A HAND-BOOK 
OF 
POST-MORTEM EXAMINATIONS 
"s 
AND OF 
MORBID ANATOMY. 
BY 
FRANCIS DELAFIELD, M.D. 
CURATOR TO BELLEVUE HOSPITAL, PATHOLOGIST TO THE ROOSEVELT HOSPITAL, ETC., ETC. 
NEW- YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1872. Entered, according to Act of Congress, in the year 1872, by 
WILLIAM WOOD & CO., 
in the Office of the Librarian of Congress, at Washington. 
S. W. Green, Printer, 16 and 18 Jacob Street, New-York. PREFACE. 
This work is intended to serve as a guide for those persons who 
may be called upon to perform post-mortem examinations. For 
most physicians this call is only an occasional one, so that they 
may feel the need of some hand-book to which they may refer. 
It is not proposed to offer a complete treatise on Pathological 
Anatomy, nor on Medical Jurisprudence, but rather a work which 
bears the same relation to them that a dissecting manual does to a 
complete Anatomy. 
The book is divided into four parts. The first gives the method 
of performing autopsies on the bodies of adults and of young chil- 
dren. The second gives in detail the lesions which have been ob- 
served in each organ of the body. The third gives the lesions 
which are found after deaths from general diseases, from violence, 
and from poisons. The fourth gives a short classification of 
tumors. 
FRANCIS DELAFIELD, 
12 West Thirty-second street. 
June, 1872. F A.R T I. 
ON THE METHOD 
OF MAKING 
POST-MORTEM EXAMINATIONS. ON THE METHOD 
OF MAKING 
POSTMORTEM EXAMINATIONS. 
The particular object of making a post-mortem examination 
varies in different cases. It may be to determine whether a per- 
son has died from violence or poisoning ; to account for a sud- 
den death ; or to study the lesions of disease. In any case, the 
examination should embrace the entire body, not merely the 
suspected organ, and it should be recorded at the time it is 
made. 
It is necessary to be very careful in asserting that a given 
lesion is or is not a sufficient cause for death. The causes of 
death, especially of sudden death, are often very obscure. Per- 
sons who have been suffering from chronic diseases frequently 
die suddenly without any discoverable cause. At all periods of 
life, from infancy to old age, we meet with cases of sudden 
death which we are unable to account for by the clinical his- 
tory or the post-mortem examination. In such cases, it is bet- 
ter to avow our io-norance than to attribute the death to a con- 
gestion of the brain or a disease of the kidneys-which does not 
exist. 
EXTERNAL INSPECTION. 
Before commencing the examination of the internal viscera, 
it is always necessary to make some inspection of the external 
surface of the body. The minuteness of this inspection will de- 
pend upon the character of the case. In the case of an un- 4 
POST-MORTEM EXAMINATIONS. 
known person, or of one who is supposed to have died from un- 
natural causes, it is necessary to search for and record not only 
all contusions, wounds, etc., their size and situation, but also 
any physical peculiarities of hair, eyes, moles, etc., by -which 
the person may be identified. In ordinary examinations, we 
only look for the evidences of external injuries, for skin diseases, 
ulcers, etc., for oedema, gouty deposits, abscesses, enlarged lym- 
phatic glands, etc. The glans penis and prepuce are to be care- 
fully searched for syphilitic cicatrices. 
It is customary to find certain changes in the external appear- 
ance of the body, which are due to the cessation of vitality in 
the tissues and to the commencement of decomposition. I 
speak now of bodies -which have not yet been buried, and which 
have been kept in the ordinary way, partly covered by a shroud, 
and lying on their backs in a loosely-covered coffin. If the 
bodies have been left in their ordinary clothes, the appearances 
are much the same. 
In such bodies, one of the first noticeable changes is the pale- 
ness of the skin and its mottling with irregular livid patches. 
After a short time, the blood settles in the vessels of the more 
dependent portions of the body, and the skin which covers the 
back of the trunk and extremities becomes of a livid red color. 
In many cases, if we cut through the skin, w'e find the tissues 
beneath congested and infiltrated with bloody serum. In 
bodies which have been kept for a number of days in cold -wea- 
ther, this red color of the skin is also seen on the anterior 
portions of the body, especially the face and neck. In hot 
weather, the red color is very soon altered by decomposition. 
If the epidermis has been detached at any point, the skin 
beneath this is dry, hard, and red. 
In warm weather, we may find, a few hours after death, 
broad, bluish lines, corresponding to the cutaneous veins, rami- 
fying in the skin of the neck and thorax. These lines are 
formed by the escape of the coloring matter of the blood from 
the vessels. 
Within a few hours after death, even in cold weather, there 
is usually some escape of frothy blood and mucus from the 
mouth and nose. METHOD OF EXAMINATION-. 
5 
If the eyelids are not closed, the conjunctiva and cornea 
soon become dry, brown, and hard. The eyeballs also become 
flaccid. 
After a considerable length of time, the skin of the abdomen 
becomes green. Still later, decomposition fairly sets in. 
The entire body is of a dark green color. The tissues are 
infiltrated with serum. The abdomen is distended with gas. 
Then the color changes from a green to a reddish brown. The 
epidermis is detached. The skin is covered with maggots. 
The entire body is swollen from the formation of gases. The 
face can hardly be recognized. The nails drop off, and the 
scalp becomes detached. When a body is in this condition, it 
can hardly be determined whether one month or five months 
have elapsed since death. 
After this, all the soft parts change into a formless, putrescent 
mass. The cavities are open, the viscera are indistinguishable, 
the bones are left bare. 
The rapidity with which these changes take place varies 
under the influence of a great number of conditions. 
The bodies of infants usually decompose more rapidly than 
those of adults. Fat bodies putrefy more quickly than lean ones. 
The bodies of persons who die suddenly from violence decom- 
pose less rapidly than the average, unless the body is a good deal 
mangled. Exhausting diseases, fevers, and the puerperal con- 
dition are followed by rapid decomposition, as is also death from 
suffocating gases. Poisoning by alcohol, by arsenic, and by 
sulphuric acid may preserve the bodies for an unusual length of 
time. Atmospheric air, moisture, and warmth quicken decom- 
position. At the same temperature, a body 'which has been for 
one week in the air, one which has been two weeks in water, 
and one which has been eight weeks buried in the usual way, 
will all exhibit the same degree of decomposition. 
The Rigor Mortis.-It is proper to notice whether or not the 
body is in the condition of post-mortem rigidity. More atten- 
tion has, perhaps, been given to this particular post-mortem 
condition than it well deserves. 
According to Kiihne, the rigor mortis is produced by a change 
in the muscular fibres. The fibres first lose their contractility, 6 
POST-MORTEM EXAMINATIONS. 
then there is coagulation of the myosine, and loss of elasticity ; 
then the muscular tissue becomes acid. When this acidity has 
reached its height, the muscle becomes softer, and the rigor 
mortis gradually disappears. Finally the acid condition 
is succeeded by an alkaline fermentation, and decomposition 
ensues. 
The rigor mortis generally begins in the muscles of the lower 
jaw and back of the neck; it then extends to those of the face, 
neck, thorax, arms, and finally the legs. It usually disappears 
in the same order. 
It usually begins in from 8 to 20 hours after death, but often 
much sooner. The bodies of persons killed on the field of bat- 
tle, and of those who have been drowned, sometimes seem to be 
overtaken by the rigor mortis at the very instant of death. The 
bodies retain the same position and the face the same expres- 
sion which they had in the last moments of life. 
The rigor mortis may continue for from one to nine days. 
Generally, but not always, death from narcotic poisons is fol- 
lowed by a feeble and short rigidity. 
It is said that death by lightning is followed by rapid and in- 
tense rigidity. 
Casper says that in foetuses born before term he has never 
observed any rigidity, and that in young children it is feeble 
and of short duration. 
It is asserted by some and denied by others that death from 
suffocation is followed by a short and feeble rigidity. 
The degree and duration of rigor mortis after death from 
violence, from different diseases, etc., is stated so variously and 
so contradictorily by different observers, that no definite rules 
can be given concerning it. 
The temperature of the living body is 98° to 99° F. In 
consequence of disease, the temperature may be increased 
several degrees. After death, the body gradually cools to the 
same point as the surrounding air. This is said to take place 
in from fifteen to twenty hours. Taylor, from the examina- 
tion of one hundred bodies, states that the average heat of the 
skin of the abdomen at a period of two to three hours after 
death is 77° ; at four to six hours, 74°; at six to eight hours, METHOD OF EXAMINATION. 
7 
70°; at twelve hours, 69°. The internal viscera retain their 
heat longer than the surface of the body. 
It is said that, after sudden death from accidents, apoplexy, 
acute disease, and asphyxia, the body retains its heat for an 
unusually long period. 
It is both asserted and denied that after death from haemor- 
rhage the body cools rapidly. The body of an adult cools 
more slowly than that of a child or of an old person; that of a 
fat person more slowly than that of a lean one. The more the 
body is covered up, the less rapidly it cools. 
In some cases, there is an exceptional retention and even an 
increase of heat in the dead body. Dr. John Davy reports that 
in a case of death from rheumatism, after the viscera had been 
exposed for several minutes, the temperature of the left ventri- 
cle of the heart was 113°, and that of the liver 112°. In a 
second case, six hours after death, the temperature of the heart 
was 108°. 
It is stated that after death from yellow-fever and cholera 
the temperature increases for several hours after death. 
There are also recorded a number of cases in which the body 
retained its heat for several days without known cause. 
It will be seen, from what has been said, that if we are 
called upon to pronounce upon the length of time which has 
elapsed since death in a given case, this is only to be done 
approximately and probably. It is necessary to take into con- 
sideration the cause and manner of death, the condition of the 
individual, the state of the atmosphere, the manner in which 
the body has been kept after death. And even after making 
these allowances, we can only say that probably a person has 
been dead for such or such a time. 
Contusions.-It is often important to determine whether vio- 
lence has been inflicted on a given body before death. With 
reference to this point, we must remember in the first place 
that blows and falls of sufficient violence to fracture the bones 
and rupture the viscera may leave no marks on the skin, even 
if the individual has survived for several days. 
In the second place, there are a number of post-mortem ap- 
pearances which simulate ante-mortem bruises. If we observe 8 
POST-MORTEM EXAMINATION'S. 
a severe contusion, as it exists during life, we see that the injury 
at first leaves no mark, or only a general redness. After a 
short time, the injured part is swollen and of a red color. 
This color is succeeded by a black and blue, and tliis again gra- 
dually fades out into a yellow. All these changes are due to an 
escape of blood from the vessels, and to subsequent changes in 
its coloring matter. If, therefore, we cut into such an ecchy- 
mosis after death, we shall find extravasated blood, or the color- 
ing matter of the blood in the form of granular pigment in the 
tissues. Post-mortem discolorations, on the other hand, al- 
though their external appearance may resemble that of ante- 
mortem ecchymosis, are not formed by an extravasation of 
blood, but by a circumscribed congestion of the vessels, or by 
an escape of blood-stained serum. If we cut into such dis- 
colorations, therefore, we find no blood outside of the vessels. 
An abrasion of the skin, by which the epidermis has been 
rubbed off, presents the same appearance whether produced be- 
fore or after death. In either case, the denuded cutis becomes 
hard, dry, and parchment-like. 
Blows on tire skin of a body which has not been dead for 
more than two hours may produce true ecchymosis, with ex- 
travasation of blood, such as can hardly be distinguished from 
those formed during life. 
Wounds.-We should notice the situation, extent, and direc- 
tion of a wound; the condition of its edges and of the sur- 
rounding tissues. If it is a deep penetrating wound, a probe or 
director should be passed into it before it is laid open. 
If we find the edges of a wound inflamed and suppurating, 
or commencing to cicatrize, it must have been inflicted some 
time before death. If a wound has been inflicted a short time 
before death, its edges are everted; there is extravasation of 
blood into the surrounding tissues, the vessels contain coagula, 
or all these signs may be absent. The chief characters of a 
wound inflicted after death are absence of bleeding, non- 
retraction of the edges of the wound, and no extravasation of 
blood. A wound inflicted within two hours after death resem- 
bles more closely one inflicted during life. In general, unless 
a wound is old enough for its edges to present inflammatory METHOD OF EXAMINATION. 
9 
changes, we must be very careful in asserting its ante-mortem 
or post-mortem character. 
Fract/wres.-It may be important to determine whether a 
bone was fractured before or after death. This point cannot 
always be decided. Generally a much greater degree of force 
is necessary to fracture bones in the dead than in the living 
body. Fractures inflicted during life are, as a rule, attended 
with more extravasation of blood and evidences of reaction in 
the surrounding tissues. But fractures inflicted within a few 
hours after death may resemble these very closely. 
Scars.-The presence of cicatrices and their appearance 
should be noticed. Scars produced by an actual loss of sub- 
stance, or by a granulating wound, never disappear entirely. 
Slight and superficial wounds, however, produce marks which 
are not permanent. The discolorations produced by tattooing 
may fade away during life. Not infrequently tattoo marks, 
which were observed during life, can no longer be found after 
death. 
INTERNAL EXAMINATION. 
In making the internal examination, it should be our object 
to make it both as thoroughly and as rapidly as possible. In 
order to do this, we must follow a regular method. It is always 
necessary to examine not merely the particular organs in which 
we expect to find lesions, but also all the other viscera. If 
this is not done, we arc always liable to fall into grave errors. 
After completing the external inspection of the body, we 
commence the internal examination. This is best done in the 
following order: 
The Head.-The scalp is divided by an incision across the 
vertex from ear to ear. The flaps are directed forward and 
backward, taking up the temporal muscles with the skin and 
leaving the pericranium attached to the bone. The internal 
surface of the scalp and the pericranium are to be examined for 
ecchymoses and inflammatory lesions. A circular incision is 
then made with the saw and the roof of the cranium removed. 
The incision in front should pass through a point three and a 
half inches above the root of the nose, behind through the occi- 
pital protuberance. 10 
POST-MORTEM EXAMINATIONS. 
If fracture of the cranium is suspected, the bones should he 
sawn entirely through. If not, it is sufficient to saw partly 
through and then separate the calvarium with the chisel. When 
the roof of the cranium is thus entirely loosened, a large hook is 
introduced under the upper edge of the calvarium, and this is 
wrenched off with a sudden jerk. Sometimes the dura mater is 
so adherent to the roof of the skull that the latter cannot be 
torn from it. We must then cut through the dura mater at the 
level of the incision in the bones, and take out the brain with 
the calvarium. 
When the calvarium is removed, we notice whether or not it 
is symmetrical. The cranial bones normally increase in size by 
a growth of bone at the edges of the sutures. If any suture 
becomes completely ossified and closed before the others, the 
bones will be unequally developed. Thus an early closure of 
the sagittal suture produces a long, narrow cranium, etc. 
The thickness of the cranium and its density vary very con- 
siderably within the limits of health. There are often deep 
depressions on the inner surface of the skull along the sagittal 
suture, caused by the pressure of the pacchionian bodies. 
We observe the degree of congestion of the bone, the exis- 
tence of fractures and of inflammatory lesions. 
The Dura Mater is now exposed to view. It will be found 
more or less adherent to the calvarium. A moderate decree of 
adherence, especially in old persons, does not denote disease. 
Very extensive and firm adhesions are usually produced by in- 
flammation. Near the median line the pacchionian bodies often 
project through the dura mater. We must look for clots, for 
new growths, and for inflammatory lesions on the outer surface 
of the dura mater. The longitudinal sinus should be laid open 
with the scissors, and its contents examined. A circular incision 
is then made through the dura mater, in a line corresponding 
with the incision through the skull, the falx is entirely divided 
between the anterior lobes of the cerebrum, and the entire 
membrane drawn back. We notice the existence of adhesions 
to the pia mater, of clots, of the products of inflammation, and 
of new growths. 
The Pia Mater is now exposed, covering the convex surface of METHOD OF EXAMINATION". 
11 
the brain. The degree of congestion and the existence of serum, 
pus, or blood beneath or in the pia mater, are to be ascertained 
at this time, before the brain is removed. The pia mater in old 
persons loses its transparency and becomes thick and white; this 
change is most marked along the longitudinal fissure and the 
large vessels. It is a simple senile change, but is frequently 
mistaken for an inflammatory lesion. Marked and general 
thickening of the pia mater, however, is produced by chronic 
inflammation. Along the longitudinal fissure, and sometimes 
at a distance from it, we find little whitish, wart-like bodies. 
These are the pacchionian bodies, which are found normally in 
adult life. 
The amount of serum beneath the pia mater varies. A con- 
siderable amount, especially in cachectic persons, may exist 
without brain disease. Clear serum lifting up the pia mater 
and separating the convolutions of the brain may be simply 
dropsical or due to chronic meningitis. Turbid and purulent 
serum beneath and in the pia mater are produced by acute 
meningitis. 
The Brain.-After examining the convex surface of the brain, 
the anterior lobes of the cerebrum are to be pulled gently 
backward, the cranial nerves and the tentorium divided, the 
medulla oblongata cut across as low down as possible, and the 
brain thus removed from the cranium. 
The adult brain weighs, in the male, from 46 to 53 oz.; in 
the female, from 41 to 47 oz. Besides the lobes and fissures of 
the brain, it is important to notice the convolutions and sulci, 
in order to note the exact situation of any lesion. 
The brain is first laid on its convex surface, and the anterior, 
middle, and posterior cerebral arteries, the basilar, and the car- 
otids examined for emboli, thrombi, and atheroma. Extravasa- 
tions of blood, new growths, and inflammatory lesions are also 
to be looked for. The brain is then turned over on its base. 
An incision is made through the pia mater, over the convex 
surface of the cerebrum ; this membrane is stripped up, and its 
adherence to the brain, its thickness and general appearance are 
noticed. The two halves of the cerebrum are then to be gently 
separated until the superior surface of the corpus callosum is 12 
POST-MORTEM EXAMINATIONS. 
Side View of the Brain. 
F. Anterior lobe. 
O. Posterior lobe. 
T. Middle lobe. 
S. Fissure of Sylvius. 
S'. Horizontal branch. 
S'. Vertical branch. 
C. Sulcus centralis, or fissure 
of Rolando. 
A. Anterior cent, convolution. 
B. Posterior cent, convolution. 
F1, F2, F3. First, Second, and Third Frontal Convolutions. 
P, f2, f3. Superior, Inferior, and Vertical Frontal Sulci. 
P1. Postero-parietal Lobule. P2. Inferior Parietal Lobule. P3. Angular Gyrus. 
i p. Inter-parietal Sulcus, p o. Parieto-occipital Fissure. 
O1, O2, O3. First, Second, and Third Occipital Convolutions. 
o1. Transverse Occipital Sulcus, o2. Inferior, Longitudinal, Occipital Sulcus. 
T1, T2, T3. First, Second, and Third Temporal Convolutions. 
t112. First and Second Temporal Sulci. 
exposed. An incision is then made through the junction of the 
corpus callosum and cerebrum, cutting outward and down- 
ward, into each lateral ventricle. This incision should be made 
carefully, so as not to cut through the ventricles into the ganglia 
below. The incision, thus made through the roof of each ven- 
tricle, is prolonged backward and forward, in the direction of 
the cornua, until the entire cavity of each lateral ventricle is 
exposed. A long incision outward and downward is then 
made into each half of the cerebrum, from the outer edge of METHOD OF EXAMINATION. 
13 
the lateral ventricles, nearly to the pia mater. A second inci- 
sion is then made from this cut surface outward, and this is re- 
peated until the cerebrum is divided into a number of long 
prismatic-shaped pieces held together by the pia mater. The 
velum interpositum is then dissected up, and the fourth ventri- 
cle opened. To complete the examination, cross-sections are 
made through all the large ganglia, the medulla, and the cere- 
bellum. Care must be taken not to overlook small clots in the 
medulla oblongata. 
The Base of the Cranium.-We now return to the skull. 
The remaining sinuses of the dura mater should be opened. 
This membrane is then to be entirely stripped off from the 
bone. The bone is to be examined for fractures, inflammatory 
lesions, and new growths. 
The Eyes can be removed by comminuting the roof of the 
orbit with a hammer, removing the fragments of bone, dissect- 
ing away the fat and muscles, so as to expose the optic nerve 
and posterior half of the eye. With a pair of scissors we can 
then cut away that portion of the globe which is not covered by 
conjunctiva, and remove it with the optic nerve. The anterior 
portion of the globe with the cornea is left in place. The nerve 
and portion of the eye removed are to be placed at once in 
Muller's fluid. 
The Spinal Cord.-The examination of the spinal cord may, 
in many cases, be dispensed with. When it is necessary, it is 
most conveniently performed after the removal of the brain. 
The body should be placed face down-ward, with a block un- 
der the thorax, and the head dropping over the edge of the 
table. An incision is made through the skin and muscles 
along the entire length of the spine, and the soft parts dissected 
off on each side, so as to expose the laminae of the vertebral col- 
umn. The laminae are then divided close to the articulating 
processes, with the rachitome, the saw and chisel, with a sharp 
chisel, or with strong cutting forceps. The spinous processes 
and laminae are then torn away together, and the cord exposed. 
The membranes of the cord may be found very considerably 
congested without indicating the preexistence of any disease. 
The roots of the spinal nerves are then to be cut across, and 14 
POST-MORTEM EXAMINATIONS. 
the cord removed in its membranes, care being taken not to 
press it in any way. It is the safest plan not to grasp the cord 
itself, bnt with a forceps to seize the dura mater, and thus lift 
up the cord. The dura mater is then laid open with scissors 
over the entire length of the cord. 
If disease of the cord is suspected, and no lesions are to be 
seen with the naked eye, the cord should always be preserved 
for microscopical examination. For this purpose, it should be 
cut into pieces an inch long; these pieces are then loosely tied 
in their order with a cord, and suspended in ajar containing a 
solution of Potass. Bichrom., gr. xv. to f | of water. After re- 
maining in this for 10 days, the cord should be removed to a 
solution of Ac. Chromic, gr. ij to 3 1 of water, and remain in 
this until hard enough to be cut into thin sections. 
After the removal of the cord, fractures and displacements 
of the vertebrae are easily recognized. 
The Thorax and Abdomen -To examine these cavities the 
body is replaced on its back. A single straight incision is made 
from the top of the sternum to the pubes. For this purpose, a 
large scalpel should be used, and the first incision should divide 
every thing down to the sternum and peritoneum. A short 
incision should then be made through the peritoneum; into 
this opening two fingers of the left hand are introduced, and 
the peritoneum divided from the ensiform cartilage to the 
pubes. The skin and muscles are then dissected off from the 
thorax on both sides as far back as the false ribs. In doino- 
this, we notice the amount of subcutaneous fat and the condi- 
tion of the muscles. 
The abdominal cavity is now exposed, and we have first to 
notice the position of the viscera. 
The Liver is situated in the right hypochondriac region, 
filling up the concavity of the diaphragm. Its upper border 
reaches in the linea mammalis to the fifth intercostal space; in 
the linea axillaris, to the seventh intercostal space; close to the 
vertebral column, to the tenth intercostal space. At the 
median line the upper border of the liver corresponds to the 
lower border of the heart. The left lobe extends about three 
inches to the left of the median line. The lower border of the METHOD OF EXAMINATION. 
15 
right lobe usually reaches to the free border of the ribs, while 
the left lobe is visible for about an inch below the ensiform 
cartilage. In women, the liver is usually lower than in men. 
The position of the liver is altered by changes in the tho- 
racic cavity, forcing it downward; by changes in the abdomi- 
nal cavity, forcing it upward; by constriction of the waist by 
tight lacing, forcing it either downward or upward; by chan- 
ges in the size of the organ itself. 
The liver may be not only displaced downward, but dislo- 
cated so that its convex surface faces the abdominal wall, and 
its posterior edge faces upward against the diaphragm. 
The Stomach is situated in the left hypochondriac and epi- 
gastric regions, extending also into the right hypochondrium. 
It lies in part against the anterior wall of the abdomen, and in 
part beneath the liver and diaphragm, and above the transverse 
colon. Its anterior surface, which is directed upward and for- 
ward, is in contact above with the diaphragm and the under 
surface of the liver, and lower down with the abdominal wall, 
opposite to the epigastric region. Its posterior surface is turned 
downward and backward, and rests upon the transverse meso- 
colon, the pancreas and the great vessels. The lesser curvature 
or upper border has attached to it the gastro-phrenic ligament 
and gastro-hepatic omentum. To the greater curvature, or 
lower border, is attached the gastro-colic omentum. Its cardiac 
orifice terminates in the oesophagus, its pyloric end in the 
duodenum. 
When the stomach is distended, the greater curvature is 
elevated and carried forward, the anterior surface is turned 
upward, and the posterior surface downward. 
The organ when distended with food or gas, is prominent; 
when empty, may be hardly seen ; when the intestines are di- 
lated, may be entirely covered by them. 
The Transverse Colon passes from one side of the abdomen 
to the other through the upper part of the umbilical region.. 
It may be lower than the umbilicus, or high up against the 
liver and diaphragm. It may be distended with gas or con- 
tracted. 
The Omentum should be found smoothly spread over the 16 
POST-MORTEM EXAMINATIONS. 
surface of the small intestines, but may be rolled up and dis- 
placed in a variety of positions, or maybe adherent at some 
point. 
It is convenient at this stao-e of the examination to look over 
the peritoneal cavity for serum, or inflammatory lesions, and 
to notice the existence of invagination, incarceration, or hernise 
of the intestines. 
If the existence of air or gas in the pleural cavities is sus- 
pected, the abdominal cavity should be filled with water and 
the diaphragm punctured below the level of the fluid. If any 
air be present, it will escape in bubbles through the water. 
The Thorax.-We now leave the abdominal viscera in place, 
and proceed to the examination of the thorax. 
With a costatome, or a strong knife, the costal cartilages are 
divided close to the ribs, the clavicles are disarticulated from 
the sternum, and the latter removed, taking care not to wound 
the large veins. 
'\We first examine the position of the heart and lungs. 
The Heart, covered with the pericardium, extends vertically 
from the second intercostal space to the sixth cartilage, and 
transversely from a little within the left nipple to about half an 
inch to the right of the sternum. The apex of the heart is 
opposite to the fifth intercostal space, about 3| inches from the 
middle of the sternum. From the fifth intercostal space to the 
upper edge of the fourth cartilage, the heart is covered by the 
lungs. The portion of the heart uncovered by the lungs is of 
an irregularly triangular shape. The vertical side of the tri- 
angle is 2 inches, the horizontal 2J, and the oblique 3 inches in 
length. The area of the heart which is found uncovered will 
vary very much according to the degree in which the lungs 
collapse after death. Any disease which diminishes the size of 
the lungs, or any pleuritic adhesions which retract or bind 
down the lungs, may increase the area of exposed heart. On 
the other hand, emphysema, pneumonia, or any disease which 
increases the size of, or retains the air in, the lungs, may dimin- 
ish the area of exposed heart. The pericardium is now opened 
by a vertical incision on its anterior surface. The existence of 
serous, fibrinous, or purulent exudation, and of adhesions, are METHOD OF EXAMINATION. 
17 
to be noticed. A small amount of clear serum exists normally 
in the pericardial sac, and this serum may be blood-stained 
from commencing decomposition. White thickenings of the 
pericardium on the anterior surface of the right ventricle are 
often seen ; they do not indicate disease. 
Now that the pericardial sac is opened, the position of the 
heart can be clearly seen. It lies transversely in the chest, its 
long axis at an angle of 60° with that of the thorax. The por- 
tion of the heart which is first seen is the anterior surface of 
the right ventricle; upward and to the right of this is the right 
auricle, which lies % on the right side of the sternum, and be- 
hind it. Its upper border usually corresponds with the plane 
of the middle of the anterior end of the second intercostal space 
on the right side. Its size varies with the amount of blood it 
happens to contain. The left auricle lies behind the root of 
the pulmonary artery, so that only its appendix is visible. The 
middle of the auricle corresponds to the third costal cartilage. 
Of the left ventricle only a narrow rim is seen on the left side 
of the right ventricle. 
The opening of the tricuspid valve corresponds to the sternal 
end of the fourth cartilage, behind the left half of the sternum. 
The pulmonary valve is behind the left edge of the sternum, at 
the middle of the anterior end of the second intercostal space. 
The mitral valve is just above the upper edge of the third 
left cartilage, near the left edge of the sternum, behind and be- 
low the edges of the pulmonary valves. 
The aortic valve is just below the sternal end of the third left 
cartilage. 
The heart should now be removed unopened, by cutting 
through the vessels at its base, after first passing the hand over 
the arch of the aorta to ascertain whether any aneurism is pre- 
sent. To determine the sufficiency of the aortic and pulmonary 
valves, a full stream of water is poured into the aorta and pul- 
monary artery, and we observe how well the valves support the 
column of fluid. To ascertain the sufficiency of the mitral and 
tricuspid valves, the auricles are first laid open so as to expose 
the upper surfaces of the valves. A large pipe is passed 
through the aorta or pulmonary artery beyond their valves, and 18 
POST-MORTEM EXAMINATIONS. 
a moderate stream of water allowed to flow into the ventricles. 
The auriculo-ventricular valves will be swollen outward, and 
we can observe the degree of their sufficiency. The tricuspid 
valve is normally somewhat insufficient. 
To ascertain the size of the different valvular openings, we 
introduce one or more fingers, held flat and with their edges 
in contact, into each of the orifices, and then measure the width 
of the fingers at the point where they fill the orifice. In this 
way we find that the aortic valve measures about 1 inch; the 
mitral valve, If inches; the pulmonary valve, If inches; the 
tricuspid valve, 2 inches. 
In order to examine the interior of the heart, we first make 
an incision through the anterior wall of the right ventricle, 
close to the septum, and reaching to the apex of the ventricle; 
through this opening the blade of the enterotome is passed into 
the pulmonary artery, and the ventricle and artery laid open. 
With a little care, the incision may be made to pass through 
one of the points of junction of the pulmonary valves. The 
ventricle may be empty, or contain fluid blood, or red clots, or 
succulent yellow clots, or firm whitish clots,' either free or at- 
tached to the heart-wall. The succulent yellow clots are very 
common; they are sometimes intimately entangled with the 
trabeculae of the ventricular wall; they are not a pathological 
condition, but are found in persons dying in every way; they 
are formed after death or during the last moments of life. The 
condition of the pulmonary valves, of the endocardium, and the 
thickness and appearance of the wall of the ventricle are then 
noticed. 
The left ventricle is then opened and examined in the same 
way, by an incision through its anterior wall close to the 
septum. We sometimes see the endocardium of the upper part 
of the left ventricle thick and white, without the existence of 
valvular lesions, or any clinical history of disease. To com- 
plete the examination of the cavities, the enterotome is passed 
into each ventricle and auricle, and an incision made from the 
apex of each ventricle through its outer border, and the outer 
border of the corresponding auricle. In this way the auriculo- 
ventricular valves are fully displayed. METHOD OF EXAMINATION. 
19 
After removing the blood, the heart should finally be weighed. 
In adults, the normal average weight of the heart is, in males, 
10 oz.; in females, 8 oz. The average relative weight to that 
of the body is, in males, 1 : 158 ; in females, 1 : 149. Accord- 
ing to Bizot, the thickness of the wall of the left ventricle is, 
in males, 7-16 in.; in females, 5-16 in.; of the right ventricle, 
in males, 3-16 in. ; in females, 2-16 in. 
Males. 
Females. 
The diameter in French lines of the mitral valve is 
45 17-30 
41 1-3 
it IC it 
tricuspid valve is 
54 12-61 
48 1-4 
ct cc a 
aortic valve is 
31 15-61 
28 4 5 
" <c <C 
pulmonary valve is 32 21-61 
30 7-60 
Generally speaking, the size of the heart corresponds to the size 
and development of the individual. In judging of an increase 
or decrease in its size, we must consider the weight of the organ 
and the thickness of its walls. If the patient dies while the 
heart is contracted, the walls of the ventricle will appear thicker, 
their cavities smaller than usual. If the patient die of some 
exhausting disease, like typhoid fever, or if decomposition has 
commenced, the heart-walls will be flabby, and the cavities will 
appear larger than usual. 
The Pleural Cavities are now examined. The hand is passed 
into each, and the existence of serous or fibrinous exudation, or 
of old adhesions, are ascertained. The method of ascertaining 
the presence of air has already been given. 
The Lungs.-Each lung is now lifted up in turn, the vessels, 
etc., at its base divided, and the organ removed. If the pleura 
is very adherent, it is better to strip off the costal pleura with 
the lung. After inspecting the external surface of the lung, 
we proceed to open the bronchi. For this purpose, we use a 
pair of scissors with long, narrow, blunt-pointed blades, one 
blade a little longer than the other. The lung is held in the 
left hand, with its base upward. We first open the large 
bronchi which run on the inner side of the lower lobe; then 
the other bronchi of the lower lobe; and afterward those of the 
upper lobe. Each bronchus should be followed to its termina- 
tion, and then its different branches opened. 
In the larger and middle-sized bronchi, the cartilage in their 20 
POST-MORTEM EXAMINATIONS. 
walls does not form a continuous coat, but appears like irregular 
white patches, visible from the internal surface of the bronchi. 
This appearance must not be mistaken for a morbid change. 
In bodies which have been dead for several days, especially in 
cold weather, the bronchial mucous membrane may be red and 
swollen as a post-mortem change. 
The contents of the stomach sometimes find their way after 
death into the pharynx, and then down into the trachea and 
bronchi, giving to them a peculiar brownish or even gangrenous 
appearance. 
Bronchitis which has existed during life does not always 
leave lesions which can be appreciated after death. 
After the examination of the bronchi, the lung is turned 
over, the vessels, etc., at its root grasped with the left hand, 
and a long, deep incision made from the apex to the base. We 
observe the appearance and texture of the lungs, whether the 
air-cells are dilated, (emphysematous,) or filled with serum, 
blood, or inflammatory exudation. All fluids can be pressed out 
of the air-cells without breaking down the lung tissue. Solid 
inflammatory exudation, on the other hand, renders the lung 
more resistant and easily broken down. It is the rule to find 
the lower lobes much more congested than the upper. 
To examine the lungs microscopically, we make sections of 
the fresh lung with a double-bladed knife; or small pieces of 
the lung are placed in alcohol, (95 per cent,) and kept there, 
changing the alcohol from time to time, until they are hard 
■enough to be cut with a razor. 
The Pharynx, Larynx, and (Esophagus.-If these organs are 
to be examined, we prolong the incision in the thorax to a point 
one inch below the chin. The soft parts are dissected off from 
the larynx, taking care not to cut the thyroid body, an incision 
is made through the floor of the mouth, following the internal 
surface of the inferior maxilla. Through this incision, the 
fingers are introduced into the mouth, the tongue drawn down, 
the posterior wall of the pharynx divided above the tonsils, and 
the pharynx and larynx thus drawn out together. These or- 
gans are then seized with the left hand and dragged downward, 
and, with the aid of the knife, the entire length of the trachea METHOD OF EXAMINATION. 
21 
and oesophagus are torn out, cutting the oesophagus just above 
the stomach. If the contents of the stomach are to be preserved, 
a ligature is placed around the oesophagus just below the point 
at which it is cut off. 
We now with the enterotome slit up the pharynx and oeso- 
phagus on their posterior surfaces. The mucous membrane thus 
exposed is examined for evidences of caustic poisons, of inflam- 
mation, of new growths, strictures, etc. 
The enterotome is then introduced into the larynx, and this 
organ and the trachea are laid open by an incision through their 
posterior walls. Here we look for oedema of the aryteno-epi- 
glottidean folds, (oedema glottidis,) and for the evidences of 
catarrhal, croupous, ulcerative, and syphilitic inflammation. 
New growths of various kinds, and diseases of the laryngeal 
cartillages are also met with. (Edema and redness of the 
larynx may be produced by post-mortem changes, especially in 
bodies which have been kept for several days in cold weather. 
To preserve the larynx and trachea for microscopical examina- 
tion, I have obtained the best results by suspending them in a jar, 
containing equal parts of alcohol and of a solution of Potass. 
Bichrom., gr. xv. to the 11 of water. The proportion of alco- 
hol is to be afterward increased until the mucous membrane 
is hard enough to be cut into thin sections. 
The Abdomen.-We now return to the abdominal cavity. We 
first dissect off the omentum. If tubercles of the peritoneum 
exist, they are best seen and studied in the omentum. 
The colon is then raised up and dissected free, to the coecum 
on one side, and to the rectum on the other. The colon and 
small intestines are then drawn first to the right and then to 
the left side, so as to expose in turn the left and right kidneys. 
As each kidney is brought into view, an incision is made through 
the peritoneum over the track of the ureter. The ureter is then 
followed out from the kidney to the bladder and its condition 
ascertained. 
The Kidneys are then removed, separating the peritoneum 
and fat from them with the hand and dividing the vessels with 
the knife. At the same time we remove the suprarenal cap- 
sules, which are attached to the upper end of each kidney. 22 
POST-MORTEM EXAMINATIONS. 
Each kidney in turn is then taken up. An incision through the 
capsule is made along the convex edge of the kidney, and this 
membrane'stripped off from it. We notice the degree of adhe- 
rence of the capsule to the kidney, and also the surface of the 
latter, whether smooth or roughened, pale or congested. An 
incision is then made along the convex surface down to the pel- 
vis, so that the organ is divided into two halves. We observe 
the relative thickness of the cortical and pyramidal portions, as 
well as the size of the entire organ. To ascertain the latter 
point, it is well to weigh each kidney: the normal weight is 
from to 5 oz. It is necessary to remember, however, that in 
a kidney which is a good deal atrophied there may be an in- 
crease of fat in the pelvis, which gives the organ nearly its nor- 
mal size and weight, while the kidney tissue proper has really 
in great measure disappeared. 
We now inspect more closely the kidney tissue, especially the 
cortical portion. It is well known that the pyramids consist 
of tubes running nearly in straight lines from the apex to the 
base of each pyramid. These straight tubes pass from the pyra- 
mids into the cortex in bundles, retaining their straight course 
until they nearly reach the surface of the kidney, then bending 
over on each side, become convoluted and end in malpighian 
bodies. In this way, the cortex of the kidney is divided up into 
alternate bands of straight and convoluted tubes, both sets of 
bands being perpendicular to the surface of the kidney. About 
the convoluted tubes is a rich venous plexus, and as the blood 
usually remains after death in this plexus and in the malpighian 
bodies, the bands containing the convoluted tubes appear red, 
while those containing the straight tubes are grayish white. 
In a normal kidney, therefore, the cortex should be regularly 
striped in red and white bands. If there be extensive conges- 
tion, the entire cortex is red. If the epithelium of the tubes 
degenerates and fills them up, or if there are changes in the 
interstitial tissue, the regular bands are lost and the cortex is 
irregularly mottled. If the tubal epithelium becomes filled with 
oil globules, this is indicated by an opaque yellow color of the 
parts affected. In many cases, therefore, the existence of kid- 
ney disease can be recognized with the naked eye. To deter- METHOD OF EXAMINATION. 
23 
mine the presence of waxy degeneration, the cut surface of the 
kidney is washed with water to get rid of the blood, and then 
brushed repeatedly with an aqueous solution of Iodine. The 
malpighian bodies and blood-vessels are the parts usually 
affected by the degeneration. If they are so affected, they will 
appear as red dots and lines on a yellow ground. Sometimes a 
whitish fluid is seen in the pelvis and can be squeezed from the 
papillae: this is produced by a post-mortem desquamation of 
the epithelium. 
If there be any doubt as to the condition of the kidneys, 
microscopical examination is necessary. For this purpose, we 
make sections of the fresh kidney with a double-bladed knife, 
or the organ is frozen and sections made with a razor, or it 
may be preserved and hardened in a solution of Potass. Bi- 
chromate, or in alcohol. The condition of the tubal epithelium 
is best seen in fresh sections, or in sections from specimens har- 
dened in alcohol and examined in glycerine; that of the inter- 
stitial tissue in Bichromate or alcohol preparations stained 
with carmine. Sections are absolutely necessary even to ascer- 
tain the condition of the epithelium. For not only is the epi- 
thelium of the tubes in the pyramids different from that of 
those in the cortex, but in the cortex the epithelium of the 
straight tubes differs from that of the convoluted tubes. In 
the straight tubes, the epithelium is regular, the edges of each 
cell and its nucleus well marked, and its body only slightly 
granular. In the convoluted tubes, the epithelium looks like a 
mass of granular matter, in which nuclei are imbedded at 
regular intervals. 
The Suprarenal Capsules are, in the foetus of an ovoid, in the 
adult, of a triangular shape. They are situated at the upper 
and inner border of the kidney, to which they are loosely or 
closely fitted. Their size varies. In the adult, the transverse 
diameter is from 40 to 55 mm. ; the vertical, 20 to 35 mm. ; 
their thickness is from 2 to 6 mm. They weigh from 8 to 120 
grains. In new-born children, their weight is to that of the 
kidney as 1.3 : in the adult, as 1.28. 
They are composed of a cortical and a medullary portion, the 
cortex forming a shell around the medula. They are inclosed 24 
POST-MORTEM EXAMINATIONS, 
in a fibrous capsule, from which fibrous processes extend into 
the cortex. 
The cortex consists of two layers : an outer yellow layer, and 
an inner thin, reddish-brown layer. Next to the capsule is a 
thin layer of polygonal and rounded nucleated cells, arranged in 
rounded groups. To the inside of this is a broad layer of poly- 
gonal, cuboid, or rounded nucleated cells, arranged in parallel 
rows or in long follicles. The long axes of the rows, or follicles, 
are at right angles to the surface of the organ. The inner layer 
of the cortex is composed of the same cells closely packed in a 
stroma with fine meshes. 
The medullary portion consists of a delicate fibrous reticulum, 
in the meshes of which are cells. The cells are very fragile, of 
polygonal or stellate shape. They are arranged in groups, or 
are irregularly contained in the stroma. 
The blood-vessels are very numerous ; they are derived from 
the aorta, the phrenic, the coeliac, and the renal arteries. 
The nerves are also very abundant. They are derived from 
the semi-lunar ganglion, the plexus renalis, the phrenic, and 
the vagus. They are especially numerous in the medullary 
portion. Ganglion cells are found in the course of the nerves 
in the medullary portion. 
It is very common to find the suprarenal capsules changed 
by decomposition. The inner layer of the cortex softens and 
breaks down, so that the outer layer of the cortex forms a sort 
of cyst filled with a reddish-brown, broken-down material. 
The cells of the cortex usually show a considerable degree of 
fatty degeneration. 
The Spleen is next to be examined. It is an organ of ellipti- 
cal, flattened shape, slightly curved on its flat surface. It is 
situated on the left side of the stomach, with its long axis ver- 
tical. Its convex surface is in contact with the diaphragm ; 
from its concave surface, or hilus, its vessels are given off. 
Its long diameter reaches from the seventh intercostal space 
to the eleventh rib. Its upper portion is separated from the 
ribs by the lungs; its lower portion by the diaphragm. Its 
normal length is from to 5| inches; its breadth from 3| to 
4 inches; its thickness, If to If inches. It weighs from 8 to METHOD OF EXAMINATION. 
25 
10| ounces. But these measurements and weights may vary 
considerably within the limits of health. The spleen is inclosed 
in a fibrous capsule covered with peritoneum. The parenchyma 
is made up of a stroma formed of blood-vessels and fibrous 
tissue, and of a soft, reddish pulp, in which are imbedded white, 
rounded bodies-the malpighian bodies. In the human spleen, 
the malpighian bodies are usually hardly perceptible to the 
naked eye. Sometimes they are very plain. Sometimes the 
fibrous stroma is very apparent; sometimes not. 
Thb size, consistence, and color of the organ may vary a 
good deal without any known cause. Decomposition softens 
it. Thickenings of the capsule and adhesions are very 
common. 
The Intestines.-If the intestines require careful examination, 
we divide the rectum, seize the gut with the left hand, and, 
keeping it on the stretch, separate it from its attachments by 
repeated incisions until we reach the duodenum, where the in- 
testine is again cut off. The entire length of the intestines is 
then laid open with the enterotome along their attached border, 
the mucous membrane is cleansed with a stream of water and 
then examined. 
The ordinary lesions are catarrhal, croupous, and ulcerative 
inflammation, perforations, strictures, new growths, and waxy 
degeneration. Caution is necessary in distinguishing normal 
from abnormal congestion. A very considerable amount of 
congestion may exist without disease. In cholera seasons, 
especially, observers are prone to call the most moderate degrees 
of congestion abnormal. 
For a more superficial examination, the intestines need not be 
removed. We can slit up the lower end of the ileum and the 
colon and rectum, and examine them in place. 
The intestines can be preserved for minute examination by 
cutting them into pieces a few inches long and suspending 
them in a solution of Potass. Bichrom. (gr. xv. to the 3 i) and 
alcohol, equal parts. 
The Stomach and Duodenum.-We now introduce the ente- 
rotome into the duodenum in its transverse portion, and open it 
on its convex border. When we reach the pylorus, the incision 26 
POST-MORTEM EXAMINATIONS. 
is carried on along the greater curvature of the stomach as far 
as the oesophagus. 
(If poisoning is suspected, a ligature should be placed on the 
lower end of the oesophagus, and at the middle of the small in- 
testines, and these organs removed unopened. They are then 
to be opened in a clean glass jar, and after inspection of the 
mucous membrane, both stomach and contents are to be deliv- 
ered to the chemist for examination.) 
We now look for the orifice of the bile-duct, which will be 
found about the middle of the descending portion of thd duo- 
denum near the lower part of its concave border. Pressure on 
the gall bladder will cause the bile to flow into the intestine, if 
the ducts are pervious. A long director is then passed into 
the bile-duct and up into its hepatic branch, and the duct laid 
open. It is said that if the upper part of the duct is stained 
by the bile, while its duodenal extremity is not stained, this 
may indicate the existence of an inflammatory swelling of the 
duodenal portion during life sufficient to obstruct the flow of 
bile into the intestine. 
The mucous membrane of the duodenum and stomach are now 
washed off and examined. Acute inflammation from caustic 
poisons, chronic catarrhal inflammation, hemorrhage, ulcers, and 
new growths are the lesions most frequently met with. In hos- 
pital patients, we sometimes find a diffused congestion of the 
stomach exactly like that produced by an irritant poison, as a 
result of small doses of croton-oil given just before death. 
The stomach can be preserved entire if hung in a large jar in 
a mixture of equal parts of alcohol and Sol. Potass. Bichrom. 
The Liver.-To remove the liver, we first divide the diaphragm 
on either side as far back as the spine. The liver is then drawn 
downward and the broad ligament and the right and left 
lateral ligaments divided. It is then turned backward into the 
thoracic cavity, the stomach and duodenum are seized and dis- 
sected off, the vessels on its under surface divided. The liver 
can then be lifted up, the coronary ligament and remaining 
vessels dissected away, and the organ removed. 
To determine the actual size of the organ, it should be both 
measured and weighed. The size of the liver varies greatly in METHOD OF EXAMINATION. 
27 
different healthy individuals, but usually bears a relation to the 
size of the body. According to Frerichs, the relative weight of 
the liver to that of the body, in healthy adults, varies from 
one twenty-fourth to one fortieth. The absolute weight is 
from 1.8 to 4.6 lbs. avoird. In children, the relative weight 
of the liver is greater. The table on page 28 is taken from 
Frerichs. 
The liver is increased in size and weight during the second 
stage of digestion; it is diminished in starvation, and is in- 
creased by congestion from any cause. 
The surface of the liver is now examined, then the organ is 
laid on its lower surface and several long and deep incisions 
made transversely from the convex surface downward. After 
examining the liver tissue, the gall bladder is opened, and 
the character of the bile and the presence of biliary calculi 
noticed. 
We often find the surface of the liver of a greenish or black- 
ish color. Less frequently this abnormal color extends into the 
substance of the organ. This color is produced by the action 
of sulphuretted hydrogen on the coloring matter of the blood. 
In some cases we find granules of black pigment, especially along 
the course of the blood-vessels. These granules are composed of 
sulphate of iron. They are produced by the combination of 
sulphuretted hydrogen with the iron of the blood. Their cha- 
racter can be demonstrated by treating them first with hydro- 
chloric acid and then with a solution of ferrocyanide of potash. 
After the addition of the latter solution, a blue color is pro- 
duced. This entire process is a post-mortem one. 
The Pancreas should now be examined. This organ is of 
oblong shape, flattened from before backward, its right ex- 
tremity or head is broad, its left extremity or tail is narrow, 
the intermediate portions or body taper^ between the two. Its 
length is from 6 to 8 inches, its breadth inches, and its 
thickness from £ to 1 inch. Its weight is from 2 to 6 ounces. 
The organ may be rounded instead of flattened, the head and 
tail may be disproportionately large. The tail may be prolong- 
ed or may divide into several processes, or be curved. At the 
position of the mesenteric artery and vein, the pancreas is 28 
POST-MORTEM EXAMINATIONS. 
Age. 
Weight 
of 
Relative 
Weight of 
Liver to 
that of 
Body. 
Weight 
of 
Spleen. 
Relative 
Weight of 
Spleen to 
that of 
Dimensions of Liver. 
Dimensions of Spleen. 
Length. 
Breadth. 
Greatest 
Thickness. 
Body. 
Liver. 
Body. 
Liver. 
Right 
Lobe. 
Left 
Lobe. 
Right 
Lobe. 
Left 
Lobe. 
Length. 
Bre'dth. 
Thickness. 
Kilog. 
Kilog. 
1 : 20.5 
0.0025 
Par. In. 
Par. In. 
Par. In. 
Par. In. 
Par. In. 
Par. In. 
Par. In. 
Par. In. 
5 months foetus 
6 " " 
0.72 
0.035 
1 : 288.0 
1 : 14 
1.3 
0.060 
1 : 21.6 
0.004 
1 : 325.0 
1 : 15 
234 
2 
2 
134 
% 
5-6 
7-12 
34 
7 " " 
2.2 
0.13 
1 : 17.0 
0.006 
1 : 366.6 
1 : 21.6 
3 
2% 
2 
234 
1 
11-12 
11-12 
5-12 
New-born child 
1.6 
0.056 
1 : 28.57 
0.008 
1: 200.0 
1 : 7 
234 
2 
2 
134 
1 
1 1-6 
1 
34 
1.4 
0.058 
1: 24.1 
0.011 
1:145.54 
1 : 5.27 
234 
134 
234 
134 
11-12 
134 
1 
34 
1 day old 
3.8 
0.185 
1 : 20.5 
0.011 
1: 345.4 
1 : 16.8 
234 
234 
234 
2 
11-12 
134 
1 
5-12 
8 days old 
2.7 
0.103 
1 : 26.1 
0.009 
1 : 248.6 
1 : 11 
234 
234 
234 
134 
11-12 
134 
IX 
5-12 
5 weeks old 
1.95 
0.090 
1 : 21.66 
0.016 
1: 121.8 
1 : 5.62 
234 
2 
1 
134 
1 
2 
134 
34 
15 months old 
8.3 
0.25 
1: 33.2 
0.020 
1: 415.0 
1 : 12.5 
334 
4 
334 
134 
134 
234 
134 
34 
5 years old 
11 " " 
8.8 
0.48 
1 : 18.3 
0.1 
1: 88.0 
1 : 4.8 
334 
434 
434 
234 
134 
334 
234 
1 
24.8 
0.97 
1 : 25.56 
0.14 
1: 177.14 
1 : 6.9 
634 
3 
634 
334 
334 
434 
3 
34 
22 " " 
64.5 
1.6 
1 : 40.3 
0.16 
1: 403. 
1 : 10 
27 " " 
50.0 
1.9 
1 : 26.5 
0.22 
1 : 227. 
1 : 8.6 
35 " " 
32.0 
0.82 
1 : 39.0 
0.08 
1: 400. 
1 : 10.2 
6 
434 
534 
234 
2 
334 
234 
34 
36 " " 
55.5 
1.5 
1 : 37.0 
0.15 
1: 370. 
1 : 10 
7 
534 
534 
4 
234 
4 
234 
34 
44 " " 
56.2 
1.4 
1: 40.1 
0.25 
1 : 224.8 
1 : 5.6 
734 
534 
6 
334 
234 
5 
334 
134 
49 " " 
59.5 
1.47 
1: 40.1 
0.15 
1: 390. 
1 : 9.8 
734 
434 
634 
334 
234 
534 
3 
34 
63 " " 
45.5 
1.4 
1 : 32.5 
0.12 
1: 379. 
1 : 11.6 
734 
534 
6 
3 
234 
5 
3 
34 
80 " " 
30.1 
0.7 
1 : 43.5 
0.1 
1 : 305. 
1 : 7 
* To reduce kilogrammes to pounds avoirdupois, multiply the numbers in the table by 2.2046. 
To reduce Paris inches to English inches, divide the numbers in the table by .9375. 
Relative and Absolute Weight ok this Liver.* 
TABLE I. METHOD OF EXAMINATION. 
29 
sometimes divided so that a portion of it lies behind these ves- 
sels. The head of the pancreas is embraced by and adherent to 
the concavity of the duodenum. The pancreatic duct usually 
joins the common bile-duct and has a common opening with it 
into the duodenum ; sometimes, however, the two ducts have 
separate openings. 
THE GENITO-URINARY ORGANS. 
(1.) The Male Organs.-If the urine is to be examined, it 
should be drawn off with a catheter. 
In many cases, it is sufficient to open the bladder on its upper 
surface, and examine it in place. If a more thorough examina- 
tion is necessary, the bladder should be removed with the ure- 
thra. For this purpose, the penis may be removed entire, or the 
skin is dissected off from it nearly up to the glans penis, 
the penis is cut through at this point, and drawn out like a fin- 
ger from a glove, leaving the skin and glans penis behind. 
That portion of the urethra which passes beneath the arch of 
the pubis may be carefully dissected away from the bones, or 
the bones may be sawn through on either side and the pubic 
arch removed, with the urethra, or the symphysis may be cut or 
sawn through and the pelvic bones violently separated. In this 
way, the urethra, prostate, vesiculse seminales, and bladder are 
removed together. 
The bladder and urethra should now be laid on the table, a 
long director passed into the urethra, the entire length of the 
canal laid open on its upper surface, and the incision prolonged 
into the wall of the bladder. 
(2.) The Female Organs.-After observing the position of 
the uterus and ovaries, these are to be removed together. 
The uterus and bladder are seized and the soft parts dissected 
away from them so that the bladder, uterus, ovaries, ligaments, 
upper part of the vagina and rectum are removed together. 
The bladder is first laid open, then the rectum, then the vagina 
and uterus on their anterior surface, then the ovaries and Fal- 
lopian tubes. In puerperal cases, incisions should be made 
through the broad ligaments and at many points in the wall of 
the uterus, to ascertain the condition of the uterine sinuses. 30 
POST-MORTEM EXAMINATIONS. 
The Uterus.-In the new-born infant, the uterus is small, the 
body flattened, the cervix disproportionately large. During 
childhood, the organ increases in size, but the body remains 
small in proportion to the cervix. At puberty, the shape 
changes, and the body becomes larger. Its length is then 2-3 
inches, its breadth 16-20 lines, its thickness 8-12 lines. At 
every menstruation, the uterus is somewhat swollen and con- 
gested. After pregnancy, it does not return to its original size, 
but remains somewhat larger. In old age, it becomes smaller, 
its walls more fibrous. 
The uterus is held in position by the broad and round liga- 
ments, by its attachments to the bladder in front, the rectum 
behind, and the vagina below. The anterior lip of the cervix 
reaches to f inch above the horizontal plane of the most supe- 
rior point of the symphysis pubis. The long axis of the uterus 
is rather nearer to the posterior than to the anterior wall. 
The shape of the uterus is that of a pear, flattened 
antero-posteriorly. The body is inclined forward at an angle 
of 140° with the cervix, while the latter is inclined somewhat 
backward. 
The uterus is covered by the peritoneum anteriorly, to a 
point a little below the level of the os internum, posteriorly as 
far as the insertion of the vagina into the cervix. The peri- 
toneum is firmly attached to the anterior and posterior surfaces 
of the uterus by a layer of connective tissue; at the sides, it 
separates to form the broad ligaments. 
The greater part of the body and neck is made up of smooth 
muscular fibres, closely joined to each other. During pregnan- 
cy, these fibres are greatly increased in size. With the fibres we 
find connective tissue, with many cells and a few elastic fibres. 
The mucous membrane of the body is composed of tubular 
follicles, either single or branching, lined with cylindrical epi- 
thelium, which in some animals is ciliated. The internal sur- 
face of the body and neck is covered with a layer of ciliated 
epithelium, which, near the external os, changes into pave- 
ment epithelium. 
The mucous membrane of the neck is thrown into folds, in 
which are contained mucous follicles, simple tubes lined with METHOD OF EXAMINATION. 
31 
cuboidal epithelium. In the lower half of the cervix there are 
small papillae covered with ciliated epithelium, between the 
openings of the mucous follicles. We also find in the mucous 
membrane closed, rounded follicles, (ovula Nabothi,) containing 
mucus and epithelium, which are regarded as retention cysts 
of the mucous follicles, or as new growths. The outer surface 
of the cervix contains no glands, but is covered with small pa- 
pillae. At every menstruation the mucous membrane under- 
goes a rapid growth, followed by a rapid degeneration. The 
changes produced in the uterus by pregnancy are so fully de- 
scribed in works on obstetrics that it is unnecessary to speak of 
them here. 
The Ovaries are two flattened oval bodies, which are placed 
one on each side, nearly horizontally, at the back of the broad 
ligament of the uterus, and are enveloped by its posterior mem- 
braneous layer. They are largest in the virgin state; their 
weight is from 3-5 scruples, and they measure about inches 
in length, inch in breadth, and nearly | inch in thickness. 
Each ovary is free on its two sides, and also along its posterior 
border; but it is attached by its anterior border. Its inner end 
is attached to the ligaments of the ovary. To its outer extre- 
mity is attached one of the fimbrim of the Fallopian tube. 
The ovary is covered by the peritoneum, except at its at- 
tached border. Beneath this is a dense fibrous capsule. The 
ovary proper consists of a connective tissue stroma, in which, 
according to some writers, are smooth muscular fibres. Scat- 
tered through the stroma are the Graafian vescicles containing 
the ova. 
In adult females, we usually find corpora lut/a in their various 
stages. 
The Fallopian Tubes are between three and four inches in 
length. They commence at the upper angles of the uterus as 
small cords, which become larger, bend backward and down- 
ward toward the ovary. They terminate in an expanded fim- 
briated extremity, about an inch beyond the ovary. 
The tubes are covered by the peritoneum. Their walls 
are composed of connective tissue and smooth muscular 
fibres. Their inner surface is thrown into folds, and lined 32 
POST-MORTEM EXAMINATIONS. 
with ciliated epithelium, continuous with the uterine mucous 
membrane. 
THE EXAMINATION OF THE BODIES OF NEW-BORN INFANTS. 
In examining the bodies of new-born children, we have to con- 
sider, besides the ordinary lesions of disease, the age of the 
child ; whether it was born alive ; how long it lias been dead ; 
what was the cause of death. 
EXTERNAL INSPECTION. 
The Size and Age.-Casper gives the following description of 
the foetus during the different months of intra-uterine life: 
At the fourth week, the embryo is 4-6 lines long. The cleft 
of the mouth and two points representing the eyes can be recog- 
nized in the head. The extremities are represented by little 
wart-like projections. The heart can be distinguished; the 
liver is disproportionately large. The umbilical vessels are not 
formed. The entire ovum has the size of a walnut. 
At the eighth week, the embryo is 15-18 lines long. The head 
forms more than a third of the entire body. The nose and lips 
can be distinguished, but not the external ear. The hand is 
longer than the fore-arm, the fingers are formed, but joined to- 
gether by a gelatinous mass ; the toes look like little buds ; the 
soles of the feet are turned inward. 1 ^he arms appear as 
points,/ The abdomen is closed. All the viscera can be recog- 
nized. Points of ossification are formed in the apophysis of the 
first cervical vertebra, the humerus, radius, scapula, ribs, and 
cranial bones. There are rudimentary external genitals, but 
the sex can hardly be distinguished. The ovum reaches the 
size of a hen's egg. 
At the twelfth week, the placenta is formed. The embryo is 
2-2| inches long, and weighs three ounces. The eyes and mouth 
are closed. The neck separates the head from the thorax. The 
nails can be recognized on the fingers. The sex can be recog- 
nized. The umbilical cord is inserted near the pubes. The THE NEW-BORN INFANT. 
33 
thymus and the suprarenal capsules are formed. The cerebel- 
lum, cerebrum, medulla, and the cavities of the heart can be 
recognized. The humerus is 3| lines long; the radius, 2| lines; 
the ulna, 3 lines; the femur, 2-3 lines; the tibia, 2-3 lines ; the 
fibula, 2| lines. The ovum is as large as a goose's egg. 
At the sixteenth week, the embryo is 5-6 inches long, and 
weighs 7^-9 ounces. The skin is of a rose-red color; there is a 
commencement of formation of fat in the subcutaneous tissue. 
The scrotum and labia are formed. The face begins to assume 
its proper appearance. There is meconium of a white color in 
the duodenum. The liver is not so disproportionately large; 
the gall bladder is formed; the anus is open. The length of 
the humerus is 8 lines; of the radius, 8 lines ; of the femur, 4-5 
lines; of the tibia, 4-5 lines. The calcaneus begins to ossify at 
the middle of the fourth month. 
At the twentieth week, the embryo is 10-11 inches long ; it 
weighs from 21-30 ounces. The nails are very perceptible. 
There is a thin down on the head. There is not yet any of the 
vernix caseosa. The secretion of bile has commenced, and 
stains the meconium. The insertion of the umbilical cord is fur- 
ther off from the pubes. The convolutions of the brain cannot 
be recognized. The humerus is 13-15 lines in length ; the ra- 
dius, 12 lines ; the ulna, 13 lines ; the femur, 12 lines; the tibia 
and fibula, each 12 lines. The astragalus begins to ossify; also 
the upper part of the sternum. 
At the twenty-fourth week, the embryo is 12-13 inches long, 
and weighs l|-lf pounds. The lanugo and the vernix caseosa 
are formed. The skin is of a dusky cinnabar red color. The 
meconium is darker. The scrotum is empty, small, and red; 
the labia majora are prominent. The pupillary membrane is 
present and easily recognized. The length of the humerus is 
16 lines; of the radius 16 lines; of the ulna, the femur, the 
tibia, and the fibula, each 17 lines. 
At the twenty-eighth week, the embryo is 14-15 in dies long, 
and weighs 3-3| pounds. The hair is more abundant and 
longer. The large intestine is filled with meconium. The hu- 
merus is 20-22 lines long; the radius, 17 lines; the ulna, 18 
lines; the femur, tibia, and fibula, each 19-21 lines. 34 
POST-MORTEM EXAMINATIONS. 
At the thirty-second week, the embryo is 15-16 inches long, 
and weighs 3-5 pounds. The skin is of a lighter color. The 
papillary membrane has disappeared. The testicles are in the 
scrotum, or the inguinal canal. The nails nearly reach the ends 
of the fingers. The humerus is 23-24 lines long; the radius, 18 
-19 lines ; the ulna, 22-23 lines; the femur, 24 lines ; the tibia 
and fibula, each 21-23 lines. The last sacral vertebra begins 
to ossify. 
At the thirty-sixth week, the embryo is 17-18 inches long, 
and weighs about 6 pounds. The scrotum begins to become 
wrinkled, and the labia to close. The hair becomes longer, 
while the lanugo begins to diminish in amount. 
At the fortieth week, the foetus is fully developed, and the 
term of its intra-uterine life accomplished. 
The fresh corpse of a new-born child at term no longer 
resembles that of the immature foetus. The skin is firm and 
pale, like that of an adult. The lanugo has disappeared, except 
on the shoulders. The average length is 19 1-7 inches; the 
weight, 7 pounds. The nails are hard, and reach to the 
points of the fingers, but not to those of the toes. The carti- 
lages of the ears and nose are hard. The point of ossification 
in the lower epiphysis of the femur should be noticed. If it is 
absent, the foetus is, as a rule, not more than thirty-seven weeks 
old; but in rare cases, it may be absent at term. A point of 
ossification | line in diameter indicates an age of 37-38 weeks, 
if the child was born dead. Rarely it is no larger than this at 
term. A diameter of f-4 lines indicates an age of 40 weeks 
at birth. A diameter of more than 4 lines indicates, as a rule, 
that the child has lived some time after its birth. The pupil- 
lary membrane has disappeared. The testicles are in the scro- 
tum. The labia cover the clitoris. 
Twenty-four hours after the birth of the child, the skin is 
firmer and paler. The umbilical cord is somewhat shrivelled, al- 
though still soft and bluish-colored. 
From the second to the third day, the skin has a yellowish 
tinge, and the cuticle sometimes appears cracked. The umbili- 
cal cord is brown and dry. 
From the third to the fourth day, the skin is more yellow, and THE NEW-BORN INFANT. 
35 
the cuticle separates from the skin and abdomen. The umbili- 
cal cord is of a brownish red color, flattened, semi-transparent, 
and twisted. The skin around its insertion is red and congested. 
Further Inspection of the Body.-The head should be exa- 
mined for the marks of injuries. Very commonly some portion 
of the scalp will be found swollen and infiltrated with blood and 
serum. This is the .caput succedaneum formed during delivery. 
The mouth and nose should be examined for the presence of 
any foreign bodies which might have caused suffocation. 
The neck should be examined for the marks of strangulation. 
The umbilical cord may be twisted around the child's neck and 
strangle it. The mark left by the umbilical cord is usually con- 
tinuous, broad, soft, not excoriated, sometimes accompanied by 
ecchymoses in the skin. 
The entire body should be examined as to the presence of 
vernix caseosa, blood, marks of injuries, and the existence of 
putrefaction. 
The umbilical cord may be found cut or torn. It usually 
separates by the fifth day, sometimes not until the tenth. If 
the umbilicus is cicatrized and healed, the child has probably 
lived for three weeks. A zone of redness around the insertion 
of the cord may exist previous to birth. Redness with swelling 
and suppuration can only be found in a child which has lived 
for several days. The drying and mummification of the cord 
may take place as well in dead as in living children. It is pos- 
sible for a child to die by haemorrhage from a cut or torn cord 
either before or after it has breathed. 
The extremities may exhibit fractures of their bones. This 
may take place during intra-uterine life, from injuries to the 
woman, or from unknown causes; or may be produced by a 
violent delivery, or by injuries after birth. 
INTERNAL EXAMINATION. 
The Head.-The fontanelles and sutures should first be exa- 
mined as to their size and for penetrating wounds. An incision 
should then be made through the scalp across the vertex, and the 
flaps turned backward and forward. With a small knife the 36 
POST-MORTEM EXAMINATIONS. 
edges of the bones should be separated from the membranous 
suture and the dura mater, beginning low down in the frontal 
suture and going back into the lambdoidal suture on either side. 
The bones are then drawn outward and cut through with a pair 
of strong scissors. The brain is removed as in the adult. 
Effusions of blood-cephalluematoma-may be formed soon 
after birth between the pericranium and bone, or more rarely, 
between the dura mater and bone. Clots are also found be- 
tween the dura mater and skull, between the dura mater and 
pia mater, and more rarely in the substance of the brain as the 
result of protracted or instrumental deliveries, or of injuries 
after birth. 
The cranial bones may be malformed, or exhibit the lesions 
of ricketts or caries, or be indented, fissured, or fractured. The 
indentations, fissures, and fractures may be produced during 
intra-uterine life by injuries to the mother, or by unknown 
causes ; by difficult deliveries, and by direct violence after 
birth. 
The brain is naturally much softer and pinker than in the 
adult; it may be much congested or anaemic without known 
cause. The ventricles contain very little serum. Malforma- 
tions, apoplexies, hydrocephalus, and inflammatory lesions are 
to be looked for. 
The pharynx should be opened and examined for foreign 
bodies. 
The thyroid gland weighs about 3 iij. It may be enlarged 
so as to interfere with respiration. 
The larynx and trachea should be examined for the lesions of 
inflammation and for injuries to the cartilages. 
The Thorax should be opened as in the adult. 
The thymus gland occupies the upper portion of the anterior 
mediastinum, covering the trachea and large vessels. Its ave- 
rage weight is half an ounce. It may be hypertrophied and com- 
press the large vessels, or be inflamed and suppurating. 
The heart lies more in the median line than in the adult. It 
weighs 1|-3| ounces. The ventricular walls are of nearly equal 
thickness. The pericardium contains very little serum. The 
serum may be increased in amount and stained red by decom- THE NEW-BORN INFANT. 
37 
position. There may be small extravasations of blood beneath 
the pericardium in still-born children, and in those born alive. 
Pericarditis with effusion of serum and fibrine may exist be- 
fore birth. 
The time of the closure of the foramen ovale and of the 
ductus arteriosus varies very widely in different cases. 
Endocarditis with consequent changes in the valves may exist 
during intra-uterine life. Malformations and malpositions of 
the heart-cavities and large vessels are not infrequent. 
The pleural cavities contain very little serum. Decomposi- 
tion may increase the amount of serum and stain it red. Small 
extravasations of blood in the sub-pleural tissue are found in 
children which have died before birth, and after protracted 
labors. Inflammation with exudation of serum, fibrine, and 
pus may exist before birth. 
The Lungs in a still-born foetus are small, do not cover the 
heart, are situated in the upper and posterior portion of the 
thorax, are of a dark red color and of firm, liver-like consistence, 
and do not crepitate. In a child born alive and which has 
respired freely, the lungs fill the thoracic cavity, are of a light 
red color, and crepitate. If respiration has been incompletely 
performed, we find various intermediate conditions between the 
foetal and the inflated states. 
If there is any doubt as to respiration having taken place, it 
is customary to employ the hydrostatic test. This is done by 
placing the lungs, first together and afterward cut into small 
pieces, in water. If they sink, the child has not breathed; if 
they float, it has. The test is not, however, a certain one. 
Taylor says: 
1. That the hydrostatic test can only show whether a child 
has or has not breathed, not whether it was born alive or dead. 
2. That the lungs of children who have lived after birth may 
sink in water, owing to their not having received air, or to 
their being in a diseased condition. 
3. That a child may live for some time with the lungs only 
partly inflated. 
4. That a child may live for twenty-four hours, when no 
part of its lungs has been penetrated by air. 38 
POST-MORTEM EXAMINATIONS. 
5. The sinking of the lungs is no proof that a child has been 
born dead. 
6. That the lungs of children which have not breathed, and 
have been born dead, may float in water from putrefaction or 
artificial inflation. 
The lesions of inflammation, and vesicular and subpleural 
emphysema may be found in the lungs of new-born children. 
The Diaphragm.-In still-born infants the convexity of the 
diaphragm reaches the fourth or fifth rib. After respiration, it 
reaches a point between the fourth and seventh rib. Its posi- 
tion is so variable that it is of little diagnostic value. 
The Peritoneum contains a very little clear serum. Bloody 
serum may be produced by decomposition. The peritoneum is 
often the seat of intra-uterine inflammation. 
The Stomach.-The mucous membrane of the stomach may 
be intensely congested as a natural condition. In still-born 
children it contains a little mucus, sometimes meconium. The 
contents of the stomach should be examined microscopically in 
doubtful cases, for the presence of milk and starch. Inflamma- 
tion and swelling of the closed follicles of the mucous membrane 
sometimes occur. 
In the small intestine, inflammation and swelling of the soli- 
tary and agminated follicles are sometimes found. 
The large intestine usually contains meconium, but this may 
be evacuated before or during birth. 
The formation of gas in the stomach and intestines does not 
usually take place until respiration is established. If decompo- 
sition has commenced, however, gas may be formed as a part 
of the process. 
The Liver is of a dark red color, full of blood, and large. 
Its size diminishes after respiration is established. The size is 
so variable before and after respiration, that it gives little in- 
formation as to the age of the child. Large extravasations of 
blood are sometimes found beneath the capsule of the liver 
without known cause. A variety of pathological conditions, fatty 
and waxy degeneration, gummy tumors, etc., may be found. 
The Spleen is large and firm. It may be abnormally large, 
and its capsule is sometimes covered with fresh exudation. THE NEW-BORN INFANT. 
39 
The Suprarenal Capsules are large. They may be dilated 
into large cysts filled with blood. 
The Kidneys are tabulated. There may be ecchymoses on 
their surfaces; inflammation and suppuration ; deposits of uric 
acid and urates in the tubes of the pyramids ; cystic dilatation 
of the tubes, sometimes reaching an enormous size. 
The Bladder may be full or empty, both in still-born children 
and in those which have breathed. Dilatation and hypertro- 
phy may exist during intra-uterine life. 
Spinal Cord.-Extravasations of blood between the mem- 
branes of the cord may occur from the same causes as in the 
brain. Spina Bifida is the most frequent malformation. F A. R T II. 
MORBID ANATOMY OF THE ORGANS. THE NERVOUS SYSTEM. 
THE MEMBRANES OF THE BRAIN. 
THE DURA MATER. 
When the Calvarium is removed, the Dura Mater is brought 
into view. It will be found somewhat adherent to the bone ; 
sometimes very adherent, as a senile change, or as the result of 
chronic inflammation. At the vertex the Dura Mater is often 
thinned or even perforated by the pacchyonian bodies, which 
may also produce indentations in the internal surface of the cal- 
varium. 
Haemorrhages.-These occur in the form of clots between the 
Dura Mater and skull, or, more rarely, in the substance of the 
membrane. , They are usually produced by direct violence ap- 
plied to the skull, and correspond in situation to the external 
injury. In children, however, clots are found between the 
dura mater and parietal bones, in connection with cephalhsema- 
toma of the pericranium. Severe injuries and penetrating 
wounds of the skull may also lacerate or penetrate the dura 
mater. In rare cases the membrane has been found ruptured 
by the pressure of fluid in hydrocephalus. 
Thrombosis of the sinuses of the dura mater is not uncommon. 
The thrombi are yellow and firm, or soft, broken down, and 
puriform. They are produced by changes in tire blood, by pul- 
monary disease, by inflammation of the skin of the face and 
scalp, with thrombosis of the veins, by inflammation and 
fracture of the cranial bones, by meningitis, by otitis, and occur 
without known cause. 44 
POST-MORTEM EXAMINATIONS. 
The thrombi may cause meningitis, small apoplexies, ence- 
phalitis, and multiple pysemic infarctions. Or a thrombus may 
be found in the vein after death, which has apparently produced 
no lesions. 
I have seen a case in which a young female domestic, with- 
out any known cause, suddenly became unconscious, comatose, 
her right arm and leg paralyzed ; her pulse rose to 140, her tem- 
perature to 103| F., and she died on the ninth day. At the au- 
topsy the straight sinus of the tentorium was found filled with 
a large, white thrombus, which extended through all the branches 
given off from the corpora striata and optic thalami. The up- 
per portion of both corpora striata, of the left optic thalamus, 
and of the fornix, were in the condition of red softening. There 
were no other lesions throughout the entire body. 
Inflammation.-Pachymeningitis may involve either the ex- 
ternal or internal layers of the Dura Mater. Inflammation of 
the external layers is secondary to injuries or diseases of the 
cranial bones. Fractures of the skull, either depressed or not, 
osteitis, caries, chronic otitis, and even external periostitis may 
produce it. The dura mater is congested, thickened, softened, 
and ecchymotic. The inflammation may go on to form pus 
between the membrane and the bone and in the substance of the 
membrane, sometimes accompanied with thrombosis of the 
neighboring venous sinuses, sometimes with gangrene of the 
dura mater. Such inflammations may extend to the pia mater 
and brain, or, the inflammation may merely produce fibrous 
thickening, w'ith or without pigmentation of the Dura Mater and 
adhesions to the skull. 
Inflammation of the internal layers of the Dura Mater occurs 
as a complication of pyaemia, puerperal fever, chronic nephritis, 
and the exanthemata. The inner surface of the membrane ap- 
pears streaked with delicate vessels, is of a rosy color, and is 
lined with a layer of exudation, which is either delicate, grayish, 
and soft, like mucus, or more consistent and membranous, or 
yellow, loose, and puriform 
There is also a primary form of inflammation of the internal 
layer of the dura mater, called Pacehymeningitis chronica hae- 
morrhagica. In this form there is found, loosely adherent to THE MEMBRANES OF THE BRAIN. 
45 
the internal surface of the dura mater, a thin membrane, grayish 
with red dots, looking like coagulated fibrine. This is com- 
posed of a homogeneous basement substance containing con- 
nective tissue-cells and a great number of capillary vessels, with 
numerous small haemorrhages. In a more advanced stage this 
new membrane may become enormously thickened, its outer 
layers change into fibrous tissue, and the haemorrhages in its 
substance may attain such a size as seriously to compress the 
brain, and even cause death. Very rarely serum accumulates 
between the layers of new membranes, and in this way cysts of 
large size can be formed. In rare cases, diffuse suppuration 
of the entire new membrane has been observed. The slighter 
degrees of this form of inflammation may occasion no symp- 
toms during life. The more advanced lesions usually occur in 
idiots, epileptics, etc. 
NEW GROWTHS. 
Cysts of the Dura Mater have only been described in a few 
rare instances. 
Fibromata, also, are very seldom met with. 
Osteoma.-New formation of bone may occur either in the 
inner or outer layers of the Dura Mater. In the inner layers it 
occurs in the form of plates, or, more rarely, globular tumors, 
most frequently in the falx, but also in other situations. These 
plates usually cause no symptoms.during- life* 
Bony growths in the outer layers are of irregular shape, and 
often become continuous with the neighboring bones. 
Lipomata have been observed in the form of small globular 
tumors attached to the inner surface of the dura mater. 
Syphilitic Growths (Gummata) are of very various sizes and 
shapes. They are usually firm, partly of a gray semi-transpa- 
rent color, partly yellow and cheesy. They grow either from 
the outer layers of the Dura Mater, and may then cause thinning, 
erosion, osteo-myelitis, caries, and necrosis of the bones; or from 
the inner layers, and invade the brain, causing secondary tumors 
and inflammation of the pia mater and brain. 
Psammoma.-Under this name Virchow has described a form 46 
POST-MORTEM EXAMINATIONS. 
of tumor growing inward from the Dura Mater. These tumors 
are small, of irregular globular shape, of firm, gritty consistence, 
of white or pinkish color. They are formed of a loose fibrous 
tissue, of round and fusiform cells, and of globular calcareous 
concretions, such as are found scattered through the normal 
brain tissues. These bodies are arranged at the ends of broad 
fibres, as if on stalks. 
Sarcoma.-These tumors grow from the inner surface of the 
dura mater, invading the brain, or from its outer surface, thin- 
ning or perforating the skull. They are very hard and -white, 
or soft and pinkish, or partly cheesy. They are composed of 
round, oval, or fusiform cells, sometimes of myeloplaxes, mixed 
with a variable amount of fibrous tissue. 
Carcinoma.-This form of new growth may occur as a pri- 
mary or secondary new growth in any part of the Dura Mater. 
The tumors may grow inward and compress the brain, or out- 
ward and project through the skull as a fungous, bleeding 
mass. Less frequently the membrane becomes infiltrated with 
the new growth forming large fiat tumors, which may invade 
the bone. They are either hard, or soft and vascular. They 
usually consist of nucleated cells arranged in alveoli, but some- 
times have the structure of epithelial cancer. 
THE PIA MATER* 
When the Dura Mater is stripped backward, it will be found 
somewhat adherent along the longitudinal fissure. The Pia 
Mater is then brought into view. This membrane will be found 
in various degrees of congestion. The vessels may be nearly 
empty or distended with blood. Generally the degree of post- 
mortem congestion is not a certain evidence of the amount of 
congestion during life. Along the edges of the longitudinal 
fissure, and more rarely on the under surface of the brain, are 
* I have followed the plan, now generally adopted, of not eonsidering the 
arachnoid as a serous sac with visceral and parietal layers, but of treating of 
only two membranes, the dura and pia mater. The dura mater has an epithe- 
lial lining on its internal surface, the pia mater has two layers, a membranous 
and a vascular. THE MEMBRANES OF THE BRAIN. 
47 
a number of small, white, firm, irregular bodies-the pacchy- 
onian bodies. They may be few and small, or numerous and 
large, and scattered over the convex surface of the hemispheres. 
They may perforate the Dura Mater, or, more rarely, the wall 
of the longitudinal sinus. They are composed of fibrous tissue, 
but may undergo fatty, or calcific degeneration. The pia ma- 
ter is also frequently thickened, opaque and white, especially 
along the course of the vessels. The pacchyonian bodies and 
the opacities of the Pia Mater are both said to be dependent 
upon repeated congestions of the membrane. They are most 
frequently found as senile changes, and do not indicate the pre- 
existence of any disease. The amount of serum beneath the pia 
mater and infiltrating its tissue is very variable in amount. It 
is not infrequent to find in hospital patients suffering from 
chronic nephritis, cardiac, or pulmonary disease, or chronic 
alcoholism, a very considerable amount of serum in this situa- 
tion, and yet the patient has been free from cerebral symptoms. 
In other cases again this same serous effusion affords the only 
explanation of grave cerebral symptoms. It is necessary to be 
very careful in judging of the importance of this accumulation 
of fluid. 
Hemorrhage.-Most authors speak of haemorrhages between 
the dura and pia mater as of rare occurrence, except from 
violence or the rupture of small aneurisms in the pia mater. 
This opinion appears to me to be erroneous ; and I have found 
clots in this situation not infrequently without any special 
cause to account for them. 
Haemorrhages in the substance of the pia mater occur spon- 
taneously in young children, but in adults are usually the result 
of violence. 
Haemorrhages between the pia mater and brain are produced 
by violence, by apoplexies in the brain substance, or occur by 
themselves. In the latter case, the clot is usually situated at 
the base of the brain and around the medulla. Some of the 
blood may escape outside of the pia mater between this mem- 
brane and the dura mater. 
Meningitis.-Inflammation of the pia mater causes the pro- 48 
POST-MORTEM EXAMINATIONS. 
duction of exudation in the substance of and beneath the pia 
mater. This exudation is composed of serum, lymphoid cells, 
and coagulated fibrine in variable proportions. It occupies 
circumscribed portions of the pia mater, or is distributed along 
the course of the vessels, or extends over a large part of the 
brain and upper part of the spinal cord. It gives to the pia 
mater a gray, yellow, or greenish color. It is rare to find any 
exudation on the free surface of the membrane. The inflam- 
mation may involve the superficial layers of the brain. This 
disease usually occurs in adults. It is either idiopathic or 
secondary to inflammations of the dura mater and cranial bones, 
to thrombosis of the large venous sinuses, to severe concussions 
of the head, or occurs as epidemic cerebro-spinal meningitis. 
This inflammation is usually fatal. In rare cases, collections 
of pus form between the pia mater and brain, and exist as ab- 
scesses for a considerable time. Sometimes the exudation un- 
dergoes cheesy degeneration, and forms firm yellow masses in 
the sulci. Sometimes the inflammation subsides entirely, leav- 
ing the pia mater thick, opaque, and adherent to the brain and 
dura mater. 
Chronic Meningitis.-This is a disease of which our know- 
ledge is imperfect. It is not always easy to draw the line be- 
tween the lesions of chronic inflammation and those of a m«>re 
degenerative character. 
The most marked form of chronic meningitis is seen in the 
general paralysis of the insane. Here we find the pia mater 
thick, opaque, and adherent to the brain. The outer layers of 
the brain are softened or sclerosed; and there are peculiar 
changes connected with the small blood-vessels. 
Another form of chronic meningitis occurs by itself. It is 
most frequent in old people. The patient is usually sick for 
some time, but the diagnosis is often not established during 
life. The pia mater is thick, opaque, and adherent to the 
brain. There is a moderate amount of turbid serum beneath 
the pia mater, and sometimes small collections of pus. The 
pia mater is infiltrated with pus cells. I have seen in some 
cases dilatation of the vessels and increase of cells in the super- 
ficial layers of the brain. THE EPENDYMA AND THE CHOROID PLEXUS. 
49 
Tubercular Meningitis.-This form of meningitis accom- 
panies the production of gray miliary tubercles in the pia 
mater. The tubercles are found most abundant at the base 
and in the sulci, and are sometimes hardly to be seen with the 
naked eye. They are very small transparent granulations 
surrounding the small blood-vessels. They are formed by an 
accumulation of small round cells within the perivascular 
sheaths. Accompanying the tubercles, serum, fibrine, and 
lymphoid cells form a turbid fluid exudation beneath and in 
the pia mater. This form of inflammation is most frequent in- 
childhood, but occurs also in adult life. It is usually found 
with tuberculosis of the other viscera. 
