*V_- SURGEON GENERAL'S OFFICE LIBRARY. L V v Oi. A .IMJLL mi 8—513 ■;& i ^V-V A «^ ** THE. MORBID ANATOMY ?7 ^ OF ^ SOME OF THE MOST IMPORTANT PARTS ".V OF THE f/fa**^pS MATTHEW BAILLIE, M. D. F. R. f % , r ELLOW OF THE ROYAL COLLEGE OF PHYSICiANS3 iND PHYSICIAN OF ST. GEORGE'S HOSPITAL* r T = illE FIRST AMERICAN EDITlo'Sr, *» . ytv s - V ■ ALBANY: J':^V\ " y PRINTED BY BARBER (3 SOUTHWICk/' • FOR THOMAS SPENCER, BOOK- SELLER, MARKET-STREET* ------- I M,DCC;XCV. «-, TO W Sir GEORGE BAKER, Bart. PRESIDENT, AND THE FELLOWS OF THE ROYAL COLLEGE OF PHYSICIANS, THIS VOLUME / i i / IS, WITH THE GREATEST RESPECT, INSCRIBED BY THEIR MOST OBEDIENT HUMBLE SERVANT, Matthew Bail lie. \ PREFACE. X HFRE~are some diseases which consist only in morbid actions, but which do not produce any change in the structure of parts: these do not admit of anatomical inquiry after death. There are other diseases, however, where alterations in the structure take place, and these become the proper subjects of anatomical examination. The object of this work is to explain more mi- nutely than has hitherto been done, the changes of structure arising from morbid actions in some of the most important parts of the human body. This, I hope, will be attended with some ad- vantages to the general science of medicine, and ultimately to its practice. It is very much to be regretted that the knowledge of morbid structure does not certainly lead to the knowledge of mor- bid actions, although the one is the effect of the other ; yet surely it lays the most solid founda- tion for prosecuting such inquiries with success. In proportion, therefore, as we shall become ac- quainted with the changes produced in the struc- ii Pre?ace1 ture of parts from diseased actions, we shall be more likely to make some progress towards a knowledge of the actions themselves, although it must be very slowly. The subject in itself is extremely difficult, because morbid actions arc going on in the minute parts of an animal body excluded from observation; but still the exam- ination of morbid structure seems to be one of the most probable means of throwing light up- on it. Another advantage, arising from the more at- tentive examination of morbid structure, is, that we shall be able to distinguish between changes, which may have some considerable resemblance to each other, and which have been generally confounded. This will ultimately lead to a more attentive observation of symptoms while diseas- ed actions are taking place, and be the means of distinguishing more accurately diseases. When this has been done, it will be more likely to pro- duce a successful inquiry after a proper method of treatment. Another advantage, arising from a more atten- tive observation of morbid structure, is, that we shall be fitted to detect diseased alterations in the organization of parts, which are but little? or not at all known. This will lay the foundation of our inquiry into the diseases themselves, so that Preface. . 111 we shall add to our knowledge of the pathology of the body, and perhaps also to our knowledge of remedies. A third advantage still, from observing atten- tively morbid structure, is, that theories, taken up hastily about diseases, will be occasionally cor- rected. The human mind is prone to form o- pinions upon every subject, which is presented to it, but, from a natural indolence, is frequently averse to inquire into the circumstances, which can alone form a sufficient ground for them.— This is the most general cause of false opinions, wrhich have not only pervaded medicine, but every other branch of knowledge. When, how- ever, the mind shall be obliged to observe facts, which cannot be reconciled with such opinions, it will be the best means of shewing that they are unfounded, and of making them be laid aside. We grant, it does not always happen that men are induced to give up their opinions, or even to think them wrong, upon observing facts, which do not agree with them, but surely it is the best means of producing this effect; and whatever change may be wrought on the individuals them- selves, the world will be convinced, who have fewer prejudices to combat. A person, who previously had attended very accurately to symptoms, but was unacquainted iv Preface. with the disease, when he comes to examine the body after death, and finds some of the appear- ances that are described in this Treatise, will ac- quire a knowledge of the whole disease. He will be able to guide himself on such knowledge in similar cases, and also to inform others. It may, perhaps, too, lead him to a proper method of treatment. When a person has become well acquainted with diseased appearances, he will be better a- ble to make his remarks, in examining dead bo- dies, so as to judge more accurately how far the symptoms and appearances agree with each other; he will be able also to give a more distinct ac- count of what he has observed, so that his data shall become a more accurate ground of reason- ing for others. The natural structure of the different parts of the human body has been very minutely ex- amined, so that anatomy may be said to have ar- rived at a high pitch of perfection; but our knowledge of the changes of structure produced by disease, which may be called the Morbid Anatomy, is still very imperfect. Such chang- es have commonly been observed only in their more obvious appearances, and very seldom with much minuteness or accuracy of discrimina- tion. Preface. v Any works explaining morbid structure, which I have seenj are very different in their plan from the present: they either consist of cases, con- taining an account of diseases and dissections, col- lected together in periodical publications, with- out any natural connection among each other; or consist of very large collections of cases, ar- ranged according to some order. In some of these periodical works, the diseased structure has been frequently explained with a sufficient de- gree of accuracy, but in all the larger works it has been often described too generally. The de- scriptions, too, of the principal diseased appearan- ces, have been sometimes obscured by taking notice of smaller collateral circumstances, which had no connection with them, or the disease from whence they arose. Both of these faults even too frequently occur in the stupendous work of Morgagni de Causis et "Sedibus Morborum, upon which, when considered in all its parts, it would be difficult to bestow too high praise ; besides, the bulk of these very large collections prevents them from being generally in the possession Of practitioners, and also renders them more diffi- cult to consult. In the present work we propose to give no cases; but simply an account of the morbid chang- es of structure, which take place in the thoracic B vi Preface. and abdominal viscera, in the organs of genera- tion in both sexes, and in the brain. This will be done according to a local arrangement, very much in the same manner as if we were describ- ing natural structure, and will be accompa- nied with observations upon morbid actions, which may occasionally arise. My.situation has given me more than the ordinary opportunities of examining morbid structure. Dr. Hunter's collection contains a very large number of pre- parations exhibiting morbid appearances, which I can have recourse to at any time for examina- tion. Being physician to a large hospital, and engaged in teaching anatomy, I have also very frequent opportunities of examining diseases in dead bodies. What this work will contain will be principally an account of. what I have seen myself; but I shall also take advantage of what has been observed by others. This work is in- tended to comprehend an account of the most common, as well as many of the very rare, ap- pearances of disease in the vital and more impor- tant parts of the human body. It is evident, from the nature of this work, that it rauft be pro- gressive : some appearances of disease will be observed in future, with which we are at present totally unacquainted, and others, which we know Preface. vii very little of now, will afterwards be known perfectly. The principal motive, which has induced me to undertake this work, is to render the morbid structure of parts more accurately and generally known, as one of the best means of advancing our knowledge of diseases. Although I have ventured to lay this work before the Public, yet I am very sensible of its imperfections. There are some appearances described, which I ^ave only had an opportunity of seeing once, and which, therefore, may be supposed to be described less fully and exactly than if I had been able to make repeated exam- inations. There are others, which I have seen long before I had any idea of undertaking this work, and which I may be supposed to have observed less accurately than if there had been a particular object in view. There are others still, which I have only had an opportunity of exam- ining in preparations. In some of these, certain appearances may be supposed to be lost, which might have been observed had they been exam- ined recently after death. All of these are sources of inaccuracy, which may be said in some de- gree to be unavoidable. I have endeavour- ed, however, to be accurate ; and if the Public viii Preface. should approve of the plan of this work, I shall be very careful, by the addition of new mate- rials, and by repeated observations, to render it more perfect. CHAPTER I. Difeafed Appearances of the Pericardium, X he pericardium, or the membrane, which fur- rounds the heart like a bag, and is reflected upon its furface, giving it a fmooth external covering, is liable to inflammation. This is not a very com- mon difeafe, although it happens fufficiently often to afford frequent opportunities of examining its effects after death. The difeafe, from its nature, cannot be confined to any particular periods of life; yet, from what I have feen, I fhould believe that it takes place more commonly when the body has for fome time arrived at the adult flate, than either in childhood or in advanced age. In inflammation of the pericardium, the mem- brane is frequently thicker than in its natural {rate, and I think is alfo a little more pulpy. This change depends upon additional matter being thrown into the membrane by theincreafed aaion [ 3 ] of the fmall veffels, which are diftributed upon it. It is alfo crowded with a very unufual number of minute veffels, which contain a florid blood, and which form various junctions with each other. Upon the infide of the pericardium, there is a layer of a yellowifh pulpy matter, which commonly does not adhere firjnly to it, but may be eafily fe- parated. It generally extends over the whole of its inner furface, and varies a good deal in its thicknefs. In fome inftances it is as thin as a wa- fer, and in others as thick as a half crown. In this matter^ which is lining the pericardium, there is frequently to be feen a flight appearance from fmall blood veffels, which are ramifying through it, but thefe are moft diflinclly detected by fine in- jection. Thefe veffels, however, are fometimes numerous, and may be traced pairing from the pe- ricardium into the pulpy matter; and I have alfo feen in jt fmall fpots of a florid blood. This cir- cumftance becomes a very convincing proof of this cxtravafated matter poffeffing a livincr princi- ple ; for one cannot imagine that blood vefteh would moot into, and ramify through, a fubflance which is dead * Upon its inner furface, this mat- ter very frequently throws out little irregular laminated projections, giving the appearance of a * This is an argument ufed by Mr. Hunter, in fupport of the living principle' of the blood. l * [ 3 2 lace -voik, and junctions are oiicn formed be- tween that portion of it lining the pericardium, which is reflected like a bag, and that other por- tion lying upon the pericardium, which is the im- mediate covering of the heart. This matter has a o ■ ■ very clofe refemblance, both in colour and ftruc- ture, to the coagulable lymph of the blood, and is probably nothing elfe than this fubflance feparat- ed from the blood by a peculiar action of the fmall veffels of the pericardium. At the fame time that this layer of pulpy matter is thrown out upon the inner furface of the pericar- dium, there is accumulated in its cavity, more or lefs of a brownifh or yellowifli fluid. There is fometimes only a few ounces of it; at other times more than a pint. In it there are floating loofe fhreds of the pulpy matter formerly explained, and there is alfo occafionally fome mixture of pus. This fluid refembles in its properties the ferum of the blood, and has commonly been confi- dered as the ferum. It is probably feparated in part from the coagulable lymph while it forms the folid layer, on the infide of the pericardium, fimi- lar to the fpontaneous feparation of the different parts of the blood after bleeding; but I fhould believe that it was not wholly accumulated in this manner, becaufe it is often in very large propor- tion to the quantity of the coagulable lymph. £ 4 •] Inflammation of the pericardium fometimes ad- vances to form pus, although rarely. Of this I have feen one inftance. The pericardium was very much thickened, was inflamed, and lined with coagulable lymph, but there was no fign of ulceration in any part of it. This laft circum- ltance will be more particularly noticed, when we come to fpeak of the difeafed appearances of the pleura. The pericardium in this cafe, contained more than a quart of common pus. When the pericardium is inflamed, which forms the imme- diate covering of the heart, the mufcular fub- ftance of the latter is occafionally inflamed to some depth. Adhejions of the Pericardium to the Heart. In opening dead bodies, adhefions of the peri- cardium to the heart, are not uncommonly found. The adhefion is fometimes at different fpots ; at other: times is extended over the whole furface. It either confifls of a thin membrane, or of a more folid matter. When it is a thin membrane, it re- fembles very much, the common cellular mem- brane of the body, and when the matter is folid, it differs little from the coagulable lymph of blood. Whether the adhefion be in the one way or the othei\ the matter of the adhesion is, in both £ 5 ] cafes, capable of being rendered vafcular from in- jection. The adhefion too, is, in both cafes, formed from the pulpy matter formerly explained, for I have oftener than once had an opportunity of tracing its gradual changes into each. Such adhefions are to be confidered as the confequence of previous inflammation, and fhew that an inflam- mation of the pericardium may be furvived. They connect the pericardium in different cafes, more clofely or loofely to the furface of the heart j and where the connection is clofe, the inflamma- tion has probably been more recent: where it is loofe, the inflammation has probably been of older date, fo that time has been given for the adhefions to be elongated by the motion of the heart. It is worthy of remark, that where there is an adhefion of the pericardium to the heart, the latter fome- times pulfates fo violently, that it is impoflible to diflinguifh it from the pulfation of an aneurifm. Dropfy of the Pericardium. This difeafe is not uncommon, and I believe is mod frequent at an advanced period of life. I have feen it however in perfons confiderably un- der the age of thirty ; and it probably alfo hap- pens occafionally in childhood. I have feen often- er than once both anafarca and afcites in children C T 6 ] under twelve'years old, which is as improbable a? the accumulation of water in the pericardium. Water is fometimes found accumulated in the pe- ricardium, while there is none in any other cavity; but generally it is accompanied with the accumu- lation of water in the other cavities of the thorax. This water varies a good deal in quantity, a- mounting in fome cafes hardly to two ounces, and in others to more than a pint. Although the quantity be large, which may happen to be accu- mulated, yet I do not recollect to have feen the pericardium very much flretched, but it has always appeared as if it could contain a greater quantity. It is probable therefore that the pericardium may really grow fo as to keep pace with the accumula- tion. The fluid, which is accumulated, is of a brown colour, having a darker or lighter fhade in differ- ent cafes, and refembles in its properties the ferum of the blood. If the perfon fhould happen at the fame time to have jaundice, then the fluid has a pretty deep yellow tinge from bile. It has how- ever frequently a yellowifh colour, like the fe- rum, without there being any reafon to fuppofe that bile has been circulating with the blood. The accumulation of water in the cavity of the pericardium, may proceed from two caufes. [ 7 ] The one is, that the fmall exhalant veffels, o- pening upon the inner furface of the pericardium, may throw out an unufually large quantity of fluid into its cavity, which is not abforbed in the fame proportion by the abforbent veflels of that part : the other is, that the fluid may be thrown, into the cavity in the natural quantity, but may not be ab- forbed in the natural,proportion, from a defect in the action of the abforbent veffels. I once had an opportunity of feeing two or three fcrofulous tumours growing within the ca- vity of the pericardium, one of which was nearly as large as a walnut. They confiited of a white foft matter, fomewhat refembling curd, or new eheefe. The pericardium is a very unufual part of the body to be attacked by fcrofula, and there- fore this.muft be a very rare appearance of difeafe. •The tumours had probably been flow in their progrefs, as in fcrofula generally, and this difeafe could not have been gueffed at in the living body. I have twice found (and it has been feen much oftener by an ■anatomift* of the belt authority) the pericardium fo changed as to refemble a common ox's bladder in fome degree dried, or like a com- mon pericardium, which had been for fome time expofed to the air. As the thorax and abdomen were entire in both cafes, no opening, whatever * Mr. Hunter. [ 8 ] having been made into either, this effeft could not arife from evaporation. Were this capable of taking place, the appearance here noticed would be very ufual in examining dead bodies, and the internal parts generally would be affefted by the influence of the fame caufe. It muft be confidered therefore as the effect of a procefs, which was going on during life. The caufe of this appearance is probably a defect in the action of the exhalant veffels of the pericardium, fo that the fluid, which naturally lubricates this part, was not fecreted in the proper quantity. There is nothing more difficult to conceive in this, than a defect in the action of any other part of the body. A portion of the pericardium has, in fome in- ftances, been obferved to be converted into car- tilage,* and in others into bone,§ but both of thefe changes are very uncommon. * See Morgagni de Caufis et Sedibus morborum, Epift. XXII. Art. 10. § Sec Bonetus, Tom. i, p. $83. [ 9 3 C H A P. II. Difeafed Appearances of the Heart. Inflammation of the fubftance of the heart is a rare difeafe, and is moll commonly connected with an inflammation of the pericardium. When the pericardium covering its furface is inflamed, the inflammation fometimes paffes a little way into the fubftance of the heart. That part of it be„ comes much more crowded with fmall veffels than in its natural flate, and there are fometimes to be feen a few fpots of extravafated blood. The fub- ftance of the heart may however be inflamed with- out inflammation of the pericardium. I recollect an inftance of this fort where no marks of inflam- mation could be obferved in that membrane, but where there was a little more water than ufual ac- cumulated in its cavity. In this cafe the pulfation had been fo ftrong, that it was impoflible to diftin- guifh it from the pulfation of an aneurifm. Au- thors have mentioned cafes of abfceffes and ulcers* of the heart, but thefe I am perfuaded are ex- * Vid. Morgagni, Epift. XXV. Artie. 17. Vid. Bonet, Tom. i; p. 849 ; and alfo Lieutandj Tom. 2, p. 27. [ 10 ] tremely rare. It happens ftill more rarely that the heart becomes mortified, although this dileafed ftate of it.has alfo been obferved.^ In opening dead bodies there is very often to be feen upon the furface of the heart, a white opaque fpot, like a thickening of the pericardium. This is fometimes not broader than a fix-pence; at other times as broad as a crown. It is moft commonly on the furface of the right ventricle, and is very rarely to be feen either on the furface of the left ventricle, or of the auricles, although it is occa- fionally on both. It confifts of an adventitious membrane, formed on a portion of the pericardium, which covers the heart, and may eafily be diffected off fo as to leave the pericardium entire. It is an appearance, I believe, of no confequence whatever, and is fo very common that it can hardly be confidered as- a difeafe. Polypus. This has been confidered by the older anato- mifts, as a very common and a very fatal difeafe. By many of the moderns it has been rejected as a difeafe altogether. It confifts in a mafs of the co- agulable lymph filling up fome of the large cavities k Vid. Lieutaud, Tom. l, p. 33. [ " ] of the heart, particularly the ventricles, and ex- tending into the neighbouring large veffels. The coagulable lymph is of a yellowifh white colour, fometimes of a very yellow colour, and has confiderable firmncfs. It fills up the cavity completely, or nearly fo, in which it is found ; and in the ventricles it fhoots out proceffes be- tween the fafciculi of the mufcular fibres. From this circumftance, probably, it has derived its name. It alfo extends into the large arteries, which arife from the ventricles, and is often moulded to the fhape of the femi-lunar valves at their, origin. Any examples of this appearance, which it has occurred to me to obferve, have been chiefly in preparations, and had undoubtedly taken place after death. In order that the circu- lation may be carried on it is neceffary that the cavities of the heart be free for the tranfmiffion of blood; and if anyone of its cavities fho-uld.be plugged up, the circulation would neceffarily be flopped altogether. A polypus, however, plugs up the cavity of the heart in which it is formed, lb entirely as to prevent the circulation. It may be faid, perhaps, that polypi ai-e formed gradually, and the circulation is. carried on for fome time, al- though very imperfectly. We have no general evidence however of coagula of blood being formed in the ordinary circulation where there is £ « J a healthy flructure of the parts concerned in this function. When polypi are examined, there is the fame fort of appearance through their whole fub- ftance, which fhews that the whole coagulum had. beeff'Tormed at the fame time. Both of thofe circumftances feem to contradict very ftrongly the opinion that polypi are formed during life. When polypi are formed,! believe that the coagu- lation of the blood does not take place very quickly after death. They are without any ad- mixture of the red globules of bloody and there- fore the blood has been fufficiently long in coagUr lating to allow thefe globules to feparate from the other parts in confequence of their greater fpecific gravity. The ordinary coagulations of the blood, which commonly do not fill up very fully the cavities of the heart (although inftances occafionally occur of this fort) take place pretty foon after death, be- caufe the red particles of the blood are generally arretted in the coagulum. It may be worth while to remark, that there is fometimes found a portion of a coagulum in one of the ventricles of a yellow colour, and with an oily appearance fo as to re^ femble exactly fat. There is however no admix- ture of oil in it, and it poffeffes all the ordinary properties of the coagulable lymph. The colour of a coaguliyn fometimes depends on a portion of [ 13 3 bile having circulated with the blood during life, as in cafes of jaundice ; but it takes place alfo when there is no reafon to fuppofe that bile is mixed with the blood. Thefe appearances depend probably on certain circumftances of the coagu- lation ; but what thofc circumftances are, it is very difficult to determine. It fometimes happens, although I believe very rarely, that the heart becomes aneurifmal. This difeafe confifts in a part of it being dilated into a pouch, which is commonly more or lefs filled with coagulated blood. Of this difeafe I have only feen one inftance. The apex of the left ventricle was dilated into a pouch large enough to contain a fmall orange, was much thinner than in the heal- thy ftructure, and was- lined with a thick white opaque membrane. There was hardly contained in it any coagulated blood ; but the quantity of the coagulated blood depends commonly on the fize of the bag. This difeafe moft probably arofe from the muf- cular ftructure at the apex of the ventricle be- coming weaker than in any other part, fo that when the ventricle contracted upon the blood it was pufhed againft the, weakened part, which was not fully able to refift its impetus, and therefore was gradually dilated. Had the ftrength of the apex of the left ventricle been in due proportion D [ 14 J to that of the other parts, it is impoflible that the aneurifmal fwelling mould ever have taken place. The moll frequent.fituation of aneurifm within- the cavity of the thorax, is at the arch of the aorta. In this difeafe the arch of the aorta is much en- larged beyond its ufual fize, fometimes forming an uniform tumour, and at other times there are fmaller aneurifmal fwellings rifing out of the larger one. This enlargement of the artery, if very confiderable, is more or lefs filled with coagulated blood, which is difpofed in concen- tric lamina?. The coats of the dilated artery are nearly of the fame thicknefs with thofe in its natural flate, and therefore in proportion as the fwelling increafes, new matter muft be depofited in the coats of the artery. This new matter is undoubtedly depofited with a view to prevent the artery from being fo foon ruptured as it would be otherwrfe, and is formed by the adion of the vafa vaforum. A portion of the new matter may perhaps alfo be formed by the action of the parts immediately in contad with the artery. The coats of the artery, both at the place where the aneurifm is formed, and near it, are confidera- bly altered from their natural ftructure. They are more readily divifible into different layers, and have often formed in them fpots of bony matter, Thefe fpots are frequently of a yellowifh t *5 ] Colour, and are formed either in the internal membrane of the artery, or immediately behind it. The coats of the artery in the neighbourhood of the aneurifm, are often found to be very irre- gular in their texture, being in fome places tranf- parent and thin, in others thick and opaque ; and there is fometimes the appearance of a double internal membrane. The fame fort of ftru6ture is alfo to be found in the coats of the aneurifm itfelf. The arteries near an aneurifm are difeafed to a greater or lefs extent in different perfons, but I do-not recollect one inftance in which they were totally free from difeafe. The difeafe fometimes ends fatally, by the en- larged artery burfting, and the blood efcaping into the cavity of the pericardium ; but it very often has a further progrefs ; the fwelling of the aneur- ifm gradually increafes, till at length it preffes againft the fternum and the cartilaginous extremi- ties of fome of the ribs. This preffure occafions a portion of the fternum and the ribs to be abforb- ed, and the tumour is thereby perceived exter- nally. This abforption of the fternum and ribs is not accompanied with the formation pus, but is a procefs, which is infenfibly taking place ac- cording to the extent of the preffure. The tu- mour gradually increafes in fize, till perhaps it is [ 16 ] as large as a child's head at birth ; the fkin then becomes in fome meafure dead, and cracks from diftention at the higheft point of the tumour, a portion of the coagulated blood is forced out by the impetus of the circulation, and the perfon is cut off inftantaneoufly. The blood fometimes oozes out flowly, and the perfon finks gradually under its lofs. Aneurifms at the arch of the aorta, as well as in every other part of the arterial fyftem, arife from the coats of the artery being previoufly dif- eafed, which are thereby unable to refift fuffi- ciently the impetus of blood that ftrikes againft them. This is obvious, both from the difeafed ftructure of the coats of an aneurifm itfelf, and of the artery in its neighbourhood. I have alfo found very frequently difeafed appearances in the arch of the aorta, which were not advanced far enough to produce aneurifm. Thefe confift in little white opaque fpots being formed in the inner membrane of the artery, and its coats are more eafily feparable from eack other than in the healthy flate. The reafon why aneurifms take place more frequently in the arch of the aorta, than in any other part of the arterial fyftem, is its curvature, which expofes it to the full impetus of the blood, propelled by the ftrength of the left ventricle. [ «7 ] Aneurifms hardly ever happen in the pulmonary artery, becaufe there is no arch formed by the pulmonary artery, and the blood readily pafles by two large branches into the fubftance of the lungs. , It may not be improbable too, that the pulmonary artery may not be fo liable as the aorta to thofe difeafed alterations of ftructure, upon which aneurifm ultimately depends. Aneurifms in the arch of the aorta, as well as in every other part of the arterial fyftem, happen much more rarely in women than in men.