OUTLINES
OF
HUMAN     PATHOLOGY
      HERBERT MAYO,  F. R. S., &c.

professoa of anatomy, physiology, and pathological anatomy >n king1
       college, London; surgeon to the Middlesex hospital.
FROM THE LAST LONDON  EDITION.
V.
         PHILADELPHIA:
CAREY   &   HART.
1841. 
V 
DungHsorfs American Medical Library.
OUTLINES
OF
HUMAN    PATHOLOGY.
BY
        HERBERT MAYO, F. R. S. &c
professor of anatomy, physiology, and pathological anatomy in king's
      college london ; surgeon to the middlesex hospital,
L-vi^xJi.
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~~ LIBRARY
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              PHILADELPHIA:
PRINTED BY ADAM WALDIE, 46 CARPENTER STREET.
                     1839. 
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INTRODUCTION.
  OF DEATH |  AND OP THE ELEMENTS OP PATHOLOGAL STUDY.

  There is a life, which is simply vegetative.  This is displayed
in plants, and in molae or imperfect conceptions of  animals.  It
consists in nutrition;  that is to say, in the performance of certain
actions  in which  the individual imbibes,  and  assimilates, and
distributes through its frame, foreign matter, with the double end
of preserving  itself against the destroying  influence  of external
agents,  and  of producing  other  similar beings to perpetuate  its
species.  The death of vegetative life is the cessation  of nutrition:
a time  arrives, when foreign  matter is no  longer imbibed and
assimilated,  and when the organised body yields to decay.
  Animal life is vegetative life, and something  more.   An animal,
like a plant, grows by nutrition; but besides  the organs employed
in assimilation and secretion, it has others [formed in it by the same
principles of growth as the assimilating organs] in which, through
a mysterious union,  sensation and  volition, instinct and reason,
temporarily reside.  Of these organs in  the higher animals, and in
man,  the brain is the essential one:  the extinction of the function
of the brain  is their death ;  whether we regard man, whose death
is the separation of the body and of an immortal soul—or animals,
whose death is the suppression of a narrower consciousness.
.  When we examine  the varieties of cerebral lesion or impairment,
that are sufficient to put an end  to  consciousness, they are  found
to be  reducible to eight distinct  heads:—mechanical or chemical
injury—mental shocks—direct action of certain poisons on the
brain—deficient momentum in the circulation of arterial blood in
the brain—circulation of black blood in  the brain—collapse follow-
ing over-excitement—deficient nutrition—sympathy with lesions of
other parts.
   I.  Mechanical or chemical injury.
   a. Concussion of the brain, if sufficiently  violent, is instantane-
ously fatal,  through (3irect extinction of cerebral power.
  b.  Partial laceration of the  upper part of  the medulla oblongata
is capable of destroying life at the instant.  This is proved  by the
following experiment.
  Cold-blooded animals  have a wonderful tenacity of life, and re-
tain sensation and volition for a considerable period after the heart 
4
INTRODUCTION.
and lungs have been removed.  If in a frog ^ "utlla*^jaa??lo™
taining lensation and volition, the upper part of the medul a oblon
gata is  injured by  passing  a needle  through it, consciousness is

dlTfeVonisponting part in man, which is  about half a square
inch in volume, is the immediate "link that  binds us  to life.   A
wound in which it is divided, an apoplectic effusion by which it is
lacerated, are at the moment fatal.  So strong is the  influence of
this little segment of the enkephalon,  that when cold-blooded ani-
mals are decapitated—as it is contrived that the separation of the
head is made higher or lower—it is in  the first case the  head m
the second the body, which is killed by the division ; the other
mutilated portion continuing for a period to exhibit sensation and
volition.  The half which has the medulla oblongata  left in it re-
mains alive, the other half is dead.  If the section divides the cer-
vical vertebra?,  the head continues alive, the  body is dead.   If the
section is carried through the occiput, so  as  to leave the  medulla
oblongata in  connection with  the  trunk,  the  trunk lives, the
severed  head is dead.   When in a perfect animal  this little part is
destroyed, one convulsion takes  place, and the  limbs are then for
ever relaxed in death.
  c.  Pressure upon the  brain carried to a certain extent, and ap-
plied so as to tell upon the medullary  oblongata, extinguishes life.
  d. The influence of chemical  lesion in irretrievably paralysing
the brain is shown in the effect  of lightning passing  through the
head.
  II.  Mental shocks.   Great and sudden terror has been known
instantaneously and  permanently to  extinguish consciousness.
And although this case is probably always complicated with syn-
cope, no reasonable doubt can beentertained  that the mortal  lesion
here, as in death by lightning, is;'cerebral palsy)
  III. Certain poisons, of which the woorara is an instance, directly
depress  the powers of the brain to a degree which is incompatible
with the persistence of consciousness.   The poison mixed with the
blood, and circulating in the brain, disturbs  its organic elements.
That disturbance,  however, may be  so slight in degree, that, al-
though  sufficient entirely to suppress consciousness for the time, its
influence will wear oft", and consciousness return, if, in the  mean
time, the ordinary nutritive processes are maintained.  This can
be accomplished by means of artificial  respiration.  If in a  horse,
in which animation has been suspended by a measured quantity
of woorara, the lungs are kept in play by being  alternately inflated
and allowed to collapse, the heart continues  to receive a supply  of
red  blood,  and to  circulate it through  the  brain ; which  after a
period  recovers itself, and  consciousness returns.  If artificial re-
spiration is not employed in this case, as the instinct of breathing is
 suspended,  recovery soon becomes  impossible in consequence  of
 black blood circulating in  the  brain.   When  a strong dose  of
 woorara has been used, all attempts at restoring the animal are 
INTRODUCTION.
5
 Vain.   The circulation  of red  blood  may be maintained till  the
 heart  ceases to  act; but  no glimpse of consciousness reappears.
 The poison has irretrievably palsied the  brain.
   IV. Deficiency of momentum in the flow of arterial blood upon
 the brain will suspend its functions.  The state of unconsciousness
 so produced is termed syncope.  It may  result either from want of
 blood  in the system through hemorrhage, or from feebleness of  the
 heart's action owing to some mental impression, or from both causes
 united.  The time that syncope may continue, without the cerebral
 functions being irretrievably extinguished, is not known.
   V.  The circulation of venous blood in the brain  produces ano-
 ther form  of unconsciousness, which is improperly termed  as-
 phyxia.  This  state occurs in death by drowning, hanging, and
 every  other  form of suffocation.  There is reason to believe that
 when  black blood has circulated for five  minutes in the brain, con-
 sciousness is irrecoverable. The poisonous or paralysing influence
 of the black blood is shown by the fact, that, if  a person fall into
 the water in a fainting fit, and the  syncope continues, he may re-
 main  a  considerable period immersed,  and animation can  after-
 wards be restored.  There has been no breathing : the blood has
 not been oxygenated ; but  it has not circulated.
   VI.  The powers of the  brain may flag and cease through  de-
 pression following over-excitement.  An animal that  is  made  to
 breathe pure oxygen, after a period of hurried breathing and  ex-
 cited circulation, falls into  stupor, and dies.  It is thus that  in the
 first stage  of acute  inflammation of the  brain, consciousness and
 life  are liable to be extinguished.  Death from exposure to intense
 heat, as far as it depends upon direct cerebral exhaustion, is refera-
 ble  to  this head.
   VII. Deficient nutrition.  In death from inanition, it is presuma-
 ble that  the weakening of the  brain in some cases causes, and in
 all contributes to death.  In death  from  age, whether  natural   or
 premature, the failure of the brain,  and cessation of consciousness,
 are sometimes owing to this cause.
   VIII. The cerebral  powers may be extinguished through the
 sympathy of the brain with other organs.
   When a limb  is torn off by  machinery, the cerebral depression
 which follows, and is often fatal  in a few  hours, exemplifies this  in-
 fluence.  The instantaneous effect of strong prussic acid applied
 upon the tongue is a still more decided instance in which a violent
 local impression extinguishes by sympathy the powers of the brain.
 Blows upon the stomach  which destroy life instantaneously, and
extensive burns that are followed in a few hours by death, are fatal
 upon the same principle.   The mortal torpor produced  by long ex-
posure  to  intense cold  likewise exemplifies cerebral depression
arising out of exhaustion or prostration of another function.
   All  the varieties of death are referable to one or other of the
kinds thus specified.  All men die in one or other of these modes.
" Omnes una manet mors."  In all, death consists in the suppres-
       18—e                                    2 may 
INTRODUCTION.
sion or exhaustion of the powers of the brain.   But many of the
instances adduced serve likewise to show that the extinction of the
function of the  brain, wherein death is, may be  the immediate and
necessary consequence of lesions of other parts.  Upon this ground,
pathologists have considered other organs besides the  brain  to be
vital organs.  These organs are the heart and the lungs. Through
their relation to the brain, the heart, which circulates the blood,
and the lungs, through which  the blood is purified, are practically
as essential to the continuance of life as the brain itself.  Death is
as certain, although not quite  as  immediate a consequence of pro-
tracted syncope or  asphyxia, as of mutilation  of the medulla ob-
longata.
  It is likewise  to be understood, that although  the different modes
of death may theoretically be laid down with precision, it is  often
difficult to tell, in individual  cases,  which  has prevailed.  Or in
the fatal termination of disease, it frequently cannot be  determined
whether  imperfect  oxygenation  of  the  blood, or  failure of the
heart's action, or primary depression of cerebral  power, has prepon-
derated in turning the  scale against  life.  Still less can the influ-
ence of those organs, which are ranked as not immediately  vital,
be rigorously measured.  Yet each exerts an  influence;  a single
step faultily made in the process of assimilation, or a trifling lesion
of the most insignificant organ, may give rise to  a local  obstruction,
or an  inflammatory action,  or an ataxic  fever, involving the de-
rangement of every other  function, and establishing, link by link,
a catenation of mortal disorder.
   The living human frame is at no time stationary; each change
that takes place within it, affects all that follow.  Life is a series of
successive reactions.   The most  perfect health is perpetually fluc-
tuating.  No two days are we sensible of exactly the same bodily
feelings or condition.   Accidents of the weather, of our diet, of our
habits, our business, our pleasures, our hopes and our fears, modify
each day our physical  being, which  is tremulous^ alive  to every
impression.   It has besides  its natural ebbs and  flows, that are to
a certain degree independent of external  influences.   To different
individuals, again, a different tone of vital endowments belongs, so
that the same influences produce not  exactly the same effects on
any two ; but there is a natural succession of changes  under simi-
lar circumstances peculiar to each, and modified even  in the same
individual by the very  hour at which they are commenced.
   The librations of health  are  the  province of physiology.  To
pathology belongs  the study of those wider excursions  from the
normal type, which constitute disease—the  investigation of those
disorders of  function and changes of structure, which,  although
some of  them tend towards  restoration, yet  may all be viewed as
exhausting in different degrees  the  resources of life, and many as
directly and inevitably leading to disorganisation and death.
   Or the  subjects of pathological enquiry may be thus summarily
stated :— 
                         INTRODUCTION.                      7