Fibroma, Angioma, Sarcoma, Lipoma, Cysts, Carcinoma, 
and Epithelioma occur in the pia mater in rare cases. Gummy 
Tumors are found in and beneath the pia mater. Tumors 
formed of cholesterine and epithelial cells have been found 
at the base of the brain. Small plates of bone are sometimes 
formed in the pia mater over the convex surface of the brain. 
Tubercular tumors occur as rounded bodies, apparently form- 
ed of an aggregation of smaller tumors. They are usually far 
advanced in cheesy degeneration so as to have an opaque yellow 
color. They are most frequent in children. 
NEW GROWTHS. 
The cysticercus cellulosse has been observed in the pia mater. 
PARASITES. 
THE VENTRICLES OF THE BRAIN. 
THE EPENDYMA AND THE CHOROID PLEXUS. 
The ventricles usually contain a small amount of clear serum. 
If there is inflammation of the pia mater, especially at the base 
of the brain, turbid or purulent serum is frequently found in the 
ventricles. A considerable amount of clear serum in the ven- 
tricles, and even a moderate dilatation of these cavities, are not 
necessarily evidences of disease. 50 
POST-MORTEM EXAMINATIONS. 
Pathological Accumulations of Serum are : 
(1.) Congenital Hydrocephalus.-The highest degrees of this 
form will be considered -with the malformations. The lesser 
degrees commence as a moderate effusion of serum into the 
ventricles, which increases to a greater or less extent, and for a 
variable time after the child's birth. In these cases, we find all 
the ventricles of the brain dilated and filled with clear serum. 
The brain substance forms a thin shell around these sacs of 
fluid. The ependyma of the ventricles is either smooth or 
thickened. 
(2.) The serum accumulates after birth, usually in badly- 
nourished children. 
The effusion may take place rapidly, with febrile symptoms. 
The serum is in variable amount, and clear; the walls of the 
ventricles, and sometimes the brain, are oedematous and soften- 
ed ; the pia mater shows no evidence of inflammation. Such 
an effusion of serum may be fatal, or may be absorbed, or may 
take on a chronic character. 
(3.) The effusion may be caused by acute or chronic hyperre- 
mia of the brain and its membranes. It may occur at any age. 
It has been ascribed to excessive bodily and mental exertion, 
alcoholism, tumors of the brain, obstruction of the venous 
sinuses and jugular veins, and to heart and lung diseases. The 
accumulation of serum is usually gradual, though the patient 
may at the last die suddenly. Such cases have been called 
serous apoplexy. 
Atrophy of the brain is usually accompanied by a serous 
effusion in the ventricles. 
The accumulation of serum in all the cases mentioned occurs 
equally in both ventricles. In rare cases, however, the effusion 
is confined to one lateral ventricle, or to the third ventricle, or 
to one of the cornua of a lateral ventricle. The dilated por- 
tion of the ventricle may then look like a cyst with a narrow 
opening. 
Haemorrhages into the ventricles take place when apoplexies 
of the brain substance break through into these cavities. 
Inflammation of the Choroid Plexus and Ependyma is usually 
secondary to a meningitis, but may be primary. The ventri- THE EPENDYMA AND THE CHOROID PLEXUS. 
51 
cles contain a moderate amount of serum made turbid by pus 
globules and broken-down particles of tissue. The ependyma 
is coated and infiltrated with the same material. The layer of 
brain tissue next the ependyma is softened or stained with 
small apoplexis. Or the entire brain may be softened and 
oedematous. Sometimes the ependyma is coated with a thick 
layer of lymphoid cells and fibrine. I have seen, in an adult, 
the ependyma thickened, of a mottled gray and red color; the 
brain substance next it soft and red; very little serum in the 
ventricles; no lesion in any other part of the brain ; and the 
patient died comatose. 
NEW GROWTHS. 
Connective Tissue may occur as a new growth, causing a uni- 
form thickening of the ependyma, or the thickening may be in 
plates, or in small granulations. In rare cases, small fibrous 
tumors are attached to the ependyma by narrow pedicles, and 
these tumors may become free. The new growth of connective 
tissue may cause adhesions between the walls of the ventricles. 
Calcification and ossification of the thickened ependyma has 
been seen in a few instances. 
Lipoma.-Small, fatty tumors have been found attached to 
the ependyma and choroid plexus. 
Enchondroma has been observed in the choroid plexus in 
small nodules. 
Cystoid Growths occur very commonly in the choroid plexus 
in the form of little transparent vesicles. These little vesicles 
are not really cysts, but are composed of small, transparent 
cells closely packed together. These bodies have no patho- 
logical significance. A cyst, as large as a walnut, filled with 
colloid matter, and a dermoid cyst containing hair, have been 
observed in this situation. 
Angioma may occur in the choroid plexus. 
Carcinoma has been seen in very rare cases in the plexus of 
the fourth ventricle, and the ependyma of the lateral ventricles. 52 
POST-MORTEM EXAMINATION'S. 
THE BRAIN. 
MALFORMATIONS. 
Cyclopia.-This malformation consists in an arrest of de- 
velopment affecting the cerebrum, which, instead of separating 
into two hemispheres, remains single, and the rudiments of the 
eyes become joined and form one eye. This single eye is in 
the middle of the face at the root of the nose, in a single orbit. 
Over this is an irregular body representing the nose. The rest 
of the face is well formed. Or the eye-ball may be wanting 
entirely, or there are two eyes joined together, or, more seldom, 
two separate eyes. The orbit is surrounded by rudiments of 
four eye-lids. The frontal bone is single, the nasal bones 
undeveloped, the ethmoid, vomer, and turbinated bones are 
absent. The optic nerve is double, single, or absent. There 
may be hydrocephalus. Such children are incapable of any 
prolonged existence. 
Anencephalia.-This malformation may be of various de- 
grees. The brain may be entirely absent, and the base of the 
cranium is covered with a thick membrane, into which the 
nerves pass. Or, the membranes may form a sort of cyst con- 
taining blood and serum, or portions of brain. Of the cranial 
bones, only those which form the base of the skull are present. 
The foetus cannot live. 
Hydrencephalocele.-(1.) The cranial bones are incompletely 
developed. The cranium is flattened or concave from above 
downward. The brain is incomplete, or hydrocephalic, or 
replaced by a bloody, spongy mass, or by a sac of serum. It 
escapes from the cranial cavity by an opening in the cranium, 
usually lies on the neck, and may or may not be covered with 
skin. The foetus is not viable. 
(2.) The cranial bones are well developed, as is also the brain. 
At some point in the cranial bones, at the root of the nose, the 
occiput, on the sides of the skull, in the sagittal suture, or at 
the base, there is an opening through which escapes a sac com- 
posed of the membranes of the brain, inclosing serum or brain 
tissue. Or a portion of brain alone may protrude, covered by 
its membranes and the skin. These tumors may be small, or THE BRAIN. 
53 
as large as the child's head. The malformation is caused by a 
partial hydrocephalus of the cavities or membranes of the brain. 
Hydrocephalus.-Hydrocephalus internus consists in an ac- 
cumulation of serum in the ventricles of the brain. It occurs in 
all degrees, according to the period of foetal life at which it 
begins. There may be only a sac formed by the membranes, 
or the brain may be partly developed, or it may be perfect. 
The cranial bones are separated at their sutures and fontanelles 
In rare cases, only part of one lateral ventricle is hydrocephalic, 
giving to the head a protuberance on one side. The viability 
of the foetus depends upon the degree of the hydrocephalus. 
Hydrocephalus externus is an accumulation of serum beneath 
the pia mater, or, according to some authors, between the pia 
and dura mater. It causes dilatation of the cranium and com- 
pression of the brain. It is of very rare occurrence. 
Microcephalia.-This is an abnormally small size of the brain, 
with a correspondingly small cranium. The diminution in 
size affects principally the cerebral hemispheres, though the 
other parts of the brain are also small. The convolutions are 
few and simple, the cavities often dilated with serum, on the 
membranes are traces of inflammation. The cranium is small, 
the face large, the rest of the body small. The malformation 
is caused by inflammation or dropsy of the brain during foetal 
life. It is endemic in some countries, but single cases may 
occur anywhere. The foetus is viable. 
Absence of portions of the brain may occur not only in idiots, 
but in persons whose minds are perfect. 
HYPERTROPHY AND ATROPHY. 
Hypertrophy.--In children, either before or after birth, less 
frequently in youth, and very seldom in adults, we find hyper- 
trophy of the brain. This hypertrophy consists in an increase 
of size of the white substance of the hemispheres. If it takes 
place before the ossification of the cranium, the bones are sepa- 
rated at the sutures and fontanelles; if after this, the inner 
table of the skull is eroded and thinned. When the cranium 
is opened, the dura mater appears tense and anaemic, the convo- 
lutions of the brain are flattened, the brain substance is firm 54 
POSTMORTEM EXAMINATIONS. 
and anaemic, the ventricles are small, the ganglia and cerebel- 
lum are either of normal size or compressed. 
The disease is usually very chronic, and destroys life with 
symptoms of compression of the brain. There may, however, 
be acute exacerbations. The hypertrophy consists in an increase 
of the neuroglia. 
Rokitansky has also described cases of hypertrophy as caused 
by tumors of the brain and compression of the medulla ob- 
longata. 
Hypertrophies of portions of the brain have been described by 
various authors. 
Atrophy.-This may occur as a senile change, or in adults 
from idiocy, alcoholism, opium or lead poisoning, or chronic 
meningitis. In children who are very much reduced by chronic 
diseases, atrophy of the brain may accompany atrophy of the 
rest of the body. 
The atrophy affects principally the cerebral hemispheres. 
The convolutions are small, the sulci broad, the ventricles di- 
lated, the brain tissue firm, the gray substance discolored, the 
white substance dark colored, the blood-vessels dilated. The 
large ganglia at the base are also small. Serum usually ac- 
cumulates beneath the pia mater and in the ventricles, the pia 
mater and often the skull become thickened; the brain sub- 
stance may be oedematous, or contain hemorrhages. 
INJURIES. 
Wounds of the brain may be inflicted in a great variety of 
ways, and by many different instruments. The brain may be 
directly wounded by the foreign body, or indirectly by frag- 
ments of bone driven into it. It is very difficult to estimate 
the degree of injury; which must cause death; persons fre- 
quently die from slight, and may recover from severe, penetrat- 
ing wounds of the brain. 
After wounds which remove a portion of the cranial bones, it 
is not uncommon, after a few days, to see a bleeding, fungus 
mass project through the opening. This mass, or hernia 
cerebri, consists of granulation tissue, brain matter, and blood. 
The brain tissue below it is softened and purulent; there is 
often an abscess in the brain substance beneath. THE BRAIN. 
55 
Severe injuries of the head which fracture the skull without 
displacing the fragments, or even cause no fracture, may pro- 
duce laceration of the brain. The laceration takes place either 
at the point of injury or at some other part of the brain. We 
find small or large portions of the surface of the hemispheres 
mottled with little haemorrhages, the brain tissue softened and 
broken down. 
HAEMORRHAGE. 
Effusions of blood in the substance of the brain are very com- 
mon and may occur at any age. They may be of small size- 
capillary apoplexies, or consist of large blood-clots. They may 
occur in the large ganglia, or at any point in the hemispheres. 
They usually produce softening and breaking down of the 
brain tissue, and often find their way into the ventricles or be- 
neath the pia mater. They cause death when of large size. 
The smaller ones sometimes undergo degenerative changes, the 
blood becomes absorbed, and there are left little cysts contain- 
ing serum, surrounded by indurated, reddish-yellow brain tissue, 
or there are little spots of a reddish color composed of a soft, 
friable material. 
These haemorrhages are produced by fatty, or atheromatous 
degeneration of the vessels of the brain, hypertrophy, and val- 
vular disease of the heart, convulsions, and external injuries. 
Often no satisfactory cause can be discovered. 
INFLAMMATION. 
Idiopathic inflammation of the brain is so rare that its ex- 
istence is denied by some authors. The alterations in the brain 
tissue are usually secondary to injuries, to inflammation of the 
meninges, or to some obstruction of the cerebral vessels. The 
changes met with are, in recent cases, diminution of consistence 
and change in color ; in chronic cases, increase of consistence. 
Injuries, which either directly bruise and lacerate the brain, 
or do so indirectly without fracture of the skull, render the 
brain tissue soft, mottled with small apoplexies, the nervous 
tissue disintegrated and degenerated, the softened mass infil- 
trated with red blood globules and lymphoid cells. ' 
Obstruction of the Cerebral Vessels occurs in a variety of 56 
POST-MORTEM EXAMINATIONS. 
ways. The arteries may be occluded by emboli or thrombi, the 
capillaries by emboli, the veins and sinuses by thrombi. Or, 
the arteries and capillaries may be the seat of atheroma and 
fatty degeneration. 
Emboli are usually portions of fibrine detached from the 
aorta or left heart, or from the pulmonary veins, or, rarely, in 
carcinoma of the lungs, portions of the new growth may be 
swept by the current of blood from the pulmonary veins. 
Sometimes, however, we can find nothing in the heart or vessels 
to account for the origin of the embolus. 
Thrombosis of the arteries is produced by atheroma of their 
walls, by dilatation or fatty degeneration of the heart, and by 
certain conditions of the blood occurring in ill-nourished and 
cachectic persons. All these conditions are most likely to 
occur in old age. 
Thrombosis of the veins and sinuses is caused by inflamma- 
tion of the dura mater, cranial bones, and pericranium, or by 
unknown changes in the quality of the blood. 
Fatty and calcific degeneration may affect the walls of a 
group of capillaries to such a degree as to interfere with the 
nutrition of portions of the brain. This condition, however, 
must not be confounded with the fatty degeneration which 
affects the capillaries as a result of softening of the brain. 
These different conditions of obstruction of the circulation 
cause various lesions in the brain. 
1. If the circulation is entirely cut off by the occlusion of a 
vessel of some size, or by occlusion or fatty degeneration of a 
group of capillaries, a portion of the brain tissue is found to be 
unchanged in color, but of soft or even fluid consistence. This 
alteration affects circumscribed portions, usually of the white 
substance of the hemispheres. These spots may be of all sizes, 
even the entire half of the cerebrum may be softened after 
ligature of one carotid. The softened tissue is composed of de- 
generated nerve fibres, large globules of myeline, compound 
granular corpuscles, corpora amylacea, concretions of lime, 
fatty ganglion cells, and lymphoid cells in variable number. 
The vessels are empty, normal, or fatty and broken into frag- 
ments. THE BRAIN. 
57 
The changes in these cases, often called " white softening," 
are, therefore, simply degenerative and necrobiotic, or of a 
very low inflammatory type. Such a spot of softening may 
remain unchanged for years, or it may become completely fluid 
and form a cyst with thick walls. 
2. If a small artery is plugged, or there is thrombosis of a 
vein, the results are entirely different. In such cases, we find 
the appearances belonging to the hemorrhagic infarctions of all 
the viscera. The set of capillaries belonging to the artery or 
vein affected are distended with blood, a certain number of 
them rupture and allow the escape of blood into the tissue. 
The tissue around and between the distended capillaries and 
extravasated blood becomes the seat of degenerative and in- 
flammatory changes. The portions of tissue affected are single 
or multiple, usually small, most frequently near the surface of 
the hemispheres. The brain tissue is red, mottled red and 
white, gray or yellow; it is soft or even puriform. It is com- 
posed of broken-down nerve fibres, globules of myeline, pig- 
ment masses, compound granular corpuscles, granular matter, 
lymphoid cells, fibrine or serum, and red blood globules. The 
blood-vessels are filled with blood, dilated, and often fatty. 
After a time, these spots of so-called " red softening" may be- 
come fairly purulent, or may, from the loss of blood pigment, 
become yellow and gray-colored, or may become sclerosed, or 
rarely cheesy. 
Abscess of the Brain.-When inflammation of the brain tis- 
sue goes on to an excessive formation of pus, abscesses are form- 
ed. A recent abscess has an irregular shape; its walls are com- 
posed of shreddy, disintegrated brain substance, and around it 
for some distance the brain tissue is softened. The pus is usual- 
ly green and fetid. An old abscess becomes inclosed in a 
fibrous capsule, smooth inside, continuous with the brain out- 
side ; often very thick. The pus is always ill-formed, and may 
change into serum alone, so that the abscess looks like a cyst. 
Fractures of the skull, either depressed or not; blows on the 
skull, without fracture; inflammation of the cranial bones or 
membranes; inflammation of the internal ear, with or without 
caries of the temporal bone, and pyaemia, are the usual causes 58 
POST-MORTEM EXAMINATIONS. 
of abscesses. The abscesses may occur in any part of the brain, 
be of any size, and be solitary or multiple. They are always 
fatal, but may exist for years before death ensues. 
Yellow Softening.-Under this name Rokitansky describes a 
peculiar condition of the brain. It occurs in circumscribed 
spots; has a moist, tremulous consistence, and a yellow color. 
The brain substance around is much swollen and oedematous. 
This form of softening may occur in any part of the brain. It 
is either idiopathic or secondary. It is found near hemorrhages 
and tumors. 
Sclerosis.-Inflammation of the brain tissue, instead of ren- 
dering it soft, may cause induration. 
As a senile change, the consistence of the brain often be- 
comes harder and dryer. In Typhus, Cholera, puerperal Peri- 
tonitis, and Scarlet Fever, the brain may be firmer than usual, 
and contain less serum. In lead poisoning, the brain may be 
both indurated and atrophied. 
In general paralysis, there is an induration of the superficial 
layers of the brain accompanying chronic meningitis. 
In two cases of mild insanity of short duration, with paraly- 
sis of all the limbs, I have seen the entire white substance of 
the brain very markedly indurated. There was also a peculiar, 
colloid-looking degeneration of the gray matter of the cord. 
Sclerosis of isolated portions of the brain {Sclerose en 
Plaques) occurs usually in connection with the same lesion of 
the cord. We may find it in any part of the white substance 
of the brain. The sclerosed patches are of variable size, num- 
ber, and shape. They are firm, depressed, and shrunken, of a 
rosy or gray color. This lesion is characteristic of paralysis 
with tremor. 
In all cases of sclerosis the essential process is an increase of 
the neuroglia, with atrophy of the nervous elements. 
Interstitial Encephalitis.-Under this name Virchow has de- 
scribed a lesion which is very frequently found in still-born and 
very young children. It consists in an enlargement and fatty 
degeneration of the cells of the neuroglia of the white substance 
of the hemispheres, so that they look like compound granular 
corpuscles. It is still uncertain whether this change is to be 
looked upon as a pathological condition. THE BRAIN. 
59 
(EDEMA. 
Infiltration of the brain with serum occurs as a consequence 
of chronic diseases-chronic nephritis, phthisis, etc.-and oc- 
curs with cardiac disease and obstruction of the jugular veins. 
Usually the amount of serum is small; the brain substance 
appears moist, and exudes a little serum on pressure. Some- 
times, however, the serum is very abundant, and the brain ap- 
pears almost semi-fluid. 
(Edema, with anaemia of the brain, is considered by Traube 
to be the cause of uraemic convulsions. 
MEL ANAEMIA. 
In persons affected by malarial disease, the gray matter of 
the brain is sometimes found to have a blackish tint. This 
color is due to the presence of black pigment granules within 
the capillary vessels. The obstruction to the vessels by these 
pigment masses may cause capillary apoplexies. 
The pigment is also found within the capillaries of the pia 
mater. Some authors hold that the pigment is situated in the 
walls of the vessels. It has always appeared to me to be within 
them. 
NEW GROWTHS. 
Carcinoma occurs in the brain as a primary or secondary 
tumor. It may be of the hard or soft varieties, or cavernous, or 
melanotic. It is found in' all parts of the brain, and may be 
single or multiple. It may increase so as to involve the dura 
mater and skull, and appear on the outside of the cranium. 
Sarcoma is usually found in the hemispheres. The tumors 
may be hard and fibrous, or soft, or vascular, or cheesy. They 
are composed of round, oval, or fusiform cells, with a connec- 
tive tissue stroma. 
Glioma.-Under this name Virchow describes a form of tumor 
composed of neuroglia. The typical growths are composed of 
a finely granular substance, in which nuclei are obscurely seen. 
They are either hard, or soft, or haemorrhagic. They frequent- 
ly appear like a hypertrophy of the brain tissue rather than 
a tumor. 60 
POST-MORTEM EXAMINATIONS. 
Osteoma occurs in the form of isolated, globular tumors in the 
cerebrum and cerebellum, or has rather the character of an ossi- 
fication of part of the brain. In these latter cases, it seems to 
be a late stage of the process of sclerosis. 
Myxoma.-These tumors are found most frequently in the 
cerebral hemispheres. They are usually of large size, and of 
soft, gelatinous consistence, so as even to resemble cysts. 
Fibroma is very rare. It occurs in the form of small, hard, 
globular tumors. 
Cholesteatoma is found in the form of rounded tumors, hav- 
ing a fibrous capsule and a glistening, white consistence. They 
are made up of crystals of cholesterine and epithelial cells. 
Angioma may occur in any part of the brain, but is most fre- 
quent in the floor of the fourth ventricle. 
Tubercle is found most frequently in the cerebellum, and 
usually in children. The tumors may be single or multiple, 
large or small. They are usually globular, and have a concen- 
tric appearance; the greater portion often undergoes cheesy 
degeneration ; but there is sometimes a layer of gray, semi- 
translucent material at the periphery. 
Gummata.-Syphilitic tumors are found usually near the sur- 
face of the brain. They have an irregular shape, the larger 
tumors being made up of a number of small ones. They have 
a mottled gray and yellow color. Isolated portions undergo 
cheesy degeneration, and are separated by other portions, which 
are grayish and composed of round and fusiform cells, or white 
and firm, and composed of fibrous tissue. 
New Growth of the Gray Matter of the brain, in the form of 
isolated nodules imbedded in the white substance, has been de- 
scribed by Virchow and others. 
Cysts and dermoid cysts have been seen in the brain, but are 
rare. All the tumors of the brain have a tendency to cheesy 
and fatty degeneration, which renders their anatomical diagno- 
sis difficult. 
PARASITES. 
Echinococci and Cysticercus cellulosae are both found in the 
brain. THE SPINAL CORD. 
61 
THE PITUITARY BODY. 
The pituitary body is sometimes entirely absent, or it may 
be atrophied and fatty. Small abscesses have been observed in 
it. Colloid degeneration may affect it, sometimes with hyper- 
trophy. Carcinoma and Tubercle may occur in it. 
THE PINEAL GLAND. 
This little body may be entirely wanting, or hypertrophied, 
or contain pus, or be changed into a cyst, or be enlarged and 
filled with globular concretions of lime. Forster reports a sin- 
gle case of secondary Carcinoma in it. 
THE SPINAL CORD. 
THE MEMBRANES. 
THE DURA MATER. 
Inflammation of the dura mater is very infrequent. It is 
only found with injuries, or disease of the vertebrge. The in- 
flammation is usually of suppurative character, and may com- 
press the spinal cord or cause a general meningitis. 
NEW GROWTHS. 
Bone of new formation in the dura mater is rare, and forms 
small plates. 
Lipoma lias been observed in several cases. 
Tubercle usually accompanies caries of the vertebrae in the 
shape of a diffused, cheesy infiltration, with softening and the 
formation of abscesses between the pia and dura maters. More 
rarely, isolated tubercles are found without disease of the bone. 
Carcinoma of the dura mater may be primary, or continuous 
from the vertebrae. It is medullary, grows inward and com- 
presses the cord, or outward, and infiltrates the soft parts out- 
side the vertebrae. 
THE PIA MATER. 
The pia mater of the cord, like that of the brain, is found in 
various degrees of congestion, and it is difficult to pronounce 
how great a degree is pathological. 62 
POST-MORTEM EXAMINATIONS. 
Haemorrhages occur idiopathically, or from injuries, or from 
general convulsions. 
Serum is present beneath the pia mater to a greater or less 
degree. It is difficult to say how large an amount is patho- 
logical. 
INFLAMMATION. 
Spinal meningitis is found at all ages. It may be idiopathic, 
traumatic, rheumatic, or caused by inflammation of the brain, 
the dura mater, or the vertebrae, or occur as epidemic cerebro- 
spinal meningitis. 
The disease usually attacks the entire length of the mem- 
brane. An exudation composed of serum, lymphoid cells, and 
flbrine infiltrates the pia mater and raises it up from the cord. 
NEW GROWTHS. 
Fibroma of the pia mater, compressing the cord, has been 
observed. 
Bone, in the form of small plates, sometimes occurs. 
Carcinoma may occur as circumscribed tumors, or as diffused 
masses. 
MALFORMATIONS. 
Ilydrorachis, Spina Bifida, consists in dropsy and atrophy of 
the cord, with or without malformation of the vertebrae. 
(1.) The vertebral canal is open on its posterior surface for 
its entire length; the cord is absent, the nerves are inserted 
into the spongy haemorrhagic membranes. 
(2.) The vertebral canal is closed. The central canal of the 
cord is dilated with serum, or the cord is absent, and the mem- 
branes are dilated with serum; or there may be an accumula- 
tion of serum beneath the pia mater, with or without atrophy 
of the cord. 
(3.) At some portion of the vertebral canal its posterior wall 
is absent, so that the membranes protrude as a sac, filled with 
serum-Spina Bifida. The serum accumulates in the central 
canal, or beneath the pia mater. The cord is absent, or rudi- 
mentary, or well formed. The walls of the sac are formed of 
dura and pia mater, or of pia mater alone. Rarely there is no 
fissure in the bones, and the sac protrudes between the laminar THE SPINAL CORD. 
63 
processes. In rare cases, there is a defect in the anterior wall of 
the canal, and the sac projects through it. I have made an 
autopsy on one very remarkable case of this kind. The patient 
was under the care of Dr. Emmet. 
A female, aged 36, ten years ago noticed a swelling as 
large as a goose's egg in the left iliac region, attended with 
severe pain and constipation. This swelling increased slowly. 
Seven years ago, she had a bloody and purulent discharge from 
the bowTels, lasting for five weeks, and followed by a decrease of 
the swelling. Was seen by Dr. Emmet about three wTeeks be- 
fore her death. There was then oedema of the right leg, pain 
in the sacrum, constipation of the bowels, urine normal, abdo- 
men tympanitic. The cervix uteri was high up ; the rectum 
was nearly occluded by a fluctuating tumor posterior to it. 
From this tumor a little clear serum was drawn off with a fine 
trochar. On the day after this operation, she had a chill, fol- 
lowed by fever, great prostration, and in seven days, death. 
Autopsy hours after death. The rectum and descending 
colon were enormously dilated with feces, nearly filling the 
abdomen. The upper edge of the uterus was two inches below 
the umbilicus, and pushed to the right side. The bladder was 
also carried up in front of the uterus. There was cystitis. 
There was a large cyst behind and to the right of the rectum, 
filling the pelvic cavity, and reaching up to the level of the 
second lumbar vertebra. This cyst was firmly bound jjown on 
all sides, but especially at the lower part of the sacrum. 
When it was removed, there vzas found an opening in the lower 
part of the anterior surface of the sacrum, through which, the 
finger could be passed into the spinal canal. 
(4.) A portion of the cord may project through an opening in 
the bones, without any serum. Isolated cases have been re- 
ported of abnormally short cord, and of a double cord. 
INJURIES. 
The spinal cord may be compressed or lacerated by penetrat- 
ing wounds, by fracture, or dislocation of the vertebrae, or by 
concussion, without injury to the vertebrae. The spinal cord is 
found simply disintegrated, or haemorrhagic, or if inflammation 64 
POST-MORTEM EXAMINATIONS. 
has followed the laceration, lymphoid cells and compound gran- 
ular corpuscles will be present. There may be marked changes 
in the minute structure of the cord, without any evidence to 
the naked eye. 
HAEMORRHAGE. 
Apoplexies in the substance of the cord are not common. 
The nervous tissue is disintegrated by the blood. The lesion 
may cause death in a very short time, or may be followed by 
myelitis. 
INFLAMMATION. 
Myelitis may be traumatic, idiopathic, or secondary. It 
occurs under so many different conditions, that it is difficult to 
speak definitely of its causation. It produces either softening 
or hardening of the cord. 
(1.) The cord is broken down, of a cream-like consistence, of 
a reddish or yellow color. The softening may affect the entire 
thickness of the cord, or be confined to certain parts; it may 
extend the entire length of the cord, or be confined to certain 
regions. It seems to commence usually in the gray matter. 
The softened portions are composed of broken-down nerve tissue, 
blood globules, lymphoid cells, and compound granular cor- 
puscles. The cord may also be softened without any change 
in its color, and then consists merely of fine granular matter, 
with a few compound granular corpuscles. 
(2.) Myelitis causing induration, (sclerosis,) may affect the 
entire organ or circumscribed portions. The diffuse form ren- 
ders the cord anaemic and hard throughout. 
The circumscribed form is identical with the sclerose en 
plaques already described in the brain. 
Locomotor Ataxy.-In this disease, part of the wdiite sub- 
stance of the cord undergoes a peculiar degeneration. The 
posterior columns are usually affected. We find them changed, 
in the earlier stages, into a reddish gray, soft substance. This 
change is produced by an increase of the neuroglia and an 
atrophy of the nerve fibres. At a later stage, the affected por- 
tions are firmer and shrunken. It is a form of sclerosis. THE SPINAL CORD. 
65 
NEW GROWTHS. 
Carcinoma, Sarcoma, Tubercle, and Syphilitic Growths have 
all been observed in the cord. They resemble closely the same 
varieties of tumor in the brain. 
A very remarkable form of new growth on the cord has been 
shown to me by Dr. E. C. Seguin. The patient was a woman, 
thirty years of age. Two years before her death, she received a 
severe blow on the back of the head. After this, first one side 
and then all the limbs became paralyzed. From this condition 
she recovered sufficiently to walk; but after a short time, she 
again grew worse, and both arms and legs were paralyzed and 
contractured. She died of bronchitis. At the autopsy there 
were found two tumors on the spinal cord within the dura mater. 
The upper tumor was on the anterior face of the cord just 
below the decussation of the medulla. It was of ovoid shape, 
and of the size of a pigeon's egg. It was composed of branched 
connective tissue with many round cells. 
The lower tumor was on the posterior face of the cord, at the 
upper part of the lumbar enlargement. It was of the size and 
shape of a large, flattened cherry. It was composed of portions 
of two spinal cords fused together, with their long axes parallel 
to that of the normal cord. There were four patches of gray 
matter, having the shape of the cornua, containing ganglion 
cells, and joined two and two by regular gray commissures, in 
each of which was a central canal. These gray portions were 
surrounded by tissue resembling the normal white substance of 
the cord. THE RESPIRATORY SYSTEM. 
THE LARYNX. 
MALFORMATIONS. 
The larynx may be entirely absent in acephalous, and other 
■monsters. It may be abnormally large, or abnormally small. 
The epiglottis may be larger or smaller than the normal stan- 
dard, or may be cleft. Portions of the cartilages of the larynx 
may be absent or defective. 
INFLAMMATION. 
Acute Catarrhal Laryngitis causes the mucous membrane 
to appear congested^ swollen, and soft. Its surface is thinly 
coated with muco-pus. The mucous glands are swollen -with 
their increased secretion. The submucous connective tissue 
is more or less infiltrated with serum. 
Chronic Catarrhal Laryngitis causes the mucous membrane 
to appear grayish and soft. The mucous follicles are swollen 
and prominent. The submucous tissue is thickened. The sur- 
face may be covered with muco-pus, and there are often small 
ulcerations. Sometimes the inflammation extends to the peri- 
chondrium of the cartilages. 
Croupous Laryngitis occurs as the " croup" of children, with 
diphtheria, pyaemia, typhus fever, and other severe, acute 
diseases, and from the inhalation of irritating substances and 
gases. We And the mucous membrane covered by a layer of 
yellowish-white, consistent material-false membrane. This 
layer consists of flbrine and lymphoid cells ; it dips down into 
the mouths of the mucous follicles, and may be found also in THE LARYNX. 
67 
the submucous tissue. The exudation adheres firmly to the 
epithelium of the part, and when, after a time, it becomes 
loosened and falls off, the epithelium goes with it. 
The diagnosis between diphtheria and the croup of children 
belongs to clinical medicine. The anatomical lesion of diphthe- 
ria is a croupous exudation on and in whatever mucous mem- 
brane the disease happens to show itself. 
Inflammation of the Submucous Connective Tissue occurs as: 
(1.) (Edema glottidis. Here we find the epiglottis swollen, 
and from its base two bags of serum, formed of the aryteno- 
epiglottidean folds, extend backward. This oedema is often 
sufficient to close the larynx and cause death. It accompanies 
acute catarrhal laryngitis, small-pox, typhoid fever, syphilitic 
and tuberculous ulcerations, facial erysipelas, and perichondritis. 
(2.) Purulent inflammation may attack the same parts which 
are implicated in oedema glottidis, and cause death in the same 
way. 
Perichondritis.-Inflammation of the perichondrium of the 
cartilages of the larynx may be idiopathic or secondary to in- 
flammations of the mucous membrane. It usually attacks first 
the cricoid cartilage, and extends later to the other cartilages. 
The inflammation causes the production of pus and separation 
of the perichondrium from the cartilage, with the death of the 
latter. The cartilage is usually found ossified, sometimes 
carious, sometimes degenerated and softened without ossifica- 
tion. The pus spreads to the submucous tissue, collects in 
abscesses, and may cause death by suffocation, or may perforate 
the mucous membrane. When the inflammation extends out- 
ward, abscesses and sinuses form on the outside of the larynx, 
and may perforate through the skin of the neck. Portions of 
the necrosed cartilages may find their way into the cavity of 
the larynx and be coughed out, or may become fixed in the 
rima glottidis and cause suffocation, or may pass into the 
bronchi. In other cases, the portions of cartilage may be dis- 
charged outward through openings in the skin. 
Syphilitic Laryngitis.-Constitutional syphilis shows itself 
very frequently in the larynx. It produces here simple catarrhal 
inflammation, or the mucous follicles may swell and ulcerate, or 68 
POST-MORTEM EXAMINATIONS. 
the little lymphatic follicles in the submucous tissue may swell 
and ulcerate. The syphilitic condylomata produce much graver 
lesions. They form small, rounded nodules on the surface of 
the mucous membrane. These nodules may become aggregated 
together so as to form masses of considerable size, and of soft, 
medullary consistence. Either the large or the small nodules 
may ulcerate. The ulceration, if extensive, may induce peri- 
chondritis, and also hypertrophy of the mucous membrane near 
the ulcerations. We find then the cavity of the larynx often 
entirely deformed by a series of changes which have caused 
destruction of tissue in some places and hypertrophy in others. 
Tubercular Laryngitis usually accompanies pulmonary phthi. 
sis. In patients affected by phthisis we often find in the poste- 
rior wall of the larynx, between the arytenoid cartilages, one 
or more small, deep ulcers with overhanging walls, whilst there 
is often at the same time catarrhal laryngitis. In more severe 
cases, these little ulcers are numerous and become joined, or 
they are from the first of large size. In such cases, we may also 
have papillary hypertrophies of the mucous membrane and 
perichondritis. 
It is still uncertain how far these lesions are to be ascribed to 
submucous tubercles, and how far to follicular ulceration. 
NEW GROWTHS. 
Ossification of the thyroid and cricoid cartilages is a regular 
senile change. The same thing is often caused by perichon- 
dritis. The epiglottis may become calcified, but does not change 
into true bone. 
Mucous Polypi are small, soft, rounded tumors with a pedi- 
cle. They are composed of a fibrous stroma covered with a 
thick layer of epithelium. Properly speaking, they are examples 
of papillary Fibroma. 
Fibrous Polypi usually occur in the upper part of the larynx, 
and may reach the size of a pigeon's egg. They are attached to 
the larynx by a broad or narrow pedicle, and are composed of 
fibrous tissue covered with epithelium. 
Chondroma.-Cartilaginous tumors grow from the thyroid THE TRACHEA. 
69 
and cricoid cartilages as flat or globular tumors. They usually 
grow inward, and may be mistaken for polypi. They may 
become ossified. 
Epithelial Cancer may appear in any part of the larynx. It 
forms irregular, fungous, ulcerating masses, projecting into the 
cavity of the larynx. The new growth may also involve the 
parts about the larynx and form tumors in the neck. These 
external tumors are often surrounded by inflamed and suppurat- 
ing tissue. 
Carcinoma as a primary disease seldom occurs in the larynx. 
It forms nodules in the submucous tissue, which may enlarge, 
project inward, and ulcerate. 
Sarcoma occurs in the form of polypoid tumors growing from 
the submucous tissue. 
PARASITES. 
In the catarrhal and croupous exudations of the larynx, the 
spores and thallus of fungi are often found. Some authors re- 
gard them as the cause of diphtheritic inflammation. 
THE TRACHEA. 
MALFORMATIONS. 
The trachea may be entirely absent. It may communicate 
with the aesophagus. There may be little fistulous canals open- 
ing from it, which penetrate the skin of the neck. The carti- 
lages may be increased or diminished in number, or parts of 
them may be wanting. The trachea may divide into three 
bronchi instead of two. It may be misplaced on the left side 
of, or behind the aesophagus. 
A uniform dilatation of the trachea is sometimes seen in old 
persons as a consequence of long-continued catarrhal inflamma- 
tion. 
Rokitansky describes a peculiar dilatation of the posterior 
wall. The ends of the cartilages are widely separated, the mu- 
ALTERATIONS IN SIZE. 70 
POST-MORTEM EXAMINATIONS. 
cous membrane appears pushed outward into numerous small 
sacs, separated by bands of muscle. 
Stenosis of the trachea may be produced by thickening from 
chronic inflammation, by ulceration and cicatrization, and by 
the pressure of tumors from without. 
INFLAMMATION. 
Inflammation of the trachea has the same characteristics as, 
and almost always accompanies that of the larynx and bronchi. 
NEW GROWTHS. 
Ossification of the tracheal cartilages is a senile change. 
Carcinoma is secondary, usually, to cancer of the oesophagus. 
A single case of primary carcinoma of the trachea and bronchi 
is described by Langhans. There were small flattened nodules 
in the submucous tissue. 
Lymphoma in the submucous tissue at the lower end of the 
trachea has been seen in leucaemia. 
Chondroma appears usually in the form of small multiple 
tumors growing from the inner surface of the tracheal cartilages. 
A number of little tumors may grow so close together that they 
become joined and form a sort of network. They may be so 
loosely attached to the cartilage that they appear to be free in 
the submucous tissue. They may become ossified. 
THE BRONCHI. 
INFLAMMATION. 
Acute Catarrhal Bronchitis occurs at all ages ; in childhood 
and old age, it is apt to attack the smaller bronchi; in adult 
life, usually the larger. The mucous membrane appears swollen, 
soft, red, and covered with mucus or muco-pus, the pulmonary 
tissue is at the same time usually congested and somewhat 
cedematous. In children, capillary bronchitis is very frequent- 
ly accompanied by peri-bronchitis, lobular pneumonia, and ate- 
lectasis. The lobules of pneumonia are of very variable size, and 
the lung tissue between them may be anaemic. The atalectasis THE BRONCHI. 
71 
is produced by stoppage of the bronchi and consequent non- 
aeration of portions of lung tissue. The portions so affected are 
dense, firm, non-aerated, of a deep purple color, the section is 
smooth and dry, resembling foetal lung. Portions of lung in a 
condition of atalectasis may become inflamed, and thus a com- 
plicated condition be produced. 
Chronic Catarrhal Bronchitis is usually a disease of adult 
life. The mucous membrane of the bronchi is of a deep red 
color, or pale, or grayish, soft, thickened or thinned, granular 
or reticulated. This reticulated or trabeculated appearance is 
found in the lungs of persons subject to long-continued cough. 
The longitudinal and transverse fibrous bands of the bronchial 
wall become separated, the tissues between them atrophied, 
so that the wall assumes a trabeculated appearance. When the 
bronchi are cut across, muco-pus exudes from them. It is very 
common to find the lungs emphysematous, or with some degree 
of fibrous induration, or congested and oedematous. In some 
cases the exudation becomes foul and stinking, and the walls of 
the bronchi black and gangrenous. Sometimes the exudation is 
entirely purulent, or of a greenish watery character. It is ex- 
pectorated in large quantities, and causes gradual emaciation and 
death of the patient. Especially in these last cases we find dila- 
tation of the bronchi. Chronic bronchitis and emphysema may 
give a clinical history very closely resembling that of phthisis.. 
They are sufficient of themselves to cause death, and even sud- 
den death. * 
From the obstructions in the bronchi, the air-cells may be 
abnormally dilated and the whole lung expanded : this condition, 
is not to be confounded with emphysema. 
Croupous Bronchitis occurs in children in connection withi 
croupous laryngitis and tracheitis. The larger bronchi, and' 
more rarely the smaller, are lined or filled with a mass com- 
posed of coagulated fibrine and lymphoid cells. Sometimes the 
exudation will be continuous through a set of bronchi and a 
complete cast of them will be coughed up. 
In adults, the disease is idiopathic, or a complication of croup- 
ous pneumonia. When idiopathic, it may run an acute course, 
or last for months and years, with repeated expectorations of 72 
POST-MORTEM EXAMINATIONS. 
casts of the bronchi. The chronic form affects only a few of the 
bronchi. The mucous membrane will be found congested or 
anaemic. The lungs are usually diseased ; either emphysema, or 
fibrous induration, or small apoplexies, or abscesses are present. 
The idiopathic form in adult life is rare. 
Croupous pneumonia is always attended with croupous exu- 
dation into the small bronchi, and in some cases the larger 
bronchi also will be found partly filled with long, whitish cords 
of the same material. 
Peri-Bronchitis.-Inflammation with the formation of lym- 
phoid cells and connective tissue in the walls of the bronchi and 
just around them is found as an acute and chronic condition. 
It not infrequently occurs in the acute pneumonia of children, 
and Ave see the hepatized lung mottled with white lines and 
spots, In the chronic inflammation of phthisis, we usually find 
the Avails of the bronchi thickened, sometimes enormously so. 
BRONCHIECTASIA. 
Dilatation of the bronchi presents itself under three forms, 
the cylindrical, the fusiform, and the sacculated. 
The cylindrical form consists in the uniform dilatation of one 
or more bronchi. It is found in bronchi of every size, but most 
frequently in those of medium diameter. The large and me- 
dium-sized bronchi may be dilated and the smaller remain nor- 
mal, or the terminal bronchi alone be affected. 
The fusiform dilatation is a mere variety of the cylindrical. 
The bronchus is uniformly dilated for a short distance, and 
then resumes its normal size. Several such dilatations may be 
found in the same bronchus. 
The sacculated dilatations form the largest cavities. These 
cavities usually communicate with the bronchus only on one 
side, the peripheral portion of the bronchus becoming obliterat- 
ed. The bronchus leading to the cavity may be of normal size, 
or dilated, or stenosed, or even completely obliterated, so that 
there is no opening into tfie bron chiectasia. 
These sacculated dilatations may attain to a very large size, 
and may be so numerous that the entire lung looks honey- 
combed. THE BRONCHI. 
73 
The walls of these bronchiectasise are found in various morbid 
conditions, but usually preserve something of their normal 
structure. 
(1.) The wall is simply swollen and relaxed. This condition 
is most frequent in the dilatations caused by bronchitis in chil- 
dren. As the bronchitis subsides, these dilatations may disap- 
pear. 
(2.) The wall is hypertrophied. The mucous membrane is 
thickened, and maybe covered with little papillary outgrowths. 
The submucous tissue, mucous glands, and cartilage may also 
be hypertrophied. 
(3.) The wall is atrophied, and the thinning may be so ad- 
vanced as to leave nothing but an attenuated, semi-transparent 
mucous membrane. 
(4.) The wall is trabeculated. The surface is no longer 
smooth, but is divided up by bands crossing each other, and 
leaving little depressions between them. These bands are the 
longitudinal and circular fibrous bands of the normal bronchi. 
The cartilages are usually thickened. 
(5.) They may ulcerate, and this ulceration may extend to 
the lung tissue, so as to form cavities, which are partly bron- 
chiectasise, and partly formed by the destruction of lung 
tissue. 
(6.) The bronchus leading to a dilatation may become entire- 
ly obliterated, and leave a cyst with smooth walls and serous 
contents. 
(7.) The walls may become calcified, or inflamed, or gan- 
grenous. 
The lung tissue will be found altered in various ways, and 
these alterations either precede, or follow, or are complications 
of the dilatations. 
(1.) The lung tissue is in a condition of fibrous induration. 
This fibrous induration may precede and cause the dilatations, 
or may be with them the result of chronic inflammation. 
(2.) The ectasise may give rise to lobular pneumonia and con- 
gestion. The lobules affected by pneumonia may be in the con- 
dition of red and gray hepatization, or may become gangrenous. 
(3.) A moderate degree of emphysema is a frequent concomi- 74 
POST-MORTEM EXAMINATIONS. 
tant of bronchiectasia; higher degrees are not so common, and 
are more apt to occur in other parts of the lung. 
(4.) Old pleuritic adhesions are very frequently found, and 
are regarded as one of the most common causes of bronchiec- 
tasise. 
(5.) In a few rare cases, pneumothorax has been caused by 
perforation of a superficial bronchial dilatation. 
The situation of bronchiectasise depends upon the previous 
disease of the lungs or pleura. Capillary bronchitis, catarrhal 
pneumonia, and atilectasis cause dilatations of the bronchi, in 
the inferior and posterior portions of the lung. Chronic inflam- 
mation, phthisis, and fibrous indurations cause dilatations prin- 
cipally in the upper lobes. Old pleuritic thickenings and ad- 
hesions cause dilatations in the portion of lung which they 
cover. Taking all the cases together, the lower lobes are the 
most frequently affected. Both lungs are as frequently involv- 
ed as one. The largest bronchi are the ones least frequently in- 
volved. 
STENOSIS. 
Narrowing of the bronchi is produced either by the compres- 
sion of external bodies, or by the contraction of their walls. 
External pressure is produced by aneurisms of the aorta, en- 
larged lymphatic glands, abscesses and new growths of the me- 
diastinum, tumors of the oesophagus, and cancer of the lungs. 
Internal contraction is produced by (1) ulceration and cicatri- 
zation, usually of syphilitic origin ; (2) inflammatory thickening 
of the bronchial walls; this is a very rare occurrence ; (3) poly- 
poid new growths ; these also are very rare. 
Stenosis of the bronchi very often produces dilatation of the 
bronchi beyond the stenosis, lobules of emphysema, or of ate- 
lectasis, capillary bronchitis and pneumonia. 
NEW GROWTHS. 
Ossification of the bronchial walls has been seen in a few rare 
instances. 
Carcinoma is secondary to the same new growth in the lungs, 
mediastinum, or oesophagus. A single case of primary carcino- 
ma of the trachea and bronchi is given by Langhans. THE LUNGS. 
75 
Lipoma in the submucous tissue has been seen in one case by 
Rokitansky. 
THE LUNGS. 
MALFORMATIONS. 
One or both lungs may be entirely wanting, or only partially 
developed. • 
A peculiar degeneration, by ■which the lung is converted into 
a number of sacs containing air and serum, and communicating 
with the bronchi, has been seen in a few instances. 
The lobes may be subdivided by deep fissures. An accessory 
lobe, separated from the lung, has been seen between the base 
of the left lung and the diaphragm. 
There may be hernia of the lung, with absence of part of the 
thoracic wall. 
There may be transposition of the lungs, with the same change 
in the position of the heart and liver. 
In rare cases, the congenital smallness of the lungs remains, 
and persons continue to live for a number of years. 
INJURIES. PERFORATIONS. 
Contusions of the thorax may cause rupture of the lung tissue 
and fatal haemorrhage. The lungs may be wounded by projec- 
tiles and penetrating instruments of all kinds, and by frag- 
ments of bone. Even severe injuries of this nature may not 
prove fatal. 
Collections of pus in the pleural cavities and mediastinum, 
and abscesses of the liver, spleen, and kidneys, may perforate 
the lungs. 
Fistulous openings from the lungs through the thoracic wall 
may be formed during phthisis, emphysema, gangrene of the 
lungs, abscesses, hydatids, and wounds. 
CONGESTION AND (EDEMA. 
These conditions are found in the dead body not only as post- 
mortem changes, but also as evidences of the same conditions 
O J 
during life. 76 
POST-MORTEM EXAMINATIONS. 
Congestion and oedema confined to the posterior portions of 
the lower lobes are usually merely post-mortem changes, and are 
most marked in hot •weather. When, however, the congestion 
and oedema are excessive, and especially when they involve the 
upper lobes, we may conclude that they existed during life. To 
determine, however, their importance in producing death, a 
reference to the clinical history is necessary. Congestion and 
oedema, in different relative proportions, occur with cardiac dis- 
ease, with changes in the nervous centres retarding the act of 
respiration, with coma from any cause, with renal disease, with 
any chronic, exhausting disease, general anasarca from any cause, 
bronchitis and pneumonia, narcotic poisons and sunstroke. 
In some of these cases, as in renal disease, general anasarca, 
bronchitis and pneumonia, the congestion and oedema appear 
to be the direct cause of death. In exhausting diseases, also, the 
case is the same, although here there is very often filling up of 
the air-cells with the products of inflammation. 
In persons dying comatose, however, from any cause, the 
condition of affairs is different. The congestion and oedema, 
although often very excessive, are merely the accompaniments 
of diseases which are of themselves sufficient to destroy life. 
HAEMORRHAGE. 
Effusions of blood which lacerate the lung tissue are not 
common. They are produced by penetrating wounds, contu- 
sions, atheroma, and dilatation of the pulmonary arteries, rup- 
ture of aortic aneurisms, and rarely by a simple effusion of 
blood into the alveoli. We find a considerable portion of the 
lung tissue broken down and infiltrated with blood, and the 
blood may also rupture through the pleura. 
Cavities in the lungs produced by phthisis, syphilis, or gan- 
grene are sometimes found filled with blood from the ulceration 
of a large vessel. 
The most common form of hgemorrhage, however, is that 
called " pulmonary apoplexy," or haemorrhagic infarction. This 
consists in the filling up of the air-cells with blood. We find 
at any portion of the lungs, and even in lungs compressed by 
pleuritic fluid, a few nodules, from the size of a chestnut to that THE LUNGS. 
77 
of a hen's egg. These nodules are firm and of a dark red color. 
The lung tissue around them is hyperaemic, or fairly in the con- 
dition of red or gray hepatization. Minute examination shows 
the alveoli, bronchi, and blood-vessels in these nodules to be 
completely filled with blood globules. These infarctions may 
cause death by their size and number, or by the pneumonia and 
pleurisy which they excite. In other cases, the blood globules 
break down and become fluid, are partly absorbed, partly 
coughed out, and partly changed into pigment. The air-cells 
which had been filled up may again be expanded with air, or 
may contract and form a spot of fibrous induration. In still 
other cases, the lung tissue becomes gangrenous and forms cavi- 
ties with irregular walls and brownish semi-fluid contents. 
Haemorrhagic Infarctions also form the most constant lesion of 
pyaemia, although with a somewhat different history. They are 
usually situated near-'the surface of the lung, are small and 
often numerous. At first they resemble the non-pyaemic in- 
farctions, and look like dark red nodules. Very soon, however, 
there is a narrow zone of pneumonia around them, then their 
centres become decolorized, soft, and white; soon this softening 
involves the entire infarction and forms a small cavity filled with 
whitish puriform fluid. 
The causation of these pyaemic infarctions is very clear. They 
are produced by the plugging of a small artery with an embolus, 
and this embolus is usually part of a broken-down thrombus in 
some vein situated in inflamed tissue. It is the necrotic and 
unhealthy character of the embolus which gives to the infarc- 
tion its tendency to rapid decomposition and suppuration. 
The non-pyaemic infarctions are in some cases undoubtedly 
produced by the same mechanism. The embolus then comes 
from vegetations in the right cavities of the heart. Whether 
such infarctions are always produced by emboli is still un- 
certain. 
Emphysema is of two kinds, vesicular and interlobular. 
(1.) Vesicular Emphysema consists in an abnormal dilatation 
of the alveoli of the lung, with thinning and atrophy of their 
walls. 
EMPHYSEMA. 78 
POST-MORTEM EXAMINATIONS. 
We must distinguish from this a simple dilatati^W the 
alveoli, which we find dependent on various conditionsfl»The 
bronchi may be partially obstructed so that the escape of aw is 
impeded, and after death the lungs remain unnaturally inflated. 
Or a considerable portion of the lung tissue is rendered imper- 
vious to air by pneumonia, oedema, or pleurisy, and the rest of 
the lung is unnaturally dilated. Or, the walls of the alveoli 
may lose their elasticity so that they no longer expel tlA air, 
but remain dilated. A 
In true vesicular emphysema, we find the lungs pa&, nnse- 
mic, large, of a soft cushiony texture, the alveoli distmctly 
visible with the naked eye. The walls of the alveoli are thinned, 
the capillary vessels are small, and the spaces between them are 
increased in size. Often a portion of the w^§ of'the alveoli 
entirely disappear, so that several alveoli becd&mTfused into one. 
These changes are apt to be most markua at the edges of the 
lobes. This change in the lung tissue may affect both lungs, or 
one lung, or part of a lung. Very often when part of a lung 
is contracted and indurated, the neighboring portions will be 
emphysematous. 
Emphysema is almost always associated with some degree of 
chronic bronchitis. It also leads to hypertrophy of the right 
ventricle of the heart, to expansion of the walls of the thorax, 
and to displacement downward of the diaphragm and the abdo- 
minal viscera. 
Emphysema and chronic bronchitis may of themselves cause 
death. In other cases, the lungs become the seat of an acute 
croupous pneumonia, and this causes death, often when only part 
of a single lobe is hepatized. Fibrous induration, either in 
bands or nodules, is also sometimes associated with emphysema. 
Interlobular Emphysema consists in the escape of air from 
the alveoli into the interstitial connective tissue, or beneath the 
pleura. In the latter situation, it may form vesicles of consid- 
erable size. This form of emphysema, is not of very frequent 
occurrence, nor of much pathological importance. It may be 
produced by any thing which causes rupture of the alveoli. In 
rare cases, there may be rupture of the pleura and pneumotho- THE LUNGS. 
79 
rax, or the air may pass into the mediastinum, and from thence 
upward into the neck, producing general emphysema. 
ATALECTASIS. 
A collapsed and unaerated condition of portions of lung tis- 
sue is either congenital or acquired. 
(1.) In congenital atalectasis we find portions of the lungs 
firm, non-crepitant, of a dark blue or purple color, depressed, 
smooth on section, and containing a variable amount of blood. 
These portions can usually be artificially inflated, and then can- 
not be distinguished from the surrounding pulmonary tissue. 
This condition is produced by the inability of the child after 
birth to fully inflate its lungs; either from want of sufficient 
vitality, or from mechanical obstruction in the bronchi. If the 
child lives for some time, and the collapsed lobules do not be- 
come inflated, they become hard, and can no longer be inflated. 
(2.) Young children may acquire the same condition as the 
result of bronchitis. A small bronchus becomes obstructed, and 
the air-vesicles which it supplies collapse. We then find, scat- 
tered through the lungs, collapsed lobules resembling those 
found in the new-born child. There may be at the same time 
lobules in a condition of inflammatory hepatization; and the 
collapsed lobules may also become inflamed. 
(3.) In adults, large or small portions of lung tissue may be- 
come collapsed, as the result of bronchitis; of stenosis of a large 
bronchus; of paralysis of the pneumogastric; of atrophy of the 
respiratory muscles; of compression of the lungs by fluid, by 
new growths, or by thickened pleura. The collapsed portions 
are unaerated, firm, smooth; of a leathery consistence; of a 
dark red or blue color, and in various degrees of congestion. 
The names of " carnification" and " splenization" have been 
somewhat loosely applied to this condition. 
PIGMENT INDURATION. 
This change in the pulmonary tissue is one of the regular 
sequelae of grave cardiac disease. Any disease of the heart 
which produces an obstruction to the free passage of blood from 80 
POST-MORTEM EXAMINATIONS. 
the left auricle into the left ventricle may produce this lesion. 
Stenosis and insufficiency of the mitral valve, and stenosis of 
the aortic valve, are the cardiac lesions most frequently found. 
The lungs appear small, the pleura somewhat thickened ; the 
surface of the lungs is of a pale pinkish color, mottled with 
brown or red. Their cut surface is of a bright red color. They 
contain less air than usual, and have a firm, leathery texture. 
Very little blood exudes from their cut surface; they are some- 
times dry, sometimes cedematous. Not infrequently there are 
lobules of hepatization and pulmonary apoplexies, or the greater 
part of a lobe may be hepatized. 
The lesion consists in. (1,) dilatation of the capillaries; (2,) 
thickening of the walls of the air-cells; (3,) increase of pig- 
ment ; (4,) an accumulation of large cells in the alveoli, as in 
a low grade of catarrhal pneumonia. This last is the most con- 
stant lesion, and the one of greatest pathological importance; 
for by it the alveoli become gradually filled up, and respiration 
is seriously impeded. The large epithelial cells produced by 
the inflammation often contain granules of dark pigment. 
INFLAMMATION. 
Inflammation of the lungs affects either the alveoli or the in- 
terstitial connective tissue. When it affects the alveoli, they 
become filled with inflammatory exudation; when the intersti- 
tial tissue is involved, it becomes increased in amount. 
1. Croupous Pneumonia is one of the most common dis- 
eases of adult life. It usually involves the greater part of a 
lobe, and may extend over one or both lungs. It passes through 
three stages. 
(1.) Congestion.-This stage usually escapes our observation 
in the human subject, but may be artificially produced in ani- 
mals. The lung is dark colored, and exudes a large amount of 
blood and serum. The blood-vessels, both large and capillary, 
are gorged with blood : the alveoli and small bronchi contain 
a small amount of a material which is coagulated by alcohol 
into an amorphous, granular, or dimly fibrillated substance. 
(2.) The first stage is soon followed by the second, that of 
Red Hepatization. The lung loses its spongy consistence, and THE LUNGS. 
81 
becomes solid. Firm pressure causes it to break down under 
the finger. The color is red, sometimes mottled with haemor- 
rhagic spots of a deeper hue. A section looks as if the lung tis- 
sue were composed of a multitude of small granules closely 
packed together; and these granules can be picked out with the 
point of a needle. If the lung is seen soon after death, the sec- 
tion is dry; in a short time, however, part of the exudation 
liquefies, and the section will be covered with a thick, grumous, 
reddish-gray fluid. The larger bronchi are not infrequently 
filled with firm, yellowq fibrinous cords, continuous with smaller 
cords in the smaller bronchi. Minute examination shows the 
alveoli and small bronchi to be filled up with a mass of new7 ma- 
terial, composed of fibrine coagulated into a delicate net-work, 
lymphoid (pus) cells, large polygonal nucleated cells, and red 
blood globules. The fibrine varies somev-hat in amount, but 
is always present. The lymphoid cells are very numerous; 
some of them are as pale as perfectly fresh pus-cells ; but most 
of them are granular and somewhat swollen. The large, poly- 
gonal, nucleated cells are identical with the cells found in very 
small numbers in the adult lung, and more abundantly in the 
infant lung. They appear to be epithelial cells. They are 
found in variable numbers, most abundantly in the pneumonia 
which attacks emphysematous and phthisical lungs. The red 
blood globules give the coloring to the mass. The walls of the 
alveoli are unchanged ; the capillary plexus in the walls con- 
tains but little blood. 
(3.) Finally comes the third stage, that of Gray Hepatization. 
The lung retains the same consistence, but is usually much 
moister; the section is covered with grumous fluid. The color 
changes from red to gray; not at once, but gradually, so that 
the lung is first mottled red and gray, and then is entirely gray. 
Minute examination shows the air-cells and bronchi still filled 
with new material; but this material has undergone changes. 
The red blood globules have vanished. The lymphoid cells and 
large cells remain, but are distended with shining granules. 
There is a considerable amount of granular matter formed by 
the breaking down of these cells and of the fibrine. This pro- 
cess of degeneration and disintegration of the elements of the 82 
POST-MORTEM EXAMINATIONS. 
exudation goes on until the alveoli are filled with a fluid mass, 
which can be coughed out, and the pneumonia is resolved. 
Sometimes, however, the change of color is not accompanied 
by changes in the exudation. A lung may be entirely gray-al- 
most white-and yet the section is dry, the fibrine remains, and 
the cells are but little degenerated. This condition is some- 
times found in persons whose lungs remain hepatized for an un- 
usually long time without either resolution or death taking 
place. In most cases, the pulmonary pleura covering the hepa- 
tized lungs will be found covered with a thin layer of fibrinous 
exudation. 
Croupous pneumonia may prove fatal at any stage ; its fata- 
lity depending on the amount of lung hepatized, the general 
condition of the patient, and the amount of congestion and 
oedema of the rest of the lung tissue. 
Sometimes abscesses form in the hepatized tissue. This takes 
place by a molecular degeneration and destruction of the walls 
of some of the air-cells, with an increased production of lym- 
phoid cells and serum. Such abscesses may prove fatal of 
themselves, or may perforate the pleura, or may be absorbed, 
or may become concrete and calcified. 
Gangrene of the lung, also, may result from hepatization, 
although in these cases there seems always to be thrombosis of 
the bronchial arteries. 
The exudation in the air-cells, after reaching the stage of 
gray hepatization, may undergo a dry, granular degeneration. 
The air-cells are then filled with a firm, dry, yellow mass com- 
posed of granules and atrophied cells ; and there is cheesy 
hepatization. 
2. Catarrhal pneumonia differs from the croupous form in 
the character of its exudation. The material which fills the 
air-cells contains little or no fibrine, a smaller number of lym- 
phoid cells, and a much larger number of the large, nucleated 
cells. The disease runs through the same stages of congestion : 
red, gray, and cheesy hepatization. The section is smoother, 
and without the granular appearance of croupous hepatization. 
There is a much stronger tendency to pass into the cheesy con- 
dition. Catarrhal pneumonia usually affects only lobules of the THE LUNGS. 
83 
lungs; sometimes only a few alveoli. There is always capil- 
lary bronchitis ; and the small bronchi are filled with pus. 
There may also be peribronchitis. 
In children under five years old, pneumonia as a rule is of 
the catarrhal variety. The pneumonia around pysemic infarc- 
tions, in pigment induration, and in phthisis, is usually also 
catarrhal. 
The attempt to class this form of inflammation of the lung 
with the catarrhal inflammations of mucous membranes is not 
altogether satisfactory. The alveoli of the lungs are not lined 
with a mucous membrane, nor does their inflammation ever 
have a true catarrhal character. All sorts of gradations, also, 
can be found between the croupous and so-called catarrhal exu- 
dations. The name is used, therefore, not as a good one, but 
for want of a better. 
3. Hypostatic Pneumonia.-In persons who have been for 
a long time confined to bed by severe and protracted illness, we 
often find the lungs, especially the lower lobes, congested and 
cedematous. A careful examination will often discover, also, 
small, irregular patches of red hepatization. In these patches, 
the alveoli are filled almost entirely with lymphoid cells, hardly 
any fibrine being present. 
4. Interstitial Pneumonia.-An increase of connective tis- 
sue fibres and cells is often seen in circumscribed portions of 
the lung, especially at the apex, either as the result of a lobular 
pneumonia or as a simple induration. With chronic bronchitis, 
emphysema, anthacosis, around al scesses, in syphilis, and with 
extensire pleuritic adhesions, it also occurs. Its most marked 
forms, however, occur in phthisis, and will be described with 
that disease. 
In rare cases, there is' suppurative inflammation of the inter- 
stitial tissue, forming thin layers of pus between the lobules of 
the lung, with abscesses beneath the pleura. 
GANGRENE OF THE LUNGS. 
Portions of the lungs may not only die, but may also under- 
go decomposition and become putrid. Such a gangrenous pro- 
cess may be caused by infarctions, by pneumonia, with throm- 84 
POST-MORTEM EXAMINATIONS. 
bosis of the bronchial arteries ; and very often occurs without 
any satisfactory reason. The gangrene may be circumscribed 
or diffuse. 
In the circumscribed form we find small nodules, usually 
near the periphery, changed into a brownish, putrid mass, 
sharply defined from the surrounding tissue. After a time, 
the periphery of the nodule becomes fluid, and there is a cavity 
filled with fluid and gangrenous tissue. The gangrene may ex- 
tend to the pleura and cause acute pleurisy or hydropneumo- 
thorax. The gangrenous cavity may communicate with a 
bronchus and cause bronchitis; or a large vessel may be eroded 
and the cavity be filled with blood. Sometimes a circumscrib- 
ed gangrene becomes the centre-of a diffused gangrene. In 
rare cases, the cavity may contract and cicatrize. 
Diffused gangrene may involve an entire lobe. The lung- 
tissue will be found changed into a moist, stinking mass. The 
neighboring lung-tissue is oedematous or hepatized, the pleura 
is inflamed or gangrenous. 
PULMONARY PHTHISIS. 
Under this name all physicians are well acquainted with a 
disease characterized by cough, mucous, purulent, or bloody ex- 
pectoration, dyspnoea, hectic fever, gradual emaciation, and 
physical signs indicating condensation of the lung tissue, and 
exudation in the bronchi. 
The lungs of persons who have suffered from this disease pre- 
sent, after death, a variety of lesions. These lesions it is con- 
venient to group under three heads, according to their most 
marked an atomical condition, namely, Catarrhal, Fibrous, and 
Tubercular Phthisis. These three forms occur either sepa- 
rately or together. 
1. Catarrhal Phthisis.-This form may run a rapid course 
or one of long duration. It may entirely resolve and leave no 
trace behind, or may invade and destroy the larger part of the 
lung tissue. The pathological process consists in a catarrhal 
inflammation affecting the alveoli and small bronchi. The 
pneumonia passes through the stages of congestion, red hepati- 
zation, and gray hepatization. After reaching the stage of gray THE LUNGS. 
85 
hepatization, the exudation undergoes a process of dry degenera- 
tion, converting it into a firm, dry, cheesy mass. This mass is 
usually of an opaque, yellow color, less frequently of a peculiar 
gray. The lung tissue is then said to he in a condition of 
cheesy hepatization. The portions of lung which pass into this 
condition of cheesy hepatization vary much in size. A large 
part of a lobe may be hepatized throughout; or there are large 
yellow lobules, the size of a hen's egg, scattered through the 
lungs; or there are great numbers of small yellow nodules, 
from the size of a pin's head to that of a pea, thickly studding the 
lung, often aggregated together, the lung tissue between them 
either anaemic, or normal, or congested, or hepatized. The larger 
masses are the infiltrated tubercles; the smaller, the miliary 
tubercles of Laennec. In all of them the lesion is the same: 
the alveoli and small bronchi are filled with exudation which 
has undergone cheesy degeneration. In the larger lobules, a 
great number of alveoli are thus filled up ; in the miliary no- 
dules, only a few alveoli or a small bronchus are hepatized. 
In the lungs of children, we find a form of miliary hepatiza- 
tion in which a small bronchus or a few alveoli are filled with 
cheesy matter, and there is at the same time a production of 
round and fusiform cells in the wall of the bronchus or of the 
alveoli. 
After the stage of cheesy hepatization, whether lobular or 
miliary, is reached, four different events may follow. The ex- 
udation in the alveoli may take up sufficient serum to become 
fluid, be coughed out, and the lung resumes its normal character. 
Or, if the hepatization is of small amount, it remains quiescent, 
shrinks, becomes calcareous, and a fibrous capsule forms around 
it. Or, the exudation softens, and at the same time the walls of 
the alveoli, having lost their vitality, degenerate and disinte- 
grate, and in this wav are formed cavities with ragged walls 
and puriform contents. These cavities usually communicate 
with a bronchus, and sometimes merely enlarge a cavity already 
formed by a bronchiectasia. Or, the process of exudation into 
the air-cells may be accompanied by inflammation of the in- 
terstitial connective tissue and fibrous induration. When the 
disease is of long standing, this new formation of fibrous tissue 86 
POST-MORTEM EXAMINATIONS. 
is the rule. We find the pleura thickened, bands and septa of 
fibrous tissue extend inward from the pleura into the lung tissue, 
the connective tissue around the vessels and bronchi is in- 
creased ; around the various cheesy nodules there is a zone of 
new fibrous tissue, the walls of the alveoli hypertrophy, and so 
the process may go on until a large part of the lung may be 
converted into fibrous tissue and cheesy nodules. The new 
fibrous tissue may be black or slate-colored, or white or gray. 
In that which is formed around the bronchi and the vessels, 
and in the walls of the alveoli we can often see an early stage 
of the process, consisting in a development of great numbers 
of small round cells. 
Fibrous Phthisis is usually associated with some degree of 
catarrhal phthisis, but may occur alone or form the principal 
part of the lesion. Like the catarrhal form, it may occur in 
small nodules, or be diffused over a large part of a lobe. The 
nodules are from the size of a pea to that of a walnut, of a 
dark slate-color, mottled with whitish points, of very hard con- 
sistence. They may be scattered in large numbers through 
both lungs, or there may be only two or three in all. They 
consist of pigmented fibrous tissue, with here and there groups 
of small, round cells, and sometimes the thickened walls of the 
alveoli can still be seen. The diffused form may involve part 
of a lobe or an entire lung. The pleura is thickened, and bands 
of white or slate-colored fibrous tissue extend inward. At the 
same time, the connective tissue around the bronchi and vessels 
and the walls of the alveoli increases until the pulmonary tissue 
is almost entirely lost in a fibrous mass. In this way, the apex 
of a lung, for example, may be changed into a firm mass tra- 
versed by dense bands of fibrous tissue, leaving; a little lung- 
tissue between them. This form of fibrous phthisis is usually 
associated with chronic bronchitis and bronchiectasia. The 
dilatation of the bronchi may be cylindrical or fusiform, or 
sacculated, or all these forms combined. The walls of the bron- 
chi are frequently trabeculated. In this way, we may find an 
entire lung converted into a honeycomb of cavities, separated 
by thick bands of fibrous tissue. 
Tubercular Phthisis is the form which is least frequent and THE LUNGS. 
87 
most difficult to study. It is seen in its most typical form in 
the lungs of children. Here we find both lungs studded with 
very small, grayish, semi-translucent granulations. When these 
granulations are discrete, and only their centres yellow and 
cheesy, they may readily be recognized. But when they be- 
come aggregated and entirely cheesy, it is difficult to dis- 
tinguish them from the catarrhal miliary phthisis of children. 
In adults the same is the case. Occasionally we meet with 
pure and typical cases concerning which there is no doubt. 
The granulations are scattered in great numbers through both 
lungs. They are very minute, can hardly be felt on the surface 
of the section, are gray, semi-translucent; some have a white 
spot at the centre; the lung tissue between them appears 
normal. The granulations seem to grow from the walls of the 
bronchi and vessels, and sometimes from the walls of the air- 
cells. They consist of small, round, and fusiform cells, and 
sometimes of larger masses of finely granular matter, contain- 
ing nuclei, (myeloplaxes.) The cells are considered by Virchow 
to be the same as the cells of lymphatic glands, and he calls 
the granulations heteroplastic lymphomata. Others regard the 
cells as belonging to connective tissue. The cells are contained 
in a matrix which is sometimes finely granular, sometimes a dis- 
tinct fibrous network. There is almost always some catarrhal 
pneumonia of the adjoining lung tissue, though it may appear 
normal to the naked eye. There are usually small granulations 
of the same appearance in the serous membranes' and in the 
liver, spleen, and kidneys. 
This is the only form of tubercles in the adult lung, which 
can be certainly recognized. The small, whitish spots which 
are often seen in fibrous induration seem to be merely such 
accumulations of round cells as are tO' be seen in any new 
growth of fibrous tissue. There are, however, sometimes small 
opaque, cheesy, miliary nodules of which it cannot be certainly 
said whether they are tubercles or miliary hepatizations. 
There is much difficulty in determining what lesions of the 
lungs are dependent upon syphilis. It is generally admitted 
PULMONARY SYPIIILI&. 88 
POST-MORTEM EXAMINATIONS. 
that two lesions can be ascribed to this disease; namely, Fibrous 
induration, and Gummy tumors. 
The fibrous induration may occur in the form of multiple, 
hard, slate-colored, or white nodules, or of a diffused indura- 
tion of part of a lobe. It does not differ anatomically from the 
lesions of fibrous phthisis, and is only to be diagnosticated with 
the concurrence of other syphilitic lesions and history. 
The gummy tumors are found in small numbers, from one to 
six or eight. They form nodules of the size of a pea to a wal- 
nut, partly white, partly gray-colored, imbedded in fibrous in- 
duration. They are cheesy in irregular patches, separated by 
bands of fibrous tissue, and consist of small, round, and fusiform 
cells. As many cheesy nodules of other origin are found in 
the lungs, gummy tumors are only to be pronounced to be such 
after very careful examination. 
In still-born children, parts of the lungs are sometimes found 
in a condition of white hepatization, the alveoli being filled with 
great numbers of epithelial cells. This lesion is usually attrib- 
uted to syphilis. 
NEW GROWTHS. 
Cysts are of very rare occurrence in the lungs. They may 
contain serum, fat, cholesterine, and hair. 
Fibroma is also very rare. Rokitansky describes the tumors 
as small, white, and firm ; or yellow,, flabby, and puckered. 
Encliondroma may be primary or secondary. The primary 
tumors are small, multiple, usually at the root of the lung, 
often attached to the bronchi and vessels. They are sometimes 
found after death, when they had given rise to no symptoms 
during life. The secondary tumors are more common. They 
may reach a large size, sometimes occupying an entire lung. 
Osteoma is rare. It forms either irregular plates, or some- 
what globular, spongy tumors. It is not to be confounded with 
calcification of the lung tissue. 
Sarcoma is not infrequent. It occurs in the form of rounded 
nodules, usually multiple. It is secondary to sarcomata in 
other organs, especially to those connected with the bones. THE LUNGS. 
89 
These tumors have the same structure as the primary tumors, 
but may be pigmented when the latter are not. 
Carcinoma is usually secondary, but may be primary. It 
may be medullary, melanotic, epithelial, or colloid. It occurs 
as nodules of various size and number, or may infiltrate large 
portions of the lung. It may spread to the pleura, the peri- 
cardium, the heart, and the walls of the thorax, and appear on 
the outside of the chest. 
Pigment is found regularly to a considerable amount in the 
adult lung. In old age, the quantity may increase very consid- 
erably. It is a very common thing to find, under the pleura, 
little nodules composed entirely of pigment. Fibrous indura- 
tion, and the pigment induration of heart-disease, are accom- 
panied by an increased formation of pigment. In miners, 
charcoal-workers, grinders, and persons who constantly inhale 
foreign particles, the lungs become intensely pigmented-an- 
thracosis. In them the pigment is partly the foreign particles 
themselves, and partly produced by the chronic bronchitis. In 
all the cases, the pigment is found in the connective tissue and 
epithelial cells, in the form of granules or masses. It is pro- 
bably derived from the coloring matter of the blood, in conse- 
quence of an abnormal stagnation in the capillaries. 
Myoma, I have seen in one instance. It occurred in a man 
aged 52, who had symptoms of bronchitis and laryngitis. The 
tumors formed large white nodules in the upper lobe of the lung. 
The nodules consisted almost entirely of smooth muscle. 
PARASITES. 
Echinococci occur in the lungs as a cyst, surrounded by a 
thick fibrous capsule. The capsule may suppurate and the sac 
be emptied into a bronchus, into the pleura, through the chest- 
wall, through the diaphragm, or into the intestines. 
Cysticercus Celluloses is not frequent in the lungs. 
Strongylus Longevaginatus has been seen in a child's lung. 
In gangrenous cavities of the lungs, vegetable parasites, be- 
longing to the varieties aspergillus, mucor, and sarcina, have 
been observed. 90 
POST-MORTEM EXAMINATIONS. 
THE PLEURA. 
HYDROTHORAX. 
Non-inflammatory exudations of serum into the pleural cavi- 
ties accompany the various diseases which cause general hydrse- 
mia. A small amount of serum, either clear or bloody, is 
often found as a mere post-mortem change. 
All chronic and exhausting diseases, renal disease, cardiac dis- 
ease, and cirrhosis, are very often attended with hydrothorax. 
The fluid is a clear serum, sometimes yellow, which may reach 
such an amount as to compress the greater part of the lung. 
HAEMORRHAGE. 
Small, dark-red extravasations in the pleura are found with 
purpura, death by suffocation, and in the lungs of young chil- 
dren. Haemorrhages into the cavity of the pleura are caused 
by the rupture of aneurisms, by the rupture of the pericardium 
previously distended with blood, and by wounds of the chest- 
wall. 
INFLAMMATION. 
Pleurisy occurs as a primary disease, or from inflammation 
of the lung tissue, or from perforation of the chest by wounds, 
by abscesses of the wall of the thorax, of the liver, spleen, 
kidneys, and around carious vertebrae. It occurs also without 
perforation with perihepatitis and perisplenitis. Pyaemia and 
puerperal fever also often cause pleurisy. 
Inflammation of the pleura is attended with exudation of se- 
rum, fibrine, lymphoid cells, and sometimes with extravasation 
of blood. The amount of these different substances varies in 
different cases. 
(1.) There may be a scanty exudation of fibrine alone. The 
surface of the pleura is found coated with a thin, membranous, 
grayish layer, consisting of fibrine entangling a few lymphoid 
cells. This may be entirely absorbed, or it may cause perma- 
nent adhesions between pulmonary and costal pleura, or be- 
tween the different lobes. The adhesions are most frequently THE PLEURA. 
91 
found after a number of such attacks. This form of pleurisy 
usually gives no marked symptoms during life, and is frequent- 
ly overlooked. It is very common to find, at the post-mortem, 
old adhesions, the existence of which was not suspected during 
life. 
(2.) The exudation consists of fibrine and serum. The pleu- 
ral cavity is partly or completely filled with turbid serum, 
mixed with flocculi of fibrine, and a few lymphoid cells. The 
pleura itself is coated with a yellow, membranous layer, com- 
posed of fibrine and lymphoid cells. Sometimes there are 
extravasations of blood on the surface of the pleura, and in the 
fluid. The serum usually occupies the lower portion of the 
pleural cavity, but sometimes is confined by adhesions and 
false membranes to other portions of the cavity. If the serum 
occupies the lower half of the cavity, the lower lobe of the lung 
is compressed and unaerated, and the entire lung pushed up- 
ward. If the cavity is full of serum, the entire lung is com- 
pressed toward its root, and against the vertebral column. Such 
a pleurisy, with effusion, may entirely disappear, leaving only 
some adhesions behind it; or it may continue so long without 
absorption of the fluid that the patient dies from its effect, or 
the effusion becomes purulent. If absorption takes place, the 
lung tissue resumes its normal consistence, although sometimes, 
when the effusion is of very long standing, the lung may 
remain compressed and bound down by adhesions. 
(3.) There is an exudation of purulent serum. The pleural 
cavity is found filled with yellow, often stinking fluid, the 
pleura is coated with fibrine and pus. The fluid is usually in 
large quantities, and in the lower part of the pleural cavity. 
Sometimes, however, it occurs in the form of circumscribed 
collections of pus between the pulmonary and costal, or dia- 
phragmatic pleura, entirely shut in by adhesions. Such a pur- 
ulent pleurisy, or empyema, is either fatal, or may be absorbed, 
or may perforate the chest-wall and escape externally, or may 
perforate the lung and escape through a bronchus, or may 
perforate the diaphragm, and find its way downward behind 
the peritoneum. Wunderlich describes a suppurative peri- 
pleuritis which forms abscesses between the costal and dia- 92 
POST-MORTEM EXAMINATIONS. 
phragmatic pleura and the chest-wall, and between the*'pul- 
monary pleura and lung. 
In pleurisy of long standing, the thickening and adhesions of 
the pleura are prominent lesions. In fibrous phthisis and in 
chronic catarrhal phthisis, the pulmonary pleura is often enor- 
mously thickened. The pulmonary and costal pleura may be- 
come inseparably adherent over an entire lung, or they may be 
united at various points by firm membranous adhesions. These 
adhesions and thickenings may, after a time, become calcified. 
HYDROPNEUMOTIIORAX. 
The pleural cavity may contain air. The air enters either 
through a perforation of the chest-wall or of the lung. 
The air is usually accompanied by a purulent exudation in 
the pleural cavity. 
In phthisis, in pysemic infarctions, gangrene, hydatid sacs, 
empyema, emphysema, bronchiectasia, abscesses of the adjoin- 
ing soft parts, perforation of the oesophagus, and in wounds of 
the thorax, air may enter the pleural cavity. - 
Fibroma occurs in the form of small, white nodules; of poly- 
poid tumors, as large as a walnut; and of small nodules, free in 
the pleural cavity. 
Lipoma occurs in the form of large masses growing from the 
connective tissue beneath the costal pleura and pushing this 
membrane inward. 
Angioma has been seen in the costal pleura. 
Cysts, both serous and dermoid, are sometimes found. 
Tubercles are found in the pleura as small, gray, miliary 
granulations. They are often found with tubercular and ca- 
tarrhal phthisis. 
Carcinoma is secondary to that disease in other organs, espe- 
cially in the mamma. It forms small, whitish nodules in the 
costal and pulmonary pleura. They are either soft or hard. 
With cancer of the mediastinum the pleura is often involved. 
I have seen a case in which there was a layer of new growth, 
two inches thick, on the outer surface of the costal pleura. 
NEW GROWTHS. THE MEDIASTINUM. 
93 
The pleural cavity remained open, and was filled with serum 
containing flbrine and blood. 
Leukemic Tumors occur as soft, white, flat, or rounded 
masses, composed of cells like those in the lymphatic glands. 
PARASITES. 
Echinococci are found in the costal and pulmonary pleura 
and in the anterior mediastinum. Sometimes they perforate 
from the liver into the pleural cavity. 
THE MEDIASTINUM. 
INFLAMMATION. 
Abscesses are found in the anterior and posterior mediastinum. 
They are caused by fractures, caries, or necrosis of the sternum 
and vertebrae, by perforation of the oesophagus, by suppuration 
of the lymphatic glands, or may be idiopathic. The pus is 
formed slowly, and may accumulate in large quantities. The 
heart and lungs may be displaced and the sternum bulged out- 
ward. They may cause pleurisy or pericarditis, or may per- 
forate outward, or into the pleural cavity, the oesophagus, the 
trachea, or a bronchus. 
NEW GROWTHS. 
Lympho-Sarcoma occurs in the form of large lobulated 
tumors, commencing in the lymphatic glands. The cervical, 
bronchial, and mediastinal glands are most frequently involved, 
and form lobulated tumors, which may occupy a large part of 
the cavity of the thorax. A persistent thymus gland may also 
be the point of origin. These tumors at first retain the charac- 
ter of enlarged glands inclosed in a capsule; later, the new 
growth invades and breaks through the capsule, and infiltrates 
the neighboring soft parts. Later still, metastatic tumors are 
formed in the lungs, liver, spleen, and kidneys. The lymphatic 
glands in other parts of the body may be enlarged at the same 
time. The growth of these tumors is rapid, and they soon 
prove fatal. 94 
POST-MORTEM EXAMINATIONS. 
Sarcoma and Carcinoma grow as primary tumors within the 
mediastinum. They originate in the periosteum of the ster- 
num, in the outer layers of the parietal pericardium, and in the 
connective tissue of the mediastinum. They grow very rapidly, 
fill up a large part of the thorax, compress and invade the 
neighboring soft parts, and form metastatic tumors in other 
organs. 
Teratoma myomatodes.-Under this name Virchow describes 
a very remarkable tumor. It grew rapidly in a man, aged 22, 
of good constitution and physical development. The right 
pleural cavity was nearly filled with a solid growth. There 
were similar growths, of smaller size, on the left rib, in the 
liver, spleen, and kidneys. 
The mediastinal tumor consisted of two portions, a larger 
and a smaller. 
The larger portion consisted of solid tissue, in which were a 
few cavities. It was very vascular. Part of it was composed 
of dense fibrous tissue. The greater portion, however, con- 
sisted of loose connective tissue fibres, of fusiform cells, and of 
large, many-nucleated cells. Some of the fusiform cells were 
small, and of the usual appearance; but many were large, and 
presented striations like those of young voluntary muscle. 
The smaller portion of the tumor looked like a multilocular 
cystoid. The cysts varied much in size, and contained serum, 
colloid matter, and blood. Some of the cysts contained a thick, 
white material, in which were hairs, epidermic scales, ciliated 
epithelium, and cholesterine. In the fibrous tissue about these 
cysts were pieces of hyaline cartilage. Near the surface of the 
tumor the tissue consisted of a fibro-cellular stroma forming 
alveoli filled with epithelium. 