—• This arifes from two caufes. The one is, that women, from their fedentary life, are lefs liable to an encreafed impetus of the blood, occafioned .by excited circulation : the other is, that the ar- teries in this fex appear to be lefs liable to dif- eafed alterations of" ftructure. This is not at all peculiar to aneurifm. Some other difeafes prevaH in the one fex from which the other is in a oreat meafure exempt. * The time of life at which aneurifms are moft frequent, feems to be about the middle age.— When very ftrong pulfation is to be felt of the heart, we are not always to confider' the difeafe as aneurifmv efpecially if the perfon be young and of the^female fex. I have known an inftancc where an adhefion of the pericardium to the heart, was attended with that very ftrong pulk- r i8 ] tion, which is'ufual in aneurifm; and I have known another inftance where there was an unu- fually ftrong pulfation at the time the heart was a little inflamed upon its furface, and there was a fmall quantity of water in the pericardium. The three femi-lunar valves at the origin of the aorta, or of the pulmonary artery, are often found difeafed. This confifts in the depofition of a bony or earthy matter. When a fmall portion of this bony or earthy matter is depofited, the valves are only fome what impaired in their function, but when ^the quantity of matter is confiderable, they muft loofe their valvular function altoge- ther. The communication between the ventricles and the arteries becomes very narrow, the cir- culation is extremely interrupted, and the perfon is at length deftroyed. This difeafe mofl com- monly takes place towards an advanced period of life, but I have feen an inftance of it in a boy ofgten years old. It fometimes happens that the femi-lunar valves are confiderably thickened, and of an opaque white colour : in this cafe the coats of the artery in the neighbourhood I believe are commonly thickened and difeafed. There is a preparation in Dr. Hunters collec- tion, where one of the femi-lunar valves is thick- ened, having at the fame time little tenacity, and [ '9 ] being of a brown colour, in which a confider- able rupture had taken place. It is very rare that fuch an occurrence happens, and in the pre- fent inftance the rupture was fo large that I be- lieve it muft have proved very foon fatal. The valvular apparatus between the auricles and ventricles, is liable to the formation of bony and earthy matter as well as the valves, which are fituated at the origin of the two large arteries^ but by no means fo frequently. What this de- pends upon it is very difficult to determine.— Thefe valves may perhaps be confidered as be- longing more to the veinal than the arterial fyf- tem, and it is very certain that offification takes place very feldom in veins, although very often in arteries. The valvular apparatus between the auricles and ventricles, is alfo occdfionally thickened, hav- ing loft all its tranfparency, and having an opaque white colour. The chordae tcndinea: are alfo thicker than natural; and the internal membrane lining the ventricles, is frequently at the fame time a good deal thickened, appearing like a firm white membrane. Under fuch circum- ftances the heart is often found to be confiderably enlarged beyond its ufual fize. I have alfo feen the valvular apparatus between the auricle-and the ventricle in a flate of inflammation, and co- [ *o J vered with a layer of coagulable lymph. This I believe to be very uncommon. It fometimes happens, and I believe chiefly in thofe who are advanced in life, that the heart at fome part becomes thinner, and upon any great exertion burfts : the blood efcapes into the cavity of the pericardium, and the perfon is inftantly deflroyed. Of fuch cafes I have feen one inftance only, but have heard from the beft authority of an- other. They both happened to men; and I mention thefe circumftances becaufe men appear to be more fubject to difeafes of the heart and blood veffels than women. It is probable that perfons dying from this caufe have, on account of the fuddennefs of their death, been fuppofed to die of apoplexy. Cafes have occurred, although very rarely, in ■which a krge quantity of blood has been accu- mulated in the cavity of the pericardium, but where no rupture could be difcovered, after the moft diligent fearch, either in the heart itfelf, or in any of its veffels. This appears very worK derful, and not at all what any perfon would ex- pect a priori. Upon the fuppofition of there be- ing no rupture, two conjectures only have occur- red to me with regard to the poflibility of fuch [ « T an effect taking place, and they are both attend- ed with confiderable difficulty. The one is, that the veffels upon the furface of the heart, may have loft a part of the com- pactnefs of their texture, fo that the blood may have efcaped through their coats by tranfudation. The other is, that blood may have been thrown out by the extremities of the fmall veffels, open- ing upon the furface of that portion chiefly of the pericardium which forms the immediate covering of the heart, whofe orifices may have been to a very uncommon degree relaxed.* It alfo happens, although I believe very rarely, that a heart is fo imperfectly formed as to allow of life being continued for fome length of time in a very uncomfortable flate, but to be ultimately the caufe of death. There are two cafes of this fort defcribed by the late Dr. Hunter,t and there is one fpecimen of this malformation preferved in his collection. The malformation preferved in the collection, confifts in the right ventricle of the heart being extremely fmall, and the pulmonary artery being very fmall alfo which arifes from it. At its origin from the right ventricle it is com- pletely impervious. The ductus arteriofus is * See Med. Obfervations, Vol. 4, p. 330. Memoirs of Med, Society, Vol. j, p. 238. | Vid. Medical Obfervations, VoL 6; p. 291. E [ 22 ] open, but forms like wife a fmall canal, and ter~ minates in the left branch of the pulmonary artery. The right auricle is larger than its natural fize, probably from the frequent accumulation of blood in it; and the .communication between the two auricles, by -means of the foramen ovale, is much larger than ufual. The child in whom this malformation was found had its fkin of a very dark colour, had very laborious refpiration, and violent action of the heart. It lived only thirteen days. In another cafe related by Dr. Hunter, the pulmonary artery was very fmall, efpecially at its origin, and there was a deficiency in the fep- tum cordis, at the bafisofthe heart, large enough to allow a fmall thumb to pafs through it. The perfon in whom this malformation of the heart was found lived about thirteen years. He never had a frefh complexion, but it was always dark, or tending to black. He was • often feized with fits, efpeci- ally when there was any hurry upon his fpirits, or there had been any brifk motion of his body. It is obvious that in thefe deviations from the natural ftructure, too fmall a quantity of blood muft pafs through the lungs to receive the benefit of refpiration, and this will be more or lefs ac- cording to the degree of the deviation. The blood will from this caufe be of a dark colour, as it is well known that it receives the florid hue [ =3 ] from the influence of the air upon it in the lungs. Hence the colour of the fkin muft be neceffarily fallow or dark, and this will be increafed when the blood is more than ufual accumulated in the veins. It is natural to think that in fuch ftruc- tures of the heart, the circulation will be carried on with much more difficulty when it is excited beyond its ufual flandard. This may even be increafed to fuch a degree that the circulation muft for a fhort time be fufpended altogether. It was from this caufe probably that fits occafionally were produced, as related in one of the cafes. There is an example alfo in Dr. Hunter's col- lection, of a heart from a child, which had a hole in the feptum ventriculorum at the b'afis of the heart, large enough to allow a goofe quill rea- dily to pafs through it. The child was ftill-born at fix months, and the hole in the feptum evi- dently arofe from original malformation. This too is defcribed by Dr. Hunter in the fixth vo- lume of the Medical Obfervations. An inftance fomewhat fimilar to this has likewife been pub- lifhed by Dr. Pulteney in the third volume of the Medical Tranfactions, where the perfon, to whom this monflrdfity belonged, lived to near fourteen years of age. I do not know how far I ought to mention, confiflently with the plan of this publication, that [ 24 ] the heart is fometimes found of a very uncommon fize, but without any difeafe in its ftructure. This occafionally takes place, and perhaps fhould properly be confidered as a monftrous formation. In moft inftances however, where the heart is a good deal enlarged beyond its ufual fize, without any external morbid appearance belonging to it, I am perfuaded that the valves between the auricles and ventricles will be found thickened from difeafe. Hydatids* have occafionally been found adher- ing to the heart, but I have myfelf met with no inftances of this fort. They do not appear to be of the fame kind in every part of the body, but their nature I will explain particularly when I come to defcribe the difeafed appearances of the liver and kidneys. A portion of the heart has been obferved to be converted into bone.t Earthy matter has alfo been found depofited in the mufcular .fubftance of the heart.J None of thofe appearances have come under my own obfervation, and they are to be looked upon as very uncommon. * See Morgagni, Epift. XXV. Art. 15. f See Morgagni, Epift. XXVII. Art. 16 ; fee alfo Med- ical Communications, Vol. 1. p. 228. % See Bonetus, Tom. I, p. 820, and p. 825. [ 25 ] CHAP. III. Difeafed Appearances in the Cavity of the Thorax. Inflammation. A me pleura, or the membrane which lines the cavity of the thorax, is very fubject to inflamma- tion. This may take place at any period of life, but is more frequent at the age when the body is juft arrived at the adult flate, and all its actions are carried on with vigour, than either in childhood or in advanced age. The pleura ap-i pears to be more liable to inflammation than any membrane lining thofe cavities which have no external opening, as the peritonaeum, the tunica vaginalis teftis, and fome others. Why this fhould be the cafe, it is perhaps difficult to de- termine. The branches of the intercoftal vef- fels, which are very numerous, piercing through the fubftance of the intercoftal mufcles, commu- nicate a good deal by anaftomofis with the exter- nal veffels on the fides of the cheft. Hence what- [ 26 ] ever may act upon thefe external veffels, fo as to> excite contraction in them, may be fuppofed capable of producing an accumulation of blood, as well as an increafed action in the inner branch- es of the intercoftals, many of which are diftri- buted upon the pleura. Perhaps too, upon an- other principle, there may be a greater confent between the action of the external and internal veffels of the cheft, than in the body generally. If thefe obfervations be juft, they would account for the very frequent inflammation of the pleura ; but they are only to be confidered in the light of a conjecture. Whatever be the caufe of it, the fact is undoubted that the pleura is more li- able to inflammation than any other membrane inverting Cavities which have no external open- ing. This is fo much the cafe that one can hard- ly examine the cheft of any perfon, wTho has arriv- ed at the adult flate, without perceiving more or lefs the traces of the prefent or former in- flammation. When the pleura is inflamed, it becomes thick- er than it is naturally, and is in fome degree pul- py. There is alfo interfperfed through it a great number of very fmall veffels containing florid blood, and a layer of coagulable lymph is at the fame time thrown out upon its furface. This layer is fometimes very thin, and at other times t 27 ] of confiderable thicknefs. It is either fmooth upon its furface, or it throws out many fine fmall flocculi, which exhibit the appearance of a rich lace work- There is alfo poured into the cavity of the thorax a ferous fluid, in which are floating many fmall broken laminae of the coagulable lymph; and there is occafionally fome mix- ture of pus. The coagulable lymph, covering the pleura which forms the external membrane of the lungs, frequently adheres to that which covers the pleura that is reflected on the infide of the ribs and the intercoftal fpaces, either in fmall portions, or by extended furfaces. Upon fuch occafions I have fometimes been able to trace the gradual change of the adhefion from the nature of a coagulable lymph to that of a cellular membrane. This co- agulable lymph is capable of being rendered vaf- cular from injection, as we have already mentioned in the inflammation of the pericardium. When the pleura is inflamed which covers thelungs, the fubftance of the latter is frequently inflamed to fome depth. Adhefions in the Cavity of the Thorax. Adhefions are often found between that por- tion of the pleura wThich covers the lungs, and [ 38 ] that other portion of it which lines the ribs and' the intercoftal fpaces, while there is no fign whatever of prefent inflammation. Thefe adhe- fions are often partial, and then they are mod commonly to be found at the upper and poflerior part of the cheft ; but they are fometimes ex- tended over the whole cavity. They either con-. nect the parts together clofely, and then they often confift of a firm thick membrane, or they connect them loofely, when they confift of a foft fpungy membrane, which exactly refembles the common cellular membrane of the body. Such adhefions are the confequence of inflammation, and are perhaps the moft common morbid appearance to be found in dead bodies. Empyema. Pus is not unfrequently found accumulated in the cavity of the cheft, forming the difeafe called empyema. This may either arife from the blood veffels of the pleura being in fuch a flate of inflam- mation as to form pus, or from the burfting of fome abfeefs in the lungs, fo as to evacuate its pus into the cavity of the thorax. When pus is formed by an inflamed flate of the pleura, there is no occafion for ulceration to take place. The pleura is found entire, but is covered with a layer [ *9 ] of the coagulable lymph. This fact has been long-ago afcertained by the late Dr. Hunter. The formation of the pus depends on a certain flate of action in the-veffels of the pleura. The pus may either be accumulated in the whole cavity of the cheft, or may be confined to a part of it by adhe- fions taking place between the lungs and the pleura, which invefts the ribs and the intercoftal fpaces. When pus is evacuated into the cavity > of the cheft by the burfting of an abfcefs in the lungs, it is almoft always confined within certain limits by adhefions. In cafes of empyema, there is frequently no particular appearance of the cheft obferveable on the outfide: there is fometimes, however, a fullnefs to be perceived externally on the fide where the matter is accumulated, and even occafionally an evident fwelling between two of the ribs, as of matter pointing. Ulcera- tion has alfo been known to take place in one or more of the intercoftal fpaces, fo that the matter has been evacuated externally. There is an ex- ample in Dr. Hunter's collection, where the mat- ter had been evacuated from the cheft by a great • many openings in the intercoftal fpaces.' F [ 30 ] Hydrothorax. A watery fluid is not uncommonly found in one or both cavities of the cheft, forming the difeafe called hydrothorax. It is often attended with the accumulation of water in other parts of the body, efpecially in the pericardium, and the cellular membrane of the lower extremities.— The fluid in hydrothorax is commonly of a brown or yellowifh colour, but occafionally has. a red colour arifing from the mixture of the red glob- ules of blood. It refembles in its properties the ferum. It is found to vary a good deal in quan- tity in different cafes, fometimes amounting only to a few ounces, and at other times to feveral quarts. When it is accumulated in very large quantity in either fide of the cheft, that fide ap- pears to be fuller to the eye externally, and when the cavity is laid open after death, the lungs on that fide are found more or lefs compreffed. I have feen a lung fo compreffed, as not to be larger than the clofed fift. Water is likewife found in the cavity of the cheft where there are confiderabie adhefions.— This fhews that a good deal of inflammation had formerly taken place, which had probably, by [ af« 3 throwing out a considerable quantity of ferum, laid the foundation of the hydrothorax.* Offification of the Pleura. ' It fometimes happens, although I believe rare- ly, that a portion of the pleura is converted into bone. This confifts of a thin plate, and fome- times extends over a pretty broad furface of the pleura. In all cafes which I have feen, the bo- ny matter feemed to me to be exactly like ordi- nary bone. I have never feen it form a thick irregular knob, but always a thin plate. The caufe which firft excites this difeafed procefs it is very difficult to determine ; but there can be no doubt that the bone is formed by the fmall veffels of the pleura taking on the fame mode of action which veffels do in the formation of ordinary bone.— This procefs is not peculiar to the pleura, but takes place in almofl every part of the body : I believe, however, that it is more common in the pleura than in any other fimilar membrane. In the cafes which I have obferved, this procefs feemed not to have been attended with much in- * This circumftance is illuftrated in feveral inftances by Mr. Cruikfliank, in his Treatife upon the Abforbent Syftem. See 2d edition, p. 116. f 32 J convenience. There was no inflammation found in the pleura furrounding the bone, nor in the fub- ftance of the lungs under it. One could imagine, however, if the bone were to grow irregularly, fo as to form pretty fharp proceffes, that it might ex- cite inflammation, and lay the foundation of a fatal difeafe. • [ 33 ] CHAP. IV. Difeafed Appearances of the Lungs.- Inflammation. Inflammation of the fubftance of the lungs, I believe, feldom takes place without fome fimilar af- fection of the pleura ; at leaft in the inftances which I have feen, this has been moft frequently the cafe. When a portion of the lungs is inflamed, its fpungy ftructure appears much redder than ufual, the colour being partly florid and partly of a darker hue. This arifes from a much greater num- ber of fmall veffels than ufual, being diftributed upon the cells of the lungs which are capable of admitting the red globules of the blood.--- There is alfo an extravafation of the coagulable.lymph into the fubftance of the lungs, and fometimes of the blood. The extravafated blood has been faid upon fome occafions to be in very large quantity; but this has never fallen under my own obfervation. In confequence of the greater quantity of blood being accumulated in the inflamed portion t 34 j of the lungs, they become confiderably heavier, and- will frequently fink in water. The pleura covering the inflamed portion of the lungs has generally a fimilar affection; it is crowded with fine red veffels, and has generally lying upon it a layer of coagulable lymph. This inflamed flate of the lungs is to be diftinguifhed from blood accumulated in fome part of them after death, in confequence of gravitation. From the body lying in the horizon- tal pofture after death, blood is often accumulated at the pofteriou part of the lungs, giving them there a deeper colour, and rendering them heavier. In this cafe there will be found no crowd of fine veffels filled with blood, nor any other mark of inflammation of the pleura; Where blood too is accumulated in any part of a lung after, death from gravitation, it is always of ed with a good deal of-force, in order to open [ 36 ] ,* V again their extremities. The late ingenious Dr. ' g Stark*, has found in fome of thefe veffels the I blood coagulated. This change in /he blood vef- fels is no--doubt ■ with a view to prevent large haemorrhages from taking place, which would certainly be almoft immediately fatal. When abfceffes of the lungs are the confe- quence of common inflammation, they, are com- paratively under the molt favourable circumftances • for recovery; but they are much more frequently the confequence of an inflammation depending on a particular conftitution, viz. what is called fcrofulous; -and in this cafe they are almoft always fatal. Tubercles.- There is no morbid appearance fo common in the lungs as that of tubercles. Thefe confift of •* rounded firm white bodies, interfperfed through their fubftance. They are I believe formed in the cellular ftructure, which connects the air cells of the lungs together, and are not a morbid af- fection of glands, as has been frequently imagined, There is no glandular ftructure in the cellular connecting membrane of the lungs; and on the * See Dr. Stark's works, p. zS. t 37 ] infide of the branches of the trachea, where there are follicles, tubercles have never been feen.-** They are at firft very fmall, being not larger than the heads of very fmall pins, and in this cafe are frequently accumulated in fmall clufters. The fmaller tubercles of a duller probably grow toge- ther, and form one larger tubercle. The moft ordinary fize of tubercles is about that of a garden pea, but they are fubject in this refpect to much variety. They adhere pretty clofely to the fub- ftance of the lungs, and have no peculiar covering or capfule. When cut into, they are found to confift of a white fmooth fubftance, having great firmnefs, and often contain in part a thick curdly pus.