    l. The elements of alteration of the bodily structures or products,
 including—the processes tending or not to reparation which follow
 mechanical or chemical lesion—the laws  of hypertrophy or excess
 of growth, of atrophy or wasting—the laws of inflammation and
 its  consequences, ulceration, effusion,  suppuration, gangreno—the
 laws of irritation and fever—the nature of tubercle—the nature of
 malignant diseases,  comprehending carcinoma, melanoma, medul-
 lary and gelatiniform  sarcoma—the laws of the disturbances of
 functional secretion.
   II.  The modifications which these pathological elements display
 in affections of different tissues and organs—in the  bones—in the
 joints—in the  muscles and sinews—in the brain and nerves—in
 the digestive organs—in  the  circulating and respiratory systems,
 and the rest.
   III. The relation of different forms of disease to each other ; as,
 for  example, the connection of gout and  stone—of  sugar  in the
 urine, or of fat in the liver, with tubercle in the lungs.
   IV. The reciprocal influence of different organs,  whether me-
 chanical—as the production of ascites and anasarca by disease of
 the mitral valves of the heart—or  chemical, as the  suppression of
 lithic  acid sand by alkalies which neutralise the acid of the sto-
 mach—or vital, as  the subsidence  of  the  increased  action  of the
 heart, of the hurried breathing, of the  cerebral excitement of con-
 tinued fever  upon the  temperature  of the surface being lowered by
 cold affusion.
   V. The influence of sex and age, in  modifying the progress and
 character of disease.
   VI.  The influence of natural and acquired temperament,  and of
 diathesis.
   In the present treatise, nothing so ambitious has been attempted
 as a complete discussion of the subjects above enumerated.   The
 author's aim  has been, to arrange in  a perspicuous  order,  and to
 describe with as much  brevity as is consistent with  clearness, the
 morbid affections to which the different organs of the human body
 are  subject.   This, with some accidental omissions,  and with the
 intentional omission of those subjects  which are commonly made
 isolated studies,  he trusts has  been  accomplished to an extent that
 may render the  following pages not without their use.   The ana-
 lysis of the elements of disease, or of those common forms, which,
 as they are found differently modified in different organs, constitute
 their specific  affections,  has  been  introduced in connection with
 those organs in which they have the greatest part.  Thus, tubercle
 is described with the lungs; carcinoma, with the breast; inflam-
 mation, effusion, suppuration, with  the capillaries.
  The author has endeavoured, for the most part, to picture dis-
ease by well-marked examples in preference to general descriptions:
 the  latter are unavoidably vague,  and wanting in  precision ;  the
former, if on the one hand they occasionally render too prominent
accidental features, on the other are clear, salient—in fact, Nature, 
INTRODUCTION.
■s she has practically to be studied-and, if properly grouped, are
clinical instruction thrown into system.          .       .
  The author is not without hope, that the following work may be
of Tervice to students, if only by giving method to their enquiries,
and by accustoming them to base the study of disease in anatomy-
^ it may be of help to those who visit or are engaged in forming
pathological collections-that it may sometimes assist in the diag-
E  of obscure cases by enabling the practitioner to review all the
continences to which particular organs are liable ; and may lead
him, by the light again which  method  gives,  to derive  increased
advantage from miscellaneous professional reading, as well as to
tabulate and profit by, and to let others  profit by, the results of his.
enlarging experience. 
OUTLINES  OF  PATHOLOGY.
                      CHAPTER I.

                         THE BONES.

  The pathological phenomena, which are displayed in the bones,
may be arranged under the  following heads : Reparation, Hyper-
trophy, Atrophy, Inflammation, Abscess,  Necrosis, Caries, Malig-
nant Growths, Hydatids.
                          SECTION I.

                      Reparation of Bone.

   The leading practical  distinction in fractures is into simple and
 compound.   A fracture is  simple, when the injury is  confined to
 the bone; compound, when the injury involves other parts, through
 the  laceration, or sloughing,  or  ulceration of which,  the broken
 bone is exposed.  The restorative process differs in some important
 respects in these two  cases.  Nevertheless, simple and compound
 fractures are originally convertible.  After a simple fracture it may
 happen, that through  one or other of the causes specified, the bone
 may become exposed.  After a compound fracture, the torn integu-
 ments  may unite by adhesion.  The peculiar features  which cha-
 racterise  the reparation of compound fractures, will be described
 in connection with the subject of necrosis.  The present section.
 will be confined to the consideration of simple fractures.
   The process of restoration after simple  fracture is  not the same
 for all  bones.
   Two forces manifest themselves in the  reparation of fractures;
one of which is developed in the tissues which surround the bro-
ken bone ; the other originates in the bone itself.  The first evinces
itself suddenly on the fourth  day by one of  a rapid  and  well-
marked succession of phen<*mena, the entire period  of  which is a
year.   The  second,  slower in its commencement  and progress, 
10
MAYO'S OUTLINES OF PATHOLOGY.
produces no sensible effects for months, and often requires  many
years before  the  perfect restoration of  the part is accomplished.
The first operates in uniting fractures-of the long bones with the
exception of those parts which are contained  in synovial cavities;
of the round bones,  with the same exception ;  of the flat bones,
with  the exception of those of the  cranium.   The second comes
into operation in the cases which form the exceptions above stated.
  I  The process  of reparation, which originates in the surround-
ing tissues, has hitherto  been minutely studied in one class of frac-
tures  alone;  in those, namely, of the shafts of long  bones: but
enough has been observed of the phenomena of the other instances
specified  under the first  head, to make it probable that  they follow
the same  law.
  Between the occurrence of fracture of the  shafts of long bones,
and the completion of the restorative process, six distinct periods
may be observed.
  1. The first, which is a period  of repose, extends  over three
days.   If a limb  is examined in  a  case where death has ensued
within a  few hours after  a  simple fracture, the following appear-
ances are ordinarily met with.  There is generally little extrava-
sation.  The soft  parts immediately adjoining are bruised and in a
state of ecchymosis.  The medullary membrane upon the fractured
surfaces is bloodshot. Near the edge of the fracture,  the periosteum
is irregularly stripped from  the bone.  During three days, the only
change which ensues is the absorption of some of the extravasated
blood. The ecchymosis at the completion of this  period is paler
than at first.  The blood effused does not contribute to  the reunion
of the broken bone.  When  there is much extravasation, the resto-
rative process,  instead of being accelerated, is retarded ; the frac-
ture does not stiffen as early as otherwise.
  2. The second period extends  from the fourth to the tenth or
twelfth day.   Under ordinary  circumstances, on the fourth day a
change supervenes, which bears some resemblance to inflammation.
The parts adjacent to the fracture become more vascular, and are
infiltrated with a gelatinous lymph.  The same substance  is dif-
fused, as  an adhesive glue,  around and  between the fractured ex-
tremities.  Sometimes the matter so  effused is more gelatinous; at
other times it has the common appearance of coagulable  lymph.
The effusion  produces a sensible  thickening  around the fracture.
The  motion  at the fracture is less free.  Consolidation appears to
have begun.   But as yet the change is limited to a general infiltra-
tion of the parts  adjacent to the fracture: all the textures so situ-
ated appear involved in this infiltration: it  may be conjectured,
however, that the filamentous tissue is its more especial seat. [c. 1*.J
  3.  The third period extends from the tenth or twelfth day to the
twentieth or twenty-first. The general tumefaction of the soft parts
adjoining the fracture now  subsides: the different textures  become
w!\vAuf' ^e7 aPpear Sradnal1V to disengage themselves
from the diffused  thickening in which thev were at first  involved; 
THE BONES.
11
so that they are eventually  disposed  on the outside of a circum-
scribed and dense mass or capsule, which immediately contains the
broken ends of the bone : that mass is termed the provisional cal-
lus.   It is of a whitish colour, and has the firmness and elasticity
of cartilage, of which nature  no doubt  it is.  The parts which were
involved in the first general thickening are not  indeed as yet so
completely extricated from it, but that the nerves and tendons often
lie in grooves, or even in channels within the callus.1   The callus
adheres to  the surfaces of the bone above and below the fracture: it
is (towards the close of the third  period) covered with a separable
membrane, which is continuous with the periosteum: there is no
periosteum between  the callus and the bone, but where the callus
begins, the  periosteum terminates in  the membrane  covering  the
latter.  In the mean  time, the lymph,  by which the  ends of  the
bones are glued together within the callus, undergoes little change.
The  work of restoration, at present, is all external.  The quantity
of callus formed bears a strict proportion to the quantity of injury.
An oblique fracture, or a comminuted  fracture, or a fracture which
has been overlooked for two  or three days, has a greater proportion
of callus than a  transverse fracture which has been  set at once.
[c. 35.]
   4.  The fourth period extends from  the twentieth or twenty-fifth
day to the thirtieth, fortieth, or sixtieth, according to the age and
vigour of  the patient.  During this  period, the provisional callus
ossifies;  and, at its  expiration, the broken limb has already suffi-
cient strength to admit of being  used.   As yet, however, no direct
ossific union has taken place between the  broken  ends.  , If  the
ossified callus is at this time divided, the extremities of the bones
are found to move easily upon each other, being  united by a layer
of soft vascular  substance  alone, which is continuous on the  one
hand with the external callus, and on the other with  the thickened
medullary membrane,  [c. 1.]
   5.  The  fifth  period extends from the fiftieth or sixtieth day to
the fifth or sixth month.  During this period, the texture of  the
ossified callus becomes closer and more compact; the ossific pro-
cess at the same time gradually extends  into the soft substance
which joins the ends of the bone.  The broken extremities thus be-
come united by a layer of  newly-formed and compact bone.  This