The tumor on the third left rib consisted of connective tissue 
fibres and cells, muscle cells, cysts, alveoli filled with epithelium, 
and a small portion of tissue resembling foetal lung. THE VASCULAR SYSTEM. 
THE PERICARDIUM. 
The pericardium may be absent, when there is ectopia of the 
heart. Cases have been observed in which the heart and the 
lung were situated in the left pleural cavity, with only rudi- 
ments of the parietal pericardium at the base of the heart. 
MALFORMATIONS. 
The pericardium may be wounded by penetrating weapons, 
by gunshot wounds, and by fragments of bone. 
It may be ruptured by severe contusions of the thorax, and 
by rapid extravasation of blood into the pericardial sac. 
Perforations may be produced by empyema, by mediastinal 
abscesses, by abscesses of the chest-wall and of the liver, by 
aneurisms of the aorta, and by suppurative inflammation of the 
pericardium. 
INJURIES. 
DROPSY. 
In most post-mortems, we find a little serum, from | ounce to 
1 ounce, in the pericardial sac. This serum is usually clear and 
of a light yellow color; if decomposition has commenced, it 
maybe of a reddish color, or it may be slightly turbid from the 
falling off of the pericardial epithelium. 
Large accumulations of serum are found as part of general 
dropsy from heart-disease, kidney-disease, etc. The serum is 
clear and of a light yellow color. Hydro-pericardium is usually 
moderate in comparison with the accumulations of serum in the 
other serous cavities; sometimes, however, there is a very large 96 
POST-MORTEM EXAMINATIONS. 
amount of serum, which hinders the movements and the nou- 
rishment of the heart. 
HAEMORRHAGE. 
Extravasations of blood in the cavity of the pericardium are 
produced by wounds and rupture of the heart, rupture of the 
aorta and of aneurisms, and occur with pericarditis. Small 
extravasations in the substance of the pericardium are found 
with scurvy, purpura, fevers, etc. 
PNEUMATOSIS. 
Air in the pericardium is sometimes found as a post-mortem 
appearance, accompanied with drying of portions of the peri- 
cardium. 
Wounds or paracentesis of the pericardium ; the perfora- 
tion of ulcers of the stomach, cavities of the lungs, and ulcers 
of the oesophagus may admit air into the pericardial cavity. 
Pericarditis, with foul, purulent exudation, may evolve gases. 
INFLAMMATION. 
Pericarditis.-The earliest change in pericarditis is a con- 
gestion of the pericardium ; this, however, we very frequently 
fail to find at the post-mortem. Small ecchymoses are not 
uncommon. The inflammation is attended with the produc- 
tion of serum, fibrine, pus, and blood in variable quantities. 
In very mild cases, there are only one or two ounces of turbid 
serum in the pericardium. In severer cases, the serum reaches 
the amount of several ounces, or even pounds, accumulating 
first at the base of the heart, and afterward surrounding it 
more uniformly. 
Instead of turbid serum there may be great numbers of pus 
globules, so that the pericarditis is suppurative. In rare cases, 
the pus may become foul and gangrenous. 
In other cases, there is but little serum or pus; but the peri- 
cardium is coated with fibrine in a thin layer, or in large quan- 
tities, sticking the visceral and parietal pericardium loosely 
together. THE PERICARDIUM. 
97 
With the serum, the pus, or the fibrine, there may be an 
extravasation of blood, sometimes in large amount. 
Pericarditis may run an acute or a chronic course. It may 
end in death; in absorption of the serum ; in membranous 
thickenings of the pericardium; in adhesions between its 
visceral and parietal portions ; or the pus and fibrine together 
may undergo cheesy degeneration. 
With large, serous effusions, especially when they are chronic, 
the heart-wall becomes soft and flabby, and there may be con- 
sequent dilatation of the ventricles. There may be also granu- 
lar degeneration of the muscular fibres, especially of those near 
the pericardium. 
In some cases of chronic pericarditis we find irregular calcific 
plates. The calcification takes place in the membranous thick- 
enings and adhesions of the pericardium, in the parietal peri- 
cardium, or in the cheesy masses of thickened pus which are 
found with and in extensive adhesions. 
NEW GROWTHS. 
Carcinoma is found in the pericardium in the form of small 
nodules, metastatic tumors from cancerous or epithelial growths 
of other parts. In cancers of the mediastinum, the greater 
part of the parietal pericardium may be involved in the new 
growth. 
Sarcoma is found in the same way in metastatic nodules, and 
as a continuous infection from mediastinal sarcomata. 
Fibroma occurs rarely. It may have the polypoid form, and 
the pedicle may atrophy so as to leave free fibrous bodies in 
the pericardial cavity. 
Cysts of the visceral pericardium have been described by 
Rokitansky. 
Tubercles in the miliary form are found in the pericardium, 
and in inflammatory membranes. 98 
POST-MORTEM EXAMINATIONS. 
THE HEART. 
CONGENITAL MALFORMATIONS. 
The malformations of the heart are usually closely connected 
with malformations of the aorta and pulmonary artery. They 
depend on arrest of, or abnormal development; on endocar- 
ditis, myocarditis, thrombosis, or mechanical causes. 
I. The common arterial trunk is only partially, or not at all, 
separated into aorta and pulmonary artery. The divisions be- 
tween the heart cavities are at the same time defective. 
(1.) There is one ventricle and no auricle. 
(2.) There is one ventricle and one auricle. 
(3.) There is one ventricle and two auricles; the aorta is alone 
or incompletely separated from the pulmonary artery. 
II. The trunk of the pulmonary artery, or of the aorta, is 
stenosed or obliterated, and from the obstruction to the current 
of blood the development of the septa, between the heart 
cavities, is prevented. 
(1.) The aorta, at its origin or in the ascending portion of 
the arch, is stenosed or closed. The pulmonary artery gives off 
the descending aorta, and supplies the carotids and subclavians. 
The foramen oval remains open, or there is no septum be- 
tween the auricles. The ventricular septum is also usually 
defective. The right ventricle is hypertrophied. 
(2.) The pulmonary artery is stenosed or closed. Its branches 
are supplied by the aorta, through the ductus arteriosus. The 
ventricular septum is defective, the foramen ovale is open, or the 
auricular septum defective. 
III. The malformation affects the aorta and pulmonary 
artery after they are more fully developed. 
(1.) There is stenosis of the aorta between the left subclavian 
and ductus arteriosus, or just at the opening of the ductus arte- 
riosus. The descending aorta is then a continuation of the 
pulmonary artery. 
(2.) The aorta gives off all its branches from the arch, but 
the descending aorta is a continuation of the pulmonary artery, 
or the carotids may spring from the aorta, the subclavians from 
the pulmonary artery. THE HEART. 
99 
(3.) The vessels are transposed, the pulmonary artery arises 
from the left, the aorta from the right ventricle; the pulmonary 
veins empty into the left, the venae cavee into the right auricle; 
or the veins also may be transposed. The septa are defective. 
IV. The aorta and pulmonary artery are normal, but the 
cardiac septa are defective. 
(1.) The foramen ovale remains partly open. This condition 
may continue through life without giving any trouble. 
(2.) The ductus arteriosus may remain open for many years ; 
this, also, causes no disturbance. 
(3.) There is a small or large opening in the ventricular 
septum. This may give rise to no symptoms unless disease of 
the heart or lungs be superadded. 
V. Either of the auriculo-ventricular orifices may be entirely 
closed. The foramen ovale remains open, and the ventricular 
septum is defective. 
VI. The valves of the different orifices of the heart may be 
absent or defective. The arteries or the ventricles are usually 
defective at the same time. 
The aortic and pulmonary valves may consist of two large or 
four small leaves, instead of the usual three. 
Generally speaking, the existence of openings between the 
two auricles or the two ventricles, admitting some admixture 
of venous and arterial blood, produces no change in the circu- 
lation. If, however, the passage of the current of venous blood 
into the right heart is in any way interfered with, the conse- 
quences are very serious. Cyanosis is produced, the skin is of 
a bluish color, the small veins and capillaries are dilated, exu- 
dation of serum and hypertrophy of connective tissue takes 
place, especially in the fingers and toes. 
Besides the malformations already mentioned, we may find a 
Entire absence of the heart. 
Abnormal septa and chordae tendinese in the heart cavities. 
Abnormal shapes of the heart. 
Abnormal positions of the heart. 
(a.) There is a smaller or larger defect in the walls of the 
thorax, so that the heart projects on the outside of the chest; 
the pericardium is usually absent. 100 
POST-MORTEM EXAMINATIONS. 
(b.) The diaphragm is absent, and the heart is found in the 
abdominal cavity. 
(c.) The heart is placed in some part of the neck or head ; 
this only occurs in foetuses very much malformed. 
(d.) The heart is transposed, being on the right side. 
Very rarely two more or less perfect hearts are found in the 
same thorax. 
HYPERTROPHY. 
All the cavities of the heart may have their walls hyper- 
trophied, or the thickening may only involve one or more. 
While the wall of a ventricle is thickened, its cavity may re- 
tain its normal size, or be dilated or contracted. The existence 
of the last condition-concentric hypertrophy-is denied by 
some authors, affirmed by others. 
Hypertrophy of both ventricles increases both the length and 
breadth of the heart. Hypertrophy of the left ventricle (alone) 
increases its length. The apex is then lower and further to 
the left than usual. Hypertrophy of the right ventricle (alone) 
increases the breadth of the heart toward the right side; but 
sometimes the right edge of the heart retains its normal situa- 
tion and the apex is displaced to the left. With large hyper- 
trophy of both ventricles, the base of the heart may sink so that 
its long axis approaches a horizontal direction. 
The exact way in which hypertrophy of the heart-walls takes 
place, whether by increase in the size or in the number of 
the muscular fibrillae, or in both ways, is not definitely deter- 
mined. 
Hypertrophy of the heart may depend upon a variety of 
(Causes. 
(1.) Changes in the valves, either insufficiency or stenosis, 
produce hypertrophy in the cavities to which the valves belong. 
(2.) Obstruction to the passage of blood through the aortic 
system <of vessels, by aneurisms, dilatation, atheroma, congeni- 
tal stenosis, the pressure of tumors, disease of the kidneys, 
((especially atrophy,) leads to hypertrophy, first of the left ven- 
tricle, and -secondarily of the right ventricle. 
(3.) -.Obstruction to the passage of blood through the puhno- 
jiary artery, by stenosis, and by diseases of the lungs, produces THE HEART. 
101 
hypertrophy of the right ventricle, and secondarily of the right 
auricle and left ventricle. 
(4.) Any cause, whether muscular or nervous, which increases 
the rapidity and force of the heart's contractions, may produce 
hypertrophy. 
(5.) Dilatation of the ventricles from any cause is frequently 
followed by hypertrophy. 
(6.) Pericarditis may produce hypertrophy by inducing soft- 
ening and dilatation of the ventricles, or by leaving adhesions 
which obstruct the heart's action. 
Finally, for some cases of hypertrophy no satisfactory cause 
can be found. 
DILATATION. 
Dilatation may be active-combined with hypertrophy ; sim 
pie-the heart-walls retaining their normal thickness ; or pas- 
sive-with thinning of the walls. 
Either one or all of the heart cavities may be dilated. The 
auricles are most frequently affected ; next, the right ventricle ; 
least often, the left ventricle. 
Active dilatation has already been described under the head 
of hypertrophy. 
In simple dilatation, the shape of the heart is changed accord- 
ing to the cavities affected. Dilatation of the right ventricle 
increases the breadth, dilatation of the left ventricle, the length 
of the heart. The walls of the heart are- of normal thickness; 
the muscular tissue is flabby; the muscular fibres are normal, 
or fatty, or waxy. 
Passive dilatation is produced by : 
(1.) Changes in the valves. Mitral or aortic stenosis, or in- 
sufficiency, may produce dilatation of the auricles and right 
ventricle. Pulmonary stenosis, or insufficiency, may produce 
dilatation of the right auricle and right ventricle. Aortic in- 
sufficiency, with or'without stenosis, or mitralinsufficiency, may 
produce dilatation of the left ventricle. Dilatations from these 
causes are often succeeded and compensated for by hypertrophy 
of the heart's walls. 
(2.) Changes in the muscular tissue of the heart-walls. 102 
POST-MORTEM EXAMINATIONS. 
Serous infiltration of the heart-wall, from pericarditis ; myocar- 
ditis ; fatty degeneration of the muscular fibres; and atrophy of 
the muscle, from chronic diseases, may all lead to dilatation. 
(3.) A heart which is already hypertrophied may, from de- 
generation of the heart-wall, become dilated. 
(4.) Acute infiltrations of the lungs, and acute pleuritic ex- 
udations, by rendering a large number of vessels suddenly im- 
permeable to the blood current, produce a rapid stasis in the 
pulmonary artery and dilatation of the right heart. 
ATROPHY. 
Atrophy of the walls of the heart may be accompanied with 
no change in the size of its cavities; or with dilatation, (the 
same as passive dilatation ;) or, more frequently, with diminution 
in the size of the cavities. 
The atrophy involves most frequently all the cavities of the 
heart, but may be confined to one or more of them. 
The muscular tissue appears normal, or brown from the pre- 
sence of little granules of pigment in the muscular fibres ; or 
the muscular fibres may undergo fatty degeneration ; or there 
may be an abnormal accumulation of fat beneath the pericar- 
dium ; or there may be a peculiar gelatinous material beneath 
the pericardium; this consists of fat which has undergone mu- 
cous degeneration. 
The causes of atrophy of the heart are: 
(1.) It is a congenital malformation ; the heart of an adult 
then looks like that of an infant. 
(2.) Any chronic and exhausting disease, repeated haemor- 
rhages, old age, typhus fever, dysentery, etc., may produce atro- 
phy. 
(3.) Chronic pericarditis, with large serous effusion, or with 
thickening of the epicardium, producing constriction of the 
coronary arteries. 
(4.) Stenosis, atheroma, calcification, or thrombosis of the 
coronary arteries, may produce partial or total atrophy. 
(5.) Myocarditis, with fatty or fibrous degeneration. 
(6.) Mitral stenosis may cause atrophy of the left ventricle. THE HEART, 
103 
CHANGES IN POSITION. 
Changes in the position of the heart are congenital or acquir- 
ed. The congenital malpositions have been already noticed ; 
the most important clinically is the transposition of the organ 
to the right side. 
The acquired malpositions are caused by: 
(1.) Hypertrophy of the heart; its long axis approaches the 
horizontal direction. 
(2.) Changes in the thoracic viscera. Emphysema of both 
lungs pushes the heart downward. Emphysema, pleurisy, with 
effusion, or pneumo-thorax of one side, push the heart to the 
other side. Pleurisy or chronic pneumonia, producing retrac- 
tion of one side of the thorax, draws the heart to that side. 
New growths, aneurisms, and curvatures of the spine displace 
the heart in various directions. 
(3.) Changes in the abdomen. Accumulations of fluid and 
new growths in the abdomen, and tympanites, may push the 
heart upward. 
WOUNDS AND RUPTURES. 
~Wounds of the heart are produced by penetrating instru- 
ments, by bullets, and by fragments of bone. The right ventri- 
cle is the more frequently wounded ; next, the left; rarely, the 
auricles. 
The wound may penetrate into the cavities of the heart, or 
only pass partly through its wall, or a bullet, or the broken end 
of a weapon, may be imbedded in the wall. 
If the wound penetrates into a cavity, and is gaping, death 
follows instantly, and the pericardium is found filled with 
blood. If the wound be small and oblique, the blood may es- 
cape gradually, and death does not ensue for several days. In 
rare cases, adhesions are formed with the pericardium, and the 
wound cicatrizes. 
Wounds which do not penetrate may cause death by the in- 
flammation which they excite, or may cicatrize. 
Bullets and foreign bodies may become encapsuled in the 
heart-wall, and remain so for years. 
Ruptures of the heart-wall occur in various ways. 104 
POST-MORTEM EXAMINATIONS. 
(1.) Severe contusions of the thorax may produce rupture, 
usually of one of the auricles. 
(2.) Spontaneous rupture occurs usually in advanced life. 
The left ventricle is the cavity most frequently ruptured. There 
is usually one rupture, sometimes two; five have been seen. 
The rupture is usually oblique, larger internally than externally; 
there may even be a small cavity filled with blood in the heart- 
wall. The heart-wall may be of normal thickness, or thin; it is 
soft and friable, the muscular fibres advanced in fatty degene- 
ration. The rupture usually takes place while the patient is 
quiet. Death is usually instantaneous, but sometimes does not 
ensue for several hours. 
Rupture of the inner layers only of the heart-wall may give 
rise to aneurisms of the heart. 
In rare cases, circumscribed inflammation, abscesses, hydatids, 
and tumors may produce rupture. 
(3.) In very rare cases, rupture is produced by stenosis of the 
aorta and dilatation of the heart cavities. 
(4.) Rupture of the papillary muscles and tendons is produced 
by fatty and atheromatous processes. 
INFLAMMATION. 
. MYOCARDITIS. 
Our knowledge of inflammation of the walls of the heart is 
still imperfect. The distinction between parenchymatous de- 
generation, and parenchymatous inflammation and their rela- 
tions to changes in the interstitial connective tissue, are obscure. 
In chronic pericarditis with effusion, we may find in the outer 
layers of muscle marked granular degeneration of the muscular 
fibrillae. This may be looked on as a parenchymatous inflam- 
mation, due to irritation, or as a simple degeneration from im- 
paired nutrition. 
A general and acute inflammation of the entire heart is de- 
scribed by Rindfleisch. It occurred in a man with a syphilitic 
history, and caused sudden death. The heart-walls were firm 
and stiff, the muscular tissue was of a fresh violet red color, 
iridescent, semi-translucent, of the consistence of caoutchouc. THE HEART. 
105 
The muscular fibres contained a finely granular substance 
collected around the nuclei, they were broken into quadrangular 
fragments. 
Abscesses of the heart-wall may be due to embolism or to un- 
known causes. Those due to embolism are multiple, scattered 
over the surface of both ventricles, and have the ordinary cha- 
racteristics of pysemic abscesses. 
Those due to other causes are usually single, situated in the 
wall of the left ventricle, or in the septum, and may be as large 
as a walnut. The abscess contains pus and broken-down mus- 
cular fibres. The pus may become thickened, cheesy, and 
inclosed in a fibrous capsule. More frequently the abscess 
opens into the pericardium or into the heart-cavity. If it opens 
into a heart-cavity, the blood enters and becomes mixed with 
the contents of the abscess, and a very favorable condition is 
afforded for the production of emboli in different parts of the 
body. The blood may finally rupture into the pericardial 
cavity, and cause death. If the abscess is in the interventricular 
septum, it may establish an opening between the two ventricles, 
or it may extend upward and form a diffused abscess in the 
connective tissue at the base of the heart. 
Change of the muscular substance of the heart into fibrous 
tissue is sometimes found. It usually occurs in the left ventricle, 
and in connection with endocarditis. We find a circumscribed 
portion of the heart-wall converted into fibrous tissue of some 
thickness, or into a thin membrane. It seems natural to ascribe 
such a condition to chronic inflammation going on in the heart- 
wall. 
These cicatricial spots may lead to the formation of aneurisms 
of the heart, or to general dilatation. 
THE ENDOCARDIUM. 
The endocardium resembles the entire coat of a blood-vessel 
spread out over the inner surface of the heart. It consists of 
several layers. On its inner surface is a layer of pavement en- 
dothelium. The cells are placed on a thick lamella, formed of 
anastomosing elastic fibres ; beneath this is a layer of loose elas- 
tic fibres mixed with a little connective tissue and some smooth 106 
POST-MORTEM EXAMINATIONS. 
muscular fibres. A layer of connective tissue separates the en- 
docardium from the muscular tissue of the heart. The valves 
are formed by a duplicature of the endocardium, so that there 
is on each face of the valve a layer of epithelium, an elastic 
layer, and in the centre a thin layer of connective tissue. Blood 
and lymph vessels are found in the endocardium. 
In intra-uterine life, endocarditis usually attacks the right 
ventricle; after birth, the left ventricle. The valves are the 
portion of the endocardium which is most frequently diseased. 
Rheumatism, Bright's Disease, and the severe febrile diseases 
are considered the usual causes of endocarditis, but there are 
many cases for which no cause can be found. 
The most moderate degree of inflammation manifests itself 
in a simple swelling of the valves. The valves are thickened 
and feel succulent and elastic. The swelling seems to be due 
to a simple swelling of the anatomical elements, with some in- 
crease in number of their connective tissue-cells. 
Another mild form exhibits itself in a simple opacity and 
thickening of the endocardium. This is usually seen in the left 
ventricle, in its upper part on the posterior wall; it may or may 
not be associated with disease of the valves. 
In more intense inflammation, the increase of cells is more evi- 
dent, so that we see little granulations on the valves or other 
parts of the endocardium. The cells increase in number till 
they reach the inner surface of the endocardium, and break 
through in a little fungous mass. On this roughened surface 
fibrine from the blood in the heart may be deposited so as to 
form vegetations of considerable size. Sometimes the cell pro- 
duction may be so great that minute abscesses are formed in 
and beneath the endocardium. 
Much more common than all of these changes is chronic en- 
docarditis, or atheroma, as it is more often called. The pro- 
cess consists in a production of small round cells, in the substance 
of the endocardium, followed by granular, fatty, or calcific de- 
generation. So that we find in the endocardium patches of an 
opaque, cheesy substance, made up of granules and debris of 
cells ; or calcareous plates. Over these patches, the inner layer 
of the endocardium may be destroyed and the patches may re- THE HEART. 
107 
main exposed, or the cheesy matter may soften and give rise to 
ulcerative destruction of tissue. 
In this way we find a great variety of lesions produced in the 
valves, and less frequently in the endocardium of the ventricles. 
The valves are simply thickened by cheesy yellow patches ; or 
they are stiff and rigid from cheesy or calcareous plates; or 
they are drawn together so as to obstruct the openings to which 
they belong; or the atheromatous matter softens, breaks down, 
and a larger or smaller part of the valve is destroyed. As soon 
as a roughened surface is produced, fibrine is usually deposited 
on it in the form of vegetations. 
The endocardium of the ventricles presents the same lesions : 
cheesy and calcareous plates and ulcerated surfaces. In the 
latter case, the muscular tissue may become involved and exca- 
vations of some little depth produced. In some cases, the pa- 
pillary muscles or chordae tendineae are destroyed so as to leave 
the valves flapping. 
Fenestration of the valves is usually a change productive of 
no bad consequences. It occurs in the aortic and pulmonary 
valves. The valves are thinner than usual, and close to their 
free edges are small slits extending from the centre to the at- 
tached edges of a leaf. 
Aneurisms of the valves are produced in two -ways. 
(1.) They are the result of endocarditis. One of the lamellae 
of the leaf of a valve is destroyed and the other lamella is 
converted into a sac filled with blood. These aneurisms are found 
in the aortic valve, projecting into the ventricle; and in the 
mitral valve, projecting into the auricle. Not infrequently the 
wall of the aneurism gives way, so that there is a rupture en- 
tirely through the valve. 
(2.) The entire thickness of a leaf of a valve is converted into 
a sac filled with blood. This occurs in the aortic, mitral, and 
tricuspid valves; its cause is unknown. 
Haemorrhage in the substance of the valves is sometimes 
found in very young children. It does not appear to have mueh 
clinical importance. 
CHANGES IN THE VALVES. 108 
POST-MORTEM EXAMINATIONS. 
Insufficiency of the valves to close the orifice to which they 
belong is produced by : 
(1.) Inflammation, thickening, shrinking, and shortening of 
the valves. To these may be joined atheroma, calcification, and 
vegetations. 
(2.) The valves may become adherent to each other or to the 
heart-wall. 
(3.) Partial destruction of a valve, of a papillary muscle, or 
of one of the chordae tendineae by inflammation. 
(4.) Dilatation of the orifice of a valve without corresponding 
increase in the size of the valve itself. 
(5.) A very high degree of fenestration of the valve. 
(6.) Large vegetations adhering to the valve. 
Stenosis of the valves is produced by inflammatory changes 
resulting either in simple rigidity, or in adhesions and contrac- 
tion of the valve. In the latter case, the stenosis may be so 
marked that a quill will hardly pass through the orifice. 
The same lesions frequently produce both stenosis and insuffi- 
ciency of a valve. 
These changes occur most frequently in the aortic and mi- 
tral valves; more rarely, in the pulmonary and tricuspid. 
Insufficiency and stenosis of the valves produce changes in 
the heart itself and in the rest of the body. 
In the heart we find dilatation and hypertrophy in various 
degrees. 
Insufficiency of the mitral valve produces dilatation and hy- 
pertrophy of the left ventricle, dilatation of the left auricle, and 
not infrequently dilatation and hypertrophy of the right ven- 
tricle and auricle. 
Stenosis of the mitral valve usually leaves the left ventricle 
of normal size, or even atrophied ; the left auricle, right ventri- 
cle, and right auricle- are usually dilated and hypertrophied. 
The tricuspid valve may be insufficient or stenosed, usually 
both at once. A small degree of insufficiency appears to be a 
physiological condition. Greater degrees are usually secondary 
to mitral stenosis. If stenosis exists, it is moderate in degree, 
and its effect is the same as insufficiency-dilatation of the right 
auricle and of the veins leading into it. THE HEART. 
109 
The aortic valve may be insufficient, or stenosed, or both. 
Insufficiency produces dilatation or hypertrophy of the left 
ventricle, secondarily of the left auricle, right ventricle and 
auricle. Stenosis, with insufficiency, produces the same lesions 
in a higher degree. Stenosis alone produces dilatation of the 
left ventricle without hypertrophy, giving the heart a globular 
form. 
The pulmonary valve is rarely insufficient or stenosed. It 
causes dilatation or hypertrophy of the right ventricle and 
auricle. 
The changes produced by valvular lesions in other parts of 
the body are due to an increase of venous, or a diminution of 
arterial pressure, both resulting in the same way, namely, in a 
constant venous congestion of the different viscera, and serous 
effusions into the different serous cavities. Stenosis of the mi- 
tral valve, or of the pulmonary artery, produces these changes 
in the highest degree. 
Pigment induration of the lungs, congestion and subsequent 
changes in the liver, catarrhal inflammation of the stomach and 
intestines, induration of the kidneys, and cyanosis of the skin 
may all be found. 
ANEURISM OF THE HEART. 
Sacs filled with blood, situated in the walls of the heart, and 
communicating with its cavities, are formed in several different 
ways. 
(1.) In consequence of inflammatory processes in the endo- 
cardium and muscular tissue, a small or large portion of the 
wall is converted into fibrous tissue. The portion thus chang- 
ed no longer resists the pressure of the blood from within, and 
is driven outward. Such a pouch may be a circumscribed sac, 
communicating with the heart cavity by a small opening, or may 
look like a dilatation of part of the ventricle. The wall of 
such an aneurism becomes thinner as the sac increases in size. 
It is composed of the endocardium, new fibrous tissue, visceral 
pericardium, and sometimes the adherent parietal pericardium., 
The walls may calcify ; or rarely they become so thin as to rup- 110 
POST-MORTEM EXAMINATIONS. 
ture externally or into the right ventricle. The sacs may con- 
tain fluid blood, or be filled up with fibrine. 
Such aneurisms are usually situated in the wall of the left 
ventricle ; rarely in that of the left auricle. If they are in the 
septum, they may project into the right ventricle. They are 
usually single ; sometimes two or three are found in the same 
heart. 
(2.) Fatty degeneration of the heart-wall may reach such] a 
point that the wall yields and is pouched out into an aneuris- 
mal sac. 
(3.) Endocarditis and myocarditis, or fatty degeneration, may 
so soften a portion of the heart-wall that the endocardium and 
part of the muscular tissue is ruptured, and a ragged cavity is 
formed. This form of aneurism usually does not attain a large 
.size, but soon ruptures externally, and causes the death of the 
patient. 
THROMBOSIS OF THE HEART. 
It is very common to find after death, in the heart-cavities, 
yellow, succulent, semi-translucent masses. They are most 
common ano of firmest texture in persons who die of acute 
inflammatory diseases. They may adhere quite firmly to the 
walls of the heart, and may extend in long, branching cords 
into the vessels. They are formed in the last hours of life, and 
just after death. They have no clinical or pathological im- 
portance. 
Coagulations of the fibrine of the blood in the heart do, how- 
ever, occur during life, and may exist for years. If the fibrine 
adheres to the valves in small masses, these are called vegeta- 
tions ; if it coagulates in the heart-cavities in larger bodies, 
they are called thrombi, or heart polypi. 
Such thrombi are found in all the heart-cavities. They form 
flattened masses firmly adherent to the endocardium ; or round- 
ed bodies in the spaces between the trabeculae; or have a poly- 
poid shape and are attached by a narrow pedicle, or are free in 
the cavity. 
They are usually found in connection with some valvular THE HEART. 
111 
lesion, which prevents the free circulation of blood through 
the heart. 
They are firm, dry, and of a whitish color, they may soften 
and break down at their centres, so as to look like cysts filled 
with pus, or they may calcify. They are usually entirely un- 
organized, consisting simply of fibrine. 
I have observed one case in which the thrombi were distinct- 
ly organized. The patient was a man found dead in the street, 
concerning whom no history was obtained. 
There were two thrombi attached to the endocardium of the 
right auricle at a point half an inch from the tricuspid valve, 
and close to each other. One of them was spherical, inches 
in diameter, attached to the auricle by a small, round pedicle. 
The other was ovoid, 3| inches long, was attached by a small 
pedicle, projected through the tricuspid valve into the right 
ventricle, was calcified, and its free end ragged and broken. 
When they were fresh, both polypi were formed of a yellow, 
semi-translucent, elastic tissue, parts of which were calcified. 
Small vessels filled with blood could be seen near the surface. 
A thin membrane continuous with the endocardium could be 
dissected up from their surfaces. The body of the polypi, 
where they were not calcified, consisted of a basement sub- 
stance partly fibrous, partly homogeneous, and of round, oval, 
fusiform, and stellate cells. Arteries and capillaries, some con- 
taining blood, were found in considerable numbers. 
I have also seen another organized thrombus in the right 
auricle. The specimens were shown to me by Dr. Mann. 
The patient was a middle aged-man, one of whose legs was 
amputated on account of some tumor. After a time, the tumor 
recurred in the stump. At the autopsy there were found sec- 
ondary nodules in the lungs, and a large thrombus in the right 
auricle and extending into the inferior vena cava. The growth 
in the stump, in the lungs, and in the auricle, all had the same 
structure. They were composed of a fibrous stroma inclosing 
rounded cavities. These cavities were filled with large nucleat- 
ed cells resembling pavement epithelium. The cells were not 
in contact with each other, but were separated by a fine fibrous 
reticulum. 112 
POST-MORTEM EXAMINATIONS. 
DEGENERATIONS. 
Fatty Degeneration affects the heart in two ways, as an in- 
crease of the subpericardial fat, and as a change in the muscu- 
lar fibres. 
The increase of the subpericardial fat may be attended with 
atrophy of the muscular tissue, or it may not. It accompanies 
an increase of adipose tissue throughout other regions of the 
body. 
Fatty degeneration of the muscular fibres produces fine 
granules in them, which may be so numerous as to apparently 
fill the sarcolemma. These granules appear to be at first of an 
albuminous, later of a fatty nature. The affected muscle ap- 
pears yellow, soft, and friable. The heart-wall may retain its 
normal thickness, or it may be much atrophied. The greater 
part of the heart may undergo this change, or only small cir- 
cumscribed portions, or only the superficial layers. The de- 
generation may lead to rupture of the heart, or to death from 
the inability of the heart to fulfil its functions. Phosphorus 
poisoning, typhus and severe fevers, pericarditis and exhausting 
diseases are found as causes for this condition, but it may occur 
in apparently healthy individuals. 
Waxy or Amyloid Degeneration is found in connection with 
the same change in the other viscera, and is due to the same 
causes. The muscular fibres are the seat of the degeneration. 
Mucous Degeneration of the subpericardial fat is found in 
persons much emaciated by chronic disease. The fat is chang- 
ed into a translucent, gelatinous substance, composed of a 
homogeneous basement substance, coagulable by alcohol and 
acids, and of connective tissue-cells and compound granular 
corpuscles. 
NEW GROWTHS. 
Fibroma is sometimes seen in the form of small nodules 
growing in the heart-wall, or projecting under the endocardium 
or pericardium. 
Lipoma is very rare in the form of a circumscribed tumor, THE HEART. 
113 
although a general increase of the subpericardial fat is com- 
mon. 
Myoma strioceUulare.-Tumors formed of voluntary muscle 
have been seen in three cases as a congenital lesion. The tu- 
mors were single or multiple, some as large as a cherry, of the 
consistence and appearance of the surrounding heart-wall, but 
looking like circumscribed nodules. In one case, the tumor was 
cavernous. In one case, there were also gummy tumors in the 
heart-wall. 
A single case has been observed, in an adult, in which the en- 
tire wall of the left ventricle was changed into a spongy mass, 
which may belong to the same category. 
Syphilitic Gummata may occur at any point of the ventricu- 
lar wall. They are usually multiple, may reach the size of a 
pigeon's egg, are of a whitish or yellow color, of fibrous or 
cheesy consistence ; sometimes softer. They are composed of 
small round cells developed between the muscular fibres. The 
tumors may be almost entirely composed of cells, or may be 
partly cheesy, or mixed with fibrous tissue. 
Tubercle are found in the heart-wall in the form of miliary 
granulations. They have also been observed in the valves. 
Cysts containing serum, and others containing a grumous 
fluid, have been seen in rare cases. 
Sarcoma sometimes occurs as a metastatic growth. 
Carcinoma of the heart as a primary tumor is very rare. 
Nodules secondary to growths in the mediastinum or other re- 
gions are more copimon. Epithelial cancer in this organ is de- 
scribed by Paget and Virchow. Carcinomatous thrombi in the 
heart cavities sometimes occur as secondary formations from the 
same growth in other regions. 
PARASITES. 
Echinococci are sometimes found in the walls of the ventri- 
cles in their usual form of hydatid cysts. 
Cysticercus sometimes occurs in connection with cysticerci in 
the voluntary muscles. 114 
POST-MORTEM EXAMINATIONS. 
THE ARTERIES. 
MALFORMATIONS. 
The most important anomalies of the aorta and pulmonary 
artery have already been mentioned in connection with those 
of the heart. Congenital stenosis of the aorta will be spoken 
of under the head of stenosis. Anomalies in the distribution 
and origin of the arteries are principally of interest to anato- 
mists. 
DILATATION. ANEURISMS. 
(1.) Cirsoid Aneurism consists in the dilatation and length- 
ening of large or small arteries. The walls of the artery are 
thinned, the vessel is tortuous, and in places sacculated. These 
changes are most frequent in small arteries, especially the tem- 
poral and occipital; they involve the trunk of the vessel, and 
its branches, or may extend to the capillaries and small veins. 
They form larger or smaller tumors beneath the skin. 
Barely they are found in the larger arteries, and even in the 
aorta. 
(2.) The ordinary Aneurism is a dilatation of the coats of the 
artery over a larger or smaller part of its course. Such dilata- 
tions are usually due to chronic endarteriitis. According to 
their shape we may distinguish two varieties : the diffuse and 
the circumscribed. 
(1.) The diffuse, cylindrical, or fusiform aneurism consists in 
a uniform dilatation of all the coats of an artery, so that it as- 
sumes the shape of a fusiform or cylindrical swelling. In the 
walls of the dilated portion of the vessel there are often smaller 
circumscribed dilatations. The wall of the aneurism is athero- 
matous or calcified; the middle coat may be atrophied. The 
arch of the aorta is the most common seat of this form of an- 
eurism ; but the entire length of the aorta, or parts of any other 
arteries, may be dilated in the same way. 
(2.) The circumscribed or sacculated aneurism consists either 
in a dilatation of the entire circumference of an artery over a 
short portion of its length, or in a dilatation of only a small 
portion of one side of the wall, so that the aneurism looks like THE ARTERIES. 
115 
a swelling attached to one side of the artery. The aneurism 
commences as a dilatation of all the coats of the vessel; but as 
soon as it attains any size, the middle coat atrophies, so that the 
wall is composed of the inner and outer coats ; or the inner coat 
is destroyed by endarteriitis, so that the outer coat alone forms 
the wall of the aneurism. As the aneurism increases in size, it 
presses upon and causes the destruction of the neighboring tis- 
sues and viscera, and portions of these tissues and viscera be- 
come incorporated with or take the place of the wall of the 
aneurism. The cavity of the aneurism is filled with fluid or 
clotted blood, or with layers of fibrine which adhere closely to 
its wall. The communication between the aneurism and the 
artery may be small or large. If arterial branches are given off 
from the aneurism, they may remain open, or become plugged 
with fibrine ; or their walls are thickened and their cavities nar- 
rowed by endarteriitis. Death is produced by the pressure and 
interference of the aneurism with the adjoining viscera, or by 
rupture. The rupture may allow enough blood to escape to 
destroy life, or the blood may be held in by the soft parts, and 
a second false aneurism formed about the original one. 
ANEURISMS OF THE DIFFERENT ARTERIES. 
The Aorta may be dilated over its entire length ; or there 
may be diffuse or circumscribed dilatations at any portion of 
its course ; or there may be several aneurisms situtated at dif- 
ferent points. 
The ascending portion of the arch of the aorta may be uni- 
formly dilated in a fusiform shape; or there may be circum- 
scribed dilatations on its anterior wall; or, more rarely, on its- 
posterior wall. The sacculated aneurisms may be of all sizes,, 
and may rupture within the pericardium ; or they may form a 
cavity in the upper part of the ventricular septum, and commu- 
nicate by openings into the pulmonary artery and left ventricle ; 
or they may dilate downward between the visceral and parietal 
pericardium, in front of the heart, pushing that organ back- 
ward. They may perforate into the right or left auricle or 
right ventricle, the superior vena cava, or the pulmonary arte- 116 
POST-MORTEM EXAMINATIONS. 
ry ; or they may reach a large size, press on and erode the right 
side of the sternum and adjoining ribs, project under the skin, 
and even rupture externally. 
The transverse portion of the arch may be dilated in a fusi- 
form shape ; or there may be sacculated aneurisms at any point 
in its wall. The sacculated aneurisms usually reach a consider- 
able size. They press on the sternum and ribs in front, or on 
the oesophagus, trachea, and bronchi behind. The large arte- 
ries given off from the arch may be occluded. They cause death 
by pressure on the air-passages, the oesophagus, and the vena 
cava; or may rupture externally, or into the oesophagus, tra- 
chea, bronchi, or pleuritic cavities. 
On the thoracic aorta we find both diffused and circumscrib- 
ed dilatations. They may reach a large size ; compress the as- 
cending vena cava, the heart, oesophagus, bronchi, and lungs ; 
may erode the ribs, destroy the vertebrae, and open into the 
spinal canal. They may rupture externally, or into the bron- 
chi, oesophagus, or pleural cavities. 
On the abdominal aorta we usually find sacculated aneurisms. 
If they are situated high up, they may project into the pleural 
cavities ; if lower down, into the abdomen. They compress and 
displace the viscera, vessels, and nerves, and erode the vertebrae. 
They may rupture behind the peritoneum, in the peritoneal 
cavity, the pleural cavities, the inferior vena cava, the lungs, 
the colon, the pelves of the kidneys, the posterior mediasti- 
num. 
The Coronary Arteries may be dilated throughout, or may 
be the seat of small sacculated aneurisms. These may rupture 
into the pericardium, or may cause rupture of the heart-wall. 
The Pulmonary Arteries are rarely the seat of aneurisms. 
Diffuse and circumscribed dilatations, however, sometimes oc- 
cur on the main trunk and on the two principal branches of 
the artery. They usually do not reach a large size, but cause 
death by rupture. General dilatation of all the branches of the 
pulmonary artery is more common. It is found in connection 
with stenosis of the mitral valves, and with compression or in- 
duration of the lung tissue. THE ARTERIES. 
117 
Of the other arteries of the body there is hardly any one 
which may not become the seat of an aneurism. 
STENOSIS. 
Stenosis and obliteration of the aorta, at the point of entrance 
of the ductus arteriosus, has been described in a considerable 
number of cases. 
The situation of the stenosis is either exactly at the entrance 
of the ductus arteriosus, or close on either side of this point. 
The degree of stenosis varies. The aorta may be entirely clos- 
ed and converted into a solid cord for a length of half an inch ; 
or there may be a circular constriction through which there is 
a larger or smaller opening. The constriction is uniformly cir- 
cular ; of there is a septum springing from the concave side of 
the vessel at the opening of the ductus arteriosus ; or there is a 
cicatricial-like contraction of the aorta. The walls of the aorta 
at this point may be thickened and sclerosed. The ductus arte- 
riosus may be closed or open. Above the constriction the aorta 
is usually dilated; below* it, it is normal, dilated, or stenosed. 
Stenosis of the aorta produces hypertrophy of the left ventri- 
cle, and, later, of the right ventricle, with venous congestion 
throughout the body; or there may be a collateral circulation 
developed between the arteries given oif above and below* the 
constriction; or there may be rupture of the aorta, the right 
ventricle or auricle. 
This condition is found at all ages, but is produced during 
foetal life, or in the first year of extra-uterine life. It is proba- 
ble that it may be caused after birth by an abnormal closure of 
the ductus arteriosus. This vessel normally becomes closed with- 
out the formation of a thrombus. If a thrombus is formed, it 
may extend into the aorta and obstruct it; or the ductus arte- 
riosus is filled with a thrombus, but increases for a time in size; 
afterward, as the thrombus is absorbed, the vessel contracts and 
draws the walls of the aorta together. 
Stenosis of the aorta and of some of the other arteries has 
been observed in a few rare cases, without any known cause. 
Endarteriitis, with the production of atheromatous and cal- 
careous patches, may obstruct or entirely obliterate the smaller 118 
POST-MORTEM EXAMINATIONS. 
arteries. This is especially seen in the arteries of the leg, foot, 
and brain, and in the coronary arteries. 
Narrowing of the aorta, and of all its branches, with thin- 
ninff of the arterial coats, is found as a congenital condition. It 
usually occurs in females in connection with want of develop- 
ment of the entire body. 
Stenosis from thrombosis or embolism is treated of elsewhere. 
RUPTURE AND WOUNDS. 
Ruptures of arteries are found under the following conditions: 
(1.) Fatty degeneration or endarteriitis, with atheromatous 
changes, may so soften and destroy the inner and middle coats 
of an artery as to admit of its rupture. The aorta, just above 
the valves, is the most frequent seat of this lesion. The rup- 
ture may run in any direction ; its edges are irregular and jag- 
ged. The blood may burst through all the coats of the aorta at 
the same point; or, more frequently, the external coat re- 
mains, and the blood is infiltrated in the middle coat, and be- 
tween it and the external coat. In this way, a dissecting aneu- 
rism is formed, which may extend along the aorta for a conside- 
rable distance. After a short time, the external coat gives way 
at some point, and the blood escapes. In rare cases, life is pro- 
longed for some time, the rupture being closed by a new mem- 
brane. 
We also find ruptures from fatty degeneration and atheroma 
in the arteries of the brain and of the lungs ; in the coronary 
arteries, the coeliae axis, and mesenteric arteries, and in the ar- 
teries of the upper and lower extremities. 
(2.) In rare cases, stenosis of a portion of the aorta may cause 
rupture at some point between the seat of stenosis and the 
heart. 
(3.) Contusions, wrenchings, and severe falls may rupture the 
wall of an artery either partially or completely, producing trau- 
matic or dissecting aneurisms, or completely severing the vessel. 
(4.) Penetrating wounds may wound or entirely sever an ar- 
tery. If the artery be of large size, death from haemorrhage is 
the usual result. A smaller artery may become closed, or be 
the seat of a false aneurism. THE ARTERIES. 
119 
In the healing of a wounded artery, two conditions coope- 
rate. The vessel retracts and contracts, and a thrombus is 
formed within it. The contraction may be alone sufficient to 
close the vessel; its coats thicken, and the inner surfaces finally 
are fused together; or the blood coagulates, and forms a throm- 
bus in the vessel near the wound. This thrombus later be- 
comes organized, and the vessel is converted into a fibrous cord. 
Spurious aneurisms are found most frequently connected 
with vessels of the extremities. When an artery is wounded, 
the blood escapes into the surrounding soft parts, and a cavity 
is formed filled with blood and broken-down tissue. This con- 
dition may terminate in several ways. 
(a.) The wound in the artery may heal, and the effused blood 
be absorbed. 
(b.) The effused blood and broken tissues may become gan- 
grenous and the surrounding soft parts be inflamed. 
(c.) A sort of sac-wall may be formed by the soft parts, 
while the wound of the artery remains open, so that we have 
an aneurismal sac through which the blood is constantly pour- 
ing. 
(5.) If an artery be wounded, and at the same time the vein 
which accompanies it, we have as the result the conditions call- 
ed Aneurismal Varix and Varicose Aneurism. In aneurismal 
varix, the artery and vein become adherent at the seat of inju- 
ry, so that the arterial blood passes directly into the vein. 
There is a smooth, rounded opening between the two vessels, 
the vein is dilated into a sac, and the veins emptying into it are 
dilated and tortuous. 
In varicose aneurism, the artery and vein do not communi- 
cate directly, but a false aneurismal sac is formed between the 
vessels, into which the blood is poured before passing into the 
vein. 
Varicose aneurism may also be produced by the spontaneous 
rupture of an aneurism into a vein. The aneurism presses 
against the vein, becomes adherent, and finally ruptures into it. 
This condition has been observed between the aorta and pul- 
monary artery; the aorta and inferior and superior vena cava; 
the popliteal artery and vein ; the femoral artery and vein ; the 120 
POST-MORTEM EXAMINATIONS. 
splenic artery and vena azygos ; the internal carotid and sinus 
cavernosus. Even in the cases of perforation by aortic aneu- 
risms, life is usually prolonged for some time. 
(6.) Destructive inflammation of the surrounding tissues may 
invade and destroy a portion of the Avail of an artery. Thus ul- 
ceration of the trachea, bronchi, bronchial glands and oesopha- 
gus, may perforate the aorta; gangrene of the lungs, the pul- 
monary arteries ; ulcer of the stomach, the gastric arteries, etc. 
INFLAMMATION. 
The Avails of arteries are composed of three layers-the inner, 
middle, and outer coats. The inner coat, or tunica intima, con- 
sists of three layers: an inner layer of flat, thin, fusiform, or 
polygonal endothelium; a middle layer consisting of a finely 
granular basement substance traversed by fibres, and containing 
numerous fusiform and stellate cells ; an outer layer composed 
in the smaller arteries of an elastic network; in the larger ar- 
teries, of one or more layers of an elastic, homogeneous fenes- 
trated membrane. 
The middle coat, or tunica media, is composed of involuntary 
muscular fibres, mostly running around the vessel, but some in 
its long axis ; and of a variable amount of fibrous tissue, elastic 
tissue, and fenestrated membranes. 
The outer coat, or tunica adventitia, consists of fibrous tis- 
sue and a network of elastic fibres. 
The vasa vasorum or nutrient vessels of the arterial Avail are 
distributed principally in the external coat, scantily in the 
middle coat. 
Inflammation of an artery attacks principally the outer coat 
-Periarteriitis-or the inner coat-Endarteriitis. 
Periarte^tis is not very common. It occurs in the larger 
arteries and is usually a secondary lesion. It is caused by in- 
juries, by inflammation of the surrounding tissues, and by throm- 
bosis or embolism. The outer and middle coats of the inflamed 
artery are congested and infiltrated, and thickened with a soft, 
grayish, structureless material. The cavity of the vessel is at 
first narrowed, afterward enlarged. At a later period, Ave find THE ARTERIES. 
121 
various changes. The outer layers of the arterial wall may be- 
come necrotic, the inner coat may also die and be cast off in 
small fragments. In other cases, pus is produced either as a 
diffuse infiltration of the outer coats, or in the form of small 
circumscribed abscesses. The inner coat degenerates into little 
fragments, or is ruptured. In other cases, the inflammation has 
a more chronic character, and leads to fibrous thickening of the 
coats of the vessel, and frequently to its obliteration. In all 
the varieties, the presence of a thrombus in the artery, either as 
cause' or effect of the inflammation, complicates the process. 
The thrombus may shrivel and be absorbed, or become organiz- 
ed, or be broken down and gangrenous, and form infarctions in 
other parts of the body. 
Endarteriitis is a chronic inflammation of the inner coat of 
arteries, resulting in the production of atheromatous and calci- 
fied plates. It rarely occurs before middle life, while in old age 
it is a very frequent senile change. The arch of the aorta is 
the most frequent seat of the lesion, but it may occur in any 
artery. 
The disease begins in the form of small, flattened elevations 
on the inner surface of the artery. These elevations are formed 
by a hyperplasia of the outer layers of the inner coat. We find 
a considerable number of round, fusiform, and stellate cells with 
a basement substance, which is hard and fibrous or soft and 
mucous. 
When the lesion has reached this stage, it goes on to fatty or 
calcific degeneration. Fatty degeneration attacks both the new 
cells and basement substance, converting them into a dense, 
yellow, cheesy mass ; or into a soft, semi-fluid, yellow, puriform 
substance. Instead of cells and basement substance, we now find 
fatty and broken cells, granules, and plates of cholesterine. 
This condition is called atheroma. The softening process ad- 
vances toward the inner surface of the tunica intima, covering 
the atheromatous patch, until a small perforation is formed and 
we find a small cavity filled with a thick, yellow fluid, com- 
municating with the cavity of the vessel by a narrow sinus. 
As more of the intima is destroyed, the opening becomes larger, 
and we find a flat ulcer, often of considerable size. On the 122 
POST-MORTEM EXAMINATIONS. 
roughened surface thus produced the fibrine of the blood is often 
deposited. The lesion may lead to the rupture of the vessel, 
or to the formation of ordinary, or of dissecting aneurisms. 
Calcific degeneration takes place by the deposition of the 
salts of lime in the plate formed by the hyperplasia of the 
intima. We find thin plates, looking like bone, still covered 
by the intima, or bare. The plates may be few and small, or 
large and numerous. The process may be accompanied by a 
calcification of the muscular cells of the middle coat. All the 
stages of simple hyperplasia, fatty, and calcific degeneration 
are often met with in the same vessel. 
Simple fatty degeneration of the intima may occur in the 
same artery in which the lesions of chronic endarteriitis are 
found. 
Under the name of Canalization Rokitansky describes a 
rare change in the inner coat. The intima is thickened and 
pierced with numerous small canals, into which the blood passes. 
In this way, the arterial wall is converted into a spongy, cavern- 
ous tissue resembling the corpus cavernosum. 
Simple Fatty Degeneration affects only small, circumscribed 
portions of the inner coat. There is a fatty degeneration of 
the cells of the intima, with absorption of the basement sub- 
stance. The process begins in the inner layers of the inti- 
ma, and gradually works outward, forming small excavations. 
It may lead to rupture of the vessel. 
Calcification of the muscular cells of the middle coat occurs 
in connection with atheroma, with caries of the bones, and as 
an idiopathic affection. It is usually found in old people, and 
involves arteries of medium size. It may lead to gangrene of 
the parts supplied by the affected vessels. 
Amyloid Degeneration of the arteries is of common occur- 
rence. The inner coat and the muscular layer are infiltrated 
with a translucent material looking like wax. In extreme cases, 
the outer coat is infiltrated in the same way. The walls of the 
vessel appear thickened, stiff, and of a peculiar waxy color, they 
are colored mahogany red by the addition of a weak solution of 
Iodine. The lumen of the affected vessel is diminished in size. 
DEGENERATION. THE VEINS. 
123 
THE VEINS. 
DILATATION. 
Dilatation of the Veins, or Plilebectasia, presents itself 
under a variety of forms. 
(1.) Simple Dilatation. The vein is uniformly dilated in a 
cylindrical or fusiform shape; its length is not increased; its 
walls are of normal thickness, or thinned; the valves increase 
in size, or are insufficient, or atrophy, or are torn. 
(2.) Cirsoid Dilatation. The vein is uniformly cylindrically 
dilated, but is also increased in length, so that it assumes a very 
tortuous course. The walls are normal, thickened or thinned. 
(3.) Varicose Dilatation. A circumscribed portion of the 
wall of the vein is dilated so as to form a globular sac. The 
sac communicates with the vein through a large or small open- 
ing. The wall of the sac is formed of the coats of the vein, 
which preserve their normal thickness, are thickened or thinned ; 
the middle coat may disappear entirely. There may be only 
one such dilatation, or there may be a number on the same vein, 
or a number of veins may be affected at the same time. The 
vein may be otherwise normal, or, more frequently, is dilated 
in the cirsoid form. 
(4.) Anastomosing Dilatation. A number of contiguous and 
anastomosing veins are dilated, both in the cirsoid and varicose 
forms. The vein then looks like a series of cavities separated 
by thin partitions. Tlie dilatations of the same vein become 
adherent to each other and to those of the adjoining veins; 
portions of the wall of the dilated parts may disappear, and we 
find a number of cavities containing venous blood, and sepa- 
rated from each other by thin partitions. The course of the 
vein can no longer be followed out. 
Spontaneous cure of dilatations of the veins is not common, 
and usually occurs only in the lesser degrees of the lesion. 
Most phlebectasim increase steadily in size and extent. Very 
frequently thrombi form in the dilated veins, and either par- 
tially or completely fill them. The wall of the dilated sac may 124 
POST-MORTEM EXAMINATIONS. 
become so thin that it finally ruptures, and the blood is dis- 
charged externally. Sometimes inflammation is set up in the 
tissues surrounding the vein, and we find both the surrounding 
tissues and the wall of the vein the seat of purulent infiltration 
or fibrous thickening. The parts of the body from which the 
dilated veins draw their blood exhibit the results of chronic 
venous congestion, oedema, hyperaemia, and hypertrophy. 
There is hardly one of all the veins of the body which may 
not be dilated. The veins of the leg and thigh ; those of the 
pelvis and pelvic viscera ; those of the spermatic cord, scrotum, 
and labia ; those of the abdominal wall; those of the neck and 
arm are the ones most frequently found in this condition. 
The causes of dilatation are some mechanical obstruction to 
the passage of the blood through the veins toward the heart. 
WOUNDS. RUPTURE. 
Wounds of the veins usually heal by a simple contraction, 
and an adhesive inflammation of their walls ; sometimes by the 
formation of a thrombus. Rupture of the veins is produced 
by severe contusions and crushings of the body, and by violent 
falls. 
Perforation of a vein is produced by suppuration of the soft 
parts and invasion of the walls of the vein; by suppurative in- 
flammation beginning in the wall of the vein ; by the pressure 
of an aneurism or of a new growth ; by thinning of the venous 
wall in phlebectasise. 
INFLAMMATION. 
Inflammation of a vein may affect principally the outer 
coat-periphlebitis-or the inner coat-endophlebitis. 
Periphlebitis is of not infrequent occurrence. It is caused 
by the presence of a thrombus, by injuries, and by inflamma- 
tion of the surrounding tissues. It may be of a suppurative or 
of an indurative character. In suppurative periphlebitis, the 
outer layers of the venous wall are congested, swollen, infil- 
trated with serum and pus-cells. The inner coat degenerates, 
and portions become necrotic, and may be cast off. In this way, 
the vein may be perforated either from the inside or the out- THE VEINS. 
125 
side. A thrombus in the vein is the constant accompaniment of 
periphlebitis. It usually is the cause of the inflammation, but 
may be its result. The changes which take place in the throm- 
bus, and the infarctions produced by its fragments in different 
parts of the body, are the most important results of phlebitis. 
Periphlebitis may terminate in absorption of the thrombus, 
with the return of the vein to its normal condition; in oblite- 
ration of the vein ; or in the death of the patient from infarc- 
tions. 
Chronic Periphlebitis produces thickening of all the coats of 
the vein, but principally of the outer coat. The surrounding 
soft parts are also thickened, so that the vein can hardly be 
separated from them. The lumen of the vein remains open, or 
is filled with a thrombus. 
Endophlebitis is an inflammation of the inner coat of the 
vein, of the same character as chronic endarteriitis. Circum- 
scribed patches of thickening of the inner coat are produced, 
which afterward undergo fatty and calcareous degeneration. 
Waldeyer has lately drawn attention to the fact that the 
division of the walls of the veins into three coats, as in the ar- 
teries, is an artificial one. The venous wall is rather a layer of 
connective tissue, covered on its inner surface with endothelium, 
and reinforced in places by muscular fibres and elastic tissue. 
If the outer part of the venous wall is inflamed, the morbid 
process is apt to extend to its inner surface. We then find on 
the internal surface of the vein very fine velvet-like granula- 
tions, which are formed by an increase of the endothelial cells. 
These granulations may increase in size until the wall of the 
vein is covered with a soft mass, which can hardly be distin- 
guished from a thrombus. The mass is, however, a soft, organ- 
ized, vascular granulation tissue, continuous with a similar cell 
growth through the entire thickness of the wall of the vein. 
The form of phlebitis is attended and followed by the forma- 
tion of a thrombus. 
NEW GROWTHS. 
Myoma has been observed in two cases : one on the saphe- 
nous vein, and one on the ulnar vein. The tumors were of small 
size, and formed by a circumscribed hypertrophy of the muscu- 126 
POST-MORTEM EXAMINATIONS. 
lar coat of the vein. The corresponding portion of the lumen 
of the vein was dilated. The growth appeared like a globular 
dilatation of the vein, with great hypertrophy of the muscular 
coat. 
Myo Sarcoma has been observed in one case. The tumor was 
as large as a man's fist, situated in the cavity of the dilated vena 
cava, extending from the liver to below the renal veins. The 
growth had invaded the adjoining portion of liver, and there 
were secondary growths in the lymphatic glands. The tumor 
consisted of connective tissue, smooth muscle, fusiform cells, 
and myeloplaxes. 
Carcinoma of the surrounding parts may perforate the wall 
of a vein, and grow in its cavity, so as to form a thrombotic 
mass of considerable size. Cases have been reported in which 
the new growth was confined to the cavity of the liver veins, 
and not found in any other part of the body. 
PARASITES. 
Echinococcus is sometimes found in the veins, either develop- 
ed there, or having perforated from the adjoining tissues. 
Eistoma hepaticum is found in the veins of the liver. 
Eistoma hamatobium has been found in the portal vein and 
its branches, principally in Egyptians. 
THE ALIMENTARY CANAL. 
THE MOUTH. 
MALFORMATIONS. 
Malformations of the lips and cheeks are usually associated 
with defective formation of the bones of the mouth. The entire 
process is generally due to an arrest of development. 
(1.) The lower jaw is absent; the upper jaw and hard palate 
small and imperfectly formed; the temporal bones nearly touch 
in the median line. The lower half of the face is therefore 
wanting; the mouth is absent, or small and closed posteriorly ; THE MOUTH. 
127 
the tongue is absent. Such a malformation is rare; the foetus 
is not viable. 
(2.) The face remains in its early foetal condition of a large 
cleft; the mouth and nose form one cavity ; the orbits may be 
united in the same cavity. The foetus is not viable. 
(3.) There is a cleft in the upper lip, upper jaw, and hard 
palate. The cleft corresponds to the point of junction of the 
processes of the superior maxilla with the intermaxillary bone. 
There may be one cleft or two, one on either side of the inter- 
maxillary bone. The cleft involves the lip alone; or the lip 
and superior maxilla; or the lip, maxilla, and palate. There 
may be a single or a double cleft in the palate; and the cleft 
may involve either the hard or soft palate, or both. If there 
are two clefts of the lip and maxilla, the portion of lip and bone 
between them may be small, or entirely absent, so as to leave a 
large open space. The soft palate may be entirely absent. 
This is a common malformation, and does not endanger life. 
(4.) Rarely we find a cleft involving the middle of the lower 
lip, and sometimes extending into the inferior maxilla. 
(5.) Either the inferior, the superior, or both maxillary bones 
may be abnormally small. 
(6.) The edges of the lips may be partly or completely-joined 
together. The opening of the mouth may be only a round 
hole. 
(7.) The lips may be absent, or imperfectly developed. 
(8.) The corners of the mouth may be prolonged by clefts in 
the cheeks nearly to the ears. 
HYPERTROPHY. 
The skin of the cheeks and lips may be hypertrophied in 
connection with elephantiasis of the face. 
There may be a thickening of the lips alone, so that they ap- 
pear double. This thickening may be due to an increase of all 
the anatomical elements of the lips; or there may be an in- 
crease and dilatation of the lymphatic vessels, giving to the 
growth a soft, oedematous character. 128 
POST-MORTEM EXAMINATIONS. 
INFLAMMATION. 
1. Catarrhal Stomatitis is seldom an object of post-mortem 
importance, except when caused by irritating poisons. It is 
found most frequently in children, but also in adults. It is pro- 
duced by a great variety of local and constitutional causes. 
Of the conditions which are seen during life, the hyperse- 
mia, increased secretion, white coating and swelling of the mu- 
cous membrane, but little remains after death. 
If irritating poisons have passed through the mouth, the mu- 
cous membrane, especially near the pharynx, will be found in- 
tensely red, or with black or white patches surrounded by in- 
tense congestion. 
2. Croupous Stomatitis is caused by local irritants; by a 
continuation of the same disease from the larynx and pharynx ; 
as a result of syphilis and mercurial treatment; with the ex- 
anthematous fevers; in cachetic subjects in the form of 
aphthae ; as epidemic diphtheria. The mildest degree of this 
form is seen in the aphthous sore mouth of children and cachec- 
tic persons. Numerous little white patches of fibrinous exuda- 
tion make their appearance on the lips and gums. The exuda- 
tion is cast off with the epithelium which adheres to it, leaving 
a superficial ulcer, and this ulcer may be again covered with 
fresh exudation. 
The severest degrees are found in endemic diphtheria. Fi- 
brinous exudation is found both on the surface and in the sub- 
stance of the mucous membrane. In consequence of this, large 
patches of the mucous membrane become gangrenous, and are 
cast off. The gangrene may extend also to the subjacent soft 
parts, and form deep ulcers. If the patient recovers, these ul- 
cers cicatrize, and may, by their contraction, produce great de- 
formities. 
3. Phlegomonous Stomatitis is caused by injuries, by diseases 
of the teeth and bones, and may be idiopathic. The inflamma- 
tion attacks the deep layers of the mucous membrane, and 
forms abscesses there. Sometimes there is so much swelling of 
the soft parts about the fauces, that there is imminent danger 
of suffocation. THE MOUTH. 
129 
ULCERATION. 
Simple follicular ulcers of the mucous membrane of the 
mouth are common and trivial. Syphilitic ulcers may be 
merely superficial, or they may be produced by the softening of 
gummy tumors in the deep layers of the mucous membrane, and 
attain a large size. Sometimes chancres are found in this situa- 
tion. 
Scorbutic ulcers may be preceded by croupous inflammation, 
or by simple gangrene of small portions of the mucous mem- 
brane. They may be extensive and of a serious character. 
GANGRENE. 
Gangrene of the lips and cheeks, or Noma, is most frequent 
in cachectic children, and as a consequence of the abuse of mer- 
cury. Much more rarely it occurs in adults after typhus 
and other exhausting diseases. The disease begins in mu- 
cous membrane of the cheeks, near one of the corners of the 
mouth. The mucous membrane becomes infiltrated with pus, 
discolored, black, and gangrenous. The same rapid gangrenous 
process extends through the entire thickness of the cheek, and 
produces perforation. At the same time the gangrene spreads 
in all directions, involves the neighboring soft parts, the bones, 
and even the neck. 
Besides this form of gangrene, other forms are produced by 
erysipelas, burns, bites of insects, and glanders. 
NEW GROWTHS. 
Adenoma occurs in the mucous membrane covering the 
mouth, lips, and soft palate. The tumors are rounded, usually 
small, but sometimes as large as a hen's egg. They may be sit- 
uated in the deep layers of the mucous membrane, or project in 
a polypoid form. They are formed by an hypertrophy of the 
normal mucous glands. The glandular acini are increased in 
number and size; the epithelial cells are increased in number, 
and often undergo colloid degeneration, so as to form cysts. 
Papilloma occurs most frequently at the edges of the lips, 130 
POST-MORTEM EXAMINATIONS. 
but is also found on the gums, the floor of the mouth, and the 
cheeks. The growths look at first like warts, and are formed 
of hypertrophied papillae covered by thickened epidermis. 
They have a marked tendency to ulcerate, and may then be- 
come the starting-point of epithelial cancer. 
In some cases, the growth of epidermis becomes the principal 
feature in the process. Over one or more hypertrophied papil- 
lae, an immense growth of epidermis takes place, so as to form 
projections over an inch in length, the so-called cornu cutaneum. 
Epithelioma occurs most frequently on the edge of the lower 
lip, but has been observed at many other parts of the mouth 
It begins either as an ulcerating papilloma, or as a small no- 
dule deep in the mucous membrane. In either case, a portion 
of the mucous membrane becomes replaced by an indurated, 
ulcerating tissue. The disease may spread over a large part of 
the lips, the cheeks, the floor of the mouth, tongue, and pharynx. 
The neighboring glands are involved, and metastatic tumors, 
may be formed in other viscera. 
Carcinoma is said to occur, in rare cases, in the lips and pal- 
ate, and to assume there the medullary form. 
Angioma is frequent on the lips, rare on the palate; it may 
be congenital or developed after birth. 
Fibroma, Lipoma, Enckondroma, have been seen in a few 
cases in the lips. When they appear in the mouth, they usually 
grow from the bones. 
THE TONGUE. 
MALFORMATIONS. 
Absence of the tongue is found in connection with the ex- 
treme defects of development in the face already mentioned. 
The anterior portion of the tongue may be absent while its 
base remains. The lower jaw is then small. 
The tongue may be partly or completely adherent to the floor 
of the mouth. The frenulum may be abnormally short, or may 
extend to the tip of the tongue. In rare cases, the sides of the 
tongue are adherent; or its upper surface may be adherent to 
the roof of the mouth. THE TONGUE. 
131 
Very rarely the tongue is separated into two halves by a cleft, 
extending from the tip to the root. 
There may be two tongues, one situated over,the other. 
HYPERTROPHY. 
Makroglossia, or hypertrophy of the tongue, is usually a con- 
genital, sometimes an acquired condition. The congenital form 
continues to increase after birth. The jaws, lips, and cheeks are 
deformed by the pressure of the enlarged tongue. 
The tongue may reach an enormous size. Its surface remains 
smooth, or is nodulated and fissured. The increase in size ap- 
pears to be due principally to a growth of connective tissue. 
The muscular fibres retain their normal development. The 
lymphatic vessels are often enlarged. The epithelium is hyper- 
trophied. The hypertrophy is not always uniform ; part of the 
tongue may be larger than the rest. 
INFLAMMATION. 
Inflammation may involve the mucous membrane, or the in- 
terstitial tissue of the tongue. Inflammation of the mucous 
membrane forms a part of the different forms of stomatitis. 
Parenchymatous Glossitis is produced by injuries of the 
tongue, by mercury, typhus fever, small-pox, etc. It usually 
runs an acute course, and involves the entire tongue. The 
tongue is swollen, red, fissured, covered with crusts or fibrinous 
exudation. 
The swelling may be so great as to cause suffocation and 
death ; or it may go on to suppuration or to gangrene; or be- 
come chronic, and result in fibrous induration. 
NEW GROWTHS. 
Cysts.-The most common forms of cyst are the large sacs 
beneath, or partly in the substance of the tongue, (Ranula.) 
Some of these are dilatations of the ducts of the submaxillary 
and sublingual glands ; others are new growths in the connec- 
tive tissue. 
Rarely cysts are found entirely in the tongue itself. 132 
POST-MORTEM EXAMINATIONS. 
Small cysts are sometimes found in the mucous membrane of 
the tongue. 
In the floor of the mouth, beneath the tongue, dermoid cysts 
have been observed. 
Angioma.-Cavernous vascular tumors are found in the sub- 
stance of the tongue, and projecting from its surface. 
Lipoma and Fibroma are rare. They may occur as nodules, 
or project in a polypoid form. Composite tumors, largely com- 
posed of fat, are found in the tongue as a congenital condition. 
Tubercles are found in rare cases in the form of ulcers, of 
which the walls are infiltrated with miliary tubercles. 
Syphilitic Gummata occur as white nodules in the intermus- 
cular fibrous tissue. 
Lupus occurs in the form of nodules and of ulcers at the base 
of the tongue. 
Sarcoma in this situation appears not to have been described. 
I have seen one such tumor in a young child. It formed a 
nodule as large as a chestnut, and was composed of round and 
fusiform cells. 
Epithelioma may begin as a primary growth in the tongue ; 
or the growth may invade it from the adjoining tissues. It 
may destroy a large part of tire organ, invade the floor of the 
mouth, and form secondary tumors in the adjoining lymphatic 
glands. 
THE PHARYNX AND THE (ESOPHAGUS. 
MALFORMATIONS. 
Fistulous openings from the pharynx, running between the 
muscles, and perforating the skin, have been seen in rare in- 
stances. These fistulas are so small as to have no practical in- 
terest. 
The oesophagus may be entirely absent, or its lower portion 
may be present, and joined to the pharynx by a solid cord ; or 
the pharynx, or the lower part of the oesophagus, may be con- 
tinuous with the trachea ; or the entire oesophagus may be re- 
presented by a solid cord. 
Diverticula of the pharynx, dilatations of the oesophagus, and THE PHARYNX AND THE (ESOPHAGUS. 
133 
division of the'middle portion of the oesophagus into two 
branches have all been observed. 
INFLAMMATION. 
Catarrhal and Croupous Pharyngitis are usually associated 
with the same forms of inflammation in the mouth, and have 
the same characters. 
Submucous Pharyngitis may occur with inflammations of the 
mucous membrane, with caries of the cervical vertebrae, with 
inflammation of the cervical and parotid glands, with periostitis 
of the cranial bones, or may be idiopathic. It may result in 
swelling and oedema, in induration, or in suppuration. It is 
most important when it affects the posterior wall of the pha- 
rynx, and forms retro-pharyngeal abscesses. Such abscesses may 
cause death by suffocation. 
Catarrhal (Esophagitis may be either acute or chronic. The 
chronic form may produce ulceration, or relaxation and dilata- 
tion of the walls, or hypertrophy of the muscular coat. 
Croupous (Esophagitis is found with croup of the pharynx, 
and after the exanthemata and other severe diseases. 
Irritating and caustic acids and alkalies destroy larger or 
smaller portions of the mucous membrane. The necrosed por- 
tions are of a black or whitish color, surrounded by a zone of 
intense congestion. If the patient recover, the patches of mem- 
brane which have been destroyed slough, fall off, and leave a 
granulating surface. In this way, dangerous stenosis of the 
oesophagus may be produced. 
Foreign bodies, which are swallowed and become fixed in the 
oesophagus, cause inflammation of the mucous membrane and 
of the adjoining soft parts. The inflammation may go on to 
produce abscesses around the oesophagus, or to destroy the wall 
of the canal, and the foreign body finds its way into the trachea, 
aorta, or pericardium. 
Inflammation of the submucous tissue of the oesophagus, 
apart from the cases just mentioned, is not common. It may 
cause the formation of abscesses, or of fibrous masses, which 
may produce stenosis. 134 
POST-MORTEM EXAMINATIONS. 
Ulceration of the Pharynx occurs in rare cases as the result 
of catarrhal inflammation. More frequently it is produced by 
syphilis, either in the form of superficial ulcers, or of deep and 
extensive destructions of tissue from the softening of gummy 
tumors. Lupus, also, sometimes attacks the upper part of the 
pharynx. 
Ulceration of the (Esophagus is not common, and but little is 
known concerning it. Some authors describe a simple perforat- 
ing ulcer, similar to that of the stomach. Foreign bodies in the 
oesophagus may perforate its wall, as already mentioned. Per- 
forations of the oesophagus from without may be produced by 
inflamed bronchial glands, by cavities and gangrene of the 
lungs, by emphysema, by abscesses in the mediastinum, by ab- 
scesses accompanying caries of the vertebrae, and by aneurisms 
of the aorta. 
Cases have been described of rupture of the normal wall of 
the oesophagus by violent coughing and vomiting; but it seems 
probable that there was really some previous disease. 
ULCERATION. 
DILATATION AND STENOSIS. 
The oesophagus may be dilated throughout its entire length, 
or at some one point. The general dilatation is most frequent- 
ly caused by stenosis of the cardiac orifice of the stomach. The 
wall of the oesophagus is usually hypertrophied. 
Less frequently the entire oesophagus is dilated, without any 
satisfactory cause to account for it. The dilatation may be so 
great that a man's arm can be introduced into the cavity of the 
oesophagus. Its walls are then usually thickened, but sometimes 
thinned. 
The circumscribed dilatations may be fusiform or sacculated. 
The fusiform dilatations are congenital, or are produced by 
a stenosis at any part of the canal. 
The sacculated dilatations are situated at the upper part of the 
oesophagus or the lower part of the pharynx. They begin as a 
small pouch in the posterior wall and at right angles to it. Such THE PHARYNX AND THE (ESOPHAGUF. 
135 
a pouch becomes longer as the food accumulates in it and hangs 
down behind the oesophagus. The pouch then compresses the 
oesophagus, and its mouth forms nearly a straight line with the 
oesophagus above it, so that the food passes more readily into 
the sac than into the oesophagus below it. In this way, the sac 
is constantly distended with food, from which it is only reliev- 
ed by occasional vomiting. In this way, the dilatation goes on 
increasing until the patient dies from starvation. 
The causes of this condition are: portions of solid food re- 
maining for some time in the oesophagus or in a fold of its mu- 
cous membrane; the traction of adhesions between inflamed 
lymphatic glands and the oesophagus ; stenosis and hernial pro- 
trusions of the mucous membrane of the pharynx through 
spaces in its muscular coat. 
Stenosis of the oesophagus is produced by changes in its walls 
or by external pressure. 
Changes in its walls are produced by new growths, by cica- 
trices, by thickening of the submucous connective tissue, and by 
hypertrophy of the muscular coat. 
Pressure from without is produced by tumors in the neck and 
thorax; by enlarged glands; by aneurisms; by exostoses of 
the vertebrae; by the right subclavian artery, when it arises 
from the arch of the aorta on the left side and passes between 
the oesophagus and the vertebrae, or between the oesophagus and 
trachea; by abscesses in the neck and mediastinum; by tu- 
mors and abscesses in the lungs, liver, and diaphragm. 
NEW GROWTHS. 
Epithelioma is the form of malignant disease which most 
frequently attacks the pharynx and oesophagus, although true 
cancer is said to occur there. 
The upper part of the pharynx is seldom the primary seat of 
the disease. Usually it is invaded by the disease beginning in 
the mouth, the cervical glands, or the base of the cranium. 
In the lower part of the pharynx and the oesophagus the dis- 
ease is usually primary. The new growth may extend along 
the wall of the oesophagus for a considerable distance, but more 
frequently encircles it for a space of from one to five inches. 136 
POST-MORTEM EXAMINATIONS. 
The growth begins in the submucous tissue. We then find a 
hard, prominent ring encircling the oesophagus and producing 
a greater or less degree of stenosis; after a time, the mucous mem- 
brane and the new growth ulcerate, and instead of the stenosis 
there is a cavity with ragged walls. Or, the mucous membrane 
ulcerates at an early stage of the disease, and the grcwth of the 
epithelioma does not exceed its destruction by ulceration. 
Then we find an ulcer encircling the oesophagus, of which the 
malignant character can be easily overlooked. More rarely 
the mucous membrane ulcerates and the pseudoplasm grows 
rapidly and projects in fungous masses into the cavity of the 
(esophagus. 
If the new growth involves tlie entire thickness of the oeso- 
phageal wall, it may go on to invade the neighboring parts and 
may perforate the trachea, the bronchi, the lungs, the aorta, 
the pulmonary artery, or the vertebrae. Secondary and metas- 
tatic tumors are very rare. 
Fibroma occurs in the pharynx in the form of small polypoid 
tumors. These little polypi are covered with mucous mem- 
brane, while their interior is made up of a loose, vascular fibro- 
cellular tissue. 
Besides these, large polypoid tumors make their appearance 
in the pharynx and posterior nares, which grow from the peri- 
osteum of the bones of the base of the skull and of the upper 
cervical vertebrae. These tumors push the mucous membrane 
before them, often reach a large size, and may prove fatal. 
Sarcomata also grow from the periosteum of the neighbor- 
ing bones and project into the pharynx. 
Lipoma is sometimes found in the wall of the oesophagus, 
forming small nodules in the submucous tissue. 
Cysts are sometimes formed in the walls of the pharynx and 
oesophagus by dilatation of the mucous glands. 
Myoma occurs in the form of hard, rounded tumors growing 
from the muscular coat. The tumors usually project inward, 
and sometimes even have a polypoid shape. THE STOMACH. 
137 
THE STOMACH. 
Malformations of the stomach are not common. The organ 
may be entirely wanting in acephalous foetuses. It may be of 
various degrees of smallness, sometimes no larger than the duo- 
denum. It may be divided into two halves by a deep constric- 
tion in the middle. The pyloric orifice may be stenosed or en- 
tirely closed. The stomach may be outside of the abdominal 
cavity from a hernial protrusion through the diaphragm, or at 
some point in the abdominal wall. It is found on the right 
side instead of the left, when the other viscera are transposed, 
and the position of the cardiac and pyloric orifices is correspond- 
ingly inverted. 
MALFORMATIONS. 
POST-MORTEM CHANGES. 
In adults, the stomach after death presents a grayish or pink- 
ish color, mottled with red ecchymoses. The mucous mem- 
brane is soft, and the epithelium easily brushed off. At the 
fundus the food is usually found collected, and here the mucous 
membrane is the softest. It is very common to find the epi- 
thelium removed from the entire fundus of the stomach, so that 
all that portion of its wall is grayer and thinner, there being a 
sharp dividing-line between the two portions. Sometimes this 
post-mortem softening process goes on to destroy all the 
coats of the stomach, and even the adjoining portion of the 
diaphragm. In this way, the contents of the stomach may be 
emptied into the pleural cavity by a large, ragged opening in 
the stomach and diaphragm. When the softening affects all 
the coats of the stomach, the softened portion is not sharply 
limited. The entire thickness of the affected portion of the 
wall is converted into a gray or yellow semi-transparent jelly, 
or into a blackish, broken-down pulp. 
This softening is most frequent in children, but also occurs in 
adults, usually in connection with severe and exhausting dis- 
eases. 
There have been and are many different opinions as to the 
nature of this softening process. Some believe it to be an 138 
POST-MORTEM EXAMINATIONS. 
ante-mortem disease with regular symptoms. Some distinguish 
an ante-mortem and a cadaveric softening, but acknowledge 
that it is. not easy to distinguish between the two after death. 
Others hold that the process is entirely a post-mortem one, but 
are divided as to whether the softening is produced by the gas- 
tric juice or is a mere putrefactive change induced by the pre- 
sence of food in the stomach. All these points can hardly even 
now be said to be settled. The weight of evidence, however, 
seems to be in favor of the post-mortem and putrefactive na- 
ture of the softening. 
INJURIES. 
Perforating wounds of the stomach cause, as a rule, fatal 
peritonitis. In rare cases, however, the patient recovers with 
a gastric fistula, or even with complete closure of the Avound. 
Rupture of the stomach is sometimes caused by severe bloAvs 
and falls. All the coats of the organ are torn through, or they 
are separated from each other by extravasated blood. 
Cases of spontaneous rupture of the stomach from over-dis- 
tension Avith food have been reported. Most, if not all, of them 
Avere probably really perforating ulcers. 
IEEMORRIIAGE. 
An effusion of blood may take place in the cavity, or in the 
Avails of the stomach. The blood may come from the mouth, 
oesophagus, or trachea, and be swallowed. Or it comes from 
the vessels in the Avail of the stomach. 
The most frequent causes are: ulcers; cancer; obstruction 
to the current of venous blood from diseases of the liver, heart, 
and lungs; poisons and foreign bodies; dyscrasise, as scurvy, 
yelloAV and relapsing fever; inflammation of the stomach ; 
and vicarious haemorrhages. 
When the haemorrhages are in the cavity of the stomach, the 
organ is found to contain blood, either in clots or mixed Avith 
food, and converted into a black, grumous fluid. Not infre- 
quently, however, the blood is vomited during life, or passes 
into the intestines, and the stomach is left empty. 
When the blood escapes from large vessels destroyed by THE STOMACH. 
139 
ulcers or cancer, the source of the haemorrhage is easily dis- 
covered. But when the bleeding is from the capillaries in con- 
sequence of obstruction to the portal circulation, no lesions are 
to be found in the mucous membrane, excepting sometimes ec- 
chymoses. 
In relapsing fever, scurvy, purpura, and such diseases, the 
haemorrhage may be in the wall of the stomach, which then pre- 
sents a mottled red and gray color, or the superficial layers of 
the mucous membrane soften and fall off over such haemor- 
rhages, leaving little depressions-haemorrhagic erosions. 
INFLAMMATION. 
Acute Catarrhal Gastritis is but seldom seen in autopsies, 
and does not present constant lesions. The mucous membrane 
may be red and swollen, covered with a layer of mucus and 
epithelium ; or the hyperaemia, which existed during life, may 
disappear after death, and the stomach present no lesions. 
Chronic Catarrhal Gastritis is, on the other hand, very com- 
mon, but its lesions are not always pronounced. In the ad- 
vanced cases, the mucous membrane is red, white, or slate- 
colored, and thickened. The thickening is uniform, or it is 
punctate, giving the appearance of numerous little promi- 
nences-etat mamelonne. The gastric follicles atrophy, and the 
connective tissue between them is increased. At the same time 
the muscular coat is hypertrophied, and the thickening may be 
so great as to cause stenosis of the pylorus. Sometimes there 
are polypoid outgrowths from the mucous membrane, and some- 
times its glands become cystic. Less frequently haemorrhagic 
erosions and ulcers are also found. 
In the lesser degrees of the disease, the mucous membrane is 
congested uniformly or in spots; or it is white and anaemic, or 
of an irregular slate-color. The pyloric portion of the stomach 
is the most frequent seat of these different lesions. 
Chronic catarrhal gastritis is either a sequence of acute 
catarrhal inflammation and due to the same causes-changes 
of temperature, irritating food or drugs, alcoholic drinks, and 
chronic diseases, such as phthisis-or it is caused by obstruc- 
tions to the venous circulation in the liver, heart, or lungs. 140 
POST-MORTEM EXAMINATIONS. 
The pressure of an aneurism of the arch of the aorta on the 
ascending vena cava may cause an intense and uniform con- 
gestion of the mucous membrane, which can hardly be distin- 
guished from acute gastritis. 
Croupous Gastritis is of rare occurrence. It is found in 
children with croupous inflammation of the pharynx and 
oesophagus, and is then usually in small patches. In adults, it is 
almost always secondary to typhus, pyaemia, puerperal fever, 
cholera, dysentery, the exanthemata, and irritating poisons. 
The false membrane is in small patches, or may line a large 
part of the stomach. The disease is usually not diagnosticated 
during life, the symptoms of the primary disease diverting at- 
tention from the gastritis. 
I have seen one case of idiopathic croupous gastritis in an 
adult. A man, 46 years old, was in good health until eight days 
before his death. At that time he caught cold, had pains over 
his bowels, tenderness over the liver, constipation, cough with 
mucous expectoration, temperature 102|°, pulse 120. On the 
day of his death, the 8th day of the disease, the temperature 
was 100°, pulse 112, tongue dry, abdomen tympanitic and ten- 
der, and he died in a prolonged attack of syncope. At the 
autopsy all the viscera were examined. Excepting evidences 
of bronchitis in the lungs, there were no lesions save in the 
stomach. About f of the internal surface of the stomach, in- 
cluding the lesser curvature and anterior and posterior walls, 
■appeared to be covered with a thick false membrane, which did 
not quite reach to the cardiac or pyloric orifices. Minute ex- 
amination showed that there was a layer of exudation on the 
internal surface of the mucous membrane. This exudation 
consisted of fibrillated fibrine and lymphoid cells, dipping into 
the mouths of the follicles. Beneath the exudation the mucous 
membrane was thickened and altered. A large number of 
lymphoid cells separated the follicles, and even replaced them 
entirely. The submucous layer was very much thickened by 
the presence of lymphoid cells, fibrillated fibrine, and fibrous 
tissue. The muscular coat was separated into layers by groups 
of lymphoid cells. 
Parenchymatous Gastritis, Gastradenitis, Parenchymatous THE STOMACH. 
141 
degeneration of the gastric tubules. This condition is found 
with many severe diseases-Scarlatina, Measles, Typhus, Phos- 
phorus poisoning, Small-Pox, etc. The mucous membrane of 
the stomach is congested, uniformly or in patches, and swollen. 