—< When a tubercle is almoft entirely changed into pus, it appears like a white capfule in which the pus is lodged. When feveral tubercles of confi- derable fize are grown together, fo as to form a pretty large tuberculated mafs, pus is very general- ly found upon cutting into it. The pus is fre- quently thick and curdly, but when in confider- able quantity it is thinner, and refembles very much the pus from a common fore. In cutting into the fubftance of the lungs, a number of ab- fceffes is fometimes found from pretty large tuber- cles having advanced to a ftate of fuppuration. In the interftices between thefe tubercles, the lungs ■\vc frequently of a harder, firmer texture, with the G [ 3» ] cells in a great meafure obliterated. The texture of the lungs on many occafions, however, round the boundaries of an abfcefs, is perfectly natural. I have fometimes feen a number of fmall ab- fceffes interfperfed through the lungs, each of which was not larger than a pea. The pus in thefe is rather thicker than what arifes from com- mon inflammation, and refembles fcrofulous pus. It is probable that thefe abfceffes have been pro- duced by a number of fmall fcattered tubercles taking on the procefs of fuppuration. The lungs immediately furrounding thefe abfceffes are often of a perfectly healthy ftructure, none of the cells being clofed up by adhefions. When tubercles are converted into abfceffes* it forms one of the moil deftruaive difeafes in this ifland, viz. pthifis pulmonalis. Tubercles are fometimes found in the lungs of children at a very early age, viz. two or three years old, but they moft frequently occur before the completion of the growth. They are apt likewife to be form- ed at rather an advanced age. In cutting into the lungs, a confiderable por- tion of their ftructure fometimes appears to be changed into a whitifh foft matter, fomewhat in- termediate between a folid and a fluid, like a fcro- fulous gland juft beginning to fuppurate. This appearance I believe is produced by fcrofulous t 39 J matter being depofited in the cellular fubftance of a certain portion of the lungs, and advancing ' to- wards fuppuration. It feems to be the fame mat- ter with that of the tubercle, but only diffufed uni- formly over a confiderable portion of the lungs, while the tubercle is cireumfcribed. I have feen another fort of tubercle in the lungs, which I believe to be very rare. It confifts of a foft tumour, formed of a light-brown fmooth fub- ftance. This is not contained in any proper cap- fule, but adheres immediately to the common ftructure of the lungs. In cutting through feve- ral of thefe tumours I did not find any of them in a ftate of fuppuration. They were commonly as large as a goofeberry, and were chiefly placed up- on the furface of the lungs ; fome, however, were fcattered through their fubftance, of a fmaller fize. Thefe are very different in their appearance from the common tubercle laft defcribed, and are the effect of a difeafed procefs, which probably is very imperfectly known. In opening into the cheft, it is not unufual to find that the lungs do not collapfe, but that they fill up the cavity completely on each fide of the heart. When examined, their cells appear full of air, fo that there is feen upon the furface a prodi- gious number of fmall white veficles. "The branches of the trachea are at the fame time much [ 40 ] filled with a mucous fluid. This is not uncom- monly the cafe in perfons who have laboured for fome confiderable time with difficulty of breath- ing, but without any fymptoms of inflammation ; fuch perfons would appear to die for want of fup- ply ofatmofphericair fufficient to produce the pro- per change in the blood which is neceffary for its ufeful circulation through the body. The lungs are fometimes, although I believe very rarely, formed into pretty large cells, fo as to refemble fomewhat the lungs of an amphibious animal. Thefe cells in the only inftance which I have feen of this difeafe, were moft of them of the fize of a common garden pea, and fome few were fo large as to be able to contain a fmall goofeberry. They were furrounded by a fine tranfparent capfule, and were fo numerous as to occupy more than one half of the portion of the lung which I faw. The only fpecimen of this fort of difeafe which I am acquainted with, is in the collection of Mr. Cruik- fhank ; and the perfon in whom it was found, had been very long fubject to difficulty of breathing. The lungs are fometimes converted into a folid fubftance very much refembling the liver. It has nearly the fame folidity, and the fame general ap- pearance. When examined more minutely, the air cells appear to be filled with a brownifh folid matter. It is very obvious, that as this procefs [ 41 ] fpreads over the lungs, refpiration muft become more difficult; there will be lefs room for the adr million of air, in order to produce that change up- on the blood which is neceffary for the preferva- tion of life, and this circumftance will produce a more frequent refpiration, in order to endeavour to remedy the deficiency. Part of the lungs is occafionally converted into a bony fubftance, but this is a very rare difeafe. The fmall veffels difpofed through the fubftance of the lungs under fuch circumftances feparate bo- ny matter from the blood. In the only inftance which I have known of this complaint, the procefs would appear to have been rapid. There was great difficulty of breathing before the perfon died, but this difficulty had only begun for a very few weeks. Each lung was undergoing the fame pro- cefs, which had made coufiderable advancement. In the particular cafe to which I allude, there had been a very ftrong difpofition to form bone in the conftitution. A very large bony tumour had been formed round one of the knees of this perfon ; and very foon after the knee and leg were re- moved by amputation, the difficulty of breathing began, which was occafioncd by a part of the lungs being converted into bone. Here was a transference of this peculiar difeafe from an ex- [ 42 j ternal to an internal part, fimilar to the tranflation of gout or rheumatifm. I have alfo feen a tumour as large as an orange, attached to the lungs on one fide by a loofe mem- branous connection, and in fome degree com- preffmg them ; this tumour confifted of a yellow- ifh, porous fubftaoce, which neither refembled the ftru6lure of what is commonly underftood to be afchirrous or fcrofulous tumour, but had an ap- pearance fomewhat peculiar to itfelf. It was pro- bably the effect of a morbid action with which we are very little acquainted. Earthy concretions have occafionally been found in the lungs, although it is a rare appear- ance of difeafe. Thefe are often fmall, but fome- times form pretty large maffes.* Even a confi- derable portion of the lungs has been known to be changed into an earthy fubftance.t Hydatids are alfo formed in the lungs, and are many of them brought up by coughing. Of their nature 1 propofe to treat particularly afterwards. * Vid. Morgagni, Epift. XVII. Art. 19. Epift. XV. Art. 25. f Vid. Morgagni, Epift. XXII. Art. 15. [ 43 1 CHAP. V. Difeafed Appearances in the Poflerior Medi- aftinum. Jjy the poflerior mediaftinum, is meant that fpace which lies between the laminae of the pleu- ra, that pafs from the root of the lungs to each fide of the fpine. The fpace is of confiderable fize, and contains a portion of the trachea arteria, of the cefophagus, of the thoracic duct, of the de- fcending aorta, and the vena azygos, befides fome abforbent glands. Difeafed Appearances of the Trachea. The inner membrane of the trachea is not uncommonly inflamed to a greater or lefs degree. In this ftate it is crouded with minute florid veffels, which give it a general appearance of vafcularity. When there is no inflammation, it appears a white pulpy membrane, but there are rarely to be feen any red veffels ramifying through it. While the inner membrane is inflamed, the fecretion from [ 44 ] its glands is very much increafed, and therefore its cavity is found a good deal filled with a mucous fluid ; even pus is fometime* formed, and both fluids are mixed with globules of air. This is probably the fituation of the trachea in a very vio- lent catarrh, and alfo in fome cafes wrhere there are fcrofulous abfceffes of the lungs, attended with hoarfenefs, and a fenfe of forenefs along the tra- chea. When the inner membrane of the trachea is inflamed, it is fometimes lined with a layer of a yellowifh pulpy matter. This does not adhere very firmly to the inner membrane, but may be eafily feparated. It extends from the upper part of the cavity of the larynx, into the fmall branches of the trachea, which are diflributed through the fubftance of the lungs. There is at the fame time a good deal of mucus in the tra chea and its branches, together with a mixture of pus. This is the appearance of the infide of the trachea, in patients who have died from the croup. Polypus. The trachea and its branches are fometimes lined with a layer of a yellowifh matter, forming [ 46 ] a fort of tube, which is applied to the inner furface loofely. It has not occurred to me to fee any inftance of it in the dead bodies which I have examined, but I have feen feveral examples of it in preparations. The inner membrane of the trachea feems to be perfectly natural, and the layer of ad- ventitious membrane refembles exactly the coagu- lable lymph, that is thrown out in other parts of the body : I have therefore no doubt of its being that fubftance. Since this difeafe (which is called poly- pus) lafts for a long time, and is not attended with fymptoms of inflammation, itappears probable, that the veffels of the inner membrane of the trachea poffefs a powerof feparating the coagulable lymph from the blood, and that this difeafe confifts in a peculiar action of thefe veffels. The trachea has been faid to be fometimes filled with a folid fubftance of the fame kind with what we have defcribed ; but in the inftances which I have ken, it has been tubular; and I believe this to be by much the moft common appearance. The trachea I have feen narrowed in diameter for two or three inches, thickened in its fubftance, and the inner membrane has been raifed into a number of little hard tubercles. This ftate of the traahea was accompanied with a fchirrous affection of fome abforbent glands, which clofely adhered to it; and H [ 46 ] it appeared to me, that the difeafe in the glands had fpread fo as to affect the trachea. The cartilaginous rings of the trachea occafional- ly become offified, although this is not a very fre- quent appearance. The change is fo natural from cartilage into bone, that we fhouldbe led to expect it more commonly. When the offification is incon- fiderable, the function of the trachea will hardly be affected, but where the rings are entirely offified, the flexibility of the trachea muft be much leffen- ed, and its cavity will not admit of being fo much contracted as in the healthy flate, by the action of the mufcular fibres, which form a part of its ftruc- ture. The confequence of this muft be, that the mucus, which is occafionally accumulated, will not be fo readily expelled by coughing, and the. air will not be thrown out in fo fmall a column, nor with fo much momentum. The trachea is no doubt liable to be deftroyed in part by ulceration, from caufes acting imme- diately upon itfelf, but in the inftances which I have feen, the ulceration has been connected with ulceration of the ccfophagus. As the cefophagus is more liable to this difeafe, it is probable that in fuch cafes the ulceration has begun in the cefophagus, and fpread to the trachea. [ 47 1 Difeafed Appearances of the Ocfophagusl The cefophagus is frequently lined with a layer of the coagulable lymph, which is continued from the cavity of the mouth. This, it is faid, fometimes extends over the whole inteftinal canal, but I fhould believe this appearance to be extremely rare, and it commonly terminates at the lower end of the cefophagus. The inner membrane of the mouth is much more vafcular than in its natural ftate,, fhewing an intenfe dark red colour, but in examinations after death the appearance of greater vafcularity is* fometimes little obferv- able in the cefophagus. This difeafe is known under the name of apthae, and is much more often to be obferved in the living than the dead body. Portions of the coagulable lymph are thrown off, and other portions formed, feveral times in the progrefs of the difeafe. The cefophagus is liable to ftriaure, produced by the contraction of its mufcular fibres at fome particular part. This difeafe is I think moft common in women whofe conftitutions are de- licate, and much fubject to nervous influence. When fuch a difeafe is examined in the dead [ 48 ] body, the cefophagus is found to be more or lefs contracted in fome part of it, and it feels harder than ufual, as all mufcles do in a con- tracted ftate. There is no appearance of dif- eafed ftructure ufually combined with it. I can fuppofe, however, that this contraction might lay the foundation of a permanent, and even a fatal difeafe. The mufcular fibres of the cefopha- gus might fo prefs on the inner membrane, as to excite inflammation in it, which might advance to fuppuration, and would moft probably ter- minate fatally. I once faw a very unufual ftricture of the cefo- phagus. It confifted in its inner membrane be- ing puckered together, fo as to form a narrow- nefs of the canal at a particular part. The canal at that part, was fo narrow, as hardly to allow a common garden pea to pafs. There was no ap- pearance, however, of difeafed ftructure in the inner membrane which was fo contracted, and the mufcular part of the cefophagus furrounding it was perfectly found. I know that this difeafe was very flow in its progrefs, for the perfon in whom it took place had been for many years af- fected with a difficulty of fwallowing, and could only fwallow fubftances of extremely fmall fize. The moft common appearance of difeafe in the cefophagus, is that of an ulcer in its cavity. [ 49 ] Ulcers of the cefophagus are fometimes of a com- mon nature, but moft frequently they are attend- ed with a fchirrous affection. When ulcers of the cefophagus arife from common inflamma- tion, the ftructure of the cefophagus, immediately furrounding the ulcer, is little thickened, and there is the appearance of the ufual erofion in ulcers. When the ulcer is of a fchirrous na- ture, the cefophagus in the neighbourhood is ve- ry much thickened, and is very hard in its tex- ture. When this texture is examined, it either confifts of an hard, uniform, flefhy fubftance, or is a little interfered by a membranous ap- pearance, or it is griftly. Under fuch circum- ftances, the canal of the aefophagus is always more or lefs narrowed, and in fome cafes is al- moft wholly obliterated. It is worthy of remark, that thefe ulcers happen moft frequently, either immediately under the pharynx, or near the cardia. Any fubftance capable of irritating the inner membrane of the cefophagus, by having fharp hard projections, will no doubt be more likely to effect the cefophagus, where it firft enters into it. In an cefophagus, therefore, predifpofed to fchirrous, fuch an accident may prove an excit- ing caufe, and the difeafe will more frequently take place at its upper end. At the cardia too, [ SO ] there is a peculiar arrangement of the mufcular fibres, which are capable of acting in fome degree like a fphincter, and which probably produce on many occafions a narrownefs of canal there. This will render the cefophagus- at the cardia more liable to be injured by the paffage of any hard fubftance, and may ultir mately lay the foundation of a fchirrous ulcer,. This is the account which the late Dr. Hunter ufed to give of the frequent fituation of ulcers at the upper and lower extremities of the cefopha-* gus, and feems to have great weight. It happens, however, moft commonly that ulcers of the cefo- phagus arife fpontaneoufly, or in other words* from caufes within itfelf which we cannot afcer- tain. When an ulcer takes place at the upper end of the cefophagus, it is apt to fpread into the fubftance of the thyroid gland. In this- cafe the gland becomes hard, enlarged, and ulcerated. A portion of the cefophagus has been obferved by fome anatomifts to be converted into cartilage, and to have its diameter at that part very much diminifhed in fize.* This was, perhaps, only a ftrong example of the griftly texture which we have above defcrrbed, or it may have been a change into a fubftance like commmon cartilage. * Vid. Bonet, Tom. 2. p. 32. [ 51 3 In this cafe it is a very uncommon appear- ance of difeafe. I have feen an inftance of a fungus arifing on the infide of the cefophagus, which is to be confidered as a rare difeafe. When cut into, it appeared to" have a fibrous ftructure, difpofed in fome ineafure at right angles to the inner membrane upon which it was formed, and was ulcerated on its furface. The pharynx, at its lower extremity, has been known to be dilated into a pouch of confidera- ble fize, which paffed behind the cefophagus. This may be fuppofed to be very rare, but there is an inftance of it preferved in Dr. Hunter's collection. The pouch in this cafe began to be formed in confequence of a cherry - ftone having refted there for fome time, which had made a kind of bed for itfelf. It remained in that fituation for three days, and then was brought up by a violent fit of coughing. A part of the food always refted afterwards in the cavity made by the cherry-Hone, by which it was gradually enlarged. At length, in the courfe of about five years, the cavity was enlarg- ed into a bag of a confiderable fize, fufficient to contain feveral ounces of fluid. This bag paffed down a good way behind the cefophagus, and the cefophagus neceffarilv acquired a val r 52 j vular communication with it. In proportion as the bag enlarged, this valvular communication would become more and more complete, till at length every kind of food muft have refted in the bag, and could not pafs into the cefophagus. In this way the perfon was deftroyed. The low- er end of the pharynx is, perhaps, the only part of the canal where fuel; an accident could hap- pen. The pharynx is not contracted gradually, fo as to lofe itfelf infenfibly in the cefophagus, but contracts itfelf rather fuddenly at the lower end. Hence a little recefs is formed, in which an extraneous body may occafionally reft. This is neceffarily at the poflerior part, fo that if the recefs fhould be enlarged into a cavity, it muft pafs behind the cefophagus. The particulars of this Angular cafe have been publifhed in the Mc dical Obfervations.* The Defending Aorta. There is hardly any other difeafe of the de fcending aorta within the poflerior mediaftinum, than aneurifm. This confifts in the aorta being a good deal enlarged beyond its natural fize, in its coats being irregularly thickened, and * See the Medical Obfervations, Vol. 3, p. 85. [ 53 ] more readily divifible into layers. There are alfo frequently depofited behind the inner ' membrane little thin laminae of bony matter. This appearance of difeafe has been formerly explained more particularly. It is rare that this part of the aorta becomes aneurifmal, unlefs there be a general aneurifmal affection over the arterial fyftem. The Vena Azygos. The vena azygos is very feldom difeafed. I have feen it however varicofe, and very much enlarged. This change in it took place from par- ticular circumftances. A confiderable portion of the vena cava inferior had become obliterat- ed ; in confequence of this, the ufual vena azy- gos, together with an uncommon one on the left fide, were the only channels through which the blood could return by a circuitous route to the heart; they were therefore neceffarily, from the impetus of the blood, much enlarged in fize, and for the fame reafon likewife varicofe. This cafe I have more particularly defcribed in the Medical and Chirurgical Tranfactions.* * See p. i25; &c- I [ 51 ] The vena azygos has been known to be ruptur- ed, when very much diftended with blood.t— Such a cafe has not come under my own obferv- ation, and I fliould believe it to be very uncom- mon. Tiie Thoracic Du?.i. The thoracic duel is alfo fubject to very few difeafes. I have never feen any other, except that of its being very much enlarged beyond its natural fize, and varicofe. In the inftance to which I allude, it was very nearly as large as the natural fide of the fubcla- vian vein, but nothing could be detected in the neighbouring parts, capable of accounting for this appearance. There wras no obilruction at the entrance of the thoracic duct into the venal fyftem, which might naturally have been ex- pected. This difeafed appearance of the thoracic duct has already been taken notice of in Mr. Cruikfhank's Treatife on the Abforbent Syftem.* The thoracic duct has been known to be ob- ftructed by an earthy matter depofited in its cav- ■\ Vid. Morgaghi, Epift. XXVI, Art. 29. . * See fecond edition, p. 207 ; and h reprefented in an engraving, pl;-.te V. [ 55 ] ity.t It does not neceffarily happen, when the thoracic duct is at fome part obftrutted, that chyle is prevented from entering into the fyftem of blood veffels. The thoracic duct not unfrequent- ly fends off one or more confider,\ble branches, which unite again with the principal trunk. II under fuch circumftances an obftruction fhould take place in a part of the principal trunk, be- tween the origin and the termination of thofe branches, no bad effeft would follow ; one or more of thofe branches would become enlarged and convey the chyle in its full quantity to the blood. The thoracic duct has alfo been known to be ruptured, although this is exceedingly rare. Abforbent Glands. The abforbent glands in the poflerior mod. aflimim, as well as in every other part of the body, are liable to feveral difeafes. The moft com- mon morbid affeftion is fcrofula. In this cafe they are frequently a good deal enlarged, and feel fomewhat fofter to the touch than in their healthy Hmdinc When cut into, however, they frequently exhibit very much the natural f Vid. Lieutaud. Tom. 2, p.'93. [ 5« ] appearances; but it is more common to find that fome of them contain a white, foft, cheefy matter, mixed with a thick pus; this is the moft decided mark of fcrofulous affection. When the abforb- ent glands in this fituation are very much enlarg- ed, they neceffarily produce fome difficulty of breathing, both by the prcffing on the lungs and the trachea. They might produce alfo fome difficulty of fwallowing. I have feen the abforbent glands in the neigh- bourhood of the trachea affected with fchirrus, although it is a rare difeafe in them. They were much enlarged, and very hard to the touch.— When cut into, they exhibited a hard brownifli ftructure, fomewhat interfered by white firm membrane, fo as to refemble exactly what is called fchirrus in other parts of the body. The trachea in contact with thefe glands was alfo affected. In this cafe the thyroid gland was fchirrous, and it is probable that the difeafe fpread from the thyroid to the abforbent glands, and fo to the trachea. The abforbent glands near the trachea, are fometimes converted into a bony or earthy mat- ter, from a peculiar fecretory action in their blood veffels; and I think that this difeafe is more common in the abforbent glands at the root of the trachea, than in any other part of the body. [ 57 ] Thefe glands when fo difeafed, by preffing againft the trachea or cefophagus, occafionally produce ulcers in them. The Anterior Mediaflinum. By the anterior mediaflinum is meant the fpace - inclofed between the laminae of the pleura, which pafs from the fternum to the pericardium ; it contains little elfe than cellular membrane, with perhaps a fmall portion of fat; and in the young- er fubject, the thymus gland. It is feldom found with any difeafed appear- ances in it. Abfceffes are occafionally formed there, but rarely. Water too is fometimes found in the cells of its cellular membrane. I have alfo feen air accumulated in thefe cells Fat is occafionally depofited in the mediafli- num in confiderable quantity. When the quan- tity is very large, it has been known to difturb a good deal the functions both of the heart and lungs. The thymus gland I have known to be much enlarged beyond its natural fize, and to have a fchirrous hardnefs. L 58 ] CHAP. VI. Difeafed Appearances within the Cavity of the Abdomen. Afcites. Ascites, or dropfy of the cavity of the abdomen, is a very frequent difeafe, and is not confined to any fex or age. I have feen feveral inftances of it in children under ten years old ; but it is much more common at the middle, and the more ad- vanced periods of life. It is alfo more com- mon in the male than the female fex. When water is accumulated in a very confiderable quantity in the cavity of the abdomen, the fu- perficial veins of the belly are generally a good deal diftended with blood; this moft probably arifes from the preffure of the water upon the deeper feated veins; it is however fometimes hardly obfervable, even when the accumulation of the water is very confiderable. The fkin at the navel is alfo often protruded, yielding eafily [ 59 j to preffure, but this is not univerfally the cafe. On many occafions the protrufion can hardly be feen, when the water is accumulated in large quan- tity. In opening into the cavity of the abdomen, there is to be feen a larger or lefs quantity of an aqueous fluid, generally of a brownifh colour, but its colour varies according to circumftances. When there is a fchirrous liver accompanying the dropfy, the water is commonly of a yellow- ifh or greenifh colour. This arifes from a mix- ture of the bile with the water, and under fuch circumftances there is almoft always a jaundiced colour of fkin. I have feen the water in afcites of a chocolate or coffee colour ; but this appearance is rare. In the cafe to which I allude, the water was thicker than that of afcites ufually is, but it.had the common properties, as far as could be known from the application of heat or of acids. When there are none of the vifcera of the abdo- men difeafed, the water in afcites refembles the {enim of the blocd in its colour, as well as in its other properties. While water is accumulated in the cavity of the abdomen, the inteftinal canal is frequently found to be fomewhat in a contracted ftate; but often too this is not obfervable. In many cafes of afcites the liver is difeafed, being hard and tn- berculated, as we fhall explain particularly when [ 60 ] treating of the difeafes of the liver. In fome cafe too the fpleen has been found to be enlarg- ed and hard. The afcites is not neceffarily connected with the accumulation of water any where elfe in the body, but it frequently happens that it is acccom- panied with the accumulation of water in the cheft, and under the fkin, particularly of the low- er extremities. Inflammation of the Peritonaeum. The peritonaeum is not uncommonly inflamed, although it is by no means fo liable to this dif- eafe as the pleura. There is a caufe of inflam- mation in it peculiar to women, arifing from the ftate of the womb after parturition, but there is alfo a variety of caufes producing it, which are equally applicable to both fexcs, fo that it is fre- quently found in men, and alfo in women who have not been pregnant. When inflammation has taken place in the peritonaeum, there are feveral appearances to be taken notice of in opening the body. The peri- tonaeum is thicker than in its natural ftate, more pulpy, and lefs tranfparent; and it is crowded with a number of very fmall veffels, carrying a f 6« ] florid blood. When a portion of the inflamed peritonaeum is feparated from the abdominal muf- cles, there is commonly no appearance whatever of the inflammation having fpread into the muf- cles ; but where the peritonaeum covers the inteftinal canal, the inflammation is fometimes found to have penetrated not only into the mufcular coat of the inteflines, but even into the villous membrane. The reafon of this dif- ference probably is, that the peritonaeum is lefs connected with the abdominal mufcles than with the inteftinal canal, fo that the inflammation is more eafily confined in the one cafe than in the other. The inflammation of the peritonaeum is fome- times flight and partial; at other times is great and univerfal. When it is flight and affects that part of the peritonaeum which is connected with the inteftinal canal, it often forms broad bands of inflammation which run along the courfe of the inteflines, and are bounded by the contact of the different portions of the inteflines among them- felyes. In this cafe, the coats of the interline are not thicker than ufual, the inflammation being flight and confined to the peritonaeum itfelf. Where the inflammation is great, the inteflines are much thicker and more maffy. This evident- ly arifes from the greater accumulation of blood K [ ^2 J in the fmall blo&d veffels, as