired influence of 
 the nerves over the renal action allowing the urine to be secreted 
 in the kidney in an alkaline state, gives rise to a new train of evils, 
 by the irritation necessarily induced in the tubular part of the kid- 
 ney and in the calycine membrane. The ammoniacal urine then 
 irritates perhaps both the cortical and the tubular part of the glands, 
 and must certainly irritate the calycine membrane, and is the cause 
 of the inflammatory states which it often presents. On this head I 
 refer the reader to the paper of Mr Stanley,* and to what I have 
 in another place said under the section on Myelitis.^ 
 
 The PROGNOSIS in Nephritis is in general not favourable. But 
 it is more favourable when the disorder is the result of external 
 violence, than when it is the efiect of any internal cause. In gouty 
 and calculous patients, the prognosis is unfavourable, because it 
 generally after one attack recurs several times, until it undermines 
 the strength by renal or vesical calculus, or by the formation of 
 renal abscess, or by total suppression (^Ischuria renalis\ causes 
 speedy death. 
 
 Renal abscess or fistula, though almost uniformly leading to 
 death, is not necessarily a fatal disorder ; but in whatever of the 
 forms specified it appears, life is always maintained in a most un- 
 comfortable and precarious condition. The least unfavourable is, 
 where none of the unnatural communications or fistulce have taken 
 place, and where the purulent matter has procured an outlet for 
 itself through the ureter into the bladder, and thence been dis- 
 charged externally. In some instances, recovery has been effected 
 after this event had taken place. Forest mentions (lib. xxiv, obs. 
 37), the case of a priest, who, after discharging purulent urine for 
 three months, and being reduced to the greatest emaciation, reco- 
 vered under the use of proper regimen, consisting, chiefly of milk. 
 M. Chomel records a case from M. Meniere of the Hotel Dieu, in 
 which a similar recovery must have taken place. The right kidney 
 was shrunk into an irregular mass, about the size of a pigeon’s egg, 
 forming a species of membranous sac, consisting of the calyces, 
 pelvis, and ureter, containing about half an ounce of clear fluid, 
 
 * On Irritation of the Spinal Chord and its Nerves in connection rvith Disease in the 
 Kidneys. By Edward Stanley, F. R. S., &c. Medico-Chirurgical Transactions, xviii. 
 p. 260. London, 1833. 
 
 t Elements of Practice of Medicine, Vol. ii. p. 398. 
 
 3 o 
 
946 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 but totally void of any trace of cortical or tubular portions. This 
 constitutes what some have named Atrophy of the kidney, which, 
 doubtless, is the effect of suppurative destruction, followed by con- 
 traction of the remaining parts. 
 
 Renal inflammation must be distinguished from the symptoms 
 produced by a calculus in the ureter, from lumbago, from psoitis 
 and lumbar abscess, from peritonitis, intestinal inflammation, colic, 
 granular disease of the kidneys, and from spinal irritation and in- 
 flammation, and disease of the spine generally. 
 
 § 10. Granular Disease — Steatosis — Stearosis of Gluge. 
 This consists in a change in the structure of the kidney, especially 
 its cortical or secreting portion, in which it is penetrated with gray- 
 ish, whitish, yellowish, or fawn-coloured adipose matter, in the form 
 of minute granules ; and in which, at the same time, the density of 
 the urine is diminished, and the urine contains less urea than it 
 ought, and more or less albumen or serum, the presence of which 
 may be shown by the application of heat, or the addition of any of 
 the acids or the metallic salts. 
 
 The texture of the kidney, especially its cortical portion, is liable 
 to become changed in various modes, and it presents in the different 
 stages of each diflferent appearances. 
 
 It is rare to observe kidneys in the first stage of this disease in 
 any of its forms, as it is not at that period by itself fatal ; and it 
 may be doubted whether it has been seen in the incipient stage. 
 The following varieties, however, may be regarded as the most 
 usual. 
 
 1. The kidney may be of a very dark-red, or brown colour, much 
 loaded with blood, and its vessels very much enlarged. The tubu- 
 lar is always of a darker colour than the cortical part ; but the 
 latter is in this case extremely dark-coloured. When it is divided 
 by a longitudinal incision, the surface of the section is altogether 
 much darker than natural, being a deep chocolate brown, while 
 the cortical portion appears, though darker than natural, yet lighter 
 coloured than the tubular, and presents the aspect of a brownish 
 red mass, surrounding and enclosing dark-brown, or amber-brown 
 coloured tubular cones. The outer surface of the gland, stripped 
 of its tunic, is also very dark-coloured, reddish brown, inclining to 
 chocolate red, is less smooth than natural, and may even be a little 
 rough and irregular, presenting small depressions containing blood- 
 vessels in clusters, and the gland is in general, in this variety and 
 
STEATOSIS OR GRANULAR DISEASE OF THE KIDNEY- 947 
 
 stage of the disorder, soft and flaccid. The whole gland is large, 
 flabby, and very vascular. 
 
 This form of the disorder is seen chiefly in persons who have 
 died from fever or pneumonia, or pleurisy, or in children with 
 symptoms of afiection of the brain. 
 
 2. In one variety next to be mentioned, the kidneys are large, 
 soft, and flaccid ; and when the tunic is stripped, the exterior sur- 
 face, though less deep in colour, is still more irregular than in the 
 last mentioned variety. The colour, indeed, begins to assume a 
 gray or fawn tint, the brown being less deep, and giving place to 
 chestnut-brown or yellowish-brown. The irregular appearance on 
 the surface is produced by numerous depressions with alternate 
 elevations. In the last case, the depressions are so few in number 
 that they leave between them considerable smooth spaces of the 
 outer surface of the kidney. But in this variety the spaces between 
 the depressions are so small, and the depressions are so numerous, 
 that the whole outer surface appears to consist of manifold alternate 
 pits and elevations. These pits are remarkable for containing little 
 clusters of red vessels. Sometimes, if the surface be attentively 
 inspected by the eye, and always by the aid of the microscope, 
 minute gray-coloured bodies like grains may be recognized depo- 
 sited in the cortical substance, decidedly differing from the latter 
 in the lighter colour which they present. Upon dividing such a 
 kidney as this by a longitudinal section, the change in structure is 
 still more conspicuous. The cortical portion has throughout be- 
 come of a lighter colour than natural, and is generally some shade 
 of orange, fawn, or yellow. Thus it may be buff-orange, which is 
 a light stone colour, or reddish orange, — a salmon red tint, or 
 deep reddish orange, or it may vary between these and honey-yel- 
 low, sienna-yellow, or ochre-yellow. When inspected carefully, 
 even by a good practised eye, and much more by the aid of a glass 
 of moderate magnifying powers, this change in colour may be traced 
 to innumerable little granular bodies, infiltrated, as it were, or de- 
 posited in the cortical substance, varying in size from the point to 
 the head of a pin. These bodies consist of the epithelial cells of 
 the tubuli infiltrated with fat, and the tuhuli themselves infiltrated 
 with albuminous deposit. The cortical or secreting matter of the 
 kidney has then in general lost most of its peculiar striated arrange- 
 ment ; and presents the appearance of reddish orange, or honey 
 yellow, or fawn-coloured matter, enclosing the tubular cones, and 
 
948 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 appearing as it were to encroach on their bounds and pass between 
 them. The tubular cones, though retaining their colour, seem 
 then rather smaller than usual, and appear like reddish oval-shaped 
 bodies, enclosed, as it were, in the gray or orange-coloured corti- 
 cal matter. 
 
 The extent to which this transformation proceeds varies in diffe- 
 rent kidneys and in different portions of the same kidney. In some 
 cases it commences in one of the extremities of the gland, and either 
 extremity is then seen to be more remarkably changed than other 
 parts. In other instances, it commences in the centre of the gland 
 or rather the centr-al part of the cortical matter ; and then this part 
 is most completely transformed. 
 
 In consequence of the peculiar change in the colour of the sur- 
 face, the pits in which are of a darker colour than the elevations and 
 intermediate portions, the kidney now described is said to be mottled. 
 
 3. Without increase in size or change in consistence, the cor- 
 tical part of the kidney may be penetrated or infiltrated with gra- 
 nular albuminous matter in various modes and degrees. 
 
 a. In one variety which appears to be comparatively in an early, 
 though not an incipient stage, when the gland is stripped of its tu- 
 nic, the surface is irregular, rough, or as it were sprinkled with 
 fine sand, of a reddish gray colour, with more of the former than 
 the latter ; and part of the cortical matter not unusually comes off 
 adhering to the tunic. The surface presents also small hollows or 
 pits, containing blood-vessels as in the last variety ; and, indeed, 
 this appearance is one of the most constant. When the surface is 
 closely inspected, numerous minute reddish gray granules may be 
 recognized, not aggregated together, but separately infiltrated into 
 the cortical matter. When the gland is divided by a longitudinal 
 section, part of the striated texture of the cortical part is still re- 
 cognized in the form of reddish-coloured streaks, extending from 
 the circumference to the tubular cones ; but all the rest of the cor- 
 tical part of the kidney is of reddish gray colour, lighter than usual, 
 and when minutely inspected either by the eye or with the aid of a 
 lens, small cream-coloured or grayish coloured granular bodies are 
 observed dispersed through the cortical matter. 
 
 In such a kidney as this, if coloured glue or isinglass be thrown 
 into the blood-vessels, it does not perfectly, as in the healthy state, 
 fill the cortical matter of the gland. The healthy parts only, or 
 those which still retain the striated texture, are reddened by the in- 
 
STEATOSIS OR GRANULAR DISEASE OF THE KIDNEY. 949 
 
 jected size ; while the diseased and gray-coloured portions receive 
 little or none of the injected size. 
 
 In general, kidneys in this state are of the natural size, and, in- 
 stead of being soft and flaccid, are either of normal consistence, or 
 a little firmer than natural. 
 
 b. In a variety, which is perhaps in a more advanced stage of 
 progress, the outer surface of the gland, if stripped of its capsule, is 
 still more extensively marked with pits containing clusters of blood- 
 vessels, so that the whole surface is irregular and vascular. These 
 blood-vessels are star-like or asteroid, branch-like or ramiform, or 
 in the shape of small dots and points, stigmatoid ; and, according 
 to the number, the size, and the aggregation of these clusters, the 
 external surface of the gland is red and vascular or otherwise. Be- 
 sides this vascular redness in pits and hollows of the surface, the 
 whole gland is moulded as it were into irregular large hollows and 
 elevations, so as to seem tuberculated or mammillated. Of the 
 parts not vascular the colour is a sort of stone-gray or light reddish 
 yellow, or fawn-coloured, in considerable masses, so as to render 
 the surface mottled or rather marbled. 
 
 A longitudinal section of a kidney in this state often shows a 
 very complete change in the cortical texture. It presents little or 
 no remains of striated matter ; but the whole cortical portion is one 
 uniform mass of yellowish gray, or buff-orange, or sienna yellow, 
 or cream-yellow. In this case the new matter is not merely infil- 
 trated, but it is so diflFused that the cortical portion is transformed 
 into it. A few tubular cones still remain more or less complete ; 
 but either they become transformed into the gray-coloured deposit, 
 or the transformed cortical matter has so much encroached on them 
 as to have diminished much their usual dimensions. 
 
 The shape of the kidney in this variety sometimes presents a 
 singular deviation from the natural standard. The gland is ta- 
 pered at each end, so as to present an apex more or less acumina- 
 ted, instead of the usual rounded end of the gland. I am unable 
 to say, whether this change in figure is congenital or the effect of 
 the disease. 
 
 The cortical matter of the kidneys, so far transformed as in this 
 variety, is almost altogether incapable of receiving injection. 
 
 4. In the next varieties, it may seem doubtful whether they are 
 different from the last, or only the most advanced stages of the 
 transformation and deposition. 
 
 The external surface of the kidney is of a slate-gray or leaden- 
 
950 
 
 GENERAL AND rATIlOLOGICAL ANATOMY. 
 
 gray colour, and presents, or may be said to consist of, numerous 
 globular granules aggregated together. These globules vary in 
 size from a small pin head to a millet seed, or the grains of sago, 
 and are mostly of the sienna- yellow, or cream-yellow, or stone-gray 
 colour, but in some parts they are of leaden-gray. Various patches 
 also of the kidney present this leaden- gray tint, which may be traced 
 partly to the intermediate spaces or lines, partly to the globular 
 granules themselves. None of the striated^ texture of the cortical 
 matter can be recognized in this variety, in which the cortical mat- 
 ter appears to be completely converted or transformed into the new 
 formation. In the longitudinal section of this all that is seen is the 
 appearance of a uniform mass of sienna-yellow animal matter, with- 
 out trace of distinct organization, sometimes minute granular bodies, 
 but almost never any striated texture. 
 
 The tubular cones retain a colour more or less bright red, and, 
 being enclosed in this buff-coloured morbid texture, present a strik- 
 ing contrast to the state of the healthy kidney. Sometimes they are 
 diminished in size, and sometimes in the section made one or two 
 of them seems either to have disappeared, while in the place which 
 they should have occupied, buff-coloured matter is deposited, or to 
 have been converted into a firm, solid, gray-coloured matter. This 
 variety of change is also unsusceptible of injection. 
 
 The kidneys in this state are almost invariably firm and hard, and 
 are sometimes smaller than usual. 
 
 5. It is very diflicult, if not impracticable, to distinguish all the 
 various forms of this buff-coloured or sienna-yellow transformation 
 of the cortical matter of the kidney. Most of them difler chiefly in 
 the shades of colour which the transformed cortical matter assumes, 
 and the degree in which the striated matter has disappeared, and 
 in which, consequently, the kidney has become incapable of receiv- 
 ing injection. The most usual colour in this stage, which is per- 
 haps the concluding, is some shade of sienna-yellow, sometimes 
 inclining to buff-orange, or to tile-red. In some rare cases the 
 colour of the new deposit is lemon-yellow or gamboge-yellow. In 
 others, it is of a tawny colour. In all these cases the kidney is in 
 general small and firm, sometimes almost cartilaginous. 
 
 The kidney is liable to the same kind of change in the dropsy 
 which follows scarlet fevej\ In some instances, the cortical portion 
 is merely mottled or marbled, and its surface presents superficial 
 hollows containing clusters of blood-vessels, while the section of the 
 gland shows part of it changed in colour, though with remains of 
 
STEATOSIS OR GEimULAE DISEASE OP THE KIDNEY. 95 1 
 
 the striated texture. The change most usual in this class of cases 
 is buflP-orange, or tile-red ; but in some instances it is so light as to 
 be of a straw-colom’ or sienna-yellow. 
 
 6. In all the cases now mentioned, the transformation either af- 
 fects chiefly, or is confined wholly, to the cortical matter of the 
 gland. In a small proportion of cases, however, it either affects 
 first and mostly the tubular portion of the kidney, or it affects that 
 after previously affecting the cortical portion. In either case, it 
 renders the tubular cones so affected very hard, almost cartilagi- 
 nous, white or gray-white, or sienna-yellow. The nature of this 
 change and its effects on the tubuli are not known. The tuhuli are 
 still pervious ; but their tissue is probably thickened and indurated. 
 The cortical matter is at the same time of a buff-colour, or tile-red, 
 or sienna-yellow, but differing in shade from the colour of the tu- 
 bular matter. 
 
 In some of these varieties of renal disorganization, the kidney 
 externally is marked by fissures so as to appear lobulated like the 
 foetal kidney. It is uncertain whether this is the remains of the 
 original foetal structure, or whether it is to be regarded as a return 
 to the type of the foetal structure, as the effect of disease. 
 
 To complete the morbid anatomy of this disease it is necessary 
 to advert to the state in which other organs are occasionally found. 
 
 The subcutaneous cellular membrane is in general more or less 
 infiltrated with serous or sero-albuminous fluid. 
 
 The serous membranes often present marks of inflammation, as 
 lymph, soft or firm, purulent fluid, masses of lymph, and adhesions 
 between their free surfaces. In the sub-arachnoid tissue of the 
 brain serous fluid is sometimes effused. But the parts most com- 
 monly presenting lymph or purulent fluid are the pleura and pe- 
 ritoneum. In other instances, sero-sanguine fluid alon6 is found 
 within the cavities of these membranes. In several cases I have 
 met with lymph in the pericardium. 
 
 The bronchial membrane is often lined with puriform mucus, or 
 muco-purulent matter streaked with blood ; and the other appear- 
 ances of chronic bronchial inflammation are manifest. 
 
 The lungs are in several cases affected with pneumonia ; being 
 in a state of red or gray hepatization. In some instances tubercles 
 and vomicas are found. In some there are the remains of pulmo- 
 nary apoplexy. 
 
 In a certain proportion of cases the heart is found hypertrophied ; 
 the mitral and aortic valves are ossified, and the apertures contracted. 
 
952 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 The intestinal mucous membrane is in persons who have present- 
 ed diarrhoea during life, rough, villous, and vascular ; the follicles 
 of Peyer are enlarged ; more frequently the isolated follicles are 
 enlarged, prominent or ulcerated ; and in some instances the isolated 
 follicles of the colon are found the seat of ulceration. 
 
 In a small proportion of cases the liver is found enlarged and its 
 acini of a nutmeg colour. In some it has been found affected with 
 kirrhosis ; and in a few with adipescence. 
 
 The bladder is generally much shrunk, and contains a small 
 quantity of urine, which when heated furnishes more or less coa- 
 gulable matter, sometimes in considerable quantity. 
 
 The blood generally contains urea. 
 
 The period at which the change now described in the structure of 
 the kidney commences varies under different circumstances. I have 
 seen a partial and limited for m of it affecting one portion of the cor ti cal 
 matter between the second and third years. One specimen I met 
 with in a complete form affecting the whole cortical matter with the 
 buff-orange transformation, in a boy between six and seven years. 
 
 Of its rate of progress almost nothing is known. At first the 
 change was observed mostly in the kidneys of adults ; and in them 
 there were few or no means of ascertaining the exact period at which 
 the disease began. From various circumstances, however, which 
 appear in the course of the symptoms, it may be inferred, that 
 it takes some time before it seriously impairs the functions of the 
 gland, and that years may elapse from the first commencement of 
 the disorder to the time, when the change in structure is so conside- 
 rable as to impede in a vital degree the function of the kidney. 
 
 Pathological Deductions.— Regarding the nature of this 
 change, and its origin, various opinions are entertained. Dr Bright, 
 who first directed attention to this change in the structure of the 
 kidney, regards it as a species of degeneration ; but thinks that 
 there is in the kidneys in the early stage a process of slow inflam- 
 mation, which lays the foundation of their future change in struc- 
 ture.* Granular degeneration, as it is usually found after death 
 by long-continued bad health, with or without anasarca^ Dr Chris- 
 tison regards as essentially a chronic disease ; but allows that, 
 when the kidneys are dark-coloured, flabby, and enlarged, in con- 
 nection with coagulable urine and eventual suppression, they may 
 have been in the state of ordinary inflammation ; {nej>hritis.\) It is 
 
 * Reports of Medical Cases, Vol. i. London, 1827, p. 72. 
 
 t On Granular Degeneration of the Kidneys, p. 10 and 11. 
 
STEATOSIS OR GRANULAR DISEASE OF THE KIDNEY. 953 
 
 also to be observed, that while several of the appearances found in 
 the kidneys after death denote unusual congestion of the cortical 
 matter, in the early stage the symptoms of pain and weight in the 
 region of the loins, dryness of the skin, and thirst, indicate the pre- 
 sence of a febrile or inflammatory state of the system. 
 
 M. Martin Solon regards the disease as a hyperemic, that is, a 
 congestive inflammatory state of the kidneys, consequent on irrita- 
 tion of their vessels from the use of stimulating drinks ; and to this 
 hyperemic state he ascribes all the early symptoms, and the sero- 
 albuminous state of the urine.* The granular interstitial de- 
 posit, and the yellow degeneration, he considers as the eflfect or 
 remote consequence of the previous hyperemic state, for this reason, 
 that the marks of hyperemia are still found associated with the yel- 
 low degeneration. In some other passages of his work, however, 
 he questions the necessary presence of inflammation in the disease. 
 
 M. Rayer, entertaining no doubt of the inflammatory nature of 
 the disease, applies to it the name of nephritis albuminosa^ and dis- 
 tinguishes it into two varieties, the acute and chronic. He is in- 
 deed the most decided and confident advocate for the inflammatory 
 nature of the disease that has yet appeared ; and his views have been 
 espoused, explained, and defended by his pupil, M. Littre. The 
 chief grounds on which M. Rayer maintains the inflammatory na- 
 ture of the fawn-coloured degeneration of the kidney are, the vas- 
 cular redness of the gland in the early stage of the distemper, the 
 enlargement or swelling of the gland, the occasional presence of 
 pain, and the general presence of feverishness ; and at a later period 
 the presence of vascular spots and patches, with the grayish or gray- 
 yellow granular deposit. He is also of opinion, that the red points 
 and spots seen in the substance of the kidney in the early stage of 
 the distemper, (first form of M. Rayer,) in general correspond to 
 the glandules of Malpighi, greatly injected with blood. 
 
 Dr Gulliver showed in 1843, that in kidneys affected by this 
 disease, fatty globules and crystalline plates of cholesterine can 
 be seen by the microscope ; while Dr Davy obtained from them 
 margarine, cholesterine, and a trace of oleine.f 
 
 Gluge maintains, from microscopical examination of kidneys in 
 this state, that the infiltrated matter is in general oil or fat. 
 
 In the first form, which is that in which the surface of the kidney 
 is yellowish with red points and millet-seed-like granulations, in- 
 
 * De rAlbumiiiurie, &c. p. 258. 
 
 -f- Edinburgh Medical and Surgical Journal, vol. Lx. p. 162. Edinburgh, 1843. 
 
954 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 flammation, with inflammatory globules and purulent matter, is as- 
 sociated with fatty infiltration or steatosis. The tuhuli, especially 
 those of the cortical substance, are filled with fat globules large and 
 small. These distend the tubuli, the convolutions of which form 
 the granulations, and afterwards appear more in the medullary 
 (straight tubular) substance. At length the fat globules are ef- 
 fused between the tubuli.^ and form masses of 10, 15, or more fat- 
 globules, which are occasionally enclosed within a membrane. 
 The Malpighian bodies and the capillary vessels are at first filled 
 with blood ; but in the further progress of the disease they are 
 bloodless and pale. The vessels of the medullary substance undergo 
 a like change, though to a smaller degree. Not unfrequently the 
 membrane of the tubuli entirely disappears. The fat globules ob- 
 serve in their mode of deposition at first the direction of these tu- 
 buli; afterwards this is lost, and a confused mass of fat-globules 
 takes their place. In rare instances the fat-globules are deposited 
 not at first in the tubuli, but in the blood-vessels and Malpighian 
 bodies. 
 
 In the second form, in which the kidneys are red-brown in their 
 cortical as well as in their medullary substance, and in which, in con- 
 sequence of a reddish striated arrangement of the medullary, the 
 two portions can scarcely be distinguished. The renal substance 
 is recognized as a reddish, soft, almost soluble, jelly-like matter, 
 in which only the cellular frame-work with wide meshes appears 
 as a separate solid element ; no trace of tubules or blood-vessels 
 is to be found either in the cortical or medullary matter ; and fat 
 globules, scattered among tubules and empty colourless Malpig- 
 hian bodies, lie in the residual cellular texture of the glands. 
 
 In the third form, in which the outline of the kidneys remains 
 unchanged or diminished, and their outer surface and the section 
 of the cortical substance is occupied with prominent pisiform gra- 
 nulations, giving the glands a rough aspect and hardish appear- 
 ance ; sometimes inflammatory globules are found with fat-globules ; 
 yet these are always in smaller proportion ; the granulations con- 
 tain many urinary tubules dilated by a yellowish granular mass 
 and fat-globules, which are also deposited between the tubules. 
 
 In short, the fat globules may be deposited within the tubules, 
 without them, and between them, and without or around the Mal- 
 pighian bodies.* 
 
 According to Vogel, the cortical substance in one form of the 
 
 * Atlas der Pathologischen Anatomic. Stearose der Niere, Taf. 3. 
 
STEATOSIS OR GRANULAR DISEASE OF THE KIDNEY. 955 
 
 disease, which is the inflammatory, is thick, white-yellowish, varie- 
 gated with red dots and lines, and very compact like lard. The 
 substance contains little blood. The vessels of the Malpighian 
 bodies are much less distinct than in the normal state. The tu- 
 bules are indistinct and confused, and between and around them 
 plastic matter is infiltrated. A similar infiltration is observed 
 among the medullary tubules.* 
 
 The views of Griuge have been confirmed in this country by the 
 researches of Dr Johnson and Mr Toynbee. The former believing 
 that the epithelial cells of the healthy kidney contain a minute 
 quantity of oil in the form of yellowish highly refracting globules, 
 maintains that granular kidney consists primarily in an exaggera- 
 tion of the fatty matter which naturally exists in small quantities 
 in the epithelial cells of the healthy gland. The epithelial cells 
 of the tubules may be in every degree and stage of distension with 
 fat-globules, until the cell is so filled that the nucleus is no longer 
 visible. The Malpighian bodies are the only parts which escape, 
 a few particles only being scattered over their interior. 
 
 The different modes and degrees in which the fatty deposit takes 
 place give rise to the different external appearances of the kidney. 
 As the accumulation of fat increases, the kidney becomes granular 
 or mottled on the surface. The smooth mottled kidneys are those 
 in which the greatest number of the tubes in the cortical portion 
 are almost uniformly distended. The granular and atrophied or 
 small shrunk kidneys are those in which the accumulation of fat 
 takes place less rapidly and less uniformly. Some convoluted tubes 
 become distended with fat, forming prominent granulations ; and 
 these compressing surrounding parts produce obliteration of vessels 
 and atrophy of tubes ; and thus the entire gland is wasted and con- 
 tracted. 
 
 Dr Johnson further finds that granular disease of the kidney is 
 often associated with fatty disease of the liver and the steatomatous 
 degeneration of the arteries, which is also an adipose deposit. 
 Among 22 cases of granular disease of the kidney examined in the 
 summer of 1845, in 17 of these there was in a most marked degree 
 fatty degeneration of the liver. In 4 of the remaining 5 cases 
 there was a decided increase of fat in the hepatic cells ; and in only 
 one case was no increase observed. During the same period Dr 
 J. met with only 4 cases of fatty liver in which there was no at- 
 tendant disease of the kidney. 
 
 * Jiilii Vogel leones Pathologicae, Tabula xxvi. p. 107. 
 
956 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 It is also associated with tubei’culation of the lungs, though in a 
 much less common degree.* 
 
 Similar are the views of Mr Toynbee. In the first stage fat be- 
 gins to be deposited in the tubules, in the form of soft white spots. 
 In the second stage he represents the Malpighian tufts to be bro- 
 ken up ; the tuhuli to be greatly enlarged ; and the parenchymatous 
 cells enlarged, and containing adipose deposits ; and in the third 
 stage the tubuli to be filled with oily cells, granular matter, par- 
 ticles of various sizes, and blood-globules.f 
 
 What is the cause of this fatty infiltration ? Is it an aberration 
 in nutrition, or the effect of a particular form of inflammation. 
 Though in favour of each of these views various plausible argu- 
 ments may be adduced, the question appears to be one incapable 
 of positive determination. I add the following remarks, not so 
 much with the intention of solving the difficulty, as in illustration 
 of the general question. 
 
 It seems scarcely possible to doubt, that, whether inflammation 
 be the cause of the steatomatous transformation of the kidney or 
 not, the process of inflammation is often present as an accompa- 
 niment. Two views, indeed, may be taken of the incipient agent 
 or generating cause, and the nature of this disease. The first is, 
 that inflammation of a particular form attacking the cortical por- 
 tion of the kidney, may be the cause of all the subsequent changes. 
 The second is, that the cortical portion of the kidney may be liable 
 to an aberration of nutrition, in consequence of which its vessels 
 deposit not the usual proper matter of the cortical portion, but 
 a different substance altogether, in the form of albuminous, 
 caseous or steatomatous matter, in the interstices of the' cortical 
 tissue. 
 
 The first of these opinions, namely, that inflammation of a pecu- 
 liar kind, most probably chronic, is the main cause of the several 
 changes, is perhaps in a large proportion of cases true. To the 
 correctness of this conclusion it is not necessary that the change 
 should terminate in suppuration. There may be, and we know that 
 there are, different forms of the inflammatory process ; and it is 
 possible that the cortical or secreting portion of the kidney may be 
 
 * On the Minute Anatomy and Pathology of Bright's Diseases of the Kidney, &c. 
 By George Johnson, M. D., Medico-Chirurgical Transactions, Vol. xxix. p. 1. Lon- 
 don, 1846. 
 
 On the Intimate Structure of the Kidney, &c. By Joseph Toynbee, F. R. S. 
 Medico-Chirurg. Trans. Vol, xxix. p. 303. 
 
 4 
 
STEATOSIS OR GRANULAR DISEASE OF THE KIDNEY. 957 
 
 liable to a peculiar form of the inflammatory process, which may 
 neither be sufficiently rapid to proceed speedily to the disorganiza- 
 tion of the kidney, nor sufficiently violent to evince its presence by 
 well-marked symptoms. That the process, whatever it may be, is 
 chronic, may be inferred from two circumstances. The first is the 
 fact, that the disease is often observed to have existed for months 
 or even years without giving rise to any marked external symptom, 
 excepting occasional diarrhoea, and sometimes attacks of rheumatic 
 pain ; and its existence is never suspected until some new symptom 
 renders it requisite to examine the urine, which is then found to 
 contain serous fluid. Rarely, indeed, do patients apply for assist- 
 ance in the commencement of this distemper ; and it is only when 
 a train of long-continued bad health has prevailed for some time, 
 or a smart attack of acute disease has come on, that the case be- 
 comes known in its true characters. The second circumstance, 
 showing the disease to be most commonly chronic, is, that when its 
 true characters have bicome known by various unequivocal symp- 
 toms, it does not proceed very rapidly to the fatal termination. 
 Some patients remain under the dropsical symptoms even for 
 months, and eventually recover from them, though the primary 
 disease may not be cured. 
 
 That the process is of the nature of vascular injection, afflux, and 
 inflammation, seems to be highly probable, from the following cir- 
 cumstances. The appearances in the kidneys are analogous if not 
 similar to those which are found in other glandular organs when 
 the seat of the congestive and inflammatory process. The dark- 
 brown colour, the increased size, and the loaded state of the vas- 
 cular system of the renal cortical matter in the early stage, are suf- 
 ficiently indicative of a congestive state to justify the inference, that 
 the cortical tissue is unduly loaded with hlood, which, as in all con- 
 gested and inflamed organs, moves at first slowly, next accumulates, 
 and then stagnates in the vessels. In those stages, which may be 
 placed after the very first, the vascular pits on the surface of the 
 kidney, with the asteroid clusters of vessels, if not to be regarded 
 as indicative of an inflammatory process, show a great derangement 
 in circulation, which is caused either by the new deposit compres- 
 sing certain vessels, or hy some similar obstruction. This process, 
 nevertheless, seems to be peculiar in this respect, that it causes ab- 
 sorption, or at least forms hollows in the cortical portion of the 
 gland. The elevations, according to Dr Johnson, consist each of 
 
958 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 a set of gorged tubules, presenting itself either at the surface of the 
 gland, or in its substance on the surface of a section. 
 
 In those stages of the disorder in which yellowish-gray or fawn- 
 coloured granules are infiltrated as it were through the cortical 
 substance, it seems consistent with correct pathology to ascribe this 
 infiltration to the effect of the inflammatory process. One of the 
 most constant efiects of that process, if unchecked, is to give rise to 
 morbid products of albuminous, tyromatous, or steatomatous cha- 
 racters ; and it seems reasonable to regard this deposit, which is 
 known to be steatomatous, as the effect of the inflammatory process. 
 
 In the aggregated slate-gray granular deposit, the same views 
 are applicable. If the isolated granular infiltration be the effect 
 of inflammatory action, a fortiori^ the aggregated granular deposi- 
 tion is the effect of the same action. It appears as the termination 
 of that process, of which the others are earlier and immediate ef- 
 fects. 
 
 One of the strongest arguments in favour of the disease origi- 
 nating in congestion or inflammation is found in the fact, that it 
 takes place after the operation of various agents which act as re- 
 mote causes of inflammation. Thus it often ensues as a sequela of 
 scarlet fever, especially if the patient have been exposed to cold. 
 In that disease, and for some time after the disappearance of the 
 eruption, the action of the skin remains feeble and languid; and 
 the blood, which ought to circulate through the cutaneous vessels, 
 is determined in excessive quantity to the kidneys and other inter- 
 nal organs. The quantity of blood thus thrown upon the different 
 internal organs is greater than their vessels can readily transmit ; 
 these, consequently, become unduly loaded and distended; and 
 hence inflammation and often discharges of blood take place at this 
 period in convalescents from scarlet fever ; and, among other in- 
 dications of this, the albuminous and occasionally the colouring 
 matter of the blood is forced through the kidneys, and is found in 
 the urine. 
 
 The inflammatory character of this disease may be illustrated by 
 considering the influence of another agent in its production. No- 
 thing seems so certainly to be followed by the formation of granu- 
 lar disease of the kidney as the use of mercury in certain constitu- 
 tions. In some instances, one single course of mercurial medicines 
 has been known to be followed by the development of the disorder ; 
 and in all cases in which repeated courses have been given, the dis- 
 
STEATOSIS OE GRANULAR DISEASE OF THE KIDNEY. 959 
 
 ease is sooner or later observed to ensue. Now it is to be observed, 
 that the use of mercury not only induces an inflammatory state of 
 the system, rendering the blood sizy, and the individual liable to 
 attacks of inflammation in various organs, hut it also renders the 
 urine serous.* Mercury further acts as an ii’ritant of the glandular 
 organs ; and it is impossible to doubt that a mineral which we know 
 is circulating with the blood, and carried to all the organs, must 
 induce in organs so vascular and complicated a high degree of 
 orgasm and the deposition of new morbid products. 
 
 Another agent, which operates in unduly stimulating the kidney 
 and its vessels, is the use of spirituous liquors. It is well ascertain- 
 ed that among the subjects of this disorder a considerable propor- 
 tion are addicted to the habitual use of these pernicious stimulants ; 
 and as they are often taken for their supposed diuretic properties, 
 the delusion leads patients to continue their use, until the disease 
 attains its confirmed and incurable stage. We know that the ha- 
 bitual use of these stimulants tends to favour the formation of the 
 steatomatous or fatty degeneration in arteries ; and it seems reason- 
 able to infer that their use is equally capable of favouring this de- 
 position in the kidneys. 
 
 Exposure to cold acts both as a predisponent and exciting cause ; 
 and in its operation causes that subverted balance in circulation 
 which generally precedes congestion and inflammation in various 
 internal organs. 
 
 It is probable that the primary cause, nevertheless, is seated in 
 disorder of the digestive organs. It is observed, that the use of 
 various indigestible articles of food, as pastry, is followed by a se- 
 rous state of the urine ; and if a single meal of this kind be follow- 
 ed by such a result, it is easy to see that the frequent use of such 
 articles will induce a habitual or constant serous state of the urine. 
 It is manifest, however, that, as this state cannot be induced with- 
 out more or less disorder in the vascular system of the kidney, the 
 continued irritation may give rise to the change in structure which 
 is eventually observed in the kidneys of persons who have become 
 victims of this disease. 
 
 The second opinion, that the glandular deposit is the effect of a 
 peculiar aberration in nutrition, may be true without being incon- 
 
 * Observations on the Dropsy which succeeds Scarlet Fever, Art. xv. ; and on the 
 Presence of the Red Matter and Serum in the Blood in the Urine of Dropsy after 
 Scarlet Fever, Art. xviu By Charles Wells, M. D., &c. Transactions of a Society, 
 iii. p. 230. London, 1812. 
 
960 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 sistent with the presence of the inflammatory process, either as a 
 cause or as a concomitant. Every aberration in nutrition is pre- 
 ceded and accompanied with a considerable change in the circula- 
 tion of the part ; and whenever the aberration consists in the infil- 
 tration or deposition of new matter, the change in circulation is 
 similar to, or the same with inflammation. This is seen in the in- 
 duration of other organs as the lungs, the brain, the liver, and the 
 prostate gland. When, therefore, the granular disease of the kid- 
 ney is called degeneration and transformation, it does not follow, 
 that the ideas thus conveyed exclude the presence of the inflamma- 
 tory process. 
 
 The urine and the blood are much changed in granular disease 
 of the kidney. 
 
 The urine contains less urea than the normal proportion, and 
 always presents more or less sero-alburainous matter. Its density 
 at the same time is diminished : and may vary from 1008, or 1010, 
 or 1011 to 1115. 
 
 The urine may be in colour brown, straw-coloured, or reddish; 
 or it may be pale and nearly colourless. Viewed by refracted 
 light, it has a peculiar pale-blue opalescent tinge. 
 
 The serum of the blood is less dense than usual, being about 
 1013, and rarely above 1022. The solid contents are reduced from 
 100 or 102 per 1000, to 68, 64, or 61 per 1000. The serum in 
 this state forms when heated a loose coagulum. It contains urea, 
 and not unusually it contains more or less oil ; in which case it is 
 milky. 
 
 The proportion of fibrin is increased in the early stage. But as 
 the disease advances it is diminished. The hematosin at the same 
 time is diminished in quantity. 
 
 When the kidneys are affected with steatosis, it is observed that 
 there is a strong disposition to the production of various inflamma- 
 tory and irritative disorders in different organs. The most usual 
 are the following. 
 
 1. In the brain and its membranes. Epileptic and apoplectic symp- 
 toms ; death by either, or by stupor. Comatose symptoms termi- 
 nating in death. The disease named by various authors Nervous 
 and Simple Apoplexy is occasionally observed in persons labouring 
 under steatosis of the kidney. 
 
 2. In the chest. Bronchitis. Emphysema of the lungs. Pneu- 
 monia and anasarca pulmonum ; tuberculation and vomicce of the 
 lungs. Pleurisy, terminating sometimes in empyema. Hydrotho- 
 
MORBID STATES OF THE KIDNEY. — HYDATOMA. 
 
 961 
 
 rax. Endocarditis^ causing valvular disease ; hypertrophy, simple, 
 excentric, and concentric ; pericarditis. 
 
 3. In the abdomen. Spontaneous or irritative vomiting, and va- 
 rious dyspeptic symptoms. Diarrhoea frequently recurring in fits ; 
 and connected with enlargement of the agminated or isolated fol- 
 licles of the ileum. Effusion within the abdomen. Hypertrophy of 
 the liver, fatty degeneration, and kirrhosis. 
 
 4. In the extremities. Anasarca. Rheumatic pains and swellings ; 
 especially synovial rheumatism, affecting the knee-joints and other 
 articulations. Erysipelas of the face or extremities. 
 
 All these morbid states are more or less dependent on the mor- 
 bid state of the blood, and especially the presence of urea in it, 
 which acts as an irritant to the different textures and organs. 
 
 § 11. Hydatoima. — The kidney is liable to the formation of small 
 watery cysts or vesiculae.^ generally of an ovoidal shape, sometimes 
 roundish, varying in size from tares or vetches up to that of small 
 beans. These bodies appear on the cortical surface of the kidney 
 as soon as the outer tunic is torn off. In some instances, they are 
 few in number, two, three, or four ; but I have seen them so nu- 
 merous that it was impossible to count them. They penetrate 
 through the whole cortical substance of the gland ; but seldom en- 
 croach much on the tubular or medullary part, which, however, 
 may present two or three of them. 
 
 On the origin of these serous cysts no correct information has 
 been adduced. Some have thought that they are degenerated Mal- 
 pighian bodies. But this idea is totally at variance with any thing 
 hitherto known as to these bodies. They may be enlarged and 
 dilated portions of the serpentine tubules. But there are no means 
 of proving this idea. The most probable opinion is, that they are 
 mere serous cysts developed as other serous cysts in the cellular 
 tissue of the kidney. The cortical matter is always removed or 
 absorbed to make room for them ; and a kidney affected by this 
 disease presents the aspect of an immense number of small ovoidal 
 cavities excavated in the cortical portion. 
 
 This change is often associated with granular degeneration ; and 
 the urine is usually albuminous. 
 
 § 12. Atrophy. — This term is applied in the kidney to two forms 
 of disease. First; — In steatosis or granular degeneration, after 
 the adipose matter has been infiltrated into the cells and tubules, 
 the cortical and vascular portion of the kidney becomes shrunk and 
 
 3 p 
 
962 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 wasted. The kidney, at least its cortical portion, is, in short, in a 
 state of atrophy. 
 