The cells in the gastric tubules are enlarged, granular, and dis- 
tend the tubules. In the more chronic cases, there is no conges- 
tion. The mucous membrane is opaque, thick, and of a yellow- 
ish color. The tubules are distended with granular cells. 
Phlegmonous Gastritis is very rare. It may be secondary or 
idiopathic. In the latter case, it may cause death in a few days, 
with the symptoms of acute peritonitis. The wall of the stom- 
ach is found thickened by exudation in its submucous coat. 
This exudation may run out, on section, as a yellow fluid of 
various degrees of density ; or it remains in place as a soft, 
sticky, yellow material. These different appearances depend 
upon the relative proportion of lymphoid cells, fibrine and serum. 
The exudation may extend over part, or the entire extent of the 
wall of the stomach. It may break through the mucous mem- 
brane by small openings. There may be at the same time gen- 
eral peritonitis. 
Toxic Gastritis.-The mineral acids, the caustic alkalies, ar- 
senic, corrosive sublimate, and the metallic salts, phosphorus, 
camphor, and all other irritating materials, cause different le- 
sions of the stomach, according to their quantity, their strength, 
and the length of time that has elapsed before death. 
In large quantities, they destroy and convert into a soft, 
blackened mass both the mucous membrane and the other 
coats, so that perforation may take place. In smaller quanti- 
ties, they produce black or white sloughs of the mucous mem- 
brane, surrounded by a zone of intense congestion. If death 
does not soon ensue, the ulcerative and cicatricial processes which 
follow such sloughs, may contract and deform the stomach in 
various ways. 
If the poisons are of less strength, they produce a diffused 
congestion of the mucous membrane, with catarrhal or croup- 
ous exudation on its surface, and serous infiltration of the sub- 
mucous coat. 142 
POST-MORTEM EXAMINATIONS. 
ULCERATION. 
The Simple Perforating Ulcer of the stomach is a lesion fre- 
quently seen. It occurs in young persons, especially females. 
It may cause death by starvation, haemorrhage, or peritonitis ; 
or may cicatrize completely, and the patient recover. 
These ulcers are usually single, but there may be several of 
them. They occur most frequently in the pyloric portion of 
the stomach, at some point in the posterior wall near the lesser 
curvature, but they may be found at any portion of the 
stomach. 
The ulcers are usually circular, sometimes oval, annular, or 
of irregular shape; or two ulcers may combine to form an irre- 
gular f gure. The perforation is largest in the mucous mem- 
brane, smallest in the peritoneum. The edges of the ulcer pre- 
sent no changes, or, if the ulcer is of long standing, are thick- 
ened and indurated. The rest of the stomach is unchanged, 
or is in a condition of chronic catarrhal inflammation. 
The ulcer may perforate directly through the walls of the 
stomach; the contents of the organ are discharged into the peri- 
toneal cavity, and fatal peritonitis supervenes. This is espe- 
cially the case when the ulcer is in the anterior wall. Or ad- 
hesions are formed between the stomach and the neighboring 
viscera, so tlmt the bottom of the ulcer is sealed. Or, if the 
liver, the intestines, or the abdominal wall.become adherent, 
they are invaded; an ulcerating cavity is formed in the 
liver, a fistulous communication is established between the stom- 
ach and the intestines, or the outer surface of the abdomen. Or 
the adhesions are only partial, and an abscess is formed about 
the perforation. Such an abscess may remain shut in by adhe- 
sions, or may break into the cavity of the peritoneum, and 
cause peritonitis. During the progress of the ulcer, there may 
be repeated small haemorrhages from the erosion of small blood- 
vessels, or large and fatal haemorrhages if large trunks are de- 
stroyed. 
In many cases, these ulcers completely cicatrize, leaving a stel- 
late scar ; or, if they are large, constricting the stomach in vari- 
ous ways. THE STOMACH. 
143 
The' way in which these ulcers are formed is very obscure, 
and the explanations usually given are theoretical rather than 
based on actual observation. It is said that they are preceded 
by a circumscribed stasis and haemorrhagic infiltration of a por- 
tion of the stomach-wall, and that the part thus infiltrated after- 
ward sloughs, and leaves the ulcer. Such a stasis may be caus- 
ed : (1) by catarrhal gastritis ; (2) by embolism, or thrombosis 
of an artery of the stomach ; (3) by chronic or acute venous hy- 
peraemia, especially from thrombosis of the gastric and portal 
veins; (4) by fatty and atheromatous degeneration of the 
blood-vessels. 
Ilcemorrhagic Erosions occur as rounded spots or narrow 
streaks, formed by a loss of substance of the mucous membrane. 
The mucous membrane at these points is congested, soft, and 
covered by small blood-clots. The destruction of the mucous 
membrane is usually superficial, but may involve its entire 
thickness. The number of these erosions may be so great that 
the entire internal surface of the stomach is studded with them. 
They give rise to repeated haemorrhages, and are accompanied 
by catarrhal inflammation of the rest of the mucous membrane. 
They occur at all periods of life, even in infants. Their usual 
seat is the pyloric portion of the stomach. 
They may be idiopathic. Usually, however, they occur in 
connection with some serious general disease. 
Catarrhal Dicers are formed with chronic gastritis. They 
are small, round, or irregular, superficial or deep, congested, 
and usually in small numbers. They may cicatrize or become 
perforating ulcers. 
Follicular deers, formed by inflammation and ulceration of 
the solitary follicles are very rare. They occur most frequently 
in young infants. 
DILATATION AND STENOSIS. 
Dilatation of the stomach is spontaneous or produced by 
stenosis. 
When produced by stenosis at the pylorus, the fundus is first 
dilated, afterward the entire stomach. If the stenosis is at 
another part of the stomach, that portion of the organ which is 144 
POST-MORTEM EXAMINATIONS. 
between the stricture and the oesophagus is dilated. The walls 
of the dilated portion retain their normal thickness or are thin- 
ned. The stenosis is usually produced by hypertrophy of the 
muscular coat, by new growths, or by the cicatrization of ul- 
cers and sloughs. 
Spontaneous dilatation is produced by traction of the stom- 
ach downward from large hernise; by habitual distension of 
the organ with food; by contusions causing paralysis. In les- 
ser degrees, dilatation is produced by chronic gastritis and peri- 
tonitis. 
In very rare cases, circumscribed, sacculated dilatations are 
produced by indigestible bodies, such as wood, metal, etc., in 
the stomach. 
Diminution in the size of the stomach is produced by new 
growths, by hypertrophy of the muscular coat, by the cicatriza- 
tion of ulcers and sloughs, and by habitual emptiness of the or- 
gan. In this way, the capacity of the stomach may become 
very small. 
NEW GROWTHS. 
Carcinoma occurs in the stomach in all its different varieties : 
medullary, scirrhus, epithelial, melanotic, and colloid. 
It is a disease of advanced life, of equal frequency in men 
and women. 
It is, as a rule, primary in the stomach, excepting the second- 
ary nodules which may occur in the peritoneal coat, and belong 
rather to the peritoneum. But Cohnheim has described a case 
in which there were nodules in the wall of the stomach, second- 
ary to carcinoma of the mamma. 
It is usually situated at the pylorus and the lesser curvature; 
less frequently at other points. It may involve a small part, or 
nearly the entire wall of the stomach; often extends to the 
oesophagus, rarely to the duodenum. The new growth may 
take an annular shape, and form a ring around the stomach; 
this is especially the case at the pylorus ; or it projects in the 
form of one or more flattened, broad tumors ; or there is a more 
uniform thickening of the walls of the stomach for a considera- THE STOMACH. 
145 
ble distance ; or there are ulcers with thickened edges and rag- 
ged floors. 
The disease begins in the submucous coat, or, according to 
some authors, in the gastric follicles. The mucous membrane is 
lifted up and pushed inward; after a time, it usually ulcerates. 
The new growth may also extend outward, and invade all the 
other coats of the stomach. There may be also an hypertrophy 
of the muscular coat, either confined to the pylorus or involv- 
ing the entire wall of the organ. The muscular coat then looks 
like a thick, gray layer, divided up by wdiite bands. The gray 
tissue is smooth muscle; the white bands are fibrous septa, 
which may become infiltrated with cells. 
The post-mortem appearances vary according to the stage of 
the disease, and the way in which it has grown. At first, the 
new growth is confined to the submucous coat, and the mucous 
membrane is uniformly lifted up, or projects in flattened tu- 
mors. Very often, however, necrotic and ulcerative changes 
soon make their appearance. The mucous membrane ulcerates, 
and the new growth projects as a ragged, fungous mass ; or the 
new growth also ulcerates, and leaves a rounded ulcer with 
thickened edges ; or the new growth ulcerates, and at the same 
time goes on to invade the subjacent tissues. In this way, the 
wall of the stomach is perforated, and peritonitis ensues; or ad- 
hesions are formed, and the perforation takes place into the in- 
testines, the abdominal wall, or the diaphragm ; or the disease 
invades the neighboring organs; the liver, pancreas, spleen, 
supra-renal capsules, kidneys, vertebrae, portal vein, and vena 
cava. The necrotic processes may even go on in the new 
growth in these other organs. Thus we find large cavities with 
fungous walls in the liver, communicating with the cavity of the 
stomach. 
When the new growth is at the pylorus, it may seriously ob- 
struct the egress of food, and in this way dilatation of the rest 
of the stomach may be produced. 
Secondary tumors are very frequently found in the neighboring 
lymphatic glands, the liver, pancreas, lungs, and other viscera. 
The above description applies to all the varieties of carcino- 
ma, excepting the colloid form. 146 
POST-MORTEM EXAMINATIONS. 
The distinction between the medullary and scirrhous forms 
seems to be unimportant. It depends merely on the relative 
proportion between the cells and stroma, a proportion which 
presents every sort of gradation. The presence of pigment 
also, forming melanotic cancer, seems to be merely an accidental 
complication. The structure of the medullary, scirrhus, and 
melanotic varieties is essentially the same: a fibrous stroma, 
inclosing cavities filled with cells ; the cells polygonal, nucleat- 
ed, and of an epithelial character. 
Epithelial Cancer of the stomach consists of cells resembling 
the normal cylindrical epithelial cells of that organ. The cavi- 
ties in which these cells are arranged are long, and resemble 
glandular follicles. The near relationship of the epithelial to 
the scirrhus and medullary cancer may be inferred from the fact 
that the secondary nodules in the liver are not always formed 
of cylindrical cells, but sometimes of polygonal cells. Epithe- 
lial Cancer with pavement cells is rare. It is secondary to simi- 
lar growths in the upper part of the alimentary canal. 
Colloid or alveolar cancer presents a different appearance. It 
usually forms a uniform infiltration of the wall of the stomach, 
especially of its pyloric portion. It has less tendency to ulce- 
rate, but often invades the entire thickness of the wall of the 
stomach, and appears on its peritoneal surface in the form of ir- 
regular nodules. The disease may spread over a considerable 
portion of the peritoneum, but does not usually form secondary 
nodules. This form of cancer consists of a fibrous stroma, form- 
ing rounded alveoli. The alveoli are filled with a gelatinous 
material, in which are imbedded polygonal nucleated cells. 
The presence of the gelatinous material gives to the entire 
growth a peculiar soft consistence, and gray translucent color. 
Sarcoma is found in the stomach in rare instances, both as a 
primary and a secondary growth. As a primary tumor, it is 
most frequent in young persons. It invades all the coats of the 
stomach, and projects inward as a fungous tumor. 
Myoma occurs in the form of rounded tumors, which origi- 
nate in the muscular coat, but gradually separate themselves 
from it, and project inward or outward. The submucous myo- 
mata are at first small tumors, lying loosely attached in the sub- THE STOMACH. 
147 
mucous tissue. As they grow larger, they push the mucous 
membrane inward, and appear as polypi, first with a broad, 
then later with a narrow pedicle. 
The subserous myomata grow in the same way, and form 
rounded or polypoid tumors beneath the peritoneal coat. 
Sometimes these tumors are partly sarcomatous. 
It seems probable that most of the fibrous tumors which have 
been described in this situation were myomata. 
Lipoma grows in the submucous tissue, and forms rounded 
or polypoid tumors. They usually project inward, but some- 
times outward beneath the peritoneum. They may also ap- 
pear in the form of numerous small yellow nodules beneath the 
mucous membrane. 
Fibroma papiUare consists in an hypertrophy of the normal 
villi of the stomach, or a new growth of similar villi. This 
growth may appear as a uniform thickening of a considerable 
portion of the mucous membrane, or in the form of polypoid 
tumors. Such polypi are single or multiple. The smallest 
form little rounded prominences; the larger have a small pedi- 
cle and large body. Their surface is smooth or villous. They 
consist of a central portion, formed of connective tissue, fibres, 
and cells. This is covered with a layer of little villi, covered 
with epithelium, and sometimes containing follicular glands. 
Adenoma is found in the shape of an hypertrophy of the 
glands of the stomach, which may assume a polypoid shape. 
Also, it occurs in the form of rounded tumors in the submucous 
coat, formed of glandular follicles, lined with cylindrical epi- 
thelium. Small glandular tumors, resembling the pancreas, 
have also been observed in the submucous and subserous coats. 
Lymphatic New Growths of the stomach are seen in some 
cases of leucaemia. They form flattened or rounded tumors, 
3-12'" broad, of soft, white consistence, and resemble in their 
structure the lymphatic glands. 
Cysts occur in the mucous membrane of the stomach from 
dilatation of the glandular follicles. They are usually small, 
but may reach a considerable size. They contain mucus and 
epithelium. 148 
POST-MORTEM EXAMINATIONS. 
DEGENERATIONS. 
Calcification of the mucous membrane is sometimes found as 
a metastatic deposit with extensive disease of the bones. The 
salts of lime are deposited in a granular form in the connective 
tissue between the glandular follicles, and more rarely in the 
muscular coat. 
Waxy Degeneration sometimes invades the stomach. It at- 
tacks the vessels of the mucous membrane, and more rarely the 
cells of the glandular follicles. The mucous membrane appears 
thin and glistening. 
THE INTESTINES. 
Diverticula of the intestines occur in several different ways : 
(1.) The abdominal walls are cleft asunder at the navel. The 
ileum opens through this cleft by a narrow aperture in its wall. 
The lower portions of the ileum and the colon are small or en- 
tirely closed. 
(2.) There is an opening in the abdominal wall as before, but 
there is not a direct opening into the ileum. There is a long 
diverticulum of the ileum, with an open end projecting into 
the opening in the abdominal wall. 
(3.) The abdominal wall is closed. There is a diverticulum 
of the ileum connected with the navel by a solid cord. 
(4.) There is an unattached diverticulum of the intestine. 
This is much the most common form. The diverticula occur 
only in the lower part of the ileum. They usually spring 
from the convex surface of the intestine, more rarely from its 
attached border. In the latter case, they are joined to the 
mesentery by a fold of peritoneum. The diverticulum forms a 
pouch, 1-6 inches long, of about the same diameter as tlie in- 
testine, smallest at its free extremity. 
Such diverticula never interfere with the functions of the 
intestines. They sometimes form part of a hernia. If they re- 
main attached by a fibrous cord to the navel, this cord may be 
the cause of incarceration of a portion of the intestines. 
MALFORMATIONS. THE INTESTINES. 
149 
Cloacse consist in the union of the rectum, bladder, and or- 
gans of generation in a common outlet. 
(1.) Simple Cloacae are : (a.) Complete, and consist in the 
common opening of the urethra or ureters, the vagina and the 
rectum into the closed bladder, or into a sinus opening outward, 
which represents either the vagina or rectum, (b.) Incomplete. 
The rectum opens into the vagina, the bladder, or the urethra, 
while the lower part of the rectum is closed or absent. 
(2.) Cloacae combined 'with cleft bladder, (a.) The simple 
cleavage of the intestines is combined with cleft bladder. The 
anterior abdominal wall from the umbilicus to the symphysis, 
the symphysis, and the anterior wall of the bladder are absent; 
the gap is tilled with a membrane which represents the pos- 
terior wall of the bladder. Into this membrane open the ileum, 
ureters, and vagina, (b.) The intestine is perfectly formed, but 
the rectum opens into a common sinus with the ureters and va- 
gina ; or the ureters open into the cleft bladder, and the rectum 
and external genitals are united; or the ureters open into the 
rectum, and the latter terminates normally. 
(3.) Cloacae combined with abdominal hernia. There is a 
hernial sac containing all the abdominal viscera. At the lower 
end of the sac is an opening leading into a sinus in which open 
the lower end of the ileum, the bladder or urethra, and the 
ureters. The rectum is absent. 
Atresia Ani consists in a deficient development of the colon 
or rectum. The entire colon may be absent; the rectum may 
be absent, or represented by a solid cord ; or the upper or lower 
part of the colon may be absent, or separated by a solid cord. 
More rarely, blind terminations of the small intestines are 
found, and sometimes narrowing so complete as to close the 
canal. 
The intestines are also found abnormally shortened in vari- 
ous degrees. 
CHANGES IN POSITION. 
Hernia. 
The abdominal viscera may escape from the abdominal cavity 
through openings formed by arrest of development, or through 150 
POST-MORTEM EXAMINATIONS. 
canals which are normally closed, or through thin portions of 
the abdominal wall. Hernias, therefore, occur in a variety of 
situations. 
(1.) Hernia inguinalis. - (a.) The hernia is congenital. 
The processus vaginalis of the peritoneum remains open, a por- 
tion of the intestines passes through into the scrotum, and is 
free in the cavity of the tunica vaginalis. 
(b.) The hernia is acquired. It is oblique and formed by a 
projection of the intestines through the internal ring, inguinal 
canal, and external ring into the scrotum. The intestines push 
before them the peritoneum, which incloses them as their sac. 
Or it is direct, and the intestines pass through some part of the 
abdominal wall internal to the epigastric artery, and then 
through the external ring. They are covered with a sac of 
peritoneum. 
(2.) Hernia femor alls.-The intestine, covered by a sac of peri- 
toneum, passes through the femoral ring, descends along the 
crural canal in the inner compartment of the sheath of the 
femoral vessels as far as the saphenous opening; through this 
opening it escapes into the areolar tissue of the groin. The 
hernia may only pass into the femoral canal, and not escape 
through the saphenous opening; it may continue along the 
course of the vein beyond the saphenous opening; or it may 
project through several openings in the sheath of the vessels. 
This form of hernia is most frequent in the female. When in- 
complete, it not infrequently escapes observation during life. 
(3.) Hernia umbilicalis. 
(a.) Congenital.-In the foetal condition a portion of the ile- 
um lies within the umbilical cord. If this coil of intestine does 
not pass back into the abdomen, and the regular closure of the 
umbilicus does not take place, there remains a sac, lined with 
peritoneum, filled with intestine, and from the end of the sac 
the umbilical cord is continued. The sac may contain only a 
small portion of intestine, or nearly all the abdominal viscera. 
The wall of the sac is thin, and may rupture before or at the 
time of birth. In other cases, either spontaneously or by 
surgical interference, the sac is obliterated and the hernia re- 
duced. THE INTESTINES. 
151 
(b.) Acquired.-The intestine covered by a sac of peritoneum 
projects into a sac formed by the skin at the umbilicus. This 
hernia occurs in young infants when the navel is not firmly ci- 
catrized ; in adults, when there has been a small hernia in in- 
fancy ; and when the navel has been dilated by pregnancy, etc. 
(4.) Hernia ventralis.-1There may be hernias of the abdomi- 
nal wall in the median line or to one side of it. The intestine 
may project through some defect in the fasciae, or there may 
be thinning and pouching of all the coats of the abdomen at 
some point. 
(5.) Hernia ischiadica.-The intestine, covered by a sac of 
peritoneum, passes along the course of the sciatic nerve through 
the sacro-sciatic foramen under the glutaeus maximus muscle. 
It is very rare. 
(6.) Hernia foraminis ovalis.- The intestine, covered by a 
sac of peritoneum, passes on the inner side of the obturator ves- 
sels through the obturator foramen. 
(7.) Hernia perincealis.-The intestine, covered by peritone- 
um, passes between the fibres of the levator ani muscle and pro- 
jects into the space between the rectum, the tuberosity of the 
ischium, and the point of the sacrum. 
(8.) Hernia vaginalis.-The intestine, covered by peritoneum, 
passes downward between the rectum and vagina, and presses the 
posterior wall of the vagina outward through the vulva. If the 
hernia is large, the wall of the vagina drags down the posterior 
lip of the cervix and the body of the uterus. 
(9.) Hernia rectalis.-The hernia takes place between the 
bladder or vagina and the rectum. The wall of the rectum may 
then be pressed outward through the anus. 
(10.) Hernia diaphragmatica. 
(a.) Congenital.-This is produced by defective development 
of the diaphragm, which may be partly or entirely wanting on 
one side. Part of the intestines or most of the abdominal vis- 
cera may thus pass into a pleuritic cavity. They are covered 
by a sac formed of peritoneum and pleura, or are without any 
sac. Or the diaphragm is complete, but part of it is pouched 
into the pleural cavity. In rare instances, persons with this 
lesion reach adult life. 152 
POST-MORTEM EXAMINATIONS. 
(b.) Acquired.-This is produced by wounds or ruptures of 
the diaphragm, or the hernia projects through one of the na- 
tural openings of the diaphragm, or through an opening formed 
by a fat hernia. 
(11.) Hernia RetroperitonceaLis.-The intestine passes into 
the fossa jejuno-duodenalis. It consists of a small part of the 
jejunum, or of most of the small intestines. It is covered with 
a duplicature of peritoneum from the posterior abdominal wall. 
For a detailed account of hernia, the text-books on surgery 
should be consulted. 
INCARCERATION. 
(1.) The most common form is that in which a portion of intes- 
tine is strangulated by a fibrous band. Such fibrous bands are 
produced by peritonitis, or are remains of foetal growth. They 
pass from the intestines to the abdominal wall, or from one part 
of the intestines to another. The intestine becomes in some 
way caught under one of these bands, and is compressed by it. 
The stricture thus produced may cause a gradual accumulation 
of feces in the intestine above it, and may last for a long time 
before death ensues. In other cases, the stricture interferes at 
once with the circulation of the blood ; the intestine is intense- 
1 y congested, becomes gangrenous, and death takes place with 
tire symptoms of general peritonitis. 
(2.) A portion of intestine becomes caught in some abnor- 
mal opening in the mesentery or omentum, or in tfe foramen 
of Winslow, or between the two layers of the mesentery. 
(3.) A coil of intestine makes half a turn at its base, so that 
the two sides of the loops cross at its base. In this way, the lu- 
men of the intestine is completely closed, and the vessels are 
compressed, so that congestion, peritonitis, and gangrene result. 
This form of incarceration is most frequent in the ascending- 
colon. In the small intestine it only occurs when .the gut is fix- 
ed by old adhesions. 
(4.) A portion of the intestine, with its mesentery, makes one 
or more complete turns on itself, closing the canal, and com- 
pressing the vessels. 
(5.) A portion of the intestine makes a half or entire turn THE INTESTINES. 
153 
about its long axis. This is very rare, and only occurs in the 
colon. 
(G.) The mesentery of a part of the intestine is long and 
loose, in consequence of a dragging down of the intestine by a 
hernia or by habitual constipation. The portion of intestine 
thus permitted to hang down is habitually filled with faeces, and 
by its pressure on some other part of the intestine produces an 
incomplete stricture. 
INTUSSUSCEPTION. 
This change of position consists in the invagination of one 
portion of intestine in another portion. Usually this takes 
place in the direction of the peristaltic movements, from above 
downward ; more rarely, in the opposite direction. 
The parts are found in the following condition : There are 
three portions of intestine, one within the other. The inner 
portion is continuous with the intestines above the intussuscep- 
tion ; its peritoneal coat faces outward. The outer portion is 
continuous with the intestine below; its peritoneal coat also 
faces outward. The h-mer portion is turned inside out, its mu- 
cous membrane is in contact with the mucous membrane of the 
outer portion. In rare cases, the intussusception is complicat- 
ed by the invagination of a second portion of intestine in the 
inner tube, and even by a third intussusception into the second 
one. These chano;es occur both in the laro-e and small intes- 
tine; most frequently the lower part of the ileum is invaginat- 
ed in the colon. The invaginated portion may be from a few 
inches to several feet in length. The lesion is most frequently 
found in early childhood. 
The intussusception, by the dragging and folding of the me- 
sentery which it produces, causes an intense congestion of the 
parts, and even large haemorrhages between the coats of the in- 
testine. The congestion may induce fatal peritonitis, or gan- 
grene of the intestine, or chronic inflammation and adhesions, 
and the patient lives for a considerable time with symptoms of 
stricture. In other cases, the invaginated portion of intestine 
sloughs, the outer and inner portion become adherent, and the 
patient recovers, with or without some degree of stricture. 154 
POST-MORTEM EXAMINATIONS. 
Besides this grave form of intussusception, we often find, es- 
pecially in children, one or more small invaginations not at- 
tended with congestion or inflammation. These are formed 
during the death-agony or immediately after death. 
PROLAPSUS. 
Prolapsus of the rectum consists in the protrusion of the 
lower part of the rectum through the anus. It begins as a 
slight prolapse of a small part of the rectum, or of its mucous 
membrane, only occurring in the act of defecation. The pro- 
lapsed portion becomes gradually larger and larger ; it no lon- 
ger returns of itself ; it is constricted by the sphincter, becomes 
hypersemic, swollen, and inflamed, so as to form a mass of large 
size. 
The lesser degrees of prolapse are common, especially in chil- 
dren, and are of little importance. The higher degrees may be- 
come the seat of severe inflammation and ulceration, and, in 
rare cases, gangrene and death may supervene. 
Sometimes only the mucous membrane prolapses, and the 
prolapse may not involve the entire circumference of the rec- 
tum, but only one or more folds of the mucous membrane. 
TRANSPOSITION. 
The position of the intestines may be the opposite of that 
usually found. The transposition may affect all the abdominal 
viscera ; the liver and caecum are on the left side, the stomach 
and spleen on the right side; or only a single viscus is trans- 
posed. 
Penetrating wounds of the intestine usually prove rapidly fa- 
tal from the peritonitis which supervenes. Sometimes, how- 
ever, the wound is closed by the formation of adhesions with tlie 
neighboring parts. The intestine may then remain bound 
down by adhesions, or after a time become free. Sometimes 
the wound in the intestine becomes adherent at the position of 
the wound of the abdominal wall, and an intestinal fistula is 
formed. 
WOUNDS, RUPTURE. THE INTESTINES. 
155 
Rupture of the intestines is produced by severe contusions. 
It is noticeable that contusions sufficiently severe to produce 
large ruptures of the intestines may not leave any bruises or 
marks on the external surface of the body, even when the pa- 
tient lives for several days after the receipt of the injury. 
Perforation of the intestines will be considered under the 
head of ulcers. 
INFLAMMATION. 
The Rectum.-Catarrhal inflammation of the rectum is acute 
or chronic. 
In acute inflammation, we find the intestine congested, swol- 
len, covered with a thin layer of mucus, pus, and epithelium; 
the epithelium in places destroyed so as to form superficial 
ulcers; the solitary glands enlarged. In chronic inflamma- 
tion, the mucous membrane is congested, or anaemic, or mottled 
with black patches. There are ulcers, either superficial or 
deep, and even perforating, so as to form fistulous openings 
into the surrounding tissues. Other parts of the mucous mem- 
brane hypertrophy, either around a solitary follicle, or around 
a group of straight follicles, or by cell-growth beneath the 
mucous membrane, and project in the form of polypi. In other 
cases, the mucous membrane is uniformly thickened. The mus- 
cular coat is relaxed and thinned, or, more frequently, hyper- 
trophied. This hypertrophy is frequently associated with 
thickening of the connective tissue around the rectum, and may 
cause fatal strictures. 
Croupous inflammation of the rectum occurs with acute 
dysentery and after the injection of irritating substances. The 
mucous membrane and submucous tissue are congested, swol- 
len, and infiltrated with serum. Its surface is covered with 
blood, epithelium, mucus, and a thin, brownish, membranous 
layer, composed of epithelium mixed with coagulated fibrine. 
This false membrane may be in patches, or may form a com- 
plete cast of the rectum. In more severe cases, the entire 
thickness of the mucous membrane is infiltrated with fibrine, 
so that large patches become gangrenous and are cast off. 156 
POST-MORTEM EXAMINATIONS. 
In this way, the greater part of the mucous membrane may 
be destroyed. The milder forms of croupous inflammation, 
in which only the superficial layers of the mucous mem- 
brane are destroyed, leave no permanent lesions. The deeper 
sloughing and ulcerative processes, on the other hand, leave 
large cicatrices and contractions of the intestines. 
The connective tissue around the rectum frequently shares 
in the inflammatory changes of the intestine, and becomes in- 
durated. It may also be the seat of idiopathic inflammatory 
changes, producing induration or abscesses around the rectum. 
The Colon.-The entire length of the colon is subject to the 
same inflammatory changes as the rectum. Acute and chronic 
catarrhal inflammation, with ulceration; thickening of the mus- 
cular coat and the formation of mucous polypi; croupous in- 
flammation, with the formation of large ulcers, both occur. In 
rare cases, idiopathic croupous inflammation of the colon 
occurs, and causes death. 
The Caecum.-Catarrhal inflammation of the caecum, or 
typhlitis, is not uncommon. It is usually produced by an 
habitual accumulation of faeces in this portion of the intestines. 
The course of the disease is usually chronic, but marked by 
acute exacerbations. The mucous membrane is at first con- 
gested, afterward ulcerated ; there is a slow, suppurative inflam- 
mation of all the coats of the intestine and of the surrounding 
tissues; fistulous openings are formed through the wall of the 
caecum, through which the faeces pass into the cavity of the 
abdomen, and cause fatal peritonitis, or produce abscesses 
which are shut in by adhesions ; or the faeces pass through the 
peritoneum into the muscles of the posterior wall of the abdo- 
men, and form large cavities filled with pus and faeces. 
Perityphlitis.-There may be an idiopathic inflammation of 
the subperitoneal tissue just beneath the caecum. It forms 
large abscesses, which may perforate the caecum and allow the 
faeces to escape. Or the wall of the caecum may become 
relaxed, so that a persistent and even fatal constipation is 
produced. 
The Appendix Vermiformis is sometimes the seat of catar- 
rhal inflammation and ulceration, excited by the presence in it THE INTESTINES. 
157 
of small foreign bodies or hardened feces. The ulcers fre- 
quently cause perforation, and, in consequence, the formation 
of abscesses, adhesions, and peritonitis. 
In other cases, the inflammation leads to closure of the neck 
of the appendix. It may then, by the accumulation of mucous 
and serum in its cavity, become a cyst of considerable size. 
The abscesses which are formed in consequence of typhlitis, 
perityphlitis, or perforation of the appendix, may perforate into 
the bladder, vagina, uterus, acetabulum, ascending vena cava, 
other parts of the intestinal canal, through the abdominal wall 
into the muscles of the abdominal wall and the pelvis, through 
the diaphragm into the pleural and pericardial cavities. 
Ileum.-The ileum, especially its lower portion, is often the 
seat of acute and chronic catarrhal inflammation. In acute in- 
flammation, the mucous membrane is congested and swollen, 
the solitary and agminated glands enlarged. 
In chronic inflammation, both the mucous and muscular 
coats are thickened, the mucous membrane is congested and 
anaemic or pigmented, often ulcerated. 
Croupous inflammation occurs in children in the form of 
aphthae; in adults, usually as the result of irritant poisons. I 
have seen, however, idiopathic croupous inflammation of the 
ileum in a few cases. The inflammation was most intense 
over about two feet of the intestine, but extended in a lesser 
degree down to the end of the ileum. Where the inflammation 
was most intense, the mucous membrane was congested, covered 
with a layer of fibrinous exudation, the solitary and agminated 
glands were not enlarged; there was an infiltration of lymphoid 
cells and fibrine through the entire wall of the intestine, and a 
recent fibrinous exudation on its peritoneal surface, which did 
not, however, extend to a general peritonitis. 
Duodenum.-Catarrhal inflammation of the duodenum occurs 
by itself or with gastritis. It runs a chronic or acute course. 
It is principally important from its effect on the gall-duct, ob- 
structing the passage of bile into the intestine. 
Suppurative Inflammation of the submucous coat of the in- 
testines is said to occur in rare cases. It is usually metastatic. 
It takes place in the form of foci of varying extent, which per- 
forate either inward or outward. 158 
POST-MORTEM EXAMINATIONS. 
ULCERATION. 
1. Catarrhal Ulceration occurs in the colon and ileum, with 
catarrhal inflammation of the mucous membrane. Small round- 
ed patches of the mucous membrane appear at first deeply in- 
jected, then soften and fall off, leaving ulcers which are at first 
superficial and then deep. These ulcers then spread laterally, 
or several become joined, so as to form large ulcers, of which 
the edges are formed by the thickened mucous membrane, their 
floor by the muscular or peritoneal coat, infiltrated with cells. 
Such ulcers may destroy a large part of the mucous membrane 
of the large intestine, and may perforate. They cicatrize in the 
form of broad, hard, pigmented patches. By their contraction 
and the accompanying hypertrophy of the muscular coat, they 
may produce strictures. 
2. Follicular Ulcers are formed by the inflammation of the 
solitary glands in the large intestine, and of the solitary and 
agminated glands in the small intestine. These glands increase 
in size; the mucous membrane over them softens and falls off, 
so that they project as little, soft, rounded bodies, filled with a 
whitish purif orm material. The gland then ruptures, discharges 
its contents, and thus forms a rounded ulcer with overhanging 
edges. In the agminated glands, the process is the same on a 
larger scale. When the ulcer is thus formed, its base and edges 
become infiltrated with lymphoid cells, and in this way the ul- 
cer may increase in breadth and depth, and even perforate the 
peritoneal coat. 
The ulcers which are frequently called tuberculous are really 
follicular ulcers ; but miliary tubercles may form in their edges 
and near them as a secondary process. 
3. Croupous Ulceration occurs in the large intestine from the 
infiltration and sloughing of portions of the mucous membrane. 
4. Simple perforating Ulcers occur in the duodenum. They 
resemble exactly the perforating ulcers of the stomach, and 
seem to be formed in the same way. They are found with ul- 
cers of the stomach, or alone. They may be single or multi- 
ple. 
5. Syphilitic Ulcers are found in the rectum as an extension THE INTESTINES. 
159 
of chancres of the vulva and perineum. They may lead to in- 
duration and stenosis of the rectum. 
EMBOLI. 
Emboli have been observed in the superior mesenteric artery 
in a number of instances ; in the inferior mesenteric they are 
less frequent. They produce an intense congestion of the in- 
testine, usually with haemorrhage from the bowels during life. 
The intestine appears of a livid red color, swollen, moist, some- 
times almost gangrenous. 
STEXOSIS AND DILATATION. 
Stenosis of the intestine is produced by hypertrophy of the 
muscular coat, by cicatrices, by new growths, by the pressure 
of tumors, (in one case by the pressure of an anterior spina 
bifida on the rectum,) by peritoneal adhesions, by foreign bodies. 
Dilatation of the intestine is produced by the accumulation 
of faeces and gas above a stricture, or by relaxation of tlie walls 
of the intestine from concussion, habitual repletion, peritonitis, 
rheumatism, typhus, dysentery, cholera, over-stimulation by in- 
jections, and purgatives, or from some disease of the nervous 
centres. In some cases, not only the calibre, but also the length 
of the intestine is increased. 
False Diverticula are formed by a hernial protrusion of the 
mucous and peritoneal coats. They form multiple nipple-shap- 
ed pouches, from the size of a pea to that of a walnut. They 
are usually on the convex side of the intestine, less frequently 
on its concave side. They are found at all parts of the large 
and small intestine. They usually cause no symptoms during 
life. In one case, however, they appeared to be the cause of an 
acute peritonitis, though no perforation was discovered. 
Dilatation of the Appendix Vermiformis is produced by the 
stenosis or occlusion of its canal at some point. Beyond the 
point of obstruction the canal dilates so as to form a large sac 
with thin walls. The contents of the sac are thick mucus and 
epithelium, or serum. 160 
POST-MORTEM EXAMINATIONS. 
NEW GROWTHS. 
Myoma.-Tumors composed of smooth muscle and fibrous 
tissue are found as small, rounded, hard bodies. They grow from 
the muscular coat, but soon project into the submucous coat, 
and push inward the mucous membrane. They may entirely ob- 
struct the cavity of the intestine, and may then be seized by the 
peristaltic action of the intestine, and produce an intussuscep- 
tion. In the duodenum such tumors may obstruct the opening 
of the biliary duct. Such tumors are also said to project under 
the peritoneal coat. 
Lipoma may occur at any part of the intestinal tract. The 
tumors project beneath the mucous coat, and form polypi, some- 
times of considerable length ; or they are simply hypertrophies 
of the normal appendices epiploicae. In these latter, there may 
be an increase of fibrous tissue and sclerosis ; or the fat may be- 
come fluid, and form a sort of cyst; or they may calcify. Such 
tumors sometimes, by the atrophy of their pedicles, become free 
in the abdominal cavity. 
Adenoma occurs usually in the form of polypoid tumors. 
They are found in the rectum, and are most frequent in chil- 
dren. They are single or multiple, small or large, rounded or 
polypoid. They consist of long glandular follicles, lined with 
cylindrical epithelium, and contained in a flbro-cellular stroma. 
Fibroma papillare has already been mentioned as produced 
by chronic inflammation of the intestines. The tumors are of 
polypoid shape, and composed of fl bro-cellular tissue, covered 
with epithelium. They are often made up of a great number 
of tufts, each covered with epithelium. 
Angioma is of very rare occurrence in the intestines, except 
in the form of the haemorrhoids of the rectum, and as a degene- 
ration of the polypi mentioned above. 
Haemorrhoids are a form of angioma. They are produced by 
tlie dilatation of the veins supplying the lower part of the rec- 
tum. These veins communicate directly with the ascending 
vena cava through the internal iliae; but they also have large 
anastomoses, with the inferior mesenteric, and in this way they 
communicate with the portal system. Haemorrhoids are inter- THE INTESTINES. 
161 
nal or submucous; external or subcutaneous; and mixed, or 
partly submucous and partly subcutaneous. The dilatation of 
the veins is accompanied with growth of connective tissue about 
them. The blood in the dilated veins sometimes coagulates and 
forms thrombi. 
Carcinoma of the intestines is usually primary. It may oc- 
cur as medullary, scirrhus, colloid, or cylindrical-celled epithe- 
lial cancer. At the anus, flat-celled epithelial cancer also oc- 
curs. The most frequent form is the epithelial cancer with 
cylindrical cells. The rectum and colon are the parts most fre- 
quently attacked. The new growth usually surrounds the in- 
testine, and produces fatal strictures. In other cases, it perfo- 
rates into the abdominal cavity. 
Sarcoma, both white and pigmented, has been observed in 
the rectum. 
Lymphoma occurs in the intestines in cases of leucaemia. 
The nodules are soft, white, flattened, or rounded, and may ul- 
cerate. They are formed either as an hypertrophy of the soli- 
tary and agminated glands, or as growths, where these glands 
are not normally found. 
Cysts are of rare occurrence. They are found in some of the 
polypoid growths. Rokitansky describes cysts in the intestines 
and mesentery, which were formed by cystic degeneration of 
the chyle glands. 
Tubercles of the intestines are principally confined to the se- 
rous coat and to the walls of ulcers. The so-called tubercular 
ulcers of the mucous coat are formed by the enlargement and 
ulceration of the solitary and agminated glands. They differ in 
no respect from the ordinary follicular ulcers already described. 
Such follicular ulcers, when of long standing, may at their 
bases be infiltrated with small cells; the lymphatics over them 
appear as white streaks, and in the peritoneal coat there may 
be a collection of miliary tubercles. 
DEGENERATION. 
Calcification attacks, in rare cases, the wall of the intestines, 
appearing in fibrous thickenings of the peritoneal coat. 
Waxy Degeneration may affect the blood-vessels of the mu- 162 
POST-MORTEM EXAMINATIONS. 
cous membrane and of the villi; the villi themselves, and, more 
rarely, the muscular coat. 
ABNORMAL CONTENTS. 
The ordinary faecal contents of the small and large intestines 
are, in inflammation, mixed with serum, epithelium, mucus, and 
blood. 
Blood in the intestines, from whatever source it is derived, 
when recent, is still red and coagulated. After a longer stay 
in the intestines, it becomes converted into a black, granular 
mass. 
Concretions are formed either of hard, dry, faecal masses, or 
of mucus mixed with dried faeces, or collected around a foreign 
body, and impregnated with salts of lime. Such concretions 
are usually small, but may reach the size of a man's fist. They 
are round, oval, laminated, angular, or of irregular shape. 
They are found to consist of mucus, bile, faecal matter, carbon- 
ate and phosphate of lime, and triple phosphate. They may 
give rise to no evil effects, or may cause inflammation, ulcera- 
tion, and perforation, especially of the appendix vermiformis. 
Sometimes the ulcerative process stops, and the concretion is 
left attached to the mucous membrane by membranous adhe- 
sions. 
.Foreign bodies of every variety may be swallowed, and pro- 
duce different effects in the intestines, according to their nature. 
PARASITES. 
Ascaris lumbricoides is found in the small intestine, either 
singly or in numbers. In rare cases, a number of worms may 
form a mass, which produces inflammation, ulceration, and per- 
foration. 
Oxyuris vermicularis is found in large numbers in the rec- 
tum. 
TricocephaVus dispar is found in the caecum. 
Ankylostomum duodendle is found in the duodenum, and may 
give rise to considerable haemorrhages. 
Trichina spiralis is found in its adult condition in the small 
intestine. THE PERITONEUM. 
163 
Pentastomum denticulatum occurs in the submucous tissue of 
the small intestine in an encapsuled condition. 
Cysticercus celluloses has been seen in a few cases on the mu- 
cous membrane. 
Taenia solium. Taenia mediocanellata, and Bothriocephalus 
latus, are all found in the small intestine. 
THE PERITONEUM. 
MALFORMATIONS. 
Arrest of development in the peritoneal sac occurs in the 
shape of fissures in the mesial line, or external to it; in the 
case of the diaphragm being absent, of a fusion with the pleura ; 
as defective development of the mesentery, the omentum, and 
the other folds of the peritoneum. 
Excess of development occurs in the shape of unusual length 
of the mesentery, the omentum, and the other fold of the peri- 
toneum ; or of supernumerary folds and peritoneal pouches. 
These are chiefly found in the hypogastric, and, more especially, 
in the iliac and inguinal regions, and near the fundus vesicse. 
There is access to these sacs by a well-defined fissure or ring, 
which is frequently surrounded by a tendinous band lying in 
the duplicature. They may give rise to internal incarceration 
of the intestines. (Rokitansky.) 
IIYPEEJSMIA AND HAEMORRHAGE. 
Congestion of the peritoneum is general or partial. It is 
caused by obstructions to the venous circulation in* the portal 
vein and vena cava, and by inflammation. It produces serous 
effusions in tlie peritoneal cavity, thickening of the peritoneum, 
small extravasations, and consequent pigmentation of the peri- 
toneum. 
Extravasations in and beneath the peritoneum are found with 
purpura, scurvy, after contusions, parturition, etc. 
Haemorrhage into the peritoneal cavity is produced by wounds, 
contusions, rupture of the abdominal viscera, and of aneurisms. 164 
POST-MORTEM EXAMINATIONS. 
INFLAMMATION. 
Inflammation of the peritoneum is acute or chronic, general 
or partial. 
Acute General Peritonitis produces congestion, and an exu- 
dation composed of fibrine, lymphoid cells, and serum. The 
amount of congestion is variable, and does not always remain 
visible after death. It is most intense at the point where the in- 
flammation begins, especially if this is produced by a wound, 
or by perforation of the intestines, or of an abscess. That con- 
gestion exists during life, can be seen in animals in whom peri- 
tonitis is artificially excited. The stage of congestion may 
exist for a certain time before exudation takes place. How 
long, and under what conditions this is the case in the hu- 
man subject, is not known. There are cases of puerperal 
women who manifest all the symptoms of peritonitis, 
and die from it, without any perceptible lesions of the perito- 
neum or uterus after death. In such cases, we may admit the 
existence of a peritonitis without exudation, and in which the 
congestion has disappeared after death. The exudation, when 
present, is scanty or abundant. It forms a thin, gray mem- 
branous layer, agglutinating neighboring parts ; or the perito- 
neum is coated with thick, yellow material, composed of fibrine 
and lymphoid cells; or there is a large amount of yellow, puru- 
lent serum in the abdominal cavity. Sometimes there are lit- 
tle extravasations of blood in the tissue of the peritoneum, and 
mixed with the exudation, and sometimes the purulent serum is 
of a peculiar dirty brown, fetid character. The muscular coat 
of the intestines may be infiltrated with serum, relaxed and 
paralyzed. General acute peritonitis is usually fatal, but may 
pass into the chronic form, or may disappear, leaving membran- 
ous adhesions. In some cases, these adhesions will inclose masses 
of pus and fibrine. These masses may then become dry, 
cheesy, or even calcified, or they become fluid and purulent. 
Such abscesses inclosed by adhesions may rupture into the peri- 
toneum, and cause a second peritonitis, or they may cause a gen- 
eral chronic peritonitis, or perforate the intestines, or' lead to THE PERITONEUM. 
165 
tlie formation of large abscesses beneath the peritoneum, or per- 
forate through the skin. 
Peritonitis is idiopathic, secondary, or metastatic. 
Idiopathic peritonitis is usually produced by wounds and 
contusions, or occurs in connection with the puerperal condition 
in women ; except in such cases, it is rare. 
Secondary peritonitis is produced by the continuation of in- 
flammatory and gangrenous processes of the abdominal viscera 
and wall. Thus, in the stomach and intestines, we find per- 
forating ulcers, irritative poisons, malignant new growths, in- 
carceration and intussusception, retention of feces, and, rarely, 
severe catarrhal and croupous inflammation, producing a local 
peritonitis. Lesions of the uterus, the ovaries, the fallopian 
tubes, frequently cause general peritonitis. Inflammation of 
the urinary bladder, vesical and renal calculi, rupture and per- 
foration of the bladder, malignant growths of the bladder, 
nephritis, perinephritis, and tuberculosis of the urinary organs, 
may all cause peritonitis. In the liver we find abscesses, biliary 
calculi, new growths, hydatid cysts, and thrombosis of the veins 
actins' as irritating causes. 
In the spleen and pancreas, inflammation, suppuration, in- 
farctions, and new growths; in the cellular tissue, beneath the 
peritoneum, and in the lymphatic glands, inflammation and 
suppuration, and new growths ; in the abdominal vessels, rup- 
tures of aneurisms, thrombosis of veins, may excite peritonitis. 
In the abdominal wall, inflammation, suppuration, and new 
growths; in the diaphragm, perforation from empyema and 
abscesses of the lungs often cause peritonitis. In some cases, 
without perforation, there is at the same time pleurisy and peri- 
tonitis, and it is difficult to say whether the two are coincident, 
or whether one is secondary to the other. 
In the bones and muscles, caries of the vertebrae and ribs, 
with abscesses in the muscles, may cause peritonitis. 
In the peritoneum itself, new growths and hydatid cysts may 
cause inflammation. 
Metastatic peritonitis is found with pyaemia, the acute exan- 
themata, scurvy, and Bright's disease. 
Partial acute peritonitis is usually produced by inflammation 166 
POST-MORTEM EXAMINATIONS. 
of some of the viscera which the peritoneum covers. The 
spleen, the liver, and the uterus are very often found covered 
with adhesions produced by attacks of local peritonitis. Such 
a partial peritonitis may give rise to few or no symptoms during 
life, and usually subsides, leaving membranous adhesions. 
Sometimes, however, it produces abscesses in the subperitoneal 
tissue. 
In rare cases, the omentum alone is the seat of acute inflam- 
mations, sometimes leading to purulent infiltration. 
General chronic peritonitis is usually the result of an acute 
peritonitis. This is especially the case when masses of exuda- 
tion are shut in by adhesions, and give rise to a series of chronic 
inflammatory processes. 
In other cases, a long-continued obstruction to the portal 
circulation, caused by disease of the liver and heart, produces 
a thickening of the peritoneum and membranous adhesions 
between the viscera.} There is usually at the same time ascites. 
In these cases the inner surface of the peritoneum is often 
covered with numberless little granules formed of clumps of 
epithelial cells. 
In rare cases, the exudation has a gelatinous appearance, and 
is produced in enormous quantities, so that the abdomen is dis- 
tended and the viscera compressed. 
In other cases of chronic peritonitis, there is a very consider- 
able thickening of the peritoneum with thick, lardaceous, false 
membranes, which cover the parietal peritoneum, form adhesions 
between it and the viscera, and cause the intestines to adhere 
together, so that they form a solid tumor. The adhesions are 
composed of connective tissue, fibrine, and fat, are yellow, of 
waxy consistence, and usually mottled with small haemorrhages. 
The lumen of the intestines is contracted, the peritoneal and 
muscular coats thickened. 
In tubercular peritonitis there are found numbers of gray, 
miliary tubercles in the peritoneum and in the false membranes. 
The proportion between the number of tubercles and the 
amount of false membranes varies very much in different cases; 
some serous effusion is also usually present. 
Chronic partial peritonitis is more common, and usually de- THE PERITONEUM. 
167 
pends on lesions of the viscera. The spleen, liver, and uterus 
are frequently the seat of a chronic inflammation, producing 
thickening of their capsules and membranous adhesions. Ulce- 
ration of the intestines, typhlitis, subperitoneal abscesses, etc., 
all lead to chronic partial peritonitis. In rare cases, the omen- 
tum alone is the seat of a chronic inflammation, producing 
fibrous thickening and adhesions. 
The most important feature of such a partial peritonitis is 
the interference with, or even stricture of, the intestine pro- 
duced by the adhesions. 
The subperitoneal tissues sometimes become the seat of sup- 
purative inflammation, by which abscesses are formed. These 
retroperitoneal abscesses are caused by perinephritis, pericysti- 
tis, perityphlitis, periproctitis, perimetritis, periovaritis, in- 
flammation of the muscles of the back and abdomen, caries of 
the vertebrae, etc. The abscesses usually reach a considerable 
size, they invade the neighboring soft parts, produce caries of 
the bones, and finally perforate inward through the peritoneum, 
or outward through the skin. 
Gangrene of the peritoneum is produced by incarceration 
and intussusception of the intestines, by abscesses, and, in in- 
fants, by gangrene of the umbilicus. The portion of perito- 
neum affected appears as a slough surrounded by a zone of in- 
tense congestion, or as a softened, black, putrid mass. 
GANGRENE. 
Besides the tarbid fluid, composed of serum, pus, and flbrine, 
which we find as an inflammatory exudation in the peritoneal 
sac, we also meet with simple dropsical accumulations of serum. 
The serum, in these cases, is nearly colorless, yellow, green, or 
red. It is perfectly transparent, or opalescent, or contains fibri- 
nogenic material, which coagulates when exposed to the air. 
The composition of the fluid resembles that of the serum of the 
blood. 
The peritoneum appears unchanged, or is white and thick, or 
there may be adhesions between the different viscera. 
ASCITES. 168 
POST-MORTEM EXAMINATIONS. 
The fluid is usually free in the peritoneal cavity, but may be 
sacculated by adhesions. Sometimes, especially in children, 
there is oedema of the omentum alone. 
The serum not only distends the abdominal walls, but pushes 
up the liver and diaphragm, and causes the lower ribs to be 
bulged outward. 
A small amount of ascites is found often in cachectic and ill- 
nourished persons. A larger amount is usual\y caused by dis 
eases of the heart, kidneys, liver, spleen, lungs, and by any ob- 
struction to the portal vein or ascending vena cava. 
Air is sometimes found in the peritoneal sac after perforation 
of the stomach, intestines, uterus, and abdominal wall. The 
spontaneous formation of gas in the peritoneum is doubtful. 
Fibroma of the peritoneum is rare. The tumors grow from 
the subserous tissue. Those which have been described in this 
situation on the intestines are probably mostly myomata. 
Others, however, grow beneath the parietal peritoneum, project 
outward into the muscles, and are true fibromata. 
Lipoma.-An abnormal accumulation of fat in the omentum 
and mesentery, and beneath the peritoneum, is often seen. Be- 
sides this, circumscribed fatty tumors are found beneath the in- 
testinal and parietal peritoneum. On the intestines they are 
usually hypertrophies of the appendices epiploicae. These tu- 
mors often degenerate, calcify, become indurated, their pedicle 
atrophies, and they become free in the abdominal cavity. 
When they grow beneath the parietal peritoneum, they may 
form fat hernhe, hernia lipomatosa. At the umbilicus, in the 
inguinal canal, and along the vas deferens, in the crural ring, 
and in the foramen obturatorium, fatty tumors may grow, pro- 
ject outward under the skin like hernia, and, by drawing the 
peritoneum after them into a pouch, may lay the foundation of 
a future intestinal hernia. 
Llyxoma.-In persons much emaciated and debilitated by 
chronic disease, the fat beneath the intestinal and parietal 
peritoneum sometimes undergoes mucous degeneration, and 
is converted into a gelatinous substance of a light yellow color. 
NEW GROWTHS. THE PERITONEUM. 
169 
Ill the pelvis of the kidneys, new growths of mucous tissue 
are found, which project inward into the abdominal cavity. 
Such tumors, however, are usually combinations of myxoma 
and sarcoma. 
Sarcoma appears in the form of solitary, slowly-growing tu- 
mors behind the peritoneum, or between the folds of the mesen- 
tery. They may reach a large size, and by their pressure on the 
veins and the intestines, cause thrombosis of the large veins and 
obstruction of the intestines. They may give rise to metastatic 
tumors of the peritoneum and of the viscera. 
In the peritoneum itself, especially in the omentum, the me- 
sentery and the appendices epiploicee sarcomata are found both 
as primary and secondary tumors. They are frequently very 
vascular. 
Carcinoma of the peritoneum is either primary or secondary. 
It assumes the form of colloid or of true carcinoma, either hard 
or soft. 
The colloid form, when primary, involves the greater part of 
the peritoneum, and forms a large mass which distends the ab- 
domen. The omentum is changed into a large gelatinous mass: 
the subjacent muscles, the lymphatic glands, and the liver are 
infiltrated with the new growth, and soft gelatinous masses pro- 
ject into the peritoneal cavity. The umbilicus is sometimes in- 
vaded, so as to project outward in the form of a semi-translu- 
cent tumor. The appearance of the new growth is that of a 
soft, jelly-like mass, imbedded in a fibrous stroma. The minute 
structure consists of fibrous alveoli, containing epithelial cells, 
and a homogeneous, transparent, gelatinous substance. When 
the disease is far advanced, no cells are to be found. 
When the new growth is secondary, it appears in the form of 
numerous little nodules on the free surface of the peritoneum. 
True carcinoma is either primary or secondary. It usually 
appears in the form of numerous small nodules in the intestinal 
and parietal peritoneum. These nodules are small, firm, and 
white. They are often united by a flat layer of the same new 
growth, so that the peritoneum is changed into a uniform, thick, 
white membrane. Less frequently, carcinoma appears as soli- 
tary, soft, medullary growths. 170 
POST-MORTEM EXAMINATIONS. 
Tubercles.-Gray and yellow miliary granulations are found 
in the peritoneum in some cases of general tuberculosis. They 
are found in the omentum without any inflammatory le- 
sions, or in the peritoneum, over ulcers of the intestines, or in 
connection with fibrinous exudation and membranous adhesions 
in tubercular peritonitis. 
Cysts.-In rare cases, dermoid cysts containing fat, hair, 
bones, etc., are found in the parietal and visceral peritoneum, 
and in the omentum. These are probably congenital. Roki- 
tansky describes a cystic degeneration of the mesenteric glands. 
In the broad ligaments of the uterus, both serous and colloid 
cysts are found. 
PARASITES. 
Echinococci are found in hydatid cysts, beneath the capsule 
of the liver, in the omentum, and beneath the parietal and vis- 
ceral peritoneum. They are surrounded by false membranes. 
THE LIVER. 
MALFORMATIONS. 
Congenital malformations of the liver are not common, and 
are of little practical importance. The organ may be entirely 
wanting, the lobes may be diminished or increased in number ; 
its form may be altered, so that it is rounded, flattened, triangu- 
lar, or quadrangular. The gall-bladder may be 'wanting, the 
ductus choledochus may be double, both ducts emptying into the 
duodenum, or one emptying into the duodenum, the other into 
the tomach. The single ductus choledochus may also empty 
intt^the stomach. 
In congenital transposition of the viscera, the liver is found on 
the left side, the stomach and spleen on the right side. 
Small, isolated bodies, having the same structure as the liver, 
have been found in the suspensory ligament. They are analo- 
gous to the little accessory spleens. THE LIVER. 
171 
Changes in the size and form of the liver are frequent. The 
cono-enital malformations remain during life, and the liver is 
found quadrangular, or with abnormal fissures and lobes, or 
with abnormal size and shape of the lobes. The left lobe espe- 
cially varies very much in size. 
In females we find changes in the shape of the liver produced 
by tight lacing. By the narrowing of the base of the thorax, the 
organ is compressed from side to side, and its convex surface is 
pressed against the ribs. In consequence of this, there are found 
ridges and furrows on its convex surface. In consequence also 
of the circular constriction, a part of the right, and usually of 
the left, lobe also becomes separated by a depression. Over 
this depressed and thinned portion of the liver, the capsule is 
thick and opaque. In extreme cases, the depressing and thin- 
ning reach such an extent that there is only a loose, ligament- 
ous connection between the separated portion and the liver. 
New growths, hydatic cysts, and abscesses often produce a 
marked increase in the size of the liver. 
Fatty and waxy degeneration increase the size of the liver. 
Cirrhosis sometimes increases the size of the liver, but more 
commonly diminishes it, and produces lobulation. Syphilitic 
hepatitis, obstruction of branches of the portal vein, and partial 
inflammations and cicatrizations, also produce lobulation of the 
liver. 
Changes in the position of the liver are produced by altera- 
tions in its size, by pressure downward from the thoracic cavity, 
and upward from the abdomen, by the constriction of tight lac- 
ing, by tumors or circumscribed serous exudation between the 
liver and diaphragm, by curvature of the spine. 
When the liver or lower portion of the liver is constricted by 
tight lacing, the axis of the organ falls downward, and the edge 
of the right lobe protrudes far below the margin of the ribs. If 
there is at the same time a deep depression in the right lobe, 
from the same cause, and the intestines lie in this groove, it may 
seem as if there was a tumor, separated from the liver, in the 
right iliac region. When the upper third of the liver is com- 
CHANGES IN SIZE AND POSITION. 172 
POST-MORTEM EXAMINATIONS. 
pressed, its axis is carried downward, and the entire organ push- 
ed toward the median line. The liver may then fill the upper 
half of the abdominal cavity. 
When the contents of the thorax are increased, the liver is 
pushed downward. In pulmonary emphysema, the liver may be 
depressed from one to one and a half intercostal spaces. 
In pleurisy, empyema, and hydropneumothorax of the right 
side, the liver is pushed downward and dislocated, so that its 
convex surface is in apposition with the abdominal wall. When 
the effusion is in the left pleural cavity, the liver is pushed 
toward the right side, and slightly depressed. 
Very great serous effusion in the pericardium may depress 
the liver, especially the left lobe. 
Intra-thoracic tumors depress the liver, according to their 
situation. 
When there is fluid or a new growth in the abdomen, or gas 
in the intestines, the liver is pushed directly upward, without 
any change in its axis. 
Structural changes in the liver increase or diminish its size, 
and cause an increase or diminution in its thickness. 
There have been a very small number (3) of cases reported of 
dislocated and movable liver. They all occurred in women 
who had borne children. The diagnosis was made during life, 
and no post-mortem examination of the cases was made. 
The transverse colon may become fixed above the liver, so as 
to push it backward, downward, and to the right. 
INJUKIES. 
Wounds of the liver produce haemorrhage and inflammation. 
They are usually fatal; but the patient may recover, even after 
the destruction of a considerable portion of the organ. 
Rupture of the liver is produced by severe contusions and 
falls ; it results in large haemorrhages, and is very fatal. 
HYPEREMIA. 
Hypersemia of the liver is either an active or a passive pro- 
cess. 
In health, the amount of blood in the liver varies at different THE LIVER. 
173 
times, being regularly increased during the process of digestion. 
When the digestive process is irritated by the ingestion of spirits, 
spices, etc., the hypermmia assumes abnormal proportions, and, 
when often repeated, leads to structural changes in the organ. 
Severe contusions over the region of the liver sometimes 
cause a hyperaemia, which may result in suppurative or in in- 
durative inflammation. 
In hot climates and in malarious districts, active and chronic 
hyperaemia of the liver are frequent, and often cause structural 
lesions. In scurvy, also, the liver is sometimes congested. 
Cessation and suppression of the menses, and of hsemorrhoidal 
bleeding, may cause hyperaemia of the liver. 
In all these varieties of active congestion, the liver is enlarged, 
of a deep red color, and blood flows freely from its ent surface. 
The passive congestions of the liver are produced by some ob- 
struction to the current of blood in the hepatic veins. Valvular 
diseases of the heart, emphysema, and fibrous induration of the 
lungs, large pleuritic effusions, intra-thoracic tumors, angular 
curvature of the spine, aortic aneurisms pressing on the vena 
cava, and constrictions of the vena cava and of the hepatic veins, 
may all produce a chronic hyperaemia of the liver. In all these 
cases, as the congestion affects principally the hepatic veins, we 
find the centre of each acinus congested and red, while its peri- 
phery is lighter colored. This gives to the liver a mottled or 
nutmeg appearance. The liver-cells in the centre of each aci- 
nus are frequently colored by little granules of red or black pig- 
ment, and the cells at the periphery become fatty, so that the 
nutmeg appearance is still more pronounced. A liver in this 
condition is usually of medium size, but may be smaller or 
larger than normal. 
When the congestion is long continued, the veins at the cen- 
tre, of each acinus may become dilated, the hepatic cells in their 
meshes become atrophied, so that the centre of each acinus con- 
sists only of dilated capillaries and new connective tissue. The 
liver then becomes small, and has a finely granular appearance. 
But I have seen the liver enlarged while these changes existed. 
In other cases, the obstruction of the hepatic veins does not 
produce the irregular nutmeg congestion. The entire organ is 174 
POST-MORTEM EXAMINATION'S. 
congested, of a dark red color, of very firm consistence, some- 
what increased in size; the intra-lobular veins and the central 
portion of the capillary plexus of each acinus are much dilated. 
ATROPHY. 
1. Senile Atrophy.-The liver may be diminished in size by 
any causes which interfere with its nutrition. Old age, insuf- 
ficient food, new growths of the stomach, chronic poisoning with 
lead, mercury, arsenic, and antimony, are among the most com- 
mon of such causes. The liver is found atrophied in all its di- 
mensions, firm, the acini small. 
2. Yellow Atrophy.-During pregnancy, after typhus fever, 
with phosphorus poisoning, and from unknown causes, we some- 
times meet with severe symptoms, coma, delirium, jaundice, 
etc., during life. After death, the liver is found small, flabby, 
yellow, anaemic, its cells in a condition of fatty and granular 
degeneration. Our knowledge concerning the nature of the dis- 
ease, its causes, and the relation between the symptoms and le- 
sions, is very imperfect. 
3. Red Atrophy.-In a few cases, symptoms of much the 
same character, but of longer duration, are accompanied by a 
different condition of the liver. The organ is very much atro- 
phied in all its dimensions. It is of a bright or dark red color, 
mottled with rounded yellow spots. In some cases, the red and 
yellow colors are more irregularly distributed, so that a large 
part of a lobe may be'yellow. In the red portions of the liver, 
the acini are atrophied; in the yellow portions, they are hyper- 
trophied. In the yellow portions, the hepatic cells are large and 
fatty. The interstitial tissue and vessels are unchanged. The 
red portions consist of loose connective tissue, in which are small 
spaces filled with granular fat and bile pigment. There are al- 
so peculiar, long, branching follicles, lined with polygonal cells, 
of which the nature is obscure. Some authors regard red atro- 
phy as a more advanced stage of yellow atrophy. 
4. Cyanotic Atrophy may be produced by any cause which 
impedes the flow of blood from the hepatic veins. The liver is 
diminished in size, is very hard, of mottled red and yellow THE LIVER. 
175 
nutmeg color, or of a uniform dark red. The veins at the cen- 
tres of the acini are dilated; the liver-cells between them are 
atrophied, pigmented, and diminished in number. The periphe- 
ral cells are normal or fatty. There is a production of lym- 
phoid cells at the centres of the acini. 
Atrophy of the liver is also produced by obliteration or ste- 
nosis of the portal vein and its branches, by obstruction of the 
capillaries by pigment, and by obliteration of the capillaries. 
Permanent obstruction of the hepatic or common bile duct 
may produce atrophy. The biliary ducts throughout the liver 
are dilated, the liver is stained at first yellow and afterward 
green, the consistence is soft, the size of the organ is much di- 
minished, and the liver-cells are pigmented, fatty, and broken 
down. 
Chronic perihepatitis, with great thickening of the entire 
capsule of the liver, sometimes produces marked atrophy with 
the symptoms of cirrhosis. 
HYPERTROPHY. 
Simple hypertrophy of the liver is to be diagnosticated with 
great caution. It is found with leucaemia, diabetes, phthisis, 
and cardiac disease, in malarious districts, and without known 
cause. The liver is inc reasedin size, the acini are larger than 
normal, the liver-cells are increased in size or number, the 
blood-vessels are also large. 
HAEMORRHAGE. 
Extravasations of blood in the hepatic tissue, or, more fre- 
quently, beneath its capsule, are found in new-born children 
after tedious or forcible labors, and with atalectasis of the lungs. 
The blood may burst through the capsule, and be found in the 
peritoneal cavity. 
In adults, such extravasations are rare. They are seen in 
the malignant, malarious fevers, especially in tropical countries ; 
in scurvy and purpura; and in consequence of external vio- 
lence. There are also a few curious cases recorded of such sud- 
den haemorrhages in which no cause was discovered. The ex- 
travasations of blood are beneath the capsule, or circumscribed 176 
POST-MORTEM EXAMINATIONS. 
in the hepatic tissue, or in the form of a diffused haemorrhagic 
softening. If tire extravasation is small, it may be absorbed, 
leaving a cicatrix. According to Stokes, such haemorrhages 
may produce gangrene of the liver. 
INFLAMMATION. 
The liver is often the seat of inflammatory changes. These 
changes affect the capsule of the organ, its interstitial connec- 
tive tissue, or its cells; they involve either a portion or the 
whole of the liver. 
PERIHEPATITIS. 
The capsule of the liver and its prolongations along the ves- 
sels are frequently inflamed. The inflammation may be part 
of a general peritonitis, or may be confined to the liver. 
When the inflammation is confined to the liver, it is depen- 
dent upon the different forms of hepatitis; upon new growths 
and hydatids of the liver ; upon pleurisy of the right side; upon 
syphilis ; rarely upon traumatic causes; and very frequently 
occurs without any assignable cause or previous symptoms. 
Perihepatitis usually results in thickening of the capsule and 
the formation of membranous adhesions. These lesions are 
usually of little consequence, and frequently give rise to no 
symptoms during life. In some cases, however, the entire cap 
side is very much thickened, the liver is small and compressed, 
and the symptoms are those of cirrhosis. 
In rare cases perihepatitis is purulent, and produces collec- 
tions of pus shut in by false membranes. 
The inflammation of the prolongations of the'capsule on the 
vessels will be considered -with diseases of the vessels. 
CHRONIC PARENCHYMATOUS HEPATITIS. 
Forster describes, under this name, a lesion which he says is 
usually confounded with cirrhosis. 
The liver is at first large, congested, or anaemic. Following 
the stage of hypertrophy, a gradual, slow atrophy sets in. The 
organ is small, anaemic, yellow, and has a granular appearance. 
This granular appearance, however, is not like that of cirrhosis, THE LIVER. 
177 
but is produced by the destruction of some of the acini, and 
the consequent undue prominence of others. The liver-cells are 
destroyed, or are small and granular. 
This lesion may produce jaundice, ascites, and sometimes 
death. 
INTERSTITIAL HEPATITIS. 
Interstitial hepatitis is acute, and leads to the formation of 
abscesses; or chronic, and results in the formation of new con- 
nective tissue. 
PURULENT HEPATITIS. 
The study of the formation of abscesses in the liver has been 
very much confused by confounding two separate pathological 
conditions. (1) Abscesses formed by a purulent hepatitis; (2) 
abscesses formed by the irritation of emboli, and from throm- 
bosis of the portal vein. The description of the first stages of 
the lesion is usually drawn from the second, and of the latter 
stages from the first of these conditions. 
(1.) Idiopathic abscesses are of rare occurrence, except in tro- 
pical climates. In temperate climates, so few cases are seen 
that we know but little of their causation. A few cases are re- 
corded in which severe contusions were the exciting causes of 
abscesses of the liver. Dysentery, with ulceration of the large 
intestine, is sometimes associated with single abscesses of the 
liver; but the exact relation between them is not well known. 
Inflammation and ulceration of the bile-ducts, excited by the 
presence of biliary calculi, or of intestinal worms, may produce 
multiple abscesses by the extension of the inflammation from 
the ducts to the liver tissue. 
Of the earlier stages of idiopathic suppurative hepatitis but 
little is known. The abscesses are not seen in autopsies until 
after they are fully formed. They may then reach a large size, 
and are usually single, though sometimes multiple. They may 
be opened by the surgeon through the abdominal wall; or rup- 
ture spontaneously into the pleural cavity, the lungs, the abdo- 
minal cavity, the stomach and intestines, the hepatic vein, the 178 
POST-MORTEM EXAMINATIONS. 
bile-ducts, the gall-bladder, the right kidney, the muscles and 
skin of the abdominal wall. Such abscesses usually prove fa- 
tal ; but sometimes their artificial or spontaneous evacuation 
is followed by recovery. 
(2.) Abscesses of the liver are formed in the same way as 
embolic abscesses in other viscera. There is thrombosis, from 
some cause, in the portal vein or its intestinal branches, or in 
the veins of the lungs, or in any of the veins belonging to the 
aortic system. A portion of such a thrombus finds its way 
either into one of the small branches of the portal vein, or of 
the hepatic artery. This sets up a suppurative inflammation of 
the adjoining portion of liver tissue. The thrombus simply 
acts as an irritant, and produces suppuration without infraction. 
(3.) In thrombosis of the portal vein, the thrombi extend into 
the liver as far as the small interlobular veins. The veins are 
filled with a thrombus, which is either firm and white, or soft 
and puriform. Their walls are thickened, the inner surface 
becomes opaque and rough, and is sometimes lifted up by little 
collections of pus, the middle and external coats and the cap- 
sule of Glisson are all infiltrated with lymphoid cells. The 
liver-cells and the branches of the hepatic veins are compressed 
and degenerate from the pressure of the enlarged and inflamed 
branches of the portal vein, the liver-cells atrophy, break down, 
and disappear, and there is left an abscess filled with pus and 
debris. 
CHRONIC INTERSTITIAL HEPATITIS. CIRRHOSIS. 
The interstitial connective tissue which accompanies the 
veins and bile-ducts, in their ramifications through the liver, 
is frequently the seat of a chronic inflammation which results 
in the formation of new connective tissue. It has been thought 
necessary by pathologists and clinicists to describe different 
stages of the disease which must succeed each other. Such a 
description is forced and without sufficient anatomical basis. 
We meet with different degrees and qualities of tlie lesion, but 
we do not know their relationship. 
The appearances vary according to the amount of new con- THE LIVER. 
179 
nective tissue, its distribution, its vascularity, and the condition 
of the hepatic cells. 
In the least advanced condition, we find the liver of normal 
size or larger, not congested, firmer and smoother than usual, 
of a light red or yellow color, with a peculiar glistening reflex, 
like that of a waxy liver. The edges of the acini are sur- 
rounded by a light yellow streak, which is composed of connec- 
tive tissue fibres, with a variable number of cells. The hepatic 
cells are usually normal, sometimes fatty. 
In other cases, the liver is increased in size, its edges rounded, 
of a yellowish brown color, its surface slightly uneven, its cap- 
sule thickened. Groups of acini are surrounded by bands of red- 
dish gray, vascular connective tissue. 
When the lesion is far advanced, the liver is usually much 
diminished in size; sometimes, however, it is very much larger 
than the normal. The capsule is thickened, the surface is 
strikingly irregular, and thrown into nodules of variable size. 
These nodules are of a yellow color, or stained green by the 
bile. They are surrounded by a layer of dense white or 
pinkish connective tissue. The increase of connective tissue 
takes place about each acinus separately, or about groups of 
acini, or in both ways. The new tissue is composed of fibrous 
tissue alone, or is largely cellular. The degree of vascularity 
also varies, and gives different shades of color. The relative 
amount of cells and fibres in the new connective tissue does 
not seem to indicate an early or late stage of the disease ; for 
in cases where the lesion is of long standing, and the liver 
atrophied, the cells are sometimes abundant. The hepatic 
cells usually become fatty, or may be waxy or pigmented, Gl- 
are broken down and destroyed. The pigment is. derived from 
the bile, and is of a yellow or green color; or from the blood, 
and is reddish brown. 
The smaller branches of the portal vein are narrowed and 
compressed by the new connective tissue. Sometimes the 
main trunk and large branches are dilated. When the new 
connective tissue has replaced the hepatic structure, the capil- 
lary venous plexus is entirely destroyed, and there are only 
irregular vessels which can be injected from the portal vein and 180 
POST-MORTEM EXAMINATIONS. 
hepatic artery. In some cases, the portal vein and its large 
branches have been found filled with large thrombi. 
The hepatic artery becomes enlarged and its branches are 
more extensive. 
The hepatic veins are usually unchanged, with the exception 
of their capillaries, which are gradually destroyed. 
The bile-ducts are compressed by the new tissue; the mucous 
membranes of the large ducts may be inflamed and swollen, and 
the gall bladder is often thickened and adherent. 
The obstruction of the portal circulation, produced by 
cirrhosis, gives rise to a number of secondary lesions. 
There are a number of veins which can afford a collateral 
circulation between the portal vein and the vena cava. There 
are normally anastomoses between the internal and inferior 
hsemorrhoidal veins; between the left coronary and the oesopha- 
geal and diaphragmatic veins; between the hsemorrhoidal 
and vesical veins ; between the coronary vein of the stomach, 
the gastro-epiploic veins and the renal veins; between the 
superior mesenteric and the left renal vein; between the vasa 
brevia and the left phrenic vein. All these vessels, however, 
are seldom enlarged in cirrhosis. 
There are sometimes large anastomoses between the veins of 
Glisson's capsule and the diaphragmatic veins. 
In rare cases, a very peculiar dilatation of the cutaneous 
veins about the umbilicus is observed. The enlarged veins 
form a circular network around the umbilicus, or a pyramidal 
tumor alongside of it, or all the veins of the abdominal wall, 
from the epigastrium to the inguinal region, are dilated. This 
condition is produced by the congenital non-closure and sub- 
sequent dilatation of the umbilical vein and its anastomoses 
with the internal mammary, epigastric and cutaneous veins. 
According to Sappey, it is not the umbilical vein which is dilated, 
but a vein which accompanies the ligamentum teres. 
There is very frequently also a dilatation of the veins of the 
abdominal wall, which has a different cause. It is produced by 
the pressure of the fluid of ascites on the vena cava, and is found 
with ascites from any cause and with abdominal tumors. 
Ascites is the most common secondary lesion of cirrhosis. It THE LIVER. 
181 
begins at an early stage of the disease, and increases constant- 
ly. It usually precedes oedema of the feet, but both may appear 
at the same time. This fluid is of a clear yellow or brown, 
green or red ; it is sometimes mixed with shreds of fibrine, and 
more rarely with blood. The peritoneum remains normal, or 
becomes opaque and thick, or there may be adhesions between 
the viscera. 
The spleen is very frequently enlarged, and the enlargement 
may be very considerable. When it is not increased in size, 
this is usually due to previous atrophy of the organ, or to 
fibrous thickening of its capsule, or to haemorrhages from the 
stomach and bowels, occurring just before death. 
The stomach and intestines are often secondarily affected by 
the obstruction to the portal circulation. 
Profuse haemorrhage from the stomach and intestines may 
occur, and sometimes causes sudden death. The mucous mem- 
brane is then found pale, or congested, or with haemorrhagic 
erosions. Sometimes the blood is infiltrated in the coats of the 
stomach and intestines. The mucous membrane of the stom- 
ach, and of the entire length of the intestines, is sometimes uni- 
formly and intensely congested, and coated with mucus. In 
other cases both the mucous and muscular coats are pale, but 
very markedly thickened. 
The causes of cirrhosis are not well known. It is a disease of 
adult life, and is often found in habitual drinkers; but there 
are many cases in which no cause can be discovered. 
SIMPLE INDURATION OF THE LIVER. 
This name has been given to a variety of chronic interstitial 
hepatitis, in which the new fibrous tissue has a different arrange- 
ment. It is produced in masses of considerable size, which re- 
place the hepatic tissue, and are smooth and dense. 
In a considerable number of cases, this lesion occurs in per- 
sons who have been the subject of constitutional syphilis. 
The history of the disease is the same as that of cirrhosis. 182 
POST-MORTEM EXAMINATIONS. 
SYPHILITIC HEPATITIS. 
Diffuse chronic interstitial hepatitis occurs not infrequently 
in persons who have suffered from constitutional syphilis. Such 
a hepatitis may assume the ordinary characters of nodular cirrho- 
sis of the liver, or it may assume a form which is peculiar and 
different from this. The difference consists merely in the dis- 
tribution of the new fibrous tissue. Instead of surrounding sin- 
gle acini, or small groups, the new connective tissue surrounds 
larger portions of the organ, and thus gives it a lobulated in- 
stead of a nodulated form. There is at the same time perihe- 
patitis, with thickening of the capsule ; and from the thicken- 
ed capsule dense fibrous septa extend into the liver. A lobe of 
the liver may be, in this way, divided up into two or more 
large subdivisions, or into a great number of small lobules. 
There are also, in some cases, gummy tumors formed in the 
fibrous septa. In other cases, the lobulation is less marked, but 
we find smooth, hard masses of fibrous tissue replacing portions 
of the hepatic tissue. 
DEGENERATIONS OF THE LIVER. 
THE FATTY LIVER. 
In the human liver there is usually a certain amount of fat 
in the liver-cells, and this amount varies considerably under dif- 
ferent conditions, without constituting a pathological lesion. 
The amount of fat in the liver-cells, and the extent to which it is 
distributed, may, however, reach such an extent as to be entire- 
ly abnormal 
The fat is found in the hepatic cells, in the form of globules 
of different sizes. A single cell may contain several small fat 
globules, or may be so distended with fat that only a narrow 
rim of cell-tissue is left. The accumulation of fat usually be- 
gins in the periphery of each acinus, next to the branches of tlie 
portal vein. The gross appearance of the organ varies a good 
deal in different cases. It is usually increased in size, flattened, THE LIVER. 
183 
and its edges are rounded; but the increase may also be in thick- 
ness, and the edges may remain sharp. In other cases, the liv- 
er is of normal size, and in others again is atrophied. The col- 
or is red, mottled with large patches of yellow on the surface ; 
in such cases, only the yellow portions of the liver are fatty. 
Or, the entire liver has a mottled red and yellow color, resem- 
bling the nutmeg-liver; this is produced by fatty degeneration 
of the cells at the periphery of each acinus, with some conges- 
tion of the veins at its centre. Or, the entire liver is of a pale 
yellow color, and contains very little blood. Or, there may be 
yellow or green staining with bile pigment. 
The consistence of the liver also varies. It may be very soft 
and greasy, or it may be firm, or even hard. This firmness may 
depend on a different character of the fat, or on the coexistence 
of chronic interstitial hepatitis, or on waxy degeneration of 
some of the liver-cells. 
Of the causes of fatty liver we are, in a great measure, igno- 
rant. In persons affected with pulmonary phthisis, and in hab- 
itual drinkers, the lesion is so often met with that it may be 
considered as dependent upon those conditions; but it is also 
seen associated with many other diseases. 
Fatty liver may produce jaundice and symptoms of bile- 
poisoning. 
THE WAXY LIVER. 
The liver is not infrequently the seat of an infiltration with 
a peculiar transparent, homogeneous, glistening substance. This 
substance, called amyloid, waxy, or lardaceous material, has 
the property of being stained of a deep-red color by a weak 
solution of iodine. It has been supposed to be analogous to 
cellulose; to be an albuminous substance; to be dealkalized 
fibrine, etc.; but as yet there is no exact knowledge of its real 
nature. In the liver, the waxy material affects, first, the walls 
of the branches of the hepatic artery ; then the liver-cells mid- 
way between the centres and peripheries of the acini; then the 
centres of the acini; and lastly, the whole of the acini. The 184 
POST-MORTEM EXAMINATIONS. 
walls of the venous capillaries may also be infiltrated. Accord- 
ing to Wagner, only the hepatic artery and the venous capil- 
laries become waxy, while the hepatic cells are only atrophied. 
Most observers, however, place the lesion in the hepatic cells. 
The gross appearance of a waxy liver varies according to the 
extent of liver-substance invaded, the way in which the waxy 
material is distributed, and the coexistence of fatty degenera- 
tion, and interstitial hepatitis. 
There may be only a few waxy cells scattered here and there 
in different acini, and the rest of the liver tissue be normal. 
Then the liver will have its normal size and appearance. Or, 
if the degeneration affect the greater part of the liver, the organ 
will be much enlarged, of a peculiar reddish, translucent color, 
and of a firm, waxy consistence. Or, in rare cases, there are a 
few circumscribed nodules of waxy cells, while the rest of the 
organ is not waxy. Or, if there is at the same time fatty de- 
generation of the other hepatic cells, the consistence and color 
of the liver will be modified. Or, if there is interstitial hepa- 
titis, the liver will be nodulated or lobulated. Waxy degenera- 
tion of the liver is frequently associated with the same degenera- 
tion of the spleen, kidneys, and intestines. It does not produce 
ascites, except in a few cases, which seem to depend rather on 
general hydrsemia than on obstruction to the portal circulation. 
It may in exceptional cases cause jaundice. 
Waxy degeneration of the liver, as of other organs, is the 
result of chronic inflammation and suppuration, especially of 
the bones and lungs, and occurs in consequence of constitu- 
tional syphilis. It is also sometimes produced by long-con- 
tinued malarial poisoning. 
THE PIGMENT LIVER. 
Malarial poisoning, whether it appears in the form of remit- 
tent or intermittent fever, produces in the blood a variable 
amount of pigment. This pigment, which is found most abun- 
dantly in the blood of the portal vein, is of black, brown, or 
reddish color. It is found in the form of small granules em- THE LIVER. 
185 
bedded in transparent, finely granular cell-bodies of irregular 
shape, and in larger flakes of pigment alone. There are also 
colorless cells, like those holding pigment, which contain no pig- 
ment. The white globides of the blood are frequently also in- 
creased in number. These pigment bodies are found in the 
greatest number in the blood of the spleen and liver. These 
organs, therefore, assume a black or olive-brown color. The 
liver is usually of normal size, and the hepatic cells are normal; 
but it may be hypertrophied or atrophied, and the liver-cells 
may be fatty, or waxy, or cirrhosed. The pigment is found 
in the venous capillaries and in the branches of the hepatic 
artery. 
This pigmentation is most constantly found in the spleen, but 
in exceptional cases is found in the liver and not in the spleen. 
In marked cases, the brain, lungs, intestines, kidneys, and sub- 
cutaneous connective tissue are found of a brownish color, and 
their capillaries contain pigment. 
In the brain, the pigment masses may block up the small 
arteries and produce numerous punctate apoplexies. The black 
masses of sulphate of iron, produced by decomposition, can be 
distinguished by their blue color when treated with hydrochlo- 
ric acid and ferro-cyanide of potash. 
GRANULAR, OR PARENCHYMATOUS DEGENERATION. 
We find a peculiar change in the liver-cells as an accompani 
inent of several different pathological processes. The hepatic 
cells are at first filled with fine granules, soluble in alkalies, and 
apparently of albuminous nature. At a later stage, the cells 
are filled with coarser and glistening granules, soluble in alco- 
hol and aether, and of fatty nature. 
These changes in the hepatic cells are found as a result of 
impeded circulation, of infectious diseases, and of poisons, or of 
general disturbances of nutrition. 
Thrombosis of the portal vein, abscesses, and cirrhosis may 
produce granular degeneration of circumscribed portions of the 
hepatic tissue. 