well as from the ex- travafarion of fluids into the fubftance of the in-? teftines, in confequence of the ftrong inflammato- ry action of the veffels. Themefentery and me- focolon are much thicker than in their natural ftate, and there is alfo a remarkable change in the omentum. It is frequently as thick as a perfon's hand, and lies as a circumfcribed mafs along the great curviture of the flomach. The principal caufe of this change in thefe parts, is the extravafa- tion of coagulable lymph into the cellular mem- brane, between the laminae of the peritonaeum which form them. In many places there is thrown out a layer of a yellowifh pulpy matter, gluing different portions of the vifcera together. This is fometimes. a thip layer, at other times is of confiderable thicknefs ; and it appears to be the coagulable lymph of the blood. The layer of the coagulable lymph is of- ten found to extend beyond the immediate furface which is inflamed. This arifes from the coaaula- ble lymph being thrown out from the veffels in a fluid ftate, and therefore need not be limitted by the boundaries of the inflamed furface when it becomes folid. There is alfo a confiderable quan- tity of brownifh fluid in the cavity of the abdomen, refembling the ferum, which is mixed with fmall fhreds of the coagulable lymph, and fometimes r 63 ] with pus, giving it a turbid appearance. The quantity of the coagulable lymph, and of the fluid, is fometimes large, in proportion to the degree of the inflammation. Air is frequently too found accumulated in the flomach and the inteftinal ca- nal, which had been formed in the progrefs of the difeafe. At other times this air is wanting. Adhefions in the Cavity of the Abdomen. When there has been inflammations of the peri- tonaeum, either generally or partially, fufficient to liave thrown out coagulable lymph, and the pa- tient has furvived the difeafe, the coagulable lymph is changed into a fine tranfparent membrane, which is the membrane of adhefions. The time, which is occupied in the change of the coagulable lymph into the membrane of adhefions, is not very long, for I have had feveral opportunities of tracing the gradual progrefs of the change from the one into the other, while the inflammation appeared to have been recent. This membrane confifts of a cellu- lar fubftance, fimilar to the general cellular mem- brane of the body, and has a moderate fhare of vafcularity. It does not naturally fhew many veffels large enough to admit the red globules of the blood, but it fhews its vafcularity upon flight [ 64 ] degrees of inflammation, or by ufing the fine in* jettion. This membrane is capable of elongating gradually by the motion of the vifcera upon them^ felves, fo as ultimately to be attended with very little inconvenience. I have very often had an opportunity of obferving thefe adhefions, either joining all the vifcera of the abdomen more or lefs together, or joining fome particular vifcera to each other. I have obferved alfo pus formed in an inflamed ftate of the peritonaeum ; but I have never feen this membrane mortified independent of the mor- tification of fome of the vifcera. I have feveral times had an opportunity of ob- ferving a white, foft, granulated matter, adhering univerfally behind the peritonaeum. In fome. places it formed a mafs of confiderable thicknefs ; in others it was fcattered in fingle fmall maffes. In one cafe I recollect it formed a fubftance as thick as my hand, between the peritonaeum and the abdominal mufcles, while it was fcattered in fmall feparate portions in the mefentery and the peritonaeum, covering the inteftinal canal. The omentum I have fometimes feen changed into a cake of this fubftance. The matter itfelf appeared to me to be fcrofulous,. fpr it refembled exactly the ftructure of a fcrofulous abforbent gland be- fore pus is actually formed. I am not at all cer- r 6S ] tain how far this appearance of difeafe fhould have: been claffed along with thofe of the peritonaeum i k does not take place (at leaft in the cafes which I have feen) in the peritonaeum itfelf, but behind itj yet at the fame time adhering to it. It appears, however-, upon the whokj to pe placed here with more propriety than it could have been any Where elfe. I have alfo feen fome fmall cancerous tumours growing from the peritonaeum. Thefe were ex- tremely hard, of a white colour, and refembled exactly in their ftructure the cancerous maffes which are formed in the flomach. What puts the appearance I allude to beyond doubt, is, that in the fame body I found a cancerous tumour of the flomach. The cancerous tumours of the perito- naeum Were not at all connected with this other, but were in that part of the membrane which lines the recti abdominis mufcles, nearly oppofite to the region of the flomach. Hydatids have occafionally been found to oc- cupy a portion, or even the whole, of the cavity of the abdomen. In fuch cafes many of them are connected with the vifcera, which were pro- bably the bafis of their formation, of which the chief are the liver, and the fpleen. This ap- pearance of difeafe is very uncommon. [ 66 ] Air has been occafionally faid to be accumu- lated in the cavity of the abdomen, while little or none is contained in the inteflines* This I believe to be a very rare occurrence. Air is not unfrequently found accumulated in confiderable quantity in the inteftinal canal, while there is none at all in the cavity of the abdomen* * Vid. Lieutaud, Tom. l, p. 432- [ 67 ] CHAP. VII. Difeafed Appearances of the Stomach. Inflammation. It fometimes happens, although not very fre- quently (unlefs poifons have been fwallowed) that inflammation takes place in the ftomach, fo as to fpread over a very confiderable portion of its inner membrane, or perhaps the whole of it. It is much more common, however, for inflamma- tion to occupy a fmaller portion of the ftomach. In fuch cafes too, the inflammation is generally not very violent. The ftomach upon the outfide, at the inflamed part, fhews a greater number of fmall veffels than ufual, but frequently net much crowded. In opening into the ftomach, it is found to be a little thicker at the inflamed part, the inner membrane is very red from the number of fmall florid veffels, and there are frequently fpots of extravafated blood. It does not often occur that [ 68 ] a common inflammation of the ftomach proceeds to form pus, or to terminate in gangrene. When arfenic has been fwallowed (which is the poifon moft frequently taken) the ftomach is af- fected with a moft intenfe degree of inflammation. Its fubftance becomes thicker, and in opening in- to its cavity there is a very great degree of red- nefs in the inner membrane, arifing partly from the very great number of minute veffels, and partly from extravafated blood. Portions of the inner membrane arc fometimes deftroyed, from the violent action that has taken place in confe- quence of the immediate application of the poi- fon. I have alfo feen a thin layer of the coagu- lable lymph thrown out upon a portion of the inner furface of the ftomach. Moft commonly too fome part of the arfenic is to be feen in the form of a white powder, lyings upon different portions of the inner membrane. In opening the bodies of perfons who have died from hydrophobia, the inner membrane of the ftomach is frequently found inflamed at the cardia, and its great end. This inflam- mation, however, is generally ineonfiderable, is, I believe, never very great, and in fome in- ftances has been faid to be wanting. [ 69 ] Ulcers of the Stomach. Opportunities occafionally offer tbemfelves of obferving ulcers of the ftomach. Thefe fometimes refemble common ulcers in any other part of the body, but frequently they have a peculiar appearance. Many of them are hardly furrounded with any inflamma- tion, nor have they irregular eroded edges as ulcers have generally, nor is there any particu- lar difeafed alteration in the ftructure of the ftomach in the neighbourhood. They appear very much as if fome little time before a part had been cut out from the flomach with a knife, and the edges had healed, fo as to pre- fent an uniform fmooth boundary round the excavation which had been made. Thefe ulcers fometimes deftroy only a portion of the coats of the ftomach at fome one part, and at other times deftroy them entirely. When a portion of the coats is deftroyed entirely, there is fometimes a thin appearance of the ftomach furrounding the hole, which has a fmooth furface, and depends on the pro- grefs of the ulceration. At other times the ftomach is a little thickened furrounding the L [ 70 ] hole ; and at other times ftill, it feems to have the common natural ftructure. Schirrus and Cancer of the Stomach. This affection of the ftomach is not very un- common towards an advanced period of life, and, I think, is more frequently met with in men than in women. This, perhaps, arifes from the greater intemperance in the one fex, than in the other. It cannot, however, be produceed en- tirely by intemperance; there muft be added a confiderable predifpofition of the parts towards this difeafe. Hence, when there is no previous difpofition, the flomach does not become affect- ed with this difeafe, whatever be the intemper- ance. When, however, there is this previous difpofition, there is reafon to think that it is en- couraged and brought forwards by this mode of living. Schirrus fometimes extends over almoft every part of the ftomach, but moft commonly it attacks one part. The part which is affected with fchir- rus has fometimes no very diftinct limit between it and the found ftructure of the ftomach, but mod commonly the limit is very well marked. When fchirrus attacks a portion of the flomach only, t 71 ] it is generally towards the pylorus. The princi- pal reafon of this probably is, that there is more of glandular ftructure in that part of the ftomach than any other ; and it would appear that glan- dular parts of the body are more liable to be af- fected with fchirrus, than parts of the body gen- erally. When the whole ftomach, or a portion of it, is fchirrous, it is much thicker than ufual, as well as much harder. When the difeafed part is cut into, the original ftructure of the ftomach is fre- quently marked with fufficient diftinctnefs, but very much altered from the natural appearance. The peritonaeal covering of the ftomach is many times thicker than it ought to be, and has almoft a griflly hardnefs. The mufcular part is alfo very much thickened, and is interfered by frequent pretty ftrong membranous fepta. Thefe mem- branous fepta are, probably, nothing elfe than the cellular membrane intervening between the fafciculi of the mufcular fibres, thickened from difeafe. The inner membrane is alfo extremely thick and hard, and not unfrequently fomewhat tuberculated towards the cavity of the ftomach. It very frequently happens that this thickened mafs is ulcerated upon its furface, and then a ftomach is faid to be cancerous. Sometimes the inner membrane of the ftomach throws out [ 7* ] a procefs which terminates in a great many final- ler proceffes, and produces what has been com- monly called a fungous appearance. It alfo happens that the ftomach at fome part lofes entirely all veftige of the natural ftructure,- and is changed into a very hard mafs, of a whit- ifh or brownifh colour, with fome appearance of membrane interfering it; or it is converted into a griftly fubftance, like cartilage fomewhat foftened. The abforbent glands in the neigh- bourhood are at the fame time commonly enlarg- ed, and have a Very hard white ftructure. I have feen feveral inftances of a fchirrous tu- mour being formed in the ftomach about the fize of a walnut, while every other part of it was healthy. This tumour has moft frequently a fmall depreffion near' the middle of its furface, and appears a little radiated in its ftructure.— While this tumour remains free from irritation, the functions of the ftomach are probably very little affected by it; when, however, it is irritat- ed, it muft occafion very confiderable diforder in the functions of the ftomach, and perhaps lay- the foundation of a fatal difeafe. A part of the ftomach is occafionally formed into a pouch by mechanical means, aldrough very rarely. I have feen one inftance of a pouch being fo formed, in which five halfpence [ 73" ] had been lodged. The coats of the flomach were thinner at that part, but were not inflam- ed or ulcerated. The halfpence had remained there for fome confiderable time, forming a pouch by their preffure, but had not irritated the ftom- ach in fuch a manner as to produce inflamma- tion or ulceration. The orifice of the ftomach may be almoft, or perhaps entirely, ffiut up by a permanent con- traction of its mufcular fibres, either at the car- dia or the pylorus. It is much more likely, how- ever, to occur moft frequently at the pylorus, from natural circumftances : there is both lefs op- pofition to prevent the contraction at this orifice of the ftomach than at the cardia, and there is alfo belonging to it a ftrcnger and more direct circular mufcular power. A lefs contraction too, at the pylorus, will produce an obftruction in the canal, than at the cardia. I have feen one in- ftance of this contraction at the pylorus, which, even there, is a very rare difeafe. The contrac- tion was fo great as hardly to admit a common goofe quill to pafs from the ftomach into the duo- denum, and it had prevented a number of plum ftones from pairing, which were therefore de- tained in the ftomach. The flomach is fometimes found fo contract- ed through the whole of its extent as not to be [ 74 ] larger than a portion of the fmall interline ; at other times, it is enlarged to much more than its ordinary fize. Neither of thefe appearances are to be confidered as arifing from difeafe. They de- pend entirely on the mufcular fibres of the ftom- ach being in a ftate of contraction or relaxation, at the time of death. It happens, I think, more frequently that the ftomach is dilated than con- tracted. The flomach is very commonly found, in a dead body, flaccid and almoft empty, but not unfrequently it is found more or lefs diftended with air : this air may have been formed after death, but it is often formed during life. When this is the cafe, we may fuppofe it to be pro- duced by a new chemical arrangement in the contents of the flomach ; but, I believe, it more frequently happens that air is feparated from the-blood in die blood veffels of-the ftomach, and poured by the fmall exhalants into its cavity. This has been more particularly taken notice of by Mr. Hunter, in his Effay upon Digef- tion,* and by myfelf, in a paper which is pub- lifhed in the Medical and Chirurgical Tranfac- tions.t * See Mr. Hunter's Obfervations on certain parts of the animal economy, p. 164. f See cafe of emphyfema, p. 202. [ 75 1 In looking upon the coats of the ftomach at its great end, a fmall portion of them there appears frequently to be thinner, more tranfpar- ent, and feels fomewhat more pulpy than is ufual, but thofe appearances are feldom very ftrongly marked. They arife from the action of the gaftric juice refling on that part of the ftomach in great- er quantity than any where elfe, and diffolving a fmall portion of its coats. This is therefore not to be confidered as the confequence of a difeafe, but as a natural effect, arifing from the action of the gaftric juice, and the ftate of the flomach after death. When the gaftric juice has been in confiderable quantity, and of an active nature, the ftomach has been diffolved quite through its fub- ftance at the great end, and its contents have been effufed into the general ,#cavity of the abdomen. In fuch cafes the neighbouring vifcera are alfo partially diffolved. The inftances, however, of fo powerful a folution are rare, and have almoft only occurred in perfons who, while in good health, had died fuddenly from accident. The true explanation of thefe appearances was firft given by Mr. Hunter, and publifhed, at the requeft of Sir JohnPringle, in-the Philofophical Tranf- actions.* * See Philofoph. Tranfatf. Vol. 62, p. 447- [ 7^ j Tumours, confifting of a fuetty fubftance, have been fometimes found in the ftomach, but they are to be confidered as a very rare appearance of difeafe. Ruyfch relates, that he has feen a tu- mour from the ftomach of a man which contained hair, together with fome dentes molares; and this he has preferved in his collection.t Calculi with different appearances have been defcribed as being occafionally found in the ftom- ach. They have never come under my own ob- fervation, and are to be reckoned very uncom- mon.J Papillae and puftules, fomewhat refembling the fmall-pox, have alfo been defcribed as being formed on the inner membrane of the ftomach, but thefe are exceedingly rare.§ Even true fmall-pox puftules have been faid to be formed in the ftomachs of perfons who have died from this difeafe.|| In later diffections, how- ever, this appearance has not been obferved, fo that, at leaft, it muft be confidered as very uncommon. ■f Vid. Ruyfch, Tom. 2. Adverfar. Anatomicor. Decad. Tert. $ Vid. Lieutaud, Tom. 1, p. 17. § Vid. Lieutaud, Tom. 1, p. 23. U Vid. Lieutaud, Tom. i, p. 371. [ 77 -I CHAP. VIII. Difeafed Appearances in the Inteflines. Inflammation. 1 he inteftinal canal is fubject to inflammation from a variety of caufes, and therefore it is very ufual to obferve its effects after death. When a portion of the interline is inflamed, there is fpread upon its outer furface a number of fmall veffels, many of which are carrying a florid blood. When the interline is 'cut into, fo as to exhibit its inner membrane, it appears highly vafcular, from the fmall veffels of the villi being loaded with blood, and there are frequently to be feen a few fpots of blood extravafated. In inflammation of the intef- lines, the peritonaeum is often very little, or not at all affected. When the inflammation, however, is very great, the peritonaeum is alfo inflamed, and covered with a layer of coagulable lymph. I have likewife feen, in violent inflammation, fcat- M [ 78 J tered portions of coagulable lymph thrown out upon the furface of the villous membrane. 7"he interline is at the fame time much more thick and maffy than in a healthy ftate, and its colour is fometimes very dark, from a large quantity of black extravafated blood. This ftate of an intef- tine has often been miftaken for mortification. It very commonly happens that inflammation of the inteflines advances to fuppuration and ul- ceration. Ulceration, however, does not appear to be fo common in the fmall as in the great in- teftines. When it takes place either in the one or the other inteftine,. it is attended with confiderable variety in its appearance : the edges of the ulcer have fometimes confiderable thieknefs; at other times, they are not thicker than the healthy ftruc- ture of the intefjine ; the edges and general ca-' vity of an ulcer are fometimes ragged, and at other times they are fmooth, as if»a portion had been cut out from the inteftine with a knife. Sometimes, through a confiderable length of the inteftine (efpecially the great one) the inner mem- brane hangs in tattered fhreds, occafioned by the great ravage of the ulceration. I have alfo feen a confiderable portion of the inteftine completely (tripped of its inner membrane, from the extent of this procefs. and its mufcular coat appeared as diftinct as if it had been very carefully diffected. [ 79 '] ■In the follicular glands, which are' gathered together in little oval groups, I think I have feen ulceration more frequently than in the other parts of the inteftine. * v, When ulceration advances very actively, it fometimes eats through the coats of an inteftine entirely. When this is the cafe, a portion of the contents of the inteftine occafionally paffes into the general cavity of the abdomen, producing there inflammation. This, however, does not very often happen ; moft commonly that portion of the gut where the ulcer is fituated, adheres by inflammation to fome other portion, or to a neigh- bouring vifcus, and a communication is formed between the one and the other. I have feen com- munications formed in this manner between the rectum and the bladder in a male, and between the rectum and the vagina in a female. I have even feen a communication formed between the kidney and a portion of the inteftine from this caufe, by which the pus produced in the kidney was evacuated through the inteftine. Thofe com- munications are the means of preferving life (although in a very uncomfortable ftate) for a much'longer time than it could be, were the mat- tar to pafs into the general cavity of the belly. It would there produce peritonaeal inflammation, which would very foon deftroy. [ 8o j Inflammation of the inteflines fometimes, al- though rarely, advances to mortification. When this is the cafe, the mortified part is of a dark livid colour, and has loft its tenacity ; it is in this ftate very eafily torn through, or the fingers will pafs through it as through a rotten pear. The Avant of the natural tenacity, when attended with the odier circumftances which Ave have mentioned, is the only fure criterion of a part being mordfied, in examinations after death. A portion of intef- tine may be of a very dark colour, and yet may not be mortified. This darknefs of colour may be occafioned by a large quantity of extravafated blood thrown out during a high'degree of inflam- mation, where the principle of life is maintained in full vigour. Thus we fee blood effufed into the cellular membrane under the fkin producing a very dark appearance, yet the parts are all alive. It has often happened too, that a very dark por- tion of inteftine has been returned in the opera- tion for the bubonocele, and yet the parts have recovered their natural functions. This could never have happened if the black portion of the inteftine had really been mortified. Under fuch circumftances, the mortified part would have fe- parated from the living, and the function of the gut muft have been deftroyed. When a portion of gut has been for fome time mortified, there is [ 8i ] formed a confiderable quantity of air, which is accumulated in its cavity. This is a part of the natural procefs which takes place in all dead ani- mal fubftances. Intus Sufceptio. This is a difeafe which is not very uncom- mon, and which is frequently fatal. It con- fifts in a portion, of gut paffing for fome length Avithin another portion, and there alfo enters along with it a part of the mefentery. The portion of gut which is received into the other, is found generally in a contracted ftate, and is fometimes of confiderable length. It ufually happens that an upper portion of in- teftine falls into a loAver ; but the contrary likewife occurs, although rarely. Intus fufcep- tio may take place in any part of the inteftinal canal, but it happens moft frequently in the finall inteftine, and alfo where the ilium termi- nates in the colon. In this laft fituation, it appears to me to happen more frequently than any where elfe. This, perhaps, depends on the great disproportion in bulk between thefe two portions of inteftine. In opening into the bodies, particularly of infants, an intus fufceptio [ 82 ] is not unfrequently found, Avhich had been attended with no mi fchief: the parts appear per- fectly free from inflammation, and they would probably have been eafily difentangled from each other by their natural periftaltic motion. At other times, however, violent inflammation takes place, the parts are thickened and glued together by adhefions, and the paffage of the in- teflines is obftructe-d. This is the fatal flate of the difeafe. Ruptures. A portion of the vifcera of the abdomen fre- quently paffes out of that cavity, being lodged in a bag of elongated peritonaeum, and this difeafe is called a rupture. It happens moft commonly from fome hidden and violent concuffion of the body, where the Aveaker parts of the parietes of the abdomen give way ; it is a more frequent dif- eafe too, I think, among fat than lean people : this depends on the increafed fize of the vifcera, which therefore prefs with more force againft the fides of the abdomen. There is hardly any vif- cus Avhich has not, at fome time or other, been found in the fack of a rupture, but moft frequent- ly it is either a portion of the omentum, or of the r 83 i. lHteftine. The bag formed by the elongated pe- ritonaeum may be thruft out almoft at any part. of the belly, but this happens more frequently at the ring of the external oblique mufcle, under Pau- part's ligament, and at the naval : it alfo, fome- times, takes place at other parts of the abdomen. The moft ufual fituation of a rupture in the male, is at the ring of the external oblique mufcle ; and this arifes probably from the larger fize of that opening in the male, than in the female. The moft ufual fituation of a rupture in the female is either under Paupart's ligament, or at the navel. The reafon of the frequency of the firft fituation,. is the particular fhape of the pelvis in the female, by which there is a larger empty fpace under Pau- part's ligament, than in the male, fo that the vifcera here are lefs firmly fupported. The reafon why the fecond fituation of a rupture occurs often in the female, is, probably, frequent child-bearing. During pregnancy, at its advanced period, the navel opens, or gives way, and where pregnancies have been frequent, it probably never recovers its original ftrength. The vifcus Avhich is moft commonly found in the lack of a rupture, is the omentum. This. perhaps, arifes from its being a loofe mafs, not tied down to any particular fituation, and therefore it . readily paffes into any cavity which communi- [ 84 ] cates with the abdomen. When it has once fallen down, it has no means of pulling itfelf out, like a portion of inteftine, which is another reafon it is fo often found in a rupture. When it has remained long in any fack, it forms a pretty com- pact mafs, fometimes having no connection with, but at other times adhering to the inner furface of the fack. There is frequently no inflammation produced in the omentum while in this fituation, but occafionally violent inflammation takes place, which may even advance to mortification. A portion of gut is very often lodged in the fack of a rupture, either by itfelf, or along with a portion of the omentum. The portion of gut is fometimes very fmall, but at other times it is very confiderable. Very often the functions of the inteflines go on properly in this fituation, but occafionally violent inflammation is produced, interrupting their function, and often terminating fatally. This inflammation is produced by the preffure of the narroweft part of the fack againft the gut, viz. that part of the fack which immedi- diately paffes out of the cavity of the abdomen. This .inflammation exhibits the different appear- ances, upon diffection, which we have fo often explained. The gut too, is frequently found mor- tified : this is fhewn by its dark colour, by its want of proper tenacity, and by the air which is [ «5 J formed. When the inflammation of the gut in a fack has not been very violent, and has reced- ed, it frequently leaves adhefions behind it, con- neding the gut with the inner furface of the fack. It is perhaps poffible too, that adhefions may be formed by long clofe contaft, without inflamma- tion. When the fack of a rupture has not been of long Handing, it confifts of a thin, firm, white, opaque, membrane ; this is an elongation of the peritonaeum, fomewhat thickened by preffure.