 Secondly; when Nephropyema proceeds to a great extreme, 
 causing distension of the calyces and extenuation of the whole cor- 
 tical portion of the kidney, it may happen that the greater part of 
 the matter is discharged either through the ureter and bladder, or 
 by a new opening formed into the transverse arch of the colon, 
 through that bowel, or even externally ; part is removed by ab- 
 sorption ; and the purulent inflammation of the calycine membrane 
 ceases. As these processes advance, the distended and attenuated 
 residue of the kidney contracts ; the calyces contract, and some 
 may be united by mutual adhesion of their walls and membrane. 
 Eventually the whole residual portion of the kidney is contracted 
 and shrunk into a small, flattened, shapeless body, not larger 
 than a dried fig ; and when divided, it is difficult to recognize in 
 the remains the vestiges of the original structure. The ureter 
 alone remains, to prove the fact that this body represents all that 
 was a kidney. The pelvis sometimes is left in a contracted form : 
 and not unusually the pelvis and ureter are obstructed and con- 
 verted into a solid chord. Some small traces of one or two calyces 
 remain ; but in general the tubular portion of the kidney is gone, 
 and the cortical is either very much shrunk, or so changed, that its 
 characteristic structure can no longer be recognized. This is atro- 
 phy of the kidney after Nephropyema. 
 
 The lesion is not common ; for the disease of which it is the se- 
 quela is usually fatal. I have nevertheless seen three examples of 
 it ; the preparation of one of which is preserved in the collection of 
 the University.* Job A. Meek’ren records three instances of it, 
 in one of which the right kidney was so destroyed, that it is stated 
 to have been wanting.! I have already shortly noticed a case which 
 occurred to Chomek! 
 
 § 13. Hypertrophy. — The kidney may be enlarged in all its 
 dimensions without serious change in its intimate structure. In the 
 most usual case, that of atrophy of one kidney after Nephropyema, 
 or any similar form of destruction, the opposite kidney is always 
 
 * Notice of a case of Cyanosis or the Blue Disease, \yith mutual adhesion of the se- 
 milunar valves of the Pulmonary Artery. By David Craigie, M. D. Edin. Med. and 
 Surg. Journal, VoL lx. Case I. p. 268. Edinburgh, 1843. 
 
 Jobi A. Meekren, Observationes Medico-Chirurgicae. Amstelodami, 1682. Cap. 
 39, 40, and 44. 
 
 t P. 945. 
 
MORBID STATES OF THE MAMMA. 
 
 963 
 
 much enlarged both in its cortical and tubular portion ; its vessels 
 are large and numerous ; and little doubt can be entertained that 
 it performs the functions of both glands. Such I found to be the 
 state of the residual kidneys in the instances of atrophy already 
 mentioned. 
 
 § 14. Heterologous Products. — The kidneys are liable to be 
 aflFected by these, chiefly by enkephaloma^ and sometimes by carci- 
 noma. But most usually they are involved in the growth extend- 
 ing from other organs. In other circumstances, these growths in 
 the kidney present nothing peculiar. 
 
 Section VI. 
 
 Diseased States of the Female Breast. 
 
 These are inflammation and its effects ; suppurative induration ; 
 chronic inflammation ; lacteal tumour ; simple chronic tumour ; 
 strumous enlargement ; the hydatomatous tumour ; irritable or 
 neuralgic tumour ; adipose tumour ; atrophy ; hypertrophy ; scir- 
 rhus; pancreatic sarcoma, and enkephaloma. 
 
 § 1. Inflammation is seen sometimes spontaneously, more fi’e- 
 quently as the eflfect of the irritation from the first attempt at the 
 secretion of milk. It usually proceeds to abscess, which, however, 
 is seated most in the cellular tissue of the gland. 
 
 § 2. Induration is a common effect of inflammation, and depends 
 on the infiltration of lymph which undergoes coagulation, and on 
 the presence of blood in the vessels, from which the lymph is sepa- 
 rated. 
 
 § 3. Strumous enlargement is common in young females. Tu- 
 bercular matter or a liquid containing fat and caseous matter is in- 
 filtered within the tubes and around them. In certain cases, after 
 this has subsisted some time, it undergoes an imperfect suppuration ; 
 and causes a peculiar copious secretion of matter and abscesses of 
 the perimastoid cellular tissue. 
 
 § 4. Hydatoma. Cystosarkoma Simplex and Cystosarkoma 
 Proliferum of Muller — In the hydatomatous tumour, a number of 
 serous cysts is formed in the breast, which is generally consolidated 
 by adhesive inflammation. The cysts may be only one or two, but 
 are generally more numerous. In certain cases they appear to be 
 true hydatids or Acephalocysts ; and in others, the serous cyst 
 {hydatoma). In the latter case they are either a cyst composed of 
 
964 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 numerous lamellae, like the crystalline humour, or they are a bag 
 containing serous fluid.* 
 
 The cystosarhoma is in short a tumour or growth, consisting of a 
 fibrous or fibro-vascular frame-work or stroma, containing cysts 
 more or less complete, of various sizes, and more or less numerous. 
 
 Dr Hodgkin describes a tumour consisting of hydatid cysts as 
 incident both to the female breast and testis of the male.f 
 
 § 5. The irritable or neuralgic tumour consists in painful hai'd- 
 ness with or without swelling of one or two lobes of the mamma. 
 The pain is disproportionate to the hardness or enlargement. The 
 surface is tender, and does not bear handling. This is more a dy- 
 namic affection than a disease of the mamma ; and its presence is 
 connected with the state of the uterus and ovaries. It occurs in 
 young females between 15 and 30, 
 
 § 6. The adipose tumour is sometimes an increased deposit of 
 the natural adipose tissue ; or fat may be deposited in one or more 
 cysts. Fatty matter is also liable to be infiltrated within the lac- 
 teal tubules when the period of menstruation ceases, causing a sort 
 of steatosis of the gland, 
 
 § 7, Atrophy, — The breasts undergo a species of shrinking or 
 atrophy in all females after menstruation ceases and the period of 
 child-bearing is past. In some instances, apparently in connection 
 with some morbid state of the ovaries, one or both breasts are 
 liable to become shrunk in this manner previous to the normal time 
 for the cessation of menstruation. In other instances fat is deposit- 
 ed and the glandular structure diminishes or disappears, 
 
 § 8. Hypertrophy. — In some females, particularly about the 
 age of 18, 20, or between that and 25, a peculiar enlargement of 
 the breast is observed. The gland becomes enlarged and heavy ; 
 the skin over it is likewise enlarged. If the enlargement continue, 
 the breast is so bulky and pendulous that the tension of the skin is 
 no longer adequate to support it ; but it hangs down loose, bulky, 
 and pendulous. The nipple is flattened ; the areola expanded. 
 So far as can be judged, this is a true hypertrophy of the glandular 
 structure. 
 
 § 9. Cartilaginous and ossific transformation has been observed 
 
 * Illustrations of the Diseases of the Breast. By Sir Astley Cooper, Bart. Lon- 
 don, 1829. 4to. 
 
 t On the Anatomical Characters of some Adventitious Structures. By Thomas 
 Hodgkin, M. D. Medico-Chirurg. Transactions, Vol, xv. London, 1829. 
 
MORBID STATES OF THE MAIkBIA SKIRRHUS. 
 
 965 
 
 in the breast. The change is most likely confined to the galacto- 
 phorous tubes. 
 
 § 10. Skirrhus. — In no organ has skirrhous structure been more 
 frequently studied than in the mamma. Yet information is not 
 very precise and presents several discordant points, 
 
 a. It seems certain that diflferent forms even of morbid structure 
 belonging to skirrhus may affect the breast. In one set of cases, 
 the gland is affected with hardness in lumps or masses, to which 
 the skin is drawn down in a shrivelled corrugated manner, and ad- 
 heres over various points of the surface. Internally, white, firm, 
 fibrous lines are seen intersecting each other through the gland; 
 and within these is deposited a softer gray-coloured matter, which 
 presents numerous minute irregular cells and granules, from the 
 surface of which oozes a serous fluid. The nipple is retracted 
 and introverted. 
 
 In one of these tumours of the breast Vogel found the two ele- 
 ments now mentioned united in the following manner. In the 
 centre or middle of the tumour were longitudinal bands apparently 
 cylindrical, thick at middle, but pointed at each end, not straight, 
 but slightly contorted. These were crowded very closely in the 
 centre ; but at the margin where their pointed extremities terminat- 
 ed, they were more apart. In the interstices between these firm 
 longitudinal chords were deposited granules spherical, spheroidal, 
 or pyriform, which were cellular, and had nuclei and nucleoli. Be- 
 sides these, were very minute granules, which seemed to be fat.* 
 
 b. In another set of cases the same matter is deposited in a tuber- 
 cular form, and assuming the appearance of irregular masses of 
 reddish-gray coloured hardish tubercles aggregated together, giving 
 the whole the aspect of the pancreas. 
 
 According to Muller, the gray structure of simple scirrhus of 
 the breast bears only a remote resemblance to cartilage. Whitish 
 chords are not regularly observed. Skirrhus of the mamma pre- 
 sents sometimes at various points fibres, in which may be recognized 
 a canal, containing a colourless, or whitish, or yellowish content. 
 These white fibres may be formed from the thickened walls of the 
 milk-tubes and lymphatic vessels. In skirrhus of parts not glandu- 
 
 * Julii Vogel leones Histologise Pathologic®. Tabula xxt. Lipsi®, 1843. 
 
 The above description was written from personal examination of a number of skir- 
 rhous mamm® long before the engravings of J. Vogel were published. The only point 
 deserving notice is, that they correspond as accurately as can be expected. I refer to 
 the engraving of Vogel because it illustrates the subject well. 
 
966 
 
 GENERAL AND rATHOLOGICAL ANATOMY. 
 
 lar, these hollow white lines are not observed. The mass of the 
 skirrhus consists of a fibrous and granular gray substance. The 
 fibrous mass is rarely manifest on section ; but it is distinguished by 
 scraping the gray mass, for which the fibrous seems the frame-work. 
 When the gray globular mass is removed by scraping or macera- 
 tion, the fibrous framework appears to be a very irregular network of 
 solid fibrous bundles. The gray matter, which is easily removed 
 from this framework by scraping, consists entirely of microscopical 
 globules, which have little mutual connection. They are trans- 
 parent, hollow cells or vesiculae^ varying from looooo to loo^^ooj 
 ®od 10 0^0*0 0 of a Paris inch in diameter. They are insoluble in 
 vinegar and water cold and boiling. In many of these cells are 
 seen only some punctula or dots like small granules ; in others 
 may be recognized a larger corpuscle like a nucleus, or like a 
 smaller vesicula contained within a cell-globule. After examining 
 many scirrhous mammae, Muller could not satisfy himself of the 
 existence of small or young cellules in the formation-globules ; yet 
 these he saw evidently in some.* 
 
 c. A form of cancer more common than simple scirrhus in the 
 breast, is, according to Muller, that which he denominates reticu- 
 lar carcinoma. This attains in a shorter time than simple skirrhus a 
 large size, and it differs from the latter in its tendency to the lobu- 
 lar arrangement. In consistence it sometimes approaches skirrhus, 
 and sometimes is softer, approaching that of enkephaloma. 
 
 Reticular carcinoma consists of a gray globular frame-work, im- 
 bedded in a reticular texture of fibrous bundles, which is recognized 
 when the gray granular mass is scraped or macerated. The gray 
 mass consists of transparent formation-globules or cell-globules, 
 similar to those observed in simple scirrhus. These contain often 
 one, two, or more small vesiculcB with colourless nuclei. In other 
 instances the smaller germinal cells cannot be recognized within 
 the larger formation-globules. On the other hand, in the interior 
 of the transparent cell-globules, appear very many granules. Similar 
 small granules are also observed sometimes in large quantity, free be- 
 tween the vesiculffi, — the smallest with molecular action. The colour- 
 less cell-globules have a diameter of from i.ooVooo 100,000 
 10 5,000 of one Paris inch. The diameter of the enclosed granules 
 is only from one-fifth to one-fourth of the diameter of the cells. 
 
 * Ueber den Feinein Ban iind die Foimen der Krankhaften Geschwiilste. von Dr Jo- 
 hannes Miiller. Erste Liel'eriing. Berlin, 1 o38. Seite 1 4. 
 
 3 
 
MORBID STATES OF THE TESTIS. 
 
 967 
 
 This form of cancer is distinguished by tlie peculiarity of the 
 constant white or whitish-yellow reticulated figures being more or 
 less manifest. These figures are irregularly net-like, sometimes 
 branched or spotted. There are no dilated vessels with thickened 
 walls as are sometimes seen in simple carcinoma, but characteristic 
 formation. The reticulated figures arise from the deposition of 
 white granules in the gray mass. These granules appear not cel- 
 lular, but resemble most a conglomeration of opaque granules with 
 roundish or elongated corpuscles. 
 
 Cavities are sometimes formed in this structure ; and in these is 
 enclosed a coagulable albuminous matter ; while the walls are oc- 
 cupied by whitish bodies. 
 
 Though this sort of cancer is very common in the female breast, 
 it is not peculiar to that organ, being found also in other parts. 
 This shows that its presence and formation are not necessarily con- 
 nected with the structure of the lacteal glands.* 
 
 d. The female mamma is further liable to be attacked by enkepha- 
 loma, which appears with its usual characters. It forms, however, 
 a softer and more compressible tumour ; and it appears more lobu- 
 lated ; and some of these lobules seen to be cysts containing fluid. 
 It appears also in younger subjects ; and is more a disease of early 
 life than scirrhus. 
 
 This disease, however, when it appears in the mamma, is rarely 
 confined to this gland. The same structure is usually developed 
 in the liver, or more or fewer of the internal organs. 
 
 e. The nipple is liable to various morbid changes. The most com- 
 mon is excessive development or growth in its nucleus^ which is at- 
 tended with pain and some swelling. Usually it ceases of its own 
 accord. But if it do not, it is liable to form a small tumour, which 
 is said often to pass into the malignant state. This I believe is 
 very doubtful, if the subjacent gland remain sound. Other morbid 
 conditions are atrophy, hypertrophy, or excessive nutrition, tuber- 
 cular skirrhus, and enkephaloma. 
 
 Section VII. 
 
 Morbid States of the Testis. 
 
 The diseased state incident to the testis are inflammation and its 
 effects ; hydrocele ; suppuration within the testis ; strumous dis- 
 
 Ueber den Feinern Biiu und die Formen den Krankhaften Geschwiilste. 
 
968 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 ease ; atrophy ; hsematocele ; hydatoma or cystic disease of the 
 testis ; cystosarcoma ; fibrous disease ; skirrhus ; enhephaloma ; and 
 kolloma. 
 
 § 1 . Orchitis. — Inflammation is acute or chronic. In acute in- 
 flammation the anatomical characters are more or less swelling and 
 enlargement ; sero-albuminous matter effused within the tunica va- 
 ginalis ; lymph lining the tunic ; the gland redder and more vas- 
 cular than natural, though not much enlarged ; bloody serum in- 
 filtrated into its parenchyma ; and eflPusion of a brownish coloured 
 fluid into the cellular tissue of the epididymis and that connecting 
 it to the testis, — causing enlargement and induration of that body. 
 
 Inflammation afiects more frequently the right testis than the 
 left. Among 138 cases of orchitis, in 78 the right testis was af- 
 fected ; in 49 the left ; and in 1 1 cases both glands. 
 
 The most usual causes are the poison of gonorrhoea ; a blow or 
 other violence on the gland ; urethral irritation ; the previous ex- 
 istence of mumps ; and probably rheumatism. 
 
 This process may leave the testis a little enlarged and indurated ; 
 the epididymis much enlarged and indurated ; or eflPusion of fluid 
 within the vaginal coat forming hydrocele. 
 
 § 2. Abscess in the centre of the Testis. — Suppuration is 
 not a common result ; but it may after some time ensue ; and then 
 it generally appears in the form of a collection of matter within the 
 centre of the testis. This is not easily distinguished from chronic 
 disease, as there is constant pain, some induration and some enlarge- 
 ment. The disease is liable to be mistaken for malignant ; and the 
 testis may accordingly be removed. But there is found only a 
 quantity of greenish-yellow opaque purulent matter in a cavity or 
 cyst in the centre of the gland, the walls of which are lined with 
 lymph. This I have seen many years ago ; and I find that the 
 same had been met with by Sir A. Cooper. 
 
 § 3. Obstruction of the Tubuli. — One of the eflPects of in- 
 flammation, if obstinate and long continued, is the eflPusion of sero- 
 albuminous matter within and around the tubuli. The serous part 
 disappears ; the albuminous or plastic matter remains, filling and 
 obliterating the tubules, causing enlargement and induration, and 
 afterwards if extensive, atrophy of the testis. When this eflPusion 
 affects only a portion of the tubules it obliterates them so com- 
 pletely that they no longer perform their functions of secreting 
 
 canals ; and the lymph outside causing them all to adhere, the part 
 
 4 
 
MORBID STATES OF THE TESTIS. 
 
 969 
 
 SO affected is hard, of a reddish gray colour, sometimes with white 
 fibrous lines, the remains of the tubules. This portion afterwards 
 shrinks, and is in the state of partial atrophy. 
 
 § 4. Strumous Disease. Tyroma. — Chronic inflammation in 
 the strumous is an affection of the testis not unusual. It gives rise to 
 effusion of tyromatous sero-albumen within and around the tubules, 
 filling and obstructing their cavity with tyromatous matter, and 
 uniting the whole in a mass of tubercular matter. The testis is 
 more enlarged than in common inflammation ; and it is more or 
 less irregular and nodulated on the surface according to the irre- 
 gularity of the agglutinated masses of tubules composing the gland. 
 
 Of this disease there are two forms ; one mild, another more se- 
 vere. In the former, the matter deposited is a peculiar yellow ho- 
 mogeneous substance, which when first formed is fluid or semifluid 
 and afterwards acquires consistence and firmness. It adheres 
 closely to the tubuli, and involves them so completely as to convert 
 them into one mass. In this state it may remain a long time, 
 forming merely a much enlarged testis, or rather a tumour in- 
 volving the testis. 
 
 In this form, however, it is liable to undergo ulterior changes. 
 Portions of the mass, which are always of a low degree of vitality, 
 may undergo inflammation. Some of these become dead ; or por- 
 tions are perhaps struck with death previously, and excite the vital 
 parts to reaction. Sloughing and suppuration proceed, until con- 
 siderable portions of the new mass are ejected ; and if the patient’s 
 general strength is adequate to endure all this process, the parts 
 eventually heal after the separation of the greater part or the whole 
 of the new growth, which generally involves the original tubular 
 structure of the testis. 
 
 In another form of this disease, the matter deposited contains a 
 large proportion or consists wholly of tubercular matter. This 
 tubercular matter possesses a degree of vitality still lower than the 
 last, and more readily passes into disorganizing processes. Strumous 
 abscesses are formed at the surface, or in the substance of the new 
 growth ; and terminate in fistulae and sinuses. Some parts become 
 dead, and these slough away as in the former case. The pro- 
 cess, however, is more enfeebling, whether from its natural vio- 
 lence or the weakness of the constitutions of those in whom it takes 
 place. Many patients die under the process. 
 
 The main cause of the sloughing in this form of disease appears 
 
970 
 
 GENERAL AND PATHOLOGICAL ANATOBIT. 
 
 to be the dense and unyielding nature of the iunica albuginea and 
 its processes, and the tension with which it encloses the testicular 
 tubes, in consequence of the constriction by which, when new mat- 
 ter is infiltrated into the tubiilar structure, as no adequate expan- 
 sion takes place, the enclosed parts are, as it were, strangulated and 
 deprived of vitality by the compression of their blood-vessels by the 
 tunica albuginea. 
 
 § 5. Atrophy. — Under this head are comprehended arrest of 
 development and wasting. 
 
 a. Arrest. Most commonly the testis has not descended from the 
 abdomen ; and when it has, one or both are smaller than usual, 
 shrunk, and manifestly not adequately nourished. The tubular 
 portion is imperfectly developed. 
 
 b. Wasting. When the testis has been fully developed, it may 
 be attacked by wasting. Either after a blpw, contusion, or other 
 violence, or sometimes, as was observed in the soldiers of the French 
 army in Egypt, after sexual excesses, the testis becomes at first a 
 little larger, then softer than natural, then small and shrunk. In 
 this form of atrophy, the tubules undergo a species of chronic in- 
 flammation, causing obliteration from infiltration of lymph, and 
 sometimes of oily matter. The secreting structure is thus disor- 
 ganized. The blood-vessels shrink, and less blood than usual is 
 conveyed to the gland. 
 
 In a testicle affected by wasting, the testis feel soft ; and its tex- 
 ture is pale and with few blood-vessels. The fluid expressed from 
 the tubuli is void of spermatozoa. Mr Gulliver found fatty matter 
 in the glandular substance. 
 
 § 6. Haematocele ; or effusion of blood takes place most 
 usually within the tunica vaginalis, constituting the affection called 
 Haematorchis, already noticed. 
 
 § 7. Fibrous transformation. Desmosis. — In some instances, 
 not very common, the testis has been found converted into a spe- 
 cies of fibrous mass ; while its proper secreting structure has dis- 
 appeared. This change I regard as depending on increased deve- 
 lopment of the tunica albuginea and its processes, all of which be- 
 come thick, dense, and increased in size ; and by compressing the 
 tubular structure cause its absorption. The lesion is not very com- 
 mon ;■ but in the instances in which I have seen it, this view ap- 
 ])eared to be directly suggested by the phenomena and characters 
 of the change. 
 
DISEASED STATES OF THE EROSTATE GLAND. 
 
 971 
 
 § 8. Ossification is probably always to be traced to the tunica 
 albuginea. Patches of bone appear in this and in its processes. 
 
 § 9. Hydatoma. Cysto-sarkoma. — The testis resembles the 
 female mamma in the frequency with which this growth is formed 
 in its substance. Cysts, similar to hydatids, one, two, or several in 
 number, sometimes many, are formed in the parenchyma of the 
 gland. These may be so numerous as to occupy the w'hole body of 
 the testis, the natural structure of which is displaced and disappears. 
 
 The nature and origin of this disease is imperfectly known. Sir 
 Astley Cooper was inclined to regard it as formed from enlarged 
 and obstructed seminiferous tubes, because they are not distinct 
 bags, but send out solid processes by which they are connected with 
 other bags. Dr Hodgkin regards them as serous cysts formed in 
 the substance of the gland. It must be allowed that the cysts are 
 rarely so large as in the breast ; and it is quite possible that this 
 lesion of the testis may be different from the hydatoma of the breast. 
 
 It merely remains to be observed, that cysts of the kind now de- 
 scribed seem common to the kidney, the mamma, and the testis. 
 
 § 10. Of the Heterologous Growths, both skirrhus and en- 
 kephaloma are observed in the testis. It is difficult to say which of 
 these two is the most common. Skirrhus occurs, as in other or- 
 gans, rather at a late period of life. Enkephaloma may take place 
 at any age, but shows a preference for the early period, that is, 
 before 40. A character of distinction more important is that, when 
 enkephaloma appears in the testis, the same structure is generally 
 found in the abdomen. 
 
 The anatomical characters of both are similar to those in other 
 organs. 
 
 § 11. Colloid or Gelatiniform cancer takes place in the 
 testis ; but much more rarely than the other two lesions now men- 
 tioned, and infinitely more seldom in the testis than in the stomach 
 and some other organs. 
 
 § 12. Melanoma also occurs, but not very frequently, unless at 
 the same time at which it appears in the abdomen. 
 
 Section VHI. 
 
 Diseased States of the Prostate Gland. 
 
 The principal morbid states of the prostate gland are suppura- 
 tion within the ducts ; chronic enlargement or hypertrophy of the 
 gland and its effects ; and enlargement of the middle lobe. 
 
972 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 § 1. Prostatopyema. — Suppui’ation within the ducts, or sup- 
 puration of the mucous membrane of the ducts, is a disease of stru- 
 mous character. The whole mucous membrane, from their outlets 
 into the urethra upwards to their remote extremities, is inflamed, 
 secretes lymph, and a foul imperfectly formed purulent matter, 
 which does not easily escape, hut remaining, as it is increased by 
 fresh secreted matter, distends and enlarges the ducts into small or 
 middle-sized cavdties, with narrow outlets. A prostate gland in this 
 state is large, bulging, and elastic-compressible, as if containing 
 fluid, and lobulated on the surface ; and when divided by incision, it 
 appears, as if it consisted of several distinct encystedabscesses. These 
 apparent abscesses are formed by the ducts of the gland distended 
 and enlarged by purulent matter and lymph. When the matter is 
 removed, the epithelial membrane of the ducts is observed lined 
 with lymph, yet not in a state of ulceration. The surface is indeed 
 unbroken. 
 
 This disease may take place at any period of life, but is most 
 common in strumous subjects between the ages of 20 and 30. 
 
 It causes great disorder of the general health, occasionally hec- 
 tic, and peculiar depression of spirits. 
 
 § 2. Chronic Enlargement and Hypertrophy. — This may 
 affect either one lobe, or both, or part of both. The substance of 
 the gland is enlarged, firm, and greatly more crowded with veins 
 and arteries than usual. The veins are distended, enlarged, and 
 varicose. Blood and lymph is infiltrated into the substance of the 
 gland ; and eventually, if the process be not arrested or stop spon- 
 taneously, either one or two abscesses are formed ; or the pros- 
 tatic substance becomes extremely hard, dark*coloured, and almost 
 cartilaginous ; while its original structure can no longer be recog- 
 nized. The substance of the gland shows whitish specks and 
 lines, which are manifestly lymph effused. 
 
 When the prostate gland is in this state it is liable to two morbid 
 actions. One is a secretion of ropy viscid, almost puriform mucus 
 from the ducts of the gland, and occasionally the purulent collec- 
 tions within these ducts uoticed under the last head. The other is 
 a discharge of blood from the vessels of the gland more or less 
 copious. The latter is caused by the previous distended state of 
 the vessels, and the pressure exerted on them by the enlarged and 
 condensed parenchyma of the gland. 
 
 Similar enlargement may affect the third lobe of the prostate 
 gland. 
 
BOOK VI. 
 
 THE LUNGS AND HEART. 
 
 CHAPTER I. 
 
 The Lungs. 
 
 Section I. 
 
 The Minute Structure of the Sound Lung. 
 
 The lungs may be regarded as the ramifications and terminal ends 
 of the bronchial tubes, pulmonary artery, and pulmonary veins, all 
 united by filamentous-cellular tissue and enclosed within the pleura. 
 
 The filamentous-cellular tissue now mentioned forms with these 
 enclosed textures the pulmonic substance, tissue, or parenchyma. 
 
 The main point, however, which it is important to know, in 
 order to understand either the structure of the lungs, as explana- 
 tory of their morbid condition, or the functions of these organs 
 during health, is the mode in which the bronchial tubes are distri- 
 buted and terminate. 
 
 This point has been partly considered already, when speaking 
 of the ultimate termination of the bronchial mucous membrane. A 
 few points I have here to add, in consequence of the question of 
 these terminations having been again made the subject of research. 
 
 Malpighi, who first studied the structure of the lungs with 
 attention, maintained that the bronchi terminate in closed ends, 
 slightly expanded into the form of spherical or globular vesiculae 
 {vesiculae orbiculares), which he in one passage compares to the 
 cells of bee-hives.* This shows that he believed' that these vesiculae 
 communicate with each other. He thought it also probable that 
 these vesiculae are continuations or processes from the inner mem- 
 brane of the windpipe,' — in other words, from the bronchial mem- 
 brane. 
 
 Duverney maintained, in 1699, that these vesicles or cells com- 
 municate with each other; and Stephen Hales, who examined 
 them in the calf by the microscope, represents them as little cubes 
 or hexaedral figures, not spherical, and estimates their diameter at 
 ■s 50 p3^rt of one inch.f 
 
 * De Pulmonibus, Epistola I. J. Alphonso Borelli. Marcelli Malpighi, Opera l 
 Omnia. Londini, 1686. Folio. Tomus Secundus, p. 133 and 134. 
 
 + Statical Essays Vol. i. pp. 239 and 241. London, 1731. 
 
974 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Senac next maintained that the lungs consist of lobules ; that 
 each lobule consists of vesiculae^ in each of which ends a bronchial 
 tube; and that each vesicida consists of small polyedral cells, 
 not more than the sixth part of one line in diameter. 
 
 This idea of vesicles or small cells. was adopted by James Keill, 
 Cheselden,* * * § Winslow, f and various systematic authors ; and the 
 idea of Duverney that they communicate, appears at the same time 
 to have been added. 
 
 Helvetius on the other hand was of opinion, from various exa- 
 minations and experiments, that the representation of round vesi- 
 cul(2 or cells was entirely a fiction ; that what Malpighi describes 
 as air vesicles are the cells of the cellular tissue ; and that the 
 closed ends of the bronchial tubes are the last recipients of the at- 
 mospheric air.J 
 
 Haller, though inclined to the doctrine of Helvetius, inferred 
 nevertheless, that considering all the circumstances and the pheno- 
 mena of experiments and dissections in living or recently dead 
 adult animals, each bronchial tube does not terminate in an in- 
 dividual cavity, but that there is in the human as in the reptile 
 lung, a cellular arrangement, the imperfect chambers of which 
 communicate freely with each other, until the investment of each 
 lobule delays the passage of the air and prevents it from proceed- 
 ing from lobule to lobule. 
 
 All these observers speak in a manner ratber confused and some- 
 times contradictory ; and, though it seems singular, that any one 
 accustomed to inquiries of this kind could confound the termina- 
 tions of the bronchial tubes, whether forming cells or not, with the 
 cells of the pulmonic cellular tissue, there is reason to believe that 
 this was done by Dr Hales. 
 
 The doctrine of communicating air-cells was accordingly very 
 generally taught by anatomists, and is distinctly presented by 
 Soemmering, who may be taken as the representative of anatomical 
 
 * “ They are each composed of very small cells, which are the extremities of the 
 aspera artcria or hrmchos. The figure of these cells is irregular, yet they are fitted 
 to each other so as to have common sides and leave no void space.” — Anatomy, 
 Book iv. Chap. vii. p. 173. Lond. 1784. 
 
 Exposition Anatomique de la Structure du Corps Humain. Par Jacques-Benigne 
 Winslow, de I’Academie R. des Sciences, &c. Paris, 1732. 4to. N. 104 et 1 36. 
 
 J Memoires de I’Academie des Sciences, 1718, p. 24 — 28. 
 
 § Elementa Physiologic, Lih, viii. Sectio ii. § xxix. § xxx. Tom. iii. p. 170. 
 Lausanne, 1766. 
 
MINUTE STRUCTURE OF THE LUNGS. 
 
 975 
 
 doctrine at the close of the 18th century, and for the first fifth 
 of the 19th. According to Soemmering the substance of the lung 
 consists of small air-cells or vesicuM. Several of these vesiculce. 
 form a cluster, (acervulus) ; several clusters compose small lobxJes ; 
 these unite into large lobules ; and these by their union form the 
 lobes of the lungs. 
 
 These cells appear to be round, polygonal and irregular. When 
 inflated they are about the eighth or the tenth part of one line in 
 diameter ; and they communicate with each other through the 
 wind-pipe, in such manner that air blown into one cell easily passes 
 from this into the bronchia, and by these penetrates into all the other 
 cells of the lungs. The cells of neighbouring lobules, however, 
 do not communicate with each other ; and it is only the cells be- 
 longing to each cluster and lobule that thus communicate.* 
 
 If this description be understood literally, it implies that the al- 
 leged cells of the lungs do not communicate with each other by 
 themselves, but only by the arrangement of the bronchial tubes 
 terminating in them. From this it follows, that these air-cells are 
 mere shut ends of the bronchial tubes. 
 
 In 1808 Reisseissen examined in various modes the terminal ends 
 of the bronchial tubes, and arrived at the conclusion, that the lung 
 possesses no arrangement like that described as air-cells, and that 
 closed ends of the bronchial tubes, not communicating with each 
 other however, but which retaining the peculiar structure to their 
 extremities, present the appearance of air-cells or air-vesicles.t 
 
 The essay of Reisseissen was not published till 1822 ; and it was 
 only subsequent to that time that his statements became known or 
 their correctness ascertained. 
 
 Magendie examined in 1821 the minute structure of the lungs 
 by inflating and drying small portions ; and concluded that there 
 is a cellular or vesicular arrangement at the extremities of the 
 bronchial tubes communicating with these tubes, and in which these 
 tubes finally terminate ; that these cells present no regular form, 
 and appear to be void of membranous walls ; that they are formed 
 by the last divisions of the pulmonary artery, the radiculcB or roots 
 of the pulmonary veins, and the numerous anastomoses of these 
 vessels ; that all the cells of one lobule communicate with each 
 
 * De Fabrica Corporis Humani. Tomus sextus, § xxi. 
 
 -f- Franz Daniel Reisseissen iiber den Ban der Lungen. Berlin, 1 822. Folio ; and 
 Edinburgh Medical and Surgical Journal, Vol. xxi. p. 444. Edinburgh, 182*4. 
 
976 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 other, but not with those of contiguous lobules; and that these 
 cells vary in size at different ages.* 
 
 Reynaud, who exaniined the bronchial tubes with the view of 
 ascertaining the accuracy of the representations of Reisseissen, 
 arrives at the following conclusions. 
 
 Any given bronchial tube when traced through the lung is found 
 to divide before and behind, and on each side into small branches ; 
 which again traced still further are found to be subdivided into 
 branches still smaller than these. These divisions become shorter 
 and shorter, and of smaller calibre, end in becoming rounded, as 
 if they had formed at their side a number of small shut ends or de- 
 pressions, and at length they terminate in an extremity shut and 
 scarcely enlarged. This is shown by mercury poured into them 
 and urged forward by pressure, when the mercury demonstrates, as 
 it were, the last divisions of the diminutive bronchial tree, — and also 
 by insufflation and dissection.; These small tubes all terminate 
 at right angles to the pleura, which allows the observer to recog- 
 nize only the assemblage of their terminal sacs, and not the bron- 
 chial tubes from which they proceed. 
 
 He mentions, however, the following disposition also. A greater 
 or smaller number of bronchial tubes larger than others do not 
 end thus at the pleura ; but having come near it, instead of termi- 
 nating more or less rectangularly at the pleura, proceed beneath 
 this membrane parallel to it, and terminate at the distance of two, 
 three, four, or five lines from their point of emergence. The air 
 which filled these tubes appeared like the mercury, in the instance 
 above mentioned, to represent these small trees with perfect regu- 
 larity, and to demonstrate their arborescent disposition to that 
 point, when pressure more or less forcible was inadequate to urge 
 the air onward, and where it was evident it had reached its last 
 limits. 
 
 These ends of bronchial tubes are about two lines from the 
 pleura, or even less ; and to demonstrate them fully, it is often 
 requisite to open them the whole length, and urge a bristle through 
 them, so as to perforate that membrane, or to make a small counter 
 opening. In this manner the end of the bronchial tube is displayed, 
 showing the membrane continuous from the upper part of the tube 
 
 + Memoire sur la structure du poumon de I’homme ; sur les modifications qu’ 
 eprouve cette structure dans les divers ages ; et sur la premiere origine de la phthisic 
 pulmonaire ; par M. Magendie. Journal de Physiologic, Tome i. p. 78. Paris, 1821. 
 
MINUTE STRUCTURE OE THE LUNGS. 
 
 977 
 
 throughout. The only other circumstance is, that at two lines 
 from the termination, it looks as if perforated by many small de- 
 pressions, which it had not previously presented. Small apertures 
 leading into small ultimate branches are likewise seen more and 
 more near to each other.* 
 
 The general correctness of this description is strongly confirmed 
 by the phenomena of obliteration of the bronchial tubes. 
 
 Bourgery made known to the Academy first in 1836, and after- 
 wards in 1842, the results of researches on the minute structure of 
 the lungs, of which the following is a summary. To every minute 
 lobule of the lung is sent one central bronchial tube, which pro- 
 ceeds to the peripheral basis of the lobule, and is distributed with 
 progressive ramification to the terminal ends of the same. During 
 this course, the central stem sends within the lobule alternately, 
 radiating in all directions, subordinate shoots, Vi^hich are to be con- 
 sidered as terminal branches of the proper air-tube tree, and which 
 Bourgery denominates ramified bronchial canals. Beyond these 
 commences, according to M. Bourgery, the capillary air-sucking 
 system. Each ramified bronchial canal ends in a small, irregular, 
 winding, elongated dilatation, which is sometimes two-lobuled or 
 three-lobuled. These are bounded, in their course and in their di- 
 latations, by walls perforated in a sieve-like fashion by small orifices, 
 by which the branched and ramified bronchial tree, as an inferent and 
 efibrent apparatus, is connected with those parts of the lungs which 
 are to be viewed as the proper functional substance. This part 
 forms a labyrinth of tubes expanded in three directions, which are 
 distributed in a tortuous course along the windings of the vessels, 
 observe a proportional diameter, and at their ends also, as in the 
 lateral walls, communicate with each other by many orifices.f 
 
 Dr Thomas Addison maintains the existence of a collection of 
 cells in which a filiform bronchial tube terminates. 
 
 Mr William Addison gave in 1842 an account of the results of 
 various researches which he had made by the aid of the microscope, 
 on the distribution of the ends of the bronchial tubes, and arrived at 
 the conclusion that these tubes do not end in closed sacs ; and that 
 after dividing into numerous minute branches, which take their 
 
 * Memoire sur I’Obliteration des Bronehes ; par A. G. Reynaud, D. M. &c. Me- 
 moires de I’Academie Royale de Medecine, T. iv. p. 116. Paris, 1836. 4to. 
 
 -1- Extrait d’un Memoire sur la Structure intime des Poumons dans I’homme et les 
 Mamraiferes, (lu a PAcademie des Sciences, 11 Juillet 1 842,) by J. M. Bourgery. Ga- 
 zette Medicale, 1842, Tom. x. N. 20. 
 
 3 Q 
 
978 
 
 GENERAL AND PATnOLOGICAL ANATOMY. 
 
 course in the cellular interstices of the lobules, they terminate in their 
 interior in branched air passages, and freely communicating air-cells. 
 
 It is proper to premise, that to each lobule of the lung belongs 
 one bronchial tube of some size ; that the divisions or branches of 
 this bronchial tube are confined to the lobule to which it belongs, 
 which indeed it forms, and do not copimunicate with the branches 
 of adjoining lobules ; and that each lobule is enclosed in cellular 
 or filamentous tissue, firmer than that within the lobule, and which 
 thus separates that lobule from the surrounding ones. The small 
 bronchial divisions within each lobule are intralobular ramifications. 
 
 In the foetal lung, these intralobular bronchial divisions pursue a 
 regular branched arrangement, subdividing in all directions, and 
 terminating at the boundary of the lobule in closed extremities. 
 Many also terminate in the interior of the lobule. These intralo- 
 bular branches do not anastomose. 
 
 In the foetal lung, there are no air-cells properly speaking. But 
 when an animal breathes, the air entering by its pressure into tbe 
 windpipe and bronchial tubes proceeds to the intralobular brandies ; 
 and in this manner distends each lobule speedily to as great extent 
 as these intralobular branches allow. After this they are found to 
 form a series of communicating cells, which are permanently occu- 
 pied by air ; and in this all the trace of the original branched ar- 
 rangement is lost or obscured. These cells are pentagonal or 
 hexagonal in shape. 
 
 This may be regarded as the statement of the fact as given by 
 Mr Addison. The cause of this cellular formation is twofold ; 
 first, the forcible pressure of the air which enters by the windpipe, 
 and is perpetually impelled to the ultimate extremities of the tubes 
 and their intralobular ramifications ; and the delicate and yielding- 
 membrane of these ramifications, which, by presenting an unequal 
 resistance, is thus distended into cells. 
 
 The air-cells do not, however, communicate with each other in 
 the interior of a lobule in an indiscriminate and general manner. 
 As the intralobular bronchial ramifications do not anastomose, the 
 air-cells formed along one branch do not communicate with those 
 formed along another ; and so on through the whole lobule. 
 
 The lobules nevertheless present in their interior branched pas- 
 sages forming a communication between the cells. But these pas- 
 sages are stated to be neither tubular nor cylindrical. They are de- 
 nominated lobular passages. 
 
 3 
 
DISPOSITION OF THE AIR-CELLS IN THE LUNGS. 
 