  yThere are four opinions as to the source of the provisional callus:  that
it is produced by the periosteum; that it is an exudation from the extremi-
ties of the broken  bone, particularly from  the medullary membrane; that it
is derived by  direct growth from the animal structure of the bone; that it
originates in an infiltration of the textures adjacent to the bone. The  first
is the opinion of Dubamel, the second that of Haller, the third that  of Baron
Larrey, the  fourth that of Dupuytren and of Mr. John Bell.  The  account
in the  text is drawn up after M. Sanson's  account of Dupuytren's  observa-
tionsr(Journal*Universel des Sciences Medicales, tome  xx,) and some ex-
periments of my own, published  in the Medical and Physical Journal several
years  ago. 
12
MAYO'S OUTLINES OP PATHOLOGY.
is called the definitive callus.   In  proportion as the definitive cal-
lus is established, the provisional callus diminishes in volume.
   6.  The sixth period extends from the sixth to the tenth or twelfth
month.  In this  the  provisional callus is entirely absorbed;  and
the definitive callus,  losing  its primitive compactness, is wrought
into cells and  canals, by which the continuity of the medullary
cavity of the bone is restored, [c. 6.]
   The changes, the succession of which has been described, are the
natural consequences  of a fracture, and are intended to minister to
its reparation.   But in order to render them effectual, certain con-
ditions must be observed.
   a. The ends of the broken  bone must be kept at rest.   Motion
causes the absorption  of the lymph effused between them, and con-
verts the provisional callus into a membranous capsule.  The ex-
tremities of the bone  enclosed within this  capsule are sometimes
partially united  by fibrous substance; but in general they move
freely on each other ;  the opposed  surfaces being formed partly of
smooth bone of unusual compactness, partly of firm animal  matter.
The friction of the ununited ends upon each other causes them to
enlarge, and shapes them into determinate articular faces, flat if the
fracture has been oblique, concave and convex if the fracture has
been transverse.   The former  I have seen in the tibia, the latter in
the ulna and in a rib.  [c. 40. c. 41. c. 42.]
   This degeneration  of the restorative  process  constitutes  a false
joint.   Such  a case is not hopeless:  there are several means by
which a new  action  may be excited  in  and around the fracture,
which will lead to its  consolidation.   These are, rubbing the ends
of the bone roughly together ; the introduction of a seton between
them, to be retained for weeks, if necessary ;  their removal by the
saw.
   b. The ends of a broken bone must be kept in proper apposition,
or the limb, if union take place, will be  permanently shortened, or
bent, or twisted, or all three together.  The cause, which tends to
displace the ends  of a  broken bone, is the action of muscles.
   In general  the effect of muscular action on a broken limb is to
shorten it, causing the bones  to ride, or even to meet at an angle,
as in  fractures of the  clavicle and of  the bones of the extremities.
[c. 33.]
   In  certain  cases, however, the portions of the broken bone are
drawn  asunder  by the muscles, as in transverse fractures of the
patella and of the olecranon ; and  (although upon a different prin-
ciple) in fractures of the lower jaw. [g. 7. g. 8. g. 9.1
   In other cases the bones are in danger of uniting twisted.  When
the radius is broken, above the pronator teres, the" muscles  have a
tendency to supinate the upper part, and to pronate the lower   In
fractures of the thigh  and leg, the upper part of the limb is always
rotated inwards by the action of the muscles; while the lower part '
has a disposition to fall outwards.
   In  producing artificial extension of a limb,  it must be  remem- 
THE BONES.
1^»
O
bered that the means which are  employed stretch the joints as well
as the fracture.  A broken  limb, when  set,  should therefore be
longer than the sound one.
   c The same means, which maintain a broken limb of the right
length and direction,  serve  to  keep  it at rest.   How soon, upon
pathological principles, should these means be applied?   As far as
the condition of the fracture is concerned, the application of splints,
or the operation of setting, is not requisite till the fourth day.  But,
upon other  grounds, it  is expedient to set  a  limb at once.  The
muscles, when no longer kept in extension, contract and  shorten;
and it is often found difficult, at the expiration of four or five days,
to restore the limb  to the length which it may have lost through
not being set at once.   It is true, indeed, that a fractured limb is
often so swollen, that splints cannot be applied.  In that case the
swelling serves the same purpose, and  keeps the limb on  the
stretch.  It deserves likewise to be stated, that fractures unattended
with swelling occasionally go on best, when nothing is  done  but
laying the broken bone in an easy position.   One of the occasions
on which this rule  is to be followed, is when spasmodic contraction
of the muscles supervenes upon  simple fracture.
   d.  In the progress of the restorative changes of bone, is there any
definite period, up to  which a readjustment of an  ill-set fracture
may be effected?  Till after the fiftieth or sixtieth day, the defini-
tive callus is not commenced; and the provisional callus either is
not ossified, or, when ossified, is of so light and porous a structure,
as to yield sufficiently  to allow of considerable  alteration in  the
co-adjustment of the parts of the bone.
   e. In connection with these views it may be enquired, what rules,
or what cautions, does a knowledge of pathology suggest, in refer-
ence to the  detection of fractures?  The limb shortened and pow-
erless, with motion  and crepitation at the fractured part,  are signs
in general  sufficiently characteristic.   But fractures near the  ex-
tremities of bones:—e. g. of the lower ends of the radius and ulna,
and  of the inner extremity of the clavicle, do  not prominently dis-
play these, features.  Clean  transverse fractures, again, of any part
of any bone—of the middle of the tibia for instance—or separation
of the epiphyses, are often  not  attended  with shortening, or total
want of power, or evident crepitation.  Fractures again,  in young
persons, may be partial; the bone appearing to be  bent  only,  the
fibres on the concave side having  escaped.  In straightening such
partial fractures, the rupture of the bone is generally  rendered com-
plete.  Finally, morbid anatomy teaches,  that there is no fracture
which can be made by hammering a skeleton, no unlikely and  ac-
cidental  separation of  parts of bones, which is not sometimes pro-
duced by injuries of the living frame;  and that there is no compli-
cation of one  fracture  with another fracture, or with dislocation,
that does not,  in the chapter of chances, occasionally occur, baf-
fling those who do not combine with extensive knowledge untiring
circumspection. 
14
MAYO'S OUTLINES OF PATHOLOGY.
   II. The instances, in which union is effected through a process
originating in the bone itself, are fractures of the cranium, and of
the neck of the thigh bone within the capsular ligament.  In the
first of these cases no  provisional callus is formed: in the second,
the provisional callus  has no means of reaching the fracture.
   1. It is difficult to explain why a provisional callus does not form
about fractures of the cranial bones.   The physical cause of this
negative phenomenon is not known.   The final cause, however, is
evident.   If a hard swelling, such  as a provisional callus, were
stretched as a ridge along the inner  aspect of a cranial fracture, it
would encroach upon the cranial cavity;  and hemiplegia, epilepsy,
or some other form of cerebral  disorder  would attend the cure of
every fracture of  the skull.  No callus, therefore, is formed.  But
the fracture after  a time shows a disposition to unite through forces
inherent in the bone itself.  Their operation  manifests itself in the
following steps.   The edges of the broken bone slowly  undergo a
change;  they lose their sharpness, and become externally rounded ;
while within, by  a gradual extension of  growth, they steal across
the interval, and finally unite.   In a fissure of the skull examined
some months after the injury, the only change  apparent is  the
rounding of the edges externally.  After  a year or two, the fissure
is united at its internal or cerebral aspect.  After the lapse of many
years, the narrowest part of the fissure is entirely filled up.  In
persons who have lived ten, twenty, fifty years after loss*of por-
tions of the cranium, the slow  restoration of the  bone appears to
have been progressive  for the whole period.  In fifty years a tre-
phine hole is nearly  closed by the shelving growth  of bone from
the margin towards the centre,   [c. 27. c. 28.]
  2. There is reason to believe, that fracture  of the neck of the
thigh bone within the capsular membrane, when it unites by bone,
unites by the same steps with a cranial fracture. Reparation, how-
ever,  by bone, in such a  fracture, is  rare.   In  general, either no
union is  found to have taken  place, or the union is by soft, white,
fibrous substance.  In examining the body of an old man, who had
died of apoplexy,  I observed that  one leg was shorter than  the
other, and that the hip joint was  deformed.   Upon opening the
joint, it was found that there  had been a fracture at some former
period of the neck of the femur  within the capsule.   The  fracture
had  not united ;  but  the  separated  head of the bone was firmly
attached by ligament-like tissue  to the margin of the acetabulum.
A very perfect false joint had formed between the fractured surface
of the head of the bone and the  shortened neck: the  new articular
faces were of ivory bone. [g. 4.]  A woman, fifty years of age, was
treated, in the Middlesex  Hospital, for an injury of the hip joint.
After thirteen months, and when she had begun to walk with a
crutch, she died  suddenly of apoplexy.  On examining the joint,
the injury was ascertained to have been a fracture of the neck of
the femur within the  capsular membrane.  The neck of the bone
was, as usual, shortened ; but the  head  was  firmly united to it by 
THE BONES.
15
soft substance.  These two cases exemplify the appearances Ordi-
narily found; and there are features in them, which make  it suffi-
ciently clear  that the absence of bony union does  not result from
imperfect nutrition or  inadequate supply of blood to the separated
portion, [g. 5.]
   The best way perhaps of bringing out the facts upon this subject
is to  ask the three following questions.  What  is the reason that
fractures of the neck of the femur within the capsule do not unite
as readily as fractures of other parts of the same bone ?  Why, or
by what process, do  they ever unite ?  Why are they  so  seldom
found united?
   In the account which  has been given above  of the union of the
shafts of long bones, the surrounding tissues are described as taking
a prominent part in the act of reparation.  But  in the case under
consideration,  these tissues are  excluded by the untorn synovial
and capsular membranes from  communicating with the fracture.
They are  sometimes, indeed, seen to  make  the  ordinary  effort
towards reparation of the adjacent fracture.  Thus a portion of an
ossified provisional callus  is often met with external to the attach-
ment of the  capsular  membrane to the  neck of the femur,  [g. 5.]
But the effort is ineffectual;  the callus  cannot  reach the fracture,
whether it remains entirely  disunited, or is  glued together by an
exudation from the ends of the broken bone.
   In  the cases in which bony union takes place, I believe the pro-
cess of ossification to  be  extremely slow.  Such instances occur in
those only, who are not greatly advanced  in life at the time of the
fracture; and in whom, through the care with which the joint is
kept at rest, direct union by soft substance takes place between the
separated portion?.   Nothing, in truth, is then  wanted for the re-
storation  of  the part, but time.  The  connecting soft substance
will certainly, in time, ossify from the adjoining bones ; not rapidly,
as when  the  process stretches inwards from a provisional callus,
but slowly, as when it spreads across a cranial fissure.
   The  reason why so few specimens are  met with of united frac-
ture within the capsule is, that this accident commonly happens to
aged people: and aged people want both  constitutional power and
time for that slow and difficult process of restoration, which is in-
dependent of a provisional callus.
   The  explanation which I offer of the rareness of bony union in
these cases,  rests upon theoretical reasoning.  The following ad-
ditional facts  may therefore  be considered of importance, in esta-
blishing its correctness.
   Fractures  which on one side have  fallen within the capsular
membrane, and on the other have extended beyond it, are occa-
sionally met  with  in  progress of union.   In  two such specimens,
which I have examined, union by soft substance alone has taken
place on the side of the fracture within the capsule, while the union
is already bony on the other  side, where it had the assistance of a
provisional callus.   In those  winding fractures, again, which dip 
16
MAYO's OUTLINES OF PATHOLOGY.
wedge-like jnto the thick upper part of the femur, and the circum-
ference of which is exterior to the capsule, the external union is
often found to be perfect, while a line of soft union alone extends
through the  interior part.   Yet the  only difference between  the
united exterior and the as yet ununited interior, is  in the close con-
tiguity of  the former to a provisional  callus, to the presence or  ex-
clusion of which I  attribute the other  differences under  discussion.
                         SECTION II.