— When the fack has been of long Handing, it is often very thick, and evidently confifts of a num- ber of layers. The fack upon the infide has a very fmooth furface, and the membrane which forms this furface can be readily traced into the peritonaeum, lining the cavity of the abdomen ; the outer furface of the fack is more rough and coarfe in its texture: the fack, where it preffes out of the cavity of the abdomen, has frequently a narrow neck, or aperture, and is diftended be- low into a bag of confiderable fize. At other times, the communication between the fack and the cavity of the abdomen, is by a larger opening. Under thefe circumftances there is lefs danger of inflammation being produced by preffure againft the gut. N [ 86 ] In bubonocele, or that fpecies of rupture which takes place at the ring of the external ob- lique mufcle, the fack is ufually quite diftinct-, from the fack of the tunica vaginalis teftis. At other times, there is no feparation between them, but the contents of the rupture are immediately in contact with the body of the teftiele : this kind of rupture is called the hernia congenita. It was formerly fuppofed, when it hap- pened, to arife from a portion of the fack of the rupture and of the tunica vaginalis giving way, fo that the contents of the rupture fell into the cavity of the tunica vaginalis teftis, and came in contaa with the teftiele. Upon a little reflec- tion, it might have been feen that this could hard- ly take place; but the account of this appearance was not knoAvn till it was explained by Dr. Hunter. Baron Haller difcovered, that till about the eighth month the tefticles do not defcend into the fcro- tum, but are fituated in the cavity of the abdo- men under the kidneys. When they defcend in- to the fcrotum, the peritonaeum which covers them is neceffarily drawn down along with them through the ring of the external oblique mufcle ; it then fonns a bag, Avhofe upper extremity com- municates with the cavity of the abdomen. Ba- ron Haller had alfo obferved, that in infants a por- tion of inteftine fometimes falls down into this t 87 ] bag after the teftiele, or along with it, produc- ing what he \called the hernia congenita. The, communication betAveen the bag and the abdo- men is commqnly foon clofed, for it is not open at birth. It appears, however, if it is prevented from clofing at the ufual time, that it does not clofe afterwards, but remains open through life.— Hence, if afty portion of an inteftine, or of the omentum, falls into the elongated fack of the pe- ritonaeum, it muft be in contact with the teftiele. When Dr. Hunter became acquainted with the obfervations of Baron Haller upon the defcent of the tefticles, he faw at once that the fpecies of rupture fometimes to be met Avith in adults,, where a portion of inteftine or omentum is in contact with the t&fticle, might be eafily explained. His explanation correfponded with what we have juft given, and has been univerfally adopted by anato- mifts and furgeons. Schirrus and Cancer of the Inteflines. Schirrus is a difeafe Avhich takes place much more commonly in the great than in the fmall inteflines, but the latter are occafionally affected by it. I have feen both a fchirrous tumour, and a cancerous ulcer in the duodenum. In the great [ 88 ] inteftine at an advanced period of life, fchirrus is not uncommon ; it is not equally liable to aft feet every portion of this inteftine, but is to be found much more frequently at the figmoid flex- tire of the colon, or in the rectum, than any where elfe; the reafon of this is, perhaps, difficult to determine. There is certainly more of glandu- lar ftructure in the inner membrane of the great inteftine, towards its loAver extremity, than in any other part of it, and I think that this fort of ftruc- ture has a greater tendencyto be affected with fchirrus, than the ordinary flructures of the body : the gut, too, is narrower at the figmoid flexure than at any other part, and therefore muft be more liable to be injured by the paffage of hard bodies; thefe, by their irritation, may excite the difeafe of fchirrus in a part which was pre-difpof- ed to it. What we have now faid, however, is merely conjectural. The fchirrus fometimes extends over a confi- derable length of the gut, viz. feveral inches ; but generally it is more circumfcribed. When it is affected with fchirrus, it exhibits the fame appear- ances of ftructure which were defcribed Avhen fpeaking of fchirrus of the ftomach. The peri- tonaeal, mufcular, and internal coats are much thicker and harder than in a natural ftate. The mufcular too is fubdivided by membranous fepta, C 89 ] and the internal coat is fometimes formed into hard irregular folds. It often happens that the furface of the inner membrane is ulcerated, pro- ducing cancer. When fchirrus affects the gut, the paffage at that part is always narrowed, and fome- times fo much fo as to be almoft entirely oblit- erated. The obliteration, or ftrictare, would fometimes appear to be greater than in proportion to the thicknefs of the fide of the difeafed gut: this, moft probably, depends upon the contraaion of the mufcular fibres of the gut, which, although difeafed, have not altogether loft their natural ac- tion. Where the paffage is very much obftrua- ed, the gut is much enlarged immediately above the obftruaion, from the accumulation of con- tents in that part of the inteftine. While this dif- eafe is going on in a portion of the inteftine, ad- hefions are formed between it and the neighbour- ing vifcera, and the ulceration fometimes fpreads from one to the other. The inner membrane of the great inteftine I have feen a good deal thickened, and formed in- to fmall irregular tubercles, fome of which were of a white, and others of a yellowifh colour ; the peritonaeal and mufcular coats were alfo thicker and harder than in a natural ftate. This is not a frequent appearance of difeafe, but it has fome- times been found to take place in very fevere [ 90 J dyfenteries, fuch as in that which has been de- fcribed by the late Sir John Pringle.* I have alfo feen the internal membrane of the great inteftine formed into broad thick folds, in which a confiderable quantity of blood was ac- cumulated ; thefe folds Avere perfeaiy independ- ent of the ftate of the contraaion in the mufcular coat, and were very different in their appearance from the irregular puckering Avdiich is often feen in the inner membrane of the great inteftine.— When thefe folds were examined : they were found to confift of an accumulation only of cel- lular membrane, lying behind the inner coat of the gut. What was the effea of this difeafed ftruaure in the living body, I had no opportuni- ty of learning. Upon the inner furface of the great inteftine, about two inches above the anus, little pro- ceffes fometimes groAV from the internal mem- brane : they generally furround the gut at fhort diftances from each other, fo as to form a fort of circle. Piles, and fiftulae in ano, are difeafes Avhich are extremely common, but which hardly ever become an objea of examination after death; they have therefore not been fo commonly in- troduced into accounts of morbid appearances * See Piingle's Difeafes of the Army, p. 246, [ 9i ] as others Avhich much more rarely occur. Piles are foft tumours commonly fituated round the verge of the anus, fometimes of a regularly bul- bous, at other times of an irregular form. They are covered with a very tender fkin, which partly confifts of the fine fkin immediately round the anus on the outfide, and partly of the inner membrane of the gut. The tumours are general- ly entire, but they have occafionally fmall open- ings through which a confiderable quantity of blood is fometimes poured ; they confift of the extremities of the branches of the mefaraica minor vein, much enlarged from the accumulation of blood. The fame fort of tumours are alfo frequently found Avdthin the cavity of the reaum, forming Avhat have been called, the internal piles. Piles are a much more frequent difeafe .in perfons Avho are advanced in life, than in thofe who are young. They arife from repeated, and long continued impediments to the return of the blood by the branches of the mefaraica minor vein, and there has been much more opportunity for thefe im- pediments to aa in old, than in young perfons. They are alfo more common in women than in men. This may arife from feveral caufes : the uterus during pregnancy muft occafion a great impediment to the return of the blood from the [ 9* ] rectum ; this is fo much the cafe, that women who have been frequently pregnant feldom efcape piles. Women too are more apt to allow of an accumulation of the proper contents of the rec- tum, than men, and this will produce fome im- pediment to the return of blood from this part. It may perhaps be added, that the greater weak- nefs of the original formation in women, than in men, may render the former more liable to this difeafe than the latter. Fiftulae in ano, are narrow canals at the lower end of the reaum, with a fmooth internal fur- face, with callous edges, and having the power of fecreting pus.* A difeafe of this fort may con- fift of one canal, opening by a very fmall aper- ture externally, at the fide of the anus; or this canal may be divided into feveral branches.—- When this laft is the cafe, the difeafe is more fe- rious, as it requires for its cure a more difficult, tedious, and painful operation. The canal, be- fides opening externally, has very commonly a fmall opening into the gut itfelf; and fometimes there is a fmall opening into the gut, without there being any externally on the fide of the anus. It is much more common, however, that there * Mr. Hunter has obferved, in his Ledlures on Surge- ry, that fiftulse have a fmooth internal furface, like a fe- creting furface, as, for inftance, the urethra. [ 93 ] fhould be an external opening of the canal only ; or, that there fhould both be an external opening, and another into the gut. It is a fpecies of monftrous formation, not very uncommon, that the reaum does not terminate in the anus, but in a cul-defac, Avithout reaching the external furface. Sometimes the extremity of the gut lies immediately behind the fkin, which is there thinner, and mews where the anus ought to have been placed. Under thefe circumftances, it is eafy to make an artificial anus. It happens often, however, that the reaum terminates more than an inch behind the fkin, and then a remedy by an operation is much more difficult and un- certain. I have alfo feen the reaum terminate in the bladder, from an original error in the formation, fo that there was no other external opening to the reaum than by the urethra : this was in a child at birth ; the mal-formation Avas of fuch a kind, as neither to admit of a remedy by art, nor to alloAv of life being continued. The reaum has alfo been known to terminate in the vagina, from a defea in the original formation ; but this is very uncommon. O [ 94 ] < * ■ 'r Worms. i Worms are formed in the inteflines of man, a, vfell as of many other claffes of animals, but not fd'Trequently in the former as in the latter. In rKbft quadrupeds and fifhes it is extremely com- mon to find a number of worms upon opening tlieir inteflines. jI The \\rorms which are found in the human fub- jea, may be reduced to three general claffes, viz. the lumbricus teres ; taenia, and afcaris. Lumbricus Teres. The lumbricus teres, or round Avorm, is much more commonly found in the inteflines of chil- dren, than in thofe of perfons full grown, or ad- vanced in life : it is very ufually met with in the firft, but rarely in the two laft. The lumbricus teres has been often confounded with the com- mon earth-AVorm, to Avhich it bears a general re- femblance, although it is really very different. By moft praaitioners, indeed, at prefent, there is known to be a difference, yet it is not ve- ry well underftood in what this difference con- fifts. The two fpecies of Avorms, if attentively [ 95 ] examined, will be found to differ a good deaSI from each other in their external appearance*} The lumbricus teres is more pointed at both -lexl tremities, than the common earth-Avorm ; sthb mouth of the lumbricus teres confifts of tYitm rounded projeaions, with an intermediate cavity; The mouth of the earth-Avorm confifts ofafffisM longitudinal fiffure, fituated on the under furface of a fmall rounded head. Upon the uffldter furface too of the worm there is a large femiltffiatf fold of fkin, into which the head retreats, or-oii'tJ of which it is elongated, which is entirely want- ing in the lumbricus teres. The anus of Wit lumbricus teres opens upon the under furfarie of the Avorm, a little way from its poflerior extremity,' by a tranfverfe curved filfure ; the anus of the1 earth-worm opens by an oval aperture at the :verV; extremity of the Avorm. The outer coverihg*q6fJ fkin in the lumbricus teres is lefs flefhy, and' lefs' flrongly marked by tranfverfe rugae, than irrrther earth-worm. In the latter there is often to be'FeefP a broad Avhitc band, furrounding the body rof W worm ; but in the lumbricus teres, this is entfret^i wanting. On each fide of the lumbricus 'teres there is a longitudinal line very well marked^itt the earth-Avorm there are three longitudinal Jfnes upon the upper half of its furface, but thefe rare? faintly marked, fo as to be hardly obfervable;'^ [ 9^ ] The lumbricus teres has nothing correfponding to feet; Avhereas the earth-A\rorm has on its under furface, and tOAvards its poflerior extremity, a double row of proceffes on each fide, very fenfiblc both to the eye and the finger, which manifeftly ferve the purpofes of feet in the locomotion of the animal. The internal ftructure of both animals is alfo extremely different. In the lumbricus teres, there is an inteftinal canal, nearly uniform and fmooth in its appearance, Avhich paffes from one extremity of the worm to the other ;* in the earth-worm, there is a large and complex ftomach, confifting of three cavities ; and the inteftinal canal in the latter is likewife larger, and more formed into facculi, than the former. The parts fubfervient to generation are very different in both : in the lumbricus teres there is a diftinaion of fex, the parts of generation being different in the male and in the female ; in the common earth-worm the organs of generation are the fame of each indivi- dual, as this animal is hermaphrodite. The ap- pearance too of the organs of generation, is ex- tremely different at firft fight in the one fpecies of animal, and the other : There is an oval mafs * Near the head of the lumbricus teres, the canal is nar- rower than it is any where elfe, and alfo fomewhat diftinct in its limits, which may be confidered as the cefophagus. [ 97 ] fituated at the anterior extremity of the earth-worm, refembling a good deal the medullary matter of the brain ; in the lumbricus teres this fubftance is wanting.* Thefe are the greater differences between the one fpecies of animal and the other, which are obvious upon a very moderate attention to each. Many other differences Avould, no doubt, be found by a perfon who might choofe to profe- cute their anatomy minutely. Taenia. The taenia, or tapeAvorm, is rarely found in the inteflines of the inhabitants of this country, but is very common in thofe of fome countries on the continent, particularly SAvitzerland. It confifts of a great many diftina portions, Avhich are conneaed together fo as to put on a jointed appearance; thefe joints are commonly of a very white co- lour, but are occafionally broAvnifh, which de- pends on a fluid of this colour that is found in their \reffels. The Avorm is ufually very long, extending often many yards, and feldom paffes entire from the boAvels. This circum- * What this fubftance is I do not know, and 1 have only mentioned its refeniblance to the medullary matter of the brain, in order to give a clearer defcvipiion of it. [ 93 ] fiance has prevented the extremities of the taenia from being often feen. The head of a taenia is fomewhat of a fquare form, with a narroAvcd projeaion forwards; in the middle of this projeaing part there is a diftina cir- cular aperture, around which is a fingle or a dou- ble row of curved fharp proceffes. At the fquare edge of the head, there are fituated four round projeaing apertures, at equal diftances from each other : this head is placed upon a narrow jointed portion of the Avorm, of confiderable length, and which gradually fpreads itfelf into the broader joints, of Avhich the body of the Avorm is com- pofed. The body of the taenia, which is moft common- ly found in the human fubjea, confifts of thin, flat, pretty long joints on one edge of Avhich there is a projeaion, Avith a very obvious aperture. In the fame Avorm fome of thefe joints appear con- siderably longer than others; this probably de- pends on one joint being contraaed, Avhile an- other is relaxed. The apertures Avhich Ave have juft mentioned are generally placed on the alter- nate edges of the contiguous joints ; but this is not uniformly the cafe ; they are fometimes placed on the fame edges of two, or even feveral conti- guous joints. When thefe joints are examined attentively, there are frequently feen, in each of [ 99 ] them, veffels filled Avith a brownifh fluid, and dif- pofed in an arborefce'nt form. Around the edges of each joint, there is alfo a diftina ferpentine canal.* The laft joint of a taenia refembles very much a common joint rounded off at its extremi- ty, and without any aperture. The defcription which I have given, is chiefly taken from Avhat I have ken myfelf, and correfponds, I believe, with what is moft common. There are differences, hoAvever, in taeniae defcribed by authors, chiefly Avith regard to the number and fituation of the ofcula of the joints, fo as to diftinguifh them into different fpecies; but they are all formed upon one general plan. Afcans. The afcaris is a very fmall worm, which is of- ten found at the loAver end of the reaum in chil- dren, and even more frequently in adults than is commonly imagined. It is Avhite in its colour, and about half an inch in length ; it is a little nar- rowed at the extremity Avhere its head is placed, * This, as well as the veffels difpofed in an arborefcent form, is very diftintfly feen injecled in fome preparations which have been made, and given to me by an ingenious young furgeon, Mr. Cailifle. [ 10° 3 and at the other extremity it terminates in a long, very fine, tranfparent procefs. Thefe Avorms are more or lefs furrounded with mucus, and this Ls probably fecreted in greater quantity by the glands in the inner membrane of the reaum, from the irritation occafioned by the worms. There is nothing in the economy of animals more obfeure than the origin of inteftinal worms; Avere they found to live in fituations out of the bo- dies of living animals, one might readily fuppofe that their ovula were taken into the body along Avith the food and drink, and there gradually evolv- ed into animals. This, however, is not the cafe; they do not feem capable of living for any length of time in any fituation, except within a living ani- mal body, Avhich appears to be the proper place for their groAvth and refidence. We might there- fore be led to another fuppofition, viz. that intefti- nal worms are really formed from the matter con- tained in the inteftines, which prcvioufly had no regular organization; but this idea is widely differ- ent from all analogy in the produaion of animals, where there has been any fatisfaaory opportunity of examining this produaion. The origin there- fore of fuch animals is a fubjea of much obfeurity, nor do I pretend at all to throw any light upon it. When the Avhole evidence, however, in fupportof the one and the other opinion, is compared toge- [ 101 ] ther, I own, that the grounds for believing that in fome orders of animals equivocal generation takes place, appear ftronger than thofe for a contrary o- pinion. It is not unufual to find air accumulated in the inteftinal canal, in greater or lefs quantity ; this air is fometimes accompanied with a flight inflamma- tion of the peritonaeum, and at other times it is not. In fuch cafes the blood Veffels, creeping upon the inteftines, are frequently filled Avith air, but not uncommonly they are Avithout it. Air is often let loofe into the inteftines after death by putrefaaion ; but that which Ave wifh particularly to confider here, has been formed during life. There are only two ways in which we can Aveli conceive air to be formed in the inteftines : the one is, fome new arrangement in the contents of the inteftines, by which air is extricated : the o- ther is, the formation of air in the blood veffels of the inteftines by a procefs fimilar to fecretion, and which air is afterwards poured out by the extremities of the exhalant arteries into the cavi- ty of the inteftines. That the blood veffels of an animal body have this power there can be no doubt ; and I own I am inclined to think that this is a very frequent mode by Avhich air is accu- mulated in the inteftines. This air probably differs fomcAvhat at different times : in feveral P [ 102 ] trials which I have made, it never fhewcd figns of containing any proportion of inflammable air, but always a very fenfible proportion of fixed air. It requires, however, to be examined by fome perfon well acquainted Avith chemical ex- periments, in order that its ingredients may be exaaiy afcertained. Thefe are the more common appearances of difeafed, or preternatural ftructure in the intef- tines ; but I have likewife had an opportunity of obferving others, which are of rarer occurrence. In one or two inftances, I have feen a fort of bony matter thrown out upon the furface of the inner membrane of the gut: I have even feen an ad- hefion between two portions of inteftine, con- verted into bone. It Avould appear, that almoft every part of the body is endued with a power of taking on this procefs. It may not improper- ly be confidered, as a natural procefs mifplaced. An adhefion being once formed, has the fame power (as far as we know) of running into differ- ■ ent proceffes, as the cellular membrane, which makes a part of the original flruaure. It may therefore form bone, as readily as cellular mem- brane, or fome other membranes of the body, which have a refemblance to the membrane of adhefions, as the pleura, and the peritonaeum. [ 103 ] I have feen one of the valvulae conniventes much larger than ufual, and paffing round on the infide of the jejunum, like a broad ring. The canal of the gut was neceffarily much narrowed at this ring, but no mifchief had arifen from it.— This mal-formation, however, might have laid the foundation of fatal mifchief. Some fubftance too large to pafs, might have refted on the ring, and produced there inflammation, ulceration, and ultimately death. Calculous matter has fometimes been knoAvn to be accumulated in fome part of the cavity of the inteftinal canal, efpecially the great inteftine ; but this has not come under my own obfervation, and, at leaft in the human fubjea, it is a very rare occurrence.* Small-pox puftules have been faid to be fome- times formed in the inteftines of perfons who have died from this difeafe.t How far this may have occafionally taken place, I will not pretend to fay, but late diffeaions, upon the beft authority, have not confirmed this faa. * Vid. Lieutaud, Tom. i, p. 77, 78. f Vid. Lieutaud, Tom. 1, p. 3. 71, [ 104 j Difeafed Appearances of the Mefentery. The mefentery is often found in a ftate of in- flammation, although I believe this hardly ever takes place, unlefs Avhen the peritonaeum gener- ally i« inflamed. When the mefentery is in- flamed, it becomes much thicker, and more maf- fy, than in its natural ftate; the large blood vef- fels which pafs between its laminae, and the abforb- ent glands, are alfo very much obfcured. Thefe different appearances depend upon the quantity of the coagulable lymph Avhich is thrown out, during the inflammatory aaion. The peritonae- um which forms the laminae of the mefentery is croAvded with fmall blood veffels, and is covered more or lefs with a layer of the coagulable lymph. A fmall quantity of pus is fometimes found on the furface of an inflamed mefentery, and even abfceffes have been obferved between its laminae; but this laft appearance is very rare. It very feldom happens, that the mefentery is found gangrenous, unlefs different portions of the inteftinal canal be found in the fame ftate. It has not occurred to me, at leaft, to fee an inftance of this fort. When the inteftines are mortified, portions of the mefentery are generally found in the fame condition. The appearances exhibited [ *05 ] in mortification are the fame when it affeas the mefentery, as any other part, and they have been already explained. The abforbent glands of the mefentery are fre- quently found to be fcrofulous, and this is more apt to take place in children, than at a more ad- vanced age. When affeaed with this difeafe, the glands exhibit different appearances, according to its progrefs : they are enlarged in their fize, and are fofter to the touch, than in a natural ftate. When cut into, they fometimes mew very much the natural ftruaure ; but more frequently thev are changed, in part, into a white, foft, curdly matter, and this is not uncommonly mixed with pus. When the abforbent glands of the mefen- tery are univerfally affeaed with fcrofula, and very much enlarged in their fize, the abdomen is very tumid, and the face and extremities appear a good deal emaciated. When a portion of the inteftinal canal becomes cancerous, fome of the abforbent glands in the mefentery generally become affeaed with the fame difeafe : this is in confequence of the matter of cancer being conveyed to thofe glands by abforb- ent veffels. The glands become enlarged in fize, and are changed into hard maffes of a fchirrous, or cancerous texture. r 45 3 ■ ing any thing of the fymptoms which it produced during life. I Avas once fent for to a Avoman a- bout two days before fhe died, who, befides other ailments, complained very much of a fevere pain in the region of the kidneys, and the urine which file paffed had a very large proportion of a fedi- ment fomewhat refembling cream. How long fhe had complained of thefe fymptoms I do not now recolfea, but tie time was confiderable. This very imperfea account is only thrown out to be fome guide to future inquiry, that this difeaf- ed procefs may be more particularly ascertain- ed. One thing furprifed me at the time, and perhaps^without reafon, viz. that this procefs had been attended with fevere pain. We are natural- ly led to expea in proceffes Avhich go on flow7- ly, and as it Avere imperceptibly, that the pain fhould be inconfiderable. Hydatids of the Kidneys. The formation of hydatids is not an uncom- mon difeafe in the kidneys. There are fome- times one or two confiderable hydatids on the furface of the kidney, lying between its fub- ftance and capfule; and at other times, the na- tural ftruaure of a kidney is almoft entirely loft, [ *46 ] and is changed into a mafs of fmall hydatids.