 979 
 
 When a thin section of inflated and dried lung is placed under 
 the microscope, a number of large well-defined oval roRAiMrisrA, 
 with a sharp delicate edge, is seen thickly distributed among the 
 cells. These foramina are portions of lobular passages. They 
 are smaller near the pleura and surface of the lung than in the in- 
 terior of the organ. 
 
 When mercury is poured into the lungs of a rabbit which have 
 been macerated, so as to expel the air, it gets into the air-tubes, 
 and appears at the surface of some in the form of globides, at that 
 of others as beaded and nodulated branches, which, according to Mr 
 Addison, combine the character of cells and passages. 
 
 The membrane of these air-cells, when examined by the micro- 
 scope, does not form round or even rounded cells, but flat mem- 
 branous plates, circumscribing polyhedral spaces. They present 
 ovate bodies as part of their structure. They possess an epithelium 
 in the form of large, round, nucleated scales, in each of which 
 from one to fifteen or more nuclei may be counted. 
 
 IMr Addison found, like Magendie, the cells in early life small, 
 and in old age large. At the age of 45, they vary from to 
 part of one inch in diameter.* 
 
 The correctness of these statements has on the whole been con- 
 firmed by the researches of Mr George Rainey. 
 
 Mr Rainey finds that when the bronchial tubes have arrived at 
 about one-eighth of one inch from the surface of the lung, the 
 membrane terminates abruptly ; that the passages conveying the 
 
 ■* On the Ultimate Distribution of the Air-Passages and the Air-Cells of the Lungs. 
 By WiUiam Addison, Esq. F. L. S., &c. Read 7th April 1812. Philosophical Trans- 
 actions, London, 1842. 
 
 On the use of the term vesicle, Mr Addison pronounces a criticism which partakes 
 more of boldness than wisdom or knowledge. “ Anatomical writers,” says Mr Addi- 
 son, “ generally use the terms air-vesicles and air-cells synonymously, so that they are 
 convertible terms ; but, strictly speaking, an air-vesicle is an air-bubble, and may exist 
 either in or out of a pulmonary air-cell.” — Phil. Trans, vol. for 1843, p. 158. 
 
 It is rather the term vesicles than air-vesicles, that anatomical writers use as s}tio- 
 nymous with that of air-cells. By what means Mr Addison has arrived at the inference 
 that vesicle means air-bubble, I know not. But, with deference to Mr Addison, he 
 will find that all the anatomical writers who have spoken of these bodies — Malpighi, 
 Senac, Winslow, HaUer, and Soemmering — employ the term in its original accep- 
 tation, that is, a small vesica, or bladder, or small membranous bag or cell. The words 
 of Soemmering are ; “ Pulmonum substantia parvis celhdis, vesiculis, vel sacculis aere 
 plenis conflatur. — Plures ejusmodi vesiculre in acervulos congeruntur.” Tomus sextus, 
 § xxi. — The idea that the word vesicula is ever used to signify an air-bubble is a mo- 
 dern invention, not sanctioned by classical use. Bulla is the word used. 
 
980 
 
 GENERAL AND PATHOLOGICAL ANATOMY, 
 
 cTir, which he terms intercellular, continue in the same direction as 
 the tubes of which they are continuations, but without perceptible 
 membranous lining ; that the diameter of the ultimate bronchial 
 tubes is from to of one inch ; that they communicate with 
 but few cells ; that the intercellular passages, the intralobular of 
 Mr Addison, are at first of a circular form, communicating also 
 with few cells ; but as they approach the surface of a lobule, their 
 number increases, and at length these communicating openings are 
 so numerous and so close, that the intercellular passage loses its 
 circular figure, and forms an irregular -shaped passage running be- 
 tween air-cells, and communicating with them in all directions, and 
 having arrived at the surface of a lobule, it terminates in an air-cell, 
 which is not dilated, but is in truth of the same size as the passage. 
 
 The air-cells are small, irregularly-shaped, yet most frequently 
 four-sided cavities, varying in size in different parts of the same 
 lung. Those are smallest, as well as most vascular, which are situ- 
 ate nearest the centre ; while their size increases, and their vascu- 
 larity diminishes, as they extend into remote parts. The air-cells 
 situate close to the bronchial tubes, or intercellular passages, open 
 into them by large circular apertures ; while those placed further 
 from these passages, communicate with them through the medium 
 of other cells. 
 
 Besides these intervening air-cells, there are others which fill the 
 angle formed by the bifurcation of the intercellular passage, and 
 which thus appear to form a communication between them. 
 
 Mr Rainey controverts the statement made by Mr Addison, that 
 in the lungs of the foetus, the air-cells are not developed. He in- 
 jected the lungs of various foetal animals which had never breathed^ 
 and found, on examining them with the microscope, that the air- 
 cells were developed proportionally with other parts of the lungs. 
 
 He adds, however, that in the very young foetus, the septa, or 
 partitions between tbe air-cells, consist almost entirely of minute 
 cellules or granules, and a small quantity of fibrous tissue, with 
 scarcely any blood-vessels ; and that, as the age of the foetus ad- 
 vances, this granular matter diminishes, while the capillaries in- 
 crease, so that at birth the same arrangement of the air-cells and 
 the other parts of the lungs is observed as in after life. 
 
 The capillaries of the lungs are situate, or contained within, a 
 fold of membrane. Traced from tbe peripheral to the central parts, 
 this membrane lines first the air-cells which are next the surface of 
 
MORBID STATES OF THE LUNGS PNEUMONIA. 
 
 981 
 
 a lobule, whether next the pleura or adjoining lobules ; then the 
 cells enclosing the capillary vessels ; and thence extending from 
 cell to cell, it arrives at the intercellular passages, and at the ter- 
 mination of the bronchial tubes becomes identified with the bronchial 
 membrane.* 
 
 In several points these statements agree ; in others they greatly 
 differ. On two points all agree. The first is, that within each 
 lobule there is a separate or proper system of minute bronchial ra- 
 mifications, with terminal ends, between which there are communi- 
 cations within the lobule only. The second is, that these bronchial 
 divisions and terminations, whether named air-cells or not, do not 
 communicate with those of the contiguous lobules. The air which 
 enters the interior of one lobule never can find its way into the in- 
 terior of the contiguous lobules. 
 
 Section II. 
 
 Morbid States of the Lungs. 
 
 The morbid states of the lungs are, inflammation and its effects ; 
 hepatization of various kinds ; suppuration ; haemorrhagic peripneu- 
 mony ; gangrene ; dilatation of the air-cells ; emphysema ; hemor- 
 hage ; tuberculation and vomicae ; parasitical animals, and various 
 heterologous growths. 
 
 § 1. Pneumonia. — The anatomical characters and morbid 
 effects of inflamed lung may be stated in the following manner. 
 Isi, On opening the chest and admitting the air, though there are 
 no adhesions, the lung does not collapse at all, or does so very 
 slightly. 2cf, The pulmonic substance, when inflamed, becomes 
 harder and denser than natural, and does not float completely in 
 water. If the induration is considerable or extensive, it sinks en- 
 tirely. 3c?, It loses its elasticity and compressibility, or cannot be 
 inflated, and no longer crepitates as in the healthy state, but re- 
 sembles a piece of solid flesh. 4:th, When divided by the knife, a 
 portion of inflamed lung is more or less firm ; its spongy or vesicu- 
 lar structure appears much redder than usual, the colour being 
 chiefly florid but partly of a darker hue ; a white or yellowish fluid, 
 somewhat frothy, flows from the cut bronchial tubes ; the substance 
 of the lung is dark red or brown-red, and very much loaded with 
 
 * On the Minute Structure of the Lungs, and on the Formation of Pulmonary Tu- 
 bercle. By George Rainey, Esq. M. R. C. S. Medico-Chirurgical Transactions, vol, 
 xxviii. p. 581. London, 1845. 
 
982 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 blood within vessels and out of them ; while bloody serum escapes 
 copiously from the proper pulmonic cellular tissue. 
 
 These may be regarded as the general characters of inflamed 
 lung. These characters nevertheless vary according to the pro- 
 gress of the disease ; and it is observed, that a lung in a state of 
 inflammation presents different characters, as that inflammation is 
 in its commencement, is established, is completed, or is subsiding. 
 
 Laennec describes three different degrees of pneumonic inflamma- 
 tion, and distinguishes them; according as the lung is red or vio- 
 let, but crepitates and discharges, when cut, a frothy blood-coloured 
 fluid ; the stage of obstruction ; 2d, as the portion of lung is destitute 
 of crepitation, and is red and granulated interiorly, without discharge 
 of fluid when cut, unless squeezed ; the stage of hepatization or 
 carnification ; 2>d, as it is consistent and granular, its section a pale 
 yellow, a straw or stone-gray colour, and as it discharges a consi- 
 derable quantity of opaque, yellowish, viscid fluid, from many points 
 of its cut surface ; — the stage of gray hepatization or purulent in- 
 filtration. In this state the substance of the lung is friable and 
 lacerable, and easily gives way. 
 
 I think four different stages may be recognized, exclusive of ef- 
 fects. 
 
 In the first, the lung is dark red, or reddish-brown, or violet- 
 coloured, and does not collapse when the chest is opened. It feels 
 also slightly more firm and resisting, but not so much as in the 
 next stage. When cut, it is observed to be loaded with blood, 
 which is very abundant in the filaraento-cellular tissue ; much blood 
 and bloody serum escapes ; frothy serous fluid also is observed to 
 issue from divided bronchial tubes. The lung still crepitates, but 
 is slightly cedematous, or at least receives the impression of the finger. 
 
 When a lung in this state is examined by the microscope, no 
 morbid product is seen in the filamento-cellular tissue. The ves- 
 sels, that is, the capillaries, are injected and loaded with fluid blood, 
 generally dark coloured, and with serum. The air-cells, or at 
 least the small divisions of the bronchial tubes, are filled with serum 
 mixed with air. This is the stage of injection or bloody congestion, 
 and it affects the capillary vessels, the filamento-cellular tissue, and 
 the air-cells of the lungs. It is therefore pneumonia with vesicular 
 bronchitis. 
 
 This state of lung may affect one or both lungs. When it af- 
 fects both, it often proves fatal, from the great extent, not the in- 
 
MORBID STATES OF THE LUNGS. — PNEUMONIA. 
 
 983 
 
 tensity of the lesion. In cases in which it affects only one lung, or 
 part of one, or part of both, recovery is more easily effected. 
 
 In the second stage, the lung is a little firmer and more resistent, 
 and may project beyond the ribs when the chest is opened. It is 
 more thoroughly loaded with blood ; and blood begins to be sepa- 
 rated into h\oodi-plasma {liquor sangumis), and serum, in being 
 effused into the filamento-cellular tissue. The blood is sometimes 
 found infiltrated extensively into the lower part of the lung, and is 
 not separated decidedly into lymph or clot and serum. Its pre- 
 sence, however, renders the lung dark-red or brown, massy, and 
 consistent ; yet it crepitates in various parts ; and in others it is 
 cedematous, not unfrequently receiving the impression of the ribs. 
 In this state it commonly affects most the lower and middle lobes. 
 
 A lung in this state shows, when examined, that its tissue is ra- 
 ther closer than usual, and contains a large quantity of blood in its 
 vessels and filamento-cellular tissue ; and blood is beginning to be 
 effused into the air-cells. This is the state called obstruction by 
 Laennec. It is the close of the state of congestion or injection. 
 
 In the third stage, a new series of phenomena is observed. The 
 blood, which had been previously in vessels mostly, and was fluid 
 or at most only beginning to become fixed, is now observed to be 
 extravasated into the interstices of the filamento-cellular tissue. 
 The part or parts of the lung thus affected are not only dark-red 
 or violet-coloured, but solid, firm, do not crepitate, and when cut 
 and washed, though they effuse blood and bloody serum, the section 
 shows patches of a rough granular aspect, as if they consisted of 
 small granules aggregated together, and which are solid, not com- 
 pressible, and manifestly totally different from the contiguous por- 
 tions of lung. At first these patches or portions with soft intervals 
 are small. Afterwards they are large ; and in some instances a 
 large portion of lung at once passes into this red, solid, rough, 
 granular condition. 
 
 The appearance now described is produced by blood eflFused into 
 the filamento-cellular tissue ; and the eflFusion thus taking place 
 closes and obliterates the small bronchial tubes and air-cells. Blood 
 may be effused into these parts also, and commonly is effused. 
 
 This is the stage of red solidification, consolidation, or hepatiza- 
 tion. Its colour is various shades of red, according to the state of 
 the effusion and the duration of the disease. In some instances it 
 
984 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 is brown, and in some violet or purple. The lung so affected loses 
 tenacity and becomes friable. 
 
 In some instances this change is of a chronic character, and it 
 appears to occupy weeks or even months in its progress to com- 
 pletion. 
 
 In other instances it seems to proceed a certain length and then 
 to stop, leaving considerable portions of the middle and lower lobes 
 in a state of red hepatization. These patches are easily distin- 
 guished by being dark- coloured, while the adjoining lung is more 
 or less red ; by being solid and incompressible, and void of crepita- 
 tion, while the other parts are soft, compressible, and crepitating, 
 by being quite insusceptible of inflation ; and by sinking in water. 
 Sections of such portions of lung show the close granular appear- 
 ance and compact structure of the pulmonic tissue already men- 
 tioned. In these circumstances the pleura is in general healthy, 
 and it is not uncommon to find that membrane in its usual state 
 over considerable portions of lung that have been long in a state 
 of red or brown solidification. 
 
 As a fourth stage of pneumonia has been generally enumerated 
 the change denominated gray hepatization. It appears to me not 
 certain that this view is correct. Gray hepatization appears to be of- 
 ten a change not succeeding to red or brown consolidation, but one 
 which follows a certain stage of the disease in a particular form and 
 in certain constitutions. Its anatomical characters are the following. 
 
 The whole lung is firm, solid, inelastic, and more or less incom- 
 pressible. It fills the chest completely, and usually projects a little 
 when the sternum is removed. The pleura is very generally co- 
 vered with patches of lymph, and sometimes it adheres extensively 
 and more or less firmly. The lung itself is most solid at the mid- 
 dle and lower lobes, and the upper lobe alone is soft and a little 
 compressible. Sections of the lung show the substance to be of 
 gray-red, or dirty yellow colour ; sometimes with portions of bluish- 
 gray, green, orange, and in short variegated. The substance is 
 solid, compact, but friable and very easily rent ; in short, it comes 
 away under the fingers. Much serous fluid, more or less turbid, 
 with some blood-coloured purulent matter, oozes from the surface 
 of the sections. When examined by the microscope, pus globules 
 are seen both in the interstitial matter and oozing from the cut sur- 
 face. Granules of lymph and blood are also observed infiltrated into 
 the interstices of the filamento-cellular tissue. When the part has 
 
MOEBID STATES OF THE LUNGS — PNEUMONIA. 
 
 985 
 
 been macerated or well washed, the section presents a granular 
 compact aspect like the section of the lung in red consolidation. 
 But it is more varied ; the substance of the lung is more thoroughly 
 destroyed or disguised, and the lung is softer and more lacerable. 
 In some instances the portions of lung present a sort of tubercular 
 induration, that is, hardened masses, bluish-gray or gray in colour, 
 and of irregular form, interspersed among whitish-gray softened por- 
 tions. In other instances, gray portions, firm, yet lacerable, are 
 interspersed among reddish portions. 
 
 It is impossible to doubt, that these changes depend partly 
 on blood infiltrated and changed, and in a greater degree on 
 lymph, and purulent matter infiltrated into the filamento-cellular 
 tissue. Various products also, as blood, liquor sanguinis, and 
 lymph, are poured into the air-cells and obliterate them. It is sup- 
 posed by some that this causes the appearance of whitish granules in 
 the lung affected by gray hepatization. It may do so ; but the infil- 
 tration of this matter takes place also into the filamento-cellular tis- 
 sue ; and while the presence of one set of granules may depend on the 
 former cause, that of another, it appears to me, depends on the latter. 
 
 In short, there are effused blood- corpuscles ; liquor sanguinis or 
 plasma, afterwards formed into granules ; and pus-globules all at the 
 same time and in the same tissue. The blood-corpuscles after some 
 time undergo changes in colour, and hence arise the bluish-gray, 
 greenish, and reddish brown or orange colours of the parts 
 affected. 
 
 The changes now specified may come on rather gradually and 
 insidiously, without very great disorder in the breathing, until the 
 greater part of one or both lungs is destroyed by consolidation. The 
 disease, if it do not begin in, certainly affects mostly the substance 
 of the lung, that is the filamento-cellular parenchyma; and along 
 with this it involves the pulmonic air-cells, which are filled with 
 blood and obliterated. From the substance, it affects eventually the 
 pleura which is covered with lymph recent and soft, or firm. In seve- 
 ral instances which have come under my own observation, the pa- 
 tients did not complain of uneasiness or disorder until the pleura 
 began to be inflamed. In general death was then not remote, and 
 took place in the course of a few days. 
 
 Inflammation usually commences in the lower part of the lung, 
 and generally attains there its greatest intensity. Thus, the whole 
 of the lower lobe may be in a state of extensive induration and he- 
 
986 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 patization, while the middle lohe is only reddened and infiltrated 
 with serum, sero-sanguine fluid, or blood, and the upper lohe is 
 comparatively healthy. The centre of the lung also, especially op- 
 posite to the lower angle of the scapula, is often the seat of inflam- 
 mation. Inflammation may take place in one lung or in both ; and 
 in the same manner it begins first, and attains its greatest intensity 
 in the lower lobes of both. In the former case, it is said to he sim- 
 ple ; in the latter, it is double pneumonia. It is not easy to esti- 
 mate the comparative prevalence of pneumonia in either lung, or 
 in both ; but from the attempts made, it appears that pneumonia 
 of the right lung is more common than in the left, in the ratio of 
 more than two to one, and that single pneumonia is more common 
 than double pneumonia in the ratio of six to one.* 
 
 It must not be imagined, however, that inflammation is always 
 seated in the lower part of the lung. Morgagni, Trank, and Brous- 
 sais often found the upper part of the lung inflamed. In the sum- 
 mer of 1837, I found, in the body of a woman who had died rather 
 suddenly, the upper part*of both lungs in a most complete state of 
 gray hepatization ; and in several cases since that time, I have 
 found the upper parts of the lungs affected with pneumonia in va- 
 rious degrees, while the lower was in comparative soundness. The 
 same occurrence is admitted by Andral, who allows that it is not 
 uncommon, and by Chomel, whose experience leads him to regard 
 it as frequent. 
 
 Pneumonic inflammation may terminate in resolution ; effusion of 
 blood or simple hepatization ; effusion of blood and lymph or granular 
 hepatization ; and suppuration ; or it may become chronic, and ter- 
 minate in mixed hepatization ; or it may terminate in gangrene. 
 
 It is very important to observe with regard to gray hepatization, 
 that persons labouring under it die apparently very unexpectedly, 
 if not suddenly. These persons have perhaps been only in a sort 
 of general ill-health, when all of a sudden they are attacked with 
 great difficulty in breathing and extreme weakness, and in this 
 state die, or even without this preliminary difficult breathing, they 
 suddenly fall down and are found dead. 
 
 Though this shows that the disease is chronic in progress, yet 
 
 * Of 210 cases of pneumonia, 121 were in the right lung, 58 in the left, 25 double 
 and 6 not ascertained. Among 75 cases given by M. Jules Pelletan, in 58 inflamma- 
 tion was in one lung, in 17 in both at once ; in the right the disease occurred 42 times ; 
 in the left 1 8 times ; in the base of the lung 24 times ; in the apex 7 times ; all over 
 24 times. Memoire Statistique in Memoires de I’Academie, Tome viiiieme Paris, 1840. 
 
MOEBID STATES OF THE LUNGS. — PNEUMONIA. 987 
 
 other points regarding chronic forms of the disease shall be im- 
 mediately considered. 
 
 Pneumonia has been distinguished by practical authors and no- 
 sologists into several varieties, according to certain modifying cir- 
 cumstances. The following list comprehends the most important, 
 1. Hemorrhagic peripneumony ; 2, The spurious or bastard Peri- 
 pneumony {Peripneumony Notha) ; 3. The chronic, slow, or latent 
 {Pneumonia Chronica') ; 4. The gastric or bilious {Pneumonia gas- 
 trica vel Pneumonia biliosa) ; 5. The nervous or Typhoid Pneu- 
 monia {Pneumonia Nervosa et Typhodes) ; and 6. The malignant, 
 pestilential, or gangrenous {Pneumonia septica vel Pneumonia ma- 
 ligna) gangraena pulmonum. 
 
 Haemorrhagic peripneumony ( Pneumonia Haemorrhagica.) 
 Cullen observed, that pneumonia had a termination peculiar to 
 itself, namely, the effusion of a quantity of blood into the cellular 
 texture, {i. e. the filamentous or parenchymatous tissue) of the 
 lungs, which soon interrupting the circulation of the blood through 
 these organs produces fatal suffocation. In some instances, how- 
 ever, this extravasation of blood does not produce immediate suffo- 
 cation. These appear to be principally when the effusion takes 
 place in limited and isolated points, for instance, forming small 
 amorphous masses about the size of a filbert or walnut in the lower 
 lobes of one or both lungs. The portions of lung thus the seat of 
 bloody extravasation become firm, resisting, uncrepitating, dark- 
 coloured and granular in structure. The boundaries are generally 
 distinctly circumscribed, and the difference between them and the 
 surrounding portion of lung is distinctly marked. When near the 
 surface of the lung they are both felt and seen through the pleura 
 by the deeper brown colour over them, by their firmness and soli- 
 dity, by not collapsing while the rest of the lung collapses, and by 
 breaking down instead of collapsing when they are compressed. 
 In these dark-brown, hard, granular masses, the blood-vessels and 
 the bronchial tubes and vesicles are completely obliterated, and 
 their canals closed, and the membrane of the contiguous bronchial 
 tubes is dark brown, thick, and friable. 
 
 The change, indicated by the presence of these masses in the 
 lung, which had originally been described by Baillie under the 
 name of the brown tubercle of the lungs, was afterwards made the 
 subject of particular attention by Laennec, under the denomina- 
 tion of pulmonary apoplexy. The chief objection to the term is that 
 
988 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 it converts into a disease, that which in correct pathology is the effect 
 of morbid action ; and that its author represents this lesion as the pa- 
 thological cause of haemoptysis. Had he said that haemoptysis or he- 
 morrhage from the lungs, and this dark-brown circumscribed indu- 
 ration of the lung were effects of the same cause, the representation 
 would have been more just. Both these phenomena are the effects 
 of the previous congestion and injection of the lungs which termi- 
 nates in this extravasation; and, providing the extravasated fluid get 
 into the bronchial tubes, it may be coughed up in the form of blood 
 more or less pure. In general, even when blood is coughed up 
 in this manner, a quantity, more or less considerable, is at the same 
 time effused into the interstices of the pulmonic filamentous tissue, 
 where it stagnates, and at length coagulating gives rise to the gra- 
 nular dark -coloured solid indurated masses found on dissection, dis- 
 seminated through the lung. These masses are not the cause, but 
 the effect of the hemorrhage, which is itself the effect of previous 
 congestion. 
 
 The change now mentioned is often found in the lungs as an 
 effect of disease of the heart, especially degeneration, ossification, 
 and arctation of the mitral valve. But I have observed it take 
 place independent of this ; and I have met with a remarkable in- 
 stance of it in the lungs of an infant of twelve or thirteen months. 
 
 These and other circumstances lead me to regard this change as 
 one of the effects of pneumonic inflammation, and I therefore refer 
 it to the present head under the name of hemorrhagic peripneu- 
 mony, {pneumonia hcemo) rhagica.') 
 
 Of the other varieties, the second is rather a species of vesicular 
 bronchitis, and as such has been already described under its proper 
 head. 
 
 The third, viz. the chronic or latent peripneumony, occurs under 
 two forms, chronic inflammation of the pulmonic tissue, and inflam- 
 mation of the lobules. 
 
 § 2. Chronic Pneumonia. — In the first it presents the same anato- 
 mical characters as the acute disease, but comes on in a more insi- 
 dious and gradual manner. Andral, indeed, represents the ana- 
 tomical character of chronic pneumonia to be hardening of the 
 pulmonic tissue, with a yellow, gray, blue, black, or brown tint, with 
 impermeability to air. This, however, is the ultimate result of a 
 series of changes, in which the portion of lung has been previously 
 the seat of red coloration and congestion, infiltration of blood, and 
 
MOEBID STATES OF THE LUNGS. — LOBULAE PNEUMONIA. 989 
 
 at length infiltration of blood and lymph. In this mode it most 
 frequently steals on imperceptibly, with cough aggravated in the 
 winter season and on exposure to cold, slight dyspnoea which in- 
 creases gradually, very slight febrile symptoms aggravated during 
 the night, gradual wasting and eventually death, either by bastard 
 peripneumony, a sudden and unexpected attack of the acute dis- 
 order, or the establishment of pleuritic Inflammation. 
 
 In less frequent cases the same change is sometimes left as a 
 residue of the acute form of the disorder. 
 
 § 3. Lobular Pneumonia In the second form of chronic pneu- 
 
 monia the inflammatory disorder comes on in a different manner. 
 Either at the same time, or successively inflammatory congestion, 
 indicated by redness, induration, and at length the effusion of blood 
 and lymph, takes place in several, sometimes many points, of one 
 or both lungs. This goes on for weeks or months, until the whole 
 of both lungs present a multitude of roundish or irregular formed 
 nodules about the size of small nuts, difiused through their sub- 
 stance. When these are divided by the knife they present an ex- 
 terior of reddish, firm vascular substance, inclosing in general 
 small grains of grayish-coloured matter, sometimes like coagulated 
 lymph, sometimes like purulent matter. They are manifestly con- 
 fined to the minute divisions or lobules of the lungs, and as the in- 
 flammatory action has thus originated in, and been chiefly confined 
 to these lobules, the disorder has not improperly been denominated 
 lobular ■pneumonia^ {pneumonia lobulorum.') The lungs at the same 
 time are infiltrated with serum ; the bronchial tubes contain puri- 
 form mucus ; the pleura is invariably more or less inflamed and 
 covered with patches of albuminous exudation, especially opposite 
 to those inflamed lobules which approach nearest to the pleura pul- 
 monalis ; the pulmonic and costal pleurae are often united by soft 
 recent adhesions ; the upper part of the apex of the lung generally 
 adheres extensively ; and sero-albuminous or puriform fluid is found 
 in the cavity of the pleura. 
 
 The symptoms of this disorder are imperfectly known. In the 
 few cases which have fallen closely under my observation, the exis- 
 tence of disease of the lungs was not even suspected ; and in one 
 case which I had occasion to inspect, the patient, a boy of fif- 
 teen, was supposed to have died of continued fever. Febrile symp- 
 toms, indeed, he presented for about eight or nine days previous 
 to the fatal event, and at the same time the breathing was rapid. 
 
990 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 he complained of headach, and afterwards a little delirium and 
 coma ensued. I learned from his relatives that he had habitual 
 difficult breathing, but I could not ascertain that he had cough or 
 expectoration. 
 
 Besides the morbid state of the lungs in this form of disorder, 
 it is usual to find inflammatory redness and enlargement of the 
 muciparous follicles of the colon, the caecum, and sometimes of the 
 ileum, and these may be affected with ulceration. 
 
 The meninges also are generally injected, and fluid is formed in 
 the subarachnoid tissue, within the ventricles, and within the spinal 
 theca. 
 
 This form of pneumonic inflammation is most usually found in 
 children and young persons. Its causes are imperfectly known. 
 But, from the circumstance of its being often associated with the 
 disorders of the joints, bones, and similar tissues usually imputed 
 to the influence of the strumous diathesis, its development may be 
 inferred to be dependent on the presence of this diathesis, and 
 created by exposure to cold or some similar exciting causes. From 
 the peculiar form which it assumes, and from its association with 
 ulceration of the intestinal follicles, as well as the circumstances in 
 diathesis already mentioned, I regard it as the early stage of tuber- 
 cular consumption. The only reason that it is not so frequently 
 met with as the other ordinary forms of pneumonia, is, that it sel- 
 dom proves fatal in the early stage, or before it has not only occu- 
 pied the whole of both lungs with the morbid deposit, but produced 
 more or less excavation. 
 
 Marks of chronic diffused pneumonia are always found, in every 
 case of tubercular infiltration and destruction of the lung. 
 
 The gastric or bilious pneumonia has been rendered a subject of 
 great importance by Lepecq de la Cloture,* * * § Stoll,f Romain,j; Ac- 
 kermann,§ Jansen, || Guidetti,1F Borsieri, Goeden, Hauff, and vai'i- 
 ous other foreign physicians. Its existence as a form of peripneu- 
 mony is almost denied by Andral, and I confess that in this 
 country it is seen so rarely, as to justly give rise to doubts of its 
 
 * Lepecq de la Cloture Observat. s'lr les Maladies Epidemiques. Paris, 1776. 
 
 T Ratio Medendi, Vol. iii. iv. and v. Part II. v. vii. p. 112, 117, 346. 
 
 + Romain Essai sur la Maniere de Traites les Peripneumonies Bilieuses. Metz, 1779. 
 
 § Ackermann Pleuritidis Biliosse brevis adumbratio. Kiliae, 178S. 
 
 II Dissert, de Peripneumonia Biliosa. Goett. 1787. 
 
 *U Guidetti, Dissert, de Pleuritide Biliosa. Heidelberg, 1790. 
 
MORBID STATES OF THE LUNGS. — PNEUMONIA. 
 
 991 
 
 individual and independent reality. Pneumonia doubtless takes 
 place in persons in whom the alimentary functions are disordered, 
 and sometimes the hepatic secretions perverted or deranged ; and 
 it sometimes happens that symptoms of gastric and hepatic dis- 
 order simulate symptoms of pneumonic inflammation. The first 
 must be regarded as a mere complication, such as is very frequently 
 met with in practice. The second must be viewed as a distemper 
 totally diflFerent, and requiring different treatment. 
 
 The class of persons in whom pneumonia and bronchitis is ob- 
 served to assume the bilious or gastric disorder in this country 
 most frequently are the intemperate, especially spirit and wine- 
 hibbers, the gouty, and those labouring under mental anxiety and 
 distress. 
 
 § 4. The term nervous or typhoid 'pneumonia has been applied to 
 pneumonia taking place, as it often does, along with typhoid fever, 
 or giving rise to symptoms of typhoid fever. Of this variety two 
 forms may be specified. 
 
 Is^, Either a person attacked with continued fever presents in 
 the course of it symptoms of bronchial inflammation or even pneu- 
 monia, not very well marked, but still sufficiently so to be recog- 
 nized by the skilful observer. Sometimes, not always, there is 
 cough ; for in certain cases the patient is so feeble that he is unable 
 to cough or expectorate. In general the respiration is laborious, 
 limited, and irregular ; the face, cheeks, and lips are livid ; the 
 hands and feet livid and cold ; and the pulse small, soft, and 
 sometimes irregular or intermitting. Upon employing ausculta- 
 tion the presence of pneumonia in the posterior and inferior region 
 of one or both lungs is recognized. In this form of the disorder 
 it is said to be typhoid fever with pneumonia. 
 
 ^d. In a person attacked with pneumonic inflammation, the 
 symptomatic fever does not assume the open and distinct symptoms 
 usually presented, but observes a slow, latent, and insidious form, 
 in which the symptoms of great feebleness {adynamia) and nervous 
 irritation [neurasthenia) are predominant. Of these the most pro- 
 minent are great oppression at the breast, intolerable anxiety, and 
 jactitation ; a sense of internal heat ; great difiiculty in breathing 
 and coughing ; total cessation of pain if previously felt ; a deceit- 
 ful calm or listlessness ; delirium in the night especially, or typho- 
 mania ; dryness and tremulousness of the tongue, unquenchable 
 thirst, meteorisraus of the belly, dry burning skin, faintings, sub- 
 
992 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 sultus tendinum, feebleness of the voice or aphonia, extreme 
 debility of the voluntary motions, great softness and weakness of 
 the pulse, which is also sometimes quick, sometimes natural. In 
 some cases vomiting or hiecup, or both ensue. The surface of the 
 skin presents dark-coloured petechial spots or a miliary eruption, 
 especially on the anterior part of the trunk. Hemorrhages from 
 the nostrils, throat, lungs, stomach, and intestinal tube are liable 
 to take place; the urine' is sometimes dark-coloured and bloody; 
 and discharges of blood from the uterus in females are not unusual. 
 The blood, if drawn from a vein, presents in general a loose, soft 
 coagulum, with a small proportion of serum. In a few rare cases 
 the clot is firm. 
 
 As the symptoms proceed, the delirium or typhomania passes 
 into lethargic sopor ; the breathing becomes stertorous, and is 
 attended with general tracheo-bronchial rattling ; the pulse be- 
 comes small, and can scarcely be felt ; convulsions occasionally 
 ensue ; the head, neck, and chest are covered with cold fetid 
 sweats ; the extremities become cold, and death follows. 
 
 Morbid anatomy shows, that this distemper is of the kind deno- 
 minated pleuropneumony, with vesicular bronchitis. Gluge and 
 Vogel however both represent the substance of the lungs to be 
 consolidated with infiltration of dark-coloured blood in patches. 
 The lungs are found gorged with blood, dark-coloured and dense 
 towards the posterior part, not indurated or consolidated, but rather 
 oedematous and doughy. The surface of the lung presents dark 
 livid patches. The pleurae contain sero-sanguine or sero-purulent 
 fluid, with shreds of lymph. Sometimes even the pericardium and 
 the peritoneum present fluids of the same kind, with flocks of lymph. 
 The chambers of the heart also and the large vessels contain large, 
 loose, soft coagula of blood. In some epidemics the intestinal tube 
 contains lumbrici. 
 
 A state of the lungs very similar to this is observed to take place 
 in persons labouring under sea-scurvy.* 
 
 § 5. Pneumonia Septica. Gangrjena Pulmonum. — It maybe 
 doubted whether pneumonia ever legitimately terminates in morti- 
 fication or gangrene of the lung ; and there is some reason to 
 think, that, when mortification does take place in these organs, it 
 
 * Vide Huxham, chapter ii. p. 186, and Henderson, Edinburgh Medical and Sur- 
 gical Journal, vol. iii. p. 10. 
 
MORBID STATE OF THE LUNGS GANGRENE. 
 
 993 
 
 is the result not of ordinary inflammation, but of a peculiar kind 
 of inflammation, the tendency of which is to gangrene. 
 
 Gangrene of the lungs takes place either as a part and conco- 
 mitant of continued fever with typhoid symptoms and pestilential 
 fevers in general, or it may occur, so far as it is possible to judge, 
 as a primary species of inflammatory disorder of the lungs. 
 
 a. In the first case, a person with the usual symptoms of aggra- 
 vated and rather intense typhoid fever, and commonly with marks 
 of imperfect general circulation and perverted and imperfect pul- 
 monary circulation, as lividity of the face, nose, cheeks. Ups, and 
 extremities, coldness of the extremities, hiccup, and small pulse, 
 presents obscure symptoms of disorder of the lungs, laborious and 
 irregular respiration, sometimes hurried, sometimes slower than 
 natural, slight cough, at first dry, afterwards moist with sputa, 
 very viscid, glutinous, orange-coloured, streaked with blood, and 
 very fetid offensive breath. The sound upon percussion is more 
 or less dull ; and upon auscultation, either the crepitant rattle, 
 sometimes with large bells, is heard, or this is heard with inaudi- 
 bility of the vesicular sound most usually In the subscapular and 
 inferior convex region of one or both lungs. With these symp- 
 toms are usually associated great feebleness, delirium or typho- 
 mania, intermittent, irregular small pulse, a tendency to gangrene 
 of the extremities and sacrum, hiccup, subsultus teudinum, diar- 
 hoea ; and at length with increasing difficulty of breathing, fetor of 
 the breath, and tracheo-bronchial rattling, death ensues. Some- 
 times hemorrhage takes place from the lungs, and contributes, with 
 the other marks of feebleness, to accelerate the approach of the 
 fatal event. 
 
 |S. In the second case, the distemper appears to come on at first 
 in general as an affection of the lungs. Either the patient has an 
 attack of pneumonic inflammation, or bronchial disease, or spitting 
 of blood, {hcBmoptysis), with more or less dull pain in some part of 
 the side or chest, most commonly in the mammary or submammary 
 region before, and the subscapular region behind, and sometimes 
 as if passing between these two points. Cough continues and in- 
 creases, with sputa in general reddish, brown, or bloody, and 
 sometimes with pure blood, and very offensive fetid breath. The 
 countenance is anxious and livid ; the complexion dingy, wan, and 
 leaden coloured ; the cheeks occasionally tinged with a reddish or 
 pink-coloured flush ; the eye heavy and pale, sometimes wild, 
 
 3 B 
 
994 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 glaring, and slightly suffused, in other instances hollow and ghastly. 
 In the other symptoms considerable variety takes place. Thus in 
 one case, no complaint or symptoms appear which indicate a serious 
 disorder of the lungs. The patient is merely feeble, with dingy 
 wan complexion, irregular breathing, cough, and a little expecto- 
 ration. In other cases, pains, more or less acute, are felt in the 
 chest, and the labour of respiration, with debility, is considerable. 
 
 The most characteristic symptom of the distemper, the foetid of- 
 fensive breath, is not an early symptom. It does not take place 
 till the disease has subsisted for some time, two weeks, or even a 
 longer period ; and indeed it appears only to take place after a 
 communication between the seat of disorder and the bronchial tubes 
 and the air inspired and exj)ired has been established. When it 
 takes place it is impossible to entertain any doubt of the pi’esence 
 of the distemper ; but gangrene of the lungs may, on the other 
 hand, exist, and have proceeded to a considerable extent, yet with- 
 out giving rise to foetor of the breath and expectoration. 
 
 As the disease advances, expectoration becomes more abundant, 
 with sputa reddish, brown, blood-coloured, or consisting of blood 
 more or less pure, and the characteristic fetid odour. Respiration 
 becomes very irregular and laborious, being at one time slow', at 
 another (juick and panting. In general, immediately before the 
 fetid odour of the breath and sputa is manifest, more or less stupor 
 and much anxiety come on, with small, feeble, irregular pulse. 
 
 In general, after the foetor of the breath and sputa is established, 
 the distemper tends rapidly to the fetal termination. In one case 
 which fell under my own observation, the distemper continued thirty 
 days before the foetid odour of the breath was evinced. The breath 
 and sputa were foetid on the thirtieth day of the disorder, and death 
 took place the second day afterwards. In one of the cases by M. 
 Schrceder, death took place nine days after the first occurrence of 
 foetor. In another case attended by myself, the offensive foetor of 
 the breath and sputa was recognized on the 23d of February, and 
 death took place on the 6th of March, eleven days after. This, I 
 believe, may be regarded as nearly as may be, the latest period 
 that life is likely to be prolonged, after the occurrence of well- 
 marked foetor of the breath and sputa. 
 
 The duration of this disease varies from four w'eeks to two months. 
 It is rare that physicians witness its commencement ; for it is only 
 when the patient can no longer move about, or pursue his ordinary 
 
MORBID STATES OF THE LUNGS. — GANGRENE. 
 
 995 
 
 occupations, that he applies for assistance ; and in general the dis- 
 ease has been proceeding for eight days or two weeks when he is 
 first seen. 
 
 The appearances found after death are of two kinds. One is 
 indicative of what is named diffusive gangrene of the lungs, the 
 other is circumscribed. In the first case, a mass of lung, about 
 two inches and a half or three inches wide, hut irregular in figure 
 and outline, is converted into a soft, pulpy, dark ash-coloured sub- 
 stance, which, when it is handled or pressed by the finger, falls 
 down into a loose moist mass — emitting a foetid offensive odour, 
 without trace of the usual structure of the lungs, except a few 
 bronchial tubes, and blood-vessels and filaments and shreds of fila- 
 mentous tissue. This mass is in general bounded by, but it does 
 not terminate abruptly in, healthy lung. It is soft, dingy, and in- 
 filtrated with a dark, ash-coloured, dirty serous liquor. Occasion- 
 ally the surrounding portion of lung is hepatized or infiltrated with 
 blood, or blood-coloured serum ; the bronchial tubes always con- 
 tain much blood-coloured viscid mucus; and sometimes pleura 
 is reddened, covered with lymph or adhesions, and contains fluid in 
 its cavity. 
 
 The part of the lung most usually thus mortified is either in the 
 lower lobe, the upper part of the lower and lower part of the middle 
 or upper lobe on the left side, or the middle lobe alone on the right 
 side ; that is, the central part of the lungs, but verging toward the 
 lower part. 
 