                    Hypertrophy of Bone.

  Hypertrophy is the abnormal increase of a part, without inflam-
mation or change of structure.  Bones are liable to partial and to
general hypertrophy; that  is  to say,  the abnormal enlargement
may affect either a portion, or the whole of a bone.  The latter
case, however, is  rarely met with.  When the  enlargement is par-
tial, it  is called an exostosis.
  Under the h^ad of hypertrophy of bone, affections of very dif-
ferent kinds are classed;  some of which are nearly connected with
the most salutary principles in the economy ; others constitute ob-
stinate but curable disorders;  while others, again, are diseases of a
troublesome or even malignant character.
  a. It is a principle which reigns in the animal economy during
health, that exercising  a  part  strengthens it.   Parts, of which the
action  is mechanical, become thus mechanically strengthened. The
arm of a blacksmith acquires, through daily  exertion,  additional
muscular force, weight, and  size; the bones in it enlarge;  their
crust becomes harder,  and of a compacter  grain ;  and  the lines
upon the surface, which give attachment  to tendons, become rough
and prominent ridges :  this is health.  In Mr. Cheshire's apparatus
for weakness of the spine, the  weight of the head and  trunk  is
thrown  upon the haunch  bones and the chin.   A  segment of a
steel hoop rests upon the ossa ilii, from the middle of which a rod
rises vertically behind the spine, higher than the head, over which
it arches, terminating in a hook : a strap passing beneath the chin
of a patient is suspended to the hook.  In those with whom this
instrument has been used, the lower jaw,  having to sustain unusual
pressure, generally enlarges, throwing out a bony swelling at the
part where the chin-strap tells.  This swelling, as it is certainly an
exostosis, might  be classed as a disease ; yet it  evidently results
from no other physical cause than  the salutary law of growth, that
a part is strengthened  in proportion to the exertion  imposed upon
it: agreeably with that law, when, on discontinuing the use of the 
THE BONES.
17
 instrument  the call for increased strength in the jaw ceases, the
 bony swelling disappears.
   b.  Nothing is  more wonderful in  physiology than the correct-
 ness with which  the proper size and  shape and outline of the dif-
 ferent parts of the body are maintained during infancy and  child-
 hood, while growth is  in rapid progress and the constituents  of the
 frame are perpetually changing.   It is all the less surprising, that,
 during this period, one or other  of the bones should sometimes
 grow out abnormally.  This incident produces another instance of
 exostosis.   The clavicle is one of the bones the most subject to it.
 The disorder requires no treatment:  it is almost sur^to disappear
 after a year or two: either the rest of the  bone grows  up  to the
 enlarged surface, or the superfluous part is absorbed, and not re-
 placed in the next substitution of new bone.
   c. Exostoses, however, are more frequent, when the body has
 recently attained  its full growth.   Nor is it difficult to imagine, on
 physiological principles,  why this should be.  But  the  disease is
 not limited  to the early or middle periods of life.  A patient sixty
 years of age who was  under my care, had an exostosis of the first
 rib, which threw rorward  the subclavian artery, so as to give the
 appearance  of a subclavian aneurism.  He  had not observed the
 swelling till some months  before he applied for advice.
   The common situations of exostoses are the upper part  of the
 humerus and of the tibia,  and the lower part of the femur.   Their
 shape varies with the kind of bone upon which they grow.  In the
 long bones,  they are generally narrow, of greater height than  thick-
 ness ; sometimes  largest at their base ; sometimes the reverse. In
 the flat bones  they are  usually broad, with no  great  elevation ;
 sometimes  they form  flat  discs, resting by short narrow pedicles
 upon bones of this class.   In the round bones, they  are rounded
 and nodular. To these laws, however, there are many exceptions.
   Exostoses present  in  their  structure all  the varieties  which
 healthy bones exhibit.  Sometimes their grain is dense  and com-
 pact; this  is especially the  case with those that grow  from the
cranial bones, as upon the temporal or frontal.  In other instances,
 they have a crust of the consistence of, but of less thickness than,
 that of the bone on which they grow, joined to a cancellous  struc-
 ture of the ordinary density.  They appear, in some instances, as
 if formed  by the developement of cancelli in a  part of the cortex:
 in other words, the  cortex which covers them, and that on which
 they rest, are together of the thickness of the cortex of the  sound
 bone adjacent,  [d. 6.]
   Exostoses have not more sensibility than healthy bone : but they
are susceptible of inflammation, and then become the seat of pain;
 and they often occasion pain by their pressure upon  more sensible
 parts.   When in  the neighbourhood of  important organs, they are
 liable  to disturb  their functions.   Fixed pains in the head,  and
epilepsy, have been  produced by the growth of exostoses from the
inner  table of the cranium. 
18
MAYO'S OUTLINES OF PATHOLOGY.
     The causes of exostoses cannot generally be traced :  it is certain,
   however, that they are occasionally mechanical; such as pressure
   or a blow.                                           .
     Exostoses sometimes spontaneously disappear.  Their absorp-
   tion is promoted by  counter-irritants,  mercury, iodine.  When re-
   moved by an  operation, they generally do  not recur.   A young
   woman was a  patient in the Middlesex Hospital, under Mr. Cart-
   wright, with a humeral exostosis, which, after several remedies had
   been tried, was sawn off.  In a year another exostosis grew, nearly
   in the same place ; but on a rubefacient plaster being  applied over
   it, an abscess formed, and the new bone was absorbed.  Exostoses
   sometimes perish by necrosis.
     d.  Sometimes the  tumour, which forms an exostosis, is not ori-
   ginally bony.  In a  child, at the age of six months, a soft tumour
   was observed to grow  from the front of the alveolar process of the
   upper jaw.  ^r  Astley Cooper  removed  the tumour; but it grew
   again, and  gradually  became hard.  The subject of the disease
   grew up a fine young woman, but for the deformity occasioned by
   the  tumour, which  was an inch  and a  half  thick,  and two  in
   breadth, and projecting two inches and a half pressed the upper lip
   against the nose.  At  the  age  of nineteen, this patient consulted
   me.  As the tumour had now ceased to grow for five years, with
   the concurrence of Sir Astley Cooper  I removed it.   It proved to
   be an exostosis of cancellated but extremely hard bone.  It is more
   than three years since the operation was  performed : the tumour
   has not returned,  [d. 5.]
     e.  Exostoses occasionally grow from the bones of the orbit and
   from the cylindrical bones, which attain a great size, and are of a
   dense and compact texture like ivory.  Three circumstances com-
   bine to give a serious character to this form  of disease.  When
   situated in the orbit, such tumours thrust  the eye from the socket;
'   occasioning pain, deformity, blindness.  When  situated in bones of
   the extremities, the weight of the tumour which involves the can-
   cellous structure as well  as the cortex, renders the  limb an incum
   brance, and necessitates  its removal.   But the mischief does not
   always terminate here.  The disposition to the  formation of ossific
   tumours may prevail throughout the  system, and display itself in
   other textures besides the  bones.   Number 533 [dry pathological
   specimens in  the Hunterian museum] is  a preparation  of ossifica-
   tion of the lungs, from a  patient  who died  of pulmonary disease
   supervening after amputation  of  the  leg for ivory exostosis.   In
   further evidence  of the occasional malignity of this kind of exos-
   tosis, I may  mention  that Mr. Stanley  possesses a  specimen, in
   which it exists combined with medullary sarcoma.
     /. There is  a  preparation, in  the King's College museum, of a
   tibia and fibula greatly enlarged, but not appearing to  have beet*
   inflamed.  The structure of the bones is healthy.   The person  oi
   whom I purchased this specimen, assured me that the bones were 
THE BONES.
19
from  a Barbadoes  leg.  It is  certainly not unlikely that such a
state of the bones should occur in that disease, [d. 3.]
  g. A patient  died in the Middlesex Hospital, who had  been
afflicted with epilepsy.  The convolutions of the brain were re-
markably flattened.   On examining the cranium, the inner  table
of the frontal,  parietal, and occipital bones, was found hypertro-
phied; all the arterial grooves were of unusual depth.  The bones
were not particularly vascular.
  h. A sort of hypertrophy of bone is the extension of ossification
into the ligaments and  muscles.  In  a  preparation, in the King's
College museum, the femur is  fixed immovably in the acetabulum
by  ossification of the anterior part of the capsular ligament, and  of
part of the iliacus  internus.  [d. 7.]  Mr.  Langstaff,  in  his  rich
pathological  collection, has a  beautiful specimen of ossification,
which appears to have spread from the femur, and involves the
vastus internus, the  structure of which  is converted  into bone, but
preserves externally its fibrous character.
  The alliance between the ossification  of ligament, muscle, ten-
don, and exostosis, (or, at all events, the origin of the  former from
the bones,) is  well  exemplified in the remarkable skeleton called
Mr. Jeff's,  in  the Hunterian museum, which is thus  described  in
the printed catalogue.
  " It  is the skeleton of a man thirty-nine years of age, and is re-
markable for the  production of ossific growths from many parts,  of
various dimensions  and extent; some  forming exostoses  merely,
whilst others pass  from one part of the  skeleton to another, and
have  thus produced anchylosis, or immobility of most of the mem-
bers.   The exostoses  may be  observed in  the os frontis,  mastoid
process,  and  occiput;  and in other parts  of the skeleton where
muscles  are attached,  as  near the  angle of the jaw,  where the
masseter is  inserted ; at the extremities of  the spines of  the  ver-
tebras, at the coronoid  processes  of the ulnse, in  the  femur at the
part where the glutaeus maximus is implanted.
  " The second  and more extensive kind of ossifications  have  in
general followed  the course of the larger muscles, and may be seen,
on  the right side, in  the situation  of the deltoid, joining the clavicle
and acromion of the scapula to the humerus, in the situation of the
supra-spinatus, and  passing from the inferior angle of the scapula
to the  humerus, in  the  situation of the  teres major and latissimus
dorsi.  On  the back, more extensive ossifications of the   muscles
appear, which affix  the scapula on both sides to the sacrum  and
ilium,  and  to  the spines of the lumbar and dorsal vertebra?.  On
the left scapula, the ossification of the teres major has not extended
quite to the humerus ;  but the dorsum presents a singular process
or  ossification, with smooth sides,  and a  flattened  overhanging
margin, like an auxiliary or second spine.
  "From the  pelvis, ossifications  extend  from  the  sacrum  and
ilium in the direction of the glutaeus  magnus ;  and from the tuber
ischii  and  os pubis in the  course of the biceps flexor and triceps 
20
MAYO'S OUTLINES OF PATHOLOGY.
adductor muscles ; these extend  to the right femur.  Ossifications
of the tendinous and ligamentous parts are still more common, pro-
ducing  anchylosis of the vertebras, of the left elbow joint, of the
tibia and fibula to each other on both sides of the ankle joint, and
general consolidation of the bones of the tarsi."
  i. A general  disposition to hypertrophy of bone is found in those
who have suffered from the opposite defect in childhood.  In one
remarkable specimen  in  the King's College^ museum, of rachitic
curvature of  the spine forwards, eight adjoining  dorsal vertebrae
are, by the extension  of ossification, anchylosed and formed into
one bone. [s. 10.]  In most specimens of recovery from rachitic
curvature of the spine, the edges of the vertebrae are enlarged, and
encroach upon  the intervening ligaments.  In the bones of the ex-
tremities, strong ridges are in like  manner thrown up along their
concave aspects.  Mr. Stanley has pointed out, that there is method
in this abnormal growth, and that the superabundant bone is placed
exactly where the curvatures of  the bones render them  mechani-
cally weaker.
                         SECTION III.