Pyaemia, septicaemia, erysipelas, epidemic cerebro-spinal 186 
POST-MORTEM EXAMINATIONS. 
meningitis, acute miliary tuberculosis, acute articular rheu- 
matism, typhus and typhoid fever, yellow-fever, cholera, the 
acute exanthemata, are all frequently accompanied by this 
change in the liver. 
Poisoning by phosphorus, by arsenic, and by antimony pro- 
duces this lesion in a marked degree. It will be found de- 
scribed more particularly under the head of poisons. 
Chronic pulmonary diseases and anaemia, from any cause, 
may produce the same lesion in the liver. 
THE HEPATIC ARTERY. 
The hepatic artery, in rare cases, is the seat of aneurismal 
dilatations, which may attain a large size. Such aneurisms 
may displace the liver, produce intense pain, compress the bile- 
ducts so as to cause jaundice, and usually rupture into the ab- 
domen or stomach. The diagnosis of this lesion is not often 
made during life. 
Embolism is not very common. It produces infarctions and 
abscesses. 
THE PORTAL VEIN. 
Thrombosis of the portal vein, is a lesion frequently met with. 
It is occasionally produced by inflammation of the vein, but 
more frequently the phlebitis is produced by the thrombus. 
Thrombi of the portal vein may be produced by : 
1. Weakening of the circulation from general debility. 
2. Diseases of the liver which destroy or compress branches of 
the portal vein. Cirrhosis, chronic atrophy, cancer of the liver, 
and dilatation of the bile-ducts are the most frequent causes. 
The thrombus usually occupies both the branches and trunk of 
the portal vein. It may fill the vessel either partly or com- 
pletely. It adheres firmly to the wall of the vein, is firm and 
hard, or may be organized, and is of a grayish, blackish, or jaun- 
diced color. Fresh red coagula may be attached as prolonga- 
tions to the firmer clots. The vein is usually dilated, its walls 
are thickened, and may be calcareous. THE LIVER. 
187 
In cancer of the liver, the thrombus may be produced by the 
pressure on the vein, or the new growth may project into the 
vein, and form part of the thrombus. In very rare cases, the 
portal vein and its branches have been found filled with a soft 
material composed of nucleated cells, while there was no new 
growth in the liver or other viscera. 
3. Tumors, or new connective tissue, which compress the 
portal vein below the liver. 
Chronic peritonitis, tumors of the stomach, pancreas, and 
omentum, and tumors or enlargements of the adjoining lym- 
phatic glands, are the most frequent causes. 
4. There may be no cause for the thrombus. This is espe- 
cially the case when isolated branches of the portal vein become 
filled and obliterated by a thrombus, and in consequence of this, 
the portions of the liver supplied by these venous branches 
become atrophied, and the liver assumes a peculiar lobulated 
shape. 
In all the conditions mentioned above, the tendency of the 
lesion is to the permanent occlusion of the branches of the por- 
tal vein which are filled with the thrombus. 
This obliterative form of thrombosis is usually attended by 
ascites, enlargement of the spleen, enlargement of the abdomi- 
nal veins, rarely by jaundice, sometimes by haemorrhage from 
the stomach and bowels. 
Thrombi in the portal vein, instead of becoming hard and 
closing the vessels, may become soft and broken down; while 
the wall of the vein becomes the seat of a suppurative inflam- 
mation. The thrombi are then of a reddish, grayish, or yellow 
color; a thin layer adheres to the wall of the vein; while the 
rest of the thrombus is partly solid, or converted into a puri- 
form fluid. Such thrombi, when they fill up the smaller veins, 
produce granular degeneration of the hepatic cells and abscesses. 
The causes of this form of thrombosis are various. 
(1.) Traumatic. Medical literature has so far only contained 
the single case, reported by Lambron, of thrombosis produced 
by a fish-bone. The bone was three centimetres long, was im- 
pacted in the head of the pancreas, penetrated the anterior 
wall of the superior mesenteric vein obliquely from above down- 188 
POST-MORTEM EXAMINATIONS. 
ward, and from before backward, traversed its interior, and was 
lodged in the posterior thickened wall of the vessel. The me- 
senteric vein at this point was filled with a grayish thrombus, 
which was continued into the portal vein and its hepatic 
branches, and was partly firm and partly broken down. There 
was a spot on the posterior wall of the stomach, near the pylorus, 
which was considered to be the point of exit of the fish-bone. 
To this case I am able to add a second observed in Bellevue 
Hospital in 1867, reported by Dr. Janeway, and examined also 
by myself. A man, aged forty-seven, about four weeks before 
his death was exposed to cold and wet. He was attacked with 
pain in the right side and cough, with the physical signs of 
pleurisy on the right side. A diarrhoea set in; the man sank 
into a typhoid condition; the abdomen became tympanitic; 
there was tenderness over the right iliac fossa; the urine con- 
tained albumen and granular casts. 
Autopsy.-The brain and heart were normal. The left lung 
was bound down by old adhesions ; in the right pleural cavity 
was a small amount of serum. 
The abdomen contained purulent serum, and the viscera were 
coated with recent fibrinous exudation. The stomach and in- 
testines were normal. 
The spleen weighed nine ounces. The kidneys weighed 
twelve ounces, and were the seat of advanced chronic diffuse 
nephritis. 
The liver weighed six and a half pounds. There were nume- 
rous small abscesses in the right lobe; two abscesses in the left 
lobe. The left division of the portal vein was filled with a firm 
red and white clot, over an inch long; the right division of the 
vein was lined with a firm thrombus ; its walls were thickened. 
In this part of the vein, and in its hepatic branches, was a good 
deal of puriform fluid. 
There was a fish-bone, two inches long, half in the mesen- 
teric and half in the portal vein. The centre of this bone was 
covered by a thrombus. 
The specimen is preserved in the museum of Bellevue Hos- 
pital. 
In young infants, the ligation of the umbilical vein, instead THE LIVER. 
189 
of producing a firm thrombus and obliterating the vessel, some- 
times produces a soft, puriform thrombus which extends into 
the portal vein. The walls of the vein are thick and succulent; 
there are frequently abscesses in the liver and general peritoni- 
tis. 
2. Ulceration of the intestines and stomach sometimes pro- 
duces thrombosis of the veins leading from the part inflamed, 
and the thrombi are continued into the portal vein, or fragments 
of them are carried into it. 
3. Abscesses of the spleen sometimes produce thrombosis of 
the splenic vein, which is continued into the portal vein. 
4. Suppurative inflammation of the mesentery, and of the 
mesenteric glands, may produce thrombosis of the mesenteric 
and portal veins. 
5. Inflammation and ulceration of the bile-ducts caused by 
gall-stones occasionally produce thrombosis of the branches of 
the portal vein. 
6. In many cases of thrombosis and inflammation of the por- 
tal vein no cause can be discovered for the lesion. 
In all the varieties of soft thrombi and phlebitis of the portal 
vein, we usually find jaundice, sometimes abscesses of the liver, 
sometimes enlargement of the spleen, and, as a rule, acute 
symptoms during life. 
RUPTURE OF THE PORTAL VEIN. 
This is a very rare lesion, of which only a few cases are re- 
corded. In some of the cases there was fatty degeneration of 
the wall of the vein. 
DILATATION OF THE PORTAL VEIN. 
Dilatation, may affect the trunk, branches, or roots of the por- 
tal vein, but very rarely the entire vessel. 
It is caused by destruction of the capillaries of the liver from 
chronic atrophy and cirrhosis; and from occlusion of the vein 
by thrombi, by cancer, and by concretions. 
The dilatation is generally uniform, sometimes varicose. 190 
POST-MORTEM EXAMINATIONS. 
CALCIFICATION OF THE PORTAL VEIN. 
Chronic endophlebitis may occur with the production of athe- 
romatous degeneration and calcification of the portal vein and 
its branches. It affects separate patches of the wall, or the en- 
tire wall for a considerable distance. 
This lesion of the vein may produce thrombosis. 
THE HEPATIC VEINS. 
The hepatic veins are found to present the same lesions as 
the portal veins, but much less frequently. 
Dilatation of these veins is produced by any obstruction to 
the passage of the venous blood into the heart. 
Chronic phlebitis and hard thrombi are produced by perihe- 
patitis. The wall of the vein is thickened ; gelatinous deposits 
or valvular projections on the inner surface of the vein may 
narrow or obliterate it. There may be apoplexies in the tissue 
of the liver. 
Soft thrombi and suppurative inflammation of the branches 
of the hepatic vein are sometimes produced by abscesses in the 
liver. 
Fibroma.-A single case of a fibrous tumor is described by 
Luschka, as occurring in the liver of a young child. 
Chondroma in the liver is of rare occurrence. It is secondary 
to chondroma in other regions of the body. 
Angioma.-Small cavernous tumors are of frequent occur- 
rence in the liver. They form irregularly-shaped, sharply-de- 
fined, reddish black spots in the liver-tissue, from the size of an 
acinus up to that of a man's fist. They are composed of a 
mesh-work, formed of connective tissue and smooth muscle; the 
cavities of this mesh-work are lined with epithelium, resembling 
that of the veins, contain venous blood, and can be injected 
from the portal vein and the hepatic artery. According to Vir- 
chow, the tumor is formed by the dilatation of all the veins of 
one or more liver acini. Rindfleisch, on the other hand, holds 
NEW GROWTHS OF THE LIVER. THE LIVER. 
191 
that the growth is formed by an interlobular hyperplasia of con- 
nective tissue, followed by a cavernous metamorphosis. 
Leukaemic New Growths are found in the liver in two forms. 
The organ is increased in size, sometimes very largely. The 
liver-cells are increased in size and number, so that the acini are 
larger. (1.) The lymphatic new growth takes the form of an 
infiltration, which accompanies the portal vein and its branches 
into the acini. The new growth then forms branched figures 
of a grayish white color, and of considerable size, or of a fine 
gray or white tracery, corresponding to different acini. 
(2.) In other cases, the new growth takes the form of small, 
rounded, miliary tumors, of a grayish white color. They resem- 
ble miliary tubercles, but are very soft, almost fluid. 
Not unfrequently these two forms are combined in the same 
liver. The new growth in both cases has the structure of lym- 
phatic glandular tissue. 
Adenoma.-Under this name authors describe two distinct 
varieties of tumor. The first consists in a new growth of liver 
tissue, the second in a new growth of follicular glandular tissue. 
1. The first form occurs as one large or several small tumors, 
scattered through the liver. The tumors are inclosed in a 
fibrous capsule, or are continuous with the liver tissue. They 
are of minute size, or may measure 3 or 4 inches in diameter. 
They are of a grayish brown color, and of firmer consistence 
than the surrounding liver tissue. They are composed of cells, 
resembling the hepatic cells, but sometimes larger, and some- 
times containing several nuclei. These cells are arranged in 
acini, like those of the liver, and the vessels and sometimes the 
bile-ducts of the liver ramify in the larger tumors. 
2. The second form of adenoma is composed of follicles or 
tubules, filled with small polygonal epithelium. The tumors are 
usually multiple, small or large, inclosed in a fibrous capsule. 
They may undergo fatty degeneration, or may suppurate. It 
is a question whether they are not really epithelial cancers. 
Tubercle.-In general tuberculosis, the liver is frequently the 
seat of numerous small, miliary, grayish, transparent granula- 
tions, which may be too small to be seen with the naked eye. 
These are found in the capsule and accompanying the vessels. 192 
POST-MORTEM EXAMINATIONS. 
Occasionally, in children, such tubercular tumors become larger 
and cheesy; it is then difficult to distinguish them from syphi- 
litic tumors. 
Syphilitic Tumors are found in connection with interstitial 
hepatitis or alone. If interstitial hepatitis is present, the gum- 
my tumors are found embedded in fibrous bands. They are 
small, or a number may be aggregated together, so as to form 
a tumor as large as a man's fist. They are of a grayish color, 
and are composed of round and fusiform connective tissue-cells. 
They usually, however, very soon undergo cheesy and fibrous 
degeneration, and are then of an opaque white or yellow color ; 
the cellular elements disappear, and we find ndthing but a 
fibrous or cheesy mass. In other cases, the tumors soften and 
break down, so that they may resemble abscesses. 
Less frequently, there is no interstitial hepatitis, and we find 
a number of small, yellow, cheesy tumors, scattered through the 
liver. I have seen, in one case, large, white, gummy tumors 
without interstitial hepatitis, which, to the naked eye, resem- 
bled cancerous nodules. 
In infants, a very minute form of these tumors is found. 
They appear as numerous, very small, white dots on the surface 
of the organ. 
Cysts are usually produced by a dilatation of the bile-ducts. 
They are small, multiple, contain serum, mucus, and epithelium. 
New-formed cysts in the connective tissue are also described. 
Sarcoma of the liver is not common. It is almost always 
secondary. The most frequent forms are melanotic or spindle- 
celled sarcomata. 
Carcinoma.-The liver is the most frequent seat of secondary 
cancerous growths. Primary carcinoma of the liver is very 
rare. The primary tumor is often small, while the secondary 
growth in the liver is very large, so that the former may be 
overlooked. In some cases, the primary tumor is situated in the 
wall of the gall-bladder. 
All the varieties of cancer, simple, medullary, scirrhus, me- 
lanotic, colloid, flat and cylindrical epithelial, are found in the 
liver; but simple cancer, either hard or soft, is the most fre- 
quent. It occurs in the form of nodules, or of a uniform infil- THE LIVER. 
193 
tration of the liver tissue. The nodules are white or yellow, 
from fatty or cheesy degeneration, or red, from haemorrhages. 
They are single or multiple, large or small; they may project 
from the surface of the liver in the form of nodules, or be even 
with it, or depressed. They are often the seat of haemorrhages, 
which may burst through the peritoneum into the abdominal 
cavity. They are hard or soft, according to the relative propor- 
tion of fibrous tissue and cells. The cancerous nodules may un- 
dergo fatty or cheesy degeneration ; they may become inflamed 
and purulent; they may soften at the centre, so as to form cyst- 
like cavities filled with viscid or thin serum. When the new 
growth infiltrates the organ, it is usually firm, white, or pinkish, 
and may occupy a large portion of the liver. The liver itself 
may be of medium size, or may attain immense dimensions. 
The hepatic cells may remain unchanged, or may become fatty, 
or be stained with bile. 
The portal vein and its branches may become filled with 
thrombi, and with portions of the new growth. Either the 
growth in the liver erodes and projects into the vein, or the wall 
of the vein is unchanged, while its cavity is filled with the new 
growth; or, in rare cases, the veins alone contain the new 
growth. The hepatic veins and their branches usually remain 
exempt from this lesion. 
The lymphatic ducts on the surface of the liver may be dis- 
tended with cancerous growth, and the neighboring lymphatic 
glands are frequently enlarged and infiltrated. 
The bile-ducts may remain unchanged, or become compressed 
and obliterated, or be dilated and rupture, or nodules of new 
growth may form in their walls. 
Alveolar or colloid cancer of the liver is rare. It usually ex- 
tends to the organ from some of the abdominal viscera. It has 
the appearance of a gelatinous, semi-translucent mass, replac- 
ing larger or smaller portions of the organ. Its minute struc- 
ture is a fibrous stroma, forming alveoli filled with gelatinous 
matter, and a variable number of cells. 
Lymphangioma Cavemosum.-Two cases of secondary tu- 
mors of this character have been observed in the liver. The 194 
POST-MORTEM EXAMINATIONS. 
growths were composed of anastomosing canals, lined with epi- 
thelium, and containing peculiar hyaline bodies. The exact na- 
ture of these growths in the liver, as well as elsewhere, is still 
undetermined. 
PARASITES. 
Echinococcus.-This form of parasite occurs frequently, form- 
ing the so-called hydatids of the liver. 
It is one of the stages of development of a small tape-worm, 
the Tsenia echinococcus, which inhabits the intestines of the 
dog. 
We find in the liver cavities lined with a layer of gelatinous 
material, to the inner wall of which are attached the heads of 
the echinococcus; or, the cavities are filled with a multitude of 
little cysts, from the inner surface of which grow the heads. Or, 
the cysts may be sterile, and we find the gelatinous material 
without any of the heads. Or, the contents of the cyst degene- 
rate, and we find their contents mixed with fat, or pus, or bile, 
or blood, or their walls may be thickened with fibrous tissue, or 
be calcified. 
In New-York, the lesion is a rare one, and we usually find 
only one or two cysts with degenerated contents. 
In other countries, the lesion is much more common and for- 
midable. The cysts reach an enormous size, the veins of the 
liver may be compressed and filled with thrombi, the bile-ducts 
compressed and ulcerated. So much of the liver tissue may be 
replaced by the hydatids, that the patient may die from this 
cause alone. Very frequently there is local peritonitis, and ad- 
hesions are formed between the liver and the surrounding parts. 
In some cases the cysts rupture, and their contents are emp- 
tied into the peritoneal cavity, the stomach, the intestines, the 
pleural cavity, or the lung tissue. Sometimes the cysts perfo- 
rate the bile-ducts, the vena cava, or some of the branches of 
the portal or hepatic veins. Sometimes the abdominal wall is 
perforated and a fistula formed between the cavity in the liver 
and the skin. 
A rare and peculiar development of the parasite was first de- 
ecribed by Virchow, under the name of Echinococcus multilocu- THE LIVER. 
195 
laris. The cysts are found in large numbers, and arranged, 
not within each other, but side by side, so that the mass has the 
appearance of an alveolar, gelatinous tumor. This mass is very 
hard. It is composed of dense fibrous tissue, forming small an- 
astomosing canals filled with gelatinous material. In this gela- 
tinous material the heads or booklets of the echinococcus may 
be present or absent. On the surface of the liver the lymphatics 
are sometimes enlarged and filled with the same material. 
Distoma, hepaticum.-This parasite has a flat, oval, leaf-shaped 
body, 3 cent, long, 12 mm. wide, and is of a dirty browm color. 
It is very seldom seen, and has no clinical history. 
Distoma lanceolatum.-This worm has a thin body, about 9 
mm. long. It is found in the gall-bladder and bile-ducts. It 
is of very rare occurrence. 
Pentastoma denticxdatum is the undeveloped form of the 
pentastoma tsenioides, a parasite which inhabits the nasal cavi- 
ty of dogs and of some other animals. In the liver of man and 
of the herbivorous animals, it is found in the form of small, 
rounded calcified cysts. The cysts contain fat, calcareous mat- 
ter, and the remains of the dead parasite. 
The Ascaris lumbricoides sometimes finds its way from the 
intestines into the bile-ducts. It may cause complete occlusion 
of the biliary passages, or dilatation, or ulceration, or the for- 
mation of abscesses in the liver. 
THE BILIARY PASSAGES. 
Catarrhal Inflammation most frequently attacks the lower 
portion of the common duct and the gall-bladder. In the acute 
form, it leaves but few changes after death. An abnormal 
coating of mucus is almost the only post-mortem lesion. If the 
inflammation, however, becomes chronic, the wall of the bile- 
duct is thickened and its cavity obstructed. In consequence of 
this, dilatation and ulceration of the bile-ducts may ensue. 
The gall-bladder may be inflamed by itself or in connection 
with the biliary passages. If the disease is chronic, the wall of 
the gall-bladder is thickened, its duct may be closed, dilatation, 
ulceration, the production of gall-stones, calcification, and atro- 
phy may ensue. 196 
POST-MORTEM EXAMINATIONS. 
Inflammation of the stomach and duodenum, hyperaemia, 
and inflammation of the liver, concretions, and parasites, are the 
usual causes of catarrhal inflammation of the biliary passages. 
Suppurative and Croupous Inflammation may attack the 
biliary passages and produce infiltration of pus in their walls, 
and purulent fluid in their cavities ; or flakes and tubular casts 
of fibrine on their walls; or infiltration of their walls with 
fibrine, and diphtheritic ulceration. 
These lesions are most frequently observed in typhoid and 
typhus fever, pyaemia, cholera, and with obstructions in the 
bile-ducts. They also occur under unknown conditions. 
These forms of inflammation may produce perforations of the 
ducts or bladder, with escape of bile, and peritonitis; or fistu- 
lous openings between the gall-bladder and the duodenum, 
colon, and stomach, or through the abdominal wall. Or the 
inflammation may extend to the liver tissue and produce ab- 
scesses. Or the portal vein may be inflamed, and even perfora- 
tions be formed between it and the bile-ducts. Constrictions of 
the biliary passages may also be produced by the same causes. 
Constriction and Occlusion are produced by inflammation of 
the ducts themselves, by new growths in their walls, by con- 
cretions or parasites in their cavities, by changes in the hepatic 
tissue, by aneurisms. 
The obliteration of the smaller bile-ducts produces no marked 
lesions. When the ductus communis, or the hepatic duct, is 
obstructed, the ducts throughout the liver are frequently di- 
lated and the liver tissue bile-stained. When the cystic duct 
is obstructed, the gall-bladder is dilated. 
Dilatation of the bile-ducts is usually produced by strictures 
in the ways just mentioned, or by calculi. When calculi have 
produced the dilatation, this condition may sometimes continue 
after they have found their way into the intestines. Some- 
times, however, we meet with very marked dilatation of the 
bile-ducts without being able to make out any present or past 
obstruction. The dilatation may affect only the common and 
hepatic ducts, or it may extend to the smaller ducts in the 
liver, which are then dilated uniformly or sacculated. They THE LIVER. 
197 
may contain bile, mucus, or calculi. The liver is at first en- 
larged, but may afterward atrophy. 
The gall-bladder may be dilated in consequence of obstruc- 
tion of the common or the cystic ducts. In the latter case, it 
may reach an immense size, and form a large tumor in the ab- 
dominal cavity. The dilatation is generally uniform, the blad- 
der retaining its normal form ; sometimes, however, there are 
diverticula, which are usually produced by calculi. 
If the obstruction to the hepatic duct is incomplete or mov- 
able, the gall-bladder contains bile, and often calculi. If the 
obstruction is complete, the contained fluid gradually loses its 
biliary character, and becomes a serous or mucous fluid of a 
light yellow color. 
The walls of the bladder may be of normal thickness, or 
thinned, or thickened, or calcified. 
If the obstruction is due to a calculus, this may pass into the 
intestine and the gall-bladder be suddenly emptied. Usually, 
the bladder fills again, owing to its loss of contractile power. 
NEW GROWTHS. 
Fibroma has been observed in rare cases in the gall-bladder 
and in the common duct. 
Carcinoma occurs both as a secondary and a primary growth. 
It is more frequent in the gall-bladder than in the bile-ducts. 
Simple cancer, villous, cylindrical, epithelial, and colloid cancer 
have all been observed in this situation. 
BILIARY CALCULI. 
These bodies are of common occurrence. They are found 
usually in the bladder; sometimes in the hepatic, cystic, and 
common ducts ; least frequently in the small ducts in the liver. 
In the gall-bladder from one to 7800 calculi have been counted. 
They are composed : 
1. Principally of cholesterine. They are round, oval, or 
faceted, single or multiple, of a pure white color, or tinged in 
various shades by bile-pigment. 198 
. POST-MORTEM EXAMINATIONS. 
2. Of cholesterine, bile-pigment, and sometimes carbonate 
and phosphate of lime. They are usually dark-colored, brown, 
red, black, or green, round or faceted. 
3. Principally of bile-pigment. These are small, not nume- 
rous, dark-colored. 
4. Of carbonate of lime. These are uncommon, have a 
nodular surface, and a clear, crystalline fracture. 
Most calculi consist of a nucleus and body. The nucleus is 
composed of cholesterine and bile-pigment; or, more rarely, of 
some foreign body. A dead parasite, a needle, and stones of 
fruit have been found as nuclei. The body of the gall-stone is 
homogeneous or laminated. 
Biliary calculi in the gall-bladder usually produce no symp- 
toms, and are only discovered after the death of the patient. 
In the hepatic and common ducts they may obstruct the flow 
of bile and produce fatal jaundice, or they pass from time to 
time into the intestine, and produce biliary colic. If they are 
impacted in the cystic duct, they may produce dilatation of 
the gall-bladder. 
THE SPLEEN. 
MALFORMATIONS. 
The spleen may be entirely absent in acephalous monsters, 
and with defective development of the other abdominal viscera. 
Very rarely it is absent in persons who are otherwise perfectly 
developed. 
Small accessory spleens, not larger than a walnut, and situat- 
ed close to the spleen, are not unfrequent. 
The existence of two spleens of equal size has been observed 
in one case. 
The spleen may be on the right side when there is transposi- 
tion of the other viscera. 
HYPERTROPHY, ATROPHY. 
In cases of typhoid fever, pyaemia, cholera, the exanthemata, 
malarial fevers, etc., the spleen is usually enlarged, soft, and of THE SPLEEN. 
199 
a dark-red color. The exact nature of this enlargement is not 
known. If the patient recovers, the organ returns to its normal 
size. 
A more chronic and persistent enlargement of the spleen is 
found with intermittent fever, heart-disease, leucaemia, with 
chronic diseases, and without known cause. The spleen is then 
simply increased in size, without other change from its normal 
appearance; or the fibrous stroma is disproportionately in- 
creased ; or there is an unusual hypersemia. 
Atrophy of the spleen occurs as a senile change. We also 
frequently find it at the autopsy, without any cause to account 
for it. 
CHANGES IN POSITION. 
The spleen may be pressed downward by any increase in the 
contents of the thorax. It may be fastened by adhesions to the 
concave surface of the diaphragm, so that its long axis is nearly 
horizontal, instead of vertical. It may be displaced by changes 
in the contents of the abdominal cavity. If the organ is in- 
creased in size, it frequently becomes tilted, so that its lower 
border reaches the right iliac region. If the ligaments of the 
spleen are too long congenitally, or if they are lengthened by 
traction, and if the organ is at the same time increased in weight, 
it may become very movable. It sinks downward, with its 
hilus turned upward ; or it may be rotated on its axis. It may, 
after a time, cause atrophy; or it may compress the duodenum. 
RUPTURE. 
The spleen may be ruptured by severe blows or falls. Fatal 
haemorrhage usually ensues, but sometimes the patient recovers. 
Rupture has also been observed in a few cases of typhoid fe- 
ver, remittent and relapsing fever, and of cholera. 
INFLAMMATION. 
It is a very frequent occurrence to find the capsule of the 
spleen thickened and adherent to the neighboring viscera. For 
the most part, the cause of these changes cannot be ascertained. 200 
POST-MORTEM EXAMINATIONS. 
Inflammation of the spleen itself occurs in the form of ab- 
scesses or infarctions. The abscesses may be traumatic, or pro- 
duced by infarctions, or occur without known cause. The ab- 
scesses are single or multiple. They may reach a great size; 
they may rupture into the abdominal cavity, the pleura, the 
lungs, the stomach, the colon, or the kidneys. 
Infarctions of the spleen are very common. Vegetations on 
the heart-valves, and thrombi in some of the veins, are the usual 
causes. Sometimes no source for the embolus can be discovered. 
We find one or more wedge-shaped portions of the spleen, at 
its surface, at first infiltrated with blood, and afterward convert- 
ed into a yellow, cheesy mass, or into a fibrous cicatrix. Less 
frequently suppurative inflammation ensues, and an abscess is 
formed. In other cases, again, the infarction becomes gangre- 
nous, and rarely the gangrene may involve the greater part of 
the spleen. In consequence of the gangrene, fatal peritonitis 
may ensue. 
DEGENERATION. 
Waxy degeneration, or rather infiltration of the spleen, is 
very common. It affects the entire organ, or only the Malpi- 
ghian bodies. In the first case, the organ is large, firm, smooth, 
reddish, and waxy-looking. Nearly the entire tissue is infil- 
trated with the waxy substance, and reacts with iodine. If 
only the Malpighian bodies are affected, the spleen appears to 
be studded with small, round, grayish bodies looking like grains 
of boiled sago. We then find the vessels and cells of the Mal- 
pighian bodies infiltrated with the waxy matter. This form is 
called the sago spleen. 
NEW GROWTHS. 
Fibroma.-Small, rounded nodules of fibrous tissue have 
been seen in the spleen in a few cases. 
Cysts are fare. They are single or multiple, and contain 
serum. Single dermoid cysts, filled with fat and hair, have also 
been seen. THE PANCREAS. 
201 
Tubercles are found in the capsule and in the splenic tissue in 
the form of gray granulations. 
Syphilitic Gummata have been seen in the spleen. 
Lymphatic Tumors in the form of white nodules are found in 
leucaemia and in pseudo-leucaemia. 
Pigment.-In persons who are the subjects of malarial poi- 
soning, the spleen is usually enlarged, and of a black color. 
The position and source of the pigment, which causes this color, 
is still uncertain. 
Carcinoma is very rarely primary in the spleen. More fre- 
quently it is metastatic; sometimes directly infiltrated from new 
growths in the stomach. 
PARASITES. 
Echinococci are sometimes found in the spleen, either as iso- 
lated bodies or as composite cysts. 
Pentastomum denticulatuin in a calcified condition has been 
seen by Wagner. 
THE PANCREAS. 
MALFORMATIONS. 
The pancreas may be entirely absent in anencephalous and 
double monsters, and in congenital umbilical hernise. The 
pancreatic duct may be double; 'it may open into the duode- 
num at some distance from the biliary duct, or into the sto- 
mach. The head of the pancreas may be unduly developed, 
and sometimes even completely separated from the rest of the 
organ, opening into the duodenum with a duct of its own. 
CHANGES IN FORM AND POSITION. 
The pancreas is so firmly bound down that its position is not 
often changed. Sometimes, however, it is found pressed down- 
ward by tight lacing, displaced by aneurisms, or contained in 
umbilical and diaphragmatic hernias. 
Atrophy of the pancreas is produced by the pressure of 202 
POST-MORTEM EXAMINATIONS. 
tumors, aneurisms, etc.; by obstruction of its duct; and is also 
found as an idiopathic process. The atrophy may reach such a 
degree that the gland can no longer be distinguished with the 
naked eye. This extreme degree of atrophy is sometimes found 
in diabetes. A moderate degree of atrophy seems to be a 
regular senile change. 
INFLAMMATION. 
Snppuratire Inflammation of the pancreas is very rare. The 
organ is found infiltrated with pus, or contains abscesses, or is 
surrounded by pus. The collections of pus thus formed may 
spread into the neighboring soft parts, and perforate into the 
abdominal cavity, the stomach, or the intestines. 
Some of the cases described as abscesses seem to be cysts with 
purulent contents. The recorded cases of suppurative inflam- 
mation of the pancreas are so few that hardly any thing is 
known of its cause. 
Chronic Interstitial Inflammation of the pancreas results in 
the production of new fibrous tissue, with induration and sub- 
sequent atrophy of the organ. The contraction of the new 
fibrous tissue may obliterate the pancreatic ducts, and may also 
compress the ductus communis choledochus, so as to produce 
icterus and even dilatation of the bile-ducts. 
DEGENERATION. 
Waxy Degeneration affects, in rare cases, the blood-vessels of 
the pancreas ; the gland-cells are not involved. 
Carcinoma of the pancreas is not common. It occurs both 
as a primary and secondary growth. 
As a primary growth, it usually takes the form of hard, fibrous 
nodules scattered through the glands, or of a uniform, scirrhous 
enlargement; more rarely, colloid cancer and cylindrical-celled 
epithelial cancer have been observed. The new growth is con- 
NEW GROWTHS. THE PANCREAS. 
203 
fined to the pancreas, or may spread to the duodenum, the 
stomach, or the neighboring lymphatic glands. 
As a secondary growth, carcinoma usually invades tne pan- 
creas by continuous infection from the duodenum, stomach, or 
lymphatic glands. 
THE PANCREATIC DUCTS. 
Concretions of carbonate and phosphate of lime are frequently 
found in the pancreatic ducts. They are usually multiple, 
small, whitish, of rough and irregular shape. Sometimes, how- 
ever, they reach a diameter of more than an inch. Besides 
these free concretions, the walls of the ducts are sometimes 
incrusted with salts of lime. 
Such concretions may produce dilatation of the pancreatic 
ducts and large cysts, or, more rarely, abscesses. 
Foreign Bodies.-Gall-stones sometimes find their way into 
the pancreatic duct. Ascarides have been found in the ducts 
in a considerable number of cases. 
Dilatation of the pancreatic ducts, and the formation of 
cysts, take place in several different ways. 
(1.) The entire duct may undergo a uniform, cylindrical di- 
latation. With this cylindrical dilatation we sometimes find 
associated small sacculi. 
(2.) There may be sacculated dilatations at some point in the 
ducts. These dilatations form cysts of large size, as large even 
as a child's head. Their walls frequently become atheromatous 
and calcified. These cysts often become filled with blood, and 
may then be mistaken for aneurisms. 
(3.) The small branches of the pancreatic duct may be di- 
lated so as to form a number of small cysts. These cysts are 
filled with serum, mucus, pus, or a thick cheesy material. 
THE SUPRARENAL CAPSULES. 
MALFORMATIONS. 
In anencephalous and other monsters the capsules may be 
entirely absent or much atrophied. Sometimes, in well-formed 
adults, the organs cannot be discovered. 204 
POST-MORTEM EXAMINATIONS. 
There may be little rounded nodules loosely attached to the 
surface of the capsules and with the same structure as these. 
If one of the kidneys is absent, or in an abnormal position, 
its capsule usually retains its proper position. 
HEMORRHAGE. 
In children, soon after birth, it is not very infrequent to find 
large haemorrhages in one of the capsules, converting it into a 
cyst filled with blood. The same lesion has been observed in a 
few cases in adults. 
THROMBOSIS. 
Klebs describes a case of capillary thrombosis of the cortex 
in both capsules in a woman after excision of the knee-joint. 
INFLAMMATION. 
The most frequent lesion of the capsules is their transforma- 
tion into fibrous tissue and cheesy matter. The capsules are 
then large, their surface smooth or lobulated, or they are con- 
tracted and irregular. The normal structure of the gland is 
lost, and we find instead a mass of fibrous tissue in which are 
embedded cheesy nodules. The cheesy nodules may soften and 
become fluid, or may calcify. Either one or both capsules may 
be involved. The early stages of this lesion are obscure, and it 
is difficult to know how far chronic inflammation, and how far 
tuberculosis is the efficient cause. 
Sometimes the medullary portion is replaced by a homogene- 
ous, grayish, structureless substance, which later becomes cheesy. 
Sometimes there are grayish nodules in the medullary sub- 
stance, which become cheesy and may fuse together. 
Sometimes there is a true suppurative inflammation with the 
formation of abscesses. 
Our knowledge of all these conditions is very imperfect. 
DEGENERATION. 
Fatty Degeneration of the cortical portion of the capsules is 
the rule in the adult. In children under five years of age, it is 
a pathological condition. THE SUPRARENAL CAPSULES. 
205 
Amyloid Degeneration may involve both the cortical and 
medullary portions. In the cortex, it usually involves only the 
walls of the blood-vessels ; in the medulla, both the blood-vessels 
and the cells of the parenchyma may undergo this degeneration. 
The capsules are usually firm and of a grayish, semi-translucent 
color. 
NEW GROWTHS. 
Carcinoma of the suprarenal capsules is not common. It 
may be primary, but is much more frequently secondary. 
Either one or both of the capsules may be the seat of the 
new growth. 
Sarcoma occurs as a primary and secondary growth. Pro- 
bably many of the older cases described as cancers were really 
sarcomata. 
Miliary Tubercles occur but rarely. 
Cylindroma,-Klebs describes a growth of this character in 
one of the capsules, secondary to a tumor of the same kind in 
the supraorbital region. He gives to such tumors the name of 
lymphangioma cavernosum. The exact character of these 
growths is still obscure. They consist of irregular follicles and 
cavities, lined with epithelium, and containing peculiar hya- 
line, structureless bodies. 
Cysts are found both single and multiple. They are usually 
situated in the cortex. THE URINARY APPARATUS. 
THE KIDNEYS. 
MALFORMATIONS. 
Entire absence of both kidneys is seen with high degrees of 
malformation of the entire body. Such foetuses are not viable. 
Absence of one kidney is found occasionally in adults, and 
seems to have no effect on their general health. The left kid- 
ney is more frequently absent than the right. The ureter be- 
longing to the absent kidney is usually entirely wanting ; but a 
small portion of it may be found attached to the bladder. The 
single kidney which is present is hypertrophied. Its ureter 
usually opens into the bladder in its proper situation, although 
Forster describes a case in which the kidney was on the right 
side, while its ureter entered the bladder on the left side. I 
have seen a case in which the single kidney was situated over the 
promontory of the sacrum. Its artery wras given off from the 
aorta at the bifurcation of the iliac arteries, and its vein from 
the vena cava, near the bifurcation. Its ureter was large and 
short; it entered the bladder midway between the usual po- 
sition of the two ureters. 
It is not uncommon to find one kidney so much atrophied 
that hardly any remains of kidney tissue are to be found; noth- 
ing but fibrous tissue and fat. In these cases, however, some 
traces of a ureter will be found. 
The foetal lobulated condition of the kidney often persists in 
adult life. Sometimes one or more of these lobules become ex- 
cessively developed, and somewhat separated from the rest of 
the kidney, so that the organ may appear double. A single THE KIDNEYS. 
207 
case is recorded by Blasius in which there were two left kid- 
neys, each with its vessels and ureter. 
The kidneys are sometimes joined together. This is effected 
by a bridge of kidney tissue, uniting the lower ends of the two 
kidneys. Sometimes such a " horse-shoe" kidney is situated 
lower than usual over the lowest lumbar vertebra, or in the pel- 
vis. The renal vessels are then given off from some abnormal 
point. 
In other cases the two kidneys are united throughout, so as 
to look like a single misshapen kidney, with two or more pel- 
ves. The kidneys thus closely united may be both situated on 
one side of the vertebral column, or in the pelvis. The arrange- 
ment and origin of their vessels vary according to the situa- 
tion of the kidneys. 
CHANGES IN POSITION. 
The kidneys may have an abnormal situation, in which they 
are either fixed or movable. 
The change in position is either lateral or downward. The 
most frequent situation is the promontory of the sacrum ; but 
the kidney has been seen at the very bottom of the pelvic cavi- 
ty. The vessels have an irregular origin and distribution cor- 
responding to the changed position of the kidney. The kidney 
is firmly attached in its unusual position. 
Movable or wandering kidneys are not congenital, but are 
found in adult life as a result of tight-lacing, pregnancy, over- 
exertion, and from unknown causes. They are more frequent 
in females than in males. The right kidney is the one more 
frequently movable ; but both organs may be found in this con- 
dition. Sometimes a kidney, which is congenitally misplaced, 
is also movable. 
The ordinary movable kidneys have their vessels regularly 
given off, but lengthened. The kidney tissue may be normal or 
may undergo any of the ordinary pathological changes. 
Cases have been observed in which the kidney, by its unusual 
position, had compressed the ascending colon, and had caused 
thrombosis of the vena cava. 208 
POST-MORTEM EXAMINATIONS. 
HAEMORRHAGE. 
Haemorrhages are produced in the kidney by wounds, and by 
severe contusions and falls, causing rupture of the kidney tissue. 
The blood collects in the kidney, beneath its capsule, or in the 
surrounding connective tissue. 
Rokitansky describes a form of haemorrhage produced by ex- 
cessive congestion. The kidney tissue is torn by the diffused 
blood. 
Smaller haemorrhages are found with infarctions, purpura, 
and nephritis. 
CHRONIC CONGESTION OF THE KIDNEY. 
Any disease of the heart or lungs, or any mechanical cause in 
the thorax or abdomen, which obstructs the passage of venous 
blood into the right auricle, and of the arterial blood from the 
left ventricle, is liable to produce a condition of chronic conges- 
tion of the kidneys. Valvular diseases of the heart are the most 
common of these causes. The pregnant uterus, by its mechani- 
cal pressure on the veins, produces the same effect. 
The clinical symptoms are a decrease in the quantity of the 
urine, with an increase of its specific gravity, together with a 
variable amount of albumen, hyaline casts, and sometimes blood 
in the urine. 
The appearance of the kidneys is very characteristic. They 
are of normal size, or a little larger; rarely they are atrophied. 
The entire organ has a stony hardness. The cortical portion is 
of normal size or thickened, rarely thinned. It is markedly con- 
gested, either in the regular red streaks which normally mark 
the cortex, or, in extreme congestion, the entire cortex is dark 
red. The pyramids are congested, and of a dark-red color. 
The Malpighian bodies are usually unchanged, but filled with 
blood. The epithelium of the convoluted tubes is unchanged, 
except that it has a peculiar, stiff appearance. The veins are 
sometimes dilated. 
This condition of chronic congestion may pass into chronic 
diffuse nephritis, and the appearance of the kidney will under- 
go corresponding changes. THE KIDNEYS. 
209 
INFLAMMATION. 
Acute diffuse Nephritis. 
This condition of the kidneys is found with scarlatina, and 
as an acute disease after exposure to cold. It is usually de- 
scribed as the first stage of chronic diffuse nephritis or Bright's 
Disease; in myopinion, improperly. It has been described by 
different authors under the names of interstitial nephritis, acute 
desquamative nephritis, acute Bright's Disease, croupous nephri- 
tis, etc. 
The clinical history of most of these cases is: Pain in the 
back, fever, oedema of the face and legs ; the urine scanty, high- 
colored; containing blood, albumen, renal epithelium; hya- 
line, granular, blood, and epithelial casts. The patient may die 
in a short time, but much more frequently entirely recovers. 
It is only exceptionally that this condition is succeeded by 
chronic nephritis. The kidneys are swollen; the capsule is not 
adherent; their texture is somewhat succulent. The entire or- 
gan is red and congested; or the cortex is white or gray, mot- 
tled with red spots; the pyramids are red. The tubes of the 
cortex and pyramids are more or less distended, with detached 
swollen or granular epithelium, with hyaline cast matter, and 
sometimes with blood. The Malpighian bodies are sometimes 
filled with extravasated blood. The intertubular connective 
tissue is infiltrated with a variable amount of serum and lym- 
phoid cells. 
Glomervlo-Nephritis.-Under this name, Klebs describes a 
modification of the condition just described. It is found with 
scarlatina. The Malpighian bodies appear large and white. 
Their capsules are filled with small cells, which compress the 
capillary tufts. 
Chronic diffuse Nephritis. 
This disease is also known under the names of parenchyma- 
tous nephritis, Bright's Disease, granular kidney, fatty kidney, 
etc. 
It is the ordinary form of chronic renal disease, with which 210 
POST-MORTEM EXAMINATIONS. 
all practitioners are familiar; attended during life with albu- 
men and casts in the urine, with changes in the quantity and 
composition of the urine, with oedema of the face and legs, with 
various other symptoms, and ending, sooner or later, in the 
death of the patient. 
The disease begins, for the most part, very slowly and insi- 
diously. Very often it is impossible to fix the precise date of 
its commencement. It has no acute stage, but begins as a chro- 
nic change. Less frequently, it succeeds acute diffuse nephritis 
and chronic congestion of the kidney. 
The gross changes in the kidneys affected by this disease are 
widely different; the minute changes are much more constant. 
The kidneys are of normal size, are enlarged, or are atrophied. 
The kidneys, which are of normal size, are but little changed 
in appearance, except that the cortical markings are irregular, 
and the capsule is adherent; or the surface is slightly nodular ; or 
the cortex is white, or grayish, or mottled white, gray, yellow, 
and red, and the organ looks as if it were atrophied from a pre- 
vious condition of enlargement. 
The large kidneys present their cortices of a white, gray, 
yellow, or mottled color. Their surfaces are nodular; their 
capsules adherent. The cortices are thickened ; the pyramids 
are enlarged, red, and at their bases radiate in red and white 
streaks. 
The atrophied kidneys exhibit all degrees of smallness. Both 
the cortex and pyramids are diminished in size. Their surfaces 
are nodular, and their capsules adherent. The fat about the 
pelvis is sometimes increased, so that the kidneys seem to be 
atrophied from within. The cortex is red, white, gray, or yel- 
low, in a great variety of combinations and shades. The tex- 
ture of the organ is firm. There may be cysts of various sizes 
throughout the kidney. 
The minute changes in chronic diffuse nephritis are present 
in variable relative proportion, and in variable degrees of devel- 
opment. 
The tubes are usually, but not always, dilated both in the 
cortex and pyramids. The dilatation may be slight, or so 
great as to form cysts visible with the naked eye. In the atro- THE KIDNEYS. 
211 
phied kidneys, there may be regions where the tubes are 
collapsed and atrophied. The basement membrane of the tubes 
may be thickened. 
The epithelium of the tubes may be slightly swollen and 
granular; or very granular, broken down, and detached; or 
filled with oil globules; or, in the dilated tubes, flattened 
against-the basement membrane. 
Hyaline cast material, white, yellow, or mixed with broken 
epithelium, is usually present in the tubes, especially near the 
apices of the pyramids. 
The arteries have their walls thickened, their cavities nar- 
rowed. It is usually impossible to inject them completely. Their 
walls may be the seat of waxy degeneration. The veins can 
usually be completely injected from the renal vein. The ca- 
pillary venous plexus of the cortex may be dilated. 
The Malpighian bodies are unchanged; or they are atrophied, 
and their capsules thickened; or the tufts are shrunken and 
impervious; or they are the seat of waxy degeneration. 
There are usually changes in the intertubular tissue, espe- 
cially in that of the cortex. We find just beneath the capsule, 
around the Malpighian bodies, and in other positions, irregular 
patches of connective tissue-fibres, and small round and oval 
cells. In the smallest and hardest kidneys, the cells may be as 
abundant in proportion to the fibrous tissue as in kidneys ap- 
parently in the early stages of the disease. 
In the atrophied kidneys of gouty persons, we often find 
white lines and dots of urate of soda in the pyramids. 
Pydo-nephritis. 
This form of kidney-disease runs an acute course, sometimes 
of only a few days, and is very fatal. The lesion of the kid- 
neys alone is sufficient to destroy life. 
The causation of this form of nephritis is peculiar, and hard to 
understand. It is secondary to inflammation of the pelvis, ure- 
ters, and bladder. But the inflammation may be confined to 
the bladder, and skip the ureters and pelvis, so that the infec- 
tion appears metastatic rather than continuous. Some authors 212 
POST-MORTEM EXAMINATIONS. 
explain this by the presence of fungi, bacteria, which find their 
way up the ureters, and into the kidney-tissue. 
The lesions of the kidney are marked. The organ is some- 
what swollen. On its surface, in the cortex, and in the pyra- 
mids, wm find small white spots, surrounded by red zones of con- 
gestion. These spots may be from the size of a pin's head to 
that of a third of the kidney. They may be firm, or soft and 
purulent. The larger spots are usually purulent. The entire 
kidney may thus be converted into a bag of pus and broken- 
down tissue. 
The minute change consists in an accumulation of lymphoid 
cells in the intertubular tissue, with degenerative changes in 
the tubes. 
Perinephritis. 
As a very rare occurrence, we sometimes find small collec- 
tions of pus between the capsule and the kidney, apparently 
produced by inflammation of the capsule. 
More frequently we find the products of inflammation out- 
side the capsule. There may be, as the result of perinephritis, 
a mass of dense fibrous tissue surrounding the organ ; or, more 
frequently, a collection of pus. These abscesses may open in- 
to the peritoneal cavity, into the intestine, or burrow in the 
muscles of the back, and open externally. 
Perinephritis may be produced by blows on the lumbar re- 
gion ; by pyelitis and pyelo-nephritis ; by abscesses in the psoas 
muscles; by abscesses in the pelvic cavity, and occur as an 
idiopathic inflammation after exposure to cold, and with typhus 
and other severe diseases. 
DEGENERATIONS. 
Chronic Parenchymatous Degeneration. 
This disease is also known under the names of catarrhal ne- 
phritis, parenchymatous inflammation, granular degeneration, 
fatty degeneration. 
It is found, not as a primary disease, but as a result of pro- THE KIDNEYS. 
213 
found changes in the nutrition of the body. Typhus fever, 
cholera, yellow fever, phthisis, chronic alcoholism, the acute 
exanthemata, phosphorus poisoning, and causes of like cha- 
racter, are the conditions with which this lesion is usually 
found. The urine contains albumen and granular casts. If 
the patient recovers from the acute disease, the kidney symp- 
toms also disappear. The gross appearances of the kidney vary 
with the degree of degeneration which has taken place. 
The kidney may be of normal size and appearance, the corti- 
cal markings regular. Or, it may be somewhat enlarged, the 
cortex opaque and white. Or, less frequently, the organ is 
congested. As a rule the capsule is not adherent, and the sur- 
face of the kidney is smooth. 
The minute changes consist in an alteration of the epithelium 
in the tubes of the cortex, of the pyramids, or of both. In the 
lesser degrees of the lesion we find the epithelium swollen so as 
to fill the tubes, and at the same time more distinct and sharp- 
ly outlined. In some of the tubes the epithelium is more gran- 
ular, broken-down, and detached from the wall of the tube. 
In other cases, the epithelium is more markedly granular, 
even fatty, and fills many of the tubes. There may be hyaline 
cast matter in the tubes of the pyramids. There are no 
changes in the intertubular tissue. 
THE WAXY KIDNEY. 
It has already been mentioned that, in chronic diffuse nephri- 
tis, the Malpighian tufts may be waxy. This change may also 
involve the small arteries, the veins in the pyramids, and even 
the basement membranes of the tubes. 
We find various views, among different authors, as to the re- 
lationship between the waxy change in the vessels and the 
other changes in the kidney. , Some hold that the condition is 
only an accidental complication of diffuse nephritis; others 
that the waxy degeneration is the first and essential part of the 
process, and that the other kidney lesions are secondary to it. 
I have never seen waxy degeneration of the tufts and vessels 
except in the advanced stages of chronic diffuse nephritis. 214 
POST-MORTEM EXAMINATIONS. 
Fehr gives the following figures as representing the causa- 
tion of the disease : Syphilis, 34 ; pulmonary phthisis, 32 ; 
with caries, 5; with other complications, 6; caries, with scro- 
fula, 26 ; empyema, 4 ; chronic bronchitis, 3 ; chronic alco- 
holism, 5; chronic articular rheumatism, 3 ; cancer, 3 ; intermit- 
tent fever, 4 ; hydronephrosis, 3 ; ulcers of the leg, 3 ; without 
known cause, 9. 
INFARCTIONS OF THE KIDNEY. 
Infarctions of the kidney are produced by the presence of an 
embolus in an artery or capillary vessel. 
If the embolus'is in an artery, the size of the infarction will 
correspond to the size of the vessel. As soon as the artery is 
plugged by the embolus, its branches are emptied or filled with 
thrombi. The wedge-shaped portion of kidney tissue, which is 
deprived of its supply of arterial blood, becomes of a deep yel- 
low color, and is a little swollen, while the epithelium in its 
tubes degenerates. Afterward, the epithelium becomes more 
granular and disappears; the tubes become collapsed and 
shrunken. At the periphery of the infarction there is a zone of 
congestion, and of accumulation of lymphoid elements in the 
intertubular tissue. After this, the infarction may continue to 
shrink, and the zone of congestion around it helps in the forma- 
tion of a fibrous cicatrix ; or the production of lymphoid ele- 
ments may be so great as to form an abscess ; or the infarction 
becomes necrotic and gangrenous. 
Capillary emboli produce a number of small infarctions. 
The kidneys are swollen, soft, mottled with numerous small, 
red spots, each with a white or yellow centre. At the centre of 
these haemorrhagic spots there can generally be found a small 
vessel plugged with a thrombus. Around this the tubal epi- 
thelium is degenerated, and the intertubular tissue infiltrated 
•with lymphoid cells. These latter cells may be so numerous as 
to form small abscesses. 
The whole appearance may resemble very closely that of pye- 
lo-nephritis. 
Cohnheim has reported a case of complete embolism of the THE KIDNEYS. 
215 
renal artery, with necrosis of the entire kidney. It occurred in 
a boy eight years old, who was recovering from membranous 
croup of the larynx and trachea. The left ventricle of the heart 
contained a firm, white, laminated thrombus. The spleen con- 
tained a large, recent infarction. There were emboli in the left 
hypogastric artery, and in the right common iliac. The left re- 
nal artery and its branches were completely filled with a firm 
thrombus. The left kidney was somewhat increased in size. 
Its surface was smooth, mottled red and yellow. The cortex 
was dry, opaque, and looked like dead tissue. The pyramids 
were bluish red. Here and there in the cortex and pyramids 
were d eep red spots. 
Thrombosis of the renal vein occurs in consequence of 
changes in the kidney; from tumors obstructing the circula- 
tion ; as a continuation of thrombi of the vena cava; and as a 
primary lesion dependent upon the general condition of the 
patient. Children, who are exhausted by diarrhoeas, etc., are 
perhaps the most frequent subjects of this lesion. The throm- 
bus may completely or only partially fill the renal vein and 
its branches. 
HYDRO-NEPHROSIS. 
Dilatation of tlie ureters and pelves of the kidneys is not 
uncommon. It is found at all ages, even before birth. It is 
produced by some mechanical obstruction to the outflow of 
urine. The obstruction may affect the pelvis, the ureter, the 
bladder, or the urethra. Calculi in the pelvis, or ureter; 
strictures of the ureters ; new growths compressing the ureters, 
especially cancer of the uterus; changes in the bladder ; stric- 
tures of the urethra are the ordinary causes. 
The dilatation usually affects the ureter and pelvis-some- 
times the pelvis alone, sometimes a single calyx. The pelvis 
and calyces are enlarged, the papillae are flattened or converted 
into cavities until there is left a large multilocular cyst, of 
which the walls are formed of a thin layer of kidney tissue. 
The kidney substance which is left, although thinned, is not 
necessarily diseased. The epithelium may be entirely normal. 
In other cases, the epithelium may undergo granular degenera- 216 
POST-MORTEM EXAMINATIONS. 
tion, or there may be chronic diffuse nephritis, or suppurative 
pyelo-nephritis. 
THE CYSTIC KIDNEY. 
We find cysts in the kidney in intra-uterine life, and at all 
ages. 
The congenital cystic kidney is a very striking pathological 
condition. The kidneys are converted into a mass of number- 
less cysts, so large as to nearly fill the abdominal cavity, and 
often to seriously hinder the birth of the child. 
The cysts are of all sizes, separated by fibrous septa, or by 
compressed kidney tissue. They contain a clear, yellow, acid 
fluid holding in solution the urinary salts. In other cases, the 
fluid is turbid and brown, and contains blood, uric acid crystals, 
or cholesterine. The cysts are lined with a simple layer of 
flat, polygonal epithelium. The cysts are formed by a dilata- 
tion of the kidney tubules, and of the capsules of the Mal- 
pighian tufts. The dilatation may be produced by a change in 
the papillae, obliterating the tubes there; or by stenosis of the 
pelvis, ureters, bladder, or urethra. This condition is usually 
associated with other malformations, hydrocephalus, club- 
foot, etc. 
In extra-uterine life, we find cysts in kidneys which are 
otherwise normal, and in those which are the seat of chronic 
diffuse nephritis. 
In the normal kidney we find one or a few cysts, from the 
size of a pin's head to that of a pigeon's egg. They are situated 
in the cortex, and may project outward. They contain clear 
serum, or a viscid, colloid substance, or cholesterine. The 
walls of the cysts are smooth, or incomplete septa project in- 
ward. There is no exact knowledge of the way in which these 
cysts are formed, although it is probable that they are produced 
by the dilatation of the kidney tubules. They do not give 
rise to any changes in the kidney tissue, nor to any clinical 
symptoms. 
In kidneys which are the seat of chronic diffuse nephritis it 
is not infrequent to find cysts. The cysts are numerous, scat- THE KIDNEYS. 
217 
tered through the cortex and pyramids, usually small, not often 
larger than a small chestnut. The cysts contain clear serum, 
or colloid matter, or brownish pigment. Their walls are thin, 
smooth, and lined with pavement epithelium. The larger cysts 
are formed by the fusion of several smaller cysts. In some of 
the cysts the remains of the atrophied Malpighian tufts can be 
found. The kidneys are usually atrophied, sometimes large. 
Minute examination shows the lesions of diffuse nephritis, with 
dilatation of the tubes and Malpighian capsules. In many 
kidneys, all the different stages of the dilatation process can be 
distinctly seen. The dilatation does not seem to be always due 
to compression of the tubes by new fibrous interstitial tissue; 
but is also caused by the plugging of the tubes with colloid cast- 
matter. 
PRECIPITATES AND CONCRETIONS. 
The Urates.-In the kidneys of new-born children, we often 
find narrow, orange-colored lines in the pyramids parallel to 
the tubes. These lines consist of small, brownish-yellow, 
rounded, or angular bodies, resembling the sediment of urate 
of ammonia so often found in the urine. If acetic acid is added, 
these bodies are dissolved, and crystals of uric acid are formed. 
These deposits are found, as a rule, in infants which have 
breathed from thirty-six to forty-eight hours. Exceptional 
cases have been reported, however, in which the same condi- 
tion was found in still-born children. 
Pigment.-In new-born children there are sometimes reddish- 
brown lines in the papillae and pyramids. They are composed 
of granules of pigments and crystals of haematoidine. They 
are the results of small haemorrhages in the tubes. They can be 
distinguished from the deposits of urates by the chemical 
reaction. 
The Carbonate and Phosphate of Lime may be deposited in 
the tubes of the pyramids, in the form of white lines. They 
are found in old persons, and with destructive diseases of the 
bones. 
Urate of Soda is deposited in white lines and spots in the 218 
POST-MORTEM EXAMINATIONS. 
pyramids and cortex in some cases of chronic diffuse nephritis, 
especially in gouty individuals. It is deposited both in the 
tubes and in the intertubular tissue, in the form of acicular 
crystals. 
Concretions of the urinary salts of all sizes and shapes, and 
in indefinite numbers, may be formed in the calyces and pelvis 
of the kidney. They may pass through the ureter into the 
bladder; or cause hydro-nephrosis, or pyelo-nephritis. 
NEW GROWTHS. 
Fibroma.-Small, hard, white, fibrous nodules are frequently 
found in the pyramids. The kidneys are normal, or the seat of 
diffuse nephritis. 
Myxoma.-Small nodules of mucous tissue are sometimes 
found in yramids. Large tumors may grow from the pel- 
vis of the kidney. They are usually a combination of myxoma, 
lipoma, and sarcoma. 
Lipoma.-There may be a diffused increase of fatty tissue 
around the capsule of the kidney ; and in atrophied kidneys an 
increase of fat about their pelves. Small, rounded, or lobu- 
lated, fatty tumors are occasionally found in the cortex, just 
beneath the capsule. 
Tubercles.-With general tuberculosis we often find small, 
miliary, gray, or cheesy granulations scattered through the 
kidney. 
Besides this condition, there is another change in the kidney, 
which is generally called tubercle, but of which the real nature 
is somewhat doubtful. First the papillae, and afterward the 
rest of the pyramids and the cortex, are converted into a yellow, 
cheesy mass, of firm or soft consistence. The entire kidney 
tissue may be destroyed in this way. The pelvis and the ureter 
are usually coated with a thick layer of the same cheesy mate- 
rial. Similar changes in the bladder, vesiculae seminales, testicle, 
prostate, uterus, and Fallopian tubes often exist in the same 
patient. The lesion is usually seen at such an advanced stage 
that nothing but the cheesy degeneration can be found. It is 
said that this condition is preceded by the formation of miliary THE KIDNEYS. 
219 
tubercles, which become aggregated and form the cheesy 
mass. 
Leukaemic Tumors are sometimes found in the kidneys in con- 
nection with similar growths in the other viscera. The tumors 
are small, whitish, composed of lymphoid cells, and situated in 
the intertubular tissue. , 
Syphilitic Gummata have been observed in a few cases. 
They were in the form of nodules of the usual character. 
Klebs describes a more diffuse growth of fusiform cells between 
the tubes in a case of congenital syphilis. 
Sarcoma occurs in the kidney in the form of metastatic 
nodules. Myxo-sarcomata grow from the pelvis. 
Adenoma.-Klebs describes under this name tumors of small 
size, situated in the cortex. They are white, soft, and rounded. 
They consist of a connective tissue stroma, supplied with ves- 
sels, and in which are long, tubular, anastomosing spaces filled 
with small, polygonal, epithelial cells. The relationship of this 
form of tumor to true carcinoma is not well established. 
Carcinoma occurs in the kidney as a primary or secondary 
disease. The secondary tumors are usually of moderate size, 
and may occur in both kidneys. 
Primary carcinoma usually affects one kidney-more fre- 
quently the right than the left. It is most frequently of a soft, 
medullary, haemorrhagic character. But scirrhus, melanotic, 
and colloid cancer also occur. The tumors gradually replace 
the kidney tissue, and often reach an enormous size. The new 
growth may project into the ureters, into the renal vein, and 
through this into the vena cava. 
Angioma Cavernosum occurs in the form of small, encap- 
suled nodules, situated in the cortex. Their structure is the 
same as that of the angiomata of the liver. 
PARASITES. 
Echinococci are of not infrequent occurrence in the kidney. 
Cysticercus cellulosce and Pentastoma denticulatum have 
been seen in a few cases. 
Eustrongylus gigas is sometimes found in the pelvis of the 
kidney. 220 
POST-MORTEM EXAMINATIONS. 
THE URINARY BLADDER. 
MALFORMATIONS. 
Ecstrophia, Extroversion, Inversion, Fissure of the Bladder 
is one of the most frequent malformations. It occurs in both 
sexes. 
(1.) The umbilicus is lower down than usual, the pubic bones 
are not united at the symphysis, the pelvis is wider and shal- 
lower than it should be. 
Between the umbilicus and pubes the abdominal wall is 
wanting. In its place is a projecting ovoid mass of mucous 
membrane, in which can be seen the openings of the ureters. 
The penis is usually rudimentary; the urethra is an open 
fissure, (epispadia;) the clitoris may be separated into two 
halves. The ureters usually open normally; sometimes their 
openings are displaced, or are multiple. They may be dilated. 
(2.) Vrolik describes a case in which there was a fissure in 
the abdominal wall, which was filled up by the perfectly 
formed bladder. 
(3.) The umbilicus may be well formed, and there is a por- 
tion of abdominal wall between it and the extrophied bladder. 
(4.) The external genitals and urethra may be well formed, 
and the symphysis pubis united, while only the bladder is 
fissured. 
(5.) The genitals, urethra, and symphysis may be wrell 
formed, the bladder closed, except at the upper part of its an- 
terior wall. The bladder is entirely or in part inverted and 
pushed through the opening in the abdominal wall. 
The Urachus normally remains as a very small canal, 5-7 
centim. long, with a small opening into the bladder, or entirely 
closed at that point. If there is a congenital obstruction to the 
flow of urine through the urethra, the urachus may remain 
open, and the urine pass through it. 
Absence of the Bladder is very rare, and only described by 
the older authors. 
The bladder may be very small, and the urine pass almost 
directly into the urethra. THE URINARY BLADDER. 
221 
The bladder may be separated into an upper and a lower 
portion by a circular constriction. It may be completely or 
.incompletely divided by a vertical septum into two lateral 
portions. 
Diverticula of the wall are also found in new-born children. 
Partial or complete closure of the neck of the bladder also 
occurs. 
CHANGES IN SIZE AND POSITION. 
Dilatation of the bladder is produced by the accumulation of 
urine in consequence of some mechanical obstacle to its escape, 
or of paralysis of its muscular walls. The dilatation is uni- 
form, and may reach a great size. If the walls of the bladder 
are paralyzed, the dilatation is accompanied by thinning of the 
wall, or it may retain its normal thickness. If the escape of 
the urine is prevented by a mechanical obstacle, the walls of 
the bladder are usually hypertrophied, but may be thinned. 
The retained urine frequently decomposes, and produces inflam- 
matory and gangrenous changes in the mucous membrane. 
In the foetus, dilatation of the bladder may reach such a size 
as to interfere with delivery. 
I have seen, in a foetus born at term, dilatation and hyper- 
trophy of the bladder, dilatation of the ureters, a diverticulum 
at the neck of the bladder, and no apparent obstacle to the 
escape of urine. 
Diverticula of the bladder are produced by the protrusion 
of the mucous coat between the hypertrophied bundles of 
muscular fibres. They may be single or multiple, small, or so 
large as nearly to fill the abdomen. Their walls are composed 
of mucous membrane thickened, and of peritoneum, if in the 
proper position. They communicate with the bladder by a 
small cleft. The urine which fills them may decompose and 
excite inflammation. Calculi may be formed in them. 
Hypertrophy of the muscular coat of the bladder is usually 
produced by mechanical obstructions to the outflow of urine, 
such as stricture of the urethra, enlarged prostate, calculi, new 
growths, etc. The muscular coat is thickened uniformly, or 222 
POST-MORTEM EXAMINATIONS. 
assumes a trabeculated appearance. The organ retains its normal 
capacity, or is dilated, or becomes smaller. The mucous mem- 
brane is frequently the seat of chronic or acute inflammation. 
Dilatation of the ureters and hydronephrosis frequently accom- 
pany this condition. 
Hernia of the bladder sometimes accompany intestinal 
herniae through the inguinal and crural canals, and the foramen 
ovale. The changes in position of the bladder, produced by dis- 
placements of the vagina and uterus, will be mentioned with 
the lesions of those organs. 
Penetrating wounds of the bladder may produce escape of 
urine into the abdominal cavity, or infiltration into the sur- 
rounding connective tissue, or permanent fistulae. Such wounds 
are always serious and frequently fatal. 
Rupture of the bladder may be produced by severe blows and 
falls when the bladder contains urine. More rarely, rupture 
takes place from over-distention. I have seen this occur in a 
patient who was being etherized preparatory to puncturing the 
bladder. Fractures of the pelvic bones may produce laceration 
of the bladder. 
Perforations of the bladder are produced by ulceration and 
gangrene, by abscesses from without, and by cancerous ulcera- 
tion from the adjoining organs. 
RUPTURE. PERFORATION. 
Catarrhal Cystitis may be idiopathic; or excited by decom- 
posed urine, or by calculi; or be an extension of gonorrhoeal 
urethritis, or vaginitis. It may run an acute or a chronic course. 
In the acute form, the mucous membrane is swollen and in- 
tensely congested. Pus, mucus, and blood are set free from its 
surface. 
In the chronic form, the mucous membrane is at first swollen, 
succulent, grayish, or mottled with spots of congestion and 
extravasation, covered with a layer of muco-pus. Later, the 
INFLAMMATION. THE URINARY BLADDER. 
223 
mucous membrane becomes brown, or slate-colored, its swelling 
is more marked, and may take the form of tufts or polypi. 
The submucous and muscular coats are hypertrophied. The 
mucous membrane may be incrusted with the salts of the de- 
composed urine. Ulcerations take place which gradually per- 
forate all the coats of the bladder and produce abscesses in 
the surrounding connective tissue. These abscesses may finally 
open into the vagina, intestines, or through the skin. In other 
cases, the muscular coat is paralyzed, and the bladder dilated. 
The mucous membrane is discolored, incrusted with salts, 
gangrenous. The gangrene may extend to all the coats, and 
the urine escape into the abdominal cavity. In all cases the 
inflammation may extend to the ureters and kidneys. 
Croupous and Diphtheritic Inflammation may accompany 
the same inflammation of the vagina; occur with scarlet fever, 
typhus fever, etc., with stone in the bladder and decomposing 
urine, with carcinoma; and are rarely an idiopathic disease. 
The entire mucous membrane or only patches of it are in- 
volved. It is intensely congested, or of a grayish color, covered 
and infiltrated with fibrine and pus, portions of it gangrenous. 
Sometimes entire fibrinous casts of the bladder are discharged 
by the urethra; very rarely the mucous membrane itself is de- 
tached and cast off. 
NEW GROWTHS. 
Fibroma, in the form of circumscribed nodules in the sub- 
mucous tissue, is described by Rokitansky as of very rare 
occurrence. 
Fibroma papillare occurs in the form of a mass of branching 
tufts, covered with cylindrical epithelium. The muscular coat 
of the bladder is often hypertrophied at the same time. The 
growth is most frequent in young persons, and even occurs in 
children. 
Fibroma polyposum occurs in the form of a circumscribed 
hypertrophy of the mucous membrane, usually near the neck 
of the bladder. It is most frequent in childhood. 
Fibro-Adenoma is found at the neck of the bladder, in the sub- 224 
POST-MORTEM EXAMINATIONS. 
mucous tissue, or projecting inward in a polypoid form. The 
tumors are from the size of a pea to that of a pigeon's egg. 
They are composed of a fibrous stroma and of glandular 
follicles, resembling those of the prostate. They seem to be 
detached outgrowths from the prostate. 
Enchondroma.-A somewhat doubtful case of diffuse infiltra- 
tion of the entire wall of the bladder with cartilage is described 
by Ordonez. 
Tubercles of the bladder are sometimes found in connection 
with tubercles of the testes, prostate, vesiculae seminales, and 
kidneys. They are only found in the male. There are at first 
gray granulations in the superficial layers of the mucous mem- 
brane. These soften and form ulcers, of which the walls are 
infiltrated with new granulations. In this way large ulcers with 
cheesy floors and edges are formed. 
Cysts.-Paget mentions a case of a dermoid cyst in the wall 
of the bladder. Sometimes small serous cysts are found in the 
mucous membrane. 
Carcinoma of the bladder is most frequently secondary to 
the same growth in neighboring organs. 
As a primary growth it occurs : 
(1.) As a diffuse scirrhous infiltration of the entire wall of 
the bladder, usually with ulcerations of its inner surface. 
(2.) As a circumscribed nodule which grows inward and out- 
ward, ulcerating on its inner surface, and sometimes producing 
perforations. 
(3.) As villous or epithelial cancer. The tumor grows from 
one or more points of the inner surface of the bladder. It is 
formed of tubular follicles, lined with cylindrical epithelium, 
and on its inner free surface of tufts covered with cylindrical 
epithelium. The new growth may involve the entire thickness 
of the wall of the bladder. 
(4.) As myo-carcinoma. Virchow describes a tumor of this 
kind situated at the trigonum, and composed of fibrous and 
smooth muscular tissues, forming cavities filled with epithelial 
cells. 
I have seen one such case, in which there were two small 
tumors at the neck of the bladder. They were composed of a THE URETHRA. 
225 
fibrous and muscular stroma, forming cavities filled with 
epithelial cells. The tumors were softer, and the muscular 
tissue more abundant, than in the case described by Virchow. 
PARASITES. 
Distoma lujematobium has been observed in the vessels of 
the mucous membrane-only in Egypt. 
Sarcina has been found with chronic cystitis. 
Eustrongylus, echinococcus, and ascarides sometimes find 
their way into the bladder from other organs. 
Every variety of foreign body may be introduced into and 
remain in the bladder. If their stay is long, they become in- 
crusted with the urinary salts. 
THE URETHRA. 
CONGENITAL MALFORMATIONS. 
Some of the malformations of the urethra are described with 
those of the penis. 
The urethra may be impervious, or may open at the root 
of the penis. More commonly there is partial obliteration or 
stricture of some part of the canal. 
The entire urethra may be dilated into a sac full of urine. 
There may be a canal on the dorsum of the penis, formed by 
the fusion of the spermatic cords, and opening in the glans 
above the urethra. 
There may be two or more openings of the urethra. 
The canal may be dislocated so as to open in the inguinal re- 
gion. 
CHANGES IN SIZE AND POSITION. 
Dilatation of the urethra is produced by strictures, or by cal- 
culi which become fixed in it. The dilatations are fusiform or 
sacculated in shape, and may reach the size of an orange and 
over. 
Strictures of the urethra are produced by inflammation of its 
walls. 226 
POST-MORTEM EXAMINATIONS. 
The stricture may be temporary, produced by a diffused in- 
flammatory swelling of the mucous membrane, or by the raising 
of the relaxed membrane into a fold or pocket. 
Permanent strictures are produced by structural changes in 
the walls of the urethra. 
(1.) The mucous membrane and sub-mucous tissue is left hard 
and unyielding by the preceding inflammation. Subsequently, 
the new fibrous tissue contracts and narrows the canal. 
(2.) Ulceration of the mucous membrane leaves cicatricial 
tissue, which contracts, and also produces adhesions and bands of 
fibrous tissue. 
(3.) There is fibrous induration of the corpus spongiosum, and 
consequent constriction of the urethra. 
The most frequent position of strictures is at the junction of 
the membranous and spongy portions of the urethra, or close to 
this point. They also occur at the fossa navicularis and the 
meatus, but frequently in the prostatic portion. There may be 
one stricture or several. 
The consequences of stricture are dilatation of the urethra, 
the bladder, the ureters, and hydronephrosis ; inflammation and 
ulceration of the urethra behind the stricture, with perforation, 
infiltration of urine, or the formation of fistulse. 
The urethra may also be obstructed by folds of the mucous 
membrane; by muscular valves at the neck of the bladder ; by 
wounds; by polypi and swollen glands; by new growths; 
by changes in the prostate and perineum; by calculi, mucus, 
blood, and echinococci coming from the bladder; by foreign 
bodies introduced from without. 
Prolapse and inversion of the mucous membrane is seen in 
young girls and women in rare cases. There is a bluish, red 
swelling, from the size of a pea to that of a walnut, at the mea- 
tus. In the male, invagination of the mucous membrane of the 
urethra has been seen after injuries of the perineum. 
WOUNDS, RUPTURE, PERFORATION. 
Wounds of the urethra are produced in many ways, but most 
commonly by catheters and bougies. The wounds may cicatrize, THE URETHRA. 
227 
or there may be infiltration of urine, or the formation of fis- 
tulte. 
Ruptures of the urethra are produced by severe contusions 
and by fracture of the pelvic bones. Extravasations of blood 
and urine, and gangrenous inflammation of the surrounding soft 
parts, are the ordinary results. 
Ulceration and perforation of the urethra lead to the forma- 
tion of fistulse, which open in various directions through the 
skin. 
INFLAMMATION. 
Catarrhal Urethritis is most frequently due to infection from 
gonorrhoea, but is also produced by a variety of causes. In its 
acute form, it involves either a portion or the whole of the ure- 
thra. The mucous membrane is red, swollen, and covered with 
muco-pus. The inflammation may extend to the fibrous wall 
of the urethra, the corpora spongiosa, and cavernosa. This may 
result in the formation of new connective tissue, or of abscesses, 
especially near the fossa navicularis. The inflammation may 
also extend to the bladder, the glands of Cowper, the prostate, 
the spermatic cord, and the testicles. The inguinal glands also 
may be swollen and inflamed, and the lymphatic vessels on the 
dorsum of the penis may be involved in the same process. 
Chronic inflammation of the urethra may exist for a long 
time without producing any lesions. In other cases it leads to 
ulceration, to fibrous induration of the wall of the canal, to in- 
duration and swelling of the mucous follicles ; to polypoid thick- 
enings of the mucous membrane. 
Croupous Inflammation is sometimes seen in children. Fi- 
brinous casts of a small or large portion of the canal are formed. 
Syphilitic Ulcers may be situated at the meatus, or as far 
back as the fossa navicularis. They are apt to produce stric- 
tures. 
NEW GROWTHS. 
Fibroma Papillare, in the form of little polypoid excrescen- 
ces of the mucous membrane, sometimes occurs. They are the 
result of chronic inflammation, and are confined to a small or 
large portion of the wall of the urethra. 228 
POST-MORTEM EXAMINATIONS. 
luberdes are rarely found in tlie mucous membrane of the 
urethra in connection with tubercles of the bladder, prostate, 
or testicles. 
Carcinoma is usually only a part of some new growth of the 
penis, prostate,'or bladder. Very rarely, isolated nodules are 
found in the wall of the urethra, secondary to carcinoma of 
the bladder. THE ORGANS OF GENERATION. 
THE VULVA. 
MALFORMATIONS. 
The external genitals may be entirely absent, or imperfectly 
developed. 
The clitoris and nymphae may be abnormally large, or the 
nymphae may be increased in number. 
The clitoris may be abnormally long, resembling a penis, at 
the same time the vagina is narrow, the uterus small and un- 
developed, the ovaries small, sometimes situated in the labia, 
the mammae small, and the body of a masculine character. 
The clitoris may be perforated by the urethra, or may be 
cleft and apparently double. 
The large or small labia may grow together, with or without 
obstruction of the urethra. There may be a fleshy septum above 
the lower commissure of the vulva. 
HAEMORRHAGE. 
Haemorrhage may take place from wounds or ulcers of the 
vulva. 
The most important form of haemorrhage is that which occurs 
in the connective tissue of the labia majora. This is produced 
during labor. One of the labia may be swollen and distended 
by the extravasated blood, until it is as large as a child's head. 
The blood may be gradually absorbed, or it may become gan- 
grenous with suppuration of the surrounding tissue. The puru- 
lent matter may escape through the skin, and the patient re- 
cover; or the suppuration may extend into the pelvis, and 
cause death. 230 
POST-MORTEM EXAMINATIONS. 
INFLAMMATION. 
The skin, mucous membrane, connective tissue, and glands of 
the vulva may be the seat of inflammation. 
Chronic catarrhal inflammation may produce a thickening and 
papillary hypertrophy of the cutis, with a moist ulcerating sur- 
face. 
Erysipelatous inflammation of the skin of the vulva is frequent 
in young children, and may cause death. In adults, it is less 
common. 
Acute oedema of the labia majora occurs in pregnant and 
puerperal women. It may terminate in gangrene or in suppu- 
ration. 
Inflammation of the vulvo-vaginal glands may be acute, and 
produce abscesses; or chronic, and produce induration of the 
gland. 
Gangrene may follow erysipelatous inflammation, may oc- 
cur after parturition, may accompany severe and exhausting 
diseases, and may occur as an epidemic disease, especially among 
children. 
Herpes, Eczema, Lichen, Prurigo, etc., may be found on the 
skin of the vulva. 
Fibroma.-Fibroma diffusum (elephantiasis) is found growing 
from the clitoris, the nymphse, and the labia majora. It ap- 
pears as a diffused hypertrophy of the parts, with a smooth or 
warty surface ; or as a polypoid growth with a narrow pedicle. 
In either case the structure is the same. If the skin remains 
smooth, its outer layers are but little changed; if it is rough, 
the papillae are hypertrophied. The new growth arises from 
the deep layers of the cutis, and consists of a loose connective 
tissue infiltrated with serum. The tumors may reach a very 
large size. 
Fibroma Papillary Papilloma.-These tumors vary from the 
size of a pea to that of an apple. They present a rough, cauli- 
flower-looking appearance. They are composed of papillae or 
tufts, with a central stroma of connective tissue and blood-ves- 
sels and a thick covering of epithelium. 
NEW GROWTHS. THE VULVA. 
231 
Fibroma Tuberosum.-Circumscribed fibrous tumors are 
found in the connective tissues of the labia, the mons veneris, 
the perineum, the clitoris, and the entrance of the vagina. 
They may attain a large size, and may be attached only by a 
narrow pedicle. When a section is made, it will be found that 
the tumor is a circumscribed growth, not continuous with the 
skin. 
Lipoma.-Fatty tumors are found in the mons veneris and 
labia majora. They may reach a large size. 
Enchondroma.-Schneevogt describes a polypoid, cartilagi- 
nous tumor growing from the clitoris. 
Cysts are found in the connective tissue of the labia majora 
and minora. They are from the size of a pea to that of a child's 
head. They contain serum, colloid matter, pus, or blood, or 
have the character of dermoid cysts. They may open through 
the skin. Cysts are also formed by dilatation of the ducts or 
acini of the vul vo-vagin al gland. 
Carcinoma of the vulva is rare. It is usually accompanied by 
the same growth in the uterus and vagina, or in the other vis- 
cera. It occurs in the form of nodules, which, after a time, 
ulcerate. 
EpitheLioma is more common. It usually begins in one of 
the labia majora. There is at first induration and thickening 
of a circumscribed portion of the labium, afterward ulceration. 
The inguinal glands may become involved, but metastatic tu- 
mors are rare. 
Lupus occurs in the labia majora and minora, the mons vene- 
ris, and the perineum in its usual forms. The cutis is infiltrated 
with small round cells. When the cell-growth reaches the sur- 
face of the skin, the epithelium falls off, and an ulcerating sur- 
face is formed. According to the extent of the infiltration and 
of the ulceration, we have the varieties: Lupus maculosus, no- 
dosus, hypertrophicus, exulcer ans. 232 
POST-MORTEM EXAMINATIONS. 
THE VAGINA. 
MALFORMATIONS. 
The vagina may be entirely absent, and the internal organs 
of generation also absent, or imperfectly developed. 
Either the upper or the lower portion of the canal may be 
absent while the remaining portion is present. 
The vagina may be closed by an imperforate hymen, or by 
fibrous septa at any part of its canal. The canal may be ab- 
normally small without being occluded. 
The vagina may be double, in connection with a double 
uterus; or, while the uterus is normal, the vagina may be in- 
completely divided by a longitudinal septum. 
The hymen is seldom entirely absent, but is often either too 
large or too small. 
CHANGES IN SIZE AND POSITION. 
Dilatation of the vagina is produced by tumors, by the pro- 
lapsed uterus, and by the accumulation of blood and mucus 
behind constrictions or obliterations of the canal. 
Lengthening of the vagina is produced by any cause which 
draws the uterus upward. 
Narrowing of the vagina is found as a senile change ; is pro- 
duced by tumors, and by ulceration of the wall of the canal. 
Extensive ulcers may even causb entire obliteration of the 
canal. 
Prolapse of the vagina occurs by itself or in connection with 
prolapse of the uterus. As an idiopathic process, it usually 
takes place soon after parturition. A larger or smaller portion 
of the canal is inverted and projects through the vulva. The 
entire circumference of the canal may be inverted and pro- 
lapsed, or only the anterior or posterior wall. The prolapse is 
at first small, but afterward gradually increases in size, and 
may drag down the uterus with it. 
In other cases, prolapse of the uterus is the primary lesion, 
and the vagina is inverted by the descent of that organ ; or, the 
body of the uterus may retain its normal position, while'an THE VAGINA. 
233 
hypertrophy and lengthening of the cervix alone drags down 
the vagina. 
Hernia vesico-vaginalis, Cystocele, may be either the cause 
or effect of a prolapse of the vagina and uterus. 
If the cystocele is the primary lesion, it begins as a small pro- 
jection of the wall of the bladder into the anterior part of the 
vagina. As the urine accumulates in this sac, it increases in 
size, projects through the vulva, draws down the vagina and 
the anterior lip of the cervix, finally the entire uterus. 
If the cystocele is the secondary lesion, it is simply produced 
by the dragging down of the posterior wall of the bladder by 
the inverted vagina. 
Hernia intestino-vaginalis.-A portion of the intestines may 
become fixed in Douglas's cul de sac between the rectum and 
uterus. This portion of intestine gradually becomes larger, 
pushes forward the posterior wall of the vagina, inverts and 
fills up that canal, and, finally, projects through the vulva. It 
may drag with it the posterior wall of the vagina and the 
uterus. 
Rectocele vaginalis.--A sac is formed by the projection of 
the anterior wall of the rectum and the posterior wall of the 
vagina. This lesion is of rare occurrence, afid does not reach 
a large size. 
WOUNDS. PERFORATIONS. 
Wounds of the vagina are made by penetrating instruments, 
by forceps and other obstetrical weapons, and by the foetus dur- 
ing delivery. Such wounds may heal; may give rise to large 
haemorrhages; may suppurate ; may produce abscesses in the sur- 
rounding tissues ; may leave fistulous openings into the vagina ; 
or may cause constriction or obliteration of its canal. 
Vesico-vaginal fistulae are usually produced by injuries from 
instruments or from the foetus during delivery; less frequently 
by ulceration of the vagina, bladder, or adjacent connective 
tissue. The fistulae form an opening between either the bladder 
or the urethra and the vagina. They allow the urine to pass 
into the vagina. Spontaneous cure does not take place. 
Recto-vaginal fistulse are formed in the same way as the last 234 
POST-MORTEM EXAMINATIONS. 
mentioned. They allow the passage of faeces into the vagina. 
They sometimes heal spontaneously. 
INFLAMMATION. 
Catarrhal Inflammation of the vaginal mucous membrane 
may be acute or chronic. It is caused by gonorrhoea, by local 
irritation, or depends on general causes. In the acute form, 
there is an abundant production of pus. In the chronic form, 
the mucous membrane may be thickened, rough, and covered 
with hard papillae ; or it may become relaxed and prolapsed. 
Croupous and Diphtheritic Inflammation occur with general 
diseases and after parturition. The mucous membrane is cov- 
ered with a grayish layer of fibrine and pus-cells, in which the 
salts of the urine may be deposited. The mucous membrane 
and the submucous tissue may also be infiltrated with fibrine 
and pus-cells. The gangrene and degeneration of these infil- 
trated portions of the mucous membrane may leave deep ulcers. 