 In the second form, or that which is circumscribed, a portion of 
 the lung generally towards the surface, presents a dark-coloured 
 hard patch, varying in size from a shilling to a half-crown piece or 
 more, often pretty exactly circular, bounded all round by healthy 
 lung, and not unusually a distinct reddened circle of vessels, or 
 vessels with lymph. This circular hard patch, which resembles 
 closely an eschar produced by caustic potass, or any of the caute- 
 ries, may either adhere or he detached. In the latter case, it gene- 
 rally leaves disclosed a cup-like cavity, a little larger than the de- 
 tached eschar, not loose or filamentous, or shreddy-like as in diffuse 
 gangrene, but firm, granular, with the blood-vessels and bronchial 
 tubes closed, and with the surrounding lung more softened, but 
 generally presenting marks of pleurisy, pneumonia^ and bronchitis, 
 all united. Sometimes albuminous exudation over the pleura and 
 within its cavity is found to have taken place, — a circumstance 
 
996 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 wliicli is to be ascribed to secondary pleurisy caused by the inflam- 
 mation induced to detach the dead eschar. 
 
 Though these forms of gangrene of the lung are sometimes dis- 
 tinct, they occasionally take place at the same time in the same 
 lung. Thus in the case of one of the patients who was treated by 
 myself, a man of fifty-six, diffuse gangrene was observed towards 
 the internal and anterior surface of the left lung, and circumscribed 
 gangrene in the form of a cup-like cavity at the outer surface of 
 the same lung. 
 
 Laennec represents this disease as occasionally terminating fa- 
 vourably. Of this I have never seen an instance, either in my own 
 practice, or in that of any of my colleagues at the Royal Infirmary. 
 It is, indeed, a disease almost necessarily fatal, whether from the 
 kinds of constitution in which it occurs, or its deleterious effects on 
 the lungs and their functions. 
 
 The causes of gangrene of the lungs are little known. The dis- 
 ease occurs either along with typhoid fever, or gives rise to typhoid 
 symptoms. It is more common in persons beyond the ages of forty- 
 five or fifty, and especially in those who have lived intemperately. 
 It also occurs in persons much younger, or between twenty and 
 thirty-six. But very often in persons at this age, it is found to have 
 taken place either during a mercurial course, or shortly after its 
 completion. 
 
 Some authorities regard it, especially when circumscribed, as the 
 effect of pulmonary apoplexy. 
 
 I have, when treating of the transporting power of the veins, ad- 
 verted to the fact, that when gangrene affects the lungs, suppura- 
 tion, or a purulent deposit, is liable to take place in the brain. 
 From the cases in which this has been observed, not many indeed, 
 I think that it is impossible to doubt, that however it may be ex- 
 plained, under certain circumstances purulent deposit, either within 
 the veins and sinuses of the brain, or within the substance of the 
 brain, takes place after gangrene of the lungs has been established. 
 Yet the necessity of the gangrenous affection to the production of 
 the effect is not obvious. On the other hand, mere suppuration of 
 the lung may be adequate. 
 
 Gangrene is liable to attack certain forms of tubercular excava- 
 tion and vomicae of the lungs. To this attention shall be directed 
 afterwards. 
 
 In certain circumstances, this disease appears to prevail epide- 
 mically, whether it be the effect of a typhoid or pestilential fever 
 
MORBID STATES OF THE LUNGS. — ABSCESS. 
 
 997 
 
 which gives rise to it, or it depeuds on the prevalence of some pe- 
 culiar telluric or atmospheric miasma. In the year 1348, a febrile 
 disorder, with intense pneumonic symptoms, often terminating fa- 
 tally by profuse or continued hemorrhage from the lungs, appeared 
 in Italy, and spread between that year and 1350 over many parts 
 of Europe, destroying much of the population of different countries 
 in an incredibly short space of time. This disorder, which w'as 
 emphatically denominated by the populace the black death, appears 
 to have possessed the character of fever with gangrenous pneumo- 
 nia. In many pestilential epidemics, however, as in that of Mar- 
 seilles, Transylvania, and other countries, carbuncular and glan- 
 dular plague appears to have been attended with symptoms of pul- 
 monary mortification. 
 
 Pneumonic inflammation, very often with vesicular bronchitis, 
 occurs secondarily in ague, remittent fever, typhoid fever, small- 
 pox, measles, pulmonary consumption, rheumatism, and rheumatic 
 gout, and disease of the kidney. I have also observed the disease 
 take place in a latent or insidious manner in the insane from 
 chronic meningeal inflammation. 
 
 § 6. Vomica or Abscess of the Lungs. — To complete the 
 history of pneumonic inflammation, I add a few remarks on abscess 
 of the lungs, and a form of suppurative inflammation to which they 
 are liable. 
 
 The formation of a distinct abscess of the lungs as a consequence 
 of inflammation, was at one time generally admitted among patho- 
 logists. Laennec, however, wdio describes suppuration of the lungs 
 under his third degree of pulmonary induration, maintains that it 
 is exceedingly rare, and gives it as the result of his observation, 
 that small abscesses are found in the pulmonic tissue not above 
 four or five times, and an extensive one not above once, in many 
 hundred cases. Grray hepatization is in one sense suppuration of 
 the lungs; for pus-globules are found in the interstices of the 
 filamento- cellular tissue, and are observed oozing from it. This 
 however is infiltration of purulent matter, not an abscess or deposit 
 in a particular cavity. Many of the reported cases of pulmonarv 
 abscess, or suppuration of lung, as a consequence of inflammation, 
 may be regarded as excavations or vomiccB formed by the softening 
 of extensive tubercular masses. Several also, I am satisfied, are in- 
 stances of chronic pleurisy terminating in empyema and condensed 
 lung. It is possible that suppuration, as a consequence of inflam- 
 mation of the lungs, may be rare, for two reasons; “Because 
 
998 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the disease may prove fatal by suffocation, before it has attained 
 the complete suppurative stage ; 2fZ, Because under the influence 
 of remedies, it may be so much modified as to prevent the forma- 
 tion of purulent matter in a distinct sac or cavity. But it must 
 not be regarded as so rare as M. Laennec represents it. Instances 
 are recorded by Moi’gagni, in which a considerable portion of the 
 pulmonic tissue was converted into a purulent abscess, with the 
 contiguous structure apparently healthy, or indurated as a conse- 
 quence of previous inflammation. Dr Baillie expresses himself 
 with some uncertainty ; for his language may be interpreted so as 
 to apply either to tubercular vomicae, or to pulmonary abscesses; 
 though it is evident, and more especially from what he says in his 
 engravings, that he believed in its ordinary occurrence. 
 
 On this subject evidence is defective ; and several good cases, 
 with the appearances after death are required, in order to ascertain 
 the frequency or the general occurrence of abscess as a consequence 
 of pneumonic inflammation. 
 
 It is impossible to doubt, nevertheless, that suppuration of the 
 lungs, that is, the proper pulmonic filamentous tissue, does take 
 place as an effect of inflammation of that tissue. In this instance, 
 purulent matter of a gray dirty aspect is formed beneath the pleura 
 or the subserous cellular tissue, and extends in this direction be- 
 tween the lobes. An excellent example of this lesion occurred to 
 me in the course of July 1843. A man in an extreme state 
 of feebleness presented himself for admission to the hospital. It 
 was manifest that he was in the last stage of some serious disease 
 of the lungs ; and death took place in the course of a few hours. 
 Inspection disclosed the following state of the lungs. The ’pleura 
 of both lungs, but especially of the right, were detached from the 
 subjacent substance of the lung by a quantity of dirty ash-coloured 
 purulent matter. In the right lung, this detachment with the cor- 
 responding purulent matter extended into the division of the lobes 
 and lobules, which were thus separated from each other. The 
 filamento-cellular tissue appeared as if it had been dissolved and 
 carried away in the purulent collection ; for it was no longer cog- 
 nizable in its wonted characters. When the matter was washed 
 away, bronchial tubes and blood-vessels were all that was left; and 
 these did not adhere as they are wont to do. In short the cohesion 
 of the whole of the lower and middle lobe of the right lung was 
 entirely destroyed. 
 
 Another example of the same lesion is recorded by Dr Stokes in 
 
 4 
 
MORBID STATES OF THE LUNGS. — DEPOSITS IN THE VEINS. 999 
 
 the third volume of the Dublin Medical Joxu'ual. This gentleman 
 found in the body of a young man who died after labouring for 
 fifteen days under symptoms of pneumonic inflammation, a consi- 
 derable collection of purulent matter beneath the pulmonic pleura 
 of the lower lobe of the left lung, and between it and the bronchial 
 tubes and vesicles of the lung — dissecting away as it were the 
 pleura, from the lung, destroying, or at least converting into puru- 
 lent matter, the pulmonic filamentous tissue, and leaving the pul- 
 monic vesicles and bronchial tubes comparatively untouched. This 
 must be regarded as not only an example of suppuration of tbe 
 lung, but as proving clearly, that the seat of this form of pneumo- 
 nia is in the pulmonic parenchyma or filamentous tissue, as already 
 inculcated.* 
 
 § 7. Pulmonary Phlebitis. Collections of Matter in 
 THE Veins of the Lungs. — I have met with two or three ex- 
 amples, in which, without expecting any morbid appearance, 
 I found the pleura sound, the lungs interspersed at considerable 
 distances with numerous minute abscesses, but tbe intermediate 
 tissue quite healthy. As it occurred that these were softened 
 tubercles, the whole organ was carefully examined, yet without 
 finding anything but minute spberical abscesses of various sizes, 
 and with the surrounding texture natural. The peculiarity, 
 therefore, of this species of suppuration, is its not being preceded 
 by tubercles, the surrounding pulmonic tissue being neither in- 
 flamed nor indurated, and the simultaneous formation of many 
 purulent points. 
 
 Dr Baillie, by whom this species of suppuration had been seen, 
 thought it probable that the abscesses were produced by a number 
 of scattered tubercles taking on the process of suppuration. When 
 however these purulent collections are carefully examined, they are 
 found to take place within the veins of the lungs. Of this I am 
 satisfied from having observed these deposits ensue after inflamma- 
 tion of the veins of the arm, consequent on blood-letting. They 
 take place also after amputation of the extremities, in which the 
 medullary membrane and veins of the bones have been inflamed 
 and suppurate, and occasionally after other injuries which proceed 
 to suppuration.! 
 
 * Dublin Journal of Medical Sciences, vol.iii. Contributions to Thoracic Patliologv, 
 by Dr Stokes, p. 51. 
 
 t Observations on Depositions of Pus and Lymph occurring in the Lungs and otlier 
 viscera after injuries of different parts of the Body. By Thomas Rose, Esq. &c. Me- 
 dico-Chirurgical Transactions, Vol. xiv. p. '251. London, 1828. 
 
1000 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 This has been mentioned by Gluge as taking place after glan- 
 ders and metastatic inflammation ; and he considers the purulent 
 matter as deposited in the pulmonic filamento-cellular tissue.* It 
 appears to me that though this may take place occasionally, yet 
 these collections are very generally in the veins of the lungs. 
 
 In one case of inflammation of the uterine veins, with matter in 
 them and the common iliac veins and cava. Dr Lee found, with he- 
 patization of the lower lobe of the left lung, matter in the pulmo- 
 nary veins and lymph in the pulmonary trunk.f 
 
 § 8. Deposits of Blood in the Pulmonary Arteries after 
 Phlebitis. — Another effect of inflammation of the veins consists in 
 deposits of blood, or lymph, or both, in the pulmonary artery and 
 its branches. While the last mentioned deposit of purulent matter 
 succeeds purulent phlebitis, this, there is every reason to believe, 
 follows lymphy or plasmatic in which either clots of blood 
 
 or lymph are formed in the inflamed vein. The following is the 
 ordinary mode in which I have seen this take place. 
 
 Symptoms of inflammation appear in a vein of the extremities ; 
 most usually in the common femoral or external iliac vein, which is 
 painful, and in the site of which a hard firm swelling is felt, with 
 general swelling and pain of the veins of the extremity. This pro- 
 ceeds for days and weeks, until the interior channel of the vein is 
 more or less, sometimes completely obstructed. 
 
 Other symptoms indicative of more or less disorder in the organs 
 of respiration take place. In some instances purulent eflPusion 
 within the pleura follows. In others there are indications of de- 
 rangement in the action of the heart, as palpitation, forcible pulsa- 
 tion in the cardiac region, irregular or intermittent pulsation and 
 droj)sical effusion. At length, after weeks or months, death en- 
 sues, when the following facts are observed. 
 
 A bloody or lymphy clot more or less firm, sometimes com- 
 pletely solid, in the external iliac and common femoral artery ; the 
 coats of the vein thickened and not collapsing, and their inner 
 membrane rough and reddened for a considerable space. 
 
 In some cases a clot of blood or lymph adheres most firmly to 
 the lacinice of the tricuspid valve, or to the walls of the right ven- 
 tricle. When the pulmonary artery is examined, one or two of its 
 branches is filled more or less completely with a brownish firm clot 
 
 * Atlas Der Pathologischen Anatomie. Sechste Lieferung. Seite 5. 
 
 •J- Case of Pulmonary Phlebitis. By Robert Lee, M. D. &c. Medico-Cliirurgical 
 Transactions, Vol. xix. p. -15. London, J 83S. 
 
MORBID STATES OF THE LUNGS. — HEMORRHAGE. 1001 
 
 of blood, and dispersed through the lungs are similar clots, brown- 
 ish-coloured, all of which may be traced to divisions of the pulmo- 
 nary artery. 
 
 This disease is sometimes chronic in its course, and may take 
 ten or twelve months before it renders the lungs unable to perform 
 their functions. But in one case it terminated in about seven or 
 eight weeks. 
 
 The occurrence of these clots of blood within the branches of 
 the pulmonary artery has been noticed by Cruveilhier,* M. Baron,| 
 Mr James Paget,| and Dr Dubini.§ It does not appear that in 
 all the cases recorded by these observers, there was proof that the 
 circumstance was preceded by inflammation in any veins of the 
 extremities, or the formation of clots within their channels. In 
 several of the cases, the obstruction came on to all appearance 
 spontaneously, and without indications of previous disease. In the 
 case given by Cruveilhier, the obstruction was connected with ute- 
 rine phlebitis. But Mr Paget thinks that there is between these 
 cases and those which he records a great difference. The cases 
 mentioned he thinks, connected either with pulmonary apoplexy, 
 especially if dependent on disease of the heart, or with pneumonia, 
 or with the presence of enkephaloid matter in the blood, or with 
 that of urea in the blood, as in the case of granular disease of the 
 kidney, in which he finds these deposits to be frequent. It appears, 
 therefore, that the formation of these deposits depends on several 
 different causes, all however agreeing in some morbid state of the 
 blood or the veins. 
 
 § 9. Pnetjmonoerhagia. Hemorrhage from the Lungs. — 
 Discharge of blood by coughing occurs under two forms. One is 
 that of bronchial hemorrhage, sometimes copious, but often in small 
 quantity. The other is that of pulmonary hemorrhage, which may 
 be small in quantity, but is generally very copious. Of the former 
 sufficient notice has already been taken under the head of diseases of 
 the bronchial membrane. The latter is to be considered in this place. 
 
 * Anatomie Pathologique, Livraison xi. 
 
 t Recherches et Observations sur la Coagulation du Sang, Dans 1-Artere Pulmon- 
 aire et ses efFets. By M. C. Baron, Archives Generales de Medecine, T. xlvii. p. 5. 
 Paris, 1838. 
 
 J On Obstructions of the Branches of the Pulmonary Arteries. By James Paget, 
 F. R. C. S. and Medico-Chirm-gical Transactions, Vol. xxvii. p. 162. London, 1844. 
 
 Additional Observations on Obstructions of the Pulmonary Arteries. By James 
 Paget, F. R. C. S. Medico-Chirurgical Transactions, Vol. xxviii. p. 352. London, 
 1845. 
 
 § Annali Universal! di Medicina di Febraio, 1845. 
 
1002 
 
 GENERi\X PATHOLOGICAL ANATOMY. 
 
 On the exact source and pathological causes of spitting of blood, 
 physicians entertained either erroneous or indistinct ideas. The 
 ancients ascribed it to rupture of some of the pulmonary vessels ; 
 and this opinion was adopted by many practitioners, and is still en- 
 tertained by the vulgar, to whom this disease has been long known 
 by the name of rupture of a hlood-vessel. This opinion, however, 
 is manifestly contradicted by anatomy and by observation. In mo- 
 dern times this opinion regarding the pathology of pulmonary 
 hemorrhage is found to be correct in two cases only ; first, when 
 an aneurismal tumour or a diseased artery bursts into the air tubes 
 {bronchia,') or the windpipe ; and secondly, when an arterial branch 
 passing through a tubercular excavation has given way during the 
 progress of ulceration. Neither of these cases, it is obvious, are 
 necessarily connected with true pulmonary hemorrhage. Both are 
 followed by immediate or very speedy destruction. But the process 
 of haemoptysis may recur from time to time during months or years 
 in the same individual, or even the whole of a long life ; yet with- 
 out being the direct cause of death. 
 
 In modern times, the opinions on the nature of pulmonary he- 
 morrhage may be referred to two heads. According to one of 
 these views, haemoptysis is the result of an actual wound or breach 
 in the bronchial or mucous membrane of the lungs. This was the 
 opinion of Barry, Grant, Gilchrist, and even of Cullen, if we un- 
 derstand him ai’ight. According to the other view, which is more 
 recent, haemoptysis is believed to depend on some disorder of the 
 bronchial membrane, and its exhalant vessels ; in consequence of 
 which they discharge blood instead of mucus. This opinion was 
 that of Bichat, who has been followed by all the physicians of the 
 Parisian school, and by many in this country. This opinion is, as 
 I have already shown, well-founded within certain limits only. 
 There are cases of haemoptysis in which the bronchial membrane 
 and its capillaries only or principally are affected ; and then the 
 blood which is occasionally coughed up is the result of exhalation, 
 or of destination, as it used to be named by the older pathologists. 
 Such are the discharges of blood which take place in slight cases 
 of haemoptysis or pulmonary catarrh, about the termination of pe- 
 ripneumony, about the commencement of consumption, and in 
 young females after the suppression or retention of the menstrual 
 discharge. 
 
 There are, however, many instances of bleeding from the lungs 
 
MORBID STATES OF THE LUNGS HEMORRHAGE. 1003 
 
 in a violent and extreme degree, for which it is impossible to ac- 
 count by capillary exhalation only. 
 
 Dr William Stark was the first who described accurately the 
 state of the lungs in these instances of hsemoptysis. The air vesicles 
 in some parts of the lungs he found filled with blood or bloody se- 
 rum. These parts did not collapse on opening the chest, but wei'e 
 firm, very dark or light-red in colour, and could neither be com- 
 pressed nor distended by the usual inflation. When cut into, thick 
 blood or bloody matter issued from the cut surfaces ; and portions 
 of the diseased parts, after being for some time macerated in water, 
 still sank as before maceration. He further showed by blowing air 
 into the blood-vessels and air- tubes of the somid and diseased por- 
 tions respectively, that in the latter, air passed from the branches 
 of the pulmonary artery and veins into the bronchial tubes, — in 
 other words, that the minute arteries and veins or capillary vessels 
 of the lungs communicated freely with the bronchial tubes and air- 
 cells.* 
 
 This description is extremely accurate, but appears to have been 
 altogether overlooked. Its accuracy has been confirmed by various 
 subsequent observers, and especially by the researches of Laennec. 
 The facts ascertained in this manner show that a considerable 
 change takes place in hsemoptysis in the pulmonary substance, or 
 the proper tissue of the lungs. A portion of the organ becomes 
 uniformly hard, of a dark-red colour, and impermeable to the air. 
 The indurated spot is always partial, fi-om one to four cubic inches 
 in extent, pretty exactly circumscribed, with healthy or pale-coloured 
 lung, and looks not unlike a clot of venous blood ; circumstances 
 by which it is to be distinguished from pneumonic induration, which 
 terminates more or less gradually in sound lung. These changes 
 consist in efilision of blood into the parenchyma of the lungs, and 
 into the bronchial tubes ; and as they are analogous to those which 
 take place in the brain in apoplexy, Laennec applies to them the 
 name of pulmonary apoplexy. These are confined chiefly, however, 
 to the severer forms of pulmonary hemorrhage. 
 
 Not even is this description, however, suflacient to explain all the 
 phenomena of pulmonary hemorrhage. The changes of the pul- 
 monic tissue described by Laennec, are rather the effects of a pre- 
 vious morbid state of the capillary circulation of the lungs, than the 
 actual state of the morbid process, which gives rise to eflFusion of 
 red blood from the bronchial membrane. When the lung is in the 
 * The Works of the late William Stark, M, D., &e, London, 1788, p. 34. 
 
1004 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 state described by this pathologist, the blood has been already dis~ 
 charged from the vessels, or extravasated not only into the cells of 
 the pulmonic tissue, but into the minute extremities of the bronchial 
 tubes, which are thus filled and obstructed within, while they are 
 compressed and obliterated without. But it is the agent that 
 causes this effect, which it is the object of the pathologist to know ; 
 it is the state of the capillary circulation which terminates in this 
 effusion, which it is necessary to explain in unfolding the pathology 
 of pulmonary hemorrhage. This it w'ill be found consists in more 
 or less injection and distension of the capillaries or minute arteries 
 and veins which are distributed through the pulmonic tissue, to w'ind 
 round, and ramify in the minute or extreme bronchial tubes, in con- 
 sequence of some derangement or impediment in the circulation. 
 
 The truth is, that in all the instances of the lesion described as 
 hemorrhage into the substance of the lungs, whether recent, or in 
 the form of pulmonary dark-brown induration, it is preceded either 
 by disease of the heart, or disease in the substance of the lungs. 
 
 1. Bichat, and particularly Cor visart, observed that, in certain forms 
 of disease of the heart, especially the active aneurism of the latter, 
 or what is at present termed hypertrophy, expectoration of blood 
 was a symptom of the second and third stages of the disease. Tlie 
 same circumstance was also noticed by Mr Allan Burns, who, how- 
 ever, has hypothetically connected this symptom with dilatation of 
 the right side of the heart. All the best marked cases of pulmonary 
 hemorrhage with hemorrhagic induration which I have seen, have 
 been connected with ossification of the mitral valve, and arctation 
 of its aperture, or hypertrophy of the left ventricle. The operation 
 of the former it is easy to understand. The blood does not pass 
 with its wonted facility through the mitral valve into the left ven- 
 tricle ; the left auricle is consequently kept in a constant state of 
 over-distension ; this distension is propagated along the pulmonary 
 veins to the pulmonary capillaries, which are thus perfectly filled 
 and distended with blood, which is not allowed to be moved into 
 their trunks in the usual manner, and with the wonted regularity. 
 As this distension is every hour and day increasing, with the per- 
 sistence and increase of the obstruction in the left auriculo-ventri- 
 cular aperture, it is not wonderful that the blood is extravasated 
 into the pulmonic filamentous tissue, and through the bronchial 
 membrane, causing in the former the dark brown-coloured circum- 
 scribed masses which are found after death, and in the latter the 
 bloody expectoration which takes place during life. 
 
MORBID STATES OF THE LUNGS. — HEMORRHAGE. 1005 
 
 It is remarkable, nevertheless, that this extravasation and its 
 effects are greatest and most conspicuous in young persons. A 
 degree of degeneration of the mitral valve and arctation of its aper- 
 ture, which produces little inconvenience at or beyond the age of 
 sixty years, causes between the ages of twenty and thirty extreme 
 dyspnoea and ortliopncea, cough, heemoptysis, and all the accom- 
 panying symptoms, with serous infiltration into the different cavi- 
 ties and the subcutaneous cellular tissue. 
 
 Much the same phenomena may take place in consequence of 
 dilatation or hypertrophy, general or partial, of the left ventricle. 
 Olten, indeed, the dilatation or excentric hypertrophy and the con- 
 centric hypertrophy are the result of disease of the semilunar valves 
 at the origin of the aorta ; but, in several instances, they take place 
 independently of this. When they do ensue, they give rise to a 
 similar state of imperfect transmission of the blood out of the ven- 
 tricle into tlie aorta ; the left ventricle, auricle, and pulmonary 
 veins become unduly distended ; and eventually the pulmonary 
 capillaries are constantly distended with an unusual load of blood, 
 which at length is extravasated, and causes the same state of the 
 lung, and the same expectoration of blood, which takes place at an 
 earlier period in the degeneration of the mitral valve. 
 
 In either of these cases now specified, but especially in disease of 
 the mitral valve and arctation of the auriculo- ventricular aperture, 
 in hypertrophy, and in that rare disease called partial aneurism of 
 the heart, hemorrhage of the lungs may take place in one or other 
 of the following modes. 
 
 After a fit of great difficulty of breathing, generally with orthop- 
 noea, a quantity of blood varying from one to six ounces is brought 
 up forcibly by coughing. In one instance I saw nearly two pounds 
 coughed up in the course of about thirty hours. In such cases the 
 large fluid rattling and gurgling, is heard all over the chest, gene- 
 rally on both sides. From this state recovery is sometimes but 
 rarely effected. Death usually takes place in the course of a few 
 days, not so much from loss of blood, which rather relieves the 
 patient than otherwise, as from the extreme difficulty in breathing. 
 The state of the lungs is then the following. They are completely 
 gorged with blood ; of a dark -red or very livid colour ; and in 
 several points brown masses not firm are formed, which are blood 
 effused into the filamento-cellular tissue. When the case is recent, 
 these masses are few and small, sometimes on the margins of the 
 
1006 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 lungs, sometimes deep in their substance. They are also soft, and 
 the blood is imperfectly coagulated. A curious appearance in 
 lungs of this kind is that of red-spotting or maculation all over the 
 surface and into their substance. When the pleura is removed by 
 dissection, these spots are observed to lie beneath it on the sub- 
 stance of the lungs, and are found to depend on blood poured into 
 the bronchial tubes and extending to their ultimate terminations. 
 
 Sprinkling or maculation with blood in the lungs from its pre- 
 sence in the bronchial tubes and air-vesicles, I have in like man- 
 ner observed in the lungs of persons who had committed suicide by 
 cutting the throat, and in sheep slaughtered in the same manner. 
 
 The lungs in this state are heavy, compact, and partially con- 
 densed: and though they crepitate and contain air in certain 
 points, yet they generally sink in water. 
 
 In another set of cases, the patient is attacked with a fit of ex- 
 treme breathlessness, amounting to orthopncea, in which the lips, 
 nose, and cheeks are blue or violet-coloured, and by coughing 
 he brings up at length frothy mucus, at first streaked, then mixed 
 with blood. This may continue for two, three, or eight days, when 
 the urgent symptoms subside, and the bloody expectoration disap- 
 pears. This is repeated several times at intervals more or less re- 
 mote. The fits however are less violent, though longer continued. 
 At length the individual has fewer and less distinct intervals of 
 relief. Breathlessness is either constant, or very nearly so. Cough 
 continues, with expectoration of bloody mucus, and blood, some- 
 times in considerable quantity. When death ensues, the follow- 
 ing is the state of the lungs. 
 
 Masses of variable size, but sometimes very considerable, that 
 is, as large as a walnut or small pippin, dark-brown, firm and 
 solid, are found dispersed through the lungs. These masses are 
 solid, granular, and friable, and, though firm, may be broken between 
 the fingers. These also sink in water. When examined carefully, 
 it is easy to see that they are blood extravasated into the filamento- 
 cellular tissue of the lungs. The vessels are closed ; the bronchial 
 tubes obliterated, at least not permeable to air. Little of the lungs, 
 indeed, is left in their elastic compressible crepitating condition. 
 
 The heart is found either in a state of great hypertrophy, or 
 w’ith the mitral valve ossified, and its aperture greatly contracted. 
 In some instances, though less numerous, the same state is found 
 when the aortic valves are ossified, and the aortic aperture is closed. 
 
MORBID STATES OF THE LUNGS. 
 
 1007 
 
 The same state of lungs takes place in partial aneurism of the 
 heart.* 
 
 These facts may be regarded as established. But another ques- 
 tion remains for solution. What is the cause of this distension or 
 injection of vessels, when it cannot be traced to disease of the 
 heart ? What is the nature of that condition of the pulmonary 
 capillaries which allows them to be so unusually distended ? What 
 change in properties do they undergo in living persons in that par- 
 ticular portion of lung, in consequence of which they become dis- 
 tended with blood, which stagnates in them, and at length is forced 
 from them by extravasation ? And lastly, why does this state not 
 give rise to inflammation and its consequences ? To these ques- 
 tions no satisfactory answer has hitherto been given, 
 
 2. Profuse hemorrhage from the lungs takes place in consequence 
 of tubercular deposition and infiltration. In various persons the 
 deposition of tubercular matter, either in the lungs or at the extre- 
 mity of the bronchial tubes and vessels, induces the same disorder 
 in the motion of the blood through the pulmonary capillaries which 
 takes place in diseases of the heart. As the presence of these bo- 
 dies encroaches both upon the lungs and the blood-vessels, the dif- 
 ferent vessels of the lung become distended with blood, which is 
 not allowed to move through them with the natural facility and ra- 
 pidity ; accumulation consequently ensues ; and afterwards extra- 
 vasation, and sometimes even vessels have been found ruptured. 
 
 When the tubercular deposition is extensive, and beginning to 
 cause vascular congestion, serous extravasation, and softening, it also 
 happens not unfrequently that the vessels become much enlarged 
 and distended ; their tunics at the same time are involved in the 
 morbid changes, become thickened and covered with morbid pro- 
 ducts, and are thereby rendered bi’ittle and lacerable ; and in this 
 condition they often give way and cause profuse hemorrhage. 
 
 3. Lastly, it has been observed, in inspecting the lungs of persons 
 who have died during the breaking down of tubercular masses, and 
 after these masses have been excavated, that, though in general some 
 provision is made against the ulcerative destruction of the blood- 
 vessels by coagula being formed in them, and by their cavities being 
 obliterated, yet in some instances a vessel has been found passing 
 near or across a tubercular cavity, and, having been opened, has 
 
 * Observations and Cases illustrating the Nature of False consecutive Aneurism of 
 the Heart. By David Craigie, M. D. &c. Edinburgh Medical and Surgical Journal, 
 Vol. lix. p. 356. Edinburgh, 1843. 
 
1008 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 poured forth much blood, which has been partly brought up by- 
 coughing, and partly filled the cavity with bloody clots, as was ascer- 
 tained by inspection after death. 
 
 The causes of haemoptysis may be understood from the account 
 already given of the different circumstances under which hemor- 
 rhage may take place. They may be shortly enumerated in the 
 following manner : First, inflammatory action and induration ; 
 secondly, hemorrhagic induration, with or without disease of the 
 heart ; thirdly, disease of the arteries ; fourthly, tubercular depo- 
 sition ; fifthly, tubercular destruction and excavation ; and sixth, 
 bronchial hemorrhage. 
 
 § 10. Tuberculatio. Tyromatosis. Tuberculosis. State 
 OF THE Lungs in pulmonary Consumption. — In the bodies of 
 those who have died after suffering from the usual symptoms of 
 pulmonary consumption, as already specified, the lungs are always 
 more or less changed in structure and more or less destroyed. In 
 those who have been long ill, and who have been much wasted, the 
 upper regions of one or both lungs are much indurated, and occu- 
 pied by one or more irregular-shaped cavities or caverns, contain- 
 ing either air, or air and a little viscid puriform dirty-looking 
 matter adhering to their walls. 
 
 Very generally the apex of one or both lungs is firmly attached 
 to the inner part of the chest, by the pulmonary -pleura adhering 
 closely to the costal pleura by means of false membrane, which is 
 usually thick, firm, and cartilaginous. The extent of this adhesion 
 may be such, as, while it surrounds the whole lung, not to descend 
 below the third or the fourth rib ; beneath which the pleura may 
 be free from inflammatory exudation or adhesion ; it then forms a 
 sort of cartilaginous cap or covering of the apex of the lung. But 
 in some instances, while the pleura investing the upper lobe ad- 
 heres firmly to the costal pleura, that covering the lower lobes and 
 the middle lobe on the right side is covered by a layer more or 
 less thick of albuminous exudation, while a quantity of sero-puru- 
 lent fluid is found in the posterior part of the thoracic cavity. 
 Almost invariably the lobes adhere by interlobular false mem- 
 brane. 
 
 Sometimes the greater part of one upper lobe is hollowed into 
 one large irregular cavity ; more frequently the upper lobe pre- 
 sents two or three caverns, either isolated or communicating ; and 
 in some instances the upper lobe is occupied by a number of cavi- 
 
MORBID STATES OF THE LUNGS. — TUBERCLES. 1009 
 
 ties of moderate size, some containing air, others pnriforra dirty -look- 
 ing mucus. The largest cavities are most commonly formed in the 
 apex or upper region of the upper lobe ; but occasionally a con- 
 siderable cavity is found near the middle, or tending towards the 
 base of the upper lobe, and corresponding with the pectoral and 
 axillary regions externally. Cavities filled entirely or partially with 
 matter have been named VomiccB, sometimes abscesses rather im- 
 properly, and with greater propriety softened tubercular masses. 
 When wholly or partially emptied, they are usually named tuber- 
 cular cavities, or cavities, tubercular excavations, or simply excava- 
 tions. 
 
 Lower down, for instance in the lower part of the upper lobes, 
 the cavities are few, small, or none ; in the middle lobe of the right 
 side, also cavities are rarely observed ; and the lower lobes of both 
 sides are in general entirely free from cavities. The whole of these 
 parts, however, are more or less indurated by the presence of hard, 
 solid, irregular-shaped masses, variable in size, but in general 
 larger and more numerous in the upper and middle region of the 
 united lungs than in the lower region. 
 
 When the caverns (vomiccz,') above noticed, are examined, they 
 are observed to vary, not only in size, but in shape. They vary 
 from the size of a large pea or small bean to that of a walnut, a 
 pigeon’s egg, or even a small pippin. Though their shape is more 
 or less ovoidal, they are always irregular, and sometimes consist of 
 one large or considerable cavern with two or three small append- 
 ages. The interior is always irregular, and more or less traversed 
 by cylindrical bands or chords, (septa,) (trabeculce,) about the 
 twelfth, the tenth, or the eighth of an inch in diameter, passing in 
 various directions, but generally observing that of the longitudinal 
 diameter of the lung, or observing a slight degree of obliquity. 
 
 These bands or chords (trabeculae,) are formed in various modes. 
 Laennec believed them to be formed of the natural tissue of the 
 lungs, condensed as it were, and charged with tubercular matter, 
 and maintains that he in no case found them to present traces of 
 having contained blood-vessels. Schroeder, on the other hand, who 
 frequently injected tuberculated and excavated lungs, represents 
 them to be formed chiefly by the gradual and progressive oblitera- 
 tion of small blood-vessels by means of inflammation, the large ones 
 receiving nutriment after the small ones have ceased to do so.=^ 
 
 * Observationes Anatomico-Pathologici et Practici Argumenti, Auctore J. C. L. 
 Schroeder Van der Kolk, Med. et Art. Obstet. Doct. Fasciculus I. Amstelodami, 
 1826, 8vo, p. 77 and 78. 
 
 3 s 
 
1010 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 It is not improbable that they consist partly of inflamed and con- 
 densed cellular, that is, filamentous tissue, especially that investing 
 the lobules, and partly of obliterated blood-vessels. 
 
 The inner surface of a cavity, chiefly or altogether emptied, 
 though irregular, rugged, and hollowed into several subordinate 
 depressions and eminences, presents, nevertheless, a smooth firm 
 surface, which is observed to be owing to the presence of a newly 
 formed membrane. When, indeed, the fluid and granular matter 
 is removed by washing it repeatedly in water, it appears, though 
 hard and somewhat cartilaginous, to be almost like an imperfect 
 mucous membrane, or rather the villous surface of a fistula or 
 sinus. This Laennec regards as a false membrane, or newly formed 
 product ; and certainly it presents several of the characters of false 
 or morbid mucous membrane. Thus it is thin, smooth, whitish, or 
 gray, semitransparent, soft, friable, and easily removable by the 
 scalpel. In some instances subjacent to this thin semitransparent 
 membrane, are one, or portions of one a little firmer, rather more 
 opaque, and more closely adherent to the walls of the cavity. 
 
 When the texture surrounding the cavity, and forming its walls, 
 is examined, it is found to he solid, firm, incompressible, almost 
 cartilaginous, entirely void of elasticity, more or less dark-red or 
 brown, and serous fluid oozing abundantly from the divided sur- 
 faces. The bronchial tubes passing through such parts, and open- 
 ing into the cavity or cavities, are often enlarged, and their mem- 
 brane is invariably of a deep or bright-red colour, rough and villous, 
 and lined with viscid mucus. In general these bronchial tubes 
 are cut transversely across, or truncated at the point of junction 
 with the cavity. In some rare cases, one bronchial tube is found 
 passing through a cavity or a vomica, showing that it has escaped, or 
 resisted the destroying process which commonly cuts it through. 
 This fact, noticed by Schroeder, I have also seen. But in general 
 such bronchial tubes are at length destroyed, if the life of the 
 patient be sufficiently prolonged. Neither Laennec nor Louis ap- 
 pear to have met with bronchial tubes within cavities ; and perhaps 
 the occurrence is rare. 
 
 The solidity and firmness of the surrounding texture is caused 
 by two circumstances ; the first, the presence of tubercular deposi- 
 tion in the lungs ; and the second, inflammatory induration. 
 
 The tubercular deposit appears in the form of hard masses, 
 wliich are amorphous or void of regular shape, and variable in size. 
 IVhen divided, these masses are solid, firm, sometimes almost car- 
 
MORBID STATES OF THE LUNGS TUBERCLES. 1011 
 
 tilaginous, of a bluish or dirty gray colour, and when closely in- 
 spected, consist of granular bodies, various in size, from a millet- 
 seed to a small pea, closely aggregated together, and mutually 
 pressing each other. In various points are observed portions of 
 whitish or grayish coloured viscid semifluid matter, which when 
 removed are observed to be contained in small cavities. Such 
 masses cannot be said to be homogeneous. Though invariably 
 much more Arm and incompressible than the surrounding lung, 
 and than healthy lung, they consist of portions of different degrees 
 of consistence, and of different colour. To the masses and their 
 component parts, the name of tubercles is indiscriminately applied. 
 It would be more correct if the denomination of tubercle were con- 
 fined to one or the other, especially to the smaller component por- 
 tions ; in which case the large masses might be denominated 
 tubercular. 
 
 The tubercular masses, as thus described, may occupy the supe- 
 rior and middle parts of the lungs, leaving very little of the sound 
 lung intermediate' between them. Lower down, and especially in 
 the lower lobe, they are less extensively diffused, and smaller in 
 size, so that portions of the lung are unoccupied by them. In 
 general, also, they are more abundant at the posterior than at the 
 anterior part of the lungs. 
 
 Tubercular masses vary in size, and may be distinguished in 
 this respect into small, middle-sized, and large. The small masses 
 are those about the size of garden peas, or small beans ; the 
 middle-sized are those about the size of a filbert, or small goose- 
 berry, and all those above this may be designated as large. In 
 general, when they have attained the latter dimensions, they have 
 either become partially softened, or they have begun to soften. 
 
 Though the tubercular masses vary in size, their component 
 parts, viz. the minute tubercles, are generally about the same 
 magnitude. These are commonly about the size of a millet-seed 
 or a little larger ; but in general the whole of the interior of a 
 tubercular mass presents in the advanced stage such a confused 
 mass of morbid texture, that it is impossible then to recognize the 
 individual tubercles, or distinguish them from each other and the 
 whole mass. It is only by examining tuberculated lungs in the 
 early stage, and before the disease has proceeded far, that it is 
 possible to form an accurate notion of the characters of a tubercu- 
 lated mass. 
 