                       Atrophy of Bone.

  Atrophy is degeneration of growth,  deficiency in the size anrJ
weight of a part, and  commonly of one or more of its usual con-
stituents in particular. Atrophy in bone is attended with deficiency
of bone  earth, and with more or  less alteration of the  gelatin of
bone and of the medullary membrane.
  a. As  use strengthens  parts, disuse weakens them.  In a limb
long unused from  disease, the bones together with the soft parts,
waste, or are atrophied.  A young woman had her leg amputated
for  disease of  the  tibia, which had existed eleven years.  At its
commencement, it had attacked the head of the bone, and implicated
the knee joint, which  became anchylosed.  The disease  then  left
the knee, and established itself in the lower part of the tibia.  The
patient could not use the limb; and where not swollen by disease,
it wasted.  On examining the limb, the  upper part was found to be
atrophied.  The head of  the  tibia is  a  thin shell of bone ; and
instead  of its proper close concellous structure, a few fine threads
only of bone are drawn across it.   Among these, the marrow lay in
large masses,  semifluid, supported by the medullarv  membrane
alone,   [d. 29]
  b. In  childhood, and particularly among female  children,  the
round bones are liable to a form of atrophy which  corrects itself
with advancing  years.  The weakness involves the ligamentous 
THE BONES.
21
structures.   It shows itself at the ankles, at the knees, but princi-
pally  in the  back;  the spine becomes  curved from weakness,
inclining to one side at the loins, but being simultaneously bent at
the upper part in the opposite direction, so that ihe trunk may pre-
serve the perpendicular.  This complaint is atrophy from  arrest or
retardation of structural growth.   The weight and size of  the child
increases faster than  the hardness and strength of its bones arid
ligaments.   Sometimes  the spine is twisted, sometimes incurvated
forward as well as  laterally.
  c. In  old age, the bones become weaker and more brittle.   The
cortex is thinner ; and in it and in the cancelli, the  due quantity of
bone earth is wanting. This is the cause of the frequency of fracture
of the neck of the thigh bone in elderly persons.  The mechanical
disadvantage arising out of the obliquity of that part now  becomes
apparent; it breaks from trifling accidents.  Through  senile atro-
phy, the neck of  the  femur, when not broken,  often  becomes
depressed and shortened.
  d. Sometimes in middle  life, without any assignable cause, the
bones are unusually brittle.  A stout looking man was a patient in
the Middlesex Hospital,  with some trifling ailment.  He was cutting
a slice of bread, when the  humerus broke.   The  bone united as
readily as another  bone ; and this is observed in general of atro-
phied bones, except in extreme cases, or where a malignant growth
exists in addition in the bone ; or where the system is scorbutic, or
tainted with  lues or mercury.
  e. In  persons affected with carcinoma of the breast, the ribs are
commonly found atrophied, so that they admit of being cut with a
knife.   The cortex is thin ;  and the osseous plates  and threads of
the cancelli are thinner and fewer than  natural.   The cells contain
a reddish-brown and slightly gelatinous fluid.   The bones  of the
extremities are often unusually brittle.   Sometimes,  but very rarely,
carcinomatous tumours  are found in these brittle bones, [d. 74.]
  /. No definite line can be drawn between common atrophy of the
bones of children [6], and rickets, or rachitis.   Every intermediate
condition is  met with, between  the degree of weakness described
under the above head, and  the worst  cases of rachitic deformity.
Rickets  is a  softening of the bones, which commonly shows itself
in early childhood, but may make its appearance at  any time before
puberty. In the worst cases, the spine  becomes curved in various
directions ;  the sternum projected; the  ribs depressed and  twisted ;
the sacrum pressed towards the pubes ;  the clavicles become more
bent and prominent forward; the os humeri is distorted outwards;
the lower ends of the  radius and ulna are twisted  in the same
direction ; the thighs are curved forwards or outwards; the knees fall
inwards; the spine of  the tibia becomes  convex, and  the feet are
thrown  outwards;  that is to say, the trunk and limbs become bent in
directions determined by the action of the muscles, and by the weight
and pressure which they have to sustain.  The state of the bones,
which renders them thus flexible, is the following:—The  cortex is
       18—f                                     3 may 
22
MAYO'S OUTLINES OF PATHOLOGY.
thinner than usual, and more porous ; and the bony cancelli have dis-
appeared.   The bones in the worst cases again have a consistence
approaching that of common cartilage; but their texture is areo-
lated.  The cells are in some parts large, and contain a brownish
gelatinous substance.1 [d. 14. d. 12. d. 13. &c]
  g. Preternatural brittleness and flexibleness of the bones are the
results of different  degrees  of  the same  cause.   One  degree of
atrophy produces brittleness; a greater degree,  flexibleness  with
greater brittleness.  The disease in which these features are shown
in the highest aggravation, is one which attacks adults,  but  is of
very rare occurrence. It is named mollilies ossiuin.
   In the museum of the  College of Surgeons there is a specimen of
an adult humerus, of which the cortex is as thin as a wafer, and
the interior looks as if filled with  tallow: towards the lower  part,
for about two inches above the condyles, the  bone appears to  be a
vascular sac of membrane.   Mr. Hunter considered  this to be the
mollities ossium.  In the museum of the London Hospital are spe-
cimens from the body of a woman, who died  at the age of seventy-
two, which nearly resemble that above referred to.   This woman
had been confined to her bed for four years  with  paralysis of the
lower extremities.   The hip and knee joints had been for a  con-
siderable time permanently fixed: her appetite was  always good.
A month before her  death, on making  a slight exertion,  the right
thigh bone broke ; and, shortly after, the right arm.  Mr.  Hamilton,
with great liberality, has presented to the King's College mustum
a preparation of one of the bones from this body; and the following
is his account of the general post mortem appearances.
  "The lungs were healthy; the heart  rather large and soft; the
abdominal viscera  and  mesenteric glands  healthy.  There was
considerable calcareous deposit in the lumbar and iliac glands.  In
the cranium, when   the dura  mater was opened,  three or  four
ounces of fluid  escaped, and  there were  some  small  tubercles
attached to its under surface.   The  substance  of the  liver was
natural.  The articulations were in a healthy state.  The perios-
teum covering the bones generally appeared  natural; but over the
trochanters it was entirely detached.  The bones of the cranium
and  pelvis could  be cut  with a knife ; while the ribs and vertebra?
were but slightly  affected, and scarcely less firm than usual.   The
bones of the lower  extremities  were far more extensively diseased
than those of  the upper.  The  thigh  bones consisted of a  mere
shell of  bone,  filled with a fatty substance : the fractured extremi-

ti?n»rrf 156MUrand hllmerus  had a sliSht ligamentous connec-

  In Mr. Wilson's description of  a case of mollities ossium,  in  a
ZZZ7^t  lf at/orty;ei?ht y^rs of age,  the only bones which
were not entirely softened were  the sacrum  and the bones of the
volSvii.a Papef by Mr' Stanley>in ^e  Medico-Clnrurgical Transactions, 
THE BONES.
23
feet.   The bones consisted of a thin flexible and brittle shell; and
in the place of cancelli, a substance resembling coagulated  blood
was found, with cells containing oil.
  In the  fourth volume of  the  Medico-Chirurgical Transactions,
Dr. Bostock  describes an analysis,  by  himself, of "two of the
dorsal vertebra? of an adult  female, whose bones were discovered,
after death, to be unusually soft and flexible," the  result, as it was
supposed, of  mollities ossium.  The composition of the bones was
as follows:—
• Cartilage	57.25
Jelly and oil	22.5
Phosphate of lime	13.6
.Sulphate of lime .	4.7
.Carbonate of lime	1.13
^Phosphate of magnesia. .	.82
	llt.it
                          SECTION IV.

                 Simple Inflammation of Bone.