— When this is the cafe, the mafs is commonly much larger than in the natural fize of a healthy kid- ney. Thefe hydatids do not appear to be of the fame nature Avith the hydatids of the liver : they are not inclofed in firm cyfts, like thofe of the liver : their coats are alfo thinner, and lefs pul- py, and not uncommonly thev are almoft as thin as any membrane of the body. I do not recolfea likewife to have feen any inftance of fmall hyda- tids attached to the coats of larger hydatids in the kidney, as may be frequently obferved in the liver. It is therefore probable that the hy- datids of the kidney depend on a difeafed altera- tion of the ftruaure of this organ, and are not dif- tina organized fimple animals. Calculi of the Kidneys. The formation of calculi is not peculiar to the kidneys, but it is a more frequent difeafe in them than in any other part of the body. Small gra- nules of ftone are fometimes found in the tubular portion of the kidneys, which may cither be attended with inflammation, or be Avithout it. Moft com- monly, however, there is found a calculus of con- fiderable fize lodged either in fome part of the [ 147 ] fubftance of the kidney, or in the pelvis of tfie ureter. The laft fituation is by much the moft frequent. When a ftone in this fituation is fo large as not to be capable ofpafling through the ureter, it is after- wards gradually increafed in fize, from the con- taa of the urine. In its groAvth, it neceffarily fol- lows the branches of the pelvis, which are called infundibula, and is therefore of an arborcfcent form. Such calculi vary in their colour and fur- face; they arc fometimes of a light broAvn, fome- times of a dark brown, and fometimes of a Avhite colour. They are alfo fometimes fmooth, and at other times a little roughened on their furface. Of the nature of urinary calculi Ave fhall fpeak after- Avards, when we come to take notice of the difeaf- ed appearances of the bladder. When a ftone in the pelvis of the ureter has increafed to a very con- fiderable fize, it prevents the urine almoft altoge- ther from palTing into the ureter. The urine is therefore accumulated in the pelvis above the ftone, and hence enlarges it very much in fize, as Avell as the cavity of the kidney. From the pref- fure too of the urine behind the ftone, the pelvis of the ureter, befides being enlarged, is thruft out from the fubftance of the kidney. If the interrup- tion to the paffage of the urine from the kidney arifes from fome obftruaion in the loAver extremi- [ i48 J ty of the ureter, or at the neck of the bladder, or in any part of the urethra, not only the pelvis of the ureter is then enlarged, but the ureter itfelf. I have ken the ureters of both kidneys enlarged from this caufe to twice or thrice their natural fize. Whatever be the nature of the obftruaion, if the pelvis of the ureter be very much enlarged from the accumulation of the urine, the cavity of the kidney is at the fame time enlarged. As this procefs advances, the fubftance of the kidney be- comes more and more compreffed, and its cavity becomes enlarged in proportion. The fubftance of the kidney is, at length, in a great meafure loft, and is converted into a capfule, containing a great many cells, which communicate Avith each other. The capfule is fometimes very thin, and the Avhole mafs is a great deal larger than the natural fize of a healthy kidney. It is worthy of remark, ' that the urine is fecreted even when the natural ftruaure of the kidney is almoft entirely loft. This is both feen in the derangement of the kidneys noAV under confideration, and Avhen they are converted into a mak of hyda- tids. It Avould appear from this faa, that either a very fmall portion of the natural ftruaure of the kidneys is capable of fecreting very nearly the or- dinary quantity of the urine, or that the urine [ 149 ] can be fecreted by a ftruaure that is different from the ordinary ftruaure of the kidneys. Without pretending to determine this queftion, we fhall take the liberty of obferving, that as the urine is a fluid which is excrementitious, and requires on- ly to be feparated from the blood, without under- going further changes like many fecreted fluids, it is probable that it can be feparated by a more Tim- ple apparatus, and under more varied circum- ftances, than where the fecretion from its nature muft be more complicated. The kidneys^ have been faid to be converted into an earthy fubftance.* A kidney has alfo been known to become offified. $ Thofe appearances have never come under my own obfervation, and I am perfuaded are extremely rare. The kidneys are fubjea to a good deal of va- riety in their natural circumftances, from origin- al formation. The two kidneys are fometimes found to be joined together: they are fometimes fituated before the lumbar vertebrae, and fome- times on the fides of the pelvis. They are occa- fionally very fmall in their fize, and a kidney on one fide is fometimes wanting; Avhenthis is the cafe, the other kidney is larger than the ordinary fize. * A/id. Lieutaud, Tom. i, p. a82. S See Medical Communications, Vol. i, p. 416. [ 15° ] It would be very difficult to affign a fatisfaao- ry reafon why there fhould be fuch variety in the kidneys, but we can fee that there is no difadvan- tage to the animal funaions produced by this variety. The kidneys are not large in their fize, and therefore may be changed in their fituation with- out any fenfible inconvenience. As their func- tion is independent of relative fituation, it muft be precifely the fame wherever the kidneys are placed. When the kidneys are fmall, the fecretion of the urine may be very nearly in the common quantity, from a greater aaivity in the carrying on their funaion; or fuch perfons may be dif- pofed to fweat more than ufual, to counterba- lance the deficiency of the urine. We know ve- ry well that the fecretions of the fweat and the urine are vicarious. When a kidney is Avanting the other, being of a large fize, is probably ca- pable of doing the office of tAvo kidneys. Difeafed Appearances of the Renal Capfules, The renal capfules are fcarcely ever found difeafed. Inftead of the dark coloured fubftance in the centre, I have fometimes feen a blackifh [ 151 ] fluid, and this is probably what is meant by au- thors when they fay that they have found in fhe cavity of a renal capfule a fluid like ink. In fuch cafes we may either fuppofe the dark co- loured fubftance to be converted into the black- ifh fluid ; or we may fuppofe that the former is removed by abforption, and tire latter is depo- fited. The renal capfules have been obferved to contain pus.* Little granules of ftone have been found in the fubftance of the renal capfules.^ Both of thefe appearances are very rare, and have not fallen under my OAvn obfervation. * Vid. Lieutaud, Tom. i, p. 285. § Vid. Lieutaud, Tom. 1, p. 286, [ 152 ] CHAP. XIV. Difeafed Appearances of the Bladder. Inflammation of the Peritoneal Covering. X he bladder is covered on the outfide partial- ly by the peritonaeum, which is very liable to be inflamed. That portion of it which belongs to the bladder, is not very often inflamed by it- felf, but it partakes of the inflammation which extends over the membrane generally. The ap- pearances accompanying its inflammation have been fufficiently often defcribed. When the inflammation fubfides, adhefions are frequently left behind, conneaing the bladder more or lefs to the neighbouring parts ; in a female, to the uterus, and in a male, to the reaum. Inflammation of the inner Membrane. The inner membrane too is fometimes inflam- ed. When this happens, the inflammation is ei- [ 153*3 uiCi cAtcuueu over the whole cavity, or is con- fined to a particular portion of it. The portion which is moft frequently inflamed is near the neck of the bladder. This may arife from two caufes ; the one is, that in this fituation, or near it, fome obftruaion is frequently found to the paffage of the urine, which may produce irritation, and bring on more or lefs of inflammation; the other is, that inflammations of the urethra occafionally extend fome Avay Avithin the cavity of the bladder, and even fometimes over the whole of it. It is well known that the inner membrane of the blad- f | der hardly fhews veffels which carry red blood in its natural ftate, but when it is inflamed it is crowded with.a prodigious number of extremely fine blood veffels, and accompanied fometimes ||. | with fmall fpots of extravafated blood. When the inflammation is in a high degree, the mufcular coat of the bladder may be affeaed ; but as this is . ■: 6nly loofely attached to the inner membrane, the inflammation will not very readily pafs from the , I one to the other. Ulcers. \ i Inflammation of the inner membrane of the ;. , bladder advances fometimes to the formation of [ 154 ] pus, and abfceffes and ulcers are occafionally pro- duced. Thefe, Avhen the inflammation has been of the common fort, exhibit the ordinary appear- ances which have been often mentioned* They fometimes advance fo far as to deftroy a portion of the bladder entirely, and to form communica- tions between it and the neighbouring parts : as with the general cavity of the abdomen, with the reaum of die male, and the vagina in the female. When the communication is formed with the ge- neral cavity of the abdomen, the urine efcapes into it, producing there general peritonaeal inflamma- tion, of which I recolfea a very ftriking example. When the communication is formed with the va- gina or the reaum, the urine will efcape by thefe paffages, producing in them more or lefs of irrita- tion and inflammation. When abfceffes take place in the bladder, they are produced more frequently from local vio- lence, than from a previous fpontaneous inflam- mation. One of the moft common caufes of vi- olence is the incifion of the bladder in the oper- ation of lithotomy. When the part has been very much irritated in the operation, or the con- ftitution is fuch that it is excited into violent ac- tion from the common degree of irritation, an ulcer is formed at the lips of the Avound, and [ 155 1 fpreads more or lefs into the cavity of the blad- der. It fometimes happens, although I believe ve- ry rarely, that the Avhole of the inner membrane of the bladder is deftroyed by ulceration, and its mufcular fibres appear as bare as if they had been nicely diffeaed. In the cafe Avhere I recol- lea this procefs to have taken place moft com- pletely, the bladder was almoft filled with a fcro- fulous pus. This had exaaiy the fame appear- ance as when a fcrofulous abforbent gland fup- purates, viz. there Avas a curdly Avhite matter mixed with pus. Schirrus and Cancer. I do not think that fchirrus or cancer often attack the bladder by itfelf, but it fometimes par- takes of this difeafe from its contiguity to parts which are very liable to it. The difeafe on fome occafions fpreads to the bladder from the reaum, and on others from the uterus : under fuch cir- cumftances the bladder becomes very thick and hard, and exhibits the ordinary cancerous ftruc- ture. Communications too are generally form- ed either with the reaum, the uterus, or the vagina. [ '5<$ ] Fungous Excrefcences. Sometimes fungous excrefcences arife from the inner furface of the bladder, either in one mafs, or in feparate portions. When examined, they are found to confift of a loofe fibrous ftruc- ture. When they are fituated a little behind the neck of the bladder, Avhich is not uncommonly the cafe, they muft produce a confiderable ob- ftruaion to the paffage of the urine. A ftronger aaion will, therefore, be required in the bladder to expel the urine, and its mufcular coat Avill be confequently thickened: accordingly it is fre- quently found thickened; and it is not improba- ble that even where the fituation of the fungus may not obftrua the paffage of the urine into the urethra, its prefence may ftill irritate the blad- der fo as to excite it to more frequent and ftrong- er aaions than in a natural ftate, and the muf- cular coat become thereby thickened. Elongations of the inner Membrane. I have alfo known the inner membrane of the bladder elongated in fome parts, fo as to form irregular proceffes. Thefe when cut into, were t >57 3 found to confift of a confiderable quantity of cel- lular membrane, intermixed with a little fat.— The procefs producing fuch an appearance was probably a flow one, and was probably alfo attended with no pain. If thefe elongations Avere to be fituated at a diftance from the neck of the bladder, one can hardly perceive how they could produce any* inconvenience, but if fituated near the neck of the bladder, they might occafion ex- treme difficulty in making water, and even lay the foundation of a fatal difeafe. Mufcular Coat Thickened. One of the moft ordinary changes in the blad- der, from its natural ftruaure, is the great thick- ening of its mufcular coat. In a natural ftate, the mufcular coat of the bladder (when it is mo- derately diftended) confifts of thin layers of muf- cular fibres, running in different direaions.— Thefe are probably altogether, not more than the eighth of an inch in thicknefs. The mufcu- lar coat of the bladder, however, is occafionally found at leaft half an inch thick. This arifes from an additional quantity of mulcle being form- ed in confequence of extraordinary efforts being neceffarv in the bladder. The efforts take place * v "[ 158 ] when there is any confiderable difficulty in mak- ing Avater, as happens Avhen the proftate gland is a good deal enlarged, Avhen there is a ftone in the bladder, or when there are ftriaures of the urethra. It. is ufual, therefore, to find this thick- ening of the mufcular coat of the bladder when there is any of thefe difeafes. When the blad- der is thickened, the fafciculi of Ayhjch its muf- cular coat is compofed become much larger, but never, or at leaf! very feldom, acquire the full red colour Avhich mufcles have in other parts of the body. This is a deviation from the general plan of nature with regard to the increafe of muf- cles from exercife. When mufcles are enlarg- ed in fize from exercife, they alfo become of a deep red colour. There is no other inftance too in the body, as far as I recolfea, of a mufcle being fo much enlarged beyond its natural fize in confequence of increafed exertion, as the muf- cular coat of the bladder. Between the fafciculi of the mufcular fibres, little pouches are formed by the inner membrane. This arifes from the preffure of the urine againft the inner membrane of the bladder which is impelled by the ftrong poAvers of the mufcular coat. Thefe pouches are often large enough to admit the end of the finger, and contain occafionally fmall calculi.— The bladder in this ftate admits of verv little dif- [ 159 ] tenfion, fo that it is capable Of containing little water ; hence the inclination to make water is fre- quent, and frequent efforts of the mufcular coat are required, which increafe more and more its / thicknefs. It is much more common to find this appearance of the bladder in the male than in the female, becaufe in the latter there are fewer caufes to produce it. There is in that fex a want of the proftate gland altogether, and the urethra being fhort and Avide, obftruaions fel- dom take place in it. When the mufcular coat of the bladder is thickened, I believe that it has been fometimes miftaken for fchirrus. Calculi. Calculi are not uncommonly found in the blad- der, and are confined in their formation to no particular period of life. They are formed in ve- ry young children, and alfo in perfons of middle and advanced age. This difeafe is not fo frequent- ly met with in the female as in the male, which may depend on two caufes; the one is, that there is not fo ftrong a tendency to their formation in that fex; and the other caufe is, that ftones efcape through the urethra in women, which Avould be detained in the bladder of men, and lay the foundation there of larger calculi. [ 160 ] The ftones which are found in the bladder, are either originally formed in the kidneys, and pafs through the ureters into the bladder, or they are firft formed in the bladder itfelf. When the laft circumftance takes place, the earthy matter is fometimes firft depofited round fome extraneous body, which becomes the nucleus of the calculus, although moft frequently no nucleus whatever is to be obferved. The nuclei which I have feen have been fmall portions of lead (probably bro- ken off from a leaden bougie) fmall nails, and lit- tle maffes of hair. In fhort, any extraneous bo- dy which may happen to be introduced into the bladder, may become a nucleus. It is natural to think that fuch nuclei are more common in the calculi found in the bladder of women, than of men ; their urethra is wider and fhorter, fo that an extraneous body can be much more eafily in- troduced into the bladder; and Avomen too, from the particular frame of their minds, are more apt to make experiments of this fort than men. The calculi of the bladder either lie loofe in it, or are confined to fome fixed fituation, from particular circumftances. When .they are of a fmall fize, they are fometimes lodged in pouches, or facculi, formed by the protrufion of the inner membrane of the bladder between the faf- ciculi of its mufcular fibres. - A calculus alfo [ i6i ] is occafionally attached to an exerefcence of the bladder, fo as to be kept in a fixed fitua- tion. There is frequently one calculus only in the bladder at a time, and then it is ufually of an oval form ; but there are often more, and the calculi by rubbing upon each other acquire flat fides and angles. Calculi have fometimes a fmooth uniform furface, but moft frequently the furface is granulated. Thefe granules are com- monly placed very near each other over the whole furface of the calculus, giving it a certain degree of roughnefs. I have alfo feen them gathered into clufters on particular parts of the furface of a calculus. Thefe granules are alfo fometimes of a fmaller, at other times of a larger fize, and in different calculi are more or lefs ele- vated. Some calculi have an irregular porous ftruaure upon the furface, inftead of being gra- nulated. Calculi when divided by the faAV, or broken, exhibit moft commonly a laminated ftruaure. Thefe laminae are difpofed in concentric curves, and are applied together with more or lefs com- paanefs. They alfo differ in their thicknefs in different calculi : The laminated ftruaure fome- times pervades uniformly the whole mafs of the calculus; at other times different portions of [ 16a ] it are interrupted by a coarfe porous texture. In fome calculi no laminated ftruaure whatever is obfervable, but it is entirely porous. The colour of calculi varies confiderably. They are moft frequently of a brown colour, which is fometimes of a lighter, and at other times of a darker fhade. They are alfo fometimes of a white, and often of a yellowifh colour. It is re- markable, that different portions of the fame cal- culus are frequently of a different colour. Some lamina?, for inftance, are perfeaiy white, while the other laminae are brown. In this fort of mix- ture, I have moft commonly found the Avhite la- minae on the outfide, and the brown lamina? in the middle ; and I do not recolfea feeing one inftance of lamina? of different colours, difpofed in alternate ftrata. The fpecific gravity of urinary calculi differs very confiderably, as they differ a good deal in their compaanefs ; but they are generally a little more than twice the fpecific gravity of water. The chemical properties of different urinary calculi,. I am apt to believe, differ more from each other than has generally been imagined. Any trials which I have made have led me to this opi- nion ; but I am fo little accuftomed to chemical experiments that I do not reft upon it with much confidence. [ 163 ] The celebrated Scheele made a number of ex- periments to afcertain the nature of urinary calculi, of which the following are the chief. 1. Diluted vitriolic acid does not aa on urina- ry calculi at all, but the concentrated diffblves them in heat. 2. Marine acid, whether diluted or concentrat- ed, does not aa on urinary calculi, not even when boiled with them* 3. Nitrous acid diluted, or aqua fortis, aa a little on urinary calculi in the cold, but on the application of heat aa with effervefcence and with vapours. 4. This folution tinges the {kin with deep red fpots Avithin half an hour after being applied, is not precipitated by alkalis, but on the ap- plication of lime-water yields a Avhite precipi- tate. 5. Ponderous earth diffolved in marine acid, does not occafion any precipitate from this folu- tion. 6. Acid of fugar, or fait of forrel, does not pro- duce any precipitate from this folution. 7. A calculus Avhen pounded and boiled in a folution of alkali of tartar, remains unchanged ; * I have m=t with an urinary calculus capable of being diffolved in marine acid, even in the common temperature of the atmofphere. [ 1*4 J but perfeaiy pure, or cauftic alkali, fuch as does not fhew the leaft mark of the a?rial acid, diffolves the calculus even in the cold. 8. Lime-water diffolves the urinary calculus, by digeftion, in the proportion of four ounces of lime-water to twelve grains of the calculus. 9. Pure water diffolves an urinary calculus, in the proportion of five ounces of the water to eight grains of calculus ; and this folution changes tinaure of lacmus to a red colour. 10. On diftilling, in a fmall glafs retort, one drachm of calculus in the open fire, there was ob- tained a volatile alkaline liquor like that of harts- horn, but no oil. In the neck of the retort there was a brown fublimate. Upon heating the retort thoroughly red hot, and then leaving it to. cool, there was obtained a black coal, weighing twelve grains, which when put upon red hot iron in the open air, retained its black colour. The fubli- mate, which feemed to have been fomewhat fufed, Aveighed twenty-eight grains; and upon being puri- fied by a new fublimation, it grew Avhite. It had no fmell, but a fomeAvhat fourifh tafle, and was eafily foluble in boiling water : it alfo diffolved in fpirit of Avine, but a larger quantity than of water wras requifite for this purpofe. Lime-water Avas not precipitated. The fublimate feemed to agree in fome refpeas with the fal fuccini. [ i<55 ] From thefe and fome other experiment? Scheele concludes, that urinary calculi are nei- ther gypfeous nor calcareous, but confift of an oily, dry, volatile acid concrete, mixed with fome gelatinous matter. Bergman, by burning the charcoal of urinary calculi to a Avhite cinder, obtained fome calcare- ous earth, and calculates mat the proportion of it in thefe flones is about 1-200 part. Although the world is much obliged to thefe two celebrated chemifts, Scheele and Bergman, for their labours upon this as well as many other fubjeas, yet I am inclined to think that a fuffici- ent number of urinary calculi has not yet been examined, to afcertain all the variety of their con- ftituent parts. Although the matter of calculus in the bladder is generally formed into one or more circumfcrib- ed maffes, yet I have feen the whole bladder fill- ed with a fubftance like mortar. This could not be removed entirely from it; but a great many fmall irregular portions ftill adhered to the fides of its cavity. I believe this matter to have been of the fame nature Avith a common calculus, becaufe it exhibited the fame affinities with the common acids. In opening dead bodies, the bladder is occafi- onally found to be very much diftended, and Z [ 1(56 ] to occupy the loAver part of the cavity of the ab- domen. This might arife from fome accidental circumftance of the water being accumulated, Avhile the mufcular coat of the bladder ftill poffefs- ed its proper poAvers; or the mufcular coat of the bladder may have been paralytic, and therefore not capable of expelling the Avater. I do not think it is poffible to discriminate between thefe two dif- ferent filiations by any examination after death, but they can always be afcertained by inquiry in^ to the hiftory of the cafe. The bladder is alfo found contraaed to fuch a degree as hardly to have any cavity. This is ge- nerally not to be confidered as a difeafe, but fim- ply as having arifen from a very ftrong aaion of the mufcular coat of the bladder previoufly to death. The anterior part of the bladder is occafionally found wanting, and inftead of it there is a very foft vafcular flefh, fituated externally at the lowTer part of the abdomen. This foft vafcular flefh is ufual- 1}' formed into irregular projeaing maffes, and in the living bodv is covered with a thick ropy mu- cus. The two ureters open fomewhere upon this vafcular flefh, diftilling gradually the urine as it is fecreted upon its furface, which the mucus is in- tended to proteft againft the ftimulus of that fluid. When there is fuch a formation of the bladder. I [ i«7 ] believe that there is always found a deficiency of the bone at the fymphyfis pubis, and alfo a mon- ftrous formation of fome of the organs of genera- tion. This fpecies of monftrofity I have defcribed at large in the Medical and Chirurgical Tranfac- tions.* Another kind of monftrous formation in the bladder occafionally happens, viz. that at its de- pending part there is a communication between it and the reaum, the latter being continued into the former. Of this I have feen one inftance, and it has been already taken notice of, when treating of the difeafed and preternatural appearances of the inteftines. A portion of the bladder at its fundus, has been known to be lodged in a hernial fack, both at the abdominal ring and Paupart's ligament ; but this is very rare, and has not fallen under my own ob- fervation.