1012 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Tlie tubercular masses receive not injection, and hence cannot 
 be said to receive vessels from the large vessels of the lungs. At- 
 tempts to inject tuherculated lungs were made by Dr William 
 Stark ; and he always found that the injection reached neither the 
 vomicae nor the tubercular masses. He found that blood-vessels 
 which were of considerable size, at a little distance from a tuber- 
 cular mass or masses, speedily became contracted, so that a large 
 vessel, which at its origin measured nearly half an inch in circum- 
 ference, could not be cut open further than an inch ; and that 
 when cut open, such vessels presented a very small canal, which 
 was filled by fibrous substance, evidently albumen or coagulated 
 blood. The same fact he also proved by blowing air into the 
 vessels, or injecting them with wax. When air is blown into the 
 vessels of a tuherculated lung, the air either does not pass along 
 the vessels at all, or does so in a very imperfect manner, nor does 
 air in this manner reach the vomicae. If coloured wax or isinglass 
 be thrown into the pulmonary artery and vein, the parts least 
 aflPected by disease, and which before injection are soft and elastic, 
 become afterwards the hardest and firmest; and the parts most 
 occupied by tubercular masses, and which before injection are 
 hardest, become after it much softer than the others. When a 
 lung so injected is divided by incision, numerous minute branches 
 filled with injected matter are seen in the sound parts ; but in the 
 diseased parts, few or no injected branches; and the matter is ob- 
 served never or seldom to enter the tuherculated masses or their 
 vomiccB. 
 
 These and similar experiments were performed by Schroeder, 
 who found that no vessels pass through the centre of a vomica, but 
 are closed, and as it were truncated at the margin of the vomica ; 
 that in cases in which numerous vessels pass transversely across a 
 vomica or ulcer, though many of them are filled with wax, when 
 injected, yet the small or capillary branches adhere to the trunks 
 externally like filaments, or in the form of slender cellular tissue, 
 but are obstructed and impervious, so that they do not admit the 
 injected matter; whereas the trunks penetrating the vomica are 
 surrounded by no pulmonary parenchyma, excepting the filaments 
 described as the remains of the capillary vessels. 
 
 From these facts M. Schroeder concludes that the obliteration 
 begins in the small vessels and proceeds to the large trunks; that 
 this obliteration is the effect of inflammation of the vasa vasorum, 
 
 4 
 
MORBID STATES OF THE LUNGS. — TUBERCLES. 1013 
 
 by which lymph is effused into the eanal of the vessel which unites 
 its walls and renders its trunk impervious ; that the vasa vasorum 
 may not be so much affected by this inflammation, as to interrupt 
 their circulation, and may continue, consequently, to nourish the 
 obliterated trunk, which then forms the septum of Laennec, and 
 the trabecula of Schroeder ; but that in those instances in which 
 these nutrient vessels have become involved in the inflammation 
 and obstructed, the trunk becomes black, dies, and is dissolved in 
 the general suppurative destruction of the tubercular mass. 
 
 The state of the lymphatic vessels it is extremely difficult to dis- 
 tinguish in the lungs ; and though M. Schroeder injected with 
 mercury in lungs affected with vomicae, some lymphatic vessels of 
 the pulmonic pleura, yet he never found any one of them penetrat- 
 ing the substance of the lung. Subsequently, however, in the 
 sound lung, he succeeded not only in injecting with mercury the 
 lymphatics of the whole surface of the lung (the pulmonic ^Zewra 
 1 presume), but traced several branches into the pulmonic paren- 
 chyma so distinctly, that he was satisfied that the lymphatics en- 
 compassed the lobules like meshes of net-work ; and further traced 
 to a small black tubercle in the surface of the lung, not far from 
 the windpipe several lymphatic vessels, which partly penetrated the 
 tubercle, and partly poured mercury into it. From this circum- 
 stance, and from the analogous one, that tubercles in this situation 
 often contain calcareous matter, M. Schroeder thinks it not un- 
 unlikely, that the calcareous tubercles are the result of degenera- 
 tion of the lymphatic vessels or glands. 
 
 It appears that the nervous filaments terminate with the vessels 
 at the margin of the vomica, so that they appear to have been con- 
 verted into a species of cartilage or tough cellular tissue. In one 
 case described by this author, the nervous branches were reddened 
 and thickened, numerous vessels being brought into view upon 
 them by means of injection. Like Mr Swan, M. Schroeder saw 
 in phthisical persons the pneumogastric nerve reddened and thick- 
 ened ; but in other cases he admits that he found it quite unchang- 
 ed, so that he is averse to make any positive conclusion. 
 
 Before proceeding to describe the state of the other respiratory 
 and circulating organs, and that of the intestinal canal, it is pro- 
 per to consider here the mode in which these tubercular masses are 
 formed, their nature, their progress and progressive changes, and 
 their termination. 
 
1014 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 The question of the original formation of tubercles requires the 
 previous consideration of three points ; in which texture of the 
 lungs are the tubercular bodies first deposited ; in what fornu 
 fluid or solid, are they first deposited ; and what is the cause of the 
 deposition. 
 
 1. Dr Stark represents tubercles as formations in the filamento- 
 cellular substance of the lungs ; and Baillie inferred from dissec- 
 tion, that tubercles were deposited in the cellular, that is the fila- 
 mentous tissue of the lungs. This opinion, which has been very 
 generally received without much question or inquiry, and is espous- 
 ed by Laennec, derives verisimilitude from the appearances pre- 
 sented on dissection of the lungs of phthisical persons, in which in 
 general it is impossible to distinguish anything but the tubercular 
 masses, imbedded as it were, in the parenchyma of the lungs. We 
 shall see, that, in order to obtain just views on this point, it is re- 
 quisite to examine lungs in which the diseased deposit is just be- 
 ginning, or not very far advanced, or very generally diffused 
 through the lungs. 
 
 2. Another opinion, originating in the idea that consumption 
 is a strumous distemper, and that strumous distempers are seated 
 in the lymphatic system, is that tubercles are morbid formations or 
 a degeneration of the lymphatic glands of the bronchi and lungs. 
 This opinion has been more or less strongly maintained by Portal, 
 Heberden, Broussais, and Nasse. “Upon dissecting the bodies 
 of consumptive persons,” says Heberden, “ I have seen the lung 
 crowded with swelled glands, some of which are inflamed, and some 
 suppurated or even burst.”* “ After the most attentive examina- 
 tion,” says Portal, “ I think that the tubercles constituting primary 
 consumption are formed both by enlargement of the lymphatic 
 glands distributed in almost all the parts of the lungs, or remote 
 from the bronchi, and also by lymphatic swellings of the cellular 
 tissue of the lungs, which, after becoming more or less indurated, 
 frequently end in bad suppuration.”! 
 
 The same doctrine has been not less explicity and forcibly taught 
 by Broussais in several of his writings ; and more recently by 
 Nasse.! 
 
 * Commentarii. London, 1782. 
 
 -f- Observations sur la Nature et le Traitement de la Phthisic Pulmonaire, Tome ii. 
 p. 309. 
 
 J Horn’s Archiv. 1824, Juli, Aug. p. 106, et apurf Rust Plandbueh der Chirurgie, 
 B. xvi. TuJjcrculosis, p. 439. 
 
MORBID STATES OF THE LUNGS. — TUBERCLES. 1015 
 
 The gi’eat objection under which this doctrine labours, is its be- 
 ing at variance with anatomical facts. The lymphatic bronchial 
 glands are situate chiefly round the ramifications of the bronchi ; 
 and though ' these glands are sometimes enlarged, and sometimes 
 infiltrated with tyromatous matter in young subjects, this change 
 is not uniformly or even often observed in pulmonary consumption. 
 The bronchial glands, further, may be affected by tyromatous de- 
 position, when the lungs are themselves either healthy, or at least 
 not affected by tubercular deposit. Lastly, in those instances in 
 which the bronchial glands are enlarged, indurated, infiltrated with 
 tyromatous matter, or softened into suppuration, along with tuber- 
 cular deposit, and tubercular excavations of the lungs, the former 
 can always be readily distinguished from the latter, by the peculiar 
 site which they occupy, and still more by their appearance, figure, 
 and other physical characters. It is chiefly in children that this 
 tyromatous enlargement, and transformation of the bronchial glands 
 is observed ; and in those cases in which the enlargement is asso- 
 ciated with tubercular disease of the lungs, dissection at once shows 
 the difference between the two lesions. The sections of the bron- 
 chial glands are large, homogeneous, circular, or elliptical, whitish, 
 or grayish coloured, or grayish-blue surfaces round the large bron- 
 chial tubes. The sections of the tubercular masses are irregular, 
 variable in consistence ; hard points and spots being mixed with 
 softer portions, and the colour gray-blue, or bluish-red, situate in 
 the substance of the pulmonic lobes and lobules. 
 
 As the affection of the lymphatic glands, therefore, is not ade- 
 quate to account for the morbid appearances presented by phthisi- 
 cal lungs. Portal admitted that tubercles might be seated in other 
 two textures. The first of these was in the lymphatic glands of the 
 lungs, properly so called, which are smaller than the bronchial 
 glands, more regularly rounded, and harder ; and these he con- 
 ceived became the seat of tubei’cular infiltration in certain forms of 
 consumption, in which the disease began by plethoric or inflamma- 
 tory symptoms. 
 
 The other texture in which he admitted that tubercles might 
 be formed, is the cellular or filamentous tissue around the lympha- 
 tic glands, that is, the parenchyma of the lungs, agreeing in this 
 respect with Stark and Baillie. This takes place, however, only 
 under particular circumstances. After adverting to the induration 
 of the lungs of phthisical persons, and their increased weight above 
 
1016 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the average, he states that this is owing to the extravasation of 
 glutinous matter (albuminous matter,) which, after filling the lym- 
 phatic glands and the lymphatic vessels terminating in them, is fur- 
 ther extravasated into the tissue of the lungs, and forms these tu- 
 bercles sometimes in infinite numbers. 
 
 Part of this doctrine seems to be well founded, and part of it is 
 perhaps open to objection. When it is admitted that tubercles 
 may arise from extravasation of albuminous matter into the sub- 
 stance of the lung, the exclusive deposition of these bodies in the 
 bronchial or lymphatic glands is virtually abandoned. The only 
 question is, whether this eflfusion is the effect of the preliminary 
 abundance of fluid in the glands and lymphatic vessels ; and whe- 
 ther this alleged extravasation, which forms tubercles in the fila- 
 mentous tissue of the lungs, may not take place without affection 
 of the glands, and does not take place, as Broussais seems to think, 
 previously to that affection of the glands. It is proper to add, that 
 M. Andral admits that this mode of the formation of tubercles in 
 the lungs, viz. by tubercular matter being deposited in the lympha- 
 tic ganglions of the interior of the lung, is not improbable.* 
 
 3. An opinion, which appears to be most consonant to the facts, 
 is that which was brought forward in 1821 by Magendie, and in 1826 
 by M. Schroeder, who fix the seat of tubercular deposition in the 
 extremities of the bronchial tubes, or in what are named the pul- 
 monic vesicles, in which the tubercles are deposited from the fine 
 mucous membrane in a state of inflammation. 
 
 According to Magendie, the fii’st indications of tubercular 
 phthisis consist in the deposit of a certain quantity of grayish-yel- 
 low matter, in one or more cells of the lung. The yellow matter 
 sometimes fills completely and distends the cells ; but it is easy to 
 perceive the small blood-vessels which circumscribe the matter de- 
 posited. In other instances the yellow matter is movable within 
 the cells, and may probably be expelled from them. 
 
 In some instances only one or two cells contain yellow matter ; 
 but most frequently it fills all the cells, forming a lobule. In this 
 case the matter adheres to the small vessels ; and these soon dis- 
 appear ; on which the whole lobule seems formed by yellow or tu- 
 bercular matter. 
 
 After opening numerous bodies, M. Magendie never saw in the 
 
 * Clinique Medicale, Partie iii. sect. iii. 
 
MORBID STATES OF THE LUNGS. — TUBERCLES. 1017 
 
 cells the small pearly granules which, according to certain authors, 
 are the first germs of phthisis. On the contrary, the matter first 
 seen is that named tubercular matter, which is presented as if 
 secreted by the walls of the small pulmonary blood-vessels.* 
 
 These views on the first origin of tubercular deposition, were 
 afterwards elaborated and illustrated by M. Schroeder and Dr 
 Carsewell; and they seem from various facts to he most pro- 
 bable. 
 
 In order to form a clear conception of the origin of the process 
 of tubercular deposition in the lungs, it is necessary to examine 
 these organs in the bodies of persons cut off by other diseases, and 
 in the earlier stages of consumption, when the disease has made 
 little progress. At this stage of the disease it is still uncomplicated 
 with mai'ks of general inflammation of the lung, or its component 
 tissues ; and at the worst there is merely topical change. 
 
 If in this state tubercles he divided and inspected by the aid of 
 the microscope, it then appears that the air-cells of the lungs are 
 filled with some opaque material, which renders them less pellucid, 
 the nearer the eye is directed to the edge of the tubercles. The 
 cells filled with pellucid coagulable lymph are harder than the 
 neighbouring sound cells, and do not admit the air, as easily ap- 
 pears by slight pressure in water. This lymph contained in the 
 cells is sometimes so limpid, that the tubercle can scarcely be dis- 
 tinguished by the eye from the sound structure of the lung, and 
 requires the aid of touch. 
 
 In other spots, however, the centre of the tubercle is already 
 white, and losing its transparency, has become opaque ; so that by 
 the aid of the microscope, in the centre of the cell little or nothing 
 can be distinguished, and their parietes appear united with the 
 matter of the tubercle, while the adjoining cells still contain trans- 
 parent matter. From this fact the author infers, in opposition to 
 the representation of Laennec and Lorinzer, that in certain air-cells, 
 or in a lobule of the lung, local inflammation may be developed, 
 and produce effusion of lymph which obstructs the air-cells. 
 
 As this exudation proceeds, the walls of the cells are at length 
 compressed on all sides, and not only unite with the contained 
 lymph ; but, as the effusion hardens and becomes opaque princi- 
 
 * Memoire sur la structure du poumon de Phoinme, &c. &c., et sur la premiere ori- 
 gine de la phthisie pulmonaire ; par M. Magendie. Journal de Physiologie, Tome 
 I. p. 78. Paris, 1821. 
 
1018 
 
 GENERAL AND rATHOLOGICAL ANATOMY. 
 
 pally from the centre to the circumference, a mass of lung thus 
 occupied becomes solid and granular in the centre, and softer at 
 its margins. 
 
 The shape of the tubercular mass thus formed depends on the 
 sti’ucture of the lung, — a circumstance on which authors have not 
 bestowed sufficient attention. The lobes of the lungs consist of 
 lobules united by cellular tissue ; and each lobule receives a sepa- 
 rate bronchial tube, which terminates in many air-cells, all pervious 
 to air, — and a peculiar artery and vein, each subdivided into many 
 minute vessels, all penetrable by injected fluids in the sound state. It 
 hence results that the beginning of tubercular deposition is confined 
 at first to one lobule only, without affecting the contiguous lobules, 
 and is recognized only by the greater opacity and firmness of that 
 lobule than of the healthy ones. It is also found, by injecting the 
 arteries and veins of the lung, that some lobules are less penetrated 
 with this tubercular deposition than others, the vessels of the for- 
 mer being more susceptible of injection, while those of the latter 
 are few in number and less penetrable by injection, and diminish 
 in this manner in number and susceptibility of injection, till in the 
 truly and perfectly tuberculated lobule the small vessels are com- 
 pletely shut and obliterated, and the large one only remains per- 
 vious. In such lobules the structure of the lung can no longer be 
 traced ; the shape of the air-cells is destroyed ; and in the centre 
 of these tuberculated lobules, which is hollow, suppuration has 
 commenced. Such tuberculated lobules are whiter than the ad- 
 joining ones, and are surrounded by thick cellular tissue separating 
 them from the adjoining lobules, which may at this stage of the 
 disease be less affected. Very soon, however, the air-cells of these 
 lobules become penetrated by the same deposition, which in like 
 manner becomes opaque and firm, and agglutinates the cells into a 
 similar firm, inelastic mass, also surrounded by indurated filamen- 
 tous tissue. When at length several lobules have in this manner 
 become penetrated and occupied by tubercular deposition, with the 
 suppurative destruction proceeding in their respective centres, the 
 coalescence into a single undistinguishable mass is followed by the 
 union of their i*espective minute cavities into one or more larger 
 ones. In the course of this process, the cellular, or rather what 
 I term the filamentous, tissue of the lung being placed outside the 
 penetrated cells, naturally resists longest the suppurative process, 
 
 and may even become thickened and indurated. At length, how- 
 
 6 
 
MORBID STATES OF THE LUNGS. — TUBERCLES. 1019 
 
 ever, this also may give way, and be destroyed partially or entirely; 
 and hence appears the reason why some anatomists maintain that 
 the tubercle or small vomica is surrounded by a membrane, while 
 by others this is denied. 
 
 From this account of the progressive formation of tubercles, it 
 results that not only the air-cells are filled, and then obliterated by 
 the exudation of coagulable lymph, but that the areas of the blood- 
 vessels are so contracted, that they no longer admit the wax of in- 
 jection, and become obliterated, and incapable of receiving and 
 conveying blood to the ultimate terminations ; and hence the cen- 
 tre of the tubercle wastes, and is consumed and degenerated ; and 
 that the vessels, still pervious, assuming the inflammatory action, 
 secrete purulent matter, which dissolves the tubercle already soft- 
 ened and macerated. M. Schroeder van der Kolk further regards 
 this deposition as coagulable lymph, because by immersion in spirit 
 it is coagulated and rendered opaque ; and he therefore contends 
 that it is impossible to adopt the view of Laennec and Lorinzer, 
 or Nasse, that tubercles are formed without previous inflammation. 
 The argument also adduced by the latter author, that tubercular 
 deposition takes place generally in the upper lobe of the lung, 
 whereas peripneumony occurs more frequently in the lower one, 
 he thinks of no moment. He admits the fact, but maintains that 
 it merely shows that tubercular deposition and the consequent vo- 
 miccB diflPer from peripneumony, and that chronic inflammation dif- 
 fers from the acute form of the disease. 
 
 The question regarding the origin of tubercles from degenerated 
 bronchial glands, he allows to be more difficult of decision, — from 
 the fact, that frequently degeneration and inflammation of the 
 glands of the neck, or some other part, precede the appearance of 
 consumption, and that strumous persons are very liable to the dis- 
 ease. He observes, however, that in examining carefully the bo- 
 dies of the strumous, when the vessels were filled with fine injection, 
 he found very minute tubercles occupied in different points by con- 
 cretions, and in general calcareous rather than tubercular matter 
 deposited. In examining such lungs microscopically, he found the 
 minute branches of the bronchial tubes, at least to one-fourth of a 
 line in diameter, everywhere reddened within by injected vessels, 
 and a beautiful net-work expanded on the internal mucous mem- 
 brane ; in some of the minute branches, he saw the smaller glands 
 thick and somewhat whiter ; the miliary tubercles were surrounded 
 
1020 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 by a net-work of vessels, in which he could distinguish the air-cells 
 still open. These tubercles generally adhered externally to the 
 branches of the bronchial tubes, or to the pulmonary arteries and 
 veins ; in some cases a small bronchial tube seemed to end in a 
 tubercle. Externally the pulmonic pleura was marked by black 
 round lines like rings, which appeared to be lymphatic vessels. 
 Where the degeneration was a little greater, the cells were oblite- 
 rated, and the tubercles, the vessels of which were impervious, ap- 
 peared to have coalesced into a whitish mass. 
 
 This author doubts, nevertheless, whether these bodies, which he 
 denominates miliary tubercles, were not obliterated vessels, which, 
 when cut across, presented the appearance, but had not the reality 
 of tubercles, the more so, that these tubercles could be traced 
 through the lungs in the direction of ramification. He further ex- 
 presses the opinion, that these tubercles are first formed by thicken- 
 ing, and inflammatory degeneration of lymphatic glands, and that 
 this is the reason why they present a different appearance from that 
 of the ordinary tubercles of the air-cells already described, — since 
 they seem to adhere most to the small bronchial tubes. 
 
 As to the origin of the calcareous matter, he does not admit that 
 these concretions can be formed by the inhalation of dust or sand, 
 since their structure is too complex, and the opinion is sufficiently 
 refuted by analysis ; but he thinks, that the surrounding membrane, 
 whether that of a gland, or an air-cell, had so degenerated by in- 
 flammation as to assume the fibrous character, and the faculty of osse- 
 ous or calcareous secretion. 
 
 He infers, therefore, that the lungs present two kinds of tu- 
 bercles ; one produced by chronic inflammation of the air-cells, by 
 which their membrane is made to secrete lymph, which fills and 
 unites them into a mass ; the other more calcareous, produced ap- 
 parently by degeneration of the minute glands ; but both agreeing 
 in inducing inflammation of the adjoining air-cells, and vomicae. 
 The suppuration which produces the latter change, and which com- 
 mences most frequently in the centre, though sometimes in the side 
 of the tubercle, presents this peculiar difference from common sup- 
 puration, or that which takes place in wounds, that whereas in the 
 latter granulations are formed by which the cavity is filled, in the 
 former no granulations take place, because no new vessels are 
 formed ; and as the vessels are obstructed and convey no new 
 matter, the tubercular mass is softened by a species of partial death. 
 When this suppurative destruction begins, it proceeds in general 
 
MORBID STATES OF THE LUNGS. — TUBERCLES. 
 
 1021 
 
 till the tubercular mass is broken down and excavated ; and it is 
 much less common to find a tubercle partly dissolved than entire, 
 or a small vomica^ after the tubercle has been destroyed by sup- 
 puration. In this state the vomica is lined by a thin vascular 
 membrane, sometimes by a thick yellowish one ; and if small, it is 
 rarely traversed by any vessel ; but this is not unusual in large 
 vomiccs. The author also observes, that these tubercular masses 
 afford, in the process of softening, an illustration of the general 
 principle formerly laid down, that every inflamed part and ulcer 
 presents at the same time different degrees of inflammation. The 
 centre of the tubercle may be dead or expelled after the process 
 of solution ; its crust may be in a state of suppurative softening ; 
 the circumference may be inflamed ; and this process diminishes in 
 the parts of the lung farthest removed from the margin of the air- 
 cells. 
 
 In the manner now mentioned, the cavity of a vomica is progres- 
 sively enlarged, until in desperate cases of consumption the patient 
 sinks under the disease. The extent to which the lung is destroyed 
 before this event takes place, varies according to the age of the 
 parties. 
 
 Similar views of the mode in which tubercles are originally de- 
 posited in the lungs have been taken by M. Andral, Dr Carsewell, 
 M. Ravin,* and other pathologists. The bronchial tubes terminate 
 in shut sacs, lined by a fine mucous membrane, and enclosed by the 
 submucous or filamentous tissue. This fine mucous membrane is 
 liable to various forms of inflammation, in which it secretes a fluid 
 or semifluid matter which contains much albumen, and conse- 
 quently is liable to undergo spontaneous coagulation. This has 
 been sometimes named strumous matter, glutinous matter, (Portal,) 
 plastic lymph, (Schroeder,) coagulable lymph, purulent matter of 
 particular nature, (Lerminier and Andi’al,) and tubercular matter. 
 None of these denominations convey a just notion of the object; 
 and the latter is objectionable, because it is applied indiscrimi- 
 nately to several kinds of morbid texture, different both in nature 
 and in form. But it is sufiicient to know that the mucous mem- 
 brane of these bronchial terminations or vesicles is liable to a kind 
 or form of inflammation, which is perhaps peculiar, and that in this 
 state it secretes matter, which, though at first fluid, afterwards be- 
 
 • Memoire sur les Tubercules, pour repondre a la question proposee par I’Academie 
 Royale de Medecine dans 28 Aout 1827. Par F. P. Ravin, D. M., &c. Memoires 
 de I’Academie Royale de Medecine, Tome IV. Paris 1835, p. 324. 
 
1022 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 comes solid, filling up and obstructing the terminations of the tubes. 
 As the matters effused become solid, they naturally assume the 
 rounded or oblong-rounded form of the pulmonic vesicles ; and in 
 this state, as they are small, firm, rounded bodies, harder than the 
 neighbouring parts, and giving them a knotty appearance, they are 
 tubercles {tuhercula), or little tuberosities. 
 
 That this is one and perhaps the most usual mode in which 
 tubercles are formed, must be regarded as established by the accu- 
 rate and beautiful delineations of Dr Carsewell, who has repre- 
 sented the tubercular matter, as he terms it, when deposited on the 
 free surface of the bronchial mucous membrane, at the extre- 
 mities of the bronchial tubes. Andral manifestly takes the same 
 view of one of the modes in which pulmonary tubercles may be 
 formed. 
 
 Frederic Peter Ludovic Cerutti, who published in 1839 a short 
 but learned dissertation on the subject, states, that after repeated 
 observations, he had not been able to satisfy himself of the facts 
 adduced by Schroeder ; but allows it to be proved that the cells 
 of the lung in those parts becoming occupied by tubercular matter, 
 and which differ from healthy cells, in presenting a different colour, 
 contain no air, because not only individual portions of lung sink in 
 water, but also a whole lobe, which still fresh, on being immersed 
 in w'ater, sunk more than one-half, immediately after being inflated 
 by air, rose to the surface. 
 
 From this fact, he is convinced that tubercles in their origin 
 consist of a fluid exudation, which moistens the walls of the pulmonic 
 cells, which, he argues, are mutually compressed by the increased 
 weight caused by this humidity, to such a degree only, that though 
 the inspired air is unable to enter them, they may nevertheless be 
 expanded by artificial inflation.* 
 
 In the first commencement of this distemper, the colour of the 
 affected portion of the lung only is changed ; and as yet the secreted 
 matter is probably soft and semifluid, or at least not very firm. 
 But after some time, when the effused matter has acquired consis- 
 tence, and become a little firm, the part is felt between the fingers as 
 if it contained several hard knots. These are granular or graniform 
 bodies within the air cells, filling, distending, and preventing them 
 
 * Collectanea quaedam de Phthisi Pulmonum tuberculosa scripsit et in Uiiiversi- 
 tate Lipsiae in die xviii. .Tunii A. C. 1839, publice defendet, Dr Frid. Petrus Ludovi- 
 cus Cerutti, Pathologi® et Therapiae Specialis, P. P. 0. Des. Lipsiae, 183.9. 4to, 
 
 p. 22. 
 
MORBID STATES OF THE LUNGS.— TUBERCLES. 1023 
 
 from collapsing. The size of these bodies in this stage is about 
 that of a pin-head, rising to a millet-seed or a grain of mustard- 
 seed. These bodies, now described, have been, in this state, re- 
 garded as the miliary tubercles of Bayle and Laennec, the dissemi- 
 nated tubercles of Gendrin, and the simple tubercles of Dr Lombard 
 and Dr Home. But this does not appear to be established with 
 unquestionable certainty. One variety, at least, of the miliary 
 tubercle, I am inclined to think, is formed in the filamentous tissue 
 of the lungs ; and certainly differs widely from the arrangement 
 and appearance of the bodies now mentioned. 
 
 A good method of demonstrating the origin of the most usual 
 forms of pulmonary tubercles, is by observing what takes place in 
 lobular pneumonia. In this disease inflammation attacks the lung 
 in individual lobules, perhaps beginning first like vesicular hron- 
 cJiitis, that is, affecting the terminations of the bronchial tubes, and 
 the air cells, and perhaps in a slight degree the submucous fila- 
 mentous tissue, or the parenchyma of the lung in which these vesi- 
 cles are imbedded. The result of this inflammation is effusion 
 within the vesicles of a species of soft semifluid matter, intermediate 
 between albumen and gelatine, but which undergoes coagulation, 
 and thereby fills the vesicles with an equal number of small round- 
 ish bodies, of moderate consistence, but which eventually become 
 firm, and at length hard, while their mutual proximity aggregates 
 them together into small hard masses, isolated, and limited to each 
 pulmonary lobule, or part only of a lobule. As the disease proceeds, 
 it affects the whole lobule, and its investing tissue or capsule, giv- 
 ing it the appearance of a hard knotty mass, irregular in shape and 
 figure, and surrounded by natural pulmonic tissue. This disease 
 may either affect one or two, or many lobules simultaneously and 
 successively ; and in proportion to the extent over which it is dif- 
 fused, the lung is occupied by bodies having all the characters of 
 tubercles, and which eventually constitute pulmonary tubercles. 
 
 In this state, these masses, when divided, are firm, of a bluish- 
 gray colour, and consist of minute portions aggregated together, 
 in a confused manner, so as to form a mass not quite homogeneous, 
 but firmer than the surrounding lung. In this state, before these 
 masses have become softened, they constitute what has been named 
 by Laennec crude or yellowish tubercles {tuber cula cruda)^ ^^gglo- 
 merated tubercle by Gendrin, multiple tubercle by Lombard, and 
 aggregated tubercle by Dr Home. These masses vary in size. 
 
1024 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 from that of a garden pea or a cherry-stone, to that of a walnut or 
 even larger. Though the surrounding lung may be sound, yet 
 the portions of lung which previously were in the place of these 
 tubercular masses are completely solidified; and hence neither 
 bronchial tubes nor blood-vessels are traced into them. 
 
 Another lesion, which has been believed to form a certain stage 
 of this process of the conversion of isolated or simple tubercles 
 into aggregated tubercles, is that which has been named gray, 
 semitransparent granulations, and which, indeed, are the miliary 
 or cartilaginous tubercles of Bayle. It is certain, both from the 
 researches of Dr Carsewell, Andral, and Cerutti, that they may 
 exist in the lungs without giving rise to the peculiar structure 
 already described as tubercular. They are generally isolated, very 
 seldom aggregated, disseminated or dispersed through the lungs 
 almost indiscriminately ; and it is very doubtful whether, if they be 
 formed in the air-cells, they are always formed in them. 
 
 Andral regards these gray granulations as indurated and hyper- 
 trophied air cells. I have several times observed them in the fila- 
 mentous tissue of the lung, in such circumstances that I thought it 
 scarcely possible for them to be formed in the cells. In some in- 
 stances they appear like transformation of certain portions of the 
 lymphatic vessels or glands of the lungs. They are occasionally 
 observed in tbe lungs of quarry-men, stone-cutters, and hewing- 
 masons. 
 
 In certain cases, however, of this sort of lesion, it has been as- 
 certained that these gray, semitransparent, hard tubercles are de- 
 posited originally in the pulmonic vesicles. Thus, Dr Home men- 
 tions that a specimen of this kind of tubercle, occurring in a bew- 
 ing-mason, was presented in 1838 to the Anatomical Society, in 
 which it was found that in the centre of each tubercle was contained 
 a grain of sand or earthy matter, ascertained to consist of silica and 
 carbonate of lime, and which had no doubt been inhaled, and gave 
 rise, by mechanical irritation, to chronic inflammation in the ends 
 of the bronchial tubes. 
 
 A third lesion, which has been sometimes rather vaguely called 
 tubercular, is what may be termed gray hepatization, occurring in 
 definite masses, or circumscribed gray hepatization, or, what might 
 be less objectionable, circumscribed tyromatous deposition. 
 
 In this state, a portion of lung, more or less extensive, becomes 
 tbe seat of considerable induration and solidification ; and when a 
 
MORBID STATES OF THE LUNGS. — TUBERCLES. 1025 
 
 portion thus affected is divided, it is observed to consist of various 
 minute, gray-coloured, firm bodies or grains aggregated together, 
 and which give the section a gray or light-yellow colour, and a 
 granular aspect. There is no doubt that this change in the con- 
 sistence and appearance of the lung is the effect of inflammation, 
 acute, subacute, or chronic ; but it is not quite certain that the pre- 
 sence of this state is a necessary step in the formation of tubercles. 
 This change may probably take place in any part of the lung ; but 
 the situations in which I have most usually seen it are the upper 
 lobe near its apex, and sometimes the middle lobe of the right side. 
 This has been observed by Baillie, and is described by Laennec, 
 under the name of tubercular infiltration, and by Dr Home under 
 the name of diffuse tubercle. 
 
 In this form of the disorder, the morbid deposition does not be- 
 gin in the air-cells exclusively, as in the first described, but affects 
 all the elementary tissues of the luug by lobules, at once in one uni- 
 form disorder ; and it gives rise to extravasation of albuminous or 
 tyromatous matter, over the whole space which it affects, but effused 
 into the cells and filamentous tissue, and compressing and thereby 
 obliterating the air vesicles, the tubes, and the blood-vessels all at 
 once. Often also the surrounding tissue of the lobule is converted 
 into a sort of membrane or capsule, so that the tyromatous deposit 
 appears as it were encysted. The size which these masses acquire, 
 varies from that of a small gooseberry to a large one or more. 
 When divided, besides the yellow or gray colour already mentioned, 
 they present a much more uniform or homogeneous aspect than the 
 other forms of tubercular deposit. 
 
 The state of the surrounding lung, though often congested or 
 reddened, varies much both in these different forms of deposition 
 and also in different stages of its progress. In the early stage, or 
 that of crudity, the substance of the lung around may be crepitat- 
 ing, elastic, and compressible ; and even in the advanced stage, 
 some observers have found the lung interposed and surrounding, 
 free from induration or much redness. Thus Baillie and Soemmer- 
 ing found the substance of the lung surrounding considerable tu- 
 bercular masses healthy ; and Laennec and Louis appear to have 
 observed the same fact. Much more frequently, however, there 
 are more or less reddening, vascular congestion, and infiltration of 
 serum into the substance of the lung ; and in a considerable num- 
 ber of cases I have observed pneumonic inflammation either in its 
 first or in its second stage. 
 
 3 T 
 
1026 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 In the case of the isolated tubercular infiltration, chronic pneu- 
 monia is very common. At least in the cases of that form which 
 have fallen under my own observation, I have observed, that symp- 
 toms altogether like those of pneumonia or peripneumony took 
 place during life, and, upon inspection after death, the usual ap- 
 pearances left by inflammation of tbe substance of the lung were 
 found.* These tubercles, indeed, do not appear readily to under- 
 go the process of softening, and most usually prove fatal either by 
 being complicated with or inducing pneumonic inflammation. 
 
 It may be here mentioned, that, both in simple red or brown and 
 gray consolidation, and when these changes are accompanied by 
 the presence of tubercles, fat-globules and adipose particles may be 
 recognized. 
 
 The manner in which tubercular masses are softened or broken 
 down and discharged, or what may be termed tbe mechanism of 
 tubercular softening and excavation, has attracted some notice, 
 and deserves consideration. At one time, it was imagined to be 
 either identical with, or analogous to, suppuration in other tissues; 
 and it was supposed that tubercular vomica were merely abscesses 
 of the lungs. But the process, though perhaps analogous to, is not 
 the same with suppuration. It seems to be more complicated, and 
 not so uniform in its progress. It seems to be difficult to ascertain 
 at what part softening commences. In one case it may begin in 
 the centre, and proceed to the circumference ; in another it may 
 begin at tbe circumference, and go round the whole mass, detach- 
 ing it from the surrounding lung ; in a third case it may begin at 
 once at the centre, and at the margins ; and, in other cases, it has 
 been observed to commence at the same time in several parts of the 
 substance of the tubercular mass. The latter is tbe course, especi- 
 ally in the case of large tubercular masses. Cerutti,f who enter- 
 tains this opinion, states that, in the section of a tubercular mass 
 in this state, the portion or spots about to be softened appear to 
 lose firmness and to become friable, and, if examined by the mi- 
 croscope, they present numerous minute holes, as if punctured by a 
 needle. This condition extends over the -whole mass, until its 
 parts are detached from each other ; and minute grains are found 
 amidst a semifluid or fluid opaque mass. While this is proceeding, 
 
 * Two Cases of Tubercular Deposition, &c. By D. Craigie, M.D. Edin. Med. and 
 Surg. Journal, Vol. xliii. jr. 273. 
 
 -j- Collectanea quaedam de Phthisi Pulmonum tubereulosa scripsit et in Universitate 
 Lipsiae in die xviii. Junii A. C. 1839, publice defendet, Dr Frid. Petrus Ludovicus 
 Cerutti, Pathologiae et Therapiae Specialis, P. P. O. Des. Lipsiae, 1839, 4to, p. 22. 
 
MORBID STATES OF THE LUNGS IN CONSUMPTION. 1027 
 
 a communication is established with one or more bronchial tubes, 
 the small end of which are destroyed or dissolved in the soften- 
 ing process, and the semifluid matter reaching them irritates them, 
 causing secondary catarrh, and excites coughing, hy which it is ex- 
 pelled. The transition of this semifluid matter through the bron- 
 chial tubes is the cause of the redness and villous appearance of the 
 mucous membrane of the bronchial tubes, so generally observed in 
 the lungs of those destroyed by this distemper. 
 
 On the means by which this softening is effected, different opini- 
 ons have been entertained. An opinion very generally received is, 
 that the tubercular masses, acting in some manner as foreign bodies, 
 give rise to irritation and vascular action in their vicinity, and 
 thereby induce a sort of congestive and inflammatory afflux of fluids, 
 in which they are dissolved in imperfect suppuration. This opinion 
 is supported by those facts which show that tubercles begin to sof- 
 ten near the circumference of the masses. 
 
 Many tubercular masses, nevertheless, seem to possess an inter- 
 nal and innate tendency to destruction. Their texture is imperfect ;* 
 and in some instances the internal substance begins to soften, ap- 
 parently whether any irritation of the surrounding lung has taken 
 place or not. There is no doubt that, in a considerable proportion 
 of cases, the presence of the irritation of severe bronchitis or peripneu- 
 mony appears to have pushed the tubercular masses into speedy li- 
 quefaction ; and the frequency with which the symptoms of pneu- 
 monic inflammation are succeeded by those of consumption, shows 
 that in the formation of softening at least, if not in the develop- 
 ment of tubercular deposits, inflammatory congestion has great 
 influence. 
 
 As softening proceeds, whether it has been attended with pneu- 
 monic inflammation or not, it is speedily followed by that, and by 
 bronchial inflammation, the latter being chiefly induced and main- 
 tained by the incessant irritation kept up by the transition over the 
 membrane of the contents of the tubercular softening. If the tu- 
 bercular mass be large, or if the degree of pneumonic inflammation 
 be considerable, it affects a third membrane, viz. the pleura. In 
 all cases, indeed, in proportion to the size of tubercular mass, and 
 the consequent excavation to be formed, and as that advances from 
 the substance to the surface of the lungs, pleurisy takes place. The 
 
 * See p. 1012. 
 
1208 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 great use of this inflammation, or what may be termed its final 
 cause, in the softening and expulsion of tubercular masses, is, by 
 the effusion of lymph and the formation of adhesions between the 
 pulmonic and costal pleura, to prevent perforation of the lung, the 
 escape of air and tubercular matter into the cavity of the pleura 
 {pneumothorax, and empyema), and the consequent formation of 
 pleurisy complicated with pneumothorax, — a lesion generally fatal. 
 By the slow and gradually advancing inflammation of the pleura, 
 and the consequent albuminous exudation and adhesion, this acci- 
 dent is prevented. This is so common, that in one case only among 
 112 were the lungs free of adhesions. 
 
 It, nevertheless, sometimes happens that this accident takes 
 place. The apex of the lung, I have already said, is very gene- 
 rally covered all round with a thick, cartilaginous coat of false 
 membrane, uniting it to the interior of the thoracic walls ; and any 
 cavity formed in this region is thus prevented from opening into 
 the pleura, and the general cavity. But if in the lower region of 
 the lower lobe, any large tubercular mass is softened and expelled, 
 and leaves a considerable cavity, verging towards the pectoral and 
 axillary regions, it occasionally happens that adhesion has not taken 
 place there, and that the walls of the cavity, already extenuated to 
 an extreme degree, give way, or are perforated, especially during 
 a fit of coughing, air and once tubercular matter escape into the 
 pleural cavity, and there produce first collapse of the lung, and 
 then pleuritic inflammation. Among 112 cases observed by Louis, 
 perforation was known to take place in eight cases, and in seven of 
 these it took place on the left side. Among 100 cases recorded in 
 the Royal Infirmary Report, perforation took place in six, in three 
 on the right side, and in three on the left. Since the publication 
 of that report, I have met with two cases of perforation, among 
 eighteen cases inspected under my own care ; and in one case, per- 
 foration took place in the left side, in the lower part of the supe- 
 rior lobe, and another in the middle lobe of the right side. 
 
 Morbid Anatomy of the appendages of the Lungs and 
 THE OTHER ORGANS. — Besides the state of the lungs above de- 
 scribed, the trachea, larynx, and epiglottis are liable to present 
 various lesions. The membrane of the epiglottis is always redden- 
 ed, and sometimes softened ; and the whole laryngeal and tracheal 
 membrane is reddened and softened, or rendered flaccid. Ulcers 
 also, various in size and shape, may be formed in these parts. 
 
MORBID STATES OF OTHER ORGANS IN CONSUMPTION. 1029 
 
 Among 102 cases examined by Louis, ulcers of the epiglottis were 
 found in eighteen cases (one-sixth), ulcers of the larynx in twenty- 
 two cases (one-fifth), and ulcers of the trachea in thirty-one cases 
 (one-third). 
 