  The bones are susceptible of inflammation, which presents  dif-
ferent features,  according to the kind of bone attacked,  and to the
state of the constitution which attends or produces it.
  When a cylindrical bone (either the shaft or articular extremi-
ties, excluding  the immediate articular surface) is  inflamed, in  a
person of unimpaired constitution, it  often passes into  conditions
which are comparatively wholesome,  and from which the  step to
restoration is direct.   These conditions are,  inflammatory enlarge-
ment, abscess, necrosis.                                 ...
  But when the articular aspect (that is, the surface to  which, the
articular cartilage immediately adheres) of a cylindrical bone, or
when a  round  or flat bone is inflamed,  a  different consequence
ensues, the bone  becomes carious.   The same  result  ordinarily
follows in any bone, if the inflammation depends  upon vice of the
constitution, as struma, or taint in the habit,  as syphilis.
  These rules, however, are  not so constantly observed, but that
exceptions to them occur.   On the one hand,  caries  occasionally
follows common inflammation of the  shaft of a cylindrical bone.
And on the other, inflammation of a round or flat bone, whether
simple, or strumous, or syphilitic, often either terminates in reso-
lution without going into caries, or produces necrosis in combina-
tion with caries. 
24
MAYO'S OUTLINES OF PATHOLOGY.
  In studvincr the phenomena of simple inflammation of bone, it is
important to distinguish inflammation of the membranes from in-
flammation of the proper osseous tissue.   The existence of such a
distinction  might be conjectured  from anatomy.   I he external
periosteum, although  continued by innumerable tubes  and  fila-
ments into the substance of a bone, yet in the healthy state readily
peels from it as a separable and separate texture; and  the medullary
membrane,  although reflected over the  cancelli,  has little else m
common with them.  Accordingly, each of these members is liable
to be attacked with inflammation, independently oT the bone: they
are not, however, the less liable to be drawn into  inflammation
through extension of action from the proper osseous tissue.
  Inflammation of the periosteum is of frequent occurrence.  In-
flammation of the  medullary membrane  is, on  the  contrary, ex-
tremely rare.  Both are liable to  present  themselves under an acute
character.  Acute periostitis often follows exposure to  cold.  It is
attended with swelling, that is, with thickening of the  periosteum,
with pain, and  increased sensibility.   Under proper treatment, it
quickly terminates  in  resolution.  Acute inflammation of the  me-
dullary membrane I have  seen demonstrated  in  one specimen
alone, which  Mr. Stanley showed to me, from a case in which this
affection had followed amputation.
  Subacute or chronic inflammation of the periosteum  is often
produced by mechanical injury.
  Periostitis is attended, first with tumefaction or thickening of the
membrane, which becomes painful and acutely  sensible  to  pres-
sure; secondly, with a growth of osseous tissue between  the ex-
ternal surface of the bone and the membrane.  The newly-lormed
bone is porous, and  has  but slight adhesion to the old [d. 20.]: in
time, it becomes compact and hard, and adheres inseparably. [</.21.]
Part of the pain of periostitis arises from  the tension of the mem-
brane,  and  may therefore be relieved by dividing the membrane to
the bone.
  Simple inflammation of the substance  of a cylindrical  bone is
characterised by the slowness of its progress.  It is  attended with
enlargement  of  the bone  affected, with  aching, and a sense of
weight.
  The surface of a  cylindrical  bone  enlarged through inflamma-
tion, is uneven, often presenting the appearance  of fiat and irregu-
larly-plaited chords [d. 22.]; in  other instances it is  highly porous,
[d. 23.], and  never perhaps as  uniformly dense and compact as
healthy bone.  The enlargement is commonly partial, and limited
often to one aspect of the bone.   The different appearances found
on making sections of inflamed cylindrical bones are the follow-
ing:—

TdVl gr°Wth °f porous  bone suPerimposed  upon the cortex.

  2. A growth of compact bone  in the same situation,  [d, 21.] 
THE BONES.                       25
  3. An expansion of the cortex  through its conversion into po-
rous bone. [d. 24.]
  4. An expansion of the cortex, through  its apparent separation
into an outer and inner layer, with porous or cancellous structure
between [d. 25.]; or the expansion consists of an outer part com-
pact, an inner part porous bone.  [d. 26.]
  5. Expansion of the cortex, with compactness of texture through-
out, [d. 23.]
  6. The medullary cavity more  or less diminished, either by the
encroachment of the cortex inwards, or through  the solidification
of the cancellous structure, [d. 27.]
  Several of these appearances are often met with together.   It is
evident what combinations are possible, upon considering how each
appearance is  produced.   The two first  have  been already ac-
counted for as consequences of periostitis.  The rationale of the
production of the four  last may be understood by reference to the
healthy structure of bone.   In  the fabric of a healthy cylindrical
bone there seem to be two types of structure: there is, however, in
reality but one.   The cortical part is not essentially different from
the medullary.  When a dry cylindrical  bone  has been  broken
transversely, on examining the surface of fracture with a magnify-
ing glass,  the transition from the lightest cancellous  structure to
the densest part of the cortex is seen to be perfectly gradual; the
channels only are narrower, and the partitions stronger, where the
grain appears to be closest.  In the conversion, therefore, of com-
pact bone into porous bone,  all  that  necessarily takes  place  is the
enlargement of existing cells: in the conversion of porous into
compact bone, the  partitions only require  to be thickened.  The
varieties of enlargement,  in the cases 3, 4, and 5, may thus  be ex-
plained as successive stages of inflammation of the cortex.
  Simple  inflammation  of bone is either produced in a single bone
through some local impression, or occurs in several, as the result
of a general disposition to inflammatory enlargement in the osseous
system.
  In the former case, it commonly follows a blow, or exposure to
cold : it frequently begins with periostitis, and is seldom unattended
with more or less necrosis.  In the latter case, the affection seldom
alters its original character, but remains from first to last a greater
or less enlargement of bone, with more or less pain and weight of
the limb affected; sometimes continuing a few weeks only, in other
instances  enduring for  months and years, its  course in general
being  steady, and  without  fluctuation;  the attack  coming on
slowly, progressing slowly, receding slowly, and being unattended
with affections of other organs.
  A patient under thirty years of  age, in whom the whole of the
tibia, radius, and part of the os humeri,  had been thus affected for
many months, died  in the Middlesex Hospital of erysipelas.  The
enlarged bones were perfectly dense throughout,  [d. 27.]
  Another patient, about the same age, had a considerable enlarge- 
26
MAYO'S OUTLINES OF PATHOLOGY.
ment of one tibia, and a smaller swelling of the other: he happened
Thave broken the ulna some weeks before his admission   What
had principally alarmed  him was a sudden  enlargement at the
point wherePthe broken bone had united : an elastic tumour had very
suddenly appeared  there about the size of a walnut.   This patient
had no sore throat or spots upon the skin ; but was of a pale com-
plexion, and out of health.   He recovered in a few weeks, upon
taking sarsaparilla  with the oxymuriate of mercury,  and living on
a regulated diet, and in the equal temperature of an  hospital ward.
  A lad was in the Middlesex  Hospital with painful enlargement
of the lower end of the shaft of the femur.  He recovered after
some months, having derived evident benefit from caustic issues.
  The tibia  is more frequently inflamed  than any other bone in
the frame.  Its dependent situation, which is opposed  to the  free
return of the blood,—the extent of its subcutaneous surface, which
renders  it obnoxious to  changes  of temperature,—its  place  and
office  in  locomotion, which expose it to be frequently struck,—
sufficiently account for  this circumstance.  After  the tibia, the
femur, humerus, radius,  ulna,  are most  frequently  attacked with
simple inflammation.
  In  a  collection of bones which I purchased, there were several
of the cylindrical bones of one skeleton affected with  the same form
and stage of inflammation.   The femur, for instance, and  the hu-
merus, were enlarged; the whole shaft of the first, the  lower  half
of the second.  The enlargement  consisted in the uniform expan-
sion of the cortex into a porous or cancellous texture. In the same
skeleton, the bones of  the head and face had undergone a similar
change. They were considerably thickened, but remarkably porous
and light; the compact tables of the cranial bones  having expanded
like the shell of some of the long bones, [d. 2S.]
   I have seen, in living  persons, two instances of simple inflam-
matory enlargement of the ribs: one  occurred  in  a young lady,
whose general health was not otherwise considerably impaired: the
result of the case is unknown to me.  The other had the following
history:  A young gentleman, through hard study and neglect of
exercise, became dyspeptic, with pain in the head, and inability to
collect his thoughts.  After a time, three or four of his ribs  on  each
side enlarged, and  were painful. He gave up his studies, and went
to the south of Europe, where  he  recovered.  A year or two after-
wards, he became a medical student in London.' In a little  time
his former indisposition returned ; and he became again dyspeptic,
with  hypochondriasis and  painful  swellings of the ribs.  Upon
going into the country he recovered. 
THE BONES.
27
                          SECTION V.

                        Abscess in Botie.

   When inflammatory enlargement of a single bone has long ex-
 isted, suppuration may have taken  place: there may have  been
 wrought within it a  cavity or cavities,  lined with vascular mem-
 brane, and filled with pus.   Abscess, if  in a cylindrical bone, is
 commonly situated in one of the articular extremities.
   The best account of this  form of disease is  in a paper by Sir
 Benjamin Brodie, in the seventeenth volume of the Medico-Chirur-
 gical Transactions.  In this paper three cases are described, in  each
 of which the abscess occurred in the tibia; twice  in the lower, once
 in the upper end.  The  ages  of the patients were twenty-four,
 twenty-three, and thirty-four.  In each the bone had been diseased
 for several years.  In  the first case the limb was amputated : and
 the stale of the bone, when examined afterwards, is thus described.
   u The whole of the lower extremity of the tibia was harder and
 more compact than under ordinary circumstances, in consequence,
 as it appeared, of some deposit of bone in the cancellous structure;
 and in its centre, about one-third of an inch above the ankle, there
 was a cavity of the size of an ordinary walnut, filled with a dark-
 Coloured pus.  The bone immediately surrounding this cavity was
 distinguished from  that in the neighbourhood  by  its being  of a
 whiter colour, and of  a still harder texture; and  the inner surface
 of the cavity presented an appearance of high vascularity.   The
 ankle joint was free from  disease."
   In the second case, Sir Benjamin Brodie was led, by its similarity
 to the first, to suspect  the  real nature of  the disease: he therefore
 trephined the bone at  a spot two inches below the knee, to which
 the pain was immediately referred; and then, by  means of a chisel,
 removed several other small  portions of the bone at  the bottom of
 the cavity made by the trephine.  At this part of the operation, the
 patient suddenly experienced a sensation, which he afterwards de-
 scribed as similar to that  which is produced by touching  the cavity
 of a  carious tooth, but much more severe; and immediately about
 two drams of dark-coloured pus issued slowly from the part to which
 the chisel had been last  applied.   From this instant the peculiar
 pain belonging to the disease entirely ceased, and it  has never re-
 turned ; the  patient being able to walk in three months after the
 operation, and the wound being completely cicatrised in  six.
   The  early history  of  this case is an  instructive comment on
 some of the remarks which  have been before  made.  Two years
 before the operation above described, the patient applied for advice,
 having  then  suffered  for "ten years  with slight  enlargement and
pain in  the upper extremity of the tibia.   The swelling now occu-
pied about a  third of the  length of the bone, and  the patient  com-
plained of excessive pain, which disturbed  his rest at night: some 
2S
MAY0?S 0UTLTNES OF PATHOLOGY.
 parts of the swelling were tender to the touch.  On the supposition
 that the disorder was chronic periostitis, the following practice was
 adopted.   An incision  was made longitudinally on the anterior and
 inner part of the tibia, extending from the  knee four inches down-
 wards, and penetrating through  the  periosteum into  the substance
 of the bone.  The periosteum was found considerably thickened;
 and the new bone, which had been deposited beneath, was soft and
 vascular.  The immediate effect of the operation was to relieve the
 pain  which the patient  suffered.  The wound gradually healed,
 and it was for some  time supposed that a  perfect cure had  been
 accomplished.   The enlargement of the upper extremity  of the
 tibia, however, never entirely subsided.  In a year and a half pain
 was again experienced  in it, which in five months became constant,
 but more severe at  one  time than  at another, often  preventing
 sleep during several successive  nights.  The  enlargement of the
 tibia was as great as before; and the skin  covering it was tense,
 and adhered more closely than natural to the surface  of the bone.
   I have  met with but  one  case of abscess in bones.  The patient
 was a young woman, who had suffered eleven  years  with enlarge-
 ment and pain in the right tibia.  The correspondence of some°of
 the symptoms  with those of the cases just narrated, made it likely
 that part of the disease was abscess in the  bone.   But there were
 reasons which rendered the amputation of  the  limb  preferable to
 any other operation.   The disease had originally commenced in
 the upper part of the tibia, and had involved the knee joint,  which
 had become anchylosed at  an  inconvenient angle.   The present
 enlargement occupied the lower  two  thirds  of the tibia:  the limb
 was wasted, and the patient in very delicate  health. On examining
 the amputated  limb, an  abscess of the size of a chestnut was found
 in the lower extremity of the bone, within a third of an inch of the
 joint.   The cancellous  structure round it was not much  closer or
 harder than in health, [d. 29. d. 30.]
   The preceding case exemplified in  addition the  formation  of ab-
 scess in the shaft of a bone: a second but  much  smaller abscess
 was found in this situation.
   Another specimen of abscess in the shaft was given to me bv Mr
 Aniot .   It was situated in the middle of the femur.  Vhe caneI
lous structure round it  was nearly consolidated.  The abscess was