Suppurative Inflammation of the fibrous coat of the vagina 
is produced by injuries, and occurs in pregnant and puerperal 
women. Abscesses are formed, which may penetrate into the 
labia, or into the pelvic connective tissue. 
Syphilitic Ulceration may be found in any part of the 
vagina. 
NEW GROWTHS. 
Myomata are sometimes found growing from the posterior 
wall of the vagina. They usually grow backward and upward, 
very rarely project into the cavity of the vagina in a polypoid 
form. 
Papilloma.-Small and large polypoid growths composed of 
papillae, or tufts covered with epithelium, are occasionally met 
with. 
Tubercles of the vagina are rare. They accompany tubercu- 
losis of the uterus, or of the urinary apparatus. They are found 
in the form of gray granulations, or of a diffused, yellow layer 
formed of many such granulations. 
Cysts are sometimes met with deep in the vaginal mucous THE UTERUS. 
235 
membrane. They are usually small, and contain serum or 
mucus. 
Sarcomata are sometimes found in the wall of the vagina. 
They may surround the urethra. 
Carcinoma is usually secondary to the same new growths in 
the uterus, but may be primary. It presents the same forms 
as are described in the uterus. 
Myoma strio-cellulare myxomatodes.-Under this name 
Frau Kaschewarowa-Rudnewa has described a peculiar tumor 
of the vagina. The tumor occurred in a girl 15 years old. It 
grew from the anterior wall of the vagina, and first appeared 
like a small polypus. It was removed, but recurred in a few 
weeks. It then grew rapidly until it reached the size Of a 
child's head. The patient died exhausted by the disease. The 
growth was composed of round, fusiform, and stellate cells im- 
bedded in a mucous basement substance, and of striated mus- 
cular fibres. 
THE UTERUS. 
CONGENITAL MALFORMATION. 
The uterus, up to the end of the third month of intra-uterine 
life, consists of two large cornua, which, by the fusion of their 
lower ends, form the uterus. 
The uterus, tubes, and vagina may be entirely absent, with 
or without absence of the ovaries and external genitals. Or the 
uterus alone, or the upper part of the vagina also, may be 
absent. 
The uterus may be only rudimentary, while the vagina is 
normal. It then appears as a flattened, solid body, with solid 
cornua. Or there are two cornua joined at their lower ex- 
tremities so as to form a small double uterus. Or the uterus is 
represented by a small sac, which may or may not communicate 
with the vagina. Or there is a very small uterus with thin, 
muscular walls and two large cornua. 
Only one of the cornua, which should form the uterus, may 
be developed, while the other is arrested in its growth. The 
uterus is then a long, cylindrical body, terminating above in 236 
POST-MORTEM EXAMINATIONS. 
one tube. On the side where the other horn should have been 
developed, there is no tube, or only a rudimentary one. Both 
ovaries are usually present. 
The two cornua may be fully developed, but their lower ends 
remain separated, and form a double uterus. An entire separa- 
tion into two distinct uteri and vaginae is very rare. More fre- 
quently, the uterus consists of one body, divided by a septum 
into two cavities. There are then two cervical portions of the 
uterus projecting into a single vagina, or each into a separate 
vagina. Or there is only a. single cervix. The septum in the 
uterus may be complete, or only partial. 
We also find abnormal size of the uterus, abnormal flexions ; 
the cervix may be solid, or may be closed by the vaginal mu- 
cous membrane. 
CHANGES IN SIZE. 
In the new-born infant, the uterus is small, the body flattened, 
the cervix disproportionately large. During childhood, the or- 
gan increases in size, but the body remains small in proportion 
to the cervix. At puberty, the shape changes, and the body be- 
comes larger. Its length is then two to three inches; its 
breadth, sixteen to twenty lines; its thickness, eight to twelve 
lines. At every menstruation the uterus is somewhat swollen 
and congested. After pregnancy, it does not return to its vir- 
gin size, but remains somewhat larger. In old age, it gradually 
becomes smaller; its walls are harder and more fibrous. 
Abnormal Smallness of the uterus is sometimes found as an 
arrest of development. The uterus in adult life retains the size 
and shape of that of the infant. 
Atrophy of the uterus results from chronic endometritis, from 
repeated pregnancies, from puerperal endometritis, and from 
old age. Its walls are friable, its size is diminished, its cavity 
is smaller, or is distended with mucus. Large myomata some- 
times cause marked atrophy of the uterine wall. 
Atrophy of the vaginal portion of the uterus is sometimes 
observed after repeated pregnancies, sometimes without known 
cause. 
Narrowing and obliteration of the cavity of the uterus and THE UTERUS. 
237 
of the cervix are usually produced by chronic inflammation. 
They may cause an accumulation of blood or mucus, and con- 
sequent distention of the uterus. 
Hypertrophy of the uterus may occur in consequence of too 
early development. It is accompanied with abnormally early 
development of all the sexual organs and functions. 
Heart-disease, prolapse and abnormal flexions and versions of 
the uterus, chronic inflammation, repeated pregnancies, myo- 
mata, accumulations of blood or mucus in the uterine cavity, 
may all produce hypertrophy of the uterus. 
Hypertrophy of the vaginal portion is produced by the same 
causes as the above, and also is found without known cause. 
The hypertrophy consists in a uniform increase of size of one 
or both lips, or either one or both lips are hypertrophied and 
irregularly lobulated. There may be, at the same time, reten- 
tion-cysts formed in the mucous follicles of the cervix. 
Dilatation of the uterus is produced by accumulations of 
blood, mucus, or pus, in consequence of narrowing or oblitera- 
tion of the cervix or vagina. The walls of the uterus may re- 
tain their normal thickness, be thickened or thinned. 
The most frequent position of the stenosis is the os internum. 
The retained mucus and pus, after a time, change their charac- 
ter, and are replaced by a thin serum-hydrometra, or may be 
mixed with blood. The dilated uterus is not usually larger 
than an apple, but cases are recorded of enormous dilatation. 
If both the os internum and os externum-are closed, the ca- 
vity of the cervix is also dilated, and the uterus has the shape 
of an hour-glass. 
If the obstruction is in the vagina, the uterus and vagina 
form a large flask-shaped body, and the line of demarcation be- 
tween the cervix and vagina is lost. 
In some cases, the dilatation is confined to the cervix. 
If the obstruction is not complete, the retained fluid may es- 
cape into the vagina, and afterward accumulate again. 
Hoematometra.-Accumulation of menstrual blood in the ca- 
vity of the uterus is usually produced by congenital stenosis of 
the cervix or vagina. The dilated uterus may reach an enor- 
mous size. If the fluid is not evacuated by surgical interference, 238 
POST-MORTEM EXAMINATIONS. 
there may be either rupture or ulcerative perforation of the 
uterus. The blood may escape into the abdominal cavity, or 
be shut in by adhesions, or perforate into the bladder or intes- 
tines. Sometimes the blood passes into the Fallopian tubes, 
dilates them, and escapes through their abdominal ends. 
CHANGES IN POSITION. 
The body of the uterus may become fixed in an abnormal 
position; while the situation of the cervix is unchanged. The 
body may be bent forward-ante-flexion; backward-retroflex- 
ion ; or sideways-lateral flexion. The flexion may be slight, or 
so great that the neck and body form an acute angle. Ante- 
flexion is the most common variety, and that in which the 
flexion is greatest. 
Peritoneal adhesions, flaccidity of the uterine walls, atrophy, 
ovarian tumors, etc., are the usual causes. 
The Versions of the uterus consist in an abnormal inclination 
of the long axis of the organ to that of the vagina. The uterus 
may be inclined backward, forward, or to one side. 
Retroversion is very much the most common. The fundus 
uteri is directed backward and downward ; the cervix, forward 
and upward. This condition is found in various degrees; in 
the highest, the fundus lies in Douedas's cul de sac with the cer- 
vix upward, so that the axis of the uterus is parallel to that of 
the vagina, but in a direction exactly opposite to the normal 
one. 
Abnormal looseness of the uterine ligaments, abnormally 
large capacity of the pelvis, hypertrophy or tumors of the 
uterus, and pregnancy during the first four months, are the 
usual causes of this lesion. 
The greater degrees of version may produce very grave 
lesions. The urethra and rectum are compressed. Cystitis, 
perforation of the bladder, dilatation of the ureters and 
hydronephrosis, and fatal obstruction of the bowels may follow. 
If pregnancy exist, abortion may take place, or the inverted 
uterus may be forced through the peritoneum and posterior 
wall of the vagina, and project through the vulva. THE UTERUS. 
239 
In the non-pregnant uterus, pressure on the veins, and conse- 
quent chronic inflammation of the organ, may follow. 
Anteversion. Inclination of the fundus forward and down- 
ward, and of the cervix backward and upward, is not common, 
and seldom reaches a high degree. Pressure on the bladder and 
rectum may be produced by it. 
Lateral version is produced by congenital shortness of one of 
the broad ligaments, by adhesions, or by the pressure of tu- 
mors. 
Prolapsus Uteri consists in a descent of the uterus in the va- 
gina. The position of the uterus may be only slightly lowered, 
or it may project through the vulva. In complete prolapse, we 
find a large tumor projecting through the vulva, covered by the 
distended vagina, and presenting the opening of the os exter- 
num near its centre. The bladder and rectum may be drawn 
down with the vagina, or may remain in place. The exposed 
cervix and vagina may become inflamed and ulcerated, or the 
mucous membrane may become thick and resistant. 
The process is frequently complicated by hypertrophy of the 
cervix. In the lesser grades of prolapse, the hypertrophy of 
the cervix often seems to be the most important part of the 
lesion. 
Sudden prolapse usually occurs after parturition, less fre- 
quently in virgins and in old women. Gradual prolapse is fre- 
quently caused by a cystocele or rectocele of the vagina. The 
vagina is dragged down, and draws the uterus with it. 
Elevation of the uterus is produced by mechanical causes- 
adhesions, tumors, etc. The vagina is drawn up and length- 
ened, and the vaginal portion of the cervix is obliterated. 
Inversion of the uterus consists in an invagination of the fun- 
dus. The fundus may be invaginated in the body ; the fundus 
and body in the cervix; or the entire organ in the vagina. 
The most common cause is traction on the umbilical cord dur- 
ing parturition. It may also take place spontaneously after 
parturition. Lesser degrees of inversion are produced by intra- 
uterine polypi, or hydro- or haematometra. 
Ilerniaz of the uterus are very rare. Ventral hernias occur 
during the latter months of pregnancy. The peritoneum, 240 
POST-MORTEM EXAMINATIONS. 
aponeuroses, and skin are forced outward to form a sac, in 
which the uterus is placed. Crural hernias are produced by the 
drawing down of the uterus and ovaries into the sac of an 
intestinal hernia. Inguinal hernia is produced in the same 
way, or is congenital. Ischiadic hernia has been seen in one 
case. 
Pregnancy may occur in the uterus while situated in a cru- 
ral or inguinal hernia. 
RUPTURE PERFORATION. 
Rupture of the unimpregnated uterus is rare.. It may, how- 
ever, occur when the uterine cavity is distended with blood or 
serum, or in connection with large myomata of the uterine 
walls. 
In the gravid uterus, ruptureshave been seen in nearly every 
month of pregnancy. The rupture may be produced by thin- 
ning of the uterine wall by tumors, or by violent contusions. 
The act of parturition is the most frequent cause. Malposi- 
tions of the foetus, narrowing of the pelvis, long protracted 
labor, thinning of the uterine wall from tumors, forcible use of 
the forceps and other instruments are the ordinary causes. The 
rupture may be in the body of the uterus or the cervix ; it may 
be large or small; it may extend completely or only partly 
through the uterine wall. The consequences of partial rupture 
are haemorrhage, gangrenous inflammation of the edges of the 
rupture, peritonitis, and usually death. In rare cases, the rup- 
ture cicatrizes, and the patient recovers. Complete rupture 
usually causes death in a short time. The foetus escapes partly 
or completely into the abdominal cavity. If the patient sur- 
vives the immediate shock, fatal peritonitis soon ensues. In 
rare cases, the foetus is shut in by adhesions, and the patient 
survives. 
Perforations of the uterus may be produced by carcinoma, by 
abscesses in its neighborhood, and by ovarian cysts. THE UTERUS. 
241 
HAEMORRHAGE. 
Effusion of blood into the cavity of the uterus occurs normal- 
ly at every menstrual period. An excessive or deficient flow of 
blood at these periods is determined by causes which are de- 
scribed by the gynaecologists. 
Effusions of blood at other than the menstrual periods may 
be caused by mechanical hyperaemia, by haemorrhoids, by acute 
hyperaemia, by intra-uterine polypi, by acute and chronic inflam- 
mation, by typhus fever, scurvy, etc., by ulcerating carcinoma, 
by abortions and miscarriages. 
A peculiar form of haemorrhage is the polypoid haematoma, 
or fibrinous polypus of the uterus. It occurs after parturition 
and after abortions. The portion of the uterine wall where the 
placenta was attached, with or without a portion of retained 
placenta, forms the point of attachment of the pedicle of the 
polypus. We find a large, polypoid, bloody mass, firmly at- 
tached by a pedicle to the uterine wall. The uterus enlarges 
with the growth of the polypus ; the cervix is dilated, and the 
thrombus projects into and may even fill up the vagina. The 
formation of such a thrombus is accompanied by repeated 
haemorrhages. 
Haemorrhage in the substance of the uterus occurs in old ao-e. 
The mucous membrane and uterine wall are infiltrated with 
blood, and there is some blood in the uterine cavity. 
Retro-uterine, or Peri-uterine Ilwmatocele, consists in an 
accumulation of blood around the uterus or in Douglas's cul 
de sac. It may consist of blood extravasated into the abdominal 
cavity, which settles into the pelvis; or, in consequence of local 
hyperaemia, there may be repeated extravasations of blood. In 
the latter case, the local peritonitis may produce false' mem- 
branes, between the layers of which haemorrhages take place. 
A similar condition more rarely occurs in the male. 
The haemorrhagic mass may be absorbed, or may soften, sup- 
purate, and perforate into the rectum or vagina. 
Some authors describe an extra-peritoneal haematocele which 
lies between the folds of the broad ligament. Tyler Smith be- 
lieves that an extravasation may be inclosed by a secondary 242 
POST-MORTEM EXAMINATIONS. 
false membrane. Most authors hold that the extravasation pro- 
ceeds from the uterus, ovaries, and tubes. This is denied by 
Virchow, who holds that in most cases the blood comes from the 
vessels of membranes formed by local peritonitis. 
The extravasation usually begins at a menstrual period, and 
increases at the succeeding periods. 
INFLAMMATION. 
1. Of the Unimpregnated Uterus. 
Acute Catarrhal Endometritis is seldom seen after death. It 
occurs spontaneously, from gonorrhoea, with typhus fever, scur- 
vy, etc. During life, the mucous membrane is swollen and 
congested, and covered with an increased quantity of muco-pus. 
After death, these appearances may remain or disappear. 
Chronic Catarrhal Endometritis involves the body or cervix, 
or both. It may be the continuation of an acute inflammation, 
or begin as a chronic disease. It is found at every age ; but is 
most common after puberty. It is produced by a great variety 
of causes. In the lesser grades of inflammation, we find no re- 
liable lesions aftei' death. In the more marked cases, the mu- 
cous membrane is thickened, grayish, or blackish colored, cover- 
ed with muco-pus. The papillae of the cervix are hypertrophied ; 
the mucous follicles are swollen, and their outlets obstructed. 
The uterine wall becomes i accid and atrophied, or may be hy- 
pertrophied, especially the cervical portion. This simple hy- 
pertrophy of the uterus from catarrhal endometritis is often 
mistaken for inflammatory enlargement of the organ. During 
the course of the inflammation, we find ulceration of the mucous 
membrane, especially in the cervix, and hypertrophy of the pa- 
pillae of the cervix. There may also result contraction or oblite- 
ration of the canal of the cervix. The inflammation may ex- 
tend to the Fallopian tubes, or to the vagina. 
Croupous Inflammation of the uterus is rare. It occurs with 
cholera, typhoid fever, and the exanthemata. The disease 
usually extends to the vagina, sometimes to the Fallopian 
tubes. 
Acute Metritis is usually the result of acute catarrhal endome- THE UTERUS. 
243 
tritis. The organ is swollen, succulent, congested; the mucous 
membrane covered with muco-pus; the peritoneal coat congested. 
There may be small extravasations of blood in the wall or cavity 
of the uterus. The inflammation, in rare cases, becomes suppu- 
rative, and abscesses are formed in the uterine wall. These 
may perforate into the peritoneal cavity or into the rectum. 
Chronic Metritis is the result of an acute metritis, or accom- 
panies acute or chronic endometritis; or is idiopathic. The 
uterine walls become thick and hard. Many of the cases called 
chronic metritis are only catarrhal endometritis with hypertro- 
phy of the uterus. 
Perimetritis.-The peritoneal coat of the uterus may be in- 
flamed with the production of membranous adhesions or of pus. 
The adhesions may be small or very extensive. The inflamma- 
tion usually accompanies chronic metritis and endometritis. In 
prostitutes, adhesions are almost the rule. 
Parametritis.-The connective tissue about the uterus, be- 
tween that organ and the reflexions of the peritoneum, may be 
the seat of suppurative inflammation. It most frequently 
causes the death of the patient. 
2. Of the Pregnant Uterus. 
The same forms of inflammation which have just been de- 
scribed may attack the pregnant uterus. 
Catarrhal endometritis may produce effusion of serum, extra- 
vasations of blood, and abortions. 
Metritis may lead to softening of the uterine wall, so that 
ruptures take place during labor. 
Perimetritis and parametritis produce adhesions and abscesses 
about the uterus. 
For a week after delivery, we find the inner surface of the 
still dilated uterus rough, especially at the insertion of the pla- 
centa, and covered with blackened, gangrenous-looking shreds 
of blood, mucous membrane, and placenta. This condition is 
not to be mistaken for inflammation. 
PUERPERAL INFLAMMATION. 244 
POST-MORTEM EXAMINATIONS. 
In endometritis, the internal surface is covered with a thicker 
layer of gangrenous material, and there are patches of croupous 
exudation which may extend into the vagina. The uterine 
sinuses are filled with thrombi, for the most part broken down 
into a puriform fluid. There may be also a diffuse purulent 
infiltration of the uterine wall, or circumscribed abscesses. Very 
frequently there are also peritonitis and pyeemic infarctions of 
the viscera. 
ULCERATION. 
Phagedamic or Corroding Ulcer.-Tliis rare form of ulcera- 
tion usually occurs in old age, without assignable cause. It 
begins in the cervix and extends gradually until it may destroy 
the greater part of the uterus. It may even invade the blad- 
der and rectum. The ulcer is of irregular form, its base is 
rough and blackish, its walls indurated. 
Syphilitic Ulceration may attack the vaginal portion or inte- 
rior of the cervix, or the internal surface of the body of the 
uterus. It has the usual forms of the hard and soft chancre. 
Catarrhal Ulceration is most common in the cervix. It ac- 
companies catarrhal endometritis. The ulcers are superficial 
erosions or formed from inflamed follicles. 
DEGENERATION. 
Waxy Degeneration has been observed by Virchow in one 
case. The uterus was hypertrophied and the muscle-cells were 
infiltrated with the waxy material. 
NEW GROWTHS. 
Myoma.-These tumors, often called fibrous tumors, are very 
common in the uterus. They occur after puberty, and usually 
in advanced life. They are usually multiple, and may reach 
an immense size. Their favorite situation is the body of the 
uterus, rarely the cervix. According to their position we may 
distinguish a subserous, submucous, and intra-parietal form. 
The subserous myomata grow from the outer muscular lay- THE UTERUS. 
245 
ers of the uterus in the form of little nodules. As they in- 
crease in size, they separate themselves from the uterine wall 
and remain attached only by a narrow pedicle, or by a little 
connective tissue. If they are situated on the sides of the ute- 
rus, they may work their way between the folds of the broad 
ligament until they are at some distance from their point of 
origin. Some authors mention cases in which the tumors be- 
came entirely detached from the uterus and were free in the 
abdominal cavity. 
In some cases, the tumors excite inflammation of the adjacent 
peritoneum, leading to the formation of adhesions or of collec- 
tions of pus. 
In other cases, the tumor reaches a large, size, but remains 
firmly attached to the uterus. This organ is then drawn up- 
ward, the cervix and vagina are elongated and narrowed. The 
traction may be so great that the body of the uterus is entirely 
separated from the cervix. The bladder may also be drawn 
upward, producing incontinence of urine and cystitis. 
This form of myoma is usually hard and dense, the fibrous 
tissue more abundant than the muscular. Calcification fre- 
quently takes place. 
The submucous myomata grow from the inner muscular lay- 
ers of the uterine wall. They commence as rounded nodules 
which lift up the mucous membrane. Their usual position is 
the fundus uteri, sometimes the anterior or posterior wall, rarely 
the lateral portions. In the cervix they are very seldom 
found. 
As the tumors increase in size, they project into the uterine 
cavity. They then remain continuous with the uterine wall, 
over a large area, or are attached by a large or small pedicle. 
They are well supplied with vessels. The uterus dilates with 
the growth of the tumor, and its walls are also thickened. 
The tumor may reach such a size as to entirely fill the cavity 
of the dilated uterus and project through the cervix into the 
vagina. 
The submucous myomata are usually single, although there 
may be at the same time subserous and intra-parietal tumors. 
These myomata are usually soft, of whitish or reddish color, 246 
POST-MORTEM EXAMINATIONS. 
of a lamellated or reticulated structure. The spaces between 
the lamellae or in the reticulum may be so large that the growth 
has a cavernous or cystic character. 
If the polypus is of large size and projects through the cer- 
vix, it may drag down the fundus of the uterus and produce 
inversion of that organ. 
Haemorrhages take place from the surface and in the sub- 
stance of these myomata. Inflammation, suppuration, and 
partial gangrene also occur. The surface of the tumor may 
look like a ragged, gangrenous mass. 
In some cases, the pedicle of the growth is destroyed and the 
tumor is spontaneously expelled. 
The intra-parietal myomata grow in the substance of the 
uterine wall, but if they attain a large size, project beneath 
the serous or the mucous coat. They are found in every part 
of the uterus, but are most frequent in the posterior wall. 
The shape of the uterus is altered in every conceivable way 
by the presence of these growths ; its cavity is narrowed, dilat- 
ed, or misshapen; it undergoes flexion and version in every di- 
rection. The tumors may grow outward, between the folds of 
the broad ligament. They may sink downward and become 
attached to the posterior wall of the vagina, looking as if they 
grew from it. They may project into the cavity of the uterus, 
fill it up, and project through the cervix, but have no pedicle 
like the submucous form. The uterus is dilated, its wall hyper- 
trophied or atrophied. 
The muscular fibres may undergo fatty degeneration, and 
the tumor diminish in size; cases of entire atrophy in this way 
are reported. Or, the muscular tissue atrophies, the connective 
tissue increases in amount and density, and the tumor becomes 
smaller and harder. Calcification may also take place, espe- 
cially in the smaller myomata, and convert them into a stony 
mass. 
Some of these tumors are soft. This takes place in several 
different ways. The interstitial connective tissue may be con- 
verted into mucous tissue, rich in cells and infiltrated with 
mucus. Or the connective tissue may undergo an oedematons 
softening, while the muscular fibres atrophy. We then find the THE UTERUS. 
247 
tumor filled with small cavities containing serum. Or the soft 
consistence may be simply due to the preponderance of muscu- 
lar tissue. 
Occasionally we find in a portion or in the whole of a tumor 
an abundance of dilated blood-vessels, which gives the part a 
true cavernous structure, like that of an erectile tumor. These 
tumors may change their size suddenly from the variable 
amount of blood which they contain. 
A very important change, which is sometimes found in these 
tumors, is the development of cysts in their interior, (fibro- 
cystic tumors.) This takes place in those tumors which grow 
outward beneath the peritoneal coat. We find one oi' more 
cavities, communicating with each other, with rough, trabecu- 
lated walls. The appearance is more that of cavities than of 
cysts. There may be a number of smaller cavities, or they 
may fuse to form one large one. The fluid contained in the 
cavities is like synovia, or is mixed with blood. These cystic 
myomata may reach an immense size, and fill the abdominal 
cavity. The diagnosis between them and ovarian cysts is very 
difficult, and they have frequently been the subjects of fatal 
operations. 
The intra-parietal myomata may give rise to profuse haemor- 
rhages ; they may suppurate and become gangrenous ; the intra- 
uterine ones may undergo spontaneous expulsion ; those which 
project beneath the peritoneum may produce inflammation of 
the neighboring tissues. 
In the cervix uteri, myomata are rare. They may grow as 
polypi beneath the mucous coat; or produce enlargement of the 
anterior or posterior lips; or may grow outward into the ab- 
dominal cavity. I have seen a cystic myoma of large size grow- 
ing from the posterior wall of the cervix and the upper part of 
the vagina, which was mistaken for an ovarian cyst. 
In the wall of the vagina, myomata are still more rare. They 
usually grow outward, toward the rectum or bladder; very 
rarely project inw'ard as polypi. 
Fibroma Papillare, Papilloma, occurs in the form of (1) 
small, soft, polypoid growths from the mucous membrane of 
the uterus or cervix; (2) as syphilitic condylomata of the 248 
POST-MORTEM EXAMINATIONS. 
cervix; (3) as large papillary growths from the cervix. The 
structure is that of papillae, or branching tufts formed of a 
stroma of connective tissue and vessels, and covered with epi- 
thelium. The larger growths are closely related to epithelial 
cancer, and after a time exhibit a growth of epithelial cells 
which places them unmistakably in that class. 
In some of the smaller polypi, the vessels may be so large 
and numerous as to give the growth a cavernous structure. In 
others, the follicles of the mucous membrane are present in 
large amount. 
Angioma.-Virchow describes a single case of a small caver- 
nous angioma in the wall of the uterus. 
Cysts.-In the cervix uteri the mucous follicles are fre- 
quently dilated so as to form cysts filled with colloid matter 
and epithelium-ovula Nabothi. Sometimes there is an inflam- 
matory growth of connective tissue around these cysts, so that 
they resemble the molluscum of the skin. In other cases, the 
cysts may project from the mucous membrane until they take 
the form of a polypus. The same changes are found less fre- 
quently in the mucous membrane of the body of the uterus. 
In rare cases, serous and dermoid cysts are found in the wall 
of the uterus. 
Tubercles.-We sometimes find the cavity of the uterus and 
of the Fallopian tubes lined with a yellow, cheesy mass. This 
is said to be produced by the degeneration of multitudes of 
gray, miliary tubercles scattered through the mucous membrane. 
Syphilitic Gummata are occasionally found in the uterine 
wall in the form of whitish, rounded nodules. 
Sarcoma occurs as a metaplasia in myomata of the uterus, 
forming myo-sarcomata. There is a growth of round, fusiform, 
and stellate cells, and of mucous tissue replacing the muscular 
and fibrous tissue. At the same time, large and small cysts 
may be formed in the tumor. 
Sarcoma also occurs as a primary growth from the uterine 
mucous membrane. The tumors may grow from a large part 
of the internal surface of the uterus, or they may assume a 
polypoid shape. In the latter case, large portions have been 
removed at successive operations, followed by recurrence. THE UTERUS. 
249 
Carcinoma.-The most frequent form of cancer of the uterus 
is classed by different authors either as a true carcinoma, or as 
an epithelioma or cancroid. So that we find some saying that 
epithelioma, and others that carcinoma, is the more frequent, 
while both really mean the same growth. This apparent dis- 
crepancy arises partly from the different significations given to 
the words epithelial and true cancer, and partly from the pecu- 
liar anatomy of the growth. 
The distinction between true and epithelial cancer is one 
which was never very sharply drawn, and now that the epithe- 
lial character of all cancers is so strongly insisted on, the two 
classes are being brought more and more nearly together. 
The anatomy of this form of growth is partly that of the 
epithelial and partly that of the true cancers. There is a 
stroma composed of connective tissue fibres and round cells 
in variable proportions. This stroma may be abundant or 
scanty, but is usually well marked. In the stroma are cavities 
of round, oval, and tubular shape filled with cells. The cells 
resemble somewhat the epithelium of the vaginal portion of the 
cervix, but are more irregular in shape. They are large, poly- 
gonal, or rounded, with one or two large nuclei. In rare cases, 
they have the form of cylindrical epithelium. The cells are 
sometimes closely packed, and form concentric nests ; in other 
cases, they merely fill the alveoli. 
According to the manner in which this new growth invades 
the uterus, the gross appearances vary. 
(1.) We find at first, in the vaginal portion of the cervix in 
the submucous connective tissue, either nodules or a general 
infiltration of a whitish new growth. The cervix then appears 
large and hard. Very soon the mucous membrane over the 
new growth degenerates and falls off, the superficial layers of 
the new growth undergo the same changes. After this, the 
formation of the new growth and its ulceration go on simulta- 
neously, producing first an infiltration, and then destruction of 
the cervix, and often of a part of the body of the uterus. The 
growth frequently extends to the vagina, the bladder, and rec- 
tum with the same destructive character, so that we often find 
the cervix and upper part of the vagina destroyed, and in their 250 
POST-MORTEM EXAMINATIONS. 
place a large cavity, with ragged, gangrenous, cancerous walls. 
Less frequently the pelvic bones are invaded in the same way. 
Metastatic tumors in the lymphatic glands and viscera are rare. 
I have seen small secondary nodules in the lungs, formed of 
large, flat cells closely packed in nests. 
Not unfrequently the ureters are surrounded and com- 
pressed by the new growth, so that they become dilated. The 
dilatation may extend to the pelves and calices of the kidneys. 
(2.) The development of the new growth' is more rapid than 
its destruction. We find large, fungous, soft masses projecting 
into the vagina and the canal of the cervix. 
(3.) The ulceration is more rapid than the new growth. We 
find larger or smaller ragged, ulcerating surfaces, of which the 
floor and walls are composed almost entirely of gangrenous 
new growth and uterine tissue. The amount of the new growth 
which is left may be so small as to render the diagnosis be- 
tween carcinoma and phagedaenic ulcer very difficult. 
(4.) The new growth begins in the cervix, and extends uni- 
formly over the internal surface of the cervix and of the body 
of the uterus. The entire uterus is converted into a large sac, 
of which the walls are infiltrated with the new growth, while 
the internal surface is ulcerating and gangrenous. 
(5.) In rare cases, the growth begins in the upper part of the 
cervix, or in the body of the uterus, while the lower part of the 
cervix is not involved. 
(6.) In rare cases, the entire wall of the uterus is infiltrated 
with the new growth, and the organ is much enlarged. 
Papillary Epithelial Cancer (cauliflower growth) is an in- 
frequent form of disease. It is said that simple papillomata 
may, after a time, exhibit an increased cell-growth, and epithe- 
lial nests in their stroma. But the real relationship between 
simple papilloma and papillary epithelioma of the cervix is still 
not at all understood. The growth springs from the vaginal 
portion of the cervix. It appears as a lobulated, fungous mass 
composed of numerous tufts. It may reach such a size as to fill 
the vagina. The minute structure is that of tufts covered with 
epithelium. In the stroma of the larger tufts, in the connec- 
tive tissue at the base of the growth, and in the wall of the THE OVARIES. 
251 
cervix, beneath the growth, we find alveoli filled with epithelial 
cells. 
True Carcinoma is not very common in the uterus. The 
gross appearances resemble those of the more ordinary epithe- 
lial form of the growth. The tumor usually begins in the 
cervix, sometimes in the body of the uterus. It forms fungous 
masses projecting into the vagina, or growth and ulceration go 
on at the same time, or ulceration goes on faster than growth. 
Infection of the surrounding tissues is frequent; metastatic 
tumors often occur. 
Colloid Carcinoma is rare. It may involve the cervix or 
body. It has the ordinary structure of a fibrous stroma form- 
ing regular alveoli, containing gelatinous matter and cells. 
PARASITES. 
Echinococci have been observed in the body and neck of the 
uterus; they may rupture into the peritoneal cavity or into 
the vagina. 
THE OVARIES. 
MALFORMATIONS. 
Both ovaries may be absent, the other organs of generation 
being also absent or undeveloped. Or the ovaries may be 
only partially developed. 
Absence or arrest of development of one ovary is sometimes 
met with in well-formed individuals. It is sometimes accom- 
panied by a low position of the kidney on the same side. 
The ovaries may pass into the inguinal canal or into the labia 
majora, and remain fixed there through life. Less frequently 
they are found in the crural canal and the foramen ovale. 
CHANGES IN SZE. 
Atrophy is a regular senile change. The Graafian follicles 
disappear, and the organ shrivels into a small fibrous body. 
Atrophy is also produced by ascites, by chronic inflammation, 
or as an idiopathic change. 
True hypertrophy of the ovaries does not occur, but the stro- 
ma may be increased in amount. 252 
POST-MORTEM EXAMINATIONS. 
In adult life, the ovaries may descend as hernise into the in- 
guinal or crural canal, the foramen ovale, or the umbilicus. 
The position of the ovaries in the abdomen may be changed 
by the pressure of tumors, the traction of false membranes, etc. 
Rokitansky describes a twisting of the ovary on its axis, with 
twisting of the Fallopian tube around the ovarian ligament. It 
usually occurs in enlarged ovaries, and by the compression of the 
veins, leads to congestion and inflammation of the tube, ovary, 
and peritoneum. 
CHANGES IN POSITION. 
HEMORRHAGE. 
Every menstrual period is accompanied by the effusion of 
blood into a Graafian follicle. Normally, the amount of blood 
is small, becomes solid, is decolorized, and then gradually ab- 
sorbed. Sometimes the effusion of blood is much greater ; the 
follicle filled with blood is as large as a pigeon's egg. The 
blood may remain in the follicle and be absorbed, or it may 
rupture it and escape into the peritoneal cavity. Death may 
ensue from the haemorrhage, or the blood may collect in Dou- 
glas's cul de sac, and be inclosed in false membranes. Hae- 
morrhages also occur in follicles, which have become cystic. 
INFLAMMATION. 
Inflammation of the ovaries occurs most frequently in the 
puerperal condition, either as part of a general peritonitis, or as 
a primary affection. 
With puerperal peritonitis, both ovaries are usually inflamed; 
they are swollen, congested, soft, infiltrated with serum or pus, 
or gangrenous. The inflammation may attack principally the 
capsule, the stroma, or the follicles. Inflammation of the cap- 
sule results in adhesions and collections of pus, shut in by 
false membranes ; of the stroma, in abscesses and fibrous indu- 
ration ; of the follicles, in their containing purulent serum. If 
the inflammation of the ovary is the primary lesion, it is usual- 
ly confined to one organ. The stroma of the ovary is infiltrated 
with serum and pus, and may contain abscesses of large size. THE OVARIES. 
253 
In other cases, the ovary itself is but little changed, but is sur- 
rounded by a mass of fibrinous and purulent exudation. Such 
idiopathic forms of inflammation may terminate in recovery ; or 
the abscesses may perforate into the rectum and vagina; or 
the ovary is left indurated and bound down by adhesions; or 
the patient dies from the violence of the disease. 
Idiopathic inflammation of the ovaries unconnected with the 
puerperal condition is rare. It is confined to one ovary. Either 
the follicles, stroma, or capsule may be involved. The inflamed 
follicles appear enlarged, their walls thickened; they contain 
bloody or purulent serum. The stroma becomes infiltrated 
with serum or pus ; and later, we find abscesses or fibrous indu- 
ration of the organ. The inflammation of the capsule leads to 
formation of membranous adhesions between the ovary, Fallo- 
pian tube, and adjoining organs. 
Cysts.-(1.) The Graafian follicles maybe dilated so as to form 
cysts. This usually occurs only in one ovary; sometimes in 
both. The follicles become enlarged, filled with serum, the 
ovum disappears, and we find cysts with thin walls, lined with 
pavement epithelium, and containing serum. Sometimes we 
find the cyst lined with cylindrical or even ciliated epithelium. 
There are usually a number of such cysts, all of small size. 
Sometimes, however, one cyst will attain a very large size. The 
fluid contained in it will be serous, viscid, purulent, or mixed 
with blood. There maybe fibrous outgrowths from the interior 
of the cyst-wall. Such cysts usually are found after middle life, 
but may occur during youth, childhood, and even in the foetus. 
A variety of this form of cyst is formed by the dilatation of a 
follicle containing a corpus luteum. A thin layer of clot is 
then found lining the walls of the cyst. Such cysts may com- 
municate with the Fallopian tubes. 
(2.) Composite Colloid Cysts.-This is the most common form 
of ovarian cyst. Either one or both ovaries are affected. The 
cysts are found from the size of a walnut to that of the preg- 
nant uterus. The gross appearance varies according to the size, 
number, contents, and stroma of the cysts. 
NEW GROWTHS. 254 
POST-MORTEM EXAMINATIONS. 
The growth consists of a fibrous stroma, in which are tubular 
follicles lined with cylindrical epithelium, and containing colloid 
matter and rounded cells. The cysts are formed by the dilata- 
tion of these follicles. There may be a great number of follicles 
equally dilated, so as to form a number of cysts of moderate 
size; or only a few follicles are enormously dilated to form a 
large multilocular cyst, with but few compartments. The walls 
of the cysts may fuse together, and be absorbed so as to form 
one large cyst divided by incomplete septa. The stroma in 
which the follicles and cysts are imbedded may be largely de- 
veloped or very scanty. The w'alls of the follicles and smallei* 
cysts are lined with cylindrical epithelium. They contain col- 
loid matter mixed with a variable number of rounded cells. 
Sometimes the cells contain globules of colloid matter. The 
walls of the larger cysts are composed of fibrous tissue. They 
may be thin and membranous ; or we find developed on their 
internal surfaces an intra-cystic growth composed of a fibrous 
stroma and tubular follicles. These secondary follicles may 
also be filled with colloid matter, and form cysts. The intra- 
cystic growths may be so large as to fill up the original cysts. 
Sometimes the intra-cystic growth presents very little dilatation 
of its follicles, so that the entire tumor has more the character 
of a solid growth than of a cyst. The contents of the larger 
cysts are serum or colloid matter of variable consistence and 
color, and mixed with blood or pus. The cyst-walls may be- 
come inflamed and covered with fibri ne or pus. The cysts may 
rupture into the abdominal cavity, or may be discharged 
through the intestine or through the abdominal wall. 
The structure of these cysts is, therefore, that of a cystic ade- 
noma. In some of these cysts, the formation of fibrous tufts, 
covered with epithelium, becomes the most prominent feature of 
the growth. Here, as in the cylindrical-celled epithelial can- 
cers, we find the close relationship between follicles lined with 
epithelium and tufts covered with epithelium. 
In many of the cysts in which the formation of follicles and 
their dilatation is well shown, the growth of tufts to a limited 
extent is also seen. But there are other cysts in which the THE OVARIES. 
255 
cyst-cavity is filled with a mass of tufts, looking like a cauli- 
flower. Strictly speaking, such growth should be classed -with 
the papillomata, but their relationship to the adenomata seems 
to be very close. They are often supposed by clinical observ- 
ers to be cancerous, on account of their fungous appearance ; 
but they are of a totally different character. 
Dermoid Cysts.-These cysts are single or multilocular. 
They may be no larger than a walnut, or of very large size. 
They contain a thick, greasy material composed of epithelium, 
fat, and cholesterine. A portion of the internal surface of the 
cyst-wall may have the structure of the cutis : papillae, hair 
follicles, and sebaceous follicles. In the cavity of the cysts may 
be found masses of hair, teeth, bones, cartilage, striated muscle, 
nerve-fibres and cells, and gray nerve-matter. Such cysts may 
be congenital. They often last for many years without much 
inconvenience; but they may form adhesions and perforate into 
the adjoining organs. 
Fibroma.-A number of tumors have been seen in the ovaries 
by different observers, which, although resembling each other in 
their gross appearance, have a different anatomical structure. 
They occur usually in one ovary, sometimes in both. They are 
usually small, but may attain an immense size. They resemble 
the hard uterine myomata in their gross appearance. They 
occupy the entire ovary, or only part of it. They may contain 
cysts, or the follicles in the portion of ovary that is left may be 
dilated so as to form cysts. They are composed of fibrous tis- 
sue alone, or mixed with a little smooth muscle, or with fusi- 
form and round cells. They belong, therefore, to the classes of 
Fibroma, .Myo-fibroma, and Fibro-sarcoma. 
Enchondroma of the ovary is rare. Cartilaginous tissue is 
found is some composite and dermoid cysts. 
Syphilitic Gummata in the form of white nodules have been 
observed in a few cases. 
Tubercles very rarely occur in the ovary. They are describ- 
ed as cheesy nodules of some size. 
Sarcoma of the ovaries is not frequent. It may be primary 
or metastatic. The tumors are hard and dense, or softer and of 
loose texture. They are composed of fibrous tissue with fusi- 256 
POST-MORTEM EXAMINATIONS. 
form and round cells. They usually involve both ovaries, and 
occur before middle life. 
Carcinoma is found as a primary and metastatic growth, and 
as a continuous infection from the neighboring organs. Medul- 
lary carcinoma is the most frequent form, but scirrhus, mela- 
notic, and colloid cancer are sometimes found. The new growth 
may be joined with the development of cysts. 
THE FALLOPIAN TUBES. 
MALFORMATIONS. 
Absence of both tubes occurs with absence of the uterus. 
One tube may be absent, with arrested development of the cor- 
responding side of the uterus. Both tubes may be imperfectly 
developed, either of their ends may be closed, they may be in- 
serted into the uterus at an abnormal place, they may terminate 
in two or three abdominal ostia. 
CHANGES IN SIZE. 
Dilatation of the tubes, with increase of their length, is pro- 
duced by the accumulation of catarrhal secretion, or by a con- 
striction of some portion of the tube. 
Narrowing of the' tubes is produced by inflammation or by 
masses of mucus, blood, or pus. The abdominal end may be 
bound down and closed by adhesions, or the uterine end may be 
closed. In old age, the lumen of the tubes becomes very small 
or is obliterated. 
Rupture of a dilated tube sometimes takes place. 
HEMORRHAGE. 
Haemorrhage in the tubes has been observed, in Typhoid 
Fever, in puerperal women, with retroversion of the uterus, 
with abortions, in measles, with menorrhagia, with haemato- 
metra, and with tubal pregnancy. The blood may escape into 
the peritoneal cavity and cause peritonitis. THE FALLOPIAN TUBES. 
257 
INFLAMMATION. 
Catarrhal Inflammation of the mucous membrane of the 
Fallopian tubes is of common occurrence. It is connected with 
endometritis, with the puerperal condition, or is an idiopathic 
affection. Usually both tubes are involved, the mucous mem- 
brane is swollen, and there is a production of mucus and pus in 
the tubes. The inflammation may subside without leaving any 
lesions, but more frequently results in peritoneal adhesions, 
obliteration of the tubes, dilatation, and abscesses. 
Dilatation of the tubes is usually produced by obstruction or 
obliteration of their uterine extremities. The dilatation is 
generally moderate, converting the tube into a tortuous saccu- 
lated canal, containing mucus or serum mixed with pus or blood. 
More rarely, the dilatation is excessive and cysts are formed 
containing several pounds of fluid, and which may be mistaken 
for ovarian cysts. Dr. Peaslee has reported a case in which 
death ensued from haemorrhage into the cavity of such a di- 
lated tube. 
In some cases, the fluid in the dilated tubes is entirely puru- 
lent, forming abscesses in the tubes. These abscesses may rup- 
ture into the peritoneal cavity, or the pus may escape into a 
cavity shut in by adhesions, or may perforate into the intes- 
tines. 
Suppurative Inflammation of the tubes is found in connec- 
tion with puerperal peritonitis and metritis. The tubes are 
swollen, intensely congested and pus exudes from their abdo- 
minal ends. It is often difficult to determine whether the peri- 
tonitis or salpingitis is the primary lesion. 
NEW GROWTHS. 
Cysts of small size are often found on the tubes and broad 
ligaments. They are formed by dilatation of the follicles of 
the foetal organs :-the Wolffian Body, and the accessory ovary. 
Besides these, serous and colloid cysts, sometimes of large 
size, are found which seem to be true new growths. Kiwisch 
says that cysts are also found between the folds of peritoneum 
which accompany the round ligaments. 258 
POST-MORTEM EXAMINATIONS. 
Fibroma occurs in the form of small nodules in the wall of 
the tubes. They may become calcified. 
Lipoma is found between the folds of the broad ligament. 
The tumors are of small size. 
Myoma of the wall of the Fallopian tubes is very rare and 
the tumors are of small size. 
Carcinoma is found in the tubes only as a secondary growth 
continuous with the same growth in the adjoining viscera. 
EXTRA-UTERINE PREGNANCY. 
Tubal Pregnancy.-The impregnated ovum is in some way 
hindered from passing into the uterus, becomes fixed in the tube, 
and is there developed. The embryo and its membranes are 
developed until they reach such a size that the tube surround- 
ing them ruptures. This may take place in the first month, or 
not until the sixth. The ovum may remain in the tube after 
the rupture; or may escape into the peritoneal cavity still en- 
veloped in its membranes; or the membranes may be ruptured 
.and left in the tube. The rupture is generally attended with 
fatal haemorrhage. In some cases, death is caused by the rup- 
ture of a dilated vein, while the tube is still intact. 
In rare cases, death does not take place, and the foetus is shut 
in by adhesions and false membranes. The embryo soon dies. 
In favorable cases, there is a slow absorption of the soft parts of 
the foetus, the bones are separated and left imbedded in a mass 
of fibrous tissue, fat, cholesterine, and pigment. Or the foetus 
retains its shape and becomes mummified, and may then be in- 
crusted with the salts of lime. 
In unfavorable cases, degeneration and gangrene of the foetus 
take place rapidly, with inflammation and suppuration of the 
surrounding tissues. There may be perforation and escape of 
the broken-down foetus through the rectum, vagina, bladder, or 
abdominal wall. The patient may die from peritonitis or ex- 
haustion, or may recover after the escape of the foetus. 
In some cases, the foetus may escape through a rupture of the 
tube into the space between the folds of the broad ligament. 
Tubal-Abdominal Pregnancy is produced by the develop- THE PENIS. 
259 
ment of the ovum in the fimbriated extremity of the Fallopian 
tube. Adhesions are formed, so that the foetus is partly in the 
end of the tube and partly in the abdomen. 
Interstitial Pregnancy.-The ovum is arrested and deve- 
loped in the portion of the tube which passes through the wall 
of the uterus. 
Ovarian Pregnancy.-The ovum is developed in its Graafian 
follicle. The existence of this form of extra-uterine pregnancy 
is doubtful. 
Abdominal Pregnancy.-The ovum after escaping from the 
ovary does not enter the Fallopian tube, but becomes fixed at 
some point near it. It is surrounded by thickened peritoneum 
and developed in that position. 
In all forms of extra-uterine pregnancy, the uterus becomes 
enlarged, and a sort of decidua is formed on its internal surface. 
THE PENIS. 
MALFORMATIONS, 
Entire absence of the penis is met with in connection with 
great defects of development of the rest of the body. 
Absence of the penis with proper development of the other 
organs of generation is rare. The urethra then usually opens 
into the rectum. 
An abnormally small penis is found, with absence or arrested 
development of the testicles. 
Absence of the prepuce has been observed in a number of 
cases. Congenital phinosis is also not infrequent. 
Hypospadia consists in an arrest of development of the penis 
and scrotum. In its highest degrees, the penis is one half to 
one inch long, the glans penis small and resembling a clitoris. 
On the lower side of the penis is a deep cleft, lined with mu- 
cous membrane. Into this cleft the urethra opens at the root 
of the penis. The scrotum remains separated into two halves, 
resembling labia majora. The testes descend into their proper 
position on each side, or remain in the abdomen. If the testi- 
cles continue to develop normally, the individual has the appear- 260 
POST-MORTEM EXAMINATIONS. 
ance and capacities of a man; if their development is arrested, 
the individual is small and has a womanish appearance. 
In lesser grades of the same malformation, the two halves of 
the scrotum are joined and the penis is larger, but a part of the 
urethra remains open as a cleft. 
Uterus Masculunus.-This malformation consists in an ab- 
normal change in the transition from the foetal condition of 
the parts to their fully developed form. In the male, normally, 
the greater part of Muller's canal disappears, and its lower end 
forms the vesicula prostatica. In this malformation, Muller's 
canal is changed, as it is in the female, into Fallopian tubes, 
uterus, and vagina, while at the same time the testes, epididymes, 
vesicula; seminales, and spermatic cord are formed as usual. In 
the lesser degrees of this malformation, we find, in the place of 
the vesicula prostatica, a pear-shaped sac, as large as a pigeon's 
egg, with muscular walls and an epithelial lining. This sac 
may be incompletely divided into a uterus and vagina, and it 
opens into the urethra. In the higher grades, we find a well- 
formed vagina and uterus. The uterus may or may not have 
Fallopian tubes. The testicles are usually retained in the abdo- 
men or inguinal canals, and are small. The spermatic ducts 
run on the sides of the uterus and open into the urethra or 
remain closed. The penis and scrotum appear as in hypospa- 
dia, or are well formed. The appearance of the individual 
varies with the development of the testicles. 
A rare modification of this malformation consists in the exis- 
tence of hypospadia; of a vagina and uterus; of a Fallopian 
tube and ovary on one side, and of a testicle and spermatic 
cord on the other side. 
HYPERTROPHY. ATROPHY. 
Hypertrophy of the penis is sometimes caused by venous 
congestion from heart-disease; by long-continued masturbation, 
the corpus cavernosum losing its contractility; and in rare 
cases, by hypertrophy of the stroma of the corpus cavernosum. 
Atrophy is sometimes produced by chronic ulceration of the 
glans penis, and sometimes follows atrophy of the testicles. THE PENIS 
261 
Balanitis, inflammation, of the prepuce, is usually produced 
by gonorrhoea, or by accumulations of smegma. The skin is 
red and swollen, and may ulcerate. Condylomata may be 
formed, and adhesions between the prepuce and glans. The 
glans may ulcerate and the prepuce may be much thickened. If 
the prepuce is long, there is an inflammatory phymosis, and the 
products of inflammation accumulate within the swollen pre- 
puce. In some cases, the prepuce becomes gangrenous. 
Paraphymosis is produced by the retraction of a narrow 
prepuce behind the glans, with consequent stricture, inflamma- 
tion, and gangrene. 
Inflammation of the Corpora Cavernosa is produced by gon- 
orrhoea, injuries, fistulse, typhus fever, measles, and occurs in 
connection with inflammation of the connective tissue of the 
pelvis. It results in fibrous induration of portions of the cor- 
pora cavernosa; in rare cases, in abscesses or diffuse purulent 
infiltration ; sometimes in gangrene. 
Syphilitic Ulcers frequently occur on the glans penis and 
prepuce. 
The indurated chancre is formed either from an excoriation 
in which a pustule is formed, or from a little nodule. The pus- 
tule breaks and its walls are infiltrated with small, round cells. 
The nodule softens, breaks down, and forms an ulcer, of 
which the walls are infiltrated with cells in the same way. 
Phagedsenic ulcers occur, and may destroy a considerable 
part of the penis. 
Herpes of the prepuce occurs in the form of small vesicles, 
which may later become ulcers. 
Erysipelatous and furuncular inflammation sometimes in- 
volve the skin of the penis. 
INFLAMMATION. 
NEW GROWTHS. 
Papilloma is found on the prepuce and glans penis. It pc- 
curs in the form of little warty growths, or of composite, cauli- 
flower masses, even as large as a fist. In either case, the struc- 262 
POST-MORTEM EXAMINATIONS. 
ture is the same-hypertrophied papillae covered with epithe- 
lium. 
Fibroma diffusum, or elephantiasis, occurs in the prepuce. It 
consists in a growth of fibrous tissue from the deep layers of the 
cutis, and forms tumors, which may reach an immense size. 
Cysts, Lipoma, Fibroma, Angioma, have all been observed in 
the skin of the penis. 
Fibrous Tissue is sometimes developed in the corpora caver- 
nosa, and may become calcified. 
Epithelioma is not infrequent in the prepuce and glans penis. 
It takes the form of nodules, which ulcerate, or of papillary 
outgrowths. The structure is that of epithelial cancer with 
large, flat cells. The growth may involve the entire skin of the 
penis, and invade the deeper tissues. The inguinal glands may 
be secondarily affected. 
Eberth reports a case in which a cylindrical-celled epithelioma 
of the rectum was followed by secondary nodules in the liver 
and in the corpus cavernosum of the penis. 
Carcinoma of the penis is not common. It begins in the 
glans penis or prepuce, in the form of nodules or of a diffuse 
infiltration. The growth goes on to involve the corpora caver- 
nosa ; the inguinal glands become affected, and metastatic tu- 
mors may be formed in the viscera. 
THE SCROTUM. 
The skin of the scrotum is subject to the various forms of 
inflammation, which may affect any part of the integument. 
In very rare cases, tumors containing a considerable portion 
of the foetal skeleton have been found in the scrotum. 
Dermoid Cysts containing hair, bone, cartilage, etc., some- 
times occur. 
Lipoma and Fibroma are sometimes found in the skin of the 
scrotum. 
Epithelioma, Chimney Sweep's Cancer, occurs in the form of 
small nodules in the skin, which ulcerate, and from which little 
fungous growths arise. 
Fibroma diffusum, elephantiasis of the scrotum, forms tumors THE TESTICLES. 
263 
which reach an immense size. The growth consists in a deve- 
lopment of connective tissue from the deep layers of the cutis, 
and is sometimes accompanied by dilatation of the lymphatic 
vessels. 
THE TESTICLES. 
MALFORMATIONS. 
Absence of all the organs of generation is found in connec- 
tion with other extensive malformations. 
Absence of both testicles, either with or without absence of 
the epididymes, spermatic cord, and vesiculse seminales, occurs in 
rare cases. The scrotum is only indicated, or may contain the 
epididymes. The penis is small, and the individuals are small 
and poorly developed. 
Instead of being entirely wanting, the testes may be imper- 
fectly developed. The individuals are weakly and effeminate. 
Absence of one testicle, with healthy development of the 
other, is more frequent. The corresponding epididymis and 
cord may be absent or present. 
The spermatic cords and vesiculse seminales may be absent 
or imperfectly developed on one or both sides, while the testes 
are normal. 
Either one or both testicles may remain permanently in their 
foetal position, or may not descend into the scrotum for several 
years after birth. Their descent may even be delayed until the 
thirtieth year of life. 
This condition may depend on an arrest of development in 
the testes, or the gubernaculum testis; on adhesions produced 
by intra-uterine peritonitis ; on narrowing of the inguinal canal; 
on narrowing or shortening of the vaginal process of the peri- 
toneum ; or on abnormal size or position of the testicle. 
Usually the malformation is confined to one testicle, and then 
is more frequent on the left side. 
The testicle is found in the abdomen close to the mouth of 
the inguinal canal; in the inguinal canal, just below the exter- 
nal ring; beneath the skin in the perineum; or in the crural 
canal with the femoral vessels. 264 
POST-MORTEM EXAMINATIONS. 
Sometimes, while the testis is retained, the epididymis and 
spermatic cord descend into the scrotum. 
The retained testis is usually not fully developed, or under- 
goes fatty or fibrous degeneration. It may become the seat of 
malignant new growths. Sometimes, however, although both 
testicles are retained, the individual is capable of procreation. 
In rare cases, the position of the testis may be changed, so 
that the epididymis and cord are in front. 
The existence of a supernumerary testis has been asserted in 
some cases, but is rather doubtful. 
In cases of abnormally early development, we sometimes find 
the testes in a young child as large as they should be in an adult. 
INFLAMMATION. 
Inflammation of the testicles is caused by injuries, exposure 
to cold, inflammation of the urethra, syphilis, and occurs with 
parotitis. The testes, epididymis, or tunica albuginea may be 
principally involved. Usually only one testicle is inflamed; 
sometimes both. The inflammation may extend to the vas 
deferens. 
The inflammation may be acute or chronic. Acute inflam- 
mation is more frequent in the epididymis and the tunica albu- 
ginea. The organ is congested and infiltrated with serum. 
From this condition, it may return to the normal, or small ab- 
scesses may form in the testis and epididymis, and destroy the 
greater part of the organ. In other cases, the epididymis re- 
mains swollen and indurated for a long time; in other cases, it 
becomes atrophied. 
Chronic inflammation occurs as a sequel of acute inflamma- 
tion, or as an original condition. It usually affects the testis, 
but may extend to the epididymis and spermatic cord. The 
organ is slowly enlarged. The tubes of the testis are enlarged 
and filled with degenerated epithelium; the interstitial fibrous 
tissue is increased in amount. The testis and epididymis are 
then found to be composed of a mass of fibrous tissue, imbedded 
in which are cheesy nodules-the remains of the degenerated 
tubules. In some cases, nothing but fibrous tissue is found; in THE TESTICLES. 
265 
others, there is calcification. Sometimes abscesses are formed, 
and these may perforate through the scrotum, and be accom- 
panied by a growth of granulation tissue which projects as a 
fungous mass. 
Syphilitic inflammation affects principally the didymis. The 
tunica albuginea is thickened, and bands of fibrous tissue extend 
into the organ. In the new fibrous tissue, there may be gummy 
tumors. 
HYDROCELE. 
Hydrocele of the tunica vaginalis consists in an accumula- 
tion of serum in the cavity of this membrane. It is usually 
confined to one side. It is caused by acute or chronic inflam- 
mation of the tunica vaginalis, by varicocele, or by general 
dropsy. The serum is found in small or in large quantities; it 
is usually transparent, may contain cholesterine, or be purulent, 
or be mixed with blood. When spermatic cysts of the epididy- 
mis open into the cavity of the tunica vaginalis, the fluid con- 
tains spermatozoa. The tunica vaginalis remains unchanged, 
or is thickened, or contains plates of bone, or is covered with 
polypoid fibrous bodies, which fall off, and are found free in 
the cavity of the sac. There may be adhesions between the 
layers of the tunica vaginalis, and in this wray the fluid becomes 
sacculated. The testis is pushed downward and backward; it 
remains unchanged, or is atrophied. 
Hydrocele of the processus vaginalis consists in an accumu- 
lation of serum in the cavity of the vaginal process of the 
peritoneum, which remains open after the descent of the testicle. 
There are several different varieties. 
(a.) The vaginal process is entirely open, and there is a free 
communication with the peritoneal cavity. The serum may 
originate in the cavity of the peritoneum, or of the vaginal pro- 
cess, and passes freely from one to the other. 
(b.) The processus vaginalis is closed in the inguinal canal, 
while its lower portion is filled with serum. 
(c.) The processus vaginalis is closed about the testis, and the 
visceral layer of the tunica vaginalis is formed. The serum ac- 266 
POST-MORTEM EXAMINATIONS. 
cumulates in the upper part of the vaginal process, which com- 
municates with the peritoneal cavity. 
(d.) The vaginal process is closed in the inguinal canal and 
over the testis; the serum accumulates so as to form one or 
more sacs between these two points. Inguinal hernia may 
complicate this form of hydrocele. 
Hydrocele of the spermatic cord consists in a general oedema 
of the connective tissue of the cord, or in the development of 
circumscribed cysts in this connective tissue. 
A peculiar form of hydrocele is produced by the accumula- 
tion of serum in the sac of an inguinal hernia, from which the 
intestine has become retracted. 
TLEMATOCELE. 
Hsematocele of the tunica vaginalis consists in an effusion of 
blood into the cavity of this sac. It may be produced by an 
injury, or may complicate a preexisting hydrocele. The effused 
blood soon degenerates, and we find the sac filled with a brown- 
ish fluid, or a thick, grumoiis mass. The tunica vaginalis is 
usually thickened. The testis remains normal, or is atrophied. 
Hsematocele of the spermatic cord occurs in rare cases as a 
diffused infiltration of blood in the connective tissue of the cord. 
Or blood may be effused into a hydrocele of the cord. 
NEW GROWTHS. 
Fibroma occurs in the form of dendritic or polypoid growths 
of the visceral layer of the tunica vaginalis. The tumors are of 
small size; their pedicles may atrophy, and the little bodies 
become free. They are usually found in connection with hy- 
drocele. Small fibrous tumors have also been observed on the 
spermatic cord. Sometimes the entire testis is replaced by a 
mass of fibrous tissue. 
Lipoma occurs as a lobulated growth arising from the con- 
nective tissue of the spermatic cord, from the tunica albuginea 
of the testis, and from the tunica dartos of the scrotum. The 
tumors may reach a considerable size, are entirely composed of 
fat, or may be combined with myxoma or sarcoma. THE TESTICLES. 
267 
Myxoma occurs in the testis as a soft gelatinous growth, which 
may break through the scrotum, and appear as a fungous mass. 
Enchondroma occurs in the testis in the form of soft, hyaline 
tumors, which may attain a very large size. In some cases, we 
find great numbers of peculiar papillary cartilaginous out- 
growths partly contained in the enlarged lymphatic vessels of 
the tumor. Combinations of enchondroma with cysts, sarcoma, 
and carcinoma are common. 
Tubercle usually begins in the epididymis, and may extend 
from there to the testis. More rarely, it begins in the testis. 
The growth begins in the form of small, gray granulations, 
which become cheesy, and fuse together into dry, yellow masses 
of considerable size. They are accompanied by a chronic in- 
flammation of the surrounding tissues, and the cheesy mass may 
perforate the scrotum, and project as a fungous growth. The 
growth may also extend to the vas deferens, vesicular seminales, 
and prostate. 
Cysts.^Single, simple cysts containing serum, and dermoid 
cysts containing epithelium, are sometimes found in the testis. 
Cysts containing spermatozoa are found in the epididymis ; they 
are probably formed by dilatation of the follicles of the Wolffian 
Body. Cysts containing serum alone are formed from the same 
follicles. Small serous cysts are also formed in the connective 
tissue beneath the tunica vaginalis of the testis and epididymis. 
Compound Cysts, Hydatid Tumor, Cysto-sarcoma, Cysto- 
fibroma, Fibro-cystic Tumor, Cysto-adenoma.-These names are 
given to a growth in the testis which is not of very frequent 
occurrence. The organ is converted into a mass of cysts con- 
taining serum, or colloid matter. The walls of the cysts are 
lined with pavement or cylindrical epithelium ; their internal 
surfaces are smooth, or there are intra-cystic papillary growths. 
Sometimes the smaller cysts are filled with epithelium packed 
in concentric layers. The stroma is composed of fibrous tissue, 
with few or many connective tissue-cells; sometimes of mucous 
tissue ; sometimes nodules of cartilage, and rarely striated mus- 
cle are found. Or there may be a combination with carcinoma. 
In the only example of this form of tumor which I have 
seen, the cysts were lined with cylindrical epithelium; the stro- 268 
POST-MORTEM EXAMINATIONS. 
ma was composed of fibrous tissue, in which were a few minute 
nodules of cartilage, and, in a few places, long, narrow, striated 
cells looking like embryonic striped muscle. 
These tumors are usually considered benign; but Billroth 
mentions a case in which the removal of the testicle was fol- 
lowed by the growth of a retro-peritoneal carcinoma. 
Sarcoma occurs both in the testis and epididymis. The tu- 
mors may attain a considerable size, are soft, with little stroma, 
or with a mucous basement substance; the cells mostly fusi- 
form, belonging to the medullary and myxo-sarcomata. In 
some cases, we find cysts and canals lined with epithelium, and 
containing fluid, colloid matter, or epithelial contents. The 
canals and cysts are probably formed from the spermatic tu- 
bules. 
Myoma.-A new growth of striped muscular fibres has been 
observed in four tumors of the testicle, in cases which are de- 
scribed as cystoid growths. The muscle was in the form of 
fusiform cells, with well-marked striation. I can add two 
other cases. In one, the tumor was removed by Dr. H. B. Sands, 
in May, 1868. It occurred in a middle-aged man, and was 
eighteen months in growing. The tumor weighed twenty-eight 
ounces, was confined to the epididymis, inclosed in the thick- 
ened albuginea, was soft and succulent, and contained many 
cysts. It consisted of connective tissue-fibres; of large num- 
bers of long, fusiform cells; of long, fusiform, nucleated 
cells resembling embryonic striped muscle; of similar cells 
with marked striations; of large, well-shaped, striped muscular 
fibres, inclosed in their sarcolemma; of large, oblong, and 
round striated bodies looking like portions of muscular fibres. 
In the second case, the tumor was removed by Dr. Wood. It 
was a compound cystic tumor. In a few places, there were 
numbers of long, narrow, striated cells. 
Carcinoma usually involves only one testicle. It is most 
frequently primary. It begins in the testis or the epididymis, 
rarely in the tunica vaginalis. The tumors are usually large, 
soft, succulent, often haemorrhagic, or may be cystic. They are 
composed of a stroma, forming rounded spaces, in which are 
large, nucleated, rounded, or polygonal cells. The tunica albu- THE PROSTATE. 
269 
ginea expands with the growth and incloses it, even when of 
large size. More rarely the stroma is abundant, and the tumor 
is hard and scirrhous. Metastatic tumors of the inguinal and 
lumbar glands often occur. 
Syphilitic Tutors occur in connection with syphilitic orchi- 
tis^ The albuginea is thickened, and bands of fibrous tissue 
extend into the organ. In this new fibrous tissue we find 
cheesy nodules, sometimes of considerable size. The epididy- 
mis is rarely involved. 
THE PROSTATE. 
HYPERTROPHY AND ATROPHY. 
Hypertrophy of the prostate is a frequent senile change; it 
is general or partial. 
In general hypertrophy, the entire organ is enlarged, and may 
reach the size of a man's fist. The enlargement is symmetri- 
cal, or is most marked in one half or in the so-called middle 
lobe. The organ is hard and dense, or soft, or alveolar, contain- 
ing numerous small openings, from which a turbid fluid exudes. 
These different appearances depend upon the character of the 
hypertrophy. The muscular and fibrous tissue alone may be 
increased, or at the same time the glandular tissue, or the 
glandular tissue alone. 
In partial hypertrophy, we find circumscribed nodules of 
muscular tissue, or of muscular and glandular tissue. They 
are usually situated at the periphery of the organ, and project 
into the bladder. They may become detached from the pros- 
tate, and are found as small, movable tumors beneath the 
mucous membrane of the bladder. 
Both forms of hypertrophy frequently produce retention of 
urine and changes in the bladder. 
Atrophy of the prostate is sometimes seen in connection with 
atrophy of the testicles, and with castration. Sometimes the 
ducts of the glandular portion are enlarged, or there may be 
fibrous degeneration of the organ. 270 
POST-MORTEM EXAMINATIONS. 
Inflammation of the prostate is caused by gonorrhoea, by in- 
juries, or, more rarely, is idiopathic. It'may run an acute or 
chronic course. The gland may after a time return to its nor- 
mal condition, or is gradually converted into a mass of fibrous 
tissue filled with abscesses. The abscesses may perforate into 
the bladder, urethra, vesiculee seminales, rectum, or peritoneum. 
Or the inflammation may extend to the connective tissue of the 
scrotum, or beneath the pelvic peritoneum. The pus may be- 
come thickened and cheesy, or even calcified. 
INFLAMMATION. 
NEW GROWTHS. 
Myoma has been already described under the head of partial 
hypertrophies of the prostate. 
Tubercle is found in connection with tubercles in the testicles, 
vesiculee seminales, and kidneys. Miliary granulations become 
aggregated in large numbers, and form, after degenerating, 
large cheesy masses. 
Concretions are formed in the ducts of the glands. The 
smallest are rounded, colloid, lamellated bodies, which are 
stained red by iodine. The larger are hard, yellow or blackish, 
rounded or faceted, and contain phosphate or oxalate of lime. 
Carcinoma of the prostate is not frequent. It is usually 
primary. It is soft and medullary, and may involve the sur- 
rounding soft parts. 
THE MAMMA. 
The mammae are racemose glands, imbedded in connective 
tissue and fat. During childhood, they remain small and unde- 
veloped. At puberty, the glands become larger and the acini 
are increased in size and number. The acini are filled with 
small, rounded, epithelial cells; the ducts are lined with cylin- 
drical epithelium. During pregnancy, there is a further in- 
crease in the size and number of the acini, and at full term, the 
epithelium becomes filled with fat globules. The milk is THE MAMMA. 
271 
formed by an emulsion of these fat globules in serum. In old 
age, after the menses have ceased, the epithelium atrophies, the 
acini collapse, and finally we find nothing but a mass of fibrous 
tissue and fat, in which are imbedded the ducts of the gland. 
In the male, the mammary gland remains undeveloped 
through life. It consists of a few ducts and acini imbedded in 
connective tissue. 
MALFORMATIONS. 
Absence of both mammae is only found in connection with 
other marked malformations. 
Absence of one mamma has been observed in a few cases, 
with and without defective development of the corresponding 
half of the thorax. 
Absence of one or of both nipples is more common. 
Arrest of development of the mammae is found in connec- 
tion with arrest of development of the organs of generation, 
and, to a less degree, alone. 
Supernumerary mammae and nipples have been observed in 
a number of cases. The glands may all secrete milk during 
lactation. 
Too early development of the mammae is sometimes found 
in young children in connection with abnormal development of 
the organs of generation. 
INFLAMMATION. 
The nipple, during lactation, is often the seat of cracks or 
fissures of the skin, sometimes complicated with inflammation. 
Syphilitic ulcers may occur on the nipple in the form of 
primary chancres and secondary mucous patches. 
Chronic eczema is found affecting the skin of the nipple. 
Erysipelatous inflammation of the skin over the mamma 
may have its origin in the fissures of the nipples, or in un- 
known causes. 
Acute inflammation of the mamma occurs during lactation. 
The connective tissue beneath the gland, between the gland 272 
POST-MORTEM EXAMINATIONS. 
and the skin, and surrounding the gland, may be the seat of the 
inflammation. If the connective tissue-stroma of the gland is 
the seat of inflammation, usually only circumscribed nodules 
are affected. The inflammation may resolve, or goes on to 
suppuration. The abscesses usually open through the skin and 
soon cicatrize. Sometimes, however, the abscesses become 
chronic, with induration and formation of granulation tissue 
about them. Rarely, they perforate into the pleural cavity. 
In new-born children, we sometimes find a painful swelling and 
redness of one or both breasts, with a secretion of thin milk. 
This inflammation usually subsides in a few days, but may go 
on to suppuration. 
At the time of puberty, a subacute form of mastitis may 
occur in both sexes. The gland is somewhat swollen, hard, and 
painful; rarely, there is a small secretion of milk.. 
In women, after puberty, subacute mastitis sometimes occurs 
unconnected with lactation. There are circumscribed, indu- 
rated nodules in the gland, which may resolve without marked 
symptoms, or may slowly suppurate. 
Chronic inflammation and the formation of cold abscesses 
are rare. They occur in married and unmarried women after 
puberty. We find circumscribed, hard nodules in the breast, 
which may remain unchanged for years. Or they may break 
down slowly into abscesses, containing a thin pus with cheesy 
fragments. Several such abscesses may communicate by sinu- 
ses. They may become surrounded by a thick wall of fibrous 
tissue. 
HAEMORRHAGE. 
In young women, who suffer from amenorrhoea and dysme- 
norrhoea, small haemorrhages sometimes occur on and in the 
mamma, at the time of the menses. 
Contusions of the breast may produce extravasations of blood 
in the connective tissue. The blood may be afterward ab- 
sorbed, or may remain as a hard mass surrounded by dense 
connective tissue. THE MAMMA. 
273 
NEW GROWTHS. 
General Hypertrophy of the mamma is a rare lesion. It 
may affect one or both breasts. It usually is found in young, 
unmarried women ; sometimes, however, in advanced life. The 
glandular acini are increased in number and size. The inter- 
stitial connective tissue is also much increased. 
Cysts are formed by dilatation of the ducts and acini of the 
mammary gland; as new growths in the connective tissue ; and 
as an accompaniment of some forms of new growth. 
Cysts containing milk are formed, during lactation, by the 
dilatation of the glandular acini and ducts. In the latter case, 
they may reach an enormous size, and contain several pounds of 
fluid. The milk may become mixed with serum, mucus, blood, 
colloid matter, and coagulated fat. 
The acini may be dilated so as to form a great number of 
little cysts, containing serum or mucus. Minute examination 
shows the change beginning in the terminal acini as a simple 
dilatation. The epithelium is at first preserved. This condi- 
tion is found in young women, with a too rapid development 
of the gland; in old women, with its atrophy. 
Dilatation of the glandular ducts produces cysts of larger size. 
These cysts may be simple, or incompletely divided by septa, or 
there may be papillary ingrowths from their walls. 
Cysts are formed in the stroma of the gland, independently 
of the glandular tissue. Their walls are lined with pavement 
epithelium, their contents are serous or colloid fluid. Their 
size varies from that of a pea to that of a man's fist. They are 
found in small and large numbers. There may be haemorrhages 
into their cavities, inflammation and calcification of their walls, 
and papillary ingrowths. 
Fibroma Diffusum.-This process may be classed as a new 
growth or as a chronic inflammation. There is an increase of 
the fibrous stroma throughout the gland, the glandular tissue 
remaining intact. Afterward, the new connective tissue 
shrinks and becomes harder, the glandular tissue is atrophied, 
and there may be cystic dilatation of the acini and ducts. The 
entire process is often accompanied by a great deal of pain, 274 
POST-MORTEM EXAMINATIONS. 
and the atrophied condition is difficult to distinguish from atro- 
phied carcinoma. Sometimes the growth of connective tissue, 
instead of being general, is confined to one or more circum- 
scribed portions of the gland. We then find one or more hard 
nodules, which may become atrophied and indurated in the 
same way as the diffuse growth. 
Fibroma Nodosum.-Small, circumscribed, fibrous tumors in 
the stroma of the gland are described, but appear to be rare. 
Fibroma Papillare occurs in the form of intra-canalicular 
growths. Little papillary fibrous growths are formed on the 
walls of the milk-ducts. As the growths increase, the ducts 
become dilated, and we find a solid tumor divided up by clefts 
and fissures in every direction. The clefts are lined with pave- 
ment of cylindrical epithelium. 
Lipoma usually occurs as a diffused increase of fat about the 
gland. In this way the mamma may appear to be enormously 
hypertrophied. More rarely, we find smaller, circumscribed 
lipomata in the stroma of the gland. Billroth describes a large 
lipoma, which grew behind the pectoralis muscle, and pushed 
the mamma downward and forward. 
Enchondroma of the mamma is very rare. A single case is 
described by Astley Cooper, and another by J. Muller. A few 
other cases are described of enchondroma combined with carci- 
noma. 
Adenoma.-A new growth of glandular tissue, resembling 
that of the mammary gland, sometimes occurs. Rarely, the 
glandular tissue forms the principal part of the new growth, 
which is then soft and succulent. More frequently, there is 
at the same time a growth of connective tissue. The tumor is 
then firm, but succulent, circumscribed, and movable, (Paget's 
Mammary Glandular Tumor.) The connective tissue between 
the new glandular follicles may be rich in cells, and pass gra- 
dually into the structure of a sarcoma. For this reason, Vir- 
chow regards the entire growth rather as a sarcoma with per- 
sistence of the normal glandular tissue, than as a new growth 
of glandular tissue. It sometimes happens that in a breast, 
which has been for some time the seat of a hard adenoma, a 
carcinoma is afterward developed as a separate tumor. THE MAMMA. 
275 
Cystoid Adenoma • CystoSarcoma ; Adenoid Sarcoma.- 
These names are given to a group of tumors of the breast 
which have a very complex structure. They usually occur in 
middle-aged women; grow at first slowly, afterward rapidly, 
and may reach an immense size. In some cases, there is no re- 
currence after extirpation; in others, there are local recur- 
rences, and even metastatic tumors. When these tumors are 
cut open, they look like a solid mass separated by clefts and 
fissures, and in which are cysts. The solid tissue appears as a 
uniform mass, or as a loose tissue, or as if made up of tufts. It 
is white and hard, or pinkish and soft, or grayish and colloid. 
The general arrangement is that of dilated ducts filled with 
intra-canalicular growths. The intra-canalicular growths are 
tufts composed of connective tissue fibres and cells, containing 
blood-vessels, and covered with epithelium. Or they may con- 
tain glandular follicles. The extra-canalicular part of the 
growth consists of connective tissue-fibres, and cells, and of 
glandular follicles. The follicles are in variable numbers; they 
resemble those of the normal gland, or are larger, and lined 
with cylindrical epithelium. They are regarded as part of the 
normal gland, or as a new growth, by different authors. The' 
connective tissue may be nearly pure fibrous tissue, or may con- 
tain so many cells as to merit the name of a sarcoma, or may 
be partly mucous tissue. In different tumors, therefore, or in< 
different parts of the same tumor, we find a preponderance oi 
fibrous, cellular, mucous, or glandular tissue. The prognosis 
seems to depend upon the relative amount of the connective 
tissue-cells, and the consequent more or less sarcomatous nature 
of the growth. 
Myxoma occurs in the form of polypoid, pendulous tumors, 
covered with skin, and hanging down from the breast. It is 
also found as a more diffused growth in the stroma of the breast. 
The glandular tissue may atrophy and disappear in the new 
growth or the milk-ducts may be dilated, or there may be 
intra-canalicular growths of mucous tissue. In the latter case 
the tumors may resemble the adenoid sarcomata. 
Sarcoma occurs in the mamma in the form of circumscribed 
nodules, or oi larger growths replacing the entire breast. The' 276 
POST-MORTEM EXAMINATIONS. 
tumors may be composed of round, stellate, or fusiform cells, oT 
of pigmented cells. The basement substance may be fibrous 
and abundant, or scanty, or may be mucous tissue. The glan- 
dular tissue may disappear, or the milk-ducts may be dilated, 
or there may be intra-canalicular sarcomatous growths. These 
tumors are more frequent in young than in old women. 
We find, therefore, that there are fibrous, mucous, and sarco- 
matous tumors, in which the milk-ducts are dilated, and there 
are intra-canalicular growths. The gross appearance of these 
tumors may be the same, although their structure and charac- 
ters are different. 
Carcinoma.-Epithelial cancer, of the flat-celled form, is of 
rare occurrence in the mamma. It begins in the skin covering 
the gland, or in the nipple. Billroth describes a single case in 
which the glandular acini were enlarged and filled with hyper- 
trophied epithelial cells. 
Forster says that epithelial cancer with cylindrical cells is of 
not infrequent occurrence, and has the same course as ordinary 
cancer. 
True Carcinoma usually occurs as scirrhus, medullary, or 
atrophic carcinoma, sometimes in the alveolar or colloid form. 
It is, generally speaking, a disease of advanced life. The tu- 
mor begins as a small, hard nodule, which increases slowly or 
quickly, and becomes fused with secondary nodules. If it 
grows rapidly, it may attain a considerable size, the skin is in- 
volved, and ulceration takes place. If the growth is slower, 
the tumor is smaller and harder, and ulceration may not take 
place for a long time. In some cases, the growth is very slow, 
there is great retraction of the new fibrous tissue, and the en- 
tire mamma is converted into a small, hard mass, which hardly 
looks like a tumor. s 
The tumors are made up of a connective tissue stroma and of 
epithelial cells. The stroma, is composed of connective tissue- 
fibres and cells in varying proportion. It is usually well mark- 
ed, sometimes forms almost the entire tumor, occasionally is 
very scanty. The epithelial cells are of moderate size and re- 
gular shapes, or large and malformed. They contain one or 
more nuclei. These cells are arranged in long, tubular follicles, THE MAMMA. 
277 
or in irregular spaces; or are found in large numbers, appa- 
rently from the fusion of several follicles. Whether the new 
growth of cells begins in the normal glandular follicles, in the 
connective tissue, or in the lymphatic vessels, is still an open 
question. 
If the cells are numerous and the stroma scanty, the growth 
is called a medullary cancer; if the cells are few and the stroma 
abundant, a scirrhus cancer; if there are hardly any cells and 
a dense, hard, retracted stroma, an atrophic cancer. 
All these forms are accompanied by secondary and metasta- 
tic growths. The axillary glands, the skin of the thorax, the 
liver, the bones, and nearly all the viscera may be the seats of 
metastatic tumors. 
Alveolar or colloid carcinoma is rare. It occurs in the form 
of a circumscribed nodule, with the usual structure. 
PARASITES. 
Echinococci contained in hydatid cysts have been seen in a 
few cases in the mamma. 
THE MALE MAMMA. 
There may be an abnormal number of mammse. 
In young children, the mammae may be swollen and inflamed 
as in young girls. 
Cases are recorded in which adult males possessed large 
mammae, which secreted milk. 
Hypertrophy of the breasts from an increase of connective 
tissue, or of fat, sometimes occurs. 
Cysts from the dilatation of the glandular ducts are not very 
infrequent. 
Cysto-Sarcoma, Sarcoma, and Carcinoma have been observed 
in a few cases. THE BOXES. 
MALFORMATIONS. 
(1.) Defective Formation exhibits itself in the absence and 
imperfect development of the bones, as in acephalous mon- 
sters, in microcephalia, in absence or smallness of the extremi- 
ties. 
(2.) Excessive Formation is seen in the abnormal size or ab- 
normal number of the bones. 
(3.) The formation of Fissures is seen in cleft palate, hemi- 
crania, spina bifida, etc. 
(4.) The fusion of bones is seen in the extremities and cra- 
nium. 
(5.) The ossification of the epiphyses may take place abnor- 
mally early or abnormally late. 
CHANGES IN SIZE. 
(1.) Hypertrophy.-The bones are enlarged in all their dimen- 
sions, and retain their normal texture. This condition may ob- 
tain in all the bones, as with giants ; may be a congenital ab- 
normality of a single bone, especially of the fingers and toes ; 
may be an acquired condition, as in the bones of a hydrocephalic 
skull after the hydrocephalic process is at a stand-still. The 
bone may be increased in all its dimensions or simply elongated. 
Chronic inflammation of the bone or adjoining soft parts ; re- 
lease of a bone from physiological pressure, as in luxations; 
the effort to compensate for the destruction of an adjoining 
bone, may all produce hypertrophy. 
(2.) Hyperostosis.-The bones retain their normal length or 
breadth, but are increased in thickness. The change may in- 
volve an entire bone, or only a circumscribed portion of it. In 
the latter case, the growth has more the character of a tumor. THE BONES. 
279 
The periosteum is thickened, the surface of the bone is rough, 
irregular, often covered with osteophytes of various forms. 
The walls of the bone are increased in thickness, and often in 
density; the medullary remains normal, or is narrowed, or even 
obliterated. 
This change is most frequently found in the long bones and 
in the cranial bones. It is produced by chronic periostitis, by 
osteitis, rickets, and sometimes appears to be an idiopathic 
process. 
(3.) Sclerosis consists in a change in the texture of the bone 
tissue by which it becomes denser and heavier. The process by 
which this is caused is an osteo-myelitis with the production of 
osteoid connective tissue, in which the salts of lime are after- 
ward deposited. Most frequently there is at the same time a 
periostitis with production of new bone on the surface. Thus 
in the cranium the diploe may become filled with compact bone, 
while there is also an increase of bone beneath the periosteum, 
and in this way all the cranial bones may become enormously 
thickened. 
The sclerosis may be idiopathic, or be caused by chronic in- 
flammation of the joints or other parts near the affected bone, 
or be the termination of a rarefying osteitis. 
(4.) Osteoporosis.-This change consists in an increase of the 
size of a bone with diminution of its density. The compact 
tissue of the walls of the bone is converted into a spongy, can- 
cellous structure filled with red medulla. The bone may seem 
to consist of a system of concentric lamellae, the medullary 
canal may be filled up with cancellous bone, or remain open ; 
the change may affect most of a bone or only a circumscribed 
portion of it. 
This condition is produced by inflammatory changes. 
ATROPHY. 
1. The atrophy may be due to defective development of the 
bones, and, therefore, occurs in young subjects. 
(a.) It may be congenital, and affect all the bones, as in 
dwarfs, cretins, etc. 280 
POST-MORTEM EXAMINATIONS. 
(b.) It may be the result of rickets, and then takes the form 
of a shortening of the long bones. 
(c.) It is produced by an abnormally early ossification of the 
epiphyses and the interosseous cartilages. Thus diseases of the 
joints (in children) producing anchylosis and ossification of the 
epiphyses ; ossification of the sacro-iliac inter-articular cartilage; 
ossification of the cranial sutures, etc.-all produce an arrest of 
development in the bones affected. 
(d.) It may be produced by any cause which diminishes the 
nutrition of the bone, as paralysis of the muscles, or joint dis- 
eases, which render the limb useless. 
2. The atrophy affects bones which are already fully deve- 
loped, and occurs in adults. 
We may distinguish two forms of atrophy : an eccentric and 
a concentric. 