§ * See Medical and Chirurgical Tranfadlions, p. 189. § See Pott on Ruptures, p. 226. C 168 ] CHAP. XV. Difeafed Appearances of the Veficula Seminales. J. he difeafed appearances of the veficula? femi- nales are not very commonly known, becaufe from their fituation thefe bodies cannot be feen without a good deal of diffeaion; whereas many of the vifcera come immediately into view when the cavity is fimply laid open in which they are lodged: difeafed appearances, however, have been occafionally obferved in them. It has never occurred to me, to obferve the veficula? feminales inflamed by themfelves, al- though they are, no doubt, liable to this difeafe like every other part of the body. I have feen them, however, involved in the natural confe- quences of inflammation with the furrounding parts. Thus I have feen the pofterior furface of the bladder, the veficula? feminales, and a portion of the reaum adhering with unufual firmnefs toge- [ i69 ] ther, in the fame manner as other parts of the bow dy frequently do after inflammation. The veficula? feminales are alfo affeaed with fcrofula. Upon one occafion»I recolfea to have feen one of tlje veficula? feminales filled with true fcrofulous matter, the diftinguifhing chara&eriftic of which has been often mentioned. The duas of the veficula? feminales open natu- rally by two diftina orifices into the cavity of the proftate gland, but they are occafionally wanting, and the veficula? feminales terminate in a cul-de- fac. The vafa deferentia are at the fame time without their natural termination, for they end in the cul-de-fac of the veficula? feminales. This is a fpecies of monftrofity which is very rare, but it is of great confequence, becaufe it prevents the femen from palling into the urethra, and fruftrates one of the moft important funaions in the animal economy. The veficula? feminales differ a good deal in their fize in different adult bodies, and indeed it is very common for the one to be confiderably fmaller than the other ; but I have oftener than once feen both of them fo fmall that they muft have "been very little able to fulfil the intentions for which they Avere formed. [ 17° ] One of the veficula? feminales is occafionally wanting altogether. Under fuch circumftances I fhould believe that the extremity of the vas deferens upon that fide is moft frequently enlarg- ed and tortuous, becoming a fort .of fubftitute for it. This was at leaft the cafe in the inftance which I have feen of this mode of formation. The extremity of the vas deferens has at all times a ftruaure fimilar to that of the veficula? femi- nales, and renders therefore this conjeaure very probable. The veficula? feminales have alfo been obferv- ed to be fchirrous; but this is not at all com- mon.* ■>* See Morgagni, Epift. XLVI. Art. 5. [ 171 J CHAP. XVI. Dfcafed Appearances of the Proflate Gland. Abfcefs in the Proflate Gland. X he proftate gland is not often found in a ftate of common inflammation. I have feen, however, an abfcefs in it, without any uncommon thicken- ing and enlargement of the gland, and where the pus appeared to be of the common fort. This muft be confidered as being a common abfcefs, and muft have been preceded by the ordinary fort of inflammation. . Scrofula of the Proflate Gland. The proftate gland is fometimes fcrofulous. I have feen, in cutting into it, precifely the fame Avhite curdly matter, Avhich takes place in a fcro- fulous abforbent gland. In fqueezing it alfo. [ *72 ] I have forced out from its duas a fcrofulous pus. Schirrus of the Proflate Gland. The moft common difeafe of the proftate gland is a fchirrous enlargement of it. The proftate gland, it is well known, is naturally about the fize of a large chefnut, but when it is attacked by fchir- rus, it is often enlarged to the fize of the fift. In this enlarged ftate, the external appearance of its ftruaure is not different from what is natural, but Avhen cut into, it' exhibits a very firm, whitifh, or brown fubftance, with membranous fepta running through it in various direaions, which are often very ftrongly marked. This is the appearance of fchirrus in other parts of the body. When the proftate gland is a good deal enlarged, its cavity becomes deeper from the growth of its fides, and the pofterior extremity forms a confiderable projeaion into the cavity of the bladder, which interrupts the paffage of the urine into the urethra. According to the degree of this projeaion, the urine is paffed with greater or lefs difficulty, as Avell as an inftru- ment for drawing it off. When the projeaion is very great, it has fometimes been found impof- [ 17? ] fible to pafs an inftrument over the proje&ion, and an artificial paffage has occafionally been made through it accidentally, by which the urine has been evacuated. Under fuch circum- ftances the gland has been known not to be irritated by the violence ufed in making this new paffage, and life has been prolonged for a greater length of time than it would have been otherwife. Still, however, the inftrument ought to be made to pafs over the projeaion, if poffible ; and \\ve fhould never run the rifk, by injuring the gland, of bringing on immediate fatal confe- quences. Sometimes in the progrefs of the enlargement the proftate gland groAVs irregularly, and a winding paffage is formed through it, by an alter- ation in the fhape of its cavity. This increafes the difficulty to the patient of making Avater, and to the furgeon of introducing an inftru- ment. When the proftate gland is enlarged, its internal furface is fometimes ulcerated, but commonly it is not. Fiftulous communications are fometimes formed betAveen an enlarged proftate gland and the reaum. It is obvious too, from Avhat has been mentioned, that in an enlarged ftate of the proftate gland, the difficulty of making water muft be very great. This difficulty excites extraordinary and very frequent A a [ 174 ] efforts in the bladder to overcome it. Its muf- cular coat becomes confequently much flrong- er and thickened. A proftate gland, therefore, is never found enlarged to any confiderable degree, without the bladder having undergone this change ifWts mufcular coat. This difeafe is hardly ever to be found in a young perfon, but is not at all uncommon at an advanced pe- riod of life. Calculi in the Duels of the Proflate Gland. There is another difeafe of the proftate gland, which occafionally takes place, although it is by no means fo frequent as the former, viz. a forma- tion of fmall calculi, which are lodged in its duas. They are ufually of the fize' of a fmall pea, and thofe which I have feen have been of a brown or black colour. What is their exaa na- ture I cannot pofitively afcertain, becaufe to do this requires a much nicer management of chemi- cal experiments than I pretend to poffefs, but from fome very imperfea trials which I have made, they feemed to differ in their properties from urinary calculi.* What I fay, however, re- * They were almoft entirely diffolved in the vitriolic acid, bnt were only feparated into a fine powder by the nitron*. [ 175 ] lates only to the brown calculi ; Avith regard to the other, I have had no opportunity of examin- ing them. **■ ; Duels of the Proflate Gland enlarged, v The proftate gland is fometimes feen Avith its cavity very much Avidened, and its du£ts enlarg- ed. In the natural ftate of the gland, the orifices of its duas can hardly be feen, but they fome- times are fo much enlarged as to be capable of ad- mitting a crow quill. When the duas are fo enlarged, there is always a great obftruaion to the paffage of the urine through the urethra, arifing moft commonly from ftriaure there. The urine either paffing in very fmall quantity, or being en- tirely obftruaed, is accumulated in the cavity of the proftate gland and the bladder. The effea of this accumulation is, that the cavity of the prof- tate gland is Avidened, and the duas very much enlarged. The bladder too, from making extra- ordinary efforts to overcome the obftruaion, has its mufcular coat gradually thickened, and often to a very confiderable degree. Attending, there- fore, this ftate of the proftate gland there is a thick- ened bladder, and an obftruaed urethra. [ *7* ] The Proflate Gland preternaturally fmall. I have alfo feen the proftate gland of an ex- tremely fmall fize, fo that onegcould hardly fup- pofe it from this circumftance to be fit for its of- fice. It was attended with a monftrous formation of the urinary bladder and fome of the organs of generation, and has been particularly defcribed by me in the Medical and Chirurgical Transac- tions.} \ See p. 194. [ 177 J CHAP. XVII. Difeafed 'Appearances of the Urethr-a. Abfceffes. /\bcesses are occafionally formed in the mem- branous part of the urethra. Thefe may arife from an inflammation, produced by fome latent caufe, as abfceffes are formed in any part of the body ; but they happen moft frequently from an obftruaion to the paffage of the urine through the urethra. This obftruaion is produced generally by a ftriaure in fome part of this canal, but moft frequently it is a little anterior to the membran- ous portion of it. The urine being forced by the efforts of the bladder behind the ftruaure, ir- ritates that part, producing inflammation and fup- puration ; the abfcefs breaks externally, and the urine is evacuated by this opening. While it remains in the ftate of an abfcefs, it is not at all different from any common abfceffes Avhich may communicate with the bladder. [ '7» ] Fiflultf. While the obftruaion in the urethra conti- nues, the opening made by the breaking of the abfcefs is not alloAved to clofe, but a fiftulous cvrifice is gradually formed. This is furround- ed with parts fomewhat thickened and hard, as fiftulae are generally. The moft common fituation for thefe fiftulous openings is behind the fcrotum, near the membranous part of the urethra, becaufe the moft common fituation of the ftriaure is a little anterior to this part of the urethra. Not uncommonly there are more than one of thefe openings leading to fhort canals which run in different direaions. The membranous part of the urethra I have alfo feen formed into a bag large enough to con- tain a hen's egg, and confifting of a pretty firm fubftance. This bag Avas occafioned by a large ftone which had lodged there. I do not recolfea to have feen Cowpers glands difeafed, Avhich are fituated near this - part of the urethra. They muft be liable to changes from difeafe, like other parts of the body; but they are fmall and difficult of accefs, fo that they have very feldom become an objea of examination. [ 179 J Morgagni mentions one of them being con- verted into a ligamentous fubftance;* and one of the excretory duas in another inftance be- ing obliterated.$ The inner membrane of the urethra is very li- able to be inflamed, particularly at its anterior extremity, and the inflammation occafionally fpreads over the whole extent of the canal. This exhibits no appearance different from the inflam- mation of membranes lining fecretory canals Avhich open externally. The inner membrane of the urethra is much more crowded Avith fmall blood veffels than in a natural ftate. and there is an increafed fecretion of the glands which open it. The inflammation is often not confined to the inner membrane of the urethra, but fpreads into the fubftance of the corpus fpongiofum, affeain^ both its cellular ftruaure and its glands. Under thefe circumftances, the corpus fpongiofum is en- larged and harder from the extravafation of the coagulable lymph into its cells, and is more vafcular than in a natural ftate. The glands being increafed in fize from the inflammation, become fenfible to the touch, like very fmall rounded tubercles. * See Morgagni, Epilt. XLIV. Art. 3. § See Morgagni, Epift. XLIV. Art. 12, [ *8o ] Ulcers arc alfo feen occafionally in laying o- pen the urethra, but thefe are not frequent. Stricture. The moft ordinary difeafed appearance of the urethra is ftriaure. This confifts in a part of the canal being narroAved, or perhaps altogether obli- terated. It may take placein any part of the canal, but it is moft frequent a little anterior to the mem- branous part of the urethra. This ftriaure con- fifts fometimes of an approximation fimply of the oppofite fides of the canal, fo as to form a line of obftruaion, and at other times the canal is nar- rowed for fome length. The inner membrane, at the ftriaure, fometimes exhibits the natural appear- ance of furface ; at other times the furface is abraded or ulcerated. Thefe effeas are generally produced by bougies, and fometimes falfe paf- fages have been made into the corpus fpongiofum urethras in confequence of employing too much violence in the ufe of this inftrument. There is very commonly more than one ftriaure in the fame urethra. It fometimes happens too, that the ftriaure is more on one fide of the canal than the other, fo that the paffage there is crooked. [ i8i ] Caruncle. A fmall flefhy excrefcence fometimes grows in the urethra. This is called caruncle, and ufed formerly to be confidered as the moft common caufe of obftruaion in this canal, but fince diffeaions of dead bodies have become more frequent, it has been found in reality to be very rare. I have known one inftance of a thin layer of earthy matter extending from the bladder through the whole length of the urethra. Preternatural Orifice of the Urethra. The urethra fometimes does not open at the projeaing extremity of the glans penis, but under it, where the frenum is naturally fituated ; and in fuch cafes there is no frenum. It confifts of a fmall rounded opening, much lefs than when there is the natural termination in the glans. I have known an inftance in this ftruaure of parts, of a canal being formed befides the urethra, about two inches in length, which terminated at one extremi- ty in a cul-de-fac, and at the other opened on the glans where the urethra commonly does. How far this variety may be frequent, I cannot pre- t »8« ] tend to determine. This deviation in the ftruc- ture is not to be confidered as a difeafe, but fim- ply as a mal-formation of parts, and is not attend- ed with any material inconvenience, as far as I know. There are fome other difeafed appearances of the penis, fuch as ulcers, phymofes, paraphymofis, Sec. Thefe are external, are very well known, and do not properly fall within my plan ; I fhall therefore omit them entirely. C 183 ] CHAP. XVIIL Difeafed Appearances of the Teflicles, and the Spermatic Chord. Hydrocele, J[~1ydrocele, or a colfeaion of water in the tunica vaginalis teftis, is a very common complaint, and is confined to no particular period of life. It is not unfrequent in very young children, and in them moft commonly difappears without any chirurgical treatment. In perfons Avho are groAvn up, the difeafe fcarcely ever goes away fpontane- oufly, but requires the affiftance of art. The bag in which the water is accumulated is of a pyramidal fhape, and approaches more or lefs towards the ring of the abdominal mufcle, according to the degree of the accumulation. It fometimes ex- tends almoft to the ring itfelf. The bag is alfo more or lefs thick in different cafes : it is often fcarcely thicker than the tunica vaginalis in its na- [ *84 3 tural ftate ; at other times, when the accumula- tion is large, it is three or four times thicker, and is obvioufly laminated. In fuch cafes too the teftiele is a good deal compreffed, and has fome- times been known to wafte in confequence of this compreffion. The fluid which is accumulated is of a yellowifh, a greenifh, or brown colour, and refembles in its properties the ferum of the blood. This difeafe, in perfons who are advanced in life, is frequently combined with a fchirrous ftate of the teftiele, which will be afterwards particularly explained. Hydatids. Hydatids have fometimes been found in the cavity of the tunica vaginalis teftis, either loofe or adhering ; but I have had no opportunity of exa- mining them, and they are not at all common.* Adhefions. The tunica vaginalis is frequently found ad- hering to the furface of the teftiele. The adhe- fion is fometimes extended over the whole furface, * See Morgagni, Epift. IV. Art. go. [ i«5 ]■ but frequently confifts only of fcattered proceffes of membrane. The adhefions are fometimes fine, but at other times have confiderable thicknefs, and connea the tunica vaginalis to the body of the teftiele more or lefs clofely in different cafes. They are produced by fome previous inflamma- tion, as in the cavity of the cheft and belly ; but it does not often occur that a tunica vaginalis is examined after death, which immediately before had been in an aaive ftate of inflammation. Teflicle inflamed, The fubftance of the teftiele itfelf is veiy fre- quently inflamed, but this is commonly removed by art, and therefore hardly ever becomes an objea of examination after death. It exhibits, however, precifely the fame appearances as the inflammation of the fubftance of other parts, and therefore does not require to be particular- ly defcribed. When the teftiele is inflamed, the vas deferens fometimes partakes of the inflam- mation, its coats becoming confiderably thick- ened, and in fome inftances the veins of the fpermatic chord have been known to become varicofe.* After the inflammation of the tef- * See Mr. Hunter on the Venereal Difeafe, p. 5^. [ i86 J tide has fubfided, it rs not unufual for a hardnel's and fullnefs of the epidydimis to remain for a confiderable length of time, or even through life. This depends on the matter, which had been extravafated during the inflammation, not being afterwards entirely abforbed. Abfceffes too are not unfrequently formed in the tefticles, from the progrefs of common in- flammation, and are attended Avith the fame cir- cumftances as abfceffes in other parts. Teflide fcrofulous. The teftiele is fometimes completely changed from its natural ftruaure, and converted into a mafs of truly fcrofulous fubftance. Upon fuch occafions it is generally enlarged in its fize, and when cut into, fheAVS a white, or yelloAvifh white, curdly fubftance, Avhich is fometimes more or lefs mixed with pus. Teflide enlarged and pulpy. The teftiele is fometimes much enlarged in fize, and converted into a brown, uniform, pul- py matter, in Avhich its natural ftruaure is En- tirely loft. This fort of change has been fome- r >s7 ] times miftaken for fchirrus, although it is very different from what is called fchirrus in other parts of the body, and what is alfo found in the teftiele itfelf. Schirrus and Cancer of the Teflide. The teftiele is often found much enlarged, where its natural ftruaure is loft, and where it is changed into a hard mafs of a brownifh co- lour, which is generally more or lefs interfeaed by membrane. There is fometimes mixed in this ftruaure cartilage ; and fometimes there are cells formed in it containing a fanious fluid. This ftate of the teftiele I confider as the true fchirrus, and according to the progrefs of the difeafe, the epidydimis and the fpermatic cord are more or lefs, or not at all, affeaed. This difeafe not unfrequendy advances to form a foul deep ulcer, or throAVs out a fungus, and then it is called the true cancer of the teftiele. Teflide cartilaginous. The teftiele I have feen much enlarged in fize, and changed into a mafs of cartilage. This does not feem different in any effential property [ »88 J from common cartilage, but is only a little foft- er. This I fhould confider as depending upon the fame general difeafed procefs Avith the fchirrus juft defcribed, for fometimes both ftruaures are blended together in the fame teftiele. ✓ Teflide bony. The teftiele is fometimes converted into bone. This is not a very unfrequent difeafe, and is more commonly confined to fome part of the teftiele, than extended over the whole of it. I have feen a teftiele with a fmall firm cyft adhering to it, Avhich contained a worm of that fort called vena medinenfis. This is a Avorm of confiderable length, with a fmooth furface, and an uniform appearance ; at the pofterior extremi- ty it terminates in a flender hook-like procefs, and at the anterior, there is a rounded opening or mouth. It very , commonly' burrows under the fkin of the inhabitants of fome warm countries, particularly Guinea, and is very troublefbme to them. This teftiele had probably belonged to a man who had vifited fome of thofe climates in which the vena medinenfis is found, and who .had brought it over with him to this country. [ »89 ] The Epidydimis ending in a Cul-de-Sac. The tefticles have fometimes this fort of mal- formation, that the epidydimis does not terminate in a vas deferens, but in a cul-de-fac. In thefe cafes it is evident that the femen can never be evacuated by the urethra, and the perfon muft therefore be incapable of procreation. Stricture of the Vas Deferens. I have alfo feen a portion of the canal of the vas deferens obliterated by ftriaure. This had not been an original fault, but Avas the effea of a di- feafed procefs, and muft have prevented the femen of that teftiele from reaching the urethra. Teflicles very fmall and wafled. The tefticles are fometimes exceedingly fmall in their fize. I have known one cafe, in a perfon of middle age, Avhere each of them was not larger than the extremity of the finger of an adult. This, as appeared from its hiftory, arofe from a fault in the original formation, and Avas attended with a total want of the natural prapenfities. It is C c [ *9& ] much more common for a teftiele to Avafte either fpontaneoufly, or in confequence of a former in- flammation, or compreflion, fo as gradually to difappear entirely.* When this takes place in one teftiele only, the natural poAvers are preferved, but when it takes place in both, they muft be altogether loft. Sometimes one teftiele, and fometimes both re- main in the cavity of the abdomen through life, fo that a perfon appears to have only one teftiele, or to be without them altogether. The teftiele or tefticles, I believe, in thefe cafes are of a fmall fize, and Mr. Hunter fufpeas that they are by no means fo perfea as when they defcend into the fcrotum.J Difeafed Appearances of the Spermatic Chord. The fpermatic chord is alfo liable to difeafed alterations of ftruaure : one of the moft common is that of its becoming fchirrous. This I believe to be very rarely, if at all an original difeafe of the chord, but always, or almoft always, fpreads to it from the teftiele. In the early ftate of a fchir- * See Hunter on the Venereal Difeafe, p. 209. § See Mr. Hunter's Obfervations on certain Parts of the Animal Economy, p. 18. [ '9' ] rous teftiele the fpermatic chord is perfeaiy found, and this is the proper feafon for the extirpation of the teftiele ; but when the difeafe has taken place for a confiderable time, and does not remain fla- tionary, the chord becomes at length affeaed. Under fuch circumftances it is changed into a large hard mafs, exhibiting the fame appearance of ftruaure Avith the teftiele itfelf. During the laft ftage the difeafe advances to the loins, fo as to affea the abforbent glands there. When the teftiele is fcrofulous, the fpermatic chord fometimes partakes of the fame difeafe, and exhibits alfo the fame appearance of change with the teftiele itfelf. A difeafe of the fpermatic chord which is not uncommon, is an enlargement of its veins. The veins of the fpermatic chord are numerous, and fupport a very long column of blood. This laft circumftance, added to fome impediments which occafionally take place to obftrua the return of the blood, renders the veins frequently enlarged. This enlargement varies very much in different cafes, arifing from the degree and the continuance of the impediment. When the enlargement of the veins is very confiderable, they alfo become vari- cofe, and the fpermatic chord is changed into a bulky mafs, foft to the feeling, and capable of be- ing readily diminifhed upon preffure. In this [- *92i ] ftate of the fpermatic chord, the teftiele is fome- times wafted. Water has fometimes been known to be aecu^ mulated in the cells of the cellular membrane, Avhich envelopes the veffels of the fpermatic chord. The cellular membrane of this part of the body is in confiderable quantity, and when water is ac- cumulated in its cells, there is a large fwelling formed in the fituation of the fpermatic chord, which is readily diminifhed upon preffure. When preffure is ufed, the fwelling is diminifhed, not only by a part of the water being forced into the cells of the chord within the abdominal ring, but alfo by its being forced into the cellular membrane under the fkin of the lower part of the belly. Many pints have been known to be accumulated in thefe cells. It has never occur- red to myfelf to fee this difeafe, and therefore I have had no opportunity of examining the nature of the fluid, but I prefume it is of the fame fort with what is ufually found in anafarca. A fack has alfo been knoAvn to be formed in the fpermatic chord, confifting of a firm white membrane, and containing a fluid Avhich moft probably is of a ferous nature. Both of thefe cafes have been particularly defcribed by Mr. Pott in his Treatife upon Hydrocele.* * For the8firft cafe, fee Pott on Hydrocele, p. 39. For the fecond fee Pott on Hydrocele, p. 57- [ *93 ] '■'7 CHAP. XIX. ' -! ■ "'■ ■,.'... Difeafed Appearances in the Female Organs. Inflammation of the Uterus. When the uterus is inflamed, it takes place al- moft always under the fame circumftances, viz. very foon after parturition. The inflammation is fometimes confined to the uterus itfelf, or its appendages, but the peritonaeum in the neighbour- hood is moft commonly affeaed, and frequently over the whole extent of the cavity of the abdo- men. The uterus when inflamed, exhibits the fame appearances as the inflammation of the fub- ftance of other parts, and thefe are principally obfervable in its body or fundus. The inflamma- tion is frequently found to creep along the appen- dages of the uterus, efpecially the Fallopian tubes and ovaria. It often advances to fuppuration, and the pus is generally found in the large veins of [ *94 J the wromb.