 Most of the ulcers of the epiglottis are confined to the lower or 
 laryngeal surface of that cartilage. The ulcers are generally small, 
 one, two, or three lines in diameter. They are more common in 
 males than in females. 
 
 The most frequent seat of ulcers of the larynx is the junction of 
 the vocal chords ; then the vocal chords themselves, especially their 
 posterior part; and lastly, the base of the arytenoid cartilages ; the 
 upper part of the larynx, and the interior of the ventricles. In 
 some rare cases one or more of the vocal chords are denuded or 
 destroyed, and the base of the arytenoid cartilages exposed. 
 
 Ulcers of the trachea, sometimes very large, are found chiefly in 
 the posterior or fleshy part of the canal, and are attended with a 
 red colour, more or less deep, of the contiguous mucous membrane, 
 and some softening and thickening. In rare cases, the ulceration 
 spreads so much as to denude or destroy more or less completely 
 several of the cartilaginous rings ; and in that case the ulcerated 
 ends of the rings give the margins of the ulcer a peculiar, irregu- 
 lar, and denticulated appearance. 
 
 The only general result that can be established regarding the 
 heart is, that it is rendered smaller and softer than usual, or is 
 atrophied. 
 
 Mr Abernethy found that, in severe cases of pulmonary con- 
 sumption, in which the lungs were much occupied by tubercular 
 masses, by injecting the arteries and veins of the heart, the injec- 
 tion readily flowed into the chambers of the organ, and that the 
 left ventricle was first and most completely filled. He found that 
 the channels of this injection were the foramina ThehesH, which, 
 though in the natural state few and small, becomes numerous and 
 large in disease of the lungs, especially tubercular induration, 
 which impedes the circulation of the pulmonary artery, and thereby 
 distends and gorges the right chambers of the heart Mr Aber- 
 nethy also found ih^foramen ovale more or less open in the hearts 
 of persons destroyed by pulmonai’y consumption.* 
 
 In about from one-tenth to one-fifth of cases of consumption, the 
 
 * OBservations on the Ff/rainina Thehesii of the Heart. By John Abernethy, 
 F .K.S. Phil. Trans. 1708. Part I. p. ID. 
 
1030 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 stomach is enlarged or distended to two or three times its usual 
 bulk. The mucous membrane of the organ is very generally in an 
 unhealthy state, either wholly or partially. It may be in the splenic 
 end softer and thinner than natural, with a bluish-white or yellow- 
 ish colour. This takes place in one-fifth. 
 
 The same part may be reddened or softened. In about one-fifth 
 the mucous membrane of the anterior coat is red, thickened, and 
 softened, — generally in connection with enlargement of the liver. 
 Ulcers, prominences, and granulations, are found in a smaller pro- 
 portion of cases. Most of these lesions are to be viewed as the 
 effect of some form of inflammation ; and it is established that, in 
 the phthisical, irritation or inflammation of the gastric mucous 
 membrane is very readily induced. 
 
 By far the most constant lesion in the alimentary canal of the 
 phthisical, consists in some change in the mucous membrane of the 
 ileum or of the colon. 
 
 The most common lesion in the former is the presence of ulcers, 
 which are observed in five-sixths of the cases. In one-sixth they 
 occupy the whole tract of the intestine ; and in the other two-ninths 
 they are found only at the lower part of the ileum. These ulcers 
 always correspond to the aggregated glands of Peyer, in which they 
 begin ; but as the disease proceeds, if life be protracted, they ex- 
 tend to the mucous membrane in general, and thus are found to 
 occupy the greater part or the whole circumference of the bowel. 
 Their shape is elliptical, annular, or linear. In general, at the 
 commencement, they appear in one or two points, that is, in one or 
 two follicles of one of the aggregated glands. In the advanced 
 stage of the disease, several of these coalescing may form a large 
 and extensive ulcer. The latter is mostly seen at the lower end of 
 the ileum, where that bowel enters the colon. In some instances, 
 these ulcers may commence in the isolated follicles ; but this is not 
 common. 
 
 A lesion less frequent is the presence of granulations, semicar- 
 tilaginous or tubercular, in the ileum. These lesions, which appear 
 to be seated in the isolated follicles of the bowel, and which consist 
 in tubercular degeneration of the follicles, take place in three- 
 eighths of the cases. 
 
 Much in the same manner, and at the same rate, is the mucous 
 membrane of the colon liable to be diseased. It is reddened either 
 continuously or in patches. The most common lesion is the pre- 
 
MORBID STATES OF OTHER ORGANS IN CONSUMPTION. 1031 
 
 sence of ulcers, which are formed in from eight-elevenths to seven- 
 ninths, or about nine-twelfths. They may be large, middle-sized, 
 or small. The most common situations are the caecum, the ascend- 
 ing colon, the transverse arch, and the rectum, in the order now 
 specified. When the caecum is affected, the ulceration is often ex- 
 tensive, being associated with ulcers or ulceration of the lower end 
 of the ileum, the ileo-caecal valve, which is often stripped of its mu- 
 cous membrane, or altogether destroyed, and over the whole inner 
 surface of the caecum. In the ascending colon and transverse arch, 
 the ulcers present the appearance of broad flatfish patches, the 
 largest diameter being across the intestine, the converse of what is 
 observed in the ileum. These ulcers may commence in the mucous 
 follicles of the colon ; but they eventually pass to the mucous mem- 
 brane in general. 
 
 Tubercular granulations are found in the colon in a smaller 
 proportion of cases. 
 
 Of these ulcers or ulcerated patches it is a pretty general result, 
 that, as they destroy the mucous membrane, and advance through 
 the subjacent coats to the peritoneum, they cause in the latter in- 
 flammation in minute isolated points or spots, followed by eflfusion 
 of albuminous fluid, which coagulates and adheres in an equal 
 number of minute points, opaque, elevated, and generally isolated, 
 but touching each other, so as to form a rough patch, circular or 
 oval in shape. In this state, these small whitish opaque bodies pre- 
 sent the appearance of tubercular specks, and are hence called by 
 many authors tubercles of the peritonaeum. Whatever be the name 
 applied to them, they are formed in the mode now mentioned. 
 
 The final cause of this peritoneal inflammation is to counteract 
 ulcerative perforation, and to thicken and strengthen the bowel. 
 In some rare cases, however, this object is defeated, and the ulcer- 
 ation destroys all the textures, and the -peritoneum suddenly gives 
 way, allowing the escape of air and the intestinal contents into the 
 abdomen, and causing sudden fatal peritonitis. This accident is, 
 however, not very common. One example only have I met with 
 among nearly one hundred instances of fatal consumption. 
 
 In other instances, effusion of sero-purulent or purulent fluid is 
 found in the peritoneum, and soft coagulable lymph between the 
 intestinal folds, showing that it must have been inflamed during 
 life. 
 
 In the bodies of the phthisical the liver is very generally in a 
 
1032 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 morbid state. The most frequent change in this country is that 
 of kirrhosis, with more or less enlargement and induration, in which 
 sections of the gland show it to have a peculiar yellow colour, with 
 a darker hue of the acini. This fakes place in rather more than 
 one-third of the cases. The most common change in France ap- 
 pears to be the adipescent transformation of the organ which occurs 
 in one-third of the cases. In this the organ is pale, fawn-coloured, 
 more or less tender and friable, chequered with red outside as 
 w'ell as within. The bulk of the organ is always increased, some- 
 times to the amount of twice its usual dimensions. In this coun- 
 try, this change does not take place in so many as one-sixth of the 
 cases. The former lesion is most common among males ; the lat- 
 ter among females. 
 
 The brain is very generally slightly softer than natural. The 
 membranes are injected ; and fluid is effused beneath the arachnoid 
 membrane and within the ventricles. 
 
 Tubercular deposits or tyromatous matter, fluid or semifluid, or 
 solid, are found in various other organs besides the lungs. Thus 
 the ileum and the colon are said to become the seat of this deposit ; 
 but perhaps it is rather the albuminous effusion in the granular 
 shape, than real tyromatous matter, which has received this cha- 
 racter. The deposit, however, is found in the mesenteric glands, 
 the cervical lymphatic glands, the lumbar glands, the prostate, the 
 spleen, ovaries, kidneys, womb, brain, and cerebellum.^ in the order 
 now mentioned. 
 
 The usual termination of the lesions of the lungs above described 
 is in death. As the contents of the tubercular masses are softened 
 and expelled into the bronchial tubes, they cause in these and in 
 the windpipe and lungs most violent irritation and inflammation, 
 with consequent copious secretion of puriform mucus, which is 
 mingled and spit up with the proper tubercular matter. As this 
 process advances with several tubercular masses simultaneously and 
 successively, very general bronchitic and tracheal inflammation is 
 induced ; and at the same time with them symptoms of peripneu- 
 mony and pleurisy may be combined from the causes already spe- 
 cified. In this state of matters, the function of respiration is 
 gradually confined in its extent and effect, until it is nearly anni- 
 hilated, when perhaps not more than one-fourth, or, in some cases, 
 one-sixth, or one-tenth of the lungs is left permeable to air and 
 
 blood. Death then ensues, partly as the effect of the exhaustion 
 
 4 
 
MORBID STATES OF TEE LUNGS IN CONSUMPTION. 
 
 1033 
 
 from constant tracheo-bronchial irritation, partly as the effect of 
 exhaustion from annihilated respiration. 
 
 Notwithstanding the frequency of this as the usual termination 
 of the process of tubercular destruction, softening, and excavation, 
 there is reason to believe that, in an extremely small proportion of 
 cases, recoveries from very ominous states take place after all the 
 usual signs of consumption have existed for a sufficient time to 
 render the conclusion probable that these symptoms were caused 
 by tubercular softening and excavation. As the evidence of this 
 fact is at once doubtful and important, it is best to state it, as it 
 most usually is observed. 
 
 1. It occasionally happens, that, in inspecting the bodies of per- 
 sons destroyed by several different diseases, there is observed in the 
 upper lobe of the lungs a peculiar morbid state. The pleura is 
 puckered and shrivelled into small, firm, irregular portions, in 
 which there is distinctly felt a sort of leathery firmness, and beneath 
 that a spot or body or round globular, pretty firm and resisting. 
 When this is divided, the pleura is found to be shrivelled and a 
 little indurated, contracted downwards and inwards upon the hard 
 body, and the substance of the lung hardened and shrinking, en- 
 closing the hard body, which is then found either like a portion of 
 soft putty, or more consistent like chalk, slightly moistened with 
 water. This is regarded as a cicatrized or contracted vomica. 
 The putty-like or chalky contents are the thicker part of the soft- 
 ened matter of the tubercle after the thinner have been expecto- 
 rated or removed by absorption. In cases of this kind, in which 
 such chalk-like masses usually encysted, are contained in the apex 
 or upper regions of the upper lobes, the rest of the lungs are in 
 general either free from tubercular masses, or are little occupied 
 by them, or present some miliary tubercles disseminated through 
 their substance. 
 
 In some instances, these solid bodies are perfectly firm and 
 almost stony, grating against the knife. 
 
 Changes of this kind, howevei’, M. Louis thinks, do not depend 
 on any determinate lesion. From the soundness of the rest of the 
 lung, and the small space which such bodies occupy, it is possible 
 that these putty-like bodies may be tyromatous masses in the early 
 stage degenerated, and the calcareous concretions, phlebolites, or 
 concretions in parts of the lungs previously inflamed. 
 
 2. In other instances, however, appearances of a less equivocal 
 nature are recognized. In examining the bodies of persons who 
 
1034 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 have previously suffered from cough, breathlessness, expectoration, 
 and wasting, there are found in the upper lobe of the lungs, irre- 
 gular cavities lined by a semicartilaginous membrane, similar to 
 that formerly described, but firmer and smoother, containing 
 particles of whitish chalky-like matter, or even putty-like matter 
 adhering. In other instances, cavities irregular in shape, but 
 marked by septa or partitions, are found lined by a firm smooth 
 false membrane, empty, that is containing only air ; while in the 
 same lung may be found tubercular masses partially or wholly 
 softened, and in some instances, crude tubercular masses. 
 
 At the near extremity of such cavities the bronchial tubes, which 
 are truncated, are in general also dilated or enlarged in diameter ; 
 white those at the further extremity are shrunk and contracted, or 
 altogether impermeable. These cavities also themselves show a 
 tendency to contraction by the lung, and even the thoracic parietes 
 pressing them mutually together. When this contraction or 
 shrinking of the cavities takes place, the extremities of the nearer 
 bronchial tubes also are contracted, from participating in the cen- 
 tripetal pressure; and, in some instances, they are impermeable 
 and obliterated. This lesion has been well represented by Rey- 
 naud in his fourth plate, fig. 1, who has detailed several cases, 
 showing the frequency of obliteration of the tubes, in cases both of 
 fiital phthisis, and in those in which partial recovery appeared to 
 take place. 
 
 Lastly^ In some instances in the apex of the lungs are found 
 simply masses, fibrous and cellulo-fibrous, with firm cartilaginous 
 intersections without cavity, and without permeable bronchial tubes. 
 
 From these several facts it is inferred, that the cavities now 
 mentioned are tubercular cavities emptied and partially or wholly 
 cicatrized ; and 2rf, that the solid firm portions are cavities in 
 which great or complete contraction had taken place, 
 
 § 1 1. Kirrhosis. — This name Dr Corrigan applies to the following 
 condition of the lung. The substance of the lung is firm and solid 
 to touch, and void of crepitation ; it is of grayish-red colour and 
 tough ; when divided, it is traversed, in all directions, by thick white 
 bands of fibro-celiular tissue. The bronchial tubes, instead of 
 growing smaller in diameter as they proceed to their terminations, 
 increase in size and capacity, until they terminate in oval or round- 
 ed cavities, in some of which are seen crowded together the open- 
 ings of the small bronchia, giving them an appearance similar to 
 that of the bronchia of the tortoise. The lining membrane of the 
 
KIKRHOSIS OF THE LUNG. 
 
 1035 
 
 large dilated bronchia is red and thickened. The small bronchia 
 are not permeable beyond their orifices. The tubes are generally 
 filled with viscid puriforra mucus. The lung itself is generally 
 smaller than natural or contracted. No tubercles are observed. 
 But it is common to find the pleura covered with lymph, or adher- 
 ing to the costal pleura. 
 
 These changes Dr Corrigan ascribes to the previous existence 
 of chronic inflammation in the filamento-cellular tissue of the lung, 
 converting it into a fibro-cellular structure, which contracts toward 
 the centre of the organ, and in its contraction draws along with it 
 the elastic substance of the lung, in the same manner as the cellular 
 tissue of the liver is supposed to contract that organ.* 
 
 This explanation is hypothetical. The lesion has been described 
 and represented by Andral, Reynaud, and Dr Carsewell as hyper- 
 trophy and dilatation of the bronchial tubes. These are manifestly 
 both dilated and their walls are thickened and h3rpertrophied, while 
 their cellular or vesicular terminations are obliterated. These are 
 facts. All the rest are opinions. All that can be said of this 
 change is, that it seems to be the result of an inflammatory condi- 
 tion of the bronchial tubes, with obliteration of their extremities, 
 sometimes with pleuritic exudation. 
 
 It seems impossible to establish any analogy between this mor- 
 bid state of the lung and kirrhosis of the liver. In the latter dis- 
 ease, the acini or granular elements are hypertrophied, and they 
 contain bile or the matter of bile, (taurine), and colouring matter, 
 and crystalline fatty matter. Nothing analogous to this is seen in 
 the lung with hypertrophied bronchial tubes. 
 
 § 12. Concretions. — Hard gritty or stony bodies are very fre- 
 quently found in the substance of the lungs, f The most usual situation 
 for these bodies is at the apex of one or both lungs, or somewhere 
 in the upper part of the upper lobe. In some cases the pleura ad- 
 heres to the costal pleura over the site of these bodies, so that they 
 are not recognized until the lung is removed from the chest. If 
 the pleura do not adhere, it is observed that a shrivelled contracted 
 appearance of the spot with some depression has taken place, as if 
 it were the mark of a cicatrix or healed scar of the lung, while the 
 
 * On Cin-hosis of the Lung. By D. J. Corrigan, M. D. &c. Dublin Journal of the 
 Medical Sciences, Vol. xiii. p. 206. Dublin, 1838. 
 
 t A Case of Obstructed Deglutition from a preternatural dilatation of, and bag 
 formed in, the Pharynx. By Mr Ludlow, Surgeon, Bristol. Medical Observations and 
 Inquiries, Vol. iii. London, 1769, p. 98. 
 
1036 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 substance of the lung, to the extent of one-third or half of a cu- 
 bical inch is indurated. When this is divided, the centre of the 
 mass is found to consist of a whitish-gray or bluish matter, very 
 hard, and distinctly gritty, or with gritty particles disseminated 
 through the mass. These bodies have been regarded by Laennec 
 as the remains or vestiges of cicatrized vomicce. It is possible that 
 this may be the case. But it is to he ohs(;rved that these concre- 
 tions occur in lungs in which there are no tubercles and no vomica: 
 or traces of these cavities elsewhere. 
 
 Hard stony bodies may occur also in other parts of the lungs. 
 These are variable in size, from the bulk of a millet seed to that of 
 a bean. They are traced to blood-vessels, and are vein stones ; 
 (jilileholitha). 
 
 § 13. Parasitical Animals. — a. Hydatids. — The acephalocyst 
 has been found in the lungs by many observers ; and in several in- 
 stances, acepbalocysts have been discharged by coughing. They 
 are formed either in the filamento-cellular tissue, or in the fhura ; 
 from either of which they may find their way into the bronchi by 
 suppuration, and hence be discharged by coughing. Instances of 
 this kind are not uncommon.* 
 
 On the origin and pathological relation of these bodies, a new, 
 and, in several respects, peculiar view has been given by M. C. 
 Baron, who, from the phenomena of various cases, traces an inti- 
 mate connection between hemorrhagic effusions, and the presence 
 of acephalocysts. This author thinks, that when blood is effused 
 into the pulmonic substance, the mass undergoes various changes, 
 the central continuing red, the peripheral yellow. The central 
 portion may be expelled through orifices formed in the peripheral ; 
 or it is partly absorbed by the peripheral portion ; which is thus 
 progressively transformed into a cyst, which after some time may 
 become a hydatid.f 
 
 This method of explanation seems more applicable to the origin 
 
 * Case of Hydatids discliarged by Coughing. Related in a Letter from Jolm 
 Collett, M.D., Newbury, Berkshire. Transactions of College of Physicians, Vol. ii. p. 
 486. Lond. 1772. 135 acephalocysts coughed up in the course of 116 days. 
 
 Case of Hydatids coughed up from the Lungs. By Dr Doubleday of Hexham. 
 Medical Observations and Inquiries, Vol. v. p. 143. Lond. 1776. 
 
 Hydatids in the Air Tubes of the Lungs. In a Letter from a Physician in London 
 (Dr Pearson). Edinburgh Med. and Surg. Journal, Vol. vii. p. 490. Edin. 1811. 
 
 Case of Hydatids discharged from the Lungs. Guy’s Hospital Reports, Vol. i. 
 p. 507. Lond. 1836. 
 
 t De la Nature et du Developpement des Produits Accidentels. Par M. Le Doc- 
 teur Ch. Baron. Memoires de I’Academie, Tome .\i. p. 381. Paris, 1845. 
 
■\VORJIS. — ENKEPHALO:\IA OF THE LUNGS. 
 
 1037 
 
 of serous cysts than that of acephalocysts. The author neverthe- 
 less maintains its validity, because hydatids are found in the 
 blood, and their ova may therefore he effused with it. To this it 
 may be answered, that, admitting that hydatids or their germs 
 exist in the blood, it must be easy for them to find their way into 
 the lungs without the effusion of blood. 
 
 Hydatids, when existing in the lungs, either cause suppuration 
 and then expulsion with more or less disorder, general and local ; 
 or they may die ; the cysts contract and become opake ; and they 
 then form a sort of lamellated tumour, the presence of which does 
 not appear to be detrimental. 
 
 b. Worms. — Instances are recorded by several authors, among 
 others Schenke, of worms having been discharged from the lungs. 
 It has been generally believed — that these cases were the result of 
 the credulity of the recorders ; and so perhaps some of them may. 
 The same objection, however, can scarcely be urged against a case 
 recorded by Dr Thomas Percival, who mentions that a patient, 
 aged 49, after cough and oppression at the breast, expelled 
 by coughing, in February 1774, two masses, the largest the 
 size of a nutmeg, of a chocolate colour, upon dividing which it 
 was found to contain a number of worms like maggots. The cough 
 and expectoration diminished in severity ; but the result as to final 
 recovery is not stated.* 
 
 § 14. Heterologous Growths. — Both skirrhus and enkepha- 
 loma have been represented to be found in the lungs. As to the 
 latter there is no doubt. The occurrence of the former is more ques- 
 tionable. 
 
 Bayle was the first who in 1810 directed attention to the precise 
 character of cancer in the lungs. He gives three cases ; in the first 
 of which the cancerous masses were hard, and presented the white 
 shining appearance of fresh bacon or lard. In the other two the 
 tumours bore the characters of brain or genuine enkephaloma. 
 These were instances of enkephaloid disease affecting the lungs. 
 
 Laennec was decidedly of opinion that the structure named 
 Skirrhus does not take place in the lung, and that the only species 
 of Cancer found in these organs is the medullary sarkoma, or 
 enkephaloid deposit ; and if careful attention be given to the cases 
 which were published both before and since his time, we shall see 
 reason to admit, that this inference is well founded. 
 
 * Philosophical, Medical, and Experimental Essays. By Thomas Percival, M. D. 
 Vol. iii. Lond. 1778. 
 
1038 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 The cases of enkephaloid disease published in 1817 and 1818 by 
 Mr LangstafF showed, so far as negative evidence goes, that skirrhus 
 does not affect internal organs ; and that enkephaloma is the usual 
 form in which malignant disease attacks the lungs. With the ex- 
 ception of one case referred to the head of tuberculated sarkoma, 
 all presented the usual characters of enkephaloma ; and probably 
 this was enkephaloid deposit in the tuberculated form.* 
 
 These facts and considerations deducible from them, have led 
 Mr Travers to consider skirrhus and enkephaloma as dependent on 
 the same generating cause, and that this, whatever it be, produces 
 in one order of organs, mostly external, the skirrhus deposit, and 
 in another order, mostly internal, the enkephaloid formation. f It 
 is not easy to say whether this view be the correct one or not ; but 
 the facts which support it, show the truth of the doctrine which has 
 been several times stated in the course of this volume, that enkepha- 
 loma is the most common malignant deposit that affects internal 
 organs. 
 
 It seems indeed doubtful whether genuine skirrhus has been found 
 in the lungs ; for all the authentic cases hitherto recorded present 
 the characters of the enkephaloid deposit.^ It has been observed to 
 pass from the mamma to the pleura, and thence to the lungs. 
 This, however, is not the primary affection of the lungs by skirrhus. 
 
 Enkephaloma is greatly more common, and, according to the 
 most authentic evidence hitherto adduced, must be regarded as the 
 principal form in which cancer affects the lungs. It may appear 
 in four different modes. 
 
 In the first place, the enkephaloid matter is deposited in the bron- 
 chial glands, and causes the gradual enlargement of these bodies 
 and their encroachment on the bronchial tubes, and the substance of 
 the lungs. As this enlargement proceeds, the breathing is increased 
 in difficulty, and fluid is effused within the pleurce. The masses 
 
 ■* Cases of Fungus Haematodes with Observations, &c. By George LangstafF, Esq., 
 &c. Medico-Chirurgical Transactions, Vol. viii. p. 272, &c. London, 1817. 
 
 Cases of Fungus Haematodes, Cancer, and Tuberculated Sarkoma, &c. By George 
 LangstafF, Esq. Medico-Chirurgical Transactions, Vol. ix. p. 297. London, 1818. 
 
 t Observations on Local Diseases termed Malignant. By Benjamin Travers, 
 F.R.S., &c. Parts I. and II. Medico-Chirurgical Transactions, vol. xv. p. 195 and 
 228. Lond. 1829. Part III. Vol. xvii. p. 300. London, 1832. 
 
 i Case of Extensive Carcinoma of the Lungs. By George Burrows, M. D., &c. 
 Medico-Chirurgical Transactions, Vol. xxvii. p. 118. Lond. 1844. 
 
 Cases of Malignant Disease of the Lungs. By H. Marshall Hughes, M. D. Guy’s 
 Hospital Reports, Vol. vi. p. 330. Lond. 1842. 
 
ENKEPHALOMA OF THE LUNGS. 
 
 1039 
 
 vary in size according to the duration of the disease, from the bulk 
 of a gooseberry or a filbert to that of small pippins. IMost com- 
 monly several masses are found united in one irregular tumour; or 
 they form a chain of tumours extending through the posterior me- 
 diastinum along the bronchial tubes. They are gray or gray-white, 
 moderately firm, and present the usual characters of enkephaloma. 
 
 The presence of these bodies produces a peculiar form of breath- 
 lessness with orthopnoea ; at first recurring in fits, afterwards con- 
 stant, and causing a hissing, wheezing, roaring noise over the site 
 of the bronchial tubes, with crowing inspiration. 
 
 In the second form, the disease affects the lungs in the chest, 
 commencing either in the pleura, or in the substance of the lungs. 
 The enkephaloid deposit may appear either in the encysted or the 
 unencysted form. But in whichever way it appears, it rapidly oc- 
 cupies the whole interior of the chest, pushing the lung away from 
 the ribs towards the mediastinum. After some time it occupies the 
 whole of the interior of the chest with one continuous, yet lobulated 
 mass of enkephaloid deposit. The presence of this may be known 
 during life by the complete dulness emitted by the chest on per- 
 cussion, and the total absence of respiratory murmur, with great 
 breathlessness and debility. 
 
 After death, which follows quickly, the demithnrax is found oc- 
 cupied with this enkephaloid mass, and the lung compressed into a 
 very small space at the upper part of the thorax and the mediastinum, 
 is scarcely to be recognized. The tumour presents the usual charac- 
 ters of enkephaloma. Some parts are soft, pulpy, and semifluid, 
 like brain, or tbe brain of the foetus ; others are firm and consist- 
 ent like cream-cheese ; others are a mixture of soft gray-coloured 
 cerebriform matter with blood and blood-vessels. 
 
 In the third mode of approach, the enkephaloid matter appears 
 first in the liver, and after occupying the greater part of that gland, 
 it proceeds to affect the diaphragmatic peritoneum, the diaphragm 
 itself, the pleura^ and the lower lobe of the right lung. Through 
 this the enkephaloid deposit extends gradually until it occupies the 
 middle lobe and the lower part of the upper lobe. In this case it 
 is not easy to say whether the tumour displaces the lung, or the 
 enkephaloid matter is infiltrated into the pulmonary substance, as it 
 is in that of the liver. In the instances in which I have observed this 
 mode of occupation, the new growth seemed to advance by suc- 
 cessive steps from one texture to another, and the lungs appeared 
 to be occupied from their proximity to the organs first attacked. 
 
1040 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 In this mode of approach, the new growth passes to the left side 
 of the diaphragm, the tendinous centre, the pericardium, heart, and 
 part of the left lung. The extent to which the growth proceeds in 
 this direction is a mere question of time. If life he sufficiently 
 prolonged, the growth is found affecting a considerable portion of 
 the left lung. If the patient be destroyed early, then less of that 
 lung is involved. 
 
 It must further be allowed that enkephaloma appears to be de- 
 posited in the form of tuberous masses in the lungs, much in the 
 same manner in which they are deposited in the liver. Such was 
 the mode of deposition in the cases given by Mr Langstaff and Mr 
 Lawrence. The tuberosities are further stated to have been en- 
 closed within very delicate cysts. Some of these were very vascu- 
 lar. In one case given by Mr Langstaff, the deposit had affected 
 the uterus and lungs, but not the liver or other abdominal viscera. 
 These masses vary in size from the bulk of peas to that of small 
 apples.* 
 
 When the disease appears in the left demithornx, it by its increas- 
 ing size, not only displaces the lung to the mediastinum and upper 
 part of the chest, but it thrusts the heart over towards the right 
 side of the chest.f 
 
 Dr Warren records the case of a man of 25 in whom colloid 
 cancer affected the subcutaneous cellular tissue, the absorbent 
 glands, the skull, the muscles, the heart, the lungs, the liver, pan- 
 creas, and kidneys.'^: Other instances, however, would be required 
 
 to confirm the inference that colloid cancer affects the lungs. 
 
 § 15. Melanosis, — Of this deposit two forms are observed to 
 take place in the lungs ; one true melanosis ; the other consisting 
 of a deposition or formation of carbonaceous matter from smoke 
 and small dust inhaled, and which has been distinguished by the 
 name spurious melanosis. Between these affections, however, though 
 similar, there is no natural alliance. 
 
 In true melanosis the deposit takes place in two modes. In one 
 it affects first the bronchial glands, infiltrating them with a dark- 
 blue-coloured matter, most commonly solid, sometimes slightly 
 fluid, semi-fluid, or pasty. The glands are at the same time en- 
 larged, and usually increase in size as the deposit proceeds ; and 
 
 * Cases of Fungus Haematodes, &c. By George Langstaff, Esq. Medico-Chinrrg- 
 Transactions, Vol. viii. and ix. 
 
 t On Malignant Tumours connected with the Heart and Lungs. By John Sims, ■ 
 M. D., &c. Medico-Chirurgical Transactions, Vol. xviii. p. 281. London, 1833. 
 
 + Peculiar Case of Gelatiniform Cancer, &c. with the Appearances on Dissection. 
 By John C. Warren, M. D. Med.-Chirurg. Trans. Vol. xxvii. p. 385. London, 1 844. 
 
MORBID STATES OF THE LUNGS — SPINOUS MELANOSIS. 1041 
 
 thus encroach on the lung. In the other mode, the melanotic mat- 
 ter is either infiltrated into the substance of the pulmonic filamento- 
 cellular tissue, or it is deposited in cysts contained or formed within 
 the same. Of this, instances are given by various authors, among 
 others, by Mr Langstaflr. 
 
 The melanotic deposit is liable to occur in conjunction with the 
 enkephaloid. In the first variety of the second case, the melano- 
 tic matter appears in the form of black or blue specks, patches, or 
 lines and streaks disseminated through the pulmonic parenchyma. 
 In this instance, they are probably in the interlobular filamento- 
 cellular tissue. 
 
 In spurious melanosis, the black matter is diffused pretty regu- 
 larly through the whole lung. The expectoration is always more 
 or less black ; and the bronchial tubes are filled with hlack or dark- 
 blue puriform mucus. The bronchial membrane is tinged of a 
 dark colour ; and the substance of the lung is more or less exten- 
 sively black ; while it is often occupied with blue or black indurated 
 patches and masses, and not unusually with tubercular masses and 
 vomicae. From a lung in this state, a large quantity of black-co- 
 loured fluid may be expressed. 
 
 The cause of the blackening in spurious melanosis or the coal- 
 miners’ lung is various. In one set of cases, the black matter has 
 been found to be coal in a state of very minute division, most pro- 
 bably mechanical. In another set of cases, it has been represented 
 to be carbonaceous matter inhaled from the smoke of the lamps 
 and candles used by the miners. In a third set, again, it has been 
 maintained, that it is the carbonaceous matter inhaled after explo- 
 sions of the adjoining strata by means of gunpowder. For farther 
 information on all these points, I refer to the papers by Dr James 
 Gregory,* Mr Graham,f Dr William Thomson, Dr Hamilton, 
 and Dr Stratton ;§ and a memoir by M. Natalis Guillot.|| 
 
 * Case of peculiar Black Infiltration of the whole Lungs resembling Melanosis. By 
 James C. Gregory, M. D. Edin. Med. & Surg. Journ. Vol. xxxvi. p. 389. Edin. 1831. 
 
 + On the Existence of Charcoal in the Lungs. By Thomas Graham, E. R. S. E., 
 &c. Edinburgh Medical and Surgical Journal, Vol. xhi. p. 323. Edinburgh, 1834. 
 
 Cases by G. Hamilton, M. D. &c. Case 2d. Edinburgh Medical and Surgical Jour- 
 nal, Vol. xlii. p. 297. Edinburgh, 1834. 
 
 On Black Expectoration and the Deposition of Black Matter in the Lungs, par- 
 ticularly as occurring in Coal-miners, &c. By William Thomson, M. D. Med.-Chir. 
 Trans. Part I. Vol.xx. p. 230. Lond. 1837 ; and Part II. Vol. xxi. p. 340. Lond. 1838. 
 
 § Case of Anthracosis or Black Infiltration of the whole Lungs. By Thomas Strat- 
 ton, M. D. Edin. Med. and Siu-g. Journal, VoL xhx. p. 490. Edinburgh, 1838. 
 
 II Archives Generales, T. Ixvii. p. 1. Paris, 1845. 
 
 3 u 
 
1042 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 I merely observe that the general conclusion, which results 
 from the history of all the cases recorded and their phenomena, as 
 also from those which have fallen under my own observation, is, 
 that, though black infiltration observed in coal-miners may exist 
 without disease, or with little disease of the lungs, yet most com- 
 monly it is associated with very considerable disease both of the 
 bronchial membrane and lungs. The former is almost constantly 
 in a state of chronic inflammation. In the latter there are often 
 tubercles, vomicae, or indurated portions, sometimes stony concre- 
 tions. The lungs are also emphysematous. The pleura is often 
 adherent over the apex, sometimes all over. The coal dust is in- 
 haled by all coal-miners, and is stated to be freely spit up daily and 
 from time to time without inconvenience or injury. When, however, 
 the bronchial membrane becomes inflamed, either from exposure to 
 cold or the inhalation of stony particles, or in working at stony 
 strata, then the evil becomes urgent. The lungs are often occupied 
 by tubercles; and the diseased state of these and the bronchial 
 membrane aggravates into most deleterious effects the inhalation 
 of cai’bonaceous matter, which seems not to be of itself very detri- 
 mental, unless it has been continued for a long time. 
 
 CHAPTER II. 
 
 The Heart. 
 
 Section I. 
 
 Structure of the Heart. 
 
 The heart is a complex organ consisting of muscular fibres, ar- 
 ranged so as to form its different chambers, covered externally by 
 ■pericardium, and lined internally by a very delicate transparent 
 membrane to which the name endocardium is given. The latter is 
 the only element requiring notice here. 
 
 The endocardium is a very thin transparent membrane, which 
 resembles much the inner membrane of the arteries, and which is 
 composed, according to Henle, of four separate tunics. Its free 
 surface is perfectly smooth, and is formed by a sort of epithelium, 
 which is in immediate continuation with the epithelium of the ves- 
 sels ; that of the right chambers with the venous epithelium ; that 
 of the left with the pulmonary-venous and aortic epithelium. Next 
 to this free or epithelial membrane is a layer of delicate and greatly 
 
MOKBID STATES OF THE HEART. — ABSCESS. 
 
 J043 
 
 contorted fibres, similar to those which form the striated membrane 
 of the vessels. Then is a layer of elastic fibres, which may be re- 
 garded as an elastic tissue. Lastly, is a tissue which is called by 
 Henle ligamentous, but which is manifestly the filamentous tissue 
 that unites it to the muscular fibres of the heart. 
 
 Of these four tunics, the three first only are proper to the endo- 
 cardium. The fourth is common to it and the muscular fibres of the 
 heart. 
 
 This description applies most to the endocardium of the auricles. 
 
 Within the ventricles, the endocardium is altogether more deli- 
 cate than in the auricles ; the striated tunic is thinner ; and the 
 strong elastic fibres are entirely wanting. 
 
 The tricuspid and mitral valves are formed by duplications of 
 this membrane ; and in them the elastic tissue is abundant. 
 
 Section II. 
 
 Morbid States of the Heart. 
 
 The heart is liable to manifold lesions, which it would require a 
 considerable space to describe with the requisite detail and accuracy. 
 Several of these have already received consideration, for instance 
 inflammation and various lesions of the substance of the heart, un- 
 der the head of diseases of the muscular system, and pericarditis 
 under that of diseases of the serous membranes. The most im- 
 portant which deserve consideration here are inflammation of the 
 lining membrane, (endocarditis), and its effects, induration or ossi- 
 fication of the valves ; hypertrophy, partial or general ; atrophy ; and 
 passive aneurism. 
 
 § 1. Abscess of the heart. — This has been already considered 
 at some length. Besides the cases there mentioned, I may notice 
 the following as not less conclusive. Dr Chambers of Colchester 
 records an example of the lesion in a boy of fourteen. An 
 abscess, containing two ounces of purulent matter, was found 
 deeply seated in the substance of the heart, and extending from 
 auricle to auricle round the apex of the organ. In an instance of 
 partial inflammation of the substance of the heart, described by M. 
 Gintrac, matter was formed in the parietes of the left ventricle and 
 burst into the pericardium. 
 
 Mr Stallard of Leicester records an instance in a man of 60 
 
 * Case of Suppuration of the Heart. By Richaid Chambeii, M. D. Lancet, 
 1844. .July 27th. P.5,57. 
 
1044 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 years, who was attacked suddenly, while at work, with coma, cy- 
 anosis, and great feebleness. On the third day death followed. 
 The heart was fat, flabby, and rather larger than usual, and the 
 pericardium contained about one ounce of dirty serum. The 
 right auricle and ventricle were of normal size, and the valves were 
 healthy. The lining membrane was of a deep violet or wine-co- 
 loured red. The left ventricle being opened, an abscess was ob- 
 served situate near the apex, of an irregular shape, being most 
 pointed towards the apex, from which it was separated by two or 
 three lines of sound structure. Above it projected into the cavity 
 of the ventricle, with which it communicated by a small fissure. 
 The interposed space was one line thick, and appeared to consist 
 of thickened endocardium. The cavity of the abscess contained 
 bloody purulent-looking fluid. Its lining membrane was of a light 
 red colour, and was granular in appearance. The surrounding 
 muscular tissue was darker than usual, and fibrinous clots were 
 infiltrated. The coronary arteries were much ossified.* 
 
 In a female of 35, who had been suffering for some time under 
 rheumatism of the right knee, I found, with the cribriform state of 
 the aortic valves, in the walls of the auricles near the origin of the 
 aorta, a cavity containing purulent matter, and extending into the 
 attached margin of the semilunar valves. This was caused by in- 
 flammation of the muscular part of the auricles. 
 
 These cases merely confirm the truth of the general conclusions 
 formerly established regarding this lesion. 
 
 § 2. Endocarditis et Endocardostia Valvularum. Indura- 
 Tio ET IN OS CoNVERSio. Arctatio Valvularum. — The lining 
 membrane of the heart {Endocardium) is liable to inflammation, 
 sometimes idiopathically, sometimes in consequence of rheuma- 
 tism. The effect of this is, to render the folds, especially which 
 form the mitral valve and sometimes those of the semilunar 
 valves, thick, irregularly tuberculated with small hard eminences, 
 inflexible, shrivelled, and contracted. At first albumen appears to 
 be deposited in the interstices of the membranous folds ; then the 
 folds are shrivelled and thickened and indurated ; the tendinous 
 chords at the same time are shrivelled, thickened, and indurated ; 
 and, gradually, the three valvular folds, by the inflammatory action 
 continuing both at their apices and their base, produce disorgani- 
 
 * Observations on the Pathology of Abscess of the Pleart, with a Case. By J. H. 
 Stallard, Esq. &c. Provincial Transactions, Vol. xv. London, 1847. 
 
MORBID STATES OF THE HEART. VALVES. 
 
 ]045 
 
 zation of the former, and a considerable degree of contraction in 
 the latter. 
 
 As this process advances, it progressively renders the valve more 
 stiff, hard, and unyielding, until it is converted into a sort of irre- 
 gular ring of cartilage or bone, or cartilaginous matter, with patches 
 of bone intermixed. The valve is then said to be ossified. The 
 auriculo-ventricular aperture at the same time is so much contracted, 
 that the blood no longer flows from the auricle into the ventricle 
 with its wonted facility ; and a small quantity only passes into the 
 ventricle, while the auricle is kept in a constant state of distension, 
 and is dilated, and sometimes its w^alls are thickened. In this state 
 the auricle is said to be affected with hypertrophy. 
 
 In some instances the valve is occupied at its apices with warty 
 tumours or growths, which have the same effect in rendering it 
 stiff and immovable. 
 
 The tendinous chords have been known to give way during great 
 efforts, or long-continued running ; and the rupture lays the foun- 
 dation of disease of the tendinous chords and the valve. 
 