In the eccentric form, the bone retains its size and normal 
contour; but the medullary cavity is enlarged, and the walls of 
the bone become thinner and thinner, until they may be not 
thicker than a sheet of paper. In the concentric form, the 
bones become smaller from the outside; but in the long bones, 
only the thickness and not the length is diminished. In the ec- 
centric form, the space which is left by the atrophying bone is 
usually filled up with fat. 
Want of use and old age are the usual causes of atrophy of 
the bones. 
A circumscribed atrophy of the bone is produced by any con- 
tinuous pressure, usually by tumors. In this way, the wall of 
a bone may be perforated into its medullary cavity, and even 
through the opposite wall. The atrophy may be accompanied 
by sclerosis of the bone around the perforation. 
FRACTUBES, DISLOCATIONS, AND WOUNDS. 
These conditions are so fully described in works on surgery 
and surgical pathology that it is needless to describe them 
here. THE BONES. 
281 
Periostitis.-We may distinguish five varieties of inflamma- 
tion of the periosteum. 
(1.) Simple Periostitis.-In this form, we find the periosteum 
thickened, succulent, congested, infiltrated with lymphoid cells, 
its fibres swollen. It is less adherent to the bone, and more ad- 
herent to the surrounding soft parts. The increase of cells 
takes place principally in the inner layers of the periosteum. 
This variety of inflammation may terminate in degeneration of 
the new elements, and the periosteum returns to its normal con- 
dition, or it may be only the first stage of one of the other 
varieties. 
(2.) Suppurative Periostitis may begin as a simple or as a 
purulent inflammation. The pus is formed in the inner layers 
of the periosteum, and between it and the bone. The outer 
layers of the periosteum may resist for a long time the suppu- 
rative process. The accumulation of pus dissects up the mem- 
brane from the bone, and leaves the latter bare. The pus thus 
formed may remain in this position for a long time, may be ab- 
sorbed, may become dry and cheesy, or may burst through the 
periosteum, and form abscesses in the soft parts. The bone is 
separated from its nutrient membrane. It may remain un- 
changed, but more frequently necroses, or inflammation of the 
bone itself, may be set up. Such a periostitis may run an acute 
or a chronic course. Sometimes suppurative periostitis takes on 
a very malignant character. Pus is formed not only beneath 
the periosteum, but in it, forming abscesses filled with foul pus. 
The periosteum breaks down into a gangrenous, stinking mass, 
and the same change may affect the neighboring soft parts. 
The medulla may take part in the process, and break down 
into a purulent, gangrenous mass. Haemorrhages may complicate 
the process. The lymphatic glands are enlarged and swollen; 
abscesses form in different parts of the body, and the patient 
dies with the symptoms of septicaemia. 
(3.) Fibrous Periostitis is a very slow, chronic inflammation, 
producing thickening of the periosteum. It is produced by ne- 
crosis, chronic arthritis, chronic ulcers of the leg, etc. 
INFLAMMATION. 282 
POST-MORTEM EXAMINATIONS. 
(4.) Ossifying Periostitis results in the formation of new bone 
from the inner layers of the periosteum. The bone thus formed 
is, at first, of very variable shape. The osteophytes, as they are 
called, form a thin, velvet-like, villous layer; or they are little 
spiculse; or they form larger, rounded masses; or they are a 
thick, uniform layer, extending over a large part of a bone. 
They are at first very loosely connected with the bone. The 
new bone has at first a loose, spongy character. It is formed of 
thin plates of bone inclosing large cavities filled with medulla. 
Layers of compact bone tissue are formed from the medulla on 
the sides of the original plates, and thus the medullary cavities 
are gradually filled up with bone. The new bone may thus 
become as compact, or even denser, than normal bone. The 
hyperostoses and exostoses thus formed may remain indefinite- 
ly, or they may gradually become smaller and disappear. 
(5.) Syphilitic Periostitis.-The syphilitic diathesis may give 
rise to simple, purulent, fibrous, and ossifying periostitis. In 
addition, we frequently find developed in the periosteum gum- 
my tumors. These are rounded masses, sometimes gelatinous, 
sometimes firmer, composed of round and fusiform cells. They 
may disappear, may undergo cheesy degeneration, may be con- 
verted into fibrous tissue, or may suppurate. The bone beneath 
them may be unaltered or become diseased. 
OSTEOMYELITIS. 
In most of the inflammatory processes which affect the bones, 
the medulla has an important share; so that many conditions 
described as osteitis are really osteomyelitis. It is customary, 
however, to reserve the latter name for those cases in which a 
large part of the medulla is inflamed, and the bone tissue is little 
or not at all involved. 
Using the word in this sense, we may distinguish an idio- 
pathic and a traumatic osteomyelitis. 
(1.) Idiopathic osteomyelitis generally occurs in persons un- 
der twenty years of age. It usually affects one of the long 
bones, more rarely several bones at once. 
The disease begins with a diffuse hypersemia and serous infil- THE BONES. 
283 
tration of a considerable portion of the medulla of one of the 
long bones. The inflammation begins in the shaft, and soon 
extends to the cancellous tissue of one or both of the epiphyses. 
The hypersemia is succeeded by a purulent infiltration, which 
does not usually, however, soften or form abscesses. The peri- 
osteum generally becomes inflamed, and abscesses are formed 
beneath it, in it, and in the surrounding soft parts. This, com- 
bined with the osteomyelitis, often produces necrosis of small or 
large portions of the bone, or even of an entire bone. In other 
cases, the periosteum is thickened, and the shaft of the bone is 
thickened and sclerosed. 
The purulent infiltration of the medulla, after a time, dilates 
the medullary cavity, and may finally break through the wall 
of the bone. 
The joints in which the diseased bone terminates are almost 
always secondarily inflamed. There may be only a serous or a 
purulent exudation ; or the osteomyelitis may extend to the ar- 
ticular end of the bone and the cartilage, and produce severe 
and destructive inflammation. 
In young persons, the epiphyses very frequently become 
separated from the shaft by the destruction of the cartilage 
which binds them together. 
In bad cases, the medulla becomes broken down and gan- 
grenous ; the joints are soon involved ; large portions of the bone 
necrose; the periosteum and surrounding soft parts become gan- 
grenous ; the veins become filled with thrombi; and pysemic in- 
farctions are formed in different parts of the body. 
(2.) Traumatic osteomyelitis is produced by contusions, frac- 
tures, wounds, and crushing of bones, and by amputations. Its 
character is the same as that of the spontaneous variety. 
Osteitis.-The periosteum, the medulla, and the blood-ves- 
sels are essential component parts of a bone. They are the 
parts actively engaged in all inflammations of bone, while the 
bone-tissue proper, composed of cells imbedded in a calcareous 
basement substance, has but a passive share in the process. It 
is, therefore, more a matter of convenience than strictly proper 
to speak of periostitis, osteomyelitis, and osteitis, and the divi- 
sion is entirely arbitrary. Nevertheless, it is very convenient 284 
POST-MORTEM EXAMINATIONS. 
to separate these three varieties according as the periosteum, 
the medulla, and the hard bone are the parts principally 
involved. 
We may distinguish several different varieties of osteitis. 
(1.) Rarefying osteitis occurs both as an idiopathic disease 
and in connection with caries, necrosis, fractures, etc. 
In cancellous bone-tissue, the medulla becomes reddish, gela- 
tinous, or like granulation tissue, and is thickly infiltrated with 
lymphoid cells. The bony septa become thinner, and disappear 
to a greater or less extent, so that in extreme cases, instead of 
cancellous bones, we find only a mass of granulation-tissue. 
When the disease occurs in the articular extremity of a bone, 
the granulating medulla may send little off-shoots through the 
articular cartilage. The cartilage will then be perforated with 
numerous little holes, which may afterward become fused 
together, and destructive inflammation of the joint follow. 
The walls of the shafts of the long bones may by this form of 
inflammation be converted into a loose, spongy bone-tissue. If, 
at the same time, an ossifying periostitis goes on, the bone is 
thickened but spongy ; or sometimes there are concentric 
layers of compact bone separated by cancellous bone. In 
these cases, there is a production of granrdation-tissue in the 
medullary cavities and the Haversian canals; little projections 
of this granulation tissue pressing against the adjoining bone 
cause its absorption in small spaces or lacunae; these lacunae 
grow larger, fuse together, and the compact bone is thus filled 
with cavities, or entirely destroyed. Virchow supposed that 
the cavities were formed by fatty degeneration, cell-prolifera- 
tion, or enlargement of the bone-cells. These cells may indeed 
be found somewhat changed, but the active processes are 
carried on by the medulla and the tissue in the Haversian 
canals. Volkmann states that there may also be a formation 
of new blood-vessels in the osseous tissue. 
In the inflammation and granulation of the surfaces of 
wounded bone, the process is the same, and often leaves a cir- 
cumscribed depression on the surface. 
Rarefying osteitis may terminate in osteo-sclerosis, in sup- 
puration, and in caries. THE BONES. 
285 
(2.) Condensing osteitis, or osteo-sclerosis, is, properly speak- 
ing, an osteomyelitis. The medulla is replaced by red granu- 
lation-tissue, which becomes transformed into layers of com- 
pact bone on the inner surface of the preexisting bone. The 
cancellous bone may thus be changed into compact bone, and 
the medullary canals of long bones may be completely filled 
up. There is very frequently at the same time an ossifying 
periostitis. 
The process is sometimes idiopathic, more frequently excited 
by some chronic irritation of the neighboring bone, or soft 
parts, or is the termination of rarefying osteitis. 
(3.) Carious osteitis is a variety which has been frequently 
called tuberculosis of the bones. It occurs principally in the 
cancellous ends of the bones, and in the bodies of the vertebrae. 
There is a chronic osteitis with sclerosis, or rarefaction, fol- 
lowed by cheesy degeneration of the inflamed medulla, or of 
pus, if any be formed. We then find dry, yellow, cheesy 
masses in the diploe. The process may terminate in necrosis, 
or in caries. 
(4.) Syphilitic osteitis.-The syphilitic poison may excite one 
of the varieties of osteitis already mentioned, or it may produce 
the so-called gummy growths. 
An osteitis gummosa begins as a periostitis, most frequently of 
the cranial bones. The periosteum is thickened and infiltrated 
with cells; the vessels which extend from the periosteum into the 
bone are surrounded with a new growth of small cells. At this 
stage, if we strip off the periosteum, we drag with it the vessels 
surrounded by the new cell-growth, leaving the bone beneath 
with numerous small perforations extending inward. As the 
disease goes on, the cell-growth around the vessels, and the con- 
sequent holes in the bone, become larger and larger, and fuse 
together, until a circumscribed portion of bone is replaced with 
cellular tissue. ' Then cheesy degeneration sets in, with absorp- 
tion and production of connective tissue. In this way, we find 
in the bones dry, eroded depressions or perforations, containing 
more or less cheesy matter, while the skin over them is un- 
changed. In other cases, suppurative inflammation accompa- 
nies the gummy formation, and involves the skin. The pro- 286 
POST-MORTEM EXAMINATIONS. 
cess may only involve a few small spots, or may spread over a 
large part of a bone. The portions of bone surrounded by the 
diseased portions may then necrose. 
(5.) Suppurative osteitis, abscess of bone.-This process 
occurs usually in the ends of the long bones. It begins with a 
rarefying osteitis. The medulla goes on to actual suppuration, 
the bone-tissue is destroyed, and a circumscribed cavity is 
formed in the bone, filled with pus, and lined with granulation- 
tissue. 
Less frequently, abscesses are formed in the shaft of a long 
bone, by a circumscribed suppuration of the medulla. 
These abscesses usually occur in old people. They last for 
many years, have little tendency to perforation, may gradually 
enlarge, and be accompanied by an ossifying periostitis, so that 
the bone is expanded. 
Very rarely acute suppurative osteitis, with rapid formation 
of an abscess, and perforation, has been observed. 
CARIES. 
The word caries is used by many as synonymous with chronic 
osteitis. It is convenient, however, to limit the term to one 
variety of osteitis-the ulcerative. In this sense, caries of bone 
corresponds to ulceration of the soft parts. 
One of the simplest forms of caries is produced by chronic, 
suppurative arthritis. The articular cartilages are destroyed, 
the bone beneath undergoes molecular destruction, so that the 
cancellous diploe are laid open. The medulla then takes on an 
ulcerative inflammation. 
In other cases, we find a rarefying osteitis, with a destruc- 
tive, ulcerative character. At some portion of the inflamed 
bone, either on its surface or in its cancellous tissue, the inflam- 
ed medulla suppurates, and is destroyed with the corresponding 
portions of bone. 
Sometimes this process is combined with cheesy degeneration 
of the products of inflammation, so that dry, yellow masses are 
found in the diploe, and replacing the destroyed bone. 
The minute changes are very similar to those in chronic os- THE BONES. 
287 
teitis. The bone is destroyed both by the pressure of the gran- 
ulating medulla and by a molecular destruction, forming irre- 
gular cavities, in which a sort of chalky dust can often be 
found. The basement substance of the bone may become gran- 
ular, or separate into flakes, or give up its calcareous salts, and 
become fibro-cartilaginous. The bone-cells may be enlarged, 
fatty, or contain an increased number of nuclei. 
NECROSIS. 
By necrosis we understand the death of a larger or smaller 
portion of bone. This condition is induced by causes which 
deprive the bone of its proper vascular supply from the perios- 
teum and medulla. Suppurative periostitis, osteomyelitis, and 
osteitis, traumatic separation of the periosteum, ulcers of neigh- 
boring soft parts, emboli, and diseases like typhus, which di- 
minish the vitality, may cause necrosis. 
When a portion of bone has died, an inflammation is set up 
at the dividing line between the dead and living bone. This 
inflammation has the characters of a rarefying osteitis, and 
finally separates the dead from the living bone. The dead 
bone, or sequestrum, may remain smooth and unaltered, or it 
may be eroded by the pressure of surrounding granulations. 
Necrosis may involve the superficial layers, or the entire 
thickness of the wall of a long bone; or only the spongy tissue 
and inner layers of the wall; or an entire bone; or a number 
of different portions of the same bone. 
The death and separation of the bone is very soon followed 
by the growth of new bone to repair the loss. The periosteum, 
the medulla, and the surrounding soft tissues may all take part 
in this new growth. The new bone is usually irregular, rough, 
perforated with openings, and incloses and takes the place of 
;the sequestrum more or less completely. 
RICKETS. 
Rickets is a disease of the bones affecting their growth, 
which prevents the proper ossification of the growing bone. 
The disease usually occurs during the first two years of life, 288 
POST-MORTEM EXAMINATIONS. 
but may be congenital, or may occur as late as the twelfth 
year. 
The physiological growth of bones depends upon three con- 
ditions. They grow in length by the production of bone be- 
tween the epiphysis and diaphysis ; in thickness, by the growth 
of bone from the inner layers of the periosteum. At the same 
time, the medullary canal is enlarged in proportion to the 
growth of the bone by the disappearance of the inner layers 
of bone. 
In rickets, these three conditions are abnormally affected. 
The cell-growth, which precedes ossification, goes on with in- 
creased rapidity and exuberance both between the epiphyses 
and diaphyses, and beneath the periosteum, while the actual 
ossification is imperfect or entirely wanting. At the same time, 
the dilatation of the medullary cavity goes on irregularly, and 
to an excessive degree. 
The increased cell-growth between the epiphyses and dia- 
physes produces the peculiar knobby swellings at the ends of 
the bones which are characteristic of rickets. At the same 
time, the medullary cavity increases rapidly in size, the inner 
layers of the wall of the bone become spongy, the medulla 
may be congested, its fat disappears, fusiform cells and connec- 
tive tissue are developed along the course of the muscles, and 
the process may take on the character of an osteitis. 
The result of these processes is, that the bones lose their solid- 
ity, and can no longer resist the traction of the muscles or out- 
side pressure. The epiphyses may be displaced or bent, espe- 
cially in the ribs, less frequently in the long bones. The long 
bones and the pelvic bones may be bent in a variety of forms. 
Incomplete fractures are not infrequent; complete fractures do 
not usually occur until the later stages of the disease, when the 
bones become solid again. In the head, the cranium is unna- 
turally large for the size of the face. The fontanelles and su- 
tures remain open, the bones are soft, porous, hyp er comic, and, 
at their edges, there are rough bony growths beneath the peri- 
cranium. Sometimes, especially in the occipital bone, there 
are rounded defects in the bone, filled only with a fibrous mem- 
brane. THE BONES. 
289 
After a time, the rachitic process may stop, and the bones 
take on a more normal character. The porous bone tissue 
becomes compact and even unnaturally dense, the swellings at 
the epiphyses disappear, many of the deformed bones may be- 
come of a normal shape. In severe cases, however, the defor- 
mities continue through life; especially is there a cessation of 
the growth of the bones in their long axis, so that the persons 
affected are dwarfed. 
The disease may have an acute or a chronic character. 
The acute form begins usually during the first six months 
of life. The children suffer from vomiting, diarrhoea, profuse 
sweating, chronic bronchitis and pneumonia, general anaemia, 
and wasting. They either die, or the rachitic process is gradu- 
ally developed. 
The chronic form is seen in older children, and often in those 
apparently healthy. The changes in the bones may take place 
without any constitutional symptoms, though there is often 
catarrhal bronchitis, pneumonia, and anaemia. 
OSTEOMALACIA. 
This disease consists in a softening of the adult bones. It 
occurs in adults, most frequently in females during pregnancy 
and after parturition; rarely in adult males and females without 
known cause. In puerperal women, the disease begins in the 
pelvic bones; in other cases, in the vertebrae and walls of the 
thorax. In all cases, it has a tendency to involve a large part 
of the entire skeleton. 
The disease begins with a simple disappearance of the cal- 
careous matter around the Haversian canals and medullary 
cavities, leaving the bone-cartilage and bone-cells intact. Af- 
terward this osteoid tissue breaks down, and is replaced by the 
exuberant medulla. 
When the disease is fully developed, we find the medulla 
intensely congested, the fat-cells disappear, the lymphoid cells 
are increased enormously in number. The congestion may 
then diminish, and the medulla looks like a pale jelly. The 
compact bone becomes soft and spongy, the walls of the diploe 
become thinner and thinner until, in the worst cases, there is 290 
POST-MORTEM EXAMINATIONS. 
nothing left but a layer of periosteum and thin cartilage, filled 
with a soft mass of medulla, connective tissue, blood-vessels, 
and serum. 
In consequence of these changes, the bones become bent, 
completely and incompletely fractured, contracted and atro- 
phied. 
NEW GROWTHS. 
Osteoma.-The bony tumors which grow from the bones are 
called exostoses or enostoses, according to their origin from the 
surface or interior of the bone. 
They may contain all the constituents of a normal bone: 
bone, medulla, vessels, periosteum, and cartilage. The new 
bone may be compact and like ivory, or spongy, or contain 
large cavities filled with medulla. The shape of the exostoses 
varies very much. They may be in the form of sharp, narrow 
spiculm and processes ; they may have a polypoid shape, with a 
narrow pedicle; they may form rounded tumors, with a broad 
base; or they may have more the character of an hyperostosis. 
The bone beneath them may be normal, or sclerosed, or rare- 
fied, or the medullary cavity of the bone may communicate with 
that of the exostosis. 
Exostoses are usually developed from the periosteum, some- 
times in the insertions of the tendons and muscles. 
A peculiar form is that called exostosis cartilaginea. It con- 
sists of a bony tumor covered with a thin layer of cartilage. 
Sometimes these growths are covered with a synovial sac, which 
may communicate with the cavity of a joint. They have a 
tendency to enlarge, and grow, like the long bones, from the 
inner layer of the cartilage which covers them. 
Enostoses are developed in the interior of bone from the 
medulla. They may increase in size until they project like an 
exostosis. Their most frequent situation is the bones of the 
cranium and face. 
Exostoses may be single or multiple, and may occur at all 
ages, even during intra-uterine life. 
Enchondroma.-Tumors composed of cartilage usually grow 
from the interior of the bones. THE BONES. 
291 
They are composed of cartilage with a hyaline, mucous, or 
fibrous basement substance, or with all these varieties combined 
in the same tumor. They are usually divided into lobules by 
bands of fibrous tissue, and this fibrous tissue may form a large 
part of the tumor. They may calcify, ossify, and exhibit a 
great variety of transitions and combinations, with osteoma, 
myxoma, lipoma, sarcoma, and carcinoma. 
They occur most frequently in the small bones of the hand 
and foot, in diminishing frequency in the tibia, femur, and 
humerus, lower jaw, pelvic bones, scapula, ribs, upper jaw, 
and fibula. 
They are most common in young persons, and may be con- 
genital. They may be single or multiple. 
Their prognosis depends upon their exact anatomy. If they 
are purely cartilaginous, metastases are rare, but local recur- 
rences sometimes happen. If they are combined with myxoma, 
sarcoma, or carcinoma, the prognosis becomes worse, and may 
be very bad indeed. 
Under the name of ecchondroma, Virchow describes a form 
of cartilaginous tumor which grows from permanent cartilage. 
The tumors are usually small, and of little clinical importance. 
They grow from the cartilages of the ribs, the pelvic synchon- 
droses, the intervertebral cartilages, the cartilages of the larynx 
and trachea, and the spheno-occipital synchondrosis. 
Fibroma.-Fibrous tumors may grow either from the peri- 
osteum or the medulla. The ordinary seat of the periosteae 
fibromata is the bones of the head and face. They form polypoid 
tumors, projecting into the posterior nares, pharynx, mouth, 
and the antrum of Highmore. On the other bones they are not 
common. 
The central fibromata, growing from the medulla, are rare. 
They usually occur in the lower jaw, but have been seen in the 
ends of the long bones, the phalanges of the fingers, and the 
vertebrae. 
The fibromata may calcify, ossify, contain cysts, and be com- 
bined with sarcoma and angioma. 
Angioma-Aneurism of Bone.--A very large number of the 
tumors, which have been described under these names, are- 292 
POST-MORTEM EXAMINATIONS. 
really sarcomata, or other tumors which happened to be 
very vascular. Some authors, indeed, are disposed to deny 
altogether the existence of real vascular tumors in bones. 
There are, however, reliable cases of cavernous angiomata 
growing between the periosteum and bone, and intimately con- 
nected with the latter. Whether myelogenic angiomata occur 
is doubtful. 
There are several cases described of cavities tilled with blood 
in the interior of bones, which it is difficult to interpret. They 
have mostly been found in the head of the tibia. They are 
said to have consisted of single sacs composed of thickened 
periosteum lined with plates of bone, and filled with fluid and 
clotted blood. No large vessels communicated with the sacs, 
but their walls were covered with a rich vascular plexus, 
branches of which opened into the cavity of the sac. 
Cystoma.-The cysts which occur in bones are new growths, 
not retention cysts. They are not to be confounded with cystic 
degeneration of tumors of the bones. They are found, almost 
exclusively, in the maxillary bones. They are usually mono- 
locular, contain clear serum, or a mucous, or viscous, or brown 
fluid, sometimes containing cholesterine. The cyst-wall is a 
fibrous sac lined with epithelium. They begin in the interior 
of the bone, and, as they increase in size, expand it until they 
are only covered with a thin shell of bone. They may reach a 
large size, even as large as a child's head. 
Tubercles are of rare occurrence in bone. The products of 
inflammation not infrequently undergo cheesy degeneration 
and become crude, yellow masses, which are often called tuber- 
cular, but are not so. True tubercles occur in the medulla, es- 
pecially in the bodies of the vertebrae, and the ends of the 
long bones. They are at first small, miliary, grayish nodules, 
disseminated in large numbers. They afterward become cheesy, 
and are surrounded by a zone of suppurative osteo-myelitis. In 
this way caries and cavities in the bone are formed. 
Sarcoma.-This form of tumor is especially common in the 
bones. It grows from the inner layers of the periosteum, or 
from the medulla, so that we may distinguish a periosteal and a 
myelogenic sarcoma. Sometimes the tumor attacks the bone THE BONES. 
293 
itself so early that it is impossible to say whether the tumor 
began in the periosteum or in the medulla. There is also a 
variety which grows close to the outside of the periosteum, and 
becomes connected with it-parosteal sarcoma. 
The periosteal sarcomata usually belong to the varieties 
fibro, myxo, chondro, and osteo-sarcoma, more rarely to the 
medullary variety. They are very frequently combined with 
fibroma, chondroma, and osteoma. They commence from the 
inner layers of the periosteum, pushing this membrane out- 
ward. After a time the periosteum is attacked, and the tumor 
invades the surrounding soft parts. The bone beneath may re- 
main normal, or may be eroded and gradually disappear until 
the tumor is continuous with the medulla. Portions of the tu- 
mor may be calcified, or a growth of new bone may accompany 
its growth. The new bone usually takes the form of plates, or 
spiculse, radiating outward. The minute anatomy of these 
tumors is very variable. The simplest-the fibro-sarcomata- 
are composed of fusiform, round, stellate, and sometimes giant, 
cells, (myeloplaxes,) in variable proportions, packed closely in a 
fibrous stroma. In the medullary form, the stroma is diminished 
to a minimum, and the round cells are most numerous. In the 
chondro and myxo-sarcoma, the basement substance may be 
hyaline, or mucous, and the cells follow the type of cartilage 
and mucous tissue. In the osteo-sarcoma, there is a new growth 
of osteoid tissue, more or less calcified. In the chondro, myxo, 
and osteoid sarcomata, there are usually fusiform, round, stel- 
late, and giant cells, in addition to the cartilage and bone- 
cells. 
The myelogenic sarcomata commence in the medulla and 
grow rapidly. The bone surrounding them is destroyed, and 
they project as rounded tumors. Most frequently, new bone 
is formed beneath the periosteum, so that the tumor is inclosed 
in a thin, bony shell; sometimes there are also plates of bone in 
the tumor ; sometimes the periosteum is unaltered; sometimes 
it is perforated, and the tumor invades the surrounding soft 
parts. The tumors are usually very soft, vascular, and haemor- 
rhagic, or may contain cysts. They are sometimes mistaken for 
cysts filled with blood. They are composed principally of 294 
POST-MORTEM EXAMINATIONS, 
round cells, sometimes of fusiform cells, and frequently contain 
great numbers of myeloplaxes. 
The parosteal sarcomata resemble the periosteal. They ap- 
pear to grow from the outer layers of the periosteum or from 
the adjoining connective tissue. They may be as firmly con- 
nected with the bone as the periosteal form. The periosteum 
may remain intact between the tumor and the bone, or it may 
disappear and leave them in apposition. 
Osteoid Chondroma.-This form of tumor is found usually at 
the ends of the long bones. The tumors grow between the peri- 
osteum and the bone, forming sometimes enormous growths. 
They have a pyriform shape, are not lobulated, are of a smooth, 
hard consistence, with some calcified portions. Their minute 
structure is that of bone cartilage, osteoid tissue, a hard, homo- 
geneous basement substance, in which are imbedded round, 
fusiform, and stellate cells. Blood-vessels ramify through the 
tissue, and may be arranged as if in Haversian canals. There 
is only needed a deposit of the salts of lime to convert this 
tissue into bone, and this change may take place over a large 
portion of the tumor. 
Carcinoma.-The subject of true cancer of the bones is, in 
many respects, very obscure. Of the older tumors described 
under this name, a very large number are sarcomata. This is 
especially the case with primary tumors. Secondary and me- 
tastatic tumors can be more definitely made out. They follow 
the anatomy of tide primary tumors, and may be scirrhus, me- 
dullary, or epithelial. 
Epithelial cancer of the lips and uterus not infrequently di- 
rectly invades the adjoining bones. 
A peculiar form is the developmennt of metastatic nodules in 
the bones. The primary disease is usually an atrophic carci- 
noma of the mamma, and the nodules may be found in nearly 
every bone in the body. They grow in the medulla in the form 
of hard, white nodules. The bone near them may simply dis- 
appear so that fractures occur, or the bone may lose its salts of 
lime and become soft. In this way, marked curvatures of the 
long bones may take place. THE JOINTS. 
295 
PARASITES. 
Echinococci are sometimes found in bone. They have the 
usual form of a mother cyst with daughter cysts. They grow 
in the bone tissue, but the cysts may burst beneath the perios- 
teum or in the medulla. 
Cysticercus celluloses has been seen in a single case in the 
first phalanx of the middle finger. 
THE JOINTS. 
MALFORMATIONS. 
One or more of the joints may be absent, or may be in ex- 
cess, corresponding to the absence or excess of the bones form- 
ing them. Some of the ligaments may be absent. There may 
be congenital luxations, fractures, and synostoses. 
CHANGES IN POSITION. 
Luxations may be complete or incomplete. They may be 
intra-uterine, or produced by violence, or by relaxation of the 
ligaments, or by chronic inflammation of the joints. A full 
account of dislocations will be found in works on surgery. 
INFLAMMATION. 
Acute Synovitis.-The earlier stages of acute inflammation of 
the synovial membranes are better known from experiments 
on animals than from post-mortem examinations. The first 
changes are swelling and congestion of the membrane, with in- 
creased growth and desquamation of epithelium and infiltration 
of the membrane with lymphoid cells. These conditions are 
soon followed by an exudation. 
The exudation may be a clear serum, in which epithelial cells, 
lymphoid cells, and sometimes blood, will be found. Or floc- 
culi of fibrine may float in the serum, or the fibrine may be in 
excess and the serum nearly absent. Or there is an excessive 
production of lymphoid cells, and the synovial sac is filled with 
pus. 
Serous Synovitis may be caused by contusions, penetrating 296 
POST-MORTEM EXAMINATIONS. 
wounds, gonorrhoea, rheumatism, or be idiopathic. The disten- 
sion of the sac with serum'is the most prominent lesion. The 
disease terminates in recovery or becomes chronic. 
Croupous Synovitis leads to adhesions and anchylosis of the 
affected joint. 
Purulent Synovitis may terminate in recovery with a normal 
joint. Or the articular cartilages ulcerate and are destroyed? 
the exposed bone may become carious, the pus may break 
through the capsule of the joint and form large abscesses in the 
soft parts. 
Sometimes the inflammation is not only suppurative, but 
gangrenous, and runs a rapidly fatal course. The synovial 
membrane, articular cartilages and ends of the bones all under- 
go a rapid suppuration and gangrene. 
Pyaemia and septicaemia, small-pox, measles, scarlet fever, 
diphtheria, mumps, typhus fever, glanders, the puerperal con- 
dition, exposure to cold, penetrating wounds, and injuries may 
all give rise to purulent synovitis. 
Chronic Synovitis begins as such, or is the result of a previ- 
ous acute inflammation. 
There is an increase of fluid in the joint. This fluid is thin 
and serous, or is thickened with flocculi of fibrine and epithe- 
lial and lymphoid cells, or is thick, syrupy, or even gelatinous. 
The synovial membrane is at first congested, its tufts promi- 
nent. Later it becomes thickened, sclerosed, and ansemic, the 
epithelium is destroyed, and the tufts become large and pro- 
jecting. From the distension of the capsule there may be sub- 
luxations or luxations of the joint, or the capsule may be rup- 
tured. Recovery is rare. 
Chronic Rheumatic Arthritis is a chronic inflammation of the 
joints, most common in elderly persons. Usually several joints 
are affected and disease, advances slowly and steadily. There is 
a chronic thickening of the synovial membrane and the fibrous 
tissue adjacent to it. The articular cartilages degenerate and 
disappear. The contracting synovial membranes and fibrous 
tissue render the joints stiff and deformed. Not infrequently 
fibrous and bony anchyloses are formed between the ends of 
the bones. THE JOINTS. 
297 
Chronic fungous and purulent Arthritis. Tumor albus. 
Arthrocace. Strumous Arthritis. 
These names are used to designate a chronic inflammation 
which may involve all the parts of a joint. The larger joints 
are the ones usually diseased, and children and young persons 
the most disposed to the disease. The so-called scrofulous dia- 
thesis is said to predispose to this inflammation, but local in- 
juries are frequently the exciting cause. 
The disease begins usually in the synovial membrane, some- 
times in the ends of the bones. 
The synovial membrane is thickened, congested, loses its epi- 
thelium and is converted into granulation tissue. This new 
granulation tissue appears red and succulent, or hard and 
yellow from degenerative changes, or oedematous. A variable 
amount of pus in the joint is produced at the same time with 
the changes in the synovial membrane, and may rupture the 
capsule. 
These changes are accompanied by a thickening of the fibrous 
tissue around the joint. We then find around the joint a mass 
of hard, dense, sclerosed, anaemic tissue, composed principally of 
fusiform cells. In other cases, the new tissue is soft, succulent, 
vascular, composed of round cells. 
This new tissue may become so large as to replace all the soft 
parts above it, and become continuous with the skin around the 
joint. In some cases, portions of the new tissue break down 
into pus and form periarticular abscesses. 
The articular cartilages become partially or entirely destroy- 
ed. The cartilage cells increase in number, diminish in size so 
as to resemble lymphoid cells, and degenerate, the cavities in 
which they are contained enlarge, the basement substance of 
the cartilage undergoes a kind of mucous softening. These 
changes begin on the surface of the cartilage and work inward 
until they have destroyed a smaller or larger part of it. 
If the disease begins as an osteitis of the end of the bone, 
instead of as a synovitis, the medulla of the bone becomes con- 
verted into granulation tissue, which grows into the cartilage 
and perforates into the joint by a number of sieve-like open- 
ings. 298 
POST-MORTEM EXAMINATIONS. 
The ends of the bones are found in a condition of caries, ne- 
crosis, sclerosis, fatty atrophy, or overlaid with osteophytes. 
The disease always runs a very chronic course and may de- 
stroy the patient's life. If recovery takes place before the car- 
tilages and bones are involved, the joint is preserved; but is 
stiffened, or even immovable, from the contraction of the new 
fibrous tissue around it. If the cartilages and. bones are diseas- 
ed, the joint is destroyed, and either bony or fibrous anchylosis 
results. Sometimes from the change in the articulating surfaces, 
and the contraction of the muscles and the new fibrous tissue, 
partial or complete dislocations are produced. 
Arthritis Deformans, Malum Senile Articulorum, Chronic 
Rheumatic Arthritis, Rheumatic Gout.-These names have 
been given to a species of chronic inflammation of the joints, 
producing, not destruction, but deformity. It occurs in elder- 
ly persons, and attacks one or several joints. It is idiopathic, 
or due to rheumatism, to injuries, or follows an acute arthritis. 
The capsules of the affected joints are thickened and scle- 
rosed. The synovial fluid is at first increased in quantity; later, 
diminished and thickened. The tufts of the synovial mem- 
brane become much enlarged and vascular; they may be con- 
verted into cartilage. Sometimes the capsule becomes ossified. 
The new bone grows from the edge of the cartilage within the 
capsule. Its articular surface is covered with cartilage. 
The articular cartilages are much changed. The basement 
substance splits into tufts, while the cartilage-cells are increased 
in number. Or the basement substance becomes fibrous ; or it 
is split into lamellae and the cartilage-cells multiplied; or there 
is fatty degeneration and atrophy. As a result of these changes, 
larger or smaller portions of the cartilage are destroyed, and 
the bone beneath is laid bare. The exposed bone becomes com- 
pact and of an ivory smoothness. 
The ends of the bones are much deformed. They are flat- 
tened and made broader by irregular new growths of bone, 
while at the same time they atrophy. 
The new growth of bone starts from the articular cartilages. 
The cartilage-cells increase in number, and the basement sub- 
stance in quantity. This growth is most excessive at the edge THE JOINTS. 
299 
of the cartilage, so that a projecting rim is formed there. This 
projecting rim then begins to ossify next the bone, and, at the 
same time, new cartilage is formed on its surface, so that we 
find large masses of bone covered with cartilage. 
The atrophy of the ends of the bone, which goes on at the 
same time, is not so easily explained. It seems to be a kind of 
inflammatory atrophy taking place beneath the cartilage. 
NEW GROWTHS. 
Lipoma.-A new growth of fatty tissue may begin in the 
outer portions of the synovial membrane, push this inward, 
and project into the joint in a mass of tufts-lipoma arbo- 
rescens. 
Fibroma occurs as an hypertrophy of the little tufts and 
fringes of the synovial membrane. In this way, large polypoid 
and dentritic bodies are formed. The pedicles of these 
growths may atrophy and even disappear, so that the growths 
are left free in the cavity of the joints. 
Corpora Aliena Artieulorum, Loose Cartilages in the Joints, 
These names are given to bodies of various structure and ori- 
gin, which are found free, or attached by slender pedicles in 
the favities of the joints. They are most frequently found in 
the knee; next in order of frequency, in the elbow, hips, ankle, 
shoulder, and maxillary joints. They may be single, or in 
hundreds. Their size varies from that of a pin's head to that 
of the patella. They are polypoid, rounded, egg-shaped, or 
almond-shaped; their surface is smooth or faceted, or rough 
and mulberry-like. They are composed of fibrous tissue, carti- 
lage, and bone in various proportions. 
These bodies are formed in four different ways. 
(1.) By hypertrophy of, and production of cartilage and bone 
in the physiological synovial tufts. 
(2.) More frequently by a change into cartilage of portions 
of the synovial membrane. Small, flat plates of cartilage form 
on the inner surface of the synovial membrane. These plates 
increase in size and their outer layers ossify. They may remain 
fixed in the synovial membrane, or they project and become 300 
POST-MORTEM EXAMINATIONS. 
detached from it. They then appear as flattened, concave 
bodies, composed of bone covered with cartilage on one side. 
(3.) The growth of cartilage and bone begins in the outer 
layers of the synovial membrane, or in the periosteum, near 
the joint. The new growth pushes the synovial membrane in- 
ward, and projects into the joint as a polypoid body covered 
with the inner layers of the synovial membrane. Later, the 
membrane atrophies and the growth becomes free in the joint. 
(4.) There may be cartilaginous outgrowths from the edges 
of the articular cartilages. 
Rarely portions of the articular cartilages may be detached 
by violence or disease, or fibrinous concretions may result from 
synovitis. PART III. 
THE LESIONS FOUND 
IN 
CASES OF GENERAL DISEASES; 
OF POISONING; 
AND OF VIOLENT DEATH. PYAEMIA. 
Under the name of pyaemia are commonly understood seve- 
ral different conditions, giving rise to different lesions. 
(1.) Septicmnia.-Some portion of the body is in a condition 
of gangrene. That is, the tissues are not only dead, but de- 
composing, with the evolution of gases, the softening and lique- 
faction of the solid parts, and the development of minute or- 
ganisms, either animal or vegetable. 
The gangrenous fluids thus produced are, apparently, absorb- 
ed by the lymphatics and blood-vessels, and are thus able to 
produce marked symptoms during life, and to cause death. 
As in typhus fever, and other general diseases, hardly any 
lesions of the viscera are found, and the changes in the fluids 
have as yet escaped observation. 
The bodies of persons, who have died from septicaemia, de- 
compose with unusual rapidity. The endocardium and inner 
coat of the vessels are often stained with the coloring matter of 
the blood. The viscera are soft and flabby. The spleen may 
be swollen. The kidneys may be congested, their epithelium 
degenerated. 
(2.) Simple Pyaemia.-Persons who have suppurating wounds 
or abscesses may, without much change in the wound or ab- 
scess, be seized with rigors followed by fever, become jaundiced 
and die. 
In such persons, after death, no more lesions may be found 
than in septicaemia. The same tendency to decomposition, 
flabbiness of the viscera, and congestion of the spleen and kid- 
neys is found. 
Less frequently there may be purulent inflammation of the 
serous and synovial membranes, and of the connective tissue. 
Suppurative pleurisy, pericarditis, peritonitis, synovitis, and 
abscesses in the connective tissue may be found. Nor is there 
any way of accounting for these except by supposing that the 
pus from the original wound or abscess in some way infects the 304 
POST-MORTEM EXAMINATIONS. 
system, and renders the tissues prone to take on purulent in- 
flammation. 
(3.) Metastatic Pyaemia.-This is a very different condition 
from the two preceding, and is accompanied with marked le- 
sions. Either in consequence of wounds, injuries, inflamma- 
tions, abnormal conditions of the system, or changes in the venous 
walls, the blood may become coagulated during life and form 
thrombi in the veins. These thrombi may become organized, 
or they may soften, break down, and their fragments be carried 
into the circulation. Some of such fragments ultimately be- 
come fixed in the small arteries and capillaries, and there exert 
a two-fold action. By their mechanical action in obstructing 
the vessels, they produce a collateral congestion, stasis, and 
extravasation of blood. By the irritative character of the 
thrombi themselves, they excite inflammatory action in the 
adjoining tissues. In this way are produced haemorrhagic in- 
farctions and multiple abscesses. The character of these in- 
farctions will be more minutely described in connection with 
the organs in which they occur. 
In persons, therefore, who die with metastatic pyaemia we. 
find infarctions and small abscesses in the brain, lungs, heart- 
walls, liver, spleen, kidneys, and intestines. These infarctions 
very frequently produce inflammation of the serous coverings 
of the viscera in which they occur. The lungs are the organs 
most frequently involved. Further, we may find purulent in- 
flammation of the serous and synovial membranes, and ab- 
scesses in the connective tissue. The emboli which produce 
the infarctions can sometimes be distinguished, sometimes not. 
The thrombi, from which the emboli are detached, are some- 
times readily found in the vein close to the original wound. 
In other cases, they may be in the vein at some distance from 
the wound; in other cases, it may be, in a neighboring vein, or 
even in one in some distant portion of the body. Sometimes 
no thrombus can be discovered. 
Enlargement and congestion of the spleen and kidneys, and 
jaundice, are sometimes found. THROMBOSIS AND EMBOLISM. 
305 
THROMBOSIS AND EMBOLISM. 
A thrombus is a clot, composed principally of the fibrine 
of the blood, formed during life in the cavities of the heart, the 
arteries, the veins, or the capillaries. 
An embolus is a solid body, usually a portion of a thrombus, 
carried by the blood-current into some artery or capillary, and 
becoming fixed there. 
A thrombus may entirely fill the cavity of a vessel; or it may 
only form a layer on its wall; or it may project from a smaller 
vessel into a larger one. 
An embolus may completely, or only partly, plug up a 
vessel. It may remain alone, or a thrombus may be formed 
around it. 
A thrombus may merely become harder and whiter with 
time; or it may become organized ; or it may degenerate, soften, 
and change into a mass of puriform fluid and gangrenous-look- 
ing fibrine ; or it may calcify. 
The production of thrombi is due to various causes. 
(1.) Spontaneous thrombi are produced by any cause which; 
seriously weakens the whole system, as old age and chronic ex- 
hausting diseases. They are usually formed in the veins of the 
lower limbs and pelvis, and in the sinuses of the dura mater. 
(2.) Compression of the vessels by ligatures, tumors, dislocated 
bones, and inflammatory exudation. Pneumonia may produce 
thrombosis of the pulmonary veins. Phthisis may produce 
thrombosis of the pulmonary arteries. 
(3.) Dilatation of the vessels, as in aneurisms and varicose- 
veins. 
(4.) Thrombi may form in capillaries or small veins, and in- 
crease until they project into larger veins. 
(5.) Inflammation, especially of a gangrenous and suppura- 
tive nature, in the soft parts around a vessel. 
(6.) Degenerative and inflammatory changes in the wall of a 
vessel. In the arteries and capillaries, fatty degeneration and 
endarteriitis may render the inner coat rough. The veins may 
become inflamed in consequence of inflammation of the sur- 
rounding soft parts, or of wounds of their walls. The inflam-- 306 
POST-MORTEM EXAMINATIONS. 
mation involves the outer and middle walls of the vein, produc- 
ing little abscesses and consequent necrosis of portions of the 
inner coat. Waldeyer says that there may be, without suppu- 
ration, an inflammation of the entire wall of a vein, resulting 
in the formation of minute elevations on its internal surface. 
(7.) Emboli may produce thrombi about them and in the 
veins corresponding to the arteries which they obstruct. 
The causes of embolism are also various. 
(1.) Fragments of thrombi in the veins are the most frequent 
material of emboli. 
(2.) Thrombi of the heart, vegetations on the valves and on 
the walls of the aorta. 
(3.) Portions of the endocardium and of the inner coat of 
the aorta may degenerate and be detached from endarteriitis. 
(4.) Portions of tumors which project into the veins, the pig- 
mented bodies in melanaemia, and fat may form emboli. 
In a considerable number of cases, it is impossible to find any 
source for the embolus. It must be remembered, however, in 
emboli, in connection with wounds, that not only the veins of 
the wounded region are to be examined, but also those of 
the pelvis. For, while there are no venous thrombi from 
the injury, there may be some from the decubitus and condi- 
tion of the patient. 
The consequences of thrombosis vary with the situation of 
the clot. 
Thrombi in the arteries produce anaemia of the region sup- 
plied by the artery, or congestion from the collateral circulation. 
Later, there may be inflammatory changes, softening, or gan- 
grene. 
Thrombi in the veins produce inflammation in and around 
the vein, oedema, thickening of the skin, and connective tissue, 
gangrene, haemorrhages. 
Thrombi in the capillaries produce circumscribed congestions 
and haemorrhages, (infarctions,) followed by degenerative and 
inflammatory changes, or there may be a more diffused gan- 
grene. 
The consequences of embolism vary with the character of the 
embolus and its situation. THROMBOSIS AND EMBOLISM. 
307 
A simple plug of fibrine in a vessel only produces changes in 
the circulation; but a plug from a gangrenous thrombus has a 
tendency to excite suppurative inflammation wherever it lodges. 
Again, an embolus may entirely, or only partially, occlude a 
vessel. 
The size of the artery occluded, and the character of its col- 
lateral circulation, also lead to a variety of results. If a large 
artery is stopped, the part becomes anaemic; if a small one, 
there may be venous stasis from the collateral circulation. 
Thus, if the large arteries supplying the extremities are oc- 
cluded, we find anaemia, coldness, neuralgic pains, hyperaesthesia 
or anaesthesia, pricking sensations, cramps and paralysis of the 
muscles, and finally dry gangrene. 
Emboli of the pulmonary arteries produce dyspnoea or sudden 
death; of the coronary arteries, sudden death ; of the cerebral 
arteries, paralysis and white softening of the brain ; of the reti- 
na, sudden blindness and subsequent atrophy of the optic nerve; 
of the mesenteric arteries, congestion and gangrene of the in- 
testines. 
If there is sufficient collateral circulation to partially supply 
the part with blood, we find evidences of chronic want of nutri- 
tion. The region affected becomes atrophied; its temperature 
falls ; slight injuries excite chronic inflammation ; the muscles 
undergo fatty degeneration; the bones necrose; the viscera de- 
generate ; the fingers and toes undergo dry gangrene. 
Emboli in the smaller arteries and capillaries produce the 
so-called haemorrhagic infarctions. 
We may therefore distinguish four classes of changes produced 
by emboli. 
(1.) The embolus remains at the point where it has become 
fixed, and becomes organized without producing any lesions. 
This is the case when there are abundant arterial anastomoses. 
(2.) The region supplied by the plugged artery undergoes 
necrobiotic changes, which take the form of softening, or of 
wet or dry gangrene. Such changes are seen in the brain, skin, 
and extremities. 
(3.) The region supplied by the plugged artery becomes the 
seat of venous congestion and extravasation of blood. This 308 
POST-MORTEM EXAMINATION'S. 
takes place when the obstructed artery is a small one, and is 
terminal, that is, has no arterial anastomoses beyond the situa- 
tion of the embolus. These haemorrhagic infarctions are seen 
in the lungs, spleen, kidneys, brain, eye, and alimentary canal. 
(4.) Abscesses are produced. This takes place when the em- 
bolus is of a gangrenous and irritative nature. Large abscesses 
are only found in the lungs and liver. Minute abscesses are 
found in other organs, and are probably produced by capillary 
emboli. 
The manner in which infarctions are produced has recently 
been studied afresh by Cohnheim. He has introduced little 
globules of wax into the circulation of frogs, and observed, un- 
der the microscope, the changes which take place when these 
little emboli become lodged in the branches of the lingual 
artery. 
If the plug is lodged in a terminal artery, the artery beyond 
the plug, the corresponding set of capillaries, and the vein, are 
filled with stationary blood, or are partly empty. After a time, the 
vein belonging to this system of capillaries receives a backward 
current of blood, beginning from the larger vein, into which it 
empties, this larger vein being supplied by unobstructed arte- 
ries. The backward flow of blood continues until the vein, 
capillaries, and artery are filled and distended. Up to this 
point the mechanism of the changes is clear. The next step in 
the process is more difficult to explain. There is an escape of 
blood from the congested vessels, so that the tissue is infiltrat- 
ed with blood. This can hardly be accounted for by the mere 
backward current of blood, for the pressure can be no greater 
in the congested vessels than in any other part of the venous 
system. Cohnheim explains the extravasation of blood by a 
change in the walls of the congested vessels. He found that, if 
ligatures were applied for a short time to terminal arteries, as 
in the frog's tongue, the rabbit's ear, the kidney and intestines, 
so that the system of vessels was for a time emptied of blood, 
and the ligature then removed, so that the blood could return, 
the result was an extravasation of blood, resembling an infarc- 
tion. No changes could be detected in the walls of the vessels, 
and he assumes that the temporary withdrawal of blood from TYPHOID FEVER. 
309 
the vessels in some way impairs the nutrition of their walls, so 
that when they are again subjected to the ordinary blood-pres- 
sure the walls rupture. 
An embolus produces the same condition of affairs. A set of 
vessels are at first emptied of blood, and the nutrition of their 
walls thus impaired. After a time, these vessels are filled up 
from the veins, their abnormal walls can no longer resist the 
blood-pressure, and haemorrhage takes place. 
Cohnheim also asserts that when an abscess is formed by an 
embolus, the embolus is not lodged in a terminal artery, and 
produces no infarction. The embolus merely excites a suppu- 
rative inflammation by its pressure as an irritating body. 
After an haemorrhagic infarction is formed, the subsequent 
changes in it are of a degenerative character. The blood loses 
its coloring matter, and breaks down into a mass of granules, 
forming a dry, yellow, wedge-shaped mass. It may remain in 
this condition, gradually diminishing in size. Or, it may 
soften, and break down into a puriform fluid. Or, it may be 
surrounded by a zone of inflammation, or of gangrene. 
Emboli from the left heart usually become fixed in the ar- 
teries and capillaries of the-aortic system ; emboli of the right 
heart, or portions of thrombi from veins, in the capillaries of 
the lungs ; emboli from the portal system, in the capillaries of 
the liver. Not infrequently, however, we find infarctions of 
about the same date, and referable to a venous thrombus in 
both the pulmonary and aortic systems. This may take place 
in. two ways. Emboli may be so small as to pass through the 
pulmonary circulation, and become fixed elsewhere; or, they 
lodge in the lungs, produce infarctions there, secondary throm- 
bi are formed in the pulmonary veins, and from these, emboli 
are carried into the left heart and aortic circulation. 
TYPHOID FEVER. 
The lesions of typhoid fever are well marked and constant. 
They may be conveniently divided into two classes. 
(1.) Those which are characteristic of the disease. To this 310 
POST-MORTEM EXAMINATIONS. 
class belong the changes in the lymphatic follicles of the intes- 
tines, in the mesenteric glands, and in the spleen. 
(2.) Those which are very frequently found with this fever, 
and yet are not peculiar to it. To this class belong the 
changes in the parotid and pancreas, the degenerations in the 
liver, kidneys, and voluntary muscles, thrombosis of the blood- 
vessels, infarctions, diseases of the lungs, and suppuration of 
the connective tissue in various places. 
(1.) The Intestines.-The lesions of the intestines consist in 
an inflammatory enlargement, and subsequent degeneration of 
the lymph-follicles, whether as solitary glands or as Peyer's 
patches. 
The process appears to begin with a catarrhal inflammation 
of the mucous membrane, accompanied or immediately follow- 
ed by changes in the lymphatic follicles. The lesions in the 
lymphatic follicles begin early; they have been observed in per- 
sons who have died forty-seven hours after the commencement 
of the disease. 
The increase in size of the agminated and solitary follicles 
may be rapid or gradual. The follicles may be only slightly 
enlarged, or may project so as to fill up the cavity of the intes- 
tine. The enlargement is usually more marked in the agmi- 
nated than in the solitary follicles. Usually the whole of an 
agminated follicle will be enlarged, but sometimes only a part 
of it. If the enlargement is gradual, the different follicles 
which make up a Peyer's patch are enlarged, while the septa 
between them remain but little changed, and give the patch an 
uneven appearance. 
The patches which are only moderately enlarged are of red- 
dish or reddish gray color, are soft and spongy, and their edges 
blend gradually with the adjoining mucous membrane. The 
patches which are more intensely affected are of gray or brown- 
ish color, of firm consistence, and rise abruptly from the sur- 
rounding mucous membrane, or even overhang it like a mush- 
room. The largest patches are sometimes more than f inch 
thick. 
The enlargement and infiltration may spread from the 
patches to the surrounding mucous membrane, so that the TYPHOID FEVER. 
311 
patches appear very large, a number of them may become 
fused together, and there may be even an annular infiltration 
entirely around the lower end of the ileum. 
The infiltration of the agminated follicles may also extend 
outward into the muscular coat, and even appear beneath and 
in the peritoneal coat as small, gray, rounded nodules. This 
condition is usually found only with a few patches in the lower 
end of the ileum ; sometimes in the coecum and appendix ver- 
miformis. These little gray nodules usually correspond to 
diseased patches beneath them ; but sometimes they appear to 
excite an inflammation of the peritoneum, accompanied by the 
production of numbers of similar nodules all over that mem- 
brane. Hoffmann describes a case in which the inflammation 
extended to the pleura with the production of similar nodules 
there. 
The solitary follicles are affected in the same way as Pey- 
er's patches. They may be hardly enlarged at all, or be quite 
prominent, or may be affected over a larger portion of the in- 
testine than are the patches. Very rarely the solitary follicles 
are enlarged, while the patches are not at all or but slightly 
affected. 
The inflammation and enlargement of the agminated and 
solitary follicles is followed by a healing process. The charac- 
ter of this process varies according to the intensity of the pre- 
vious inflammation. 
(1.) If the disease was mild, and the enlargement of the fol- 
licles moderate, the enlargement gradually disappears, and the 
follicles resume their normal appearance. 
(2.) In moderate enlargements, the retrograde processes affect 
first the follicles, and leave the septa between them still swollen 
and prominent. This gives to the surface of a patch a reticu- 
lated appearance. After a time, however, the entire patch 
becomes flattened and uniform. 
(3.) The solitary follicles, or the separate follicles of a patch 
soften, break down, and their contents are discharged with 
some attendant haemorrhage. This leaves a bluish-gray pig- 
mentation in the situation of each follicle. This pigmentation 
may remain for years. 312 
POST-MORTEM EXAMINATIONS. 
(4.) In more severe types of the disease, the enlargement of 
the follicles ends in ulceration. This takes place in two ways. 
(a.) The enlarged follicles soften, break down, and discharge 
their contents into the intestine. In this way are formed small 
ulcers. These ulcers increase in size by the same softening 
process, which gradually attacks their edges, and in this way 
ulcers of large size may be formed. The ulcers may extend 
outward only to the peritoneal coat, or it. may extend do the 
peritoneal coat and terminate in perforation. 
(b.) In the severest forms of the disease, considerable portions 
of the enlarged patches slough en masse, leaving a large ulcer 
with thick, overhanging edges. The slough may involve only 
the follicles, or it may extend to the muscular and even to the 
peritoneal coat. These ulcers also may afterward increase in 
area, and several of them may become joined together. 
The ulceration, if the patient recover, cicatrizes, its edges be- 
come flattened, its floor is covered with a thin membrane cover- 
ed with cylindrical epithelium. 
Both forms of ulceration sometime^ end in perforation. This 
takes place by the extension of the ulcerative process through 
the peritoneal coat, or by the rupture of the floor of the ulcer 
from some mechanical cause. Peritonitis and death are the 
usual events. In rare cases, however, the patient recovers, 
the perforation being closed by adhesions. 
The minute changes which take place in the course of the 
intestinal lesions are as follows : 
At first the blood-vessels around the follicles are dilated and 
congested, while the follicles are swollen, and the epithelium 
falls off. Then the follicles increase largely in size, and the 
increase is due to anew cell-growth. The new cells are in part 
similar to the lymphoid cells, which normally compose the fol- 
licles ; in part are large rounded cells, 6-8 times as large as 
these, and containing several nuclei. The production of new 
cells is not confined to the follicles, but extends to the adjacent 
mucous membrane. In many cases, also, little foci of the same 
cells are found in the muscular, subserous, and serous coats. 
This increased number of cells compresses the vessels, and the 
parts become anaemic. Soon the cells degenerate, either by TYPHOID FEVER. 
313 
granular degeneration of the individual cells, or by gangrene 
of a large part of a follicle. In either case, the degenerated 
portion is eliminated into the intestine, and leaves an ulcer, with 
its edges and floor infiltrated with cells. After this, the cell 
growth goes on, and the ulcer enlarges, or the cells are replaced 
gradually by connective tissue, and cicatrization follows. 
The lesions we have described are found most frequently and 
most developed in the lower part of the ileum. They are not 
always, however, confined to this situation. Enlarged and ul- 
cerated follicles may be found over the entire length of the 
ileum, and even in the jejunum. They may also extend down- 
ward, and be found in the colon, even as far down as the rec- 
tum. The same changes may also take place in the appendix 
vermiform is. 
Besides the regular typhoid lesions of the intestines which 
have been described, we occasionally meet with others of a 
more accidental character. 
Gangrene of the intestinal wall sometimes occurs. It most 
frequently involves a portion of the wall corresponding to an 
ulcer, but may also affect other portions where no ulcer exists. 
The process may terminate in perforation or in healing. 
Diphtheritic Inflammation may attack the mucous mem- 
brane of either the large or small intestine. The mucous mem- 
brane between the typhoid ulcers is covered and infiltrated with 
croupous exudation. 
Peritonitis of a mild type is a frequent accompaniment of 
the intestinal lesions. It appears to have but little influence 
on the course of the disease. 
Severe peritonitis is usually due to perforation, less frequently 
to ulcers which reach the serous coat, but do not perforate. 
When there is infiltration of the serous coat with the typhoid 
new growth, the peritonitis may be accompanied by a produc- 
tion of little gray nodules of the same character throughout the 
peritoneum. 
Infa/rctions of the spleen, inflammation of the ovaries, and 
perforation of the gall-bladder are sometimes the cause of peri- 
tonitis. 
Haemorrhage from the intestines is merely due to the inflam- 314 
POST-MORTEM EXAMINATIONS. 
matory swelling and congestion, and is slight; or it is due to 
the ulceration of the follicles and consequent destruction of 
blood-vessels. In the latter case, the bleeding may be so pro- 
fuse as to cause death. 
Mesenteric Glands.-The mesenteric glands undergo the 
same changes as the follicles of the intestines, and are usually 
affected in a degree corresponding to the intensity of the in- 
testinal lesions. 
The glands are at first congested and succulent, then there is 
a production of lymphoid cells and large cells, as in the intes- 
tinal follicles, and the gland becomes enlarged, sometimes to an 
enormous extent. When the enlargement has attained its full 
size, the congestion diminishes, and the cells begin to degene- 
rate. This degeneration may take place slowly, so that the 
gland returns to its normal appearance; or more rapidly, so 
that little foci of softened puriform material are formed. If 
these foci are small, they are absorbed, leaving a fibrous cica- 
trix ; if they are large, they become dry, cheesy, and inclosed 
in a fibrous capsule. 
The Spleen.-In nearly every case of typhoid fever, the 
spleen is enlarged. Sometimes, however, this lesion fails, and 
that without any satisfactory reason. In some cases, a preex- 
isting thickening of the capsule, or old adhesions, seem to explain 
the non-enlargement; but in others, no such obstacle exists. 
The enlargement of the spleen commences soon after the 
beginning of the disease, increases rapidly until the third week, 
remains stationary for a few days, and then diminishes. 
The organ is congested, of dark red color, and of firm consis- 
tence, while it is increasing in size. After it has reached its 
maximum size, its consistence becomes soft, and there is a con- 
siderable deposit of brown pigment. The enlargement appears 
to be due to the congestion, and to an increase of the normal 
elements of the spleen. 
Infarctions of the spleen are occasionally found in typhoid 
fever, although they are by no means peculiar to it. They 
may cicatrize, or soften and cause peritonitis. 
Rupture of the spleen is said to occur, in rare cases, without 
the presence of infarctions. TYPHOID FEVER. 
315 
The second class of lesions comprises those which are fre- 
quently found with typhoid fever, but are not peculiar to it. 
The Mouth.-A number of changes are found about this 
region. The follicles at the root of the tongue and the tonsils 
may be enlarged; the muscles of the tongue may undergo 
waxy and granular degeneration; gangrenous ulcers may at- 
tack the floor and sides of the mouth, and destroy large areas 
of tissue. 
The Pharynx may be the seat of catarrhal or of diphtheritic 
ulceration, producing superficial and deep ulcers. 
The Parotid is, in a moderate number of cases, the seat of 
an inflammation which tends to suppuration. In this process, 
both the glandular acini and the connective tissue between them 
are involved. Which of the two has the larger share in the 
process is still in dispute. 
A slight enlargement and induration of the parotid and sub- 
maxillary glands is said by Hoffmann to be a frequent lesion, 
and to depend on increase of the gland-cells and dilatation of 
the follicles with their secretion. 
The Pancreas undergoes changes similar to those in the sa- 
livary glands. It becomes at first swollen and red, then hard 
and grayish, then yellow. The vessels are at first congested; 
afterward, there is increase of the gland-cells; and lastly, 
degeneration. 
The Liver may preserve its normal character, or may present 
changes. 
In many cases, the organ will be found soft and flabby. 
Minute examination then shows that the liver-cells have under- 
gone degeneration. They are filled with fine granules and 
small fat globules, and the degeneration may go on so far that 
the outlines of the hepatic cells are lost, and nothing but a mass 
of granules can be seen. 
Less frequently, we find in the liver very small, soft, grayish 
nodules resembling those found in the peritoneum. They are 
situated along the course of the small veins, and there is, at the 
same time, a diffuse infiltration of lymphoid cells along the 
small veins. The nodules consist of lymphoid cells; they are 
often too small to be distinguished with the naked eye. 316 
POST-MORTEM EXAMINATIONS. 
The Heart.-In a considerable number of cases, the muscular 
tissue of the heart is altered. The heart feels soft and flabby, 
is of grayish or brownish color, the muscular fibres are infil- 
trated with fine granules, and sometimes with brown pigment. 
Or, the heart is firm, but friable and easily torn; its cut surface 
glistens, and its muscular fibres present the waxy changes 
which will be described with the muscles. 
Thrombi in the cavities of the heart, and vegetations adher- 
ing to the valves, are sometimes found. They may give rise to 
emboli in different organs. 
The Larynx is very frequently the seat of catarrhal inflam- 
mation, with or without superficial ulceration. Less frequently 
diphtheritic inflammation occurs, and, in severe cases, may pro- 
duce serious lesions: destructive ulcerations, perichondritis, and 
profuse haemorrhage. 
The Lungs.-The recumbent position of the patients some- 
times leads to a long-continued congestion of the lungs, which 
renders them unfit to perform their functions. The lower 
lobes of the lungs, and sometimes the upper, will be found dark- 
colored, firm, infiltrated with blood, containing but little air. 
Microscopic examination shows the capillaries filled with blood, 
and the air-cells containing a very variable number of lymphoid 
cells. 
Catarrhal bronchitis exists in a large number of cases. It 
may run its course as such, or it may become complicated with 
lobular pneumonia. This lobular pneumonia may go on to 
cheesy hepatization and be the commencement of phthisis. 
Sometimes lobar, croupous pneumonia is found. 
Infarctions are found in the lungs in all their various 
stages, apoplectic, bleached yellow and white, softened, and 
puriform. 
Gangrene of the lungs occasionally is found, either associated 
with lobular pneumonia, with infarctions, or as an independent 
condition. 
The Kidneys, in a large number of cases, present changes simi- 
lar to those in the liver; that is, a parenchymatous degeneration. 
The kidneys are of medium size, their surface smooth, but the 
regular markings of the cortex are lost and largely replaced by TYPHOID FEVER. 
317 
a white color. The epithelium, especially of the convoluted 
tubes, is granular and broken down. 
Infarctions are not uncommon. 
Small, gray nodules, like those in the liver and peritoneum, 
are seen in a few cases. 
The Ovaries.-Haemorrhage and gangrenous inflammation 
have been observed in rare cases. 
The Brain.-(Edema of the pia mater and of the brain tissue 
is found in a certain number of cases. As to its frequency, 
authorities differ. 
Acute meningitis, white softening, softening with capillary 
apoplexies and infarctions, are found in occasional cases. 
The Voluntary Muscles undergo various changes. 
(1.) The muscular fibres become filled with fatty and albu- 
minous granules to such an extent that the markings of the 
fibres disappear. This degeneration is observed in other dis- 
eases. 
(2.) The muscular fibres undergo a peculiar change, called by 
Zenker " waxy degeneration." It is not to be confounded with 
the " waxy " or " amyloid " degeneration of the liver, kidneys, 
etc. This change is also found in typhus, cholera, acute tu- 
berculosis, small-pox, and other diseases, and in connection 
with injuries of the muscles. It is most common, however, in 
typhoid fever, and at the acme of the disease. 
The change is usually found in the abdominal muscles, the 
adductors of the thigh, the pectoral muscles and diaphragm, 
and in the tongue. 
The muscles appear to the naked eye of a grayish or yellow 
color, dry, brittle, with a wax-like section, resembling fish mus- 
cle. Microscopic examination shows the muscular fibres to be 
converted into a peculiar, homogeneous, highly refracting sub- 
stance. According to the manner in which a fibre is attacked, 
we find long, wax-like cylinders, or smaller, irregular bodies of 
very various shape. The change in the fibres is accompanied 
oy followed by a new growth of muscle. We find then num- 
bers of lymphoid and fusiform cells with large fusiform bodies, 
and large, flat, plate-like bodies, each containing many nuclei, 
and some of them distinctlv striated. . 318 
POST-MORTEM EXAMINATIONS. 
The entire process is differently interpreted by different 
observers. Some hold that it is a degeneration followed by 
atrophy and a new growth. Others, that the new growth pre- 
cedes and causes the degeneration. Others, that, instead of a 
degeneration, the waxy appearance is produced by a coagulation 
analogous to that which produces the rigor mortis, and that the 
entire appearance is a post-mortem one. 
(3.) Rupture of the muscles is apparently produced by their 
wTaxy degeneration. It is accompanied by haemorrhage, some- 
times to a large amount. It may cicatrize, or become the seat 
of a purulent, gangrenous inflammation. 
(4.) Suppuration of the muscles or of their fasciae is occa- 
sionally seen ; it may produce large abscesses. 
The Shin.-Gangrenous inflammation of the skin frequently 
occurs in the form of bed-sores, affecting the skin over the 
sacrum and trochanters, where it is subjected to the constant 
pressure of the bed. Gangrene of other portions of the integu- 
ment, especially of the toes, is produced by thrombosis or em- 
bolism. 
There may be suppurative inflammation of the connective 
tissue in various parts of the body. Perhaps the most impor- 
tant is that producing retro-pharyngeal abscesses. 
BILIOUS TYPHOID. 
Under this name Griesinger describes a form of fever resem- 
bling in its symptoms both relapsing and typhoid fever, and 
attended by very grave symptoms. 
The Shin is jaundiced; sometimes ecchymotic. 
The Brain is usually anaemic. The pia mater may contain 
haemorrhages. 
The Pharynx, and Larynx may be the seat of catarrhal, 
croupous, and ulcerative inflammation. 
The Lungs.-Catarrhal bronchitis, lobar, and lobular hepati- 
zation, and infarctions are not infrequent. 
The Heart is usually flabby and pale. 
The Liver is enlarged and congested, or anaemic, flabby, yellow, 
and fatty. Its surface is often coated with fibrinous exudation. TYPHUS FEVER. 
319 
The Spleen is often coated with exudation. It is always 
enlarged, congested, soft, and may undergo spontaneous rupture. 
In most cases, it is filled with countless small, grayish nodules- 
the enlarged Malpighian bodies. These afterward soften and 
form little abscesses. Infarctions are not uncommon. 
The Stomach and Intestines are often the seat of catarrhal 
and croupous inflammation. The solitary and agminated folli- 
cles are not enlarged. 
The Mesenteric Glands and the other lymphatic glands in the 
abdomen are usually enlarged. 
The Kidneys are frequently congested, or anaemic, and the 
seat of parenchymatous degeneration. 
TYPHUS FEVER. 
The lesions of typhus fever are variable and not very charac- 
teristic. 
The Skin.-The regular eruption of typhus disappears after 
death, but sometimes small ecchymoses remain. Gangrene 
from bed-sores, and of the toes from thrombosis, are sometimes 
seen. 
Decomposition commences early, and the blood is unusually 
fluid and prone to stain the vessels. 
The Train usually presents no lesions. Acute meningitis is 
said sometimes to occur. 
The Pharynx and Larynx may be the seat of catarrhal or 
diphtheritic inflammation. Gangrenous inflammation of the 
walls of the mouth may occur. Suppurative inflammation of 
the parotid glands is not uncommon. 
f The Lungs.-Bronchitis frequently exists. Hypostatic con- 
gestion, lobular and lobar pneumonia and infarctions are 
sometimes found. 
The LLeart is soft and flabby. Its muscular fibres are often 
filled with granules. 
The Spleen is usually large and soft. There may be infarc- 
tions. 
The Inver and Kidneys may present the same parenchyma- 
tous degeneration as is observed in typhoid fever. 320 
POST-MORTEM EXAMINATIONS. 
The Lntestines may appear normal, or the agminated and 
solitary follicles may be slightly enlarged, or there may be 
catarrhal or diphtheritic inflammation. 
The Voluntary Muscles sometimes undergo the same granu- 
lar and waxy degeneration as in typhoid fever. 
The lesions of relapsing fever are neither characteristic nor 
constant. 
In some cases, no marked lesions are to be found. 
The Liver and Spleen are frequently enlarged. 
The Lungs may be congested or hepatized in the lobular or 
lobar forms. 
The Kidneys may be congested, or may undergo parenchy- 
matous degeneration. 
Haemorrhages in the walls of the alimentary canal, the air- 
passages, and in the skin are sometimes found. 
RELAPSING FEVER. 
MALARIAL FEVERS. 
INTERMITTENT AND REMITTENT FEVER. 
The lesions of malarial poisoning are usually characteristic 
and well marked. Their extent varies with the intensity and 
duration of the disease and the period at which the patient dies. 
Intermittent Fever corresponds to a mild degree of malarial 
poisoning, and seldom causes death. 
Remittent Fever, especially the "pernicious" form, corre- 
sponds to an intense degree of the poison, and frequently 
causes death. 
The Blood.-The most constant lesion is the presence of lit- 
tle particles of black or reddish pigment in the blood. The 
pigment is in the form of flakes, or of granules imbedded in 
small, irregular, transparent, finely-granular bodies. We also 
find these same transparent bodies without pigment, some of 
them looking like round and fusiform cells. Sometimes there 
is an increase of white blood-globules. MALARIAL FEVERS. 
321 
The presence of this pigment in the blood gives to the diffe- 
rent organs of the body a peculiar, dark color, varying in 
shade according to the proportion of pigment. Sometimes the 
change in color is not perceptible to the naked eye, and only 
microscopic examination shows the pigment in the vessels. The 
pigment is distributed in very different amounts in the different 
organs. 
The Spleen is the organ in which the pigment is found in the 
greatest amount and most constantly. Here it is difficult to 
ascertain whether the pigment is entirely in the vessels, or also 
in the parenchyma. The spleen will be found of reddish 
brown, olive, or black color. It is usually enlarged, sometimes 
enormously so; its consistence may be normal, or soft, or firm. 
In mild intermittent fever, the spleen may be much enlarged 
and not pigmented. 
The Liver is almost as frequently and intensely pigmented 
as the spleen. It is of a light or dark brown, or olive, orblack 
color. The pigment will be found in the venous and arterial 
capillaries and small veins. Sometimes, while the change in 
color of the liver is so slight as hardly to be appreciated, a 
small amount of pigment will still be found in the capillaries. 
The liver may be of normal size, or large and congested, or 
small. The hepatic cells usually appear perfectly normal. In 
some cases there is intense congestion, and even haemorrhages, 
in the substance of the organ. 
The Brain is much less frequently affected. In marked 
cases, the gray matter of the convolutions and ganglia appears 
of a dark gray color, contrasting strongly with the white mat- 
ter. Sometimes there are multitudes of little capillary apo- 
plexies. 
The pigment will be found in the small vessels and capillaries 
of the pia mater and gray matter. It may accumulate in the 
vessels so as to obstruct them, and produce tlie capillary apo- 
plexies just mentioned. 
In other parts of the body the pigmentation is usually not 
sufficient to be seen with the naked eye. Careful microscopical 
examination, however, will very often detect pigment in the; 322 
POST-MORTEM EXAMINATIONS. 
small vessels and capillaries of the kidneys, intestines, lungs, 
skin, and connective tissue throughout the body. 
If the patient die during a chill, all the organs are usually 
intensely congested. 
The Stomach and Small Tntestine may be the seat of catarrhal 
inflammation; the large intestine, of croupous inflammation; 
jaundice is not uncommon. 
(Edema of the feet and legs, ascites, and general anasarca, 
or ascites alone, may be found after only a few paroxysms of 
the disease. The cause of this condition is not apparent. 
Persons who have become anaemic and cachectic from long; 
continuance of the disease may develop oedema in the same way 
as other anaemic persons. 
YELLOW FEVER. 
The Skin and other tissues are usually jaundiced ; the color 
ranges from light yellow to dark mahogany. Petechiae and ec- 
chymoses are often found. The muscles sometimes contain 
large haemorrhages. 
The Brain and Spinal Cord present no marked lesions. 
The Lungs.-Catarrhal bronchitis, haemorrhagic infarctions 
of the lungs, and ecchymoses of the pleura are sometimes 
found. 
The Heart.-The pericardium may contain serous and fibri- 
nous exudation or blood. There may be ecchymoses in the 
pericardium. The heart is frequently soft and flabby, its mus- 
cular fibres far advanced in fatty degeneration. 
Alimentary Canal.-There may be deep erosions of the mu- 
cous membrane of the oesophagus. The stomach and small in- 
testines usually contain blackened blood. The mucous mem- 
brane of the stomach may be normal, or congested, with 
ecchymoses and haemorrhagic erosions. The mucous membrane 
of the stomach may also be the seat of catarrhal inflammation, 
with swelling of the solitary and agminated follicles. 
The Liver may be normal or hypersemic. Most frequently, 
however, by the third day of the disease it presents peculiar 
changes. It is of normal size, or slightly enlarged, or atro- 
phied. It contains little blood, is of a cafe, au lait or yellow CHOLERA. 
323 
color ; its consistence is flabby and dry. The hepatic cells are 
filled with granules, or with fat globules. 
In persons who have recovered from the fever and died a 
few weeks later from other causes, the liver has been found en- 
tirely normal. 
The Spleen is normal, or enlarged and congested. 
The Kidneys are frequently the seat of a parenchymatous 
degeneration analogous to that of the liver. 
CHOLERA. 
In this disease the lesions do not by any means correspond 
to the severity of the symptoms during life. This is especially 
the case in mild epidemics of the disease, and in cases which 
die during the stage of reaction. In many such cases there are 
no marked lesions. 
If death occurs during the invasion of the disease, or in col- 
lapse, in severe cases the appearances are as follows : 
The bodies remain warm for some time, and the temperature 
may even rise for a short time after death. The rigor mortis 
commences soon, and lasts unusually long. The muscles some- 
times exhibit a peculiar spasmodic twitching before the rigor 
mortis sets in, especially the muscles of the hand and arm. 
The Skin is of a dusky gray color, the lips, eyelids, fingers, 
and toes of a livid purple. The cheeks and eyelids are fallen 
in, and the face has a peculiar sunken look. 
The Brain.-The sinuses of the dura mater are filled with 
dark, thick blood. The pia mater may be normal, or oedema- 
tons, or ecchymosed, or covered with a thin layer of fibrinous 
exudation. The brain is usually normal. 
The Lungs.-The pleura is often covered with a thin layer of 
fibrinous exudation. The lungs are retracted and anaemic. 
The Heart is unchanged. 
The Peritoneum is often covered with a layer of fibrinous 
exudation. 
The Stomach is usually unchanged, sometimes the seat of 
catarrhal inflammation. 
The Small Intestine may appear normal, or anaemic, or con- 324 
POST-MORTEM EXAMINATIONS. 
gested in various degrees. The mucous membrane may be soft 
and oedematous. In the intestines we find a variable, quantity 
of the rice-water fluid seen in the evacuations during life. The 
solitary and agminated follicles may be much swollen. 
The Large Intestine is usually normal. In some epidemics, 
however, it is prone to croupous inflammation wTith ulceration. 
The Liver and Spleen undergo few changes ; they may be 
anaemic and flabby. 
The Kidneys appear normal, or large and congested, or with 
white and thickened cortex. The tubes contain degenerated 
epithelium and casts. 
The Uterus and Ovaries may be congested, and contain 
haemorrhages. 
If the patient does not die until after the acute symptoms of 
the disease have passed by, the appearances are different. 
The body does not present the same collapsed appearance. 
The Larynx may be the seat of purulent or diphtheritic in- 
flammation. 
The Lungs.-There may be pleurisy with sero-purulent exu- 
dation. The lungs may be congested and oedematous, or con- 
tain infarctions, or lobular hepatizations, or there may be bron- 
chitis. 
The Stomach and Intestines may be the seat of croupous in- 
flammation. 
EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
This disease presents itself under a variety of forms in dif- 
ferent epidemics, and in different localities. The severity of 
the disease, its duration, and its symptoms are all variable. Its 
lesions also are not constant. Those which will be enumerated 
below are not all or any of them necessarily present in every 
case; 
The Skin may be unchanged, may present petechial spots, or 
large purpuric patches. In many cases vesicles of herpes are 
found on the face and elsewhere. 
The Muscles frequently are the seat of granular degeneration. 
Sometimes there is an increase of cells between the muscular 
fibres, which may go on to the formation of abscesses. EPIDEMIC CEREBROSPINAL MENINGITIS. 
325 
The Rigor Mortis is pronounced and long continued, but de- 
composition sets in early. 
The Skull.-The bones of the skull may be hyperaemic. 
The Brain.-A few cases are reported in which no lesions of 
the brain or its membranes were seen ; but, as a rule, lesions are 
found. The dura mater may be covered on its inner surface 
with a layer of fibrinous exudation and extravasated blood ; or 
it may be adherent to the pia mater. There may be purulent 
matter between the dura and pia mater. 
The pia mater is usually congested. Infiltrated in it and be- 
neath it we find serum, gelatinous matter, and pus in variable 
amounts. There may be a general opacity and thickening of 
the pia mater, or there are scattered purulent foci. These 
changes are most frequent and most marked at the base of 'the 
brain. Microscopic examination of the pia mater, where it 
appears unchanged, often shows an increase of cells. The 
gelatinous matter beneath and in the pia mater appears to be 
made up of pus imbedded in a mucous basement substance. 
The ependyma of the ventricles may contain small ecchy- 
moses. The walls of the ventricles may be softened and oede- 
matous. There may be pus in the ventricles and in the cho- 
roid plexuses. Sometimes the ventricles are enormously dis- 
tended with serum. 
In the brain tissue there may be capillary apoplexies, large 
apoplexies, general hypereemia, spots of white softening, oede- 
matous softening, suppurative encephalitis, infarctions, granular 
softening around the small vessels, red softening, cell-growth in 
the gray matter of the cortex. 
Spinal Cord.-1There may be small extravasations of blood in 
the loose tissue outside of the dura mater. The dura mater 
may be congested, its internal surface covered with fibrinous 
exudation, or it may be adherent to the arachnoid. There may 
be pus, serum, or gelatinous matter between the dura and pia 
mater. The pia mater is congested, infiltrated with pus, serum, 
and gelatinous matter. The same substances are found beneath 
it. The exudation is found on the posterior aspect of the cord 
rather than on its anterior. The inflammatory lesions may ex- 
tend the entire length of the cord, or only over part of it, or 326 
POST-MORTEM EXAMINATIONS. 
over discontinuous portions. The central canal of the cord 
may be dilated and contain pus. The cord may be softened. 
There may be a cell-growth, or a production of pus about the 
roots of the spinal nerves. 
The Ears.-1The auditory nerves may be oedematous, 
softened, or imbedded in pus. There may be suppurative 
inflammation of the internal ear. 
The Eyes may be the seat of suppurative choroiditis. 
The Lungs.-The mucous membrane of the bronchi may be 
congested. The lungs may be congested and oedematous ; or 
there may be hepatization of larger or smaller portions of the 
lung tissue. 
The Stomach.-There is said to be sometimes an unusual 
degree of softening of the fundus. 
The Intestines.-1The solitary and agminated follicles may be 
swollen and even ulcerated. 
The Spleen may be larger, or small, or pigmented. 
The Liver is usually of medium size. The hepatic cells are 
often the seat of granular degeneration. 
The Kidneys.-The epithelium of the tubes may be the seat 
of granular degeneration. 
SCURVY. 
The bodies decompose early. The skin is of a dusky color, 
sometimes oedematous on the legs, mottled with a variable 
number of small and large, purple, blue, brown, or blackish 
spots, produced by extravasations of blood in the superficial 
layers of the cutis. 
The gums are swollen, soft, and livid, the teeth loose, the 
alveolar walls often necrotic. 
In the subcutaneous connective tissue, and in the muscles, we 
may find extravasations of blood, sometimes of very large size, 
in various stages of absorption, induration, and softening. 
Sometimes these extravasations produce perforation of the skin 
and ulcers. 
The joints may be inflamed, may contain serum or blood. 
Rarely, the haemorrhages are followed by destruction of the car- 
tilages and ends of the bones. Addison's disease. 
327 
Very rarely, there may be haemorrhage between the perios- 
teum and bone, and in the bone itself, producing softening and 
destruction of the bone, and separation of the epiphyses. The 
sternal ends of the ribs are the most frequent seat of this 
change. 
The pleura, pericardium, and peritoneum may be the seat of 
ecchymoses, or contain large haemorrhages in their cavities, or 
be coated with fibrinous exudation. 
The lungs may be congested, oedematous, or the seat of lobu- 
lar pneumonia. 
The mucous membrane of the air-passages usually contains 
ecchymoses. 
The spleen is swollen, soft, and may contain infarctions. 
The mucous membrane of the stomach and intestines is 
swollen, congested, contains haemorrhages, exhibits small hae- 
morrhagic ulcers, and may be coated with blood. 
The kidneys may appear normal, or may be in various stages 
of Bright's Disease. 
ADDISON'S DISEASE. 
Under this name is usually understood a disease characterized 
by a dark-colored or bronzed skin, by disease of the supra-renal 
capsules, and by a peculiar group of symptoms. The symp- 
toms are: A change in the mental condition; great anaemia, 
with increase of the white-blood globules, but without emacia- 
tion ; frequent and protracted syncope ; great prostration; pains 
in the back and epigastrium; dyspepsia and vomiting; diar- 
rhoea; sometimes convulsions, neuralgia, and paraplegia; ty- 
phoid symptoms and death. 
The pigmentation of the skin is the symptom which has prin- 
cipally excited attention. The change in color usually begins, 
and becomes most intense in those parts of the skin which are 
not covered by the clothing. The rest of the skin afterward 
changes color, but not uniformly ; for white patches are often 
left. The color is at first a light yellow or brown ; this becomes 
darker until it is a dark greenish brown, grayish or blackish 
brown. There may be black spots on the mucous membrane 
of the lips and mouth. 328 
POST-MORTEM EXAMINATION'S. 
Unfortunately, under the same name of Addison's Disease, 
different observers have described cases in which the symptoms 
and bronzed skin existed without disease of the supra-renal 
capsules ; cases in which the bronzed skin was the only lesion; 
cases in which the supra-renal capsules were diseased without 
symptoms or bronzed skin. 
In the present state of our knowledge, we have to admit that 
the connection between the color of the skin, the condition of 
the supra-renal capsules, and the symptoms is an unsolved pro- 
blem. Each of the three conditions, the symptoms, the colored 
skin, and the diseased capsules may exist separately, and yet in 
a very considerable number of cases they are combined. 
I can only, therefore, give such lesions as have been observed, 
without implying that they are the universal or necessary lesions 
of the disease. 
The Skin.-The pigmentation resembles that of the negro. 
It is a diffuse or granular pigmentation of the inner layers of 
the rete Malpighii. Sometimes pigment is found along the 
nerves and vessels in the cutis. 