* When the peritonaeum is alfo af- feaed by inflammation, it exhibits the fame ap- pearances which we formerly defcribed particu- larly, when treating of the inflammation of this membrane; but the extravafated fluid, and the coagulable lymph, are not uncommonly in very large proportion to the degree of the inflamma- tion.j Schii'rus of the Uterus. One of the moft frequent difeafes of the uterus is fchirrus. In this ftate it is increafed more or lefs in bulk, and often to a very large fize. Its fubftance Avhen cut into is thick and hard, and when its ftruaure is examined, it fhewTs a Avhitifh firm fubftance, interfeaed generally by ftrong membranous divirions. This is the common ap- pearance of the ftruaure of fchirrus in other parts, and it differs lefs from the natural appear- ance of the ftruaure of the uterus than that of any other part of the body. In this ftate of the uterus, its internal furface is commonly found * See Dr. Clark's Efiays, p. 69 and 70. § Dr. Clarke, who has examined a great many women that have died after parturition with inflammation of the peritonaeum, has obferved this particularly. See Dr. Clarke's Efiays, p. 136. [' *95 3 ulcerated, forming cancer, and fometimes fo much fo as to throAV out long ragged proceffes. The ulceration alfo fometimes extends to the neigh- bouring parts, as the vagina, the bladder, and the reaum, making communication* between them, and producing dreadful havock. The uterus is occafionally almoft entirely deftroyed by the progrefs of the difeafe. I have feen feveral in- ftances where the fundus of the uterus only Avas remaining, and where the reft Avas changed into a tattered ulcerated mafs. It is Avorthy of remark, that fchirrus or cancer attacks generally the cervix uteri before the fun- dus. This may perhaps depend upon a general principle, Avhich we have often mentioned : the cervix uteri is more glandular than any other part of the uterus, and fchirrus or cancer appears to be peculiarly a difeafe of glandular parts. Tubercles of the Uterus. Hard tubercles often grow from the uterus? which are either imbedded in its fubftance, or a- rife from its outer furface. They vary a good deal in their fize, viz. from that of a hazel nut to more than the fize of the fift. They are irregular in their fhape, but are commonly rounded, and are [ ^ ] in fome degree tuberculated. Thefe when cut into, fheAV a Avhitifh very firm fubftance, interfoa- ed by membranous fepta, Avhich are commonly very thick and ftrong. It is extremely rare that thofe circumfcribed maffes are found ulcerat- ed. The uterus in this ftate of difeafe is general- ly of the natural fize. A mafs of the fame kind is fometimes found in the cavity of the uterus, and often grows to a Very large fize. I have feen it a good deal larger than a child's head at birth. This mafs Avhen cut into, exhibits precifely the fame appearances Avhich we have fo lately defcribed. It is remarkable, that thofe maffes Avithin the cavity of the uterus com- monly do not adhere in any part clofely to it, but are conneaed with it loofely, by the intervention of the cellular membrane, fo that they can be very eafily peeled off, Avithout injuring the ftruc- ture of the uterus. The uterus itfelf is more or lefs enlarged according to the bulk of the mafs it contains, but appears to be perfeaiy healthy in its ftruaure. Polypus. Polypus forms a very common difeafe of the uterus, and may take place almoft at any period [ 197 3 of life ; it is more frequent, however, at the mid- dle or advanced age, and very rarely happens in perfons Avho are young. By a polypus is meant a difeafed mafs, which adheres to fome part of the cavity of the uterus, by a fort of neck or narrower portion. It is of different kinds : the moft com- mon kind is hard, and confifts evidently of a whits fubftance, divided by very thick membranous fepta. When cut into, it fhews precifely the fame ftruaure with the tubercle of the uterus late-' ly defcribed ; fo that a perfon looking upon a feaion of the one and the other, out of the body, could not at all diftinguifh between them. This fort of polypus varies very much in ks fize, fome being not larger than a walnut, and others being larger than a child's head. It adheres by a nar- roAver portion or neck, Avhich varies a great deal in its fize, and in its proportion to the body of the polypus. The largeft polypus I ever faw wTas fufpended by a neck hardly thicker than the thumb ; and I have feen a polypus, much lefs than the fift, adhering by a neck fully as thick as the wrift. The place of adhefion alfo differs confiderably. It is moft commonly at the fundus uteri, but it may take place in any other part; and I have feen a fmall polypus adhering juft on the inner part of the lip of the os uteri. When a polypus Dd t »98 ] is of any confiderable fize, there is generally but one ; but I have occafionally feen on the in- fide of the uterus, two or three fmall polypi. Another fort of polypus takes place in the uterus, which confifts of a bulky, irregular, bloody mafs, with a number of tattered proceffes hanging from it. This when cut into exhibits two different appearances of ftruaure: the one appearance is that of a fpongy mafs, confifting of laminae, with fmall interftitial cavities between them ; the other is that of a very loofe texture, confifting of large irregular cavities. Thefe are the dif- ferent varieties in polypi, which I have obferved; but perhaps there may be others, which have no come under my notice. It is very obvious, that in proportion as a polypus groAvs, the cavity of the uterus muft be enlarged, and the fame change muft take place in the vagina, Avhen a polypus leaves the uterus, and paffes into this canal. The Inverfion of the Uterus. The inverfion of the uterus occafionally takes- place, and principally from two caufes, viz. from the weight of a polypus, or from violent pul- ling in attempts to remove the placenta. When the inverfion is incomplete, the fundus uteri forms [ *99 1 a tumour within its cavity ; there is at the fame time an appearance of fiffure upon the outfide of the uterus, where the fundus ufually is; and the Fallopian tubes, round ligaments, and liga- ments of the ovaria, are drawn inwards at both edges of the fiffure. The uterus, particularly after labour, is fometimes inverted entirely, the inner furface being expofed, and the fundus uteri forming a large tumour on the outfide of the vulva. Prolapfus Uteri. The uterus fometimes leaves its natural fitua- tion and falls downwards, fo as either to get to the external parts, or out of the body entirely. This is moft apt to happen when women have a large pelvis, and where the foft parts have been very much relaxed by repeated and fevere la- bours. This difeafe is called prolapfus uteri, and will be explained more particularly when we come to treat of the difeafes of the vagina. It is much more frequent than the other difeafe called the inverfio uteri. [ 200 ] Stricture in the Cavity of the Uterus. A ftriaure is fometimes formed within the ca- vity ofahe uterus, fo that its cavity at one part is obliterated entirely. This I believe almoft always to take place at one part, viz. Avhere the cavity of the fundus uteri terminates, and that of the cervix begins, for in this place the cavity of the uterus is narroweft. As the fides of the cavity round this place lie very near each other, and form naturally a fmall aperture, it is probable that fome flight inflammation may unite the parts together, and fhut up the aperture ; or the parts may gradually approach together Avithout this caufe, as in ftriaures of the urethra. The os uteri has been found to be fo contraaed, as to have its paffage in a great meafure obliterated ;t and it has even been known to be clofed up, by the growth of an adventitious membrane.X Uterus bony. The uterus has fometimes its fubftance more or lefs converted into bone. This arifes from a par- f Vid. Morgagni, Epift. LXVII. Art.u. % Vid. Morgagni, Epift. XLVI. Art. 17. [ 201 ] ticular morbid aaion of its blood veffels, by which they fecrete from the blood bony matter, and is a very rare difeafe: The Uterus changed into an earthy Subflance. The uterus has alfo been knoAvn to be convert- ed into an earthy fubftance.|| It is probably of the fame kind with the earth of bones, and this difeafe probably differs only from the former, in there being a lefs proportion of animal gluten, to combine the earthy particles together. A bony Mafs in the Cavity of the Uterus. In the cavity of the uterus a bony mafs is fome- times found. When this is the cafe, I fufpea that the hard flefhy tubercle Avithin the cavity of the uterus, fuch as we lately defcribed, had been con- verted into bone. This at leaft had taken place in the only inftance Avhich I have known of it (for a great part of the tubercle had ftill remained un- changed) and I think it very probable, that it moft frequently happens Avhere fuch bony tumours are found. |) Vid. Lieutaud, Tom. i. p. 3;:. [ 202 ] Stones in the Cavity of the Uterus. Stones* have fometimes been found in the cavi- ty of the uterus. Thefe are defcribed by authors as varying in their appearance, fome being of a dark, and others of a light colour. About their nature they are filent, and I can fay nothing of it from my own knowledge, as it has never occur- red to me to fee an inftance of this difeafe. I fhould believe, that thefe concretions are formed from matter thrown out by the fmall arteries which open upon the internal furface of the uterus, and are in fome degree analogous to the concre- tions which are formed in fome glands of the bodpf It has alfo been known to happen, that a dead foetus has remained for a long time in the cavity of the uterus, and has there been gradually chang- ed into an earthy mafs preferving the fhape of the child. $ Water in the Cavity of the Uterus. Water has fometimes been known to be accu- mulated in the cavity of the uterus in very large * Vid. Lieutaud, p. 339. § See Chefelden's Anatomy of the Bones, plate LVI. [ 2°3 ] quantity.t In fome cafes fifty, fixty, or even a hundred pints, have been faid to be accumulated* This water is fometimes bloody in its appearance, and at other times is of a yellowifh colour. Of its nature I cannot fpeak particularly, as I have never feen an inftance of this difeafe. I fhould believe, however, from analogy, that the water ac- cumulated in the cavity of the uterus, refembles in its properties the ferum; and I fhould believe al- fo, from the fame ground of conjeaure, that it is poured out by the fmall curling arteries of the u- terus. In cafes where Avater is really accumulated in the cavity of the uterus, one muft fuppofe a ftriaure of the cervix, otherwife the water would efcape gradually into the vagina as it is formed. I am apt to believe, hoAvever, that where Avater has been faid to be accumulated in the cavity of the uterus? it has frequently been really in large hyda- tids formed in that cavity. Hydatids in the Uterus. Large maffes of hydatid^ have alfo been found in the cavity of the uterus. Whether thefe be of the fame kind Avith what occafionally grow in the f Vid. Lieutaud, Tom. i, p. 319, p. 333. £ Vid. Lieutaud, Tom. 1, p. 335. [ 204 } placenta, or like thofe in the other parts of the body, I cannot determine, as it has not occurred to me to fee an example of this difeafe. The hy- datids of the placenta are a good deal different from thofe of the liver, kidneys, and fome other parts of the body. They confift of veficles of a round or oval fhape, with a narrow ftalk to each, by which they adhere on the outfide of one ano- ther. Some of thofe hydatids are as large as a walnut,'and others as fmall as a pin's head. A Urge hydatid has generally a number of fmall hy- datids adhering to it by narrow proceffes. • Of their real nature notching is knoAvn, but they are not improbably animals. There is in quadru- peds a difference in hydatids, and this is even the cafe in the fame fpecies of quadruped; and yet thefe have been determined to be-animals. I fhould believe that the hydatids faid to be found in the uterus, have not uncommonly been only hydatids of the placenta, which had been retained there. ■ Rupture of the Uterus. Thefe are the various difeafed appearances which are Avell afcertained to take place in the uterus. I have to add, that the Avomb is not un- [ 2<>5 ] frequently ruptured, which is rather to be con- fidered as an accident than a difeafe. This, perhaps, never takes place but in the pregnant uterus, and at the time of delivery. It may arife either from too violent an aaion of the mufcular fibres of the uterus upon the child, or upon the hand of an accoucheur, who may for fome reafon or other have introduced it into its cavity, and preffed upon fome part of the uterus with a good deal of force. The ruptures which I have feen have been commonly in the fide of the womb, and of confiderable extent. The peritonaeum covering the womb is often not rup- tured, and there is a large mafs of black coa- gulated blood lying between it and the uterus, where the rupture has taken place. This black appearance is occafionally miftaken for mor- tification. Two Uteri. It has fometimes happened, although very rare- ly, that two uteri have been formed in the fame perfon inftead of one. In this cafe there is but one ovarium and one Fallopian tube to each. The vagina is at the fame time divided by a feptum in- to tAVO canals, each of which conduas to its pro- E e [ 206 ] per uterus. In the cafe which is defcribed in fhe Philofophical Tranfaaions,|| a communication Avas- formed at one part through the feptum; but how far this generally takes place m fuch a kind of mon- ftrofity I cannot determine. The uterus varies a good deal in its fize in dif- ferent perfons, in fome being fully tAvice as large as it is in others. It differs alfo fomewhat in the thicknefs of its fubftance. There is fome differ- ence too in its fituation, being often placed much nearer one fide of the pelvis than the other. All of thefe are to be confidered as varieties in the »atural formation, and not as difeafe. || See Philofophical Tranfa#ioM», Vol. 64, p. 47* [ *07 ] CHAP. XX.' Difeafed Appearances of the Ovaria. Inflammation of the Peritonceal Covering of the Ovapia. 1 hat portion of the peritonaeum Avhich covers the ovaria I believe is feldom inflamed, unlefs where the inflammation has fpread to it from the uterus, or where it has attacked this membrane ge- nerally. It is not unufual, however, for it to be inflamed under either of thefe circumftances, and it fheAVS the fame appearances as the inflammation of the peritonaeum covering any other part. Ad- hefions too are frequently found, joining the ova- ria to the neighbouring parts, which had been the confequence of fuch an inflammation. Inflammation of the Subflance of the Ovaria. Where the uterus has been inflamed to a con- fiderable degree, as after parturition, the fubftance [ 208 ] of the ovaria has alfo been occafionally attacked by the inflammation fpreading to it. The o\raria are then enlarged in fize, are harder than in a natural ftate, and are highly vafcular; and very commonly pus is found to have been formed. Schirrus of the Ovaria. Schirrus is a difeafe which fometimes attacks the ovaria, although very feldom in comparifon of its attacking the uterus. Under fuch circum- ftances the ovaria become enlarged, and are con- verted into a whitifh hard mafs, which is more or lefs interfeaed with membranous fepta. Thefe fchirrous maffes have fometimes a difpofition to be converted into bone; and in this way moft frequently, I believe, the ovaria become bony. The bony fubftance into which they are convert- ed has fometimes a greater admixture of earth than the natural bones of the body. The ovaria are fometimes very much enlarged in fize, and converted into a uniform, brown, pul- py matter. Cells are at the fame time formed in fome part of it which contain a fluid. I have alfo feen the ovaria partly changed into a fcrofulous matter, intermixed with cells. [ 209 ] Dropfy of the Ovaria The moft common difeafe of the ovaria is dropfy. The whole fubftance of an ovarium is fometimes deftroyed, and it is converted into a capfule containing a fluid. Thefe capfules are not unfrequendy of a very large fize. They confift of a white firm membrane, and contain an aqueous fluid, capable of being partly coagulat- ed. When the fubftance of the ovaria is deftroyed, and they become dropfical, it is very common for them to be converted into a number of cells which communicate with each other by confi- derable openings, and to be prodigioufly enlarged in their fize. An ovarium in this cafe may be fo enlarged as to occupy almoft the whole cavi- ty of the abdomen. The ovaria are alfo fome- times converted into a congeries of complete cyfts. Thefe vary a good deal in their fize, fome being not larger than a hazel nut, and others as laroe as an orange. Their coats are fometimes thin, at other times are of confiderable thicknefs, and confift of a compaa, white, laminated mem- brane. They contain either a ferous fluid, with which I have feen fome flimy matter mixed, or a thick ropy fluid, or a kind of jelly; and, what r 2i° ] one would not expea to find a priori, different iGyfts in the fame ovarium will fometimes contain a different fort of fluid. • Thefe cyfts, I believe, have been occafionally confounded with hydatids, to which they bear fome refemblance. They are hoAvever really very different. They have much firmer and lefs pulpy coats than hydatids; they contain a different kind of fluid, and they are differently conneaed among themfelves. Hydatids either lie loofe with regard to any conneaion among each other, or they in- clofe each other in a feries; or fmall hydatids ad- here to the coats of larger ones. Cyfts of the o- varium adhere to each other laterally by pretty broad furfaces, do not envelope each other in a feries, and appear to have no power analogous to o-eneration like hydatids, by which fmaller cyfts are formed, that are attached to thofe of a larger fize. It appears not improbable, that thefe cyfts are formed by a gradual enlargement of the fmall veficles which make a part of the natural ftruaure of the ovaria. The Ovaria changed into a fatty Subflance with Hair and Teeth. The ovaria are fometimes converted into a fat- ty fubftance, intermixed Avith long hair and teeth, [ "1 ] which is furrounded by a capfule confifting of a white ftrong membrane. The hairs are moft of them loofe in the fatty fubftance, but many of them alfo adhere on the infide of the capfule. Teeth too are formed, but are generally incomplete, the fangs being wanting. Thefe fometimes arife im- mediately from the inner membrane of the capfule, and are fometimes conneaed Avith an irregular mafs of bone. Such produaions have been commonly confidered as very imperfea impregnations, but there is good reafon to believe that they can take place without any intercourfe between the fexes. I have defcribed a cafe, which has been publifhed in the Philofophical Tranfaaions, where it was hard- ly poffiblethat impregnation could have happened. The girl in whom this change of the ovarium Avas found, could not from all appearances be more than twelve or thirteen years old; the hymen was perfea; and the uterus had not received that in- creafe of bulk Avhich is ufual at puberty. The o- ther marks of puberty were alfo wanting. From thefe circumftances I fhould judge the wbmb to be incapable of the ftimulus of impregnation. A tu- mour, confifting of teeth and hair, was preferved by the celebrated Ruyfch* in his colfeaion, Avhich he fays was found in a man's ftomach. If this be * Vid. Ruyfch, Tom. 2, Adverfar. Anaiomicor. Decad. Tert, [ 212 ] true (which there feems to be no reafon to doubt) it puts my conjeaure beyond difpute. This pro- duaion could not poffibly, under fuch circumftan- ces, have any conneaion with impregnation; and if it is produced Avithout it in one part of the body, there can be no good reafon Avhy it may not alfo take place Avithout impregnation in another part. Thefe produaions are much more frequent in the ovaria than any where elfe, probably becaufe the piocefs Avhich forms them bears fome analogy to generation, in which the ovaria are materially con- cerned. I muft ftill therefore, whatever objeaions have been made to it, retain my former opihion. Thefe maffes in the ovaria are commonly about the fize of a large orange.* A Foetus in the Ovarium. A fcetus is fometimes found in the ovarium.— This feldom arrives at the full fize, but its forma- tion as far as it goes is commonly perfea. When * I have very lately met with the fame kind of fatty fubftance intermixed with hair, and the body of one tooth covered with enamel, in the ovarium of a young woman about eighteen years of age. In this cafe the uterus was rather lefs than its ufual fize in the adult when unimpxeg- nated, and there was no membrana decidua whatever formed in its cavity. It appeared, therefore, to be under- [ 2*3 ] this happens, all veftige of the ovarium is loft, and inftead of it there is a bag of fome firmnefs containing the foetus, which is attached to the pla€enta, and is alfo conneaed Avith the chorion that is lying within it. This bag can be afcertain- ed to be the ovarium, by tracing upon it the Fal- lopian tube and the fpermatic veffels from their origin to their termination. The uterus in fuch cafes is confiderably larger than the unimpregnat- ed fize, and in its cavity there is formed the mem- brana decidua. This fhews that the uterus takes on the fame changes, although imperfeaiy, which it does in the ordinary circumftances of pregnan- cy. The fpermatic veffels are alfo enlarged, in order to fupply a fufficient quantity of blood to the ovum which is growing in the ovarium. Shrinking of the Ovaria. The ovaria commonly fhrink towards old age, and are changed in their ftruaure. They are di- going no change fimilar to what happens when there is an ovum growing in the ovarium or the Fallopian tube. The hymen too was perfe8 ] portion to the increafe of the ovum, in order to fupply it Avith a fufficient quantity of blood. While this procefs is going on in the Fallopian tube, the uterus increafes in bulk fo as to be even twice its natural fize, and becomes more vafcular. The cavity of its fundus is alfo lined by a membrana de- eidua,and the cervix uteri is plugged up with jelly. The uterus therefore undergoes a variety of changes, exaaiy fimilar to what take place in natu- ral pregnancy, being thrown into this progrefs of aaion from the original ftimulus of impregnation. The ovum fometimes makes confiderable progrefs in the Fallopian tube, and even has been known to advance to the full period of geftation, but more commonly it dies at an early period. In the / courfe of the evolution of the ovum, the Fallopian tube has been knoAvn to rupture, and the perfon to die from internal haemorrhage. A very clear and accurate account of fuch a cafe has been pub- lifhed by Dr. Clarke in the Medical and Chirur- gical Tranfkaions—page 216. Hard Tumour growing from a Fallopian Tube. I have feen a hard round tumour grOAving from the outer furface of one of the Fallopian tubes. This Avhen cut into exhibited precifely the fame [ 2i9 ] appearance of ftruaure with the tubercle which groAvs from the furface of the uterus, viz. it con- fifted of a hard white fubftance, which was inter- feaed with ftrong membranous fepta. This, how- ever, I believe to be a very rare appearance of difeafe. The round ligaments partake of the inflamma- tion of the uterus, Avhen it is confiderable, and has fpread to its appendages. They are alfo, doubt- lefs, fubjea to other difeafes, but thefe are very rare, and have not fallen under my own obferva- tion, nor do I know of their having been particu- larly noticed by authors. [ 220 ] CHAP. XXII. Difeafed Appearances of the Vagina. Inflammation of the Vagina. A he internal furface of the vagina, near the outward opening, is frequently inflamed, efpecial- ly from the application of the venereal poifon, but this hardly ever becomes the fubjea of examina- tion after death. Adhefions of the Sides of the Vagina. A very violent inflammation has fometimes been known to take place in the vagina, which has terminated in the adhefion of the fides of the cavity. This adhefion is fometimes extended over a great part of the cavity, but moft frequently is more confined, producing a ftriaure in fome one part. The vagina under fuch circumftances lofes its office as a canal fubfervient to the uterus > and according to the degree of the extent of the adhe- [ 221 ] fion, the difeafe becomes more or lefs eafy to be remedied by art. Ulcers of the Vagina. Ulcerations are not unufual in the vagina.— They fometimes appear like fpots of the internal furface, removed as it Avere by a knife, and at o- ther times there is a foul ragged ulcer. When this laft is the cafe in any confiderable degree, the ulcer has commonly not originated in the vagina, but has fpread from the Avomb, which is in a can- cerous ftate. When the ulcer fpieads very much, communications are often made with the neigh- bouring parts, producing a moft miferable ftate of exiftence. Thus communications are fometimes formed between the vagina and the reaum, or the vagina and the bladder. Schirrous Tumours in the Vagina. Schirrous tumours occafionally arife in the vagi- na itfelf (although, I believe, rarely) when the li- tems is unaffeaed. When cut into they exhibit the true fchirrous ftruaure which has been often defcribed. Such tumours may ulcerate, and pro- Cg J] '222 J dace the fame dreadful havock which we have fo lately mentioned. Inverfion cfl the Vagina, One of the moft common difeafes of the vagi- na is its inverfion,.or prolapfus : this is more apt to happen where-the natural formation of the pel- vis is large, where the external opening at the vul- va is wide, and where the parts are generally re- laxed. The prolapfus is more or lefs in different cafes ; in fome the uterus does not pafs out at .the external parts, and in others the inverfion of the vagina is complete, at the extremity of which is fituated the os uteri. The protrufion has then dif- ferent fhapes; it fometimes forms a large rounded xhafs, and at other times it is narrowed and more elongated, extending, perhaps, five inches from the body. When this laft has been the cafe, it has been fometimes miftaken for that fpecies of monftrous formation called hermaphrodite. We may here take an opportunity of mentioning, that although in fome of the common quadrupeds a re- al hermaphrodite ftruaure has been found, yet it has never been difcovered in the human fubjeft. When the vagina has been long in the habit of-be- ing inverted, its inner furface becomes in many [ *23 I parts harder; it is apt to be inflamed occafionally from external irritation, and this not uncommon- ly advances to ulceration. In inverfion of the vagina and prolapfus of the uterus, if the cavity of the pelvis be examined, the fundus only of the uterus can be feen with its appendages very imperfeaiy, or the whole of the uterus may be hid entirely : tire bladder will then appear to be in contaa with the reaum. In this ftate of the uterus and its appendages, I have known adhefions formed between them and the neighbouring parts. Thefe muft have rendered the reduction of the uterus and vagina into their natural fituation very difficult, and perhaps till they were a good deal elongated impoffible. The Vagina very fhort. *. The vagina is fometimes very fhort. I have feen it, I fhould believe, fhorter than half its na- tural length. This is an original defea in the formation, and can only be very imperfeaiy re- medied by art. The Vagina widened. The vagina is fometimes very much ftretched or widened by large tumours which are lodged [ 224 ] in it: thefe are chiefly polypi; and when they have been removed by art, the vagina, if it has not been for a long time ftretched, recovers near- ly its natural fize. The Vagina very narrow. The vaj»