trerThe0nsvmotnn£r  I fCd0n °f the fe™r  after  the  pat en
of  the knee1o7n7whTnSh tT^ t0 " Y been masked by disease
boieciS  J„H  L   2 s«frvened after  the extraction  of a
loose cartilage, and had rendered amputation necessary [d  31 ]
/. 
THE BONES.
29
SECTION VI.

  Necrosis.
  Necrosis is the death of a bone.   It may be entire or partial.  It
may be attended or not with restoration.  Its varied features require
to be grouped under distinct heads.
  I. Necrosis of the shafts of long  bones, occurring without any
evident reason,  is frequent in  children and in young persons.  The
complaint  has, at its commencement, an inflammatory character:
its  proximate cause may possibly be acute  inflammation of bone,
terminating, after a few hours, in death of the part attacked.
  The tibia  is the bone  most frequently necrosed: after it, and
perhaps in the following order, the  femur, humerus, ulna, radius,
fibula, clavicle.
  When the  shaft of a long bone is struck with necrosis, a salutary
process is immediately commenced,  which comprehends  three ob-
jects.  The first is,  the separation of the dead part, or sequestrum ;
the second, the formation of a temporary shell  of  bone, to serve
while the separation of the sequestrum is in progress ; the third, the
final restoration of the limb  by the conversion of the  temporary
shell  into perfect bone.  The 'two  first changes proceed simulta-
neously, and are the direct results of the  same cause,—-the  irrita-
tion, namely, which the presence of the  dead bone occasions.
  The detachment  of the sequestrum is effected partly by the ab-
sorption  of  the contiguous'layer  of living  substance:—this  is
proved by the  entireness of great  part of the outer  surface of a
sequestrum [d.  35.]; partly by the absorption of the superficies  of
the dead  bone:—this is presumed  to  happen,  from the excavated
and honeycombed  surface which part  of the sequestrum usually
exhibits, [d.  34.]   Mr. Wilson gives a satisfactory proof that living
tissues, in contact with a dead bone, can operate its partial absorp-
tion.   Adverting to the practice of transplanting teeth, he observes
that the  transplanted teeth used to adhere  at first, but that they
seldom remained  in  their new sockets more than three or four
years; several  such teeth, which Mr. Wilson examined, had lost
their fangs by absorption.'
  The temporary new bone is formed arou nd the dead.   1 he dead
bone is  an irritant to the surrounding tissues, which, while they
shrink from  it, thicken and  give origin  to a sort of callus; that
ossifying, as  after fracture, forms an irregular shell of porous bone.
In this shell, holes  are either  left, or wrought subsequently by  ab-
sorption, which communicate, by means of sinuses, with the surface
of the limb.  Sinuses opening opposite  to different points of an  en-
larged bone, afford strong presumptive evidence that the disease is
necrosis.   The sinuses and the holes in the shell of bone to which
' Wilson on the Bones. 
30
MAYO'S OUTLINES OP PATHOLOGY.
they lead, are the channels through which, in the common course
of things, the sequestrum is finally to make its exit.  [d. 33. d. 34.
d. 35. &c]
   No sooner is the sequestrum removed, than a  growth from the
cancellous structure of the ends of the bone, and from the interior
of the temporary shell, takes place, and fills  the  vacant cavity: at
the same time the temporary  shell of bone contracts  in volume
through a process of modeling  absorption and deposition, and be-
comes smooth upon its surface, assuming at last the exact character
of the bone which has been lost.
   In the ordinary course of a necrosis of the shaft of a cylindrical
bone, it appears to be the cortex only which dies ; at all events, the
cortex alone comes away as sequestrum.  The cancellous structure
which it contained, whether dead or living, is absorbed before the
sequestrum becomes  detached.   One may suppose  that it does not
die, for two reasons: first, the  cancellous structure  has  more vas-
cularity and vitality  than the  cortex, and might be expected to
resist an  influence which would destroy the latter; secondly,  if the
cancellous structure dies with the cortical  part, where is the agent
which removes it?
   The following cases will serve  to exemplify the ordinary features
of the form of necrosis now under consideration.
   A child between three and four years of age was seized with an
inflammatory swelling of the leg,  attended with considerable symp-
tomatic  fever.  By the use of the ordinary remedies the symptoms
vyere mitigated ; and  in three weeks a deep-seated abscess was dis-
tinguishable, which was opened.   The child recovered its health;
but the enlargement of the  leg continued,  and a sinus  remained
where the abscess was punctured.  At the expiration of a year a
piece of bone projected, which, on being drawn  out, proved to be
the cortex of the entire shaft of the fibula, [d. 33.]
   Excepting in very  young children, it is generally right to remove
the sequestrum by an operation, several months  perhaps before it
would spontaneously  come away.  For this purpose, the best  mode
 ,                   i       ^------_~_w..„ .„, nmo illl^ULIUli Willi
the natural  course  of  reparation are the following:  Protracted
confinement of the patient to his bed or couch may produce slough-
ing of the integuments,  or contraction of the limbs.  The lono- con-
finement and continued discharge of  matter may exhaust th? con-
stitution.  The protracted continuance of the sequestrum in  the

TZtTt -T7 fV° nSG t0 °arieS' and eve»  inv°lve ^e neigh-
Dounng joint in disease.                                     &

inlrhrT1' {°Veerl' atChristm^ 1S33, without any previous
 owed' ZZrTlZftW-[L?T  acro?s the left ins*P i  * swelling fol-
ble auamit:J ^T^ afterwards was opened, when a consider*-
DMhelei7  l "" attereSCfPed-   The swelling  gradually extended
«P the leg.  He remained now for several months in bed, suffering 
THE BONES.
31
 pain in  the  swollen limb, which was mitigated by the recumbent
 posture.  He lay at first on the left side, a pillow being placed be-
 tween the knees.   The  left hip, however, became sore from lying,
 when he was  shifted  to the right side.   Towards  the autumn of
 the same year, a surgeon made an incision upon the inner surface
 of the tibia, and trephined the bone: a sequestrum was  thus ex-
 posed, but not  removed.   Lint was introduced into the hole made
 by the trephine, when the hole gradually spread by ulceration, so
 as finally to lay bare more than half of the shaft of the  tibia; which
 remained, however, partially encased in new bone.   Half a  year
 afterwards, this patient came under my care, when, without having
 occasion to enlarge the opening, I removed a sequestrum eight
 inches in length, [d. 36.] The part rapidly closed.  The calami-
 tous part of this case is, that  the opposite hip joint is anchylosed at
 a right angle with the body.  This arose  from the long  confine-
 ment of the boy to one posture.  It might have been prevented by
 proper care: the removal of  the  sequestrum  at  an  earlier period,
 by shortening  the  duration  of the illness, might alone have pre-
 vented it.
   James Mills, aetat. eighteen, in April, 1834, received  a severe
 blow on the left tibia, through a chest falling against  it.  The
 bruised  part was rubbed with vinegar.  He walked about as usual
 during the next ten days.  The leg then swelled and became pain-
 ful, when leeches and fomentations were used.   At the expiration
 of a week, a surgeon opened the swelling, and a considerable quan-
 tity of  matter  was  discharged ;  afterwards other openings were
 made, and for eight or  ten weeks the limb was poulticed.  The pa-
 tient then began again to walk about, the leg continuing to dis-
 charge, but without much pain.  Towards the beginning of Janu-
 ary, however,  the pain  became again aggravated.  He was  now
 unable to walk, the leg being easy in  the  horizontal posture only.
 The upper part of the tibia  appeared enlarged to  three  times its
 proper bulk.  At either end of the enlarged part, and in the middle,
 were sinuses.   A probe  introduced into  these passed  through an
 opening  in  an  outer shell of bone, and  came  in contact with a
 sequestrum  within.  Towards the end of March, the sequestrum
 was^so loosened, as to  yield when pressed upon by the probe.   An
 incision  was therefore made through the integuments covering the
 shell of bone, and the thickened skin dissected far enough on either
 side to give room for the application of a middle-sized trephine over
 the centre of the enlarged part.  A circle of bone having been re-
 moved, the sequestrum was exposed, which I cut in half with bone
 forceps.   The trephine hole was then enlarged sufficiently to allow
 the parts of the sequestrum to be drawn out.
   Ellen  Madigan, astat. fifteen, on the  morning of St. Patrick's day,
 1830, having been  till that time in good health, and not recollect-
 ing to have received any blow or injury on the part, was awakened
from sleep by  an  acute  pain on the outside of the right thigh,
attended  with a sense of extreme heat or burning.  The thigh 
32
MAYO'S OUTLINES OF PATHOLOGY.
swelled, and continued painful for five or six months, when an ab-
scess broke on the outer and lower part of the limb.   Another ab-
scess afterwards broke above the inside of the knee.   When she
came under my care, April 3, 1835, the lower part of the thigh was
greatly enlarged ;  the knee was straight, and capable of very little
flexion ; but the joint  was not diseased.  The wound on the inside
of the thigh had long  been healed, but a deep and foul ulcer had
formed in the lower  and middle part of the  ham ;  and several
sinuses opened along  the outer and posterior aspect of the thigh.
A probe introduced into these sinuses struck upon rough and irre-
gular bone, which  was every where compact, hard, and  immova-
ble.   Taking,  however,  into  consideration the  large size  and
uneven surface of the bone, the inflammatory character of the dis-
ease, the length of time it had existed, and the  numerous sinuses,
which, as through  an effort of nature, had  opened in succession at
different points of the limb, I concluded that there must be within
the  bone, either matter, or carious bone, or a  sequestrum, which
required to  be let out or removed,  xlccordingly, an incision  was
made  down to the bone,  between the attachments of the  biceps
flexor  cruris and vastus externus.  The bone so exposed was irre-
gular and hard, but alive: and no sinus was found leading into it.
I  proceeded, however, to apply the crown of a trephine over the
middle of the  denuded surface; when, a circle of bone being re-
moved, matter escaped, and  a  sequestrum  was seen loose and de-
tached within  what was  now identified as a strong shell of new
bone.  Another portion of the shell was therefore taken away by
the trephine, to enlarge the  aperture;  and the sequestrum being
divided, the  separate portions were drawn out.   The  sequestrum
proved to be the lower half of the shaft of the femur.  It was hard,
and, being loose in  the shell of  new  bone, was not cut through
without difficulty.   A  half trephine, the bone forceps, and a chisel
and  hammer, were used in dividing it.  As the  patient recovered,
the knee gradually regained the power of flexion.
  In this case  the necrosis  had nearly  implicated the lower
articular end of the femur.  In a case which Dr. Mott mentioned
 o me as having been under his care, the head of the femur was so
involved in  a  necrosis, as to render  amputation at the hip joint
necessary.                                              ^ J