The Brain.-Softening, hydrops of the ventricles, pigmenta- 
tion of the gray matter, exudation on the arachnoid, hyperse- 
mia and angemia of the brain, chronic inflammation, degenera- 
tion of the hypophysis cerebri, and concretions in the medulla 
oblongata have all been observed. 
The Sympathetic Nerves.-Atrophy, fatty degeneration, hy- 
pergemia, pigmentation, and fibrous degeneration, especially 
affecting the abdominal portion of the sympathetic, have been 
described. 
The Supra-renal Capsules.-The most frequent lesion is pro- 
duced by a chronic inflammation with cheesy degeneration. 
Less frequently, tubercles, carcinoma, apoplexy, fatty and waxy 
degeneration have been observed. 
The most striking cases are those in which at the autopsy no 
other lesions exist, nor can any other cause for death be found 
than the change in the supra-renal capsules. GOUT. 
329 
LEUKEMIA.-PSEUD0-LEUK2EMIA. 
Under these two names, we understand two diseases, in 
which are found the same lesions of the viscera, but in which 
the condition of the blood is different. 
The lesions consist in the new growth of lymphatic glandu- 
lar tissue in different parts of the body. 
This new growth takes place as an hyperplasia of the spleen 
alone, or of the lymphatic glands alone, or of both together; or 
there may be also small growths of the same nature in the 
tonsils, larynx, and trachea, lungs and pleura, stomach and 
intestines, pericardium, liver, spleen, and kidneys. The 
lymphatic glands in every part of the body may be enormously 
enlarged, but do not become inflamed, softened, or cheesy. 
The growths in the different viscera will be found fully de- 
scribed under their respective headings. 
With these lesions in the viscera, there may be also a very 
marked increase in the number of the white blood-globules in 
leukaemia ; or the proportional number of white-globules may 
be very slightly, or not at all, increased in pseudo-leid<8emia. 
GOUT. 
The characteristic lesion of gout is the deposit of urate of 
soda in the articular cartilages, the ligaments of the joints, the 
ears, and the eye-lids. 
The most frequent situation is the metatarso-phalangeal joint 
of the great toe. The cartilage may he infiltrated or incrusted 
with the deposit. 
If the gout is of long standing, there is usually chronic diffuse 
nephritis. The kidneys are small, the cortical substance atro- 
phied, the surface irregular, the texture hard, the pyramids 
marked by white lines running parallel to the tubes. These 
white lines consist of urate of soda. 
GLANDERS.-FARCY. 
These two names are given to two varieties of the same 
disease. The disease originates in the horse, and occurs in 330 
POST-MORTEM EXAMINATIONS. 
men by contagion. According to some authors, it may be idio- 
pathic in the human subject. 
In the horse, we find four varieties of the disease: Chronic 
and acute glanders, chronic and acute farcy. 
(1.) Chronic danders.-The disease begins in the mucous 
membrane of the nose. Small, whitish nodules, composed of 
small round cells, are formed in the mucous membrane. These 
nodules soften and ulcerate. The same nodules may be found 
in the larynx, trachea, and bronchi. The ulcerations may 
remain superficial, or they may extend and attack the subjacent 
cartilage and bone. Nodules of the same kind may be found 
in the lungs. 
(2.) Acute danders.-There is the same formation of no- 
dules, which soften and ulcerate; but they are accompanied 
with an intense inflammation of the nasal mucous membrane, 
and the disease runs a rapid course. 
(3.) Chronic Farcy.-The lymphatic glands and vesicles be- 
come enlarged, and nodules are formed in the skin, lungs, and 
other viscera. The glands become cheesy, or soften and sup- 
purate. The cutaneous nodules soften and suppurate. 
(4.) Acute Farcy.-There are the same lesions of the lym- 
phatics, and nodules and abscesses are found in the skin. There 
are also nodules in, and inflammation of, the nasal mucous 
membrane, and the disease runs an acute course. 
In man, the disease occurs in an acute and chronic form, but 
does not exactly resemble any of the varieties of the disease in 
the horse. 
The acute disease runs a rapid and malignant course. The 
skin may be covered with a pustular eruption. Furuncles, car- 
buncles, and abscesses beneath the skin and in the muscles are 
found. Nodules are found in the nasal mucous membrane, the 
lungs, kidneys, testes, spleen, and liver. The joints may be 
inflamed, and there may be osteo-myelitis. 
The disease may begin at a single point, so that it may be 
mistaken for a carbuncle, or a gangrenous erysipelas. Graefe 
gives a case which began as an acute exophthalmos, and the 
nature of the disease was not ascertained until after death. 
There were little nodules in the choroid coat of the eye. SUNSTROKE. 
331 
The chronic form of the disease is still more difficult of diag- 
nosis. 
The nodules grow very slowly, are hard, and may occur in 
groups, or like a string of beads. 
The nodules may soften and form deep, chronic ulcers. 
HYDROPHOBIA. 
There are no characteristic lesions in this disease. 
Congestion of the nervous centres, and congestion and swell- 
ing of the mouth and pharynx, are observed in some cases. 
Decomposition usually commences soon after death. 
SUNSTROKE. 
During the hot summer months, cases of sunstroke are of fre- 
quent occurrence in New-York. The persons affected are, for 
the most part, adult male laborers, usually of intemperate 
habits. 
It is necessary to separate from the cases of sunstroke proper, 
when the patient is attacked while exposed to the heat of the 
sun, the cases of exhaustion from heat and fatigue, which may 
occur as well in the house. 
The patients who are seriously affected by sunstroke, exhibit, 
during life, an intense heat of the skin, convulsions, and coma. 
Death in many cases soon ensues. 
After death, decomposition sets in very early, owing to the 
state of the weather. In autopsies which I have made within 
two hours after death, the increased heat of the skin was still 
maintained. 
The Brain and its membranes were in some cases congested ; 
in others not. Sometimes there was an increased amount of 
serum beneath the pia mater; sometimes there were small and 
thin extravasations of blood beneath the pia mater, and between 
the pia and dura mater. 
In the other viscera there were no lesions except those due 
to the condition of coma, existing before death. The lungs 
and kidneys were frequently congested. 332 
POST-MORTEM EXAMINATIONS. 
TRICHINIASIS. 
The Trichina spiralis is found' in man, the pig, the dog, the 
cat, the rabbit, the guinea-pig, the rat, and in some birds, both 
in its undeveloped and in its fully developed form. 
In its fully developed form it is found in the small intestines, 
and less abundantly in the large intestine. It is a viviparous 
worm, with a long, rounded body, sharp at the head, rounded at 
the tail. The males are 1.5 mm. long, the females 2-3 mm. 
long. The intestinal canal runs the entire length of the body. 
The female organs of generation are simple, and placed for the 
most part in the second third of the body. The testicles are in 
the last third of the body. 
In its undeveloped form, the worm resembles a hair, is about 
1 mm. long, and possesses no organs but an alimentary canal. 
It is rolled in a spiral form. From one to three worms are en- 
veloped in a capsule, which is at first thin and membranous, 
afterward calcified. In this condition they are scattered in im- 
mense numbers throughout the voluntary muscles, and may re- 
main so for an indefinite number of years. 
After a man has eaten uncooked flesh containing the unde- 
veloped trichina, the worms remain in his intestines, and by the 
second day have become fully developed and freed from their 
capsules. The females are impregnated, and by the eighth day 
bear immense numbers of young worms. By the tenth day, the 
young worms find their way through the connective tissue, and 
by the blood into the voluntary muscles. By the fourteenth 
day we usually find them encapsuled throughout the muscles. 
The muscular fibrillae become homogeneous, or break down 
into granular matter; the sarcolemma is thickened, and con- 
tracts at each end so as to form a cavity for the worm. Within 
this portion of the sarcolemma the cyst is formed by a harden- 
ing and calcification of the granular substance. At the same 
time there is a growth of lymphoid cells about the affected fib- 
rillae. New capillaries are formed about the capsule, and new 
muscular fibrillae are formed to take the place of those which 
have been destroyed. (Wagner.) 
I have seen in one case, in which death took place on the four- DEATH FROM SUFFOCATION. 
333 
teenth day after eating the infected flesh, the trichinae free be- 
tween the muscular fibrillae, and at the same time an abundant 
production of lymphoid cells in the interstitial connective 
tissue. 
We most frequently find the parasites with calcified cysts in 
persons of whose history we know nothing. But occasionally 
we meet with acute cases in which death has ensued in a short 
time from the effects produced by the trichina. 
DEATH FROM SUFFOCATION. 
By suffocation we understand that condition in which air is 
prevented from penetrating into the lungs. Many deaths from 
drowning and strangulation take place in this way. 
The methods in which the supply of air may be cut off from 
the lungs are very various. The mouth and nose may be closed 
by the hand, by plasters and cloths, by wrapping up the head 
in cloths, by covering the face with earth, hay, grain, etc. 
Foreign bodies may be introduced into the mouth, pharynx, 
and larynx. Blood may pass into the trachea from an aneu- 
rism, or from a wound. The glottis may be closed by inflamma- 
tory swelling. Matters which are vomited may lodge in the 
larynx. 
External Inspection. 
The body should be examined for marks of violence, the 
cavities of the mouth and nose for foreign substances. 
The face may be livid and swollen, or present a natural ap- 
pearance. The conjunctiva may be congested and ecchymotic. 
There may be small ecchymoses on the face, neck, and chest. 
The mouth often contains frothy blood and mucus. The tongue 
may be protruded. 
Internal Examination. 
The Brain and its membranes may be congested, or anaemic 
and cedematous, or unchanged. 
The Blood throughout the body is unusually dark-colored 
and fluid. 
The Larynx may contain foreign bodies which have produced 334 
POST-MORTEM EXAMINATIONS. 
the suffocation. The mucous membrane of the larynx, trachea, 
and bronchi is congested and sometimes ecchymotic. These 
passages contain frothy blood and mucus. 
The Lungs are usually congested and oedematous, but some- 
times do not differ from their ordinary appearance. There may 
be small patches of emphysema on the surface of the lungs. 
Sometimes, especially in infants, small ecchymoses are found in 
the costal and pulmonary pleura. 
The Heart usually presents its right cavities full of blood, its 
left cavities empty. 
The Abdominal Viscera are usually congested. 
DEATH FROM STRANGULATION. 
Strangulation is effected by the weight of the body in hang- 
ing ; by pressure on the neck with the hands ; or by constric- 
tion of the neck by a cord of some kind. Death is usually 
produced by the pressure on the larynx and trachea; that is, by 
asphyxia. In some cases, death appears to be caused by pres- 
sure on the large vessels of the neck; and, in some cases of 
hanging, by fracture or dislocation of the cervical vertebrae. 
External Inspection. 
The face may be livid and swollen, the eyes prominent, the 
lips swollen, and the tongue protruded. These appearances, 
however, are not the rule. The greater number of those who 
die from strangulation cannot be distinguished by their faces 
from persons who have died in any other way. 
Erection of the penis, ejaculation of semen, and evacuation 
of faeces and urine, are appearances on which some stress has 
been laid, but they do not appear to be constant or charac- 
teristic. 
In almost all cases, there are marks left on the neck by the 
implements which have produced the strangulation. 
In cases of suicidal hanging, the cord usually encircles the 
neck between the chin and the os hyoides. The neck is but 
little compressed, while the cord leaves its mark behind the 
ears and on the sides of the occiput. When strangulation is DEATH FROM DROWNING. 
335 
effected by a cord or cloth drawn around the neck, the latter 
will bear a mark nearly encircling it. 
In both cases, the mark may be one or two lines deep, or very 
superficial. It corresponds in width to the cord which has pro- 
duced it. It is of a dirty yellow color, hard, and with the epi- 
dermis partly rubbed off; or it is of a bluish-red color and 
soft; or it is soft and not discolored; or, very rarely, there are 
ecchymoses beneath it. The same mark may present all these 
appearances in different parts of its course. 
In cases of strangulation by the fingers, the impressions left 
by them present the same appearances, but correspond in shape 
to the fingers. 
Exactly the same appearances are seen in bodies which have 
been hung or strangled soon after death. 
Internal Examination. 
The Brain and its membranes may be congested, or there 
may be extravasation of blood, or there may be no abnormal 
appearances. 
The Neck.-In some cases, we find rupture of the cervical 
muscles, fracture of the os hyoides, fracture of the cartilages of 
the larynx, rupture of the intervertebral ligaments, fracture and 
dislocation of the cervical vertebrae, rupture of the inner and 
middle coats of the carotid arteries. Similar lesions can be 
produced in dead bodies, but only by the use of great violence. 
If death takes place from asphyxia, the larynx and trachea 
are congested and full of frothy blood and mucus; the lungs 
are congested and oedematous; the right cavities of the heart 
are full of blood ; the abdominal viscera are congested. 
There are cases of strangulation in which the results of the 
post-mortem examination are entirely negative. 
DEATH FROM DROWNING. 
In examining the bodies of persons who have been drowned, 
it is necessary to bear in mind a number of questions which 
may arise: Whether the person came into the water alive or 
dead ; how long a time has elapsed since death; whether the 336 
POST-MORTEM EXAMINATIONS. 
person committed suicide, or was drowned by accident, or was 
murdered. These questions are to be solved sometimes cer- 
tainly, sometimes with probability, sometimes not at all by the 
post-mortem examination. 
External Inspection. 
It lias been asserted that the bodies of drowned persons are 
colder than the average. The point has not, however, been 
determined by any exact thermometrical observations. 
The peculiar condition of the skin called cutis anserina is 
found very constantly before decomposition has set in, except 
in the case of new-born infants. This same appearance, how- 
ever, is frequent in persons who have died in any sudden and 
violent manner. 
Analogous to this is the retraction of the penis and scrotum 
in the male, and of the nipples in the female. Casper says 
that such a retraction is almost always present. 
We sometimes find sand, earth, weeds, etc., still grasped in 
the hands, or remaining under the nails. 
The rigor mortis appears to come on quickly; so that the 
body and limbs may be found still in the convulsed and dis- 
torted attitude which they assumed at the time of death. 
When the rigidity has passed off, the limbs become relaxed. 
After the body has been in water for 12-24 hours the hands 
and feet become of a livid, grayish-blue color. After two or 
three days this change of color becomes still more marked, and 
the skin is wrinkled in long folds. 
In new-born infants the remains of the umbilical cord will 
not be found dried and mummified, unless the child was dead 
before it was placed in the water, or unless it was three or four 
days old before it was drowned. 
Decomposition takes place sooner in summer than in winter, 
sooner in stagnant water than in a running stream. As soon 
as a body is removed from the water to the air, putrefaction 
goes on much more rapidly. In bodies which have lain in the 
water decomposition begins in the face and head and goes 
downward, instead of its usual course of first appearing in the 
abdominal wall. DEATH FROM DROWNING. 
337 
The face, scalp, and neck are of a bluish, livid color, which 
soon changes to a red. The red next becomes mottled with 
greenish spots. The greenish spots become larger, and the dis- 
coloration extends down on to the thorax. The head and neck 
are swollen, the eyelids, nose, and lips project, extravasated 
blood, either fluid or coagulated, is found in the subcutaneous 
tissue. In this decomposed and softened condition, it is often 
very difficult to distinguish between the effects of ante-mortem 
violence and those of post-mortem putrefaction. Later the 
scalp is detached from the bones. The entire body is black 
and enormously swollen; the nails drop off; the joints are se- 
parated ; the muscles are saponified; the cavities of the abdo- 
men, thorax, and head are open. 
Internal Examination. 
Persons who have been drowned usually die from asphyxia. 
Sometimes, however, they die in some unknown way, without 
any evidence of asphyxia. These latter cases are said to die 
from syncope, or from neuro-paralysis. The lesions are corre- 
spondingly different. 
The Brain.-Congestion of the brain and its membranes is 
only found in a small proportion of cases. Extravasation of 
blood has only been observed in a very few cases. 
The Air-Passages.-In persons who die from asphyxia the 
mucous membrane of the larynx, trachea, and bronchi is usu- 
ally congested, the mucous glands are distended and appear 
like little vesicles, a quantity of frothy blood and mucous fills 
the air-passages. 
In those who die from syncope, these appearances are absent. 
Foreign substances from the water, and matters regurgitated 
from the stomach, may find their way into the air-passages 
during the act of drowning, or as a post-mortem occurrence. 
The Lungs usually are much increased in size, so that they 
entirely fill the thorax and cover the heart. The increased 
size is due partly to the distention of the air-vesicles with air, 
and partly to the presence of the fluid in which the person was 
drowned, The fluid is inspired in the act of drowning. The 338 
POST-MORTEM EXAMINATIONS. 
lungs are usually congested, if the death is from asphyxia. 
They do not crepitate well, but have a spongy feeling. 
. The Heart.-In those who die from asphyxia, the right cavi- 
ties of the heart are filled with blood, while the left cavities 
are empty. 
The Blood remains unusually fluid throughout the body, and 
is of a cherry-red color. 
The Stomach.-The fluid in which the person is drowned, 
mixed with earth, weeds, etc., may be swallowed during the act 
of drowning, or may find its way into the (esophagus and stom- 
ach after death. 
The Abdominal Viscera may all be congested in those per- 
sons who die from asphyxia. 
In those persons who do not die from asphyxia, but from 
syncope or neuro-paralysis, we find no lesions. 
DEATH FROM BURNING. 
Death may be caused by the inspiration of smoke and flame; 
by the immediate effect of the burning; by secondary affections 
of the viscera; and by the exhaustion produced by the long 
continued inflammation and suppuration of the skin. 
The entire body may be burnt to a coal, or completely roast- 
ed, or only a larger or smaller area of the skin be burned. 
We find the burned skin divested of epidermis, and present- 
ing a peculiar red, hard, parchment-like appearance. If the 
patient has lived some time, this is replaced by a suppurating 
surface. Or there are small, bladder-like elevations of the 
epidermis. The base of these blisters is red, and they are sur- 
rounded by a red zone, or suppuration may have commenced. 
These appearances cannot be produced by heat applied to 
the skin after death. 
The Brain may be congested, oedematous, or softened. 
More frequently it is normal 
The Larynx and Trachea may be the seat of croupous inflam- 
mation. There may be oedema of the glottis. 
The Lungs may be congested and oedematous, or hepatized, 
or the seat of pysemic infarctions. DEATH FROM LIGHTNING. 
339 
The Peritoneum may be inflamed. 
The Duodenum may be the seat of perforating ulcers. 
The liver, Spleen, and Kidneys may be the seat of pysemic 
infarctions. 
DEATH FROM LIGHTNING. 
Persons who are struck by lightning may die instantly ; or 
may continue for several hours comatose, or delirious, and then 
either die or recover; or they may die after some time from 
the effects of the burns and injuries received. 
The post-mortem appearances are very variable. Sometimes 
there are no marks of external violence. Sometimes the clothes 
are burnt and torn, while the skin beneath them is unchanged. 
Usually there are marks of contusion and laceration, or ecchy- 
moses, or lacerated, punctured wounds, or fractures of the 
bones, or superficial or deep burns. The track of the electric 
fluid may be marked by dark-red streaks on the skin. 
The internal viscera may be lacerated and disorganized in 
the same way. DEATH FBOM POISONING. 
These examinations should be made with even more than the 
usual care. The external inspection of the body and the ex- 
amination of all the viscera should be thorough and detailed. 
Every appearance should be noted at the time and nothing left 
to the memory. 
The stomach and intestines should be removed from the body 
and opened in separate clean vessels. After examining the ap- 
pearance of these organs, they should be placed each with its 
contents in clean glass jars, without the addition of any foreign 
fluid. Portions of the liver, spleen, kidneys, and brain should 
also be placed in separate glass jars. All these jars should be 
closely corked and sealed until they are given to the chemist 
for his examination. 
It is important to remember that many poisons destroy life 
without producing any lesions, and that many cases of sudden 
death occur without any discoverable cause and without the 
possibility of poisoning. 
In bodies which are exhumed for examination, the preserva- 
tion of the viscera for chemical examination is often all that 
can be done. All the tissues may be so changed that it is im- 
possible to say what lesions have or have not existed. 
SULPHURIC ACID. 
The effects of this poison vary with the amount taken, and 
its strength. Death usually takes place in from eighteen to 
twenty-four hours. Cases are recorded in which death took 
place in three quarters of an hour. When the poison is less in- 
itense, the patient may survive for several months. DEATH FROM POISONING. 
341 
The skin of the face about the mouth may be blackened 
and charred by the acid. The mouth and pharynx are of a 
grayish or blackish color, while the deeper tissues are reddened. 
Sometimes these regions escape the action of the poison. 
The larynx, trachea, and lungs are sometimes acted on, soft- 
ened and blackened by the accidental passage of the acid into 
them. This may even take place when the acid does not pass 
into the oesophagus. 
The oesophagus seldom escapes. It is grayish or blackish co- 
lored, softened, and the mucous membrane comes off in shreds. 
If life is prolonged, cicatrices and strictures are formed. 
The stomach is coated on its internal surface with a black, 
sticky layer beneath which the mucous membrane is reddened. 
Sometimes perforation takes place, and the acid blackens and 
softens the adjoining viscera. In protracted cases, cicatrices 
are formed, and the organ is contracted. If the poison is dilute, 
there may be only the lesions of chronic gastritis. 
The blood is thickened, syrupy, acid, and may form thrombi 
in the vessels. 
The body may be partially preserved from decomposition. 
Fatty degeneration of the renal epithelium is mentioned by 
some authors. 
Sulphate of Indigo produces the same lesions as sulphuric 
acid. It also stains the tissues of a dark blue color. 
NITRIC ACID. 
The surface of the mucous membrane of the mouth, pharynx, 
and oesophagus is covered with yellow eschars wherever the acid 
has touched it. Beneath and around the eschars the tissues are 
congested and red. The poison may be introduced into the 
oesophagus without acting on' the mouth. The stomach con- 
tains a viscous, sanguinolent, yellow or greenish fluid. The 
mucous membrane is congested, red, swollen, and softened, 
ecchymotic. It is rarely perforated. 
The duodenum may be inflamed, and the inflammation ex- 
tend to its peritoneal coat. The rest of the intestines usually 
escapes from the action of the acid. 342 
POST-MORTEM EXAMINATIONS. 
The larynx is very frequently acted on by the acid. There 
are yellow eschars, congestion and swelling of the mucous 
membrane, sometimes oedema of the glottis. The trachea may 
be inflamed, and the lungs congested. 
If the patient survives the first effects of the poison, the 
lesions of chronic •inflammation, cicatrization and contraction 
are found at a later period. 
The acid nitrate of mercury, if taken in a concentrated form 
into the stomach, produces the same lesions as nitric acid. 
HYDRO-CHLORIC ACID. 
The lesions are much the same as those produced by nitric 
and sulphuric acids. The eschars are of a whiter color, and it 
is more common to find false membranes on the inflamed sur- 
faces. 
OXALIO ACID. 
The dose of this poison which may destroy life is variable. 
Sixty grains may prove fatal, an ounce may not cause death. 
The same amount of poison does not always cause death at 
the same period. Three minutes and twenty-three days are 
the extremes; an hour is the usual time. The mucous mem- 
brane of the mouth, pharynx, and oesophagus is white, or coated 
with brown vomit from the stomach. The stomach contains a 
dark brown, mucous fluid. The mucous membrane is pale, 
softened, brittle, and looking as if it had been boiled in water. 
Sometimes the mucous membrane is red and congested, some- 
times it is blackened and gangrenous. If life is prolonged, the 
whitened condition of the mucous membrane is succeeded by 
congestion and inflammation. 
The duodenum may be inflamed. In some cases of death 
from this poison, there are no well marked lesions. 
Oxalate of potash produces the same lesions as oxalic acid. 
This acid is seldom used as a poison. In large doses, it may 
prove fatal. 
TARTARIC ACID. DEATH FROM POISONING. 
343 
The lesions in the cases observed were inflammation and red- 
ness of the entire alimentary canal. . 
POTASH.-SODA. 
These alkalies and their carbonates are rarely used as poisons. 
They may destroy life in a few hours, or not until after several 
weeks. 
The mucous membrane of the mouth, pharynx, oesophagus, 
and stomach is blackened and softened in patches, swollen, 
congested, and inflamed. The larynx and trachea may also be 
inflamed and swollen. If life is prolonged, cicatrices and 
strictures of the oesophagus and stomach are produced. 
AMMONIA. 
The vapor of strong ammonia may cause death from inflam- 
mation of the larynx and air-passages. 
The strong solution of ammonia produces corrosion and in- 
flammation of the mouth, oesophagus, and stomach. The larynx, 
trachea, and bronchi are frequently inflamed, and may be coat- 
ed with false membranes. 
I have seen fatal inflammation of the rectum and colon pro- 
duced by an enema of strong solution of ammonia. 
NITRATE OF POTASH. 
This salt may prove poisonous in large doses. In the cases 
which have been observed, there was intense congestion and 
inflammation of the stomach, and in one case perforation of 
that organ. 
PHOSPHORUS. 
This substance has come into very common use as a poison, 
especially in Germany. The heads of lucifer matches are the 
favorite form of administering it. It is more commonly used 
to effect suicide than to destroy the lives of others. 
The poison acts very differently in different cases. In some 344 
POST-MORTEM EXAMINATIONS. 
cases, the ingestion of the poison is followed in a few minutes 
by vomiting, and the patient dies in a few hours. In other 
cases, there is at first vomiting, then very few symptoms until 
the third day. At that time the vomiting returns, there is 
jaundice, great prostration, syncope, delirium, and coma. In 
other cases, again, there may be no symptoms whatever for 
several days. Not infrequently there are no severe symptoms, 
and the patient suddenly and unexpectedly dies. 
The post-mortem appearances vary according to the length 
of time which elapses before death. 
If death takes place in a few hours, the only lesions are 
those produced by the direct action of the poison. The mouth, 
pharynx, and oesophagus usually escape. The stomach may be 
only slightly reddened, or there may be patches of inflammation 
and erosion. The contents of the stomach are often mixed with 
blood, and may have the peculiar smell of phosphorus. There 
may be little bits of wood present when the poison has been 
taken on the heads of lucifer matches.^ It is said that the 
mucous membrane of the stomach may emit a phosphorescent 
light in the dark. 
If death does not ensue until after several days, the lesions 
are more marked. The body is usually jaundiced. There may 
be ecchymoses beneath the pericardium, pleura, and peritoneum, 
in the lungs, the kidneys, the bladder, the uterus, the muscles, 
and the subcutaneous connective tissue. 
The Stomach usually presents no very striking changes. There 
may be small circumscribed spots of inflammation and erosion. 
The most constant change is a granular degeneration of the 
cells which fill the gastric follicles. In consequence of this, 
the mucous membrane appears thickened, opaque, of white, 
gray, or yellow color. 
The small intestine appears normal or is congested. 
The Liver is found in different degrees of granular and fatty 
degeneration, and is often stained yellow from the jaundice. 
It is increased in size and of a grayish, grayish-yellow, or light 
yellow color, unless stained by the jaundice. Less frequently 
the centres of the acini are congested, or the entire liver is con- 
gested, or there are small haemorrhages in the liver tissue. The DEATH FROM POISONING. 
345 
consistence of the organ is at first flabby; in the later stages, 
that of the ordinary fatty liver. 
The hepatic cells are increased in size, granular, and, after a 
time, contain small oil-globules. The oil-globules afterward 
increase in size and number, but do not fuse together to fill 
each cell with a single oil-globule, as in the ordinary fatty liver. 
Finally there may be breaking down of the cells into a mass of 
fat and granules. 
In the interstitial tissue of the liver, we may find collections 
of lymphoid cells, also in the adventitia of the branches of the 
portal vein, and in the lobules. 
The Kidneys.-There is often granular and fatty degenera- 
tion of the epithelium of the tubes. 
There may be granular degeneration of the voluntary muscu- 
lar fibres throughout the body and in the heart. 
ARSENIC. 
From two to three grains of arsenious acid is usually consi- 
dered a fatal dose. But persons have recovered after taking a 
much larger quantity. 
Death usually takes place in from eighteen hours to three 
days. But persons have died within twenty minutes, and others 
not for twenty days. 
The mouth, pharynx, and oesophagus may be inflamed, but 
are more frequently unaltered. 
The stomach may be empty, or contain mucus mixed with 
blood. The arsenic in substance may be found adherent to the 
mucous membrane. The entire inner surface may be red and 
inflamed, or there are patches or streaks of congestion. The 
inflamed patches may be thickened and covered with false 
membrane. There may be acute gastritis even when the poison 
is absorbed by the skin, and not introduced into the stomach; 
Taylor mentions a case in which the coats of the stomach were 
thickened and gelatinous, but not congested; or there may be 
degeneration of the gastric follicles as in phosphorus poisoning. 
The entire length of the intestine may be congested and in- 
flamed, but usually the action of the poison does not extend 
beyond the duodenum. In some cases, the solitary and agmin- 346 
POST-MORTEM EXAMINATION'S. 
ated follicles are swollen, and the intestines contain white, 
rice-water fluid. 
The coats of the stomach are often preserved from decompo- 
sition for a long time after death. Death may be produced by 
arsenic without any well marked lesions. 
Arsenite of Copper, Scheele's Green, Paris Green is a favo- 
rite article in New-York for producing suicide. It is usually 
taken in considerable quantities, and is often found in the 
stomach after death. The lesions are the same as those pro- 
duced by arsenious acid. 
The sulphide and chloride of arsenic are sometimes used as 
poisons. The lesions are the same as those of arsenious acid. 
CORROSIVE SUBLIMATE. 
The mucous membrane of the mouth is swollen and whitened. 
The oesophagus is swollen and white, or congested, or is un- 
altered. 
The stomach is usually contracted. There are inflamed and 
congested, sometimes gangrenous, patches of the mucous coat. 
Perforation is said to have occurred in one case. Small ecchy- 
moses in the mucous coat are not uncommon. Sometimes 
hardly any change can be appreciated. 
The intestines may appear normal, or there may be patches 
of congestion and ecchymoses. The larynx and trachea may be 
red and congested. 
The kidneys may exhibit granular and fatty degeneration of 
the epithelium. 
LEAD. 
The different preparations of lead may prove fatal either 
from the immediate effect of large doses, or from the gradual 
effects of repeated small doses. Although there may be marked 
symptoms during life, the post-mortem lesions are few and 
variable. 
Large doses may produce acute gastritis. The kidneys are 
sometimes the seat of fatty degeneration. Chronic lead poison- 
ing may lead to chronic meningitis and changes in the brain 
substance. DEATH FROM POISONING. 
347 
COPPER. 
Sulphate of copper and verdigris are sometimes employed as 
poisons. The post-mortem appearances have only been ob- 
served in a moderate number of cases. The pharynx and 
oesophagus may be unchanged, or be somewhat inflamed. The 
stomach may be unchanged, or bits of the copper may adhere to 
its mucous coat; and there may be patches of inflammation, 
of gangrene, and even of perforation. 
TARTAR EMETIC. 
This preparation of antimony may prove fatal when admin- 
istered in a single large dose, or in repeated small doses. 
The post-mortem lesions are not constant. In cases of 
chronic poisoning there are usually no appreciable lesions. 
In cases of acute poisoning there may be evidences of acute 
inflammation of the oesophagus, stomach, intestines, and peri- 
toneum. The larynx may be congested, and the lungs may be 
engorged with blood. But none of these lesions are constant. 
VEGETABLE IRRITANTS. 
Aloes, colocynth, gamboge, jalap, scammony, savin, croton- 
oil, colchicum, veratria, turpentine. 
All these drugs sometimes produce poisonous effects. 
Vomiting, purging, and prostration are the usual symptoms. 
Congestion and inflammation of the stomach and intestines are 
the lesions which would be naturally looked for; but these 
lesions are sometimes present, sometimes absent. 
CANTHARIDES. 
This substance may be given in powder or in tincture. 
The entire length of the alimentary canal may be found 
congested and inflamed. The kidneys, ureters, and bladder 
may be congested and inflamed. 348 
POST-MORTEM EXAMINATIONS. 
OPIUM. 
The post-mortem appearances in persons who have been 
killed by any of the preparations of opium are negative. Con- 
gestion of the brain and of the lungs are spoken of by most 
authors, but they seem to depend principally on the way in 
which the patient dies, rather than on any specific action of 
the drug. 
HYDROCYANIC ACID. 
Fatal doses of this poison destroy life in a very few minutes. 
The skin is usually livid, the muscles contracted. The 
stomach may be congested, and the venous system generally is 
unusually full of blood. The most characteristic condition, 
when it is present, is the odor of the acid exhaled from the 
stomach and tissues. This odor may remain for a long time 
after death. Cyanide of potash destroys life in the same way 
as hydrocyanic acid. The lesions are equally uncertain. The 
tissues and stomach often exhale the same smell of bitter 
almonds. 
Nitro-benzole produces the same symptoms and lesions as 
prussic acid. The odor of bitter almonds in the tissues is even 
more intense. 
ALCOHOL. 
The different preparations of alcohol, when taken in large 
cpiantities, sometimes produce sudden coma and death in from 
half an hour to several hours. 
The bodies are said to resist decomposition for an unusual 
length of time. The stomach and tissues often have an alco- 
holic smell. There is congestion, and sometimes extravasation 
of blood in the brain and its membranes. The veins every- 
where are full of blood. The bladder may be distended with 
urine. 
Chronic alcoholic poisoning is of a different nature. The sub- 
jects of it may die from some other disease, or they die after a 
debauch without any thing else to account for their death. In 
the latter case, there may be delirium tremens, or the patient 
dies exhausted and comatose. Chronic alcoholism is not infre- DEATH FROM POISONING. 
349 
quently mistaken for meningitis. The dura mater is frequent- 
ly adherent to the skull. The pia mater is thickened and 
white, sometimes oedematous. The brain usually appears nor- 
mal. 
The lungs are usually congested. 
The heart is thickly covered with fat, and flabby. The 
stomach presents the lesions of chronic gastritis. 
The liver is fatty, cirrhosed, or both. 
The kidneys are in a condition of simple granular or fatty 
degeneration, or the seat of diffuse nephritis. 
CHLOROFORM. ETHER. 
Chloroform may cause death when it is inhaled, and when it 
is taken in a fluid form into the stomach. 
Death from the inhalation of chloroform has become a tol- 
erably frequent accident in surgical practice. A very consi- 
derable number of post-mortem examinations of such cases have 
been recorded. They show that there is no constant or cha- 
racteristic lesion, nor is there any satisfactory explanation of 
the way in which such persons meet their death. 
Death from the swallowing of liquid chloroform is rare. 
Taylor gives a case in which a drachm killed a boy four years 
old. Adults can take with impunity a much larger quantity. 
I have seen one case in which four ounces proved fatal to a 
woman in a few hours. After death, there was a strong odor 
of chloroform when the stomach and duodenum were opened. 
The stomach was half full of undigested food. There were 
no lesions. Other cases are reported in which there was in- 
flammation of the stomach, and one case in which the liquid 
had passed into the larynx and trachea, producing intense in- 
flammation. 
Ether, given by inhalation, occasionally causes death. The 
post-mortem signs are negative. 
There is one death recorded by Casper, from its use in a 
fluid form. The cavities of the body exhaled a strong smell of 
ether ; otherwise, there were no lesions. 350 
POST-MORTEM EXAMINATIONS. 
STRYCHNIA. NUX VOMICA. 
We possess very few good records of post-mortem examina- 
tions after death from these poisons. The contraction of the 
muscles, which exists during life, disappears after death. There 
may be excessive congestion of the membranes of the brain. 
Casper mentions a peculiar violet color of the muscles of the 
pharynx and oesophagus. Otherwise there are no lesions. 
CONIUM, ACONITE, BELLADONNA, LOBELIA INFLATA, DIGITALIS, 
STRAMONIUM, VERATRUM. 
These vegetable poisons are administered in their natural 
form of leaves, berries, and roots, or in tinctures, infusions, and 
extracts, or in the form of their active alkaloid principles. 
If the leaves, berries, or seeds are given, they may be de- 
tected in the contents of the stomach by microscopic examina- 
tion. Otherwise the results of autopsies are unreliable. 
The brain and its membranes, and the lungs, may be con- 
gested. The stomach may present patches of congestion, in- 
flammation, and extravasation, or its entire mucous coat may 
be inflamed, or it may appear normal. 
CARBONIC OXIDE. 
This gas is produced from burning charcoal, and forms the 
poisonous ingredient of illuminating gas. It is usually used as 
a poison in one of these forms. 
The most characteristic post-mortem appearance is that of 
the blood, which is of a brilliant red color. The muscles and 
viscera also appear red from the color of the blood in them. 
The viscera present the same changes as in death from suffo- 
cation. 
CARBOLIC ACID. 
A number of cases of death from this poison have been re- 
ported during the last few years. It acts as a corrosive poison 
on the mucous membrane of the mouth, pharynx, oesophagus, 
stomach, and intestines, producing white eschars with intense 
congestion. The lungs are usually intensely congested. PART IV. 
TUMORS. TUMORS. 
Any classification of tumors which can be given, at the pre- 
sent time, is in'great measure a provisional one. Our know- 
ledge of these growths is not yet sufficient to enable us to speak 
of them with certainty. There can be no doubt, however, of 
the proper method in which the study of tumors should be pur- 
sued in order to arrive at more complete results. We know 
that all new growths are composed of the same anatomical ele- 
ments as exist in the normal tissues, although their arrangement 
and mode of growth may be different. We know that no ana- 
tomical element, whether existing in a normal tissue or in a 
pathological new growth, has any inherent malignant or benig- 
nant properties. We know that no grouping or arrangement of 
such indifferent elements can give them any specific properties. 
The only scientific plan, therefore, is to begin at the beginning; 
to find out, by patient study, what is the exact structure, the 
mode of growth, and the relationship to the surrounding tissues 
of every new growth which can be observed. To this we must 
add in each case the clinical history, the age and condition of 
the patient, the situation of the new growth, whether it recurs 
after extirpation, whether it grows slowly or rapidly, whether 
it invades neighboring tissues, whether metastatic tumors of the 
same nature are formed in other organs. By an accumulation 
of such facts as these, we arrive nearer and nearer to an exact 
knowledge of tumors. The number of existing observations is 
already sufficient to enable us, from the anatomy of a tumor, 
its situation, and the history of its growth, to give a prognosis 
with greater certainty than can be done in most diseases. 
To classify tumors, therefore, we merely group them accord- 
ing to our present knowledge of their anatomy, with the expec- 
tation that this grouping is to be much changed by future in- 
vestigations. We are especially hindered at the present time; 354 
PbST-MORTEM EXAMINATIONS. 
by the prevailing uncertainty as to the exact anatomy of con- 
nective tissue. 
The classification and names of tumors which I give are, with 
some modifications, those proposed by Virchow, and adopted at 
the present day by most pathologists. 
We divide tumors into four classes : 
I. The Cysts. 
II. The simple Tissue Tumors. 
III. The Composite Tissue Tumors. 
IV. The Cellular Tumors. 
I. THE CYSTS. 
Cysts are of three kinds : (1.) Those which are formed in pre- 
existing cavities. (2.) Those which are new formations. (3.) 
Those which are formed by an abnormal development of the 
foetal tissues. 
(1.) Those which are formed in preexisting cavities : Extra- 
vasation, exudation, and retention cysts. 
The extravasation cysts are formed by the escape of blood 
into the serous sacs and natural cavities of the body. They 
are also called haematoma and haematocele. 
The exudation cysts are formed by the exudation of serum 
into the serous sacs and natural cavities of the body. They are 
also called hydrocele and hygroma. 
The retention cysts are formed by the retention of the excre- 
tions of glands and the consequent dilatation of their follicles 
and ducts. They are subdivided into follicular cysts, mucous 
cysts, and retention cysts of large ducts. 
To the follicular cysts belong the forms called comedo, 
milium, molluscum, and atheroma. Atheroma (encysted tu- 
mor) is the only one of these which is usually classed with the 
tumors. It is formed by the closure of the mouth of a hair 
follicle. In consequence of this, the hair follicle itself, and the 
sebaceous glands which open into it, are dilated. In this way is 
formed a cyst with a smooth wall and cheesy contents. The 
contents are made up of fat, epidermis, granular matter, and 
cholesterine. TUMORS. 
355 
The Mucous Cysts are formed by the dilatation of mucous 
glands. They may be single, or composite from the dilatation 
of several follicles. They may project so as to form a sort of 
polypus. They are found in the mucous membrane of the 
mouth, pharynx, nose, antrum, cervix uteri, vagina, and alimen- 
tary canal. 
The retention cysts of larger canals are formed by dilatation 
of the ducts of the salivary glands, the pancreas, the mamma, 
the tubes of the kidney, etc. 
(2.) The cysts of new formation. 
(a.) Cysts produced by softening. 
Portions of solid tissue, either normal or pathological, may 
become softened and fluid, and in this way cysts be form- 
ed. Thus we find cysts full of fluid fat in fatty tumors; cysts 
full of mucus or serum in fibromata, chondromata, and myoma- 
ta. In the sarcomata and carcinomata, this process is especially 
common. The most common ways in which the process takes 
place are by mucous degeneration of the tissue, or by a sort of 
circumscribed oedema. 
With these cysts may also be classed those formed in the 
thyroid gland, and in adenomata of the ovaries by a colloid de- 
generation of the cells lining the gland follicles. 
(b.) Cysts, properly speaking, cystoma. 
These cysts maybe produced by the irritation of extravasated 
blood, or of a foreign body. 
Or continued pressure on some part induces irritation and an 
accumulation of serum. Thus are formed the false bursae 
under corns, etc. 
Or cysts are formed as new growths in connective tissue in 
methods which are yet unknown to us. It is probable that 
some cysts are formed by dilatation of the lymphatic vessels. 
(3.) Dermoid Cysts.-In these cysts, the internal surface of the 
cyst wall has the same structure as the skin. We find in the 
cyst-wall hair and sebaceous follicles, sweat-glands, papillae, and 
an internal covering of epithelium. The cysts contain a gru- 
mous fluid in which are epithelium, fat, cholesterine, hair, teeth, 
cartilage, and bone. 
It is now generally held that these cysts are formed before 356 
POST-MORTEM EXAMINATIONS. 
birth by some change in the development of the tissues of the 
foetus. They are usually situated in the subcutaneous tissue. 
They are found in the orbit, in the floor of the mouth, in the 
neck, and less frequently in other regions. They are also found 
in the ovaries, the testicles, the membranes and the substance 
of the brain, the eye, the anterior mediastinum, the lungs, the 
mesentery and omentum, and around the uterus. 
Cysts lined with ciliated epithelium are found in the brain, 
the external ear, the liver, and the testicles. They have proba- 
bly the same nature as the dermoid cysts. 
II. SIMPLE TISSUE TUMORS. 
Fibroma, 
Myxoma, 
Lipoma, 
Chondroma, 
Osteoid- Chondroma, 
Osteoma, 
Myoma, 
Glioma, 
Psammoma, 
Neuroma. 
I. Fibroma.-Fibrous tumors. 
These are tumors composed of connective tissue fibres and 
cells ; the cells in small numbers. According to their external 
form we distinguish: 
(1.) Fibroma nodosum.-The tumors are rounded and 
nodular, composed of dense fibrous tissue. 
(2.) Fibroma diffusum, or Elephantiasis.-There is a diffused 
new growth of fibrous tissue from the deep layers of the cutis. 
(3.) Fibroma papillare, Papilloma.-The tumors are hyper 
trophies of normal papillae, or grow from surfaces where no 
papillae exist. They form papillary, or polypoid growths, often 
composed of branching tufts. They consist of a central stroma 
of connective tissue, often of the branched variety, with many 
round cells, and are covered with epithelium. These tumors grow TUMORS. 
357 
from the surface of the skin and of the mucous membranes, from 
the internal surface of the milk-ducts in the mamma, and from 
the walls of some cysts. They constitute a large part of the 
growths commonly called polypi. 
All the fibromata are, as a rule, local growths of a benignant 
character. 
II. Myxoma.-Fibro-cellular tumors, colloid. 
This name is given to tumors which are formed of mucous 
tissue. Mucous tissue consists of round, fusiform, and stellate 
cells imbedded in a gelatinous, transparent, mucine-yielding 
basement substance. It is found in the umbilical cord, in the 
foetus as the first stage of adipose tissue, and in the adult in the 
vitreous body. 
The myxomata are tumors of irregular form, lobulated, hav- 
ing a peculiar soft, gelatinous, semi-transparent appearance. 
They are identical in their minute structure with that of normal 
mucous tissue. They are but seldom found as pure myxomata. 
It is much more common to find combinations with lipoma, 
chondroma, fibroma, and sarcoma. 
These tumors occur most frequently in adult life, but are 
sometimes congenital. They usually grow as isolated tumors, 
except on the nerves, where they are multiple. They grow 
slowly ; may attain a large size; are either inclosed in a fibrous 
capsule, or invade the neighboring soft parts. 
The pure, uncombined myxomata have a merely local signifi- 
cance, but sometimes recur after extirpation. The combination 
forms with sarcoma, etc., have, on the other hand, well marked 
malignant characteristics, recur after extirpation, and form me- 
tastatic tumors. 
These tumors occur most frequently in the adipose tissue of 
the thigh, cheek, nates, hand, labia, mesentery, peritoneum, and 
pelvis of the kidney. In the female mamma, as intra-canalicu- 
lar growths; in the parotid gland; in the brain, spinal cord, 
and nerves; and in the bones, especially the maxillary bones, 
these tumors are not infrequently observed. The degeneration 
of the chorion, commonly called the hydatid mole, is classed by 
Virchow with these tumors. The umbilicus in children some- 
times gives rise to these tumors. 358 
POST-MORTEM EXAMINATIONS. 
III. Lipoma.-Fatty tumors. 
This name is given to tumors composed of adipose tissue ; that 
is, of a stroma of connective tissue containing fat-cells. 
These tumors are of irregular shape, always lobulated, soft, 
movable, and may attain a great size. 
They may undergo calcification, ossification, may soften so as 
to form oil-cysts, and may become the seat of chronic inflam- 
mation and suppuration. 
The most important combination of the lipomata is with the 
myxomata. 
The lipomata may be single or multiple. They occur most 
frequently in adults, but are found in all ages and congenitally. 
They are sometimes hereditary. They are purely local, benign 
tumors. 
They arise in preexisting adipose tissue. They are found 
very frequently in the subcutaneous adipose tissue in all parts 
of the body; between the muscles; beneath the serous mem- 
branes, especially the peritoneum; beneath the synovial mem- 
branes, protruding into the cavities of the joints ; beneath the 
mucous membrane of the mouth, trachea, bronchi, stomach, in- 
testines ; in the female mamma ; in the kidneys; in the pia ma- 
ter ; and in the scrotum and labia. These tumors, when grow- 
ing beneath the skin, or the synovial, mucous, and serous mem- 
branes, may assume a polypoid form with a narrow pedicle. 
This pedicle may sometimes atrophy and leave the tumors free 
in the peritoneal or joint cavities. 
IV. Chondroma.-Cartilaginous tumors. 
These tumors are composed of cartilage. The cartilage-cells 
may resemble those of normal cartilage, or may be deformed. 
The basement substance is hyaline, fibrous, mucous, or calcified. 
The tumors are inclosed in a fibrous capsule, lobulated, and 
divided up by bands of fibrous tissue. 
We may distinguish two varieties : 
The Ecchondroses and the Enchondromata. The ecchon- 
droses grow from the permanent cartilages of the ribs, the 
synchondroses, the inter-vertebral cartilages, and the cartilages 
of the larynx and trachea. They only reach a small size, and 
have but little importance. TUMORS. 
359 
The enchondromata most frequently grow from the medulla, 
or periosteum of the bones; in the salivary glands, the testis 
and mamma, but are also found in other regions. They may 
be single or multiple. They may reach a very large size. 
They are usually local growths of a benign character; but 
cases of recurrence and of metastatic tumors have been 
observed. 
V. Osteoid-Chondroma, Osteoid Cancer.-These tumors are 
composed of bone cartilage, such as we see normally existing 
as a stage of the ossification of the flat bones of the cranium. 
The cells are smaller than cartilage-cells, the intercellular 
substance is dense, or calcified. They are found especially at 
the ends of the long bones. Local recurrences after extirpa- 
tion and metastatic tumors are not uncommon. 
VI Osteoma.-1The formation of new bone, and the in- 
crease in size of normal bones, are of common occurrence. 
Only those bony growths, however, are classed among the 
tumors, which have a considerable size, are distinctly circum- 
scribed, and are not the result of inflammatory processes. The 
tissue of these tumors is the same as that of normal bone. 
The bone may be compact and hard, or cancellous and spongy, 
or separated by cavities containing medulla. 
Many of the fibrous and cartilaginous tumors may become 
ossified partially or entirely. Combinations of fibroma, chon- 
droma, sarcoma, and carcinoma, with osteoma, are not un- 
common. 
The osteomata occur either singly or may be developed in 
large numbers at once. They are found at all periods of life, 
and are sometimes congenital. They grow slowly and inter- 
ruptedly, usually without pain. They may be hereditary, or 
be caused by a blow, or may grow at the seat of a fracture. 
Eberth describes the case of a boy, in whom sixty-five osteo- 
mata were developed in the course of a year. The tumors ap- 
peared in groups, and each group was attended by a severe 
attack of fever. 
The osteomata are tumors of purely local significance and 
benign character. 
They grow from the bones, or from, the soft tissue. Those 360 
POST-MORTEM EXAMINATIONS. 
which grow from the bones are usually called exostoses, or, if 
they arise from the medullary cavity, enostoses. 
The exostoses are developed from the periosteum, and may 
occur on any of the bones. 
On the long bones, near the insertions of the tendons, exos- 
toses sometimes occur, which resemble the epiphyses. These 
exostoses grow out in a lateral direction, are formed of cancel- 
lous bone containing medulla, are covered by a thin layer of 
cartilage, and may even be surrounded by a synovial sac. The 
name of Exostosis cartilaginea has been given to them. 
In the soft parts, osteomata are less frequent. They are 
found near to, but not connected with the bones. As small 
tumors of little significance, they are met with in the connec- 
tive tissue in different parts of the body. 
VII. Myoma.-This name is given to those tumors which 
are composed principally of muscular tissue. 
Such tumors may be composed either of voluntary or of or- 
ganic muscular fibres. The two varieties are called respectively 
Myoma striocellulare, and Myoma Isevicellulare. 
Myoma Striocellulare.-These tumors are of very rare occur- 
rence. They have only been observed in the heart. Here they 
occur in the ventricular walls as single or multiple tumors. 
Such tumors have been observed three times in new-born 
children, and once in an adult. A new growth of striated 
muscle in composite tumors, especially in the testicle, is more 
frequent. 
Myoma Lcevicelluilare.-This form of myoma is, on the other 
hand, very common. The tissue resembles that of organic mus- 
cle, long fusiform-cells running in parallel bundles, and mixed 
with a variable amount of connective tissue. The muscular 
cells may be very abundant, and the tumor be soft, of a loose, 
areolar texture and pinkish color ; or the fibrous element may 
be in excess, and the tumor be of a stony hardness, compact 
and white. 
These tumors may undergo calcification ; portions may soften 
and break down so as to form cystoid cavities; serum may ac- 
cumulate in the soft, areolar varieties so as to form cysts; por- 
tions may become gangrenous ; fatty degeneration may occur; TUMORS. 
361 
the muscular elements may atrophy and disappear, leaving only 
fibrous tissue; or the blood-vessels may become dilated, and 
form a cavernous tumor. 
Combinations of myoma laevicellulare, with cysts, sarcoma, 
and carcinoma, are not infrequent. 
The myomata may be single or multiple. They occur most 
frequently after middle age. Their growth is slow, and they 
may become stationary, or even atrophy. Their significance is 
purely local. 
The most frequent seat of these tumors is the uterus. Here 
they are found usually at the fundus, are multiple, and are 
intra-parietal, submucous or subserous. The subserous and sub- 
mucous varieties often have a polypoid form, with a small pedi- 
cle. This pedicle may atrophy, and the tumor be left uncon- 
nected with the uterus. In the cervix uteri, vagina, broad liga- 
ments and ovaries, these tumors are less common. 
Less frequently, myomata are found in the oesophagus, 
stomach, and intestines. A certain number of the enlarge- 
ments of the prostate are due to the growth of myomata in this 
organ. 
VIII. Glioma.-This name is given to tumors which are 
composed of neuroglia. The neuroglia is the connective tissue 
of the brain. It is composed of a basement substance, which is 
amorphous and finely granular, or fibrillated, and of small, 
pale, round and oval cells, imbedded in the basement substance. 
The gliomata are composed of this same tissue, but with an 
increased number of cells. They are found in the brain, cranial 
nerves, and spinal cord. They look rather like hypertrophies 
of some portion of the brain than like separate new growths. 
Their consistence is soft and mottled by small haemorrhages, or 
hard, with a denser basement substance. 
There is a form of retinal tumor, to which the name of 
glioma is also usually given, but which seems to belong more 
properly to the sarcomata. 
IX. Psammoma.-This name has been given to a form 
of tumor which occurs in the brain, usually growing from 
the dura mater. The growths are composed of bands of 
fibrous tissue, of small, round cells, fusiform cells, and cells 362 
PO^T-MORTEM EXAMINATIONS. 
resembling the epithelium of the dura mater; of blood- 
vessels, which may be solid or calcified; and of peculiar 
rounded, laminated bodies, which are partly or entirely 
calcified. These latter bodies are found normally in the 
ependyma and choroid plexus of the brain, where they are 
called brain-sand. It is from them that the tumor is named. 
Although these tumors are of not very infrequent occurrence, 
and many observations of them have been published, their real 
nature is still very uncertain. It is convenient, for the present, 
to give them all this common name, although it is quite possi- 
ble they may belong to different classes. 
X. Xeuroma.-This name is applied to tumors which are 
composed of nervous tissue. Such tumors are found on the 
course of the nerves. They are not to be confounded with 
tumors of different structure-fibromata, myxomata, etc., 
which also occur on the nerves. 
We distinguish two varieties according to the character of 
the nerve fibres. Neuroma myelinicum, composed of nerve- 
fibres, in which the white substance of Schwann is present. 
Neuroma amyelinicum, composed of small, gray nerve fibres, 
without the white substance of Schwann. 
Those of the first kind are much the easiest to recognize and 
demonstrate. 
Those of the second kind resemble very closely connective 
tissue. 
III. COMPOSITE TISSUE TUMORS. 
These are tumors composed, not merely of a simple tissue held 
together by connective tissue, but of several different tissues 
forming an organoid growth. We distinguish : 
Angioma^ 
Adenoma. 
I. Angioma.-This name is given to tumors which are princi- 
pally composed of a new growth of vessels. We distinguish 
three varieties : The Simple Angioma, the Cavernous Angioma, 
and the Cavernous Lymph-Angioma. TUMORS. 
363 
(1.) The Simple Angioma. These tumors are formed of a 
new growth of capillary vessels. They are situated in the skin, 
or in the subcutaneous tissue. The angiomata of the skin 
(nsevi) form flattened, red growths in the skin, not separated 
from the surrounding tissue, and gradually replacing the skin 
tissue. Those in the subcutaneous tissue are more circumscribed 
and nodular. They may be joined with a new growth of fatty 
tissue. The simple angiomata are, as a rule, congenital. 
(2.) The Cavernous Angioma is formed of a connective tissue 
stroma in which are numerous cavities, communicating with 
each other, and filled with blood. The inner surface of these 
cavities is lined with endothelium. The blood in the cavities is 
usually dark-colored and venous. They communicate with 
small arteries and veins, or with large arteries and veins; they 
may pulsate. They are inclosed in a fibrous capsule, or are 
continuous with the surrounding tissues. 
These growths are congenital, or are formed at any period of 
life. 
(3.) Lymph-Angioma. 
A circumscribed new growth of lymphatic vessels sometimes 
occurs. The tumor has a cavernous structure, with its cavities 
filled with lymph, instead of blood. It forms part or the whole 
of some of the hypertrophies of the tongue, lips, and cheeks. 
It is usually a congenital condition. 
II. Adenoma.-This name is given to tumors which are com- 
posed of glandular tissue, not including the lymphatic glands. 
This is a group of tumors of which the limits and character are 
not yet well determined. They are closely related in structure 
to some of the forms of epithelial cancer, and yet many of 
the growths seem to be entirely benign. 
The new glandular tissue follows the type of that of the re- 
gion where it is situated. Sometimes it is a simple hypertrophy 
of the normal glands of the part. 
In the skin, we find adenomata formed of the sebaceous 
glands and the sweat-glands. In the mucous membranes of the 
nose, stomach, intestines, rectum, gall-bladder, and cervix uteri, 
we find new growths of glandular follicles lined with cylindri- 
cal epithelium. 364 
POST-MORTEM EXAMINATION'S. 
In the mamma, there are new growths of mammary glandu- 
lar tissue. 
In the ovaries, most of the compound cysts are adenomata 
with dilatation of the follicles. The ordinary bronchocele is an 
adenoma of the thyroid gland. 
Combinations of adenoma with sarcoma and papilloma are 
not infrequent. 
rv. CELLULAR TUMORS. 
This general and indefinite name is used, because it is general 
and indefinite, to group together a number of tumors of which 
we cannot yet decide the exact relationship. We include 
under it the following varieties : 
Tubercle, 
Syphilitic Gummata, 
Lupus, 
Lymphoma, 
Sarcoma, 
Carcinoma. 
I. Tubercle.-This name is now generally applied only to the 
small, gray, miliary granulations, which we find in the serous 
and mucous membranes and in many of the viscera. Even of 
these bodies we find different descriptions by different authors. 
In the pia mater, the little tumors are formed by an accumu- 
lation of lymphoid cells between the perivascular sheath of the 
small vessels and their outer coats. 
In other situations, the growths are made up of lymphoid 
cells, fusiform cells, large, many-nucleated bodies, (myeloplaxes,) 
large flat cells with a single nucleus, and a delicate reticulum 
of branched fibrous tissue. 
Cheesy degeneration begins early at the centre of each little 
nodule. 
II. Syphilitic Gummata.-These growths stand on the border 
line between inflammatory growths and new growths proper. 
They form tumors from the size of a pin's head to that of a 
man's fist. They are composed of small, round, oval, and fusi- TUMORS. 
365 
form cells, which have a strong tendency to undergo cheesy and 
fibrous degeneration. The larger tumors are formed by an ag- 
gregation of smaller growths. They are frequently associated 
with a new growth of fibrous tissue. 
They have been observed in nearly all parts of the body. 
III. Lupus.-This new growth is usually treated of with 
diseases-of the skin. 
It consists in the formation of small round cells in the deep 
layers of the cutis. The cell-growth goes on until all the tissues 
of the skin are replaced by the round cells; then the epidermis 
falls off, and ulcers are formed. These ulcers may become deep 
and broad, and if they cicatrize and contract, produce great de- 
formities. 
The gross appearances vary according to the size and distri- 
bution of the nodules of new growth, and their tendency to 
ulceration. 
IV. Lymphoma.-This name is given to tumors which are 
composed of tissue like that of the lymphatic glands, that is, of 
a delicate reticulum of branched fibrous tissue holding together 
a great number of small, round cells. 
The growth occurs as an hypertrophy of normal glands, and 
as an heteroplastic growth in connective tissue and in the 
viscera. 
V. Sarcoma.-This name is given to tumors which are prin- 
cipally composed of connective-tissue cells. According to the 
different forms of connective tissue, we can distinguish Sarcoma 
proper, composed of round, oval, fusiform, and stellate cells, 
with a fibrous basement substance. 
Myxo-Sarcoma, composed of the same cells, the stellate form 
predominating, and of a mucous basement substance. 
Chondro-Sarcoma, composed of cartilaginous tissue, but with 
the cells greatly in excess. 
Osteo-Sarcoma, composed of osteoid tissue, with the cells in 
excess. 
Glio-Sarcoma, composed of neuroglia, with the cells in excess. 
As it is customary to speak of connective tissue proper and 
of the connective-tissue group of bone, cartilage, mucous 
tissue, and neuroglia, so we may also speak of sarcoma proper, 366 
POST-MORTEM EXAMINATIONS. 
having its type in connective tissue proper, and of myxo, chon- 
dro, osteo, and glio-sarcoma as belonging to the same group. 
Of sarcoma proper we also distinguish several varieties, ac- 
cording to the character of the cells and the amount of the 
basement substance. Thus, a sarcoma entirely composed of 
cells, with a very scanty stroma, is called a " medullary sarcoma." 
If the cells are nearly all of the spindle-shape, a sarcoma-fusocel- 
lulare. If there are many of the large nucleated bodies called 
myeloplaxes, a sarcoma gigantocellulare, etc. If the stroma 
is abundant, and the cells less numerous, we call it a fibro- 
sarcoma. 
Besides these forms, we also find tumors in which there are 
other anatomical elements in addition to those belonging to the 
connective tissue. A tumor may be partly formed of muscular 
tissue, myo-sarcoma; of glandular tissue, adeno-sarcoma; of 
fatty tissue, sarcoma lipomatodes, etc. 
Still further, Virchow has given the name of lympho-sarcoma 
to a group of tumors which begin in the lymphatic glands and 
have the same structure as them, but have the clinical history 
of sarcoma. 
These tumors may grow from any point of the body where 
connective tissue exists. They are of very frequent occurrence. 
The group is a large one; and while there are some general 
laws which all obey, there are many modifications. 
Generally speaking, these tumors are, when of small size and 
of short duration, merely local growths. If completely removed, 
they may never recur, or not until after several years. When 
they grow quickly, become of large size, and invade the neigh- 
boring tissues, they are very malignant; recur soon after extir- 
pation, and form metastatic tumors in the viscera. 
The prognosis varies also with the situation of the tumor and 
with the age and condition of the patient. 
In the case of any given tumor, therefore, in order to give an 
intelligent prognosis, it is necessary to know the situation of the 
tumor, the time which it has been growing, and the age of the 
patient, as well as the anatomical characters of the growth. 
The different forms of sarcoma have been described under 
different names by various authors. Fibro-plastic tumor, TUMORS. 
367 
myeloid, tumeur a myeloplaxes, encephaloid, cancer, etc., are 
some of the names which have been employed. 
VI. Carcinoma.-This class of tumors is one of the most im- 
portant and, at the same time, one of the least understood. 
The name was formerly used to designate any malignant tu- 
mor ; now most authors endeavor to limit it to a particular form 
of growth. 
Generally speaking, we may say that these growths are com- 
posed of a connective tissue stroma containing cavities filled 
with cells, which resemble epithelial cells. Some authors lay 
the most stress on the arrangement of the cells ; others on their 
shape. Some hold that the new growth arises from connective 
tissue ; others that it arises from normal epithelium. The pre- 
vailing idea just at present is that, both in the normal growth of 
the body and in the formation of pathological new growths, the 
different tissues are developed from the different germinal layers, 
and do not intermix. Consequently new growths of epithelium 
can only arise from preexisting epithelium. 
We may distinguish three varieties : Epithelioma, true carci- 
noma, colloid carcinoma. 
(1.) Epithelioma. Although at present the tendency is to 
call all the carcinomata epithelial growths, it is convenient to 
group together a certain number in which this structure is most 
regular. The epithelial cancers follow the type of the epithe- 
lium near which they grow. Those of the skin, mouth, and 
vagina are formed of large pavement epithelium. Those of the 
nares, larynx, alimentary canal, and bladder are formed of 
cylindrical epithelium. Those of the conjunctiva are formed of 
small pavement epithelium. 
The large pavement epithelial cells are usually packed closely 
together in large, irregular follicles, some of the cells being 
packed into concentric nests. 
The cylindrical epithelial cells are more regularly disposed in 
tubular follicles, or covering tufts. 
The small pavement epithelium usually covers small tufts. 
These epithelial cancers resemble the adenomata on the one 
side, and the true carcinomata on the other. They are usually 368 
POST-MORTEM EXAMINATIONS. 
looked upon as less malignant than the true carcinomata, but 
their prognosis is by no means good. 
(2.) True carcinoma consists of a connective tissue stroma and 
cells. If the stroma is abundant and dense, the growth is called 
scirrhus; if the cells are abundant and the stroma scanty, the 
growth is called medullary. The cells do not exactly resemble 
normal epithelium, although they have that general character, 
but are often malformed in various ways. They are contained 
in regular tubular, ovoid, or rounded alveoli; or, if the stroma is 
scanty, appear irregularly distributed. 
The prognosis of these growths is bad. 
(3.) Colloid Carcinoma. These growths have a gelatinous ap- 
pearance and consistence. They are formed of a fibrous stroma, 
which forms small, rounded cavities filled with colloid matter 
and cells. The cells resemble pavement epithelium ; they are 
numerous, few, or absent. The colloid matter is said to be 
formed by a change in the cells; but in some of the smallest 
and youngest growths, we find alveoli filled with colloid matter 
and no cells. 
The prognosis of these growths is bad. INDEX. 
A 
PAGE 
Abdomen, Examination of 14, 21 
Aconite, Poisoning by 350 
Adenoma 363 
Addison's Disease 327 
Alcohol, Poisoning by 348 
Ammonia, Poisoning by 343 
Anencephalia 52 
Aneurism 114 
Aneurism, Spurious 119 
Aneurism, Varicose 119 
Aneurismal Varix 119 
Angioma 362 
Apoplexy, Cerebral 55 
Apoplexy, Meningeal 47 
Appendix Vermiformis ... 156 
Arsenic, Poisoning by 345 
Arteries, Atheroma of 121 
" Calcification of 122 
" Canalization of 122 
" Dilatation of 114 
" Fatty Degeneration of.. 122 
" Inflammation of 120 
" Malformations of 114 
" Rupture of 118 
" Stenosis of 117 
Waxy Degeneration of. 122 
" Wounds of 118 
Arthritis \ 296 
Ascites 167 
Atheroma 121, 354 
B 
Belladonna, Poisoning by 350 
Bile-Ducts, Carcinoma of 197 
PAGE 
Bile-Ducts, Constriction of....... 196 
" " Dilatation of 196 
" " Fibroma of 197 
" " Inflammation of 195 
Biliary Calculi 197 
Bilious Typhoid Fever 318 
Bladder, Urinary 220 
" " Carcinoma of.... 224 
" " Cysts of 224 
" " Dilatation of.... 221 
" " Diverticula of... 221 
" " Enchondroma of 224 
" " Fibroma of 223 
" " Hernia of 222 
" " Hypertrophy of.. 221 
" " Inflammation of. 222 
" " Malformations of 220 
" " Parasites of..... 225 
" " Rupture of 222 
" " Tubercles of.... 224 
Bones, Abscess of. 286 
" Angioma of 291 
" Atrophy of 279 
" Carcinoma of 294 
" Caries of 286 
" Cysts of 292 
" Enchondroma of 290 
" Fibroma of 291 
" Hyperostosis of 278 
" Hypertrophy of 278 
" Inflammation of 281 
" Malformations of 278 
" Necrosis of 287 
" Osteoid Chondroma of.... 284 
" Osteoma of 290 370 
INDEX. 
PAGE 
Bones, Osteoporosis of.. ...... 279 
" Parasites of. 295 
" Rickets 287 
" Sarcoma of 292 
" Sclerosis of 279 
" Tubercles of 292 
Brain, Abscess of 57 
" Atrophy of 54 
" Carcinoma of 59 
" Convolutions of 12 
" Embolism of 56 
" Examination of 11 
" Glioma of 59 
" Haemorrhage of 55 
" Hypertrophy of 53 
" Inflammation of 55-58 
" Injuries of.. 54 
" Malformations of 52 
" Melanaemia , 59 
" (Edema of 59 
" Sarcoma of 59 
" Sclerosis of 58 
" Thrombosis 56 
" Tumors 59 
" The Ventricles of 49 
" Yellow Softening of 58 
Bright's Disease 209 
Bronchi, Dilatation of 72 
" Examination of 19 
" Inflammation of 70 
" Stenosis of 74 
" Tumors of 74 
Burning, Death by 338 
C 
Cantharides, Poisoning by 347 
Carbolic Acid, Poisoning by 350 
Carbonic Oxide, Poisoning by.... 350 
Carcinoma 367 
Cerebro-Spinal Meningitis 324 
Chloroform, Poisoning by 349 
Cholera 323 
Chondroma 358 
Choroid Plexus, Angioma of 51 
" Tumors of 51 
Colchicum, Poisoning by 347 
Colocynth, Poisoning by 347 
PAGE 
Colon, Position of 15 
Conium, Poisoning by 350 
Contusions 7 
Copper, Poisoning by 347 
Corrosive Sublimate,Poisoning by 346 
Cranium, Examination of 13 
Croton-Oil, Poisoning by 347 
Cyclopia 52 
Cystitis 222 
Cysts 354 
D 
Death, Period of. 7 
Decomposition 4 
Dermoid Cysts 355 
Diaphragm of Infants 38 
Drowning, Death by 335 
Duodenum, Examination of 25 
Dura Mater, Carcinoma of. 46 
" Cysts of 45 
" Examination of.... 10 
" Gummy Tumors of. 45 
" Haemorrhage of. ... 43 
" Inflammation of.... 44 
" " Osteoma of 45 
" Psammoma of. 45 
" Sarcoma of 46 
" Sinuses of 43 
" Tumors of 45 
Dysentery 155 
E 
Ecchymoses 8 
Embolism 305 
Encephalitis, Interstitial 58 
Enchondroma 358 
Endarteriitis 121 
Endocarditis 106 
Endometritis 242 
Endophlebitis 125 
Ependyma, Inflammation of 51 
" . Tumors of 51 
Epithelioma 367 
Ether, Poisoning by 349 
External Inspection of the Body. 3 
Extra-uterine Pregnancy 258 
Eyes, Examination of 13 INDEX. 
371 
F 
PAGE 
Fallopian Tubes, Carcinoma of... 258 
" " Cysts of 257 
" " Dilatation of 
256, 257 
" " Examination of 31 
" " Fibroma of. ... 258 
" " Haemorrhage of 256 
" " Inflammation of 257 
" " Lipoma of 258 
" " Malformationsof 256 
" " Myoma of 255 
Farcy 329 
Fibroma 356 
Fractures 9 
G 
Gastritis 139 
Genito-Urinary Organs 29 
Glanders 329 
Glioma 361 
Gout 329 
Gummy Tumors 364 
H 
Haematocele 266, 241 
Haemorrhoids 160 
Head, Examination of 9, 17, 35 
Heart, Abscess of 105 
" Aneurism of 109 
" Atheroma of 106 
" Atrophy of 102 
" Carcinoma of 113 
" Clots 18,110 
" Dilatation of 101 
" Fatty Degeneration of.... 112 
" Gummy Tumors of 113 
" Hypertrophy of 100 
" Inflammation of 104 
" Malformations of 98 
" Myoma of 113 
" Parasites of 113 
" Position of 16 
" Rupture of 103 
" Sarcoma of 113 
" Size of 19 
" Thrombosis of 110 
PAGE 
Heart, Tubercles of 113 
" Valves of 107 
" Waxy Degeneration of... 112 
" Wounds of 103 
Hepatic Artery 186 
Hepatic Veins 190 
Hepatitis, Interstitial 177 
" Parenchymatous. ..176, 185 
Purulent 177 
" Syphilitic 182 
Hernia Cerebri 54 
Hernia of the Intestines 149 
Hydrencephalocele 52 
Hydrochloric Acid, Poisoning by. 342 
Hydrocele ... 265 
Hydrocephalus 50, 53 
Hydrocyanic Acid, Poisoning by. 348 
Hydronephrosis 215 
Hydropericardium 95 
Hydrophobia 331 
Hydropneumothorax 92 
Hydrorachis... 62 
Hydrotho rax 90 
Hypospadia 359 
I 
Infants, Age of 32 
" Examination of 32 
Infarctions. 308 
Intermittent Fever 320 
Internal Examination of the Body 9 
Intestines, Adenoma of 160 
Angioma of. 160 
Calcification of 161 
Carcinoma of. 161 
" Concretions of 162 
" Dilatation of 159 
" Diverticula of 148 
" Emboli of 159 
" Examination of 25 
" Fibroma of 160 
" Hernia of. 149 
" Incarceration of 152 
" Inflammation of 155 
" Intussusception of.... 153 
" Lipoma of 160 
" Lymphoma of 161 372 
INDEX. 
PAGE 
Intestines, Malformations of 148 
Myoma of ... 160 
" Parasites of 162 
" Prolapse of 154 
" Rupture of 154 
" Sarcoma of 161 
" Stenosis of 159 
" Transposition of. 154 
" Tubercles of 161 
" Ulceration of 158 
" Waxy Degeneration of 161 
J 
Joints, Fibroma of 299 
" Inflammation of. 295 
" Lipoma of 299 
" Loose Cartilages in 299 
" Malformations of 295 
K 
Kidney, Adenoma of 219 
" Angioma of 219 
" Calculi of 217 
" Carcinoma of 219 
" Changes in Position of. . 207 
" Chronic Congestion of. . 208 
" Cysts of 216 
" Examination of 21 
" Fibroma of 218 
" Gummy Tumors of 219 
" Haemorrhage of 208 
" Infarctions of 214 
" Inflammation of 209 
" Lipoma of 218 
" Lymphoma of 219 
" Malformations of 206 
" Myxoma of 218 
" Parasites of 219 
Parenchymatous Dege- 
neration of. 212 
" Precipitates in 217 
" Sarcoma of 219 
" Tubercles of 218 
" Waxy Degeneration of.. 213 
L 
Larynx, Examination of 20 
PAGE 
Larynx, Inflammation of 66 
" Malformations of 66 
" Parasites of . 69 
" Perichondritis of 67 
" Tumors of 68 
Lead, Poisoning by 346 
Leukaemia 329 
Lightning, Death by...." 339 
Lipoma 358 
Liver, Abscess of 177 
" Adenoma of 191 
" Angioma of 190 
" Atrophy of 174 
" Carcinoma of 192 
" Chondroma of 190 
" Cirrhosis of 178 
" Cysts of 192,194 
" Examination of 26 
" Fatty Degeneration of.... 182 
" Fibroma of 190 
" Gummy Tumors of 192 
" Haemorrhage of 175 
" Hyperaemia of 172 
" Hypertrophy of 175 
" Induration of 181 
" of Infants 38 
" Inflammation of. 176 
" Injuries of 172 
" Lymphangioma caverno- 
sum 193 
" Lymphoma of 191 
" Malformations of 170 
" Parasites 194 
" Parenchymatous Degene- 
ration of 185 
" Pigmentation of 184 
" Position of 14, 171 
" Sarcoma of 192 
" Size of 28, 171 
" Waxy Degeneration 183 
Locomotor Ataxy 64 
Lungs, Abscess of 82 
" Apoplexy of 76 
" Atalectasis 79 
" Congestion of 75 
" Emphysema of 77 
" Examination of. . 19 INDEX. 
373 
PAGE 
Lungs, Gangrene of 82, 83 
" Gummy Tumors of 88 
" Hydrostatic Test 37 
" of Infants 37 
" Infarctions of 77 
" Inflammation of 80 
" Injuries of 75 
" Malformations of 75 
" (Edema of 75 
" Parasites of 89 
" Pigment, Induration of.. 79 
" /.Tubercles of 86 
" Tumors of 86 
Lupus 365 
Lymphoma 365 
M 
Mamma, Adenoid Sarcoma of.... 275 
" Adenoma of 274 
" Carcinoma of 276 
" Cysts of 273 
" Enchondroma of 274 
" Fibroma of. 273 
" Haemorrhage of 272 
" Hypertrophy of 273 
" Inflammation of 271 
" Lipoma of 274 
" The Male 277 
" Malformations of 271 
" Myxoma of 275 
" Parasites of 277 
" Sarcoma of 275 
Malarial Fevers 320 
Mediastinum, Inflammation of... 93 
" Tumors of 93 
Meningitis 47 
" Cerebro-Spinal 324 
" Chronic 48 
" Spinal 62 
Tubercular 49 
Method of Examination 3 
Metritis 243 
Microcephalia ; 53 
Mouth, Adenoma of.-. 129 
" Carcinoma of 130 
" Epithelioma of 130 
" Gangrene of 129 
PAGE 
Mouth, Hypertrophy of .. 127 
" Inflammation of 128 
" Malformations of 126 
" Papilloma of 129 
" Ulceration of 129 
Myelitis 64 
Myocarditis 104 
Myoma 360 
Myxoma 357 
N 
Nephritis, Acute diffuse 209 
" Chronic diffuse 209 
" Glomerulo 209 
" Peri 212 
" Pyelo 211 
Nitrate of Potash, Poisoning by. 343 
Nitric Acid, Poisoning by 341 
Neuroma 362 
O 
(Edema Glottidis 67 
(Esophagus, Dilatation of 134 
" Epithelioma of 135 
" Examination of.... 20 
" Inflammation of.... 133 
" Malformations of.... 132 
" Stenosis of 135 
" Tumors of 135 
" Ulceration of 134 
Omentum, Position of... ,f 15 
Opium, Poisoning by 348 
Osteitis 283 
Osteoid-Chondroma 359 
Osteoma 359 
Osteomalacia 289 
Osteomyelitis . 282 
Ovaries, Atrophy of 251 
" Carcinoma of 256 
" Cysts of 253 
" Enchondroma of 255 
" Examination of 31 
" Fibroma of 255 
" Gummy Tumors of 255 
" Haemorrhage of 252 
" Inflammation of 252 
" Sarcoma of 255 374 
INDEX. 
PAGE 
Ovaries, Tubercles of 255 
Oxalic Acid, Poisoning by 342 
P 
Pacchionian Bodies 11 
Pachymeningitis 44 
Pancreas, Examination of 27 
" Inflammation of 2C2 
" Malformations of...... 201 
" Tumors of 202 
" Waxy Degeneration of. 202 
Pancreatic Ducts 203 
Papilloma 356 
Penis, Atrophy of 260 
" Carcinoma of 262 
" Epithelioma of 262 
" Examination of 29 
" Fibroma of 262 
" Hypertrophy of 260 
" Inflammation of 261 
" Malformations of 259 
" Papilloma of 261 
Periarteritiis 120 
Pericardium, Examination of.... 16 
Haemorrhage of... . 96 
Inflammation of.... 96 
" Injuries of 95 
Malformations of. .. 95 
Pneumatosis of..... 96 
Tumors of 97 
Perihepatitis 176 
Periostitis 281 
Periphlebitis 124 
Peritoneum, Carcinoma of 169 
" Fibroma of 168 
' Gangrene of 167 
" Haemorrhage of 163 
" Inflammation of.... 164 
" Lipoma of 168 
" Malformations of.... 163 
" Parasites of 170 
" Sarcoma of........ 169 
" Tubercles of 170 
Perityphlitis 156 
Pharynx, Epithelioma of 135 
" Examination of 20 
" Inflammation of 133 
PAGE 
Pharynx, Malformations of 132 
" Tumors of 135 
" Ulceration of 134 
Phlebectasia 123 
Phosphorus, Poisoning by .• 343 
Phthisis, Catarrhal 84 
" Fibrous 86 
" Tubercular 86 
Pia Mater, Examination of 10 
" " Haemorrhage of 47 
" " Inflammation of 48 
" " Parasites of 49 
" " of Spinal Cord 61 
" " Tumors of 49 
Pineal' Gland 61 
Pituitary Body 61 
Pleura, Haemorrhage of 90 
" Inflammation of 90 
" Tumors of 92 
Pleural Cavity, Examination of..16,19 
Pneumonia, Catarrhal 82 
" Croupous. 80 
" Hypostatic 83 
" Interstitial 83 
Poisons 340 
Portal Vein, Calcification of 190 
" " Dilatation of 189 
" " Rupture of 189 
" " Thrombosis of 186 
Potash, Poisoning by 343 
Prostate, Atrophy of 269 
" Carcinoma of 270 
" Hypertrophy of 269 
" Inflammation of 270 
" Myoma of 270 
" Tubercle of 270 
Psammoma 361 
Pseudo-Leukaemia 329 
Pyaemia 303 
R 
Relapsing Fever 320 
Remittent Fever 320 
Respiratory System 66 
Rickets 287 
Rigor Mortis 5 INDEX. 
375 
S 
PAGE 
Sarcoma 365 
Scars 9 
Sclerosis of the Brain 58 
Scrotum, The 262 
Scurvy 326 
Septicaemia 303 
Soda, Poisoning by 343 
Spinal Cord, Examination of..... 13 
" " Haemorrhage of.... 64 
" Inflammation of.... 64 
" " Injuries of 63 
" " Malformations of... 62 
" " Membranes of 61 
" " Sclerosis of 64 
" " Tumors of 65 
Spina Bifida 62 
Spleen, Examination of 24 
" Hypertrophy of 198 
" Inflammation of 199 
" Malformations of 198 
" Parasites of 201 
" Rupture of 199 
" Tumors of 200 
" Waxy Degeneration of... 200 
Stomach, Adenoma of 147 
" Carcinoma of. 144 
" Degeneration of 148 
" Dilatation of 143 
" Examination of 25 
" Fibroma of 147 
" Haemorrhage of 138 
" Inflammation of. 138 
" Injuries of 138 
" Lymphoma of 147 
" Malformations of 137 
" Myoma of 146 
" Position of 15 
" Post-mortem changes in 137 
" Sarcoma of 146 
" Softening of 137 
Stomatitis.... 128 
Stramonium, Poisoning by 350 
Strangulation, Death by 334 
Strychnia, Poisoning by 350 
Suffocation, Death by 333 
PAGE 
Sulphuric Acid, Poisoning by. . • 341 
Sunstroke 331 
Supra-renal Capsules, Degenera- 
tion of 205 
Supra-renal Capsules, Examina- 
tion of 23 
Supra-renal Capsules, Haemor- 
rhage of 204 
Supra-renal Capsules, Inflamma- 
tion of 204 
Supra-renal Capsules, Thrombosis 
of 204 
Supra-renal Capsules, Tumors of. 205 
T 
Tartar Emetic, Poisoning by.... 347 
Tartaric Acid, Poisoning by 342 
Tattoo Marks 9 
Temperature after Death 6 
Testicle, Carcinoma of 268 
" Cysts of 267 
" Enchondroma of 267 
" • Fibroma of 266 
" Gummy Tumors of 269 
" Inflammation of 264 
" Lipoma of 266 
" Malformations of. 263 
" Myoma of 268 
" Myxoma of 267 
" Sarcoma of 268 
" Tubercles of 267 
Thorax, Examination of 14-16 
Thorax of the Infant 36 
Thrombosis 305 
Tongue, Cysts of 131 
" Hypertrophy of 131 
" Inflammation of 131 
" Malformations of 130 
" Tumors of 131 
Trachea, Dilatation of 69 
" Inflammation of 70 
" Malformations of 69 
" Tumors of....; 70 
Trichiniasis 332 
Tubal Pregnancy 258 
Tubercle 364 376 
INDEX. 
PAGE 
Tumors 353 
Typhlitis 156 
Typhoid Fever 309 
Typhus Fever 319 
U 
Urethra, Dilatation of. 225 
" Examination of 29 
" Fibroma of 227 
" Inflammation of 227 
" Malformations of 225 
" Perforation of 226 
" Strictures 225 
" Tumors 227 
Uterus, Angioma of 248 
" Atrophy of 23g 
" Carcinoma of 249 
" Cysts of 248 
" Dilatation of 237 
" Examination of 29 
" Fibroma of 247 
" Flexions of 238 
" Gummy Tumorsof. 248 
" Haematometra 237 
" Haemorrhage of 241 
" Hernia of 239 
" Hypertrophy of 237 
" Inflammation of 242 
" Malformations of , 235 
" Myoma of 244 
" The normal 30 
" Parasites of 250 
" Prolapse of 239 
" Rupture of 240 
" Sarcoma of 248 
' Tubercles of 24$ 
V 
PAGE 
Uterus, Ulceration of 244 
" Versions of 238 
" Waxy Degeneration of.. 244 
Vagina, Carcinoma of 235 
" Cysts of 234 
" Dilatation of 232 
" Hernia of 23g 
" Inflammation of 234 
" Malformations of 232 
" Myoma of 234 
" Papilloma of 234 
" Prolapse of 232 
" Sarcoma of 235 
" Tubercles of 234 
" Wounds of 233 
Veins, Carcinoma of 126 
" Dilatation of 123 
" Inflammation of 124 
" Myoma of 125 
" Parasites of 126 
" Rupture of 124 
Vulva, Carcinoma of 231 
" Cysts of 231 
" Encliondroma of 231 
" Fibroma of 230 
" Haemorrhage of 229 
" Inflammation of 230 
" Lipoma of 231 
" Lupus of 231 
" Malformations of 229 
W 
Wounds 8 
Y 
Yellow Fever 322