 The change now described may take place at any period of life ; 
 and it has been observed in persons aged 18, 22, and at all ages 
 under 30. But it is more frequent beyond 40 than previous to 
 that age. 
 
 It seems very often to be the effect of inflammation of the lining 
 membrane of the heart, affecting chiefly the valve, taking place 
 along with or after rheumatism ; and even when it appears to take 
 place slowly in the course of a long series of years, it is the effect 
 of chronic inflammation of the membrane forming the valves. 
 
 The semilunar valves, at the origin of the aorta, are liable to be 
 affected with the same stiffness and induration, and to be penetrated 
 by steatomatous matter, cartilaginous matter, or portions of calca- 
 reous matter. In the beginning, and the slightest form of this kind 
 of change, the semilunar valves lose their pliancy, and can no 
 longer he made to fold completely into the axis of the artery. 
 This is easily known in the dead body, by pouring a stream of 
 water into the aorta, w'hich, falling on the valves in their healthy 
 state, detaches them from the sides of the artery, and makes them 
 meet in the centre, so that the column of water is sustained by 
 them. When they become rigid, cartilaginous, shrivelled, and 
 lose their pliancy, they cannot be detached in this manner from the 
 the sides of the vessel, but remain more or less fixed, so that the 
 water passes from the artery into the ventricle. The valves are 
 
1046 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 thus inadequate to perform their function of preventing the blood 
 from flowing backwards into tbe ventricle, when propelled from that 
 chamber. In more advanced stages of this disorder, the valves are 
 more rigid, more firm, and more penetrated by calcareous matter ; 
 their margins become rough, irregular and tuberculated or warty ; 
 their substance thickened and firm, but very much shrivelled, so 
 that they no longer retain either their membranous character or 
 their semilunar figure ; they gradually are transformed into a ring 
 of firm cartilaginous or calcareous matter ; and, at the same time, 
 the orifice of the aorta is considerably contracted. In some in- 
 stances, they remain in the horizontal position, as to the axis of the 
 artery, projecting from its walls in the form of hard firm ^’owths, 
 and impeding much the issue of blood from the left ventricle. 
 
 Cartilaginous or osseous degenerations of the semilunar aortic 
 valves are not uncommon lesions. They may take place at any 
 period of life after the fortieth year; but are found earlier; and 
 are most common in advanced life. 
 
 With or without the changes now mentioned in the aortic semi- 
 lunar valves may be observed steatomatous and calcareous deposits 
 at the commencement of the aorta, and extending into the coronary 
 arteries. In the aorta, these deposits may be in the shape of flat 
 patches, or M^arty prominences and elevations, and sometimes the 
 inner membrane is detached, and it is observed that the blood has 
 been flowing over a hollow sac with a rough continuous surface, 
 like a small and imperfect aneurism. In some instances, these 
 patches are of the nature of bony spiculae, and a considerable 
 space of the aorta is converted into a rigid calcareous tube. 
 
 The coronary arteries are occasionally affected with the same 
 deposit ; and then become rigid, firm, and unyielding, deranging 
 the circulation through the heart, causing atrophy of the organ, 
 and rendering it feeble and unable to contract with due force on 
 the blood. Such a change has been supposed to give rise to the 
 symptoms of Angina pectoris ; but it has been observed to take 
 place without inducing any symptoms, yet causing sudden death 
 either by syncope or paralysis of the heart. 
 
 These steatomatous deposits consist of fat in a crystalline state or 
 chol ester in e. 
 
 Cartilaginous or calcareous transformation of the tricuspid and 
 semilunar pulmonary valves is much more rare; a fact noticed by 
 Bichat, and repeated since his time by most pathological writers> 
 
 as distinctive of the difference between the internal membrane of 
 
 6 
 
MOKBID STATES OF THE HEART. — VALVULAR DISEASE. 1047 
 
 the arterial system and that of the venous. The lesion, however, 
 is not unknown. Instances of its occurrence are given by V ieussens, 
 Hunald, Morgagni, Bertin, the elder Horn, Cruwel, Corvisart, 
 Burns, and Mr Bransby Cooper. In a slight degree, that is, in 
 the state of cartilaginous induration, it is occasionally observed in 
 the tricuspid valve, and less frequently in the semilunar pulmonary 
 valves. It is a remarkable circumstance, that the cartilaginous or 
 ossified state of the valves of the right chambers of the heart is 
 found chiefly in the persons of those who present a preternatural 
 communication between the right and left chambers of the organ ; 
 and from this, Laennec infers that the action of the arterial blood has 
 considerable influence in the production of these calcareous deposits. 
 
 Small granular bodies loosely adhering to each other are liable 
 to grow on the valves, especially in the left chambers of the heart, 
 and sometimes from the walls of the heart itself. These loose gra- 
 nular bodies, which have been usually denominated warty growths, 
 ( verruca J, and vegetations, have been ascribed by Kreysig, Ber- 
 tin, and ’^ouillaud to the influence and efiects of inflammation. 
 The justice of this opinion Laennec questions, though he admits 
 that a false membrane, produced by inflammation, might form in 
 some rare cases the nucleus or rudiment, as it were, of the concre- 
 tion. Laennec further ascribes these productions to partial coagu- 
 lation of the blood. It seems to me doubtful, nevertheless, whether 
 Laennec has not in this view adopted too limited notions on the 
 nature of inflammation. Though these substances are so loose and 
 soft that it is difficult, if not impossible, to preserve them, yet it 
 appears to me that they may be the result of chronic inflammation 
 of the lining membrane of the heart ; and it is some argument in 
 favour of this idea, that these productions are often associated with 
 other changes, which are known to be the result of inflammatory 
 action ; for instance, cartilaginous and steatomatous transformation 
 and calcareous deposition. By Scarpa and Corvisart they are as- 
 cribed to the influence of the syphilitic poison. It is a well ascer- 
 tained fact that they are frequent in the bodies of those who have 
 been subjected to the full and repeated influence of mercury. 
 
 The lesions now described may exist for some time alone. But 
 the most usual course is, that they either give rise to, or are com- 
 plicated with, certain changes in the dimensions and capacity of the 
 chambers of the heart, and various changes in the muscular walls 
 of the organ. 
 
 Thus when the mitral valve is rendered firm or calcareous, and 
 
1048 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 the auriculo-ventricular aperture is contracted, the left auricle be- 
 comes dilated and sometimes hypertrophied, that is, its walls become 
 thick and firm. 
 
 The most common changes of this kind are dilatation of the ven- 
 tricles, dilatation of the right chambers, and hypertrophy of the 
 ventricles. 
 
 § 3. Atrophy of the Valves. — Perforating or Cribriform 
 Atrophy.' — The valves of the aorta and the folds of the mitral 
 valve are liable in certain circumstances to become extremely thin, 
 and at length to be perforated by small irregular holes. In this 
 state they are unable to perform their functions as sustaining and 
 resisting membranous folds, against the weight of the blood ; and 
 not only does the lesion cause regurgitation, but the valves may 
 give way and be ruptured. 
 
 This cribriform state is most common in the aortic valves ; next 
 to these in the mitral valve. It is occasionally seen in the tricus- 
 pid valve, and sometimes, though rarely, in the pulmonary semi- 
 lunar valves. It appears to be a species of wearing, the effect of 
 previous brittleness and attenuation, and these again the result 
 of chronic inflammation. 
 
 § 4. Contraction and Abridgment. — Under the operations 
 of chronic inflammation and aberration in nutrition, the valves 
 are liable to be not only indurated and thickened as already de- 
 scribed, but to be shortened. Thus the semilunar valves at the 
 origin of the aorta are liable to be in this manner drawn together, 
 and shortened. In some instances two valves appear to be united, 
 or to have coalesced into one ; or one is unusually short and con- 
 tracted; or the whole three may be drawn together at their margins. 
 In the same manner he ladnice of the mitral valve are liable to 
 become very much shortened, thickened, and drawn together. 
 
 It may be doubted whether this last mentioned change is justly de- 
 signated as atrophy. It is evidently one of the contracting eflfects or 
 remote consequences of the shrivelling ensuing in certain forms of 
 the inflammatory process in certain tissues. It appears to be the 
 result of inflammatory action in the elastic fibrous tissue of the 
 middle valvular tunic. 
 
 These changes are most frequently observed in the mitral and 
 aortic semilunar valves ; less usually in the tricuspid and pulmo- 
 nary semilunar valves. 
 
 § 5. The latter are liable to a lesion of a very important nature 
 from its connection with various malformations of the heart. 
 
 4 
 
MORBID STATES OF THE HEART. — PULMONARY ARTERY. 1049 
 
 The orifice of the pulmonary artery is liable to three forms of 
 lesion. The first is an unusually contracted or narrow state of the 
 cylinder of the artery, the capacity of which may be not half its 
 normal size, or at most between that and three-fourths. A second 
 is narrowing, sometimes obstruction even to obliteration of the 
 channel of the artery. This is usually accompanied with, if not 
 caused by, more or less thickening of the arterial walls, and may 
 be accompanied with some effusion of lymph or blood in the inte- 
 rior of the vessel at the part. In some instances it is like false 
 membrane uniting the opposite sides of the artery. 
 
 The third is more or less occlusion of its interior by coales- 
 cence and mutual adhesion of the valves. The most usual form 
 of this is for the three semilunar valves to be united by their 
 margins, leaving at their apices only a very moderate sized aper- 
 ture. Of this there are various degrees, regulated mostly by the 
 size of the central aperture. In some cases it is large enough to 
 admit the tip of the little finger. In others it is so contracted that 
 it allows only a catheter of middle size to pass. And in others, 
 the aperture is so small that it admits only a common probe. Se- 
 veral instances of this lesion I have published ;* and others are given 
 in the work of Kreysig on Diseases of the Heart, and in that of 
 Gintrac on Cyanosis. The latter author mentions that the pul- 
 monary artery was thus contracted in 16 among 53 cases of cy- 
 anosis, and in five more the orifice was obliterated. 
 
 The semilunar valves are in general thickened, and sometimes 
 they are indurated. They form in short a septum or diaphragm, 
 perforated in the centre, stretched across the orifice of the pulmo- 
 nary artery. 
 
 The cause of this lesion is not known. In several cases it is mani- 
 festly congenital, and must have originated in the fcntus. It is 
 possible that at that period when the artery and its valves were 
 small, slight inflammation may have taken place at the origin of the 
 pulmonary artery, and thus produced there mutual adhesion and 
 coalescence. If this were the case, then it is easy to see, that 
 this lesion would keep the pulmonary artery almost if not wholly in 
 its foetal state, so that enlargement and expansion with the other 
 organs of the body could not advance. This might be in different 
 
 * Notice of a Case of Cyanosis or the Blue Disease connected with mutual adhe- 
 sion of the Semilunar Valves of the Pulmonary Artery. By David Craigie, M.D., &c. 
 Edinburgh Medical and Surgical Journal, Vol. lx. p. 265. Edin. 1843. 
 
1050 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 degrees; but in all the effect would be to keep the orifice of the artery 
 more or less obstructed. 
 
 Such I believe to be the cause of the coalesced state of the semi- 
 lunar valves in cases of this class. 
 
 This coalition of the valves is very constantly connected with 
 more or less malformation of the heart, by which the two sides of 
 that organ communicate. Thus it is observed foramen ovale, 
 
 in perforation or deficiency of the septum, and in cases in which 
 the aorta arises from the right ventricle, or from both ventricles at 
 once. I have elsewhere attempted to show that, taking into con- 
 sideration all the circumstances of this lesion, it is probably the 
 cause of these communications, or bears to them such a relation 
 that the arctation of the pulmonary artery renders these communi- 
 cations between the right and left chambers requisite. 
 
 In some rare cases only two semilunar valves are found at the 
 orifice of the pulmonary artery ; and Dr Theophilus Thomson re- 
 cords a case of unusually large pulmonary artery in which it was 
 provided with four valves.* 
 
 §6. Dilatation OF THE Ventricles, fv4»2joZ2G^zo,)'pAssivE aneu- 
 rism of Corvisart, consists in enlargement of the chambers of the 
 heart, with thinning of their walls. The muscular substance is at the 
 same time unusually soft and flaccid, sometimes of a violet colour, 
 in other instances pale and almost yellowish. In such instances the 
 substance of the heart must be regarded as in a state of atrophy, 
 hypotrophy, or imperfect nutrition. The substance is at the same 
 time lacerable. The extenuation may be so extreme that the thickest 
 part of the ventricle does not exceed two lines, and the apex is 
 scarcely half a line ; or the muscular substance may be so stretch- 
 ed, attenuated, and absorbed, that nothing but a little fat covered 
 by pericardium retains the blood. Laceration, in such circum- 
 stances, as Burns imagined, seems not impossible ; yet neither Cor- 
 visart nor Laennec met with any instance of this accident in conse- 
 quence of dilatation of the left ventricle ; and in none of the record- 
 ed instances of rupture does the accident appear to have been the 
 result of extenuation, so much as friability or ulceration. 
 
 This disease M. Bertin ascribes to the operation of obstacles or 
 impediments to the circulation ; for instance, ossification of the 
 valves, and arctation of their apertures, congenital straitness of the 
 pulmonary artery or the aorta, professions requiring painful efforts, 
 
 * Account of a Case of Irregular Formation of the Heart, &c. By Theophilus Thom- 
 son, M.D. Medico-Chirurgical Transactions, vol. xxv. p. 247. London, 1842. 
 
MORBID states OF THE HEART HYPERTROPHY. 1051 
 
 and certain diseases of the lungs, as consolidation and tubercular 
 induration. Though the influence of these causes is considerable, 
 the most general and the most powerful is original conformation ; 
 that is, an unusually narrow pulmonary artery as to the right ven- 
 tricle, and a narrow aortic orifice as to the left ventricle. Several 
 instances of passive dilatation of the left ventricle, 1 have seen as- 
 sociated with ossification of the aortic semilunar valves, and conse- 
 quent arctation of the orifice. When the right ventricle is dilated, 
 the lesion is usually connected with more or less disease of the 
 lungs ; and the right auricle becomes at length affected in the same 
 manner, 
 
 § 7. Hypertrophy or excessive nutrition of the heart maybe said 
 to consist in increased thickness of the muscular substance of the 
 organ, which is at the same time, in general, firmer and more dense 
 than natural. It may exist in one ventricle only, or extend to 
 both ; and it may be general or partial. When the left ventricle 
 is affected, it may exceed one inch, or be even eighteen lines in 
 thickness at the base, which is fully double or three times thicker 
 than in the natural state. When the ventricle is generally afiect- 
 ed, it is thickest at the base, and diminishes gradually to the apex ; 
 but the apex sometimes participates to the extent of from two to 
 four lines. If the apex is affected, the disease is generally local. 
 In other instances, partial thickening appears most commonly in 
 the neighbourhood of the valves. In the case of the right ventri- 
 cle, the increased thickness is more uniform, extending over the 
 whole, and rendering it so firm as not to collapse when cut open. 
 The preternatural change, however, is always most distinct in the 
 neighbourhood of the tricuspid valve, and in that part of the ven- 
 tricle which gives origin to the pulmonary artery. The bulk of 
 the fleshy pillars (columnae carneae)^ is always much increased ; 
 and this condition, which is more conspicuous than in the left, with 
 the great firmness of the muscular substance, forms a striking fea- 
 ture in the anatomical characters of hypertrophy of the right ven- 
 tricle. 
 
 Hypertrophy has been distinguished by M. Bertin into three 
 forms, according to the effect it exerts on the capacity of the cham- 
 bers of the heart, or according to the mode in which the increased 
 deposit of material is applied; — Is#, simple hypertrophy; 2d, ex- 
 centric hypertrophy ; and Zd, concentric hypertrophy. 
 
 In the first form, the walls of one or more of the chambers of 
 
1052 
 
 GENERAL AND PAXnOLOGICAL ANATOMAL 
 
 the heart are thickened, while the chambers are neither enlarged 
 nor diminished in capacity. This is simple hypertrophy, in which 
 the increase of matter may be regarded as applied from the inner 
 surface outwards. 
 
 In the second form, the walls of the chambers are thickened, 
 while the capacity of these cavities is enlarged. This is excentric 
 hypertrophy, in which, with the increase of matter from within out- 
 wards, there is exerted in the same direction a dilating or dis- 
 tending force. This corresponds with the active aneurism of Cor- 
 visart. 
 
 In the third form of the disorder, the thickening of the walls of 
 the heart is combined with diminution in the capacity of the ven- 
 tricles, as if the new matter had been added chiefly to the interior 
 of the ventricle, or had been deposited, at least, from the exterior 
 to the interior surface. This is, therefore, named concentric hyper- 
 trophy. 
 
 No doubt has ever been entertained as to the existence of the 
 two first forms ; for instances of simple hypertrophy have been ob- 
 served by Morgagni, Corvisart, and others, though they have not 
 been carefully distinguished ; and excentric hypertrophy is by far 
 the most common lesion to which the heart is liable. It is diffe- 
 rent with concentric hypertrophy, the existence of which has been 
 called in question by Cruveilhier in France, and Dr Eudd in this 
 country, both of whom ascribe to the mode and circumstances in 
 which death takes place, the appearance deemed characteristic of 
 that lesion. 
 
 Cruveilhier has observed in the bodies of those who had suffered 
 death by decapitation and those cut off by violent death, the two 
 phenomena of great contraction or even obliteration of the ven- 
 tricle, and proportional thickness of the walls of the heart, and he 
 infers, therefore, that these phenomena are the effect of this species 
 of death, and regards the concentrically hypertrophied hearts of M. 
 Bertin and Bouillaud as hearts more or less hypertrophied in per- 
 sons overtaken by death in the full energy of contraction. He 
 further argues, that, as it is always possible to open and dilate these 
 hearts apparently without cavity, by introducing several fingers, 
 these circumstances indicate more forcibly that the state of the 
 heart is the effect of the last vital contractions.* 
 
 Dr Budd, finding that in such hearts the ventricle becomes re- 
 * Dictionnaire de Medecine, Art. Hypertrophie. 
 
MOBBID STATES OF THE HEART — MORIBUND CONTRACTION. 1053 
 
 laxed to its usual capacity after the heart had been macerated 
 a few days, and that during life there was no intermittence or 
 irregularity of pulse, no dilatation of the right cavities, and no 
 symptoms of impediment to the circulation, arrives at the same 
 conclusion.* 
 
 It cannot be denied, that, in various instances of sudden death, 
 as death by hemorrhage, and also in many instances of death by 
 cholera, the left ventricle is found in this greatly contracted state, 
 hard, firm, with thick walls, and almost no cavity, the internal sur- 
 faces of the ventricle being closely applied to each other, and the 
 ventricle being entirely empty. It is also to be observed, that this 
 state of the heart is found in persons, in whom none of the usual 
 symptoms of disease of the heart were observed to take place during 
 life, and consequently in whom the existence of such a lesion was 
 not suspected. It may be admitted, then, that, in a certain number 
 of cases, especially where this state of the heart is found after vio- 
 lent death, sudden death by hemorrhage, or sudden death from 
 other causes, it is not positively indicative of a peculiar morbid state 
 of the heart during life. 
 
 It seems, nevertheless, a conclusion too violent to infer, that, of 
 all cases in which this state of the heart is found, none is to be re- 
 garded as the effect of morbid thickening of the ventricle with con- 
 traction of its chambers. M. Bouillaud, accordingly, who maintains 
 the correctness of the views of M. Bertin, records in his work on 
 Diseases of the Heart, eight cases of concentric hypertrophy of 
 the right ventricle, and five of concentric hypertrophy of the left 
 ventricle. 
 
 I have met with a few cases of this state of the heart, indepen- 
 dent of those which I observed in the bodies of persons destroyed 
 by cholera; and in the Clinical Report for 1832-1833, are men- 
 tioned three cases, in two of which I think no doubt could be ex 
 tertained of the existence of this lesion. In the one case, in which 
 death was caused by granular disease of the kidney, the cavity of 
 the left ventricle was almost obliterated by the close mutual appli- 
 catiou of the walls, which were very thick, firm, and hard. In the 
 other case, in which death was caused by an attack of erysipelas, 
 the cavity of the ventricle was equally contracted, and its walls 
 were nearly as thick and firm as in the former ; and the patient had 
 presented during life symptoms of angina peetoris.\ 
 
 * Medico-Chirurg. Transact. Vol. xxi. London, 1838. 
 
 t Clinical Report for 1832-1833, Edinburgh Med. and Surg. Journal. 
 
1054 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 Excentric or aneurisinal hypertrophy is, nevertheless, by far the 
 most common lesion ; and the extent to which the heart may be 
 enlarged by it is very great. The circumference of the base of 
 the heart may amount to from 12 to 16 inches ; its transverse dia- 
 meter, 6 or 9 ; and the longitudinal diameter, from base to apex, 
 from 5 to 7 inches. 
 
 The increase in weight is the most conspicuous change. The 
 minimum weight of the adult heart is about 6 ounces 2 drachms ; 
 the average weight about 8 ounces. In the state of hypertrophy, 
 however, the weight is increased to 12 or 13 ounces at least, and 
 may be so great as 22, 26, or 28 ounces. The average of seven- 
 teen cases recorded by Bouillaud amounts to 16 ounces. The thick- 
 ness of the walls of the left ventricle varies from 7 to 14 lines. 
 The thickness of those of the right ventricle varies from 3 to 5 lines. 
 
 This lesion gives rise to, or is connected with, others very im- 
 portant to be known. It is often associated with a bloody or hemor- 
 rhagic consolidation of the lungs and haemoptysis ; and, in a con- 
 siderable proportion of cases, it gives rise to softening or hemor- 
 rhage in the brain. 
 
 Excentric hypertrophy is often associated with cartilaginous or 
 calcareous degeneration of the semilunar aortic valves, and some- 
 times with that of the mitral valve. 
 
 Excentric hypertrophy is, in a large proportion of instances, the 
 result of rheumatism affecting the heart, and giving rise to endo- 
 carditis. This can in general be known by the fact, that the indi- 
 vidual has suffered rheumatic pains in the wrists and ankles, or in 
 the elbows and knees, previous to the appearance of the symptoms 
 of hypertrophy. In some cases, hypertrophy, adhesion of the pe- 
 ricardium to the heart, and valvular disease, are united in the 
 same individual. 
 
 § 8. Partial Aneurism, or Consecutive False Aneurism. — 
 This consists in a portion of the muscular fibres of the heart giving 
 way, so as to form in the muscular walls of the organ a cavity, sac, 
 or pouch, communicating by an opening with the cavity of the 
 chamber, in the walls of which the pouch has been formed. 
 
 This change may take place in any part of the muscular sub- 
 stance of the heart ; but it is most usually seen in the left ventricle, 
 near or towards the apex. In various affections of the heart, but 
 especially in dilatation, with more or less disease of the aortic se- 
 milunar valves, it is not uncommon to observe, formed near the 
 apex of the left ventricle, small cavities or pouches, while the mus- 
 
MORBID STATES OF THE HEART — PARTIAL ANEURISM. 1055 
 
 cular walls at that part are rendered extremely thin. These cavities, 
 which contain blood in the shape of adherent clots, are formed by a 
 gradual separation of the muscular fibres and some degree of dila- 
 tation ; but no laceration or breach of continuity is in general to 
 be perceived. 
 
 It is different with partial aneurism. The muscular fibres un- 
 dergo an interruption or solution of continuity in the transverse 
 direction quite perceptible ; and by their retraction and separation, 
 a cavity or pouch, variable in size and shape, but generally round 
 or ovoidal, is formed in the walls of the heart. In some instances 
 the fibres are completely destroyed, and the outer wall of the pouch 
 is formed by the pericardium alone. This appears to have taken 
 place in a case by M. Dance, and in the case of the actor Talma. 
 
 The interior of these pouches or cavities in the walls of the heart 
 may be filled with coagulated blood, adherent to the walls, and, in 
 some instances, arranged in the form of lamincB, as in aneurism of 
 arteries. In some instances they are empty, or contain only a 
 little clotted blood or blood plasma adhering to the walls of the 
 pouch. 
 
 This lesion generally takes place in the anterior or lateral 
 part of the walls of the left ventricle, or near the apex in the an- 
 terior and left side. In ten cases among seventeen well-marked in- 
 stances of the disease collected by myself, the tumour was situate 
 near or formed in the apex. In a few cases it is found in the sep- 
 tum cordis. In one case which was under my own care, the pouch 
 or sac was formed in the base of the septum ;* and it formed a 
 large round prominence in the right ventricle. In an instance 
 given by Dr Pereira, tbe cavity was formed in the substance of the 
 septum., and consisted of four subordinate pouches, one of which 
 had burst into the right ventricle.f Mr Thurnam mentions three 
 instances, also in the septum^X and Bouillaud gives one.§ In a 
 case given by Zannini, tbe origin of the aneurismal tumour was 
 
 * Observations and Cases illustrating the Nature of False Consecutive Aneurism of 
 the Heart. By David Craigie, M. D. Edinburgh Medical and Surgical Journal, Vol. 
 lix. p. 366. Edinburgh, 1843. 
 
 -(• Case of Partial Aneurism of the Left Ventricle of the Heart. By Jonathan Pe- 
 reira. Medical Gazette, October 1845, and Edinburgh Aled. and Surg. Journal, Vol. 
 Ixvi. p. 503. Edinburgh, 1846. 
 
 J On Aneurisms of the Heart, with Cases. By John Thurnam. Medico-Chirm- 
 gical Transactions, Vol. xxi. p. 187. London. 1838. 
 
 § Traite Clinique des Maladies du Coeiu. Par J. Bouillaud. Paris, 1835. 2ieme 
 Edition. Tome i. p. 594. Pans, 1841. 
 
1056 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 situate in the lower end of the septum, and extended into the apex 
 formed by the walls of the heart.* 
 
 In size these aneurismal pouches vary. Some are small, not 
 larger than a gooseberry ; others are much larger, and make a 
 large projecting tumour externally, altering much the usual figure 
 of the heart. 
 
 The disease has been observed in general in persons above 25 ; 
 and several of the cases have occurred in persons advanced in life. 
 In only one case among 58 was the patient under 20 years. In the 
 case given by Dr Pereira, the disease took place in a girl of 15 
 years, which is the earliest period yet recorded at which it has been 
 observed. 
 
 Partial aneurism of the heart is generally associated with other 
 lesions of that organ and its valves. Thus the aortic valves are 
 very generally rigid, steatomatous, or penetrated with specks and 
 patches of bone. In some instances they are cribriform or perfo- 
 rated by holes. In a few cases, the mitral valve is rigid and slightly 
 ossified. In most cases, the lining membrane is more or less thick- 
 ened, and not unfrequently white opaque spots in it are visible. 
 Round the pouch itself there is usually observed a layer of fibres, 
 rough, firm, and rigid, not unlike horse-hair. The ventricle, 
 either right or left, is usually in a state of hypertrophy. In the 
 case examined by myself, the heart weighed with the aorta 32 
 ounces ; and if for the latter one ounce and a half or two ounces 
 be deducted, it makes the heart 30 ounces, which is about three 
 times more than the average weight of the adult heart in a state of 
 health. 
 
 Upon the mode in which these pouches are formed, it is not easy 
 to give a decided opinion. It seems certain that, in most instances, 
 the muscular fibres of the heart are lacerated transversely, and se- 
 parated in their longitudinal direction. When the pouches are 
 carefully examined, one portion of the sac is always more or less 
 distinctly formed, by what we know must be the ends of the con- 
 torted muscular fibres of the heart. These, it is true, are lined 
 or covered by lymph and blood ; but when this is removed, and 
 even sometimes without, it is possible to trace the fibres ending 
 abruptly. 
 
 On the mode in which the laceration takes place, or the causes 
 by which it may be produced, much difference of opinion prevails 
 
 ■* Observations and Cases, &c. By Dr Craigie. Case 9. 
 
MORBID STATES OF THE HEART PARTIAL ANEURISM. 1057 
 
 among writers on pathology. M. Breschet, regarding it as false 
 consecutive aneurism of the heart, and, therefore, analogous to the 
 false consecutive aneurism of the arteries, studies to illustrate its 
 nature and origin by appealing to the history of the cases of rupture 
 or laceration of the heart. Many instances of this lesion have been 
 recorded, and the successive observations of Harvey, Lancisi, Ver- 
 bruggen, Morgagni, Senac, Lieutaud, Morand, Portal, Corvisart, 
 and recently of Perms, Laennec, Kostan, Blaud, Bayle, and the 
 two MM. Rochoux, have furnished so much information on the 
 circumstances, in which rupture is most likely to^take place, that 
 we cannot expect to know much more on that subject. It is 
 known that these accidents, though they may occur in any part of 
 the organ, are, nevertheless, by far the most common in the left 
 ventricle, and especially at the apex. This circumstance is proba- 
 bly to be ascribed at once to the greater thinness and weakness of 
 the parietes at the apex, and to the strength and energy with which 
 the left ventricle contracts. It is almost clear to demonstration, 
 that, of any muscular organ, of which the greater part is thick and 
 strong in structure, and forcible in action, while one part is a little 
 thinner, the latter is most likely to give way during any action of the 
 organ unusually forcible or violent. This will, of course, be much 
 more likely to happen where either unusual resistance is presented, 
 as in disease of the aortic valves, or where the action is morbidly 
 increased from morbid though partial increase in the thickness of 
 the parietes of the heart. 
 
 M. Breschet seems to think that the position of these lacerations 
 may be employed to explain the origin of the false consecutive 
 aneurism of the heart, and he directs attention to the important 
 fact, that, in the ten cases which he records, and most of which are 
 abridged in the memoir referred to, in most the lesion was situate at 
 or near the apex of the left ventricle. The right ventricle, he ob- 
 serves, presents nothing of this nature, nor did his researches bring 
 him acquainted with any instance of its occurrence in the right ven- 
 tricle. He allows, however, that we are not entitled, from so small 
 a number of cases, to deduce any very positive conclusions. 
 
 M. Breschet, nevertheless, very properly refers to three condi- 
 tions which have been believed to be, almost necessarily implied in 
 tbe sort of lesion now described. These are ; Isif, softening of the 
 tissue of the heart, that is, of its muscular fibres ; 2d, ulceration of 
 the inner membrane ; and 3rf, rupture of the muscular fibres ; and 
 
 3 X 
 
1058 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 while he questions the effective operation of the two former, he ad- 
 vocates somewhat strongly the influence of the third cause. I must 
 refer my readers to the original paper for the arguments hy which 
 he maintains the justice of his cause. 
 
 In point of fact, while Mr Thurnam has shown that this spe- 
 cies of aneurismal dilatation or rupture may occur not only in the 
 left ventricle, but in the right, and also in the auricles, the 22d 
 case which is recorded in the memoir by the author, and the in- 
 stances of the lesion taking place in the septum cordis^ prove that 
 the lesion may take place not merely at the apex of the heart, but 
 at the base of the septum. It must be allowed, therefore, that, 
 though the lesion is most liable to take place at or near the apex 
 of the left ventricle, it may be found in other parts of the heart, 
 and consequently that the circumstances concerned in its production 
 must be applicable not to the apex only, but to other parts. 
 
 By M. Bouillaud an idea somewhat different has been ad- 
 vanced, viz. that the false consecutive aneurism of the heart is one 
 of the effects or terminations of inflammation in the muscular sub- 
 stance of the heart This author informs us, ‘‘ that the formation 
 of an aneurismal cyst consecutive to ulceration of the internal and 
 middle membranes of the heart, is accomplished by the same me- 
 chanism as that of an aneurismal cyst of the arteries. The lamel- 
 lar disposition of the coagulura is exactly the same in the false 
 consecutive aneurism of the heart, as in the false consecutive aneu- 
 rism of the arteries, I need not, therefore, dwell at length here 
 on the anatomical description of this accident of the ulcerations of 
 the heart. The tumour formed by the blood infiltrated and coa- 
 gulated is very different in quantity. Thus it may in some instances 
 not be equal to the size of a walnut or filbert, while in other cases 
 it exceeds the bulk of an egg, and may even be greater than that 
 of the two ventricles together.” 
 
 It cannot be denied that this mode of explaining the origin of 
 the aneurismal cysts of the heart is to a certain extent plausible. 
 Several of these cysts present appearances of ulceration ; and if it 
 could be proved that the ulceration always precedes the formation 
 of the cysts, and is always the effect of previous inflammation, the 
 question would be decided. This is, however, very far from being 
 the fact, or the constant result in all cases. Not only do instances 
 of aneurismal cysts in the substance of the heart take place without 
 any indications of previous inflammation or ulceration ; but in seve- 
 ral of the cases, indeed the majority, the lesion exists for a long 
 
MORBID STATES OP THE HEART PARTIAL ANEURISM. 1059 
 
 time without presenting any of the symptoms of the inflammatory 
 or ulcerative process. Thus, in the well-known case of Talma, 
 there was no indication of previous inflammation or ulceration, and 
 after it had taken place, and lasted for at least three years, it did not 
 indicate its presence by any very marked symptom of any kind, and 
 assuredly by none indicating the presence of inflammatory action, 
 either acute or chronic. In almost all the other cases also no con- 
 spicuous or urgent symptoms took place to denote the exact date 
 of the commencement of the lesion, which has, in most instances, 
 been discovered unexpectedly in examining the heart after death. 
 
 It must be allowed, nevertheless, that the inflammatory process, 
 without proceeding to ulceration, as Bouillaud requires, may have 
 a tendency to produce this lesion, by the change which it effects 
 on the tissues, in which it is seated. It is one of the most con- 
 stant, perhaps, of the properties of this process, to impair or destroy 
 the tenacity, elasticity, cohesion, and resisting power of the animal 
 tissues, and in none more decidedly than in the muscular. All 
 textures after inflammation are rendered more fragile and more 
 lacerable. This is particularly the case with the arterial tunics, 
 with tendons, with cartilages, and with the bones, and above all, 
 with the muscular tissue, which becomes less distensible, less con- 
 tractile, and more rigid than before. It is possible that some new 
 deposit may have been formed in it. But even this does not seem 
 necessary ; and the simple pre-existence of the inflammatory con- 
 gestion appears to be all that is requisite to induce this sort of 
 lacerability. 
 
 It is not improbable that these facts and considerations appear- 
 ed so conclusive to M. Cruveilhier, that, in proposing another cir- 
 cumstance as a preliminary or predisposing cause of false consecu- 
 tive aneurism, he found it difficult, if not impracticable, to exclude 
 the influence of the inflammatory process. From various pheno- 
 mena presented by the tumours and cysts in this lesion, but espe- 
 cially from the phenomena presented by the preparation described 
 in Case 17 in the memoir by myself, he infers that, in every instance 
 of false consecutive or partial aneurism of the heart, one of two 
 processes is in operation ; one the inflammatory action, and the other 
 the fibrous transformation of the muscular tissue of the heart. To 
 the latter, however, which he believes to be often primary or idio- 
 pathic, and not accompanied by inflammation, he assigns the prin- 
 cipal place. Numerous facts, he informs us, lead him to conclude 
 
1060 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 that the idiopathic fibrous transformation of the muscular fibres of 
 the heart performs a greater part in the formation of partial aneu- 
 rism than inflammation ; and if the apex of the heart be often the 
 seat of the lesion, the reason is, that it is the weakest part of the 
 left ventricle, and therefore the most frequent seat of the fibrous 
 transformation, so common a consequence of distension of the mus- 
 cular tissue. 
 
 The reason why the right ventricle, he adds, is less frequently 
 affected by partial dilatation is, that its walls are less thick, and its 
 structure more areolar than that of the left ventricle. The vigour 
 and force with which the left ventricle contracts is the anatomico- 
 physiological cause of its predisposition to this disease. 
 
 When the fibrous transformation has commenced in one point of 
 the walls of the heart, he infers that the distension which takes 
 place at each contraction becomes an incessant cause of irritation ; 
 and there are formed in this non-contractile sac clots which may 
 serve as a barrier to oppose the enlargement of the tumour. He 
 adds that he has seen cases, in which the shape of the heart was not 
 sensibly altered externally, though its apex presented the com- 
 mencement of this fibrous sac or recess, and the presence of such a 
 state had been denoted by no symptom during life. The correct- 
 ness of this observation I can confirm from personal knowledge ; 
 and of this the case of the young man. No. 21, which occurred 
 in my own practice, is an excellent example. 
 
 When, however, the part thus transformed into fibrous tissue is 
 dilated into a sac superadded to the ventricle, or pushed beyond 
 the level of its internal surface, yet communicating with its cavity 
 by a narrow orifice, it constitutes the partial aneurism described 
 by authors. 
 
 M. Cruveilhier, however, does not apply to all these tumours the 
 name of false consecutive aneurism ; and he makes a distinction 
 between this and partial aneurism of the heart. By partial aneur- 
 ism of the heart, M. Cruveilhier understands dilatation of one 
 portion of the heart into a cyst, in consequence of the fibrous 
 transformation of the tissue of the organ. These parts, however, 
 may become eroded, and hence may be lacerated ; and while the 
 cardiac pericardium prevents complete rupture, either alone or by 
 its having contracted adhesion with the capsular pericardium, the 
 partial aneurism of the heart would then be converted into false 
 consecutive aneurism.* 
 
 * Cruveilhier Anatomie Pathologique, Livraison xxi. 
 
MORBID STATES OF THE HEART. — PARTIAL ANEURISM. 1061 
 
 He maintains also that the partial aneurism of the heart com- 
 mences always by dilatation, and ought, therefore, to be regarded 
 as a true aneurism. 
 
 Throwing aside this distinction in the meantime, it must be ad- 
 mitted, that the point for which M. Cruveilhier contends, as the 
 main predisposing cause of aneurism of the heart, namely the pre- 
 vious fibrous transformation of the muscular tissue, is one which 
 derives considerable force from the appearance of many of the ex- 
 amples of the lesion. In the majority of these, the aneurismal 
 sac or cyst has presented, as in the 17th case of the essay, more or 
 less of the fibrous structure. In the case which occurred in my 
 own practice, this fibrous transformation was remarkably distinct, 
 both on the side of the left ventricle, and also on that of the right, 
 most so certainly in the latter, where it formed a firm strong pro- 
 minent mass, convex in shape towards the right ventricle. This 
 fibrous structure was also distinctly visible and very strong at the 
 margin of the opening of the sac into the left ventricle. In all the 
 cases detailed in ray own memoir, the fibrous structure is remarked 
 at the margin of the orifice of the cyst, which is described as firm, 
 elevated, and generally whitish. 
 
 The only question for consideration would appear to be, whether 
 has this fibrous transformation taken place before the aneurismal 
 dilatation or after its occurrence ? I am not sure that any of the 
 facts which I have recorded, or which have come to my knowledge, 
 are capable of determining this point. 
 
 With regard to the other point maintained by M. Cruveilhier, 
 viz. the distinction between true or partial aneurism of the heart 
 and false consecutive aneurism of the heart, it appears to me that, 
 in the present state of knowledge, it must be considered as a 
 distinction rather in the degree and stage than in the nature and 
 kind of the lesion. Several of these aneurismal cysts appear to 
 commence at first by slight laceration, and then to be enlarged by 
 dilatation. Several, on the other hand, especially those near the 
 apex of the heart, appear to commence first by dilatation, and 
 then to be enlarged by some degree of laceration. In many the 
 two processes are conjoined ; and it seems difficult to say which 
 of them is the first. It is admitted even by M. Cruveilhier him- 
 self, that the form of the disease which he denominates partial 
 aneurism is earlier and less advanced than that named false con- 
 secutive aneurism, and in which the fibrous transformation, not 
 yet effected in the former, is far advanced or completed. 
 
1062 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 One word only have I to add on the probable mechanism of 
 such cases of aneurismal cyst as that which occurred to myself. 
 The septum at its base becomes very thin ; and if it be carefully 
 dissected or boiled, it is found that, at the base, its muscular fibres, 
 gradually attenuated, are stopped by cellular tissue, and that on the 
 base, as it were, is fixed that part of the heart containing the two 
 auricles and the commencement of the pulmonary artery and aorta. 
 If, therefore, by any morbid action, the base of the septum were 
 rendered fragile or brittle, or its cohesion with the auricular part 
 of the heart were weakened or destroyed, it is not difficult to un- 
 derstand that it might be thus detached, and gradually made to 
 give way and form an aneurismal sac at its base. 
 
 Though it is doubtful whether abscess is the cause of this lesion, 
 
 I think various facts show that chronic inflammation is the main 
 predisposing cause of its origin. In the first place, the disease 
 takes place in persons rheumatic or gouty, or who have had rheu- 
 matism ; and in whom often the endocardium is or has been inflam- 
 ed. In the second place, the effect of inflammation, it has been 
 shown, on the muscular tissue is to destroy its elasticity, to render 
 it brittle and easily lacerable, and sometimes to soften it. If there- 
 fore inflammation were attacking either the endocardium and spread- 
 ing to the muscular fibres, or were attacking the latter from the 
 first, it is easy to see that it might cause in an organ so liable to 
 distension and in action so incessant, laceration. In the third place, 
 we find the lesion preceded or accompanied by various changes in 
 different textures of the heart, which are generally regarded as ef- 
 fects of chronic inflammation. 
 
 § 9. Atrophy. Steatosis. — The muscular fibres are pale, or 
 
 yellow-coloured, soft, flaccid, and lacerable. The organ is small 
 and shrunk, and collapses. Fat-globules and cholesterine are infil- 
 trated into the cylinders of the muscular fibres. 
 
 § 10. Malformations. — These must be mentioned very shortly. 
 The most important are those which cause the communication of 
 the right and left chambers, or the venous and arterial sides of the 
 heart ; with various degrees of that blue or violet colour of the 
 skin, called Kyanosis. 
 
 These are the following. Is#, The foramen ovale or aperture 
 of Botallus, more or less open, sometimes forming a large and direct 
 communication between the auricles. 2J, The septum cordis being 
 deficient, or open, or perforated, congenital, or acquired; or the 
 
MORBID STATES OF THE H EA RT. MALFORMATIONS. 1063 
 
 two last mentioned united ; as in the case by Landoury.* * * § Zd, The 
 aorta arising in such a manner that its orifice corresponds to a con- 
 genital aperture in the septum, most commonly at the base of that 
 partition. Ath, The aorta arising at once from the right and left 
 ventricle, as in the case recorded by Sandifort, that by Dr Nevin, 
 and in the 47th case given by Gintrac, the case of M. Olivry, in 
 the case recorded by Dr George Gregory, in one given by Chas- 
 sinatjt and in one given by Casper.J 5th, The pulmonary artery 
 arising from the left ventricle, while the aorta arises from the right, 
 as in the case recorded by Baillie, one by Hildehrand,§ and one by 
 Dr Walshe.|| Qth, The aorta and pulmonary artery arising from the 
 left ventricle, as in the case recorded by M. Marechale. 1th, Only 
 one auricle and one ventricle, the latter giving rise to one trunk, 
 which afterwards divides into the aorta and pulmonary artery. 
 Zthly, One auricle and one ventricle, giving rise to a separate 
 aorta on the right, and a pulmonary artery on the left, as in the 
 two cases given by M. There. IT 
 
 These errors in formation may be traced to one of two causes ; 
 arrest or interruption in the process of development ; and mis- 
 adaptation of constituent parts. All of them, however, are fur- 
 ther connected with some form and degree of that obstruction or 
 arctation in the orifice of the pulmonary artery already noticed. 
 My limits and the nature of this work do not allow me to enter into 
 detail on the consideration of this subject; and all that I can here 
 
 * Observation de Communication Anormale entre les cavites du Coeiu', &c. Par 
 H. Landoury. Archives Generales, T. xlviii. p. 436. Paris, 1838. 
 
 t Observations d’Anomalies Anatomiques remarkables de I’appareil circulatoire, 
 &c. Par M. le Docteiu- Raoul Chassinat. Archives Generales T. xli. p. 80. Paris, 
 1836. 
 
 J Wochenschrift fur die Gesammte Heilkunde. Herausgegeben von den D. D. 
 Casper, Romberg und v. Stosch. Jahrgang, 1841. No. 13. 
 
 § Merkivurdige Missbildung des Herzens und der Grossen Gefiisse. Von Dr Hilde- 
 brand. Graefe und Walthers’ Journal der Chirurgie und Augenheilkunde, Bd. xxix. 
 Heft 3, Seite 490. 
 
 II Case of Cyanosis depending on Transposition of the Aorta and Pulmonary Artery. 
 By W, H. Walshe, M. D. Medico-Chirurgical Transactions, Vol. xxv. p. 1. Lond. 
 1842. 
 
 II Memoire sur le Vice de Conformation du Coeur, consistant seulement en une 
 Oreillette et un Ventricule. Par M. Thore. Archives Generales, T. lx. 316. Paris, 
 
 1842. 
 
 Note sur une Anomalie du Coeur chez un Enfant nouveau-ne. Par M. Thore. 
 Transposition of the Aorta which is on the right ; the pulmonary artery and auri- 
 cular appendages on left ; one Ventricle. Archives Generales, T. Ixi. p. 199. Paris 
 
 1843. 
 
1064 
 
 GENERAL AND PATHOLOGICAL ANATOMY. 
 
 say is, that the facts carefully examined render it highly probable, 
 that this obstruction and impediment in the orifice of the pulmo- 
 nary artery is the incipient phenomenon in the series of changes, in 
 short, must be regarded as the main cause of those imperfections, to 
 which the name of malformations is applied. While this impedi- 
 ment is in any manner formed at an early period of foetal exist- 
 ence, the other changes with hyanosis follow as matter of course. 
 
 The first two defects, foramen ovale, and imperfect septum, 
 are the most usual. These are the immediate consequences of 
 arrest of development in the formation of the heart. 
 
 In the early period of foetal existence, it is known, that the heart 
 consists of two chambers only, that is, one auricle and one ventri- 
 cle. The auricle, in the natural progress of formation, begins 
 about the end of the second or the beginning of the third month to 
 be divided into two portions, — a right and left, — by one thin mem- 
 brane proceeding from its posterior surface forwards, and another 
 thin membrane advancing backwards from its anterior surface. 
 These have crescentic margins, which in the natural course meet 
 and pass, overlying or imbricating each other, so as at the period of 
 birth,* or soon after, generally to complete the partition. When 
 however, from obstruction or impediment in the orifice of the pul- 
 monary artery, the blood which enters the right ventricle cannot 
 obtain by that vessel and the ductus arteriosus, a ready outlet, its 
 copious passage from the right to the left division of the auricle 
 continues uninterrupted and undiminished, and the membranous 
 folds are not only prevented from meeting and overlapping each 
 other, but their increase is suddenly stopped, and i\\Q foramen ovale 
 remains unclosed. 
 
 The septum of the ventricles is a growth partly from the poste- 
 rior wall of the common single ventricle, partly from the anterior 
 wall, beginning at the apex and proceeding in growth towards the 
 base. In the early period of foetal existence, the blood which enters 
 the right ventricle, and which is supposed to be chiefly that which 
 comes from the head, neck, and superior extremities, enters also 
 the left, and there partly proceeds to the aorta without, it is be- 
 lieved, entering the pulmonary artery. There is at least nothing 
 to prevent this, as the right ventricle communicates directly with 
 the left at the base till the seventh week, when the opening is 
 still large. As intra-uterine life advances, however, provision is 
 made for stopping this by the gradual growth of the septum towards 
 
 the base ; and at the end of the second month the septum is usually 
 
 4 
 
MORBID STATES OF THE HEART — HETEROLOGOUS GROWTHS. 1065 
 
 completed, and the orifice is closed. This growth, however, may be 
 interrupted at any stage of its progress, early or late ; and the in- 
 terruption is most likely to take place, when the orifice of the pul- 
 monary artery is small and more or less obstructed. If the inter- 
 ruption take place early, the septum is very imperfect, perhaps per- 
 forated in the middle. If it take place late, it is still imperfect, 
 though less so, and is deficient only at the base of the heart, so as 
 to allow blood easily to enter the aorta. Hence it results that the 
 septum is imperfect or perforated, and that often with that is ne- 
 cessarily conjoined either the aorta communicating with the right 
 ventricle, that is, its orifice corresponding with an aperture in the 
 septum, or arising from that chamber and the left at once. 
 
 The rare example of the heart consisting of only one auricle and 
 one ventricle is merely the extreme degree of this form of arrest 
 of development. 
 
 The case of the pulmonary artery arising from the left ventricle, 
 while the aorta issues from the right, takes place in a different 
 manner. A degree of mal-apposition in the vessels and the ven- 
 tricle must have taken place at an early period of foetal existence. 
 This we know takes place with other organs, with bones for instance, 
 and with certain portions of the abdominal and thoracic viscera. 
 
 All these lesions now mentioned are in different degrees incom- 
 patible with the continuance of life. Their incompatibility is very 
 nearly in the oi’der in which they are arranged. But to this must 
 be added, that their incompatibility and fatality are regulated, to a 
 certain extent, by the degree in which the orifice of the pulmonary- 
 artery is contracted and obstructed. If the contraction be not 
 very great, life may be continued for years ; and the individual, 
 though feeble, and evidently imperfectly nourished, may attain the 
 adult age or beyond that. If the contraction be greater, and so 
 considerable that the blood does not readily enter the orifice of the 
 artery, though he attain the age of puberty, life is rarely pro- 
 longed beyond that period. Kyanosis is considerable and almost 
 constant. If the aperture be still smaller, the individual dies in 
 infancy, or may be cut off a few days after birth. And w-hen the 
 artery is entirely obstructed, death takes place shortly after birth. 
 
 §11. Heterologous Growths. — The heart is observed to be in- 
 volved in enkephaloma when that structure appears in the lungs and 
 in the liver ; and it is also affected by the melanotic deposit. In 
 the first case the enkephaloid matter forms a species of investing 
 mass encroaching on the whole substance of the heart. In the 
 
GENERAL AND PATHOLOGICAL ANATOMY. 
 
 ldl)6 
 
 latter case, the melanotic deposit may either appear in this manner, 
 or it may be infiltrated into the substance of the organ. 
 
 § 1 2. Ektopia. Displacement. — The heart is pushed to the 
 right side in cases of empyema of the left pleura, with copious eflFu- 
 sion. This, however, is the mere effect of the effusion ; and dis- 
 appears when that is absorbed. This is not ektopia. 
 
 This terra is applied to those displacements of the heart, in which, 
 from some deficiency in the formation of the enclosing parts, as the 
 sternum, the ribs, tbe diaphragm, the heart is found in a situation 
 different from its natural. The common point or character is, that 
 the heart is out of the cardiac region ; and it may be either in that 
 of the head, that of the chest, or that of the abdomen. The first 
 is rare. The second and third, which are more common, have 
 been distinguished by Fleischmann and Weese under the names 
 of Ektopia Pectoralis and Ektopia Ventralis. 
 
 Under the head of Ectopia Pectoralis are comprehended all those 
 instances of displacement, in which the heart protrudes on the sur- 
 face of the chest, either with deficiency of the sternum and ribs, 
 or these remaining entire, at either extremity of the sternum. 
 
 Under the head of Ektopia Ventralis are comprehended those 
 instances in which, from deficiency of the diaphragm, the heart is 
 protruded among the abdominal viscera. 
 
 In the first case it is rare to find the heart protruded without 
 deficiency of the sternum and ribs. It has been observed, however, 
 by Weese in the sheep. More commonly the sternum is wanting, 
 or it is divided by a fissure. With this other malformations are 
 usually associated ; for instance the foramen ovale open, the septum 
 perforated, and the aorta connected with both ventricles. The 
 pericardium is sometimes wanting ; and in some instances the me- 
 diastinum is deficient. 
 
 Ektopia Ventralis may be attended either with integrity or more 
 or less deficiency of the sternum and ribs. The prolapsed heart 
 is sometimes surrounded by a membrane like that of a hernial sac. 
 
 To these forms of Ektopia Breschet has added that in the region 
 of the head, Ektopia Cephalica. 
 
 For details I refer to the Commentary of Weese,* and the Me- 
 moir of Breschetf 
 
 * De Cordis Ectopia Commentatio Anatomico-Pathalogica. Auctore Carolo Weese, 
 M. et Cli. D. Accedunt Tabulae Aenese vi. Berolini, 1819. 4to. 
 
 -]- Memoire sur TEctopie de I’Appareil de la Circulation, et particulierement sur 
 celle dll Coeur. Par G. Breschet, D. M. &c. Repertoire Generate, T, ii. p. 1. Paris, 
 1826. 
 
 6 
 
INDEX 
 
 Abscess of the brain . Page 283 
 
 connection with abscess and 
 
 gangrene of the lungs . 285 
 
 connected with disease of the 
 
 internal ear . . 286 
 
 in the heart, instances of 402, 1043 
 
 in nver, connection between 
 
 and injuries of liver and phlebitis, 
 868, 876 
 
 of lungs, on . . 997 
 
 in testis . . . 968 
 
 Absorption, interstitial, of bones 488 
 Acephalocysts in bone . . 489 
 
 in brain . . 350 
 
 in cellular tissue or 
 
 adipose . . . 75 
 
 in heart , , 410 
 
 in liver . 905 
 
 in lungs . 1 036 
 
 in mucous membranes 678 
 
 in serous membranes 741 
 
 Acini, their nature . . 768 
 
 Addison, Mr William, his researches 
 on the air-cells of the limgs . 977 
 
 Adenoma of brain . . 333 
 
 Adenosis, inflammation of lymphatic 
 glands . . . 217, 218 
 
 Adipose membrane, its anatomical 
 characters and distribution . 49 
 
 its diseased states 55 
 
 the seat of difiuse 
 
 inflammation . . .58 
 
 Adhesion in mucous surfaces . 670 
 
 Akinopyesis, suppuration of acini of 
 Mver .... 904 
 Anatomy, general, its history . 1 
 
 Aneurism, its nature, causes, and va- 
 rieties . . .98, 102 
 
 in arteries of brain . 7 34 
 
 varicose . . 104 
 
 Air-cells, recent researches on their 
 existence and characters . 97 6 
 
 Akne, its seat . . 526, 529 
 
 Anenkephalia, deficient formation of 
 brain, its nature and causes . 355 
 
 Aneurism, partial, of heart, its nature 
 and characters, . . 1054 
 
 Angiektasis, capillary aneurism of 
 bones . . . 489 
 
 of 
 
 skin , . . 540 
 
 AngioUucitis, its characters and 
 causes . . .211 
 
 Aorta, contraction and obliteration 
 of ... 85,110 
 
 Aortic valves, morbid states of . 91 
 
 Aphtha, its seat and characters . 570 
 
 Apoplexy, febrile, its nature and pa- 
 thology . . . 304 
 
 Apoplexy, traumatic, or that from 
 violence . . Page 305 
 
 its anatomical characters 316 
 
 neonatorum, in infants 307 
 
 nervous, its true nature 308 
 
 state of brain and its ves- 
 sels in . . .291 
 
 Arachnoid membrane, its characters 
 and distribution . . 695 
 
 Arctation of bronchial tubes . 600 
 
 Artery, its anatomical characters and 
 distribution ... 76 
 
 Arteries distinguished into orders 83 
 
 morbid states of . 87 
 
 Arthropyema after phlebitis . 7 34 
 
 Atheroma, characters of . 201 
 
 Atheromatous deposition in arteries 95 
 Atrophy of the brain, its characters 
 and causes . . 330 
 
 Atrophy of muscles and muscular 
 organs . . . 407 
 
 Atrophy of pancreas . . 847 
 
 of liver . . . 886 
 
 of kidney, two forms of . 961 
 
 of breasts . . 964 
 
 of testis . .970 
 
 of heart . . 1062 
 
 of the valves of the heart 1046 
 
 of limbs dependent on atro- 
 phy of brain . . 357 
 
 Bichat, his services to general anatomy 8 
 Bidder, his researches on the Malpig- 
 hian bodies . . 996 
 
 Bilious pneumonia . . 990 
 
 Blebs or bulla, their seat . 508 
 
 Blennorrhoea . . . 654 
 
 Blood, its constitution . 1 8 
 
 Blood deposits in pulmonary arteries 1000 
 BoU, its seat and natme . 527 
 
 Bone, on its minute structure 427, 431 
 
 its development . 436 
 
 on morbid states in . 444 
 
 Bonn, Andrew, his merits in general 
 anatomy ... 6 
 
 Bony induration of muscles . 409 
 
 Bourgery, his researches on the ends 
 of the bronchial tubes . 97 6 
 
 Bo^vman, his researches on the Mal- 
 pighian bodies . . 791 
 
 Brain, structure of, and its parts 223 
 
 microscopical anatomy of 268 
 
 morbid states of . . 277 
 
 aneurisms in arteries of . 734 
 
 Bronchi, membranes spit up from 578 
 Bronchial tubes, on their terminations 97 6 
 Bronchitis, acute and chronic, its 
 seat, nature, and effects . 578 
 
 from foreign bodies in wind- 
 pipe and bronchi . . 584 
 
1068 
 
 INDEX, 
 
 Ctecum, inflammation of Page 632 
 
 Calcareous and osseous deposits in 
 brain . . .347 
 
 concretions in lungs, on 
 
 their origin and indication 1033, 1035 
 
 Capillary vessels, system of, characters 131 
 
 — morbid processes 
 
 taking place in . .136 
 
 Cartilage, its structure and forms 490 
 
 its morbid states . 492 
 
 adventitious deposits of, in 
 
 serous membranes . . 740 
 
 Cartilaginous union of ribs and other 
 bones . . . 478 
 
 Cauliflower excrescence of the uterus 680 
 Cerebellum, morbid states of . 300 
 
 Cheloid tumour . . 541 
 
 Chest, malformation in bones of 478, 481 
 Chondroma, character of in brain 344 
 
 of serous membranes 740 
 
 Chondrosis of ureters . 943 
 
 Choroid plexus, inflammation in 724 
 
 Cirsoid aneiu’ism, its characters 100 
 
 Coal miners’ lung, on its nature 1041 
 Colloid cancer in mucous membranes 676 
 Conarion or pineal gland, morbid 
 states of . . . 349 
 
 Concretions, lacrymal . 827 
 
 salivary . . 829 
 
 in pancreas . 848 
 
 in hepatic ducts . 903 
 
 in gall bladder and ducts 919 
 
 Congestion, on its characters . 139 
 
 Consolidation of lungs, on its nature 
 and causes . . 983 
 
 Contraction, morbid, of hand and fin- 
 gers , . . 421 
 
 Corpuscula of bone described 432 
 
 Croup, its nature and scat . 577 
 
 Cystidia, chronic inflammation of 
 bladder . . . 657 
 
 Cystirrhoea, suppurative catarrh of 
 bladder . . . 655 
 
 Cystosarkoma of mamma . 963 
 
 .in testis . 971 
 
 Cysts in cellular tissue . 48 
 
 in kidney . . 961 
 
 in liver . . 909 
 
 in mamma . . 963 
 
 in testis . . 971 
 
 Delirium talcing place in the phthisical 722 
 Demodex Folhculorum, the follicular 
 worm, its characters . 530 
 
 Desmodia, inflammation of ligament 
 and fascia . . . 417 
 
 Desmosis of testis . . 970 
 
 Diastasis or separation of epiphyses 447 
 Diffuse inflammation, its pathological 
 characters ... 37 
 
 Dilatation of bronchi . . 605 
 
 — the effect of 
 
 aneurismal tumours . 606 
 
 Dilatation of the heart Page 1050 
 
 Disjunctive inflammation, its seat and 
 characters . . .58, 67 
 
 Displacements of mucous membranes 680 
 Diverticula . . . 682 
 
 Dropsies, causes of . . 191,709 
 
 Duodenum, morbid states affecting 620 
 Dura mater, thickening of . 743 
 
 Dysentery, its seat and characters 639, 640 
 Ear, disease of, giving rise to abscess 
 
 of brain . . . 286 
 
 Echinococcus in the liver . 908 
 
 Ekthyma, characters and seat . 525 
 
 Ektopia of heart . . 1066 
 
 Elephantiasis, its nature . 1 94 
 
 Emphysema, superficial, yimermaiosts 46 
 
 of lungs 594 
 
 Empyema, its causes and nature 7 1 3 
 Enkephalin, its nature . . 277 
 
 Enkephalaemia or apoplexy, state of 
 brain and vessels in . . 291 
 
 Enkephalelleipsis, deficiency of brain 
 or its parts, its causes . 355 
 
 Enkephaloma in bones . . 488 
 
 in brain . . 352 
 
 in joints . . 756 
 
 in kidneys . 963 
 
 in liver . . 911 
 
 in lungs . . 1036 
 
 in mamma . 967 
 
 in pancreas . 851 
 
 in serous membranes 742 
 
 in testis . . 971 
 
 Entqzoa in brain . . 904 
 
 in liver . . .917 
 
 in lungs . . 1036 
 
 Enteria (enteritis mucosa) . 620 
 
 Epiphora, its seat . . 568 
 
 Erectile system, its anatomical cha- 
 racters . . . 169 
 
 its morbid states 1 7 6 
 
 Exanthemata, their seat . 506 
 
 Exfoliation of bones, different sorts of 450 
 Exhalant vessels, their characters 187 
 
 morbid states in 
 
 them . . .190 
 
 Exostosis, different sorts of 451, 474 
 
 medullary exostosis 474 
 
 Fascia, palmar, chronic inflammation 
 and contraction of . . 42) 
 
 Fat-globules in the renal tubules in 
 granular disease . . 953 
 
 in arteries . 1046 
 
 in liver . . 901 
 
 in heart . . 1 062 
 
 Fever, on the state of the vessels in 156 
 
 on the state of the blood in 1 63 
 
 state of the brain in . 316 
 
 Fibrous, white, system, its structure 
 and distribution . . 414 
 
 — diseases tak- 
 
 ing place in . . . 417 
 
INDEX, 
 
 1069 
 
 Fibrous and fibro-cartilagiiious tu- 
 mours . . Page 745 
 
 Fibro-cartilage, its structure and forms 494 
 
 its morbid states 495 : 
 
 Fibro-serous membranes, m orbid states ! 
 
 affecting . . . 743 
 
 Fibrous tissue, on the white . 414 | 
 
 on the yellow . 426 : 
 
 Filamentous tissue, its anatomical [ 
 
 characters and distribution . 30 ; 
 
 its morbid states 35 I 
 
 Fistulae, congenital, in neck, their ori- 
 
 gin from the branchial slits 
 
 682 
 
 FistultB of mucous cadties 
 
 683 
 
 Fleshy tubercle of the womb 
 
 679 
 
 Fluids in their soimd state 
 
 18 
 
 in morbid state 
 
 24 
 
 Follicles cutaneous, their diseased states 529 
 
 parasitical animal of 
 
 530 
 
 of mucous membranes 
 
 . 555 
 
 diseases affecting 
 
 621, 643 
 
 Follicular enteritis . 625, 643 j 
 
 fever . . 626 
 
 Fragility of bones . . 488 i 
 
 Fungus hjematodes in different or- | 
 gans. See enkephaloma 
 Gall-stones, their effects . 919, 920 
 
 Ganglions, structure of . 365, 371 j 
 
 functions of . 373 ] 
 
 Gangrene as an effect of inflammation 156 
 
 of the liver . 876 
 
 of the kidney . 941 
 
 of the lungs . 992 
 
 Gerlach, his researches on the Malpi- 
 ghian bodies . . 794 
 
 Glands, lymphatic, their anatomy, 215 
 
 morbid states of . 217 
 
 of mucous membranes . 555 
 
 diseases affecting , 621 
 
 secreting, on their structure in 
 
 general , . . 757 
 
 diseased states affecting 811, 813 
 
 Granular disease of liver . 887 
 
 of kidney . 946 
 
 Grinders asthma or bronchitis, its na- 
 tvrre and forms . . 597 
 
 Gumma, periosteal swelling so called 448 
 Hairs, structure of ; . 547 
 
 Haller, his services to general anatomy 4 
 Hsematoma, the blood-cyst, characters 
 of . . , . 198 
 
 in brain . 351 
 
 in bone . . 483 
 
 Heart, abscess of, its characters 402, 1043 
 Helicine arteries, their characters 173 
 Hemorrhages, physiological causes of 193 
 Hemorrhage from the skin . 538 
 
 from the liver . 881 
 
 from the mucous mem- 
 branes . . . 663 
 
 from the serous mem- 
 branes . . . 729 
 
 Hepatitis, its nature and varieties Page 853 
 
 Histology or doctrine of the elemen- 
 tary tissues . . 1 , 10 
 
 Hydatids in adipose tissue . 75 
 
 in bone . . 489 
 
 in brain . . 350 
 
 in heart . . 410 
 
 in liver . . 905 
 
 in lungs . . 1036 
 
 in mamma . 963 
 
 in mucous membranes . 678 
 
 in serous membranes . 1036 
 
 Hygroma or hydatoma, the serous 
 cyst in . . . 198 
 
 or hydatoma in liver . 908 
 
 ^ in kidney . . 961 
 
 in mamma . 963 
 
 Hymenarthritis, characters of . 748 
 
 Hypertrophy as an effect of inflam- 
 mation . . . 168 
 
 of the brain, its nature 327 
 
 of the spleen . 183 
 
 of the liver 
 
 of muscles and muscular 
 
 organs . . . 406 
 
 of the heart . 1005 
 
 of the bronchi . 644 
 
 of the pancreas : 819 
 
 of the parotid gland 883 
 
 of liver . . 862 
 
 of the kidnej' . 964 
 
 — — of mamma . 964 
 
 of prostate gland . 972 
 
 Ileo-coecal inflammation & abscess 42, 632 
 Ileum and ileal fo Hides, tubercular - 
 disease in . . 650 
 
 Imperforations . . 682 
 
 Indmation of cellular tissue . 43 
 
 as an effect of inflamma- 
 tion . . . 155 
 
 of the brain 320, 325 
 
 spleen . 185 
 
 lungs . 983, 1009 
 
 of intestines . 645 
 
 glands 812, 818, 820 
 
 Inflammation, on the state of the ves- 
 sels in . . .137 
 
 Inflammatory dropsy . 711 
 
 Insanit}-, state of cerebral membranes 
 in _ . . . 724 
 
 Intestines, state of, in fever . 648 
 
 pulmonary con- 
 sumption . . 1030 
 
 Itch insect, its history . 543 
 
 Ivory, degeneration in bones 489 
 
 Kaltenbrimner, accoimt of his views 
 and researches . . 140 
 
 Keloid tumour . . 541 
 
 Keroma of brain . . 341 
 
 characters of, in muscles 410 
 
 Kidneys, minute structure of 781 
 
 morbid states affecting 929 
 
1070 
 
 INDEX, 
 
 Kiernan, Mr, his researches on the struc- 
 
 ture of the liver . Page 780 
 
 Kinetic textui'es, anatomy of 395 
 
 Kirrhosis of liver, its characters and 
 nature . . . 887 
 
 of lung, its characters 1034 
 
 Kii-sus, its nature . . 212 
 
 Kolliker, his researches on the Mal- 
 pighian bodies . . 802 
 
 Kolloides of brain, its characters 340 
 Kolloid cancer in a stomach 676 
 
 in mamma . 966 
 
 in testis . 971 
 
 Kyanosis, its causes . 1062, 1064 
 
 Laceration of the brain . 299 
 
 muscles . 409 
 
 the heart . 409 
 
 Laryngitis, its seat . . 571 
 
 chronic . . 572 
 
 Liver, its structure . . 774 
 
 morbid states affecting 853 
 
 Lobular pneumonia, its seat and cha- 
 racters . . . 989 
 
 Lungs, their minute structure 973 
 
 morbid states . 981 
 
 Lupia, encysted tumour, characters 
 of ... 203 
 
 Lymph, on its production and na- 
 ture . . 143, 144 
 
 Lymphatic system, anatomical struc- 
 ture and distribution . 204 
 
 morbid states of 
 
 and affecting . . 210 
 
 glands, their anatomy 215 
 
 morbid states 217 
 
 Malakenkephalon, diminished consist- 
 ence of the brain, its causes 31 7 
 
 Malakosis of pancreas . 845 
 
 ofUver . . 878 
 
 Malformations on the mucous mem- 
 branes . . . 681 
 
 Malformation of the heart 1062 
 
 Malignant pustule, its nature 525 
 
 Malpighi, his merits as an anatomist 3 
 Malpighian bodies, on their structure 789 
 Mamma, its minute structure 810 
 
 morbid states of, and affecting 963 
 
 Marasmus, see peritonitis . 720 
 
 Margaroides or cholesterine tumour 
 of brain, characters of . 343 
 
 Marrow, its anatomical disposition 436 
 Medullary membrane, its nature and 
 distribution . . 436 
 
 Medullary sarkoma in various organs, 
 see Enkephaloma 352, 971, 967 
 
 Melanosis, occasionally encysted, in 
 brain . . . 204 
 
 in heart . . 353 
 
 in liver . . 916 
 
 in lungs . . 1040, 104 
 
 in muscles . 410 
 
 in pancreas . 853 
 
 Melanosis, spurious, or from inhalation of 
 
 black matter . Page 1041 
 
 Melikeris, characters of . 200 
 
 in skin . . 540 
 
 Melituria, its characters . 29 
 
 Membranes, their anatomy . 497 
 
 mucous, their structure 
 
 and varieties . . 548 
 
 diseased states in . 566 
 
 Meningeal irritation in fever . 722 
 
 hemorrhages, nature and 
 
 characters of . . 730 
 
 Meningitis, seat of . . 721 
 
 chronic, its state in the insane 724 
 
 Milzbrand, its nature . . 525 
 
 Mollities ossium, on . . 485 
 
 MoUuskum, its seat and forms 532 
 
 Morbid development of exhalants 197 
 
 Mucous membranes, structure and dis- 
 tribution of . . 548 
 
 diseases in, and 
 
 affecting , . . 566 
 
 Muscle, anatomy and microscopical 
 structure . . . 395, 399 
 
 morbid states of, and affecting 401 
 
 Nails, anatomy of . . 547 
 
 Nekrosis, its nature and causes 453 
 
 different theories on 459 
 
 Nephritis . . . 929 
 
 Nephropyema . . . 936 
 
 Nerves, their anatomical structure 
 and distribution . . 359 
 
 microscopical structure of 37 1 
 
 morbid states of, and in 379 
 
 Neuralgia, on its seat and nature 380 
 Neurilema, its structure and arrange- 
 ment . . . 360 
 
 morbid states of . 379, 381 
 
 Neurilemmia, its nature and effects 381 
 Newitis, its characters, causes, and 
 effects . . . 379 
 
 Neuroma or nerve-swelling, its cha- 
 racters . . . 387 
 
 Neuromation or small nerve-swelling 391 
 Node, periosteal swelling, its nature 448 
 Obliteration of arteries 85, 109, 110 
 
 of bronchial tubes . 600 
 
 of veins . . 127 
 
 Obstruction of the tuhuU testis . 968 
 
 Occlusion, or obstruction of arteries 106 
 
 — of pulmonary artery . 1049 
 
 Qilsophagus, its diseases , 607 
 
 Ophthalmia, its seat . 567 
 
 Orchitis, its seat and effects . 968 
 
 Organization, distinctive characters of 225 
 Ossification of arteries . . 92 
 
 of serous membranes 740 
 
 of veins . . 130 
 
 Osteitis, its phenomena and effects 444 
 Osteo-sarkoma, its seat and nature 451 
 Osteo-steatomatous state of cerebral 
 arteries, causing cataphora . 732 
 
INDEX. 
 
 1071 
 
 Otitis, its seat . . Page 569 
 
 Paedarthrokake, its characters and 
 causes . • . 475 
 
 Pancreas of the sturgeon, its structru-e 764 
 
 of mammalia, its structure 776 
 
 diseased states affecting 831 
 
 Parasitical animals in skin . 543 
 
 Parotid gland, diseased states affecting 816 
 
 tumours involving 825 
 
 Pellagra, its nature . . 537 
 
 Pericardial hemorrhage . . 735 
 
 Pericardium, its characters . 689 
 
 Periosteum, its influence in ossifica- 
 tion .... 423 
 
 Periostitis, its seat and effects 418, 448 
 Peritoneal hemorrhage . . 736 
 
 Peritonseum, its extent and distribu- 
 tion • . . 684 
 
 diseased states affecting 698 
 
 Peritonitis, puerperal . 716 
 
 chronic . . 720 
 
 Perityphlitis, its seat and nature 632 
 Peyer’s glands, their seat and struc- 
 ture . . . 555, 556 
 
 diseases affecting 621, 625 
 
 Phthisis laryngea, its seat . 573 
 
 pulmonaUs, state of lungs in 1009 
 
 state of other or- 
 gans in . . . 1030 
 
 Phlebitis, its seat, causes, and effects 
 
 124, 128 
 
 followed by pm’ulent de- 
 posits within joints . . 754 
 
 hepatic, circumstances un- 
 der which it occurs . . 879 
 
 pulmonary, its nature 999 
 
 Phleboliths or vein stones 130, 1036 
 Pia mater, characters and distribu- 
 tion of . . . 692 
 
 Pimples, their characters . 509 
 
 Pleurisy^ chronic, its seat . 713 
 
 Plexus, nervous, structure and ^ar- 
 rangement of . . . 368 
 
 Pneumonia, on its characters and seat 981 
 Pneumothorax, its nature and seat 7 37 
 Poisons, effects of corrosive, on sto- 
 mach . . . 616 
 
 Polypus, its forms . . 672 
 
 Pori of Havers in bone . 429, 430 
 
 Puerperal peritonitis . . 716 
 
 Pulmonary artery, blood deposits in 1000 
 
 obstruction of 1049 
 
 apoplexy or hemorrhage, 
 
 pathology of . 1001, 1004 
 
 Purulent collections within joints af- 
 ter phlebitis . . . 754 
 
 Pustules, their seat and forms . 518 
 
 Rainey, Mr George, his researches on 
 the air-cells of the lungs . 97 9 
 
 Ranula, its nature . 820, 830 
 
 Reichert, his views as to the Malpig- 
 hian bodies . . .794 
 
 Reparation of bone, on the agents of 
 
 Page 460 
 
 Reticular cancer in mucous surfaces 676 
 
 in mamma . 966 
 
 Reunion of nerves . . 383 
 
 Reynaud, his examination of the ter- 
 minal ends of the bronchial tubes 976 
 Rheumatism seated mostly in fascia 420 
 
 affecting the synovial 
 
 membranes . . .751 
 
 Ribs, cartilaginous union of . 478 
 
 Rickets on nature and characters 482 
 
 Rupture of muscular organs . 408 
 
 of the heart . . 409 
 
 Ruysch, his services to minute ana- 
 tomy ... 4 
 
 Salivary glands, their structure 775 
 
 morbid states affecting 813 
 
 Sarkoma in cellular tissue . 46 
 
 — in adipose membrane 73 
 
 Schroeder, his researches on the seat 
 of pulmonary tubercles . 1017 
 
 Scaly diseases, their seat and causes 510 
 Serous membranes, their structure, 
 distribution . . 683 
 
 and varieties 689 
 
 diseases affecting 697 
 
 Sinew, structure of . . 412 
 
 diseases occurring in . 413 
 
 Sivvens, their nature and origin 537 
 
 Skin, its structure . . 497 
 
 morbid states in and affecting 504 
 
 Skirrhus in mucous membranes 675 
 
 of pancreas, doubtful , 839 
 
 on its nature . . 848 
 
 of mamma, its nature and 
 
 varieties . . . 965 
 
 in testis . . 971 
 
 in skin, mostly in tubercular 
 
 forms . . . S44 
 
 of skin . . 542 
 
 Skleroma of brain . . 332 
 
 of intestines . . 645 
 
 of pancreas . . 337 
 
 of hver, incipient kh-rhosis 865 
 
 of ureters . . 943 
 
 Sklerenkephalia, induration of the 
 brain, its nature and character 320, 325 
 Small-pox, morbid anatomy of . 519 
 
 effects on mucous mem- 
 branes . . . 649 
 
 Sloughing in the mucous membranes, 
 its nature . . . 662 
 
 Softening as an effect of inflammation 154 
 
 of the brain, on its natirre 
 
 and characters . . 278 
 
 of the spleen, on its nature 160 
 
 of the pancreas . 845 
 
 of muscles, an effect of in- 
 flammation . . 404, 406 
 
 Spina ventosa, its nature and charac- 
 ters , . . 464 
 
J072 
 
 INDEX. 
 
 Spinal nianow, lieniorrluige from Page 312 
 
 ■ within its 
 
 sheath . . . .735 
 
 disease, disease of l<idne3'S imi- 
 tating . . . 944 
 
 Spleen, its minute structure . 174 
 
 its morbid states . 179 
 
 Steatoma, characters of . 201 
 
 Steatomatous or fatty depositions in 
 arteries ... 96 
 
 state of arteries de- 
 pends on fat or cholesterine . 1046 
 
 state of cerebral arte- 
 ries causing cataphora . 732 
 
 Steatosis of muscles, its nature . 407 
 
 of the heart . . 407 
 
 of liver . . 900 
 
 of kidneys, granular disease of 946 
 
 Stereomorphic textures, theiranatomy 395 
 Stomach, its diseased states . 607 
 
 chronic ulcer of . 609 
 
 softening of . .616 
 
 Stricture, inflammatory, its nature 668 
 Struma in liver, characters of . 910 
 
 Suppuration as an effect of inflam- 
 mation . . .149 
 
 in the heart, instances of 
 
 402, 1043 
 
 of pancreas . 833 
 
 of liver . 859, 862 
 
 — metastatic, and after 
 
 phlebitis . . . 867 
 
 Suppurative inflammation of kidney 942 
 Synovial membranes, structure of . 746 
 
 morbid states in 748 
 
 in rheumatism . 751 
 
 Teeth, on their structure and develop- 
 ment , . . 441 
 
 morbid states in . . 489 
 
 Tendon. See Sinew . . 412 
 
 morbid states affecting . 413 
 
 Testis, its structure . . 805 
 
 its diseased states . 967 
 
 Tetanus, or lock-jaw, on its pathology 385 
 Thecal inflammation . .750 
 
 Thrush, its seat and characters . 57 0 
 
 Trachea, ulceration affecting . 575 
 
 state of, in the phthisical 1029 
 
 Trichina spiralis, a microscopical 
 worm in muscle . . 411 
 
 Tubercles in liver, characters of . 911 
 
 imlmonary, not from dis- 
 eased glands . . 1015 
 
 different kinds of 1020, 1023 
 
 Tubercular disease in the serous 
 membranes . . .737 
 
 disease in ileum and fol- 
 licles . . . 650 
 
 Tuberculation of glands, on its dha- 
 racters . . Page 222 
 
 of lungs, seat and 
 
 mode of formation . 1008, 1016 
 
 Tumours of and in the brain . 332 
 
 Turgor vitahs, its physiological causes 175 
 Tympania (inflammation of tympanal 
 cavity) . . . 57 0 
 
 Typhlitis, its seat and forms . 632 
 
 Typhoid jmeumonia, its characters 991 
 Tj'phus, intestinal, its true nature 
 
 626, 628, 629 
 
 Tj'roma of brain . . 337 
 
 Tyromatosis of lungs . 1008, 1015 
 
 see tubercles and tuber- 
 culation . . . 1008 
 
 Tj'romatous deposit in lymphatic 
 glands . . . 222 
 
 in secreting 
 
 glands 853, 910, 943, 963, 969, 972 
 
 deposition in mucous 
 
 membrane . . 674 
 
 deposit in serous mem- 
 branes, especially ireritonaeum 737 
 
 or tubercular disease in 
 
 testis . . . 969 
 
 Ulcer, chronic, of stomach . 609 
 
 Ulceration of brain . . 291 
 
 of cartilages . 492 
 
 as an effect of inflamma- 
 tion . . .153 
 
 of intestines . 630 
 
 Ulcers of larynx and windpipe 575 
 
 Ulceration of nerves . . 383 
 
 Urea, its chai'acters . . 23 
 
 in blood ... 27 
 
 Urethra, purulent inflammation in 654 
 
 Vagina, affections of . . 661 
 
 Varix, its nature . . 129 
 
 aneurismal . . 104 
 
 Veins, structure and distribution of 112 
 
 diseased states of . 124 
 
 Velvet-like degeneration of synovial 
 membrane . . .750 
 
 Vesicles, their seat . . 512 
 
 Villi, on their nature . . 653 
 
 Villous membranes . 548, 553 
 
 5 diseases in . 566 
 
 Vomica, definitions of . . 997 
 
 Water in brain, see meningitis . 721 
 
 Wolffian bodies, their nature . 783 
 
 Womb, its profluvial diseases . 659 
 
 Worms in muscles . . 411 
 
 in lungs . . 1 037 
 
 in follicles of skin . 530 
 
 Yaws, their characters and nature 535 
 
 Yellow fibrous tissue, its structure 
 and properties . . 426 
 
 EDINBURGH : PRINTED BY STARK AND COJIPANV, 
 OLD ASSEMBLY CLOSE. 
 


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