1 J',w°hther f°rm  °f 'K"°f's>is de,lth of a bone <°  « greater or
cal orcPhe'nLCrSeqUenCe °f 'njUry °f "le SUrface> «*e "mechani-

Da&Ldr'd,!!i0n  ,°(, b°"e' When  ca,,sed  bY « Mo».  if the
aue  '  d'wi 'h  ,?:  ^sis The" $? 7*^,1 not necessarily
strinno,! Z},  necrosls-   V   "bm> for instance,  or  os parietale,
IKnlllZ  T P^f graZ°'0r th<"««remityo?a-bon
rac  ,re T  ' „ h,"   / broken •SUrfaCes exPosed »> "compound
»?„„?■. caP.able  of recovering  themselves   The -surfaces
foTor fil" "CSe mS,an„eS' inslead °f  becoming dry and w te n
four  or five days generally assnme a light red tint, «K^gradually 
THE BONES.
33
deepens: a gelatinous exudation is then poured out, which coagu-
lates upon the bone;  and, receiving vessels  from it, becomes a
layer of organised and florid granulations, that unite with  those
produced by the neighbouring soft textures, and close or fill up the
wound.  In the reparation  of a compound fracture, the substance
of the  bone having its vascularity increased, appears to contribute
more actively to its own reparation than  in a simple fracture.   The
whole  wound equally inflames,  suppurates,  granulates:  it  is in
these granulations that the provisional callus is formed.
   If the violence done to the bone has been more  considerable, or
if the constitution, or the bone, be already diseased, partial  necrosis
takes  place.  The exposed surface  remains  dry and white,  and
after a tew weeks is  thrown off as a thin plate or scale of bone.
The bone  is then said to exfoliate.  The thin plate of bone, or
ring, (which  is its shape if it follow an amputation.) is called an
exfoliation.  The surface from which an exfoliation has separated,
is covered with granulations, the growth and ossification of which
replaces, in some  degree, the substance lost.
   A person about thirty years of age had the  tibia  grazed  by a
blow, and denuded of periosteum.   The outer shell to the  depth of
two lines, and the length of four  inches,  was necrosed. It separated
in twelve weeks,  [d. 37.]
   In a compound fracture,  it often happens that the most project-
ing point or edge of the  broken  bone is necrosed, and exfoliates.
Where  there has  been  great violence, or previous disease, a  consi-
derable extent of  bone  is often necrosed, [c. 3S.J  Accidents of this
kind again display  the difference in the restorative  forces which
different kinds of bone possess.
   After  amputation  of the  thigh or humerus, three,  four, or five
inches of necrosed bone occasionally come away.  A person thirty-
four years  of age, who had lived intemperately, was admitted into
the Middlesex Hospital with compound  fracture of the leg:  great
swelling and inflammation followed ; and on the sixth day, violent
arterial hemorrhage.   At this period I amputated  the limb  below
the knee.  The  ends  of the  bones  became extensively necrosed:
the dead portion  came away from the  fibula in the  twenty-third
week, from the tibia in the twenty-fourth,  [d. 40.]  The  portions
were  three inches  long.  They were  genuine  sequestra:  round
each a shell of new bone had formed.
   If the integument and one aspect of the cortex of a cylindrical
bone are killed by an  injury, the cancellous  structure granulates,
and reproduces what has been lost.
   Such is the force of  reparation in  the cylindrical bones,  that
whatever 'part be destroyed,  the remaining  part  (or  if there be
none, the uninjured surrounding tissues) will  reproduce bone fit a
wonderful extent.
   3. The case is  different with other bones.
   A person sixty  years of age fell from a cart, and grazing his head
against the wheel, denuded the parietal  bone.   Towards the end of 
34             MAYO'S OUTLINES OF PATHOLOGY.

the eighth month, nearly the whole of ^^r^Zr^^
surfacS exposed was that of the granulating dura  mater.   No at-
temDt at reparation by bone had taken place.   [d.6J.}
  Some approach to restoration, after the separation of a necrosis,
has taTen pface, however, in the lower jaw,  and is said to have par-
tiallv occurred after necrosis of the scapula.
  When the articular end of a cylindrical  bone is necrosed, it ex-
cites disease of the joint, which  precludes  restoration.  In  a knee
which I amputated, half of the outer condyle was necrosed, and in
process of separating into the articular cavity,  [g. 4<5.j
  Necrosis of the bones of the  wiist and tarsus, when it occurs, as
it is sure to involve a joint,  is equally destructive.       ...
  Necrosis of the os calcis,  however, is an exception ; the bone is
of a size to allow  of disease  in it  being partial.  'Hie necrosed part
may exfoliate, and the bone recover.  There  would, however, I con-
jecture, be little replacement of bone.
                         SECTION VII.

                            Caries.

  What an ulcer is in the soft parts, caries is in bone.  The promi-
nent feature in each is loss of substance through absorption. Caries,
however, is something more than mere absorption.  When an aneu-
rism of the aorta presses against the sternum or the vertebra", the
bones are gradually eaten  through: they are  partially absorbed;
but they are not carious.   When, however,  to  take  a  different in-
stance, the face is attacked with lupus, and the ulcer spreading in
breadth and depth reaches the bones, and they become excavated
simultaneously with the soft, parts in the enlarging ulcer,  the osse-
ous tissue is not only absorbed, but truly carious.
  In caties,  absorption is preceded by a change in  the bone, which
(with very few and doubtful exceptions) has  a well-marked inflam-
matory character.   The  same condition persists during  the  pro-
gress of the absorption.   There is further present  an imperfect re-
storative action,  which is shown in the more or less partial growth
of unwholesome granulations from the ulcerated surface.  Of these
changes, the inflamed condition of the bone is the primary and most
important;  the absorption is secondary and accidental.   The ab-
sorption may be prevented by subduing the inflammation ;  or may,
having begun, be arrested, and the crop of unwholesome granula-
tions be converted into a healthy restorative growth, if the case is of
such a nature as to allow of the suppression  of the inflammatory or
specific action.
  There are four kinds of caries. 
THE BONES.
35
  1. Simple.  When in a person of sound constitution  a state of
unwholesome  and protracted  inflammation  is set up in  a  bone,
through some accidental local cause.
  2. Syphilitic.  When a disposition to a specific periosteal inflam-
mation is produced by lues.
  3. Strumous.   When  the  scrofulous diathesis gives origin to
caries.
  4. Malignant.  When the bones are absorbed  in the spread of
malignant ulcers originating in the soft parts.
  1. Simple Caries.—It has been  observed, that the bones of the
leg are particularly disposed  to inflammation.  In persons of a con-
stitution originally sound, hard labour, exposure  to weather,  bad
and insufficient nourishment, co-operating with a  dependent circu-
lation, as they frequently produce ulcers of the leg, so do they occa-
sionally produce caries of the bones of the leg.  The tibia becomes
inflamed, and then, instead of recovering or forming a circumscribed
abscess, slowly enlarges: the cortex, already more spongy than na-
tural, is next eaten through at one or  more points: the cancellous
structure within in the mean time is softened ;  and its cells are oc-
cupied with a  thick brown fluid in place of marrow.   The disease
is often  coupled with death of the bone, part of the  carious bone un-
dergoing necrosis.  The external character of the limb is the same
in necrosis and caries.   The  bone appears enlarged,  and one or
more sinuses open from it through the skin at points which are red,
and soft, and sunken.
  A child, six years of age, became my patient with an  enlargement
of the humerus immediately above the elbow : the joint was not im-
plicated in the disease.   The  enlargement was from  two  to three
inches in length, and situated principally  to the outside of the axis
of the bone : the bone had at this part three times its natural size ; the
skin covering it was inflamed;  and towards the lower part there was
an ulcerated opening, through which a probe might  be passed into the
cavity of the bone. The swelling had commenced two years before,
and was attributed to a blow which the child had received.   The
local  treatment adopted was the  following:—Having divided the
integuments to the bone on its outer edge, I made,  with a small saw
and chisel, an opening an inch long, and half an inch wide, through
the enlarged shell, and removed softened cancellous structure; leav-
ing an  exposed cavity of bone to granulate,  fill up, and contract.
This  was  a genuine  case of caries following a blow ;  the  bone in-
flaming, enlarging,  the  cortex partially  ulcerated, the cancellous
structure softened.
  The practice of making a free  opening into the diseased bone,
with the removal of (he softened part, brings to light, or is borrow-
ed from, another principle in the pathology of caries. The  diseased
part often  neither can recover itself, nor be absorbed ;  neither does
it become  necrosed.  Left to itself, the caries would  continue  year
after year,  undermining  the constitution  of the patient, gradually 
36
MAYO'S OUTLINES OP PATHOLOGY.
invading the adjacent sound bone, and  finally threatening with de-
struction the neighbouring joint.
Iz
ment
bone is to be freely opened.
  To o-ive instances of a different kind—A patient was admitted
under the care of Mr. Cartwright into the Middlesex Hospital, who
had been shot  in the groin :  the ball had perforated the  ilium, and
lodo-ed near the sacrum.   The patient survived the injury many
months.  She  died of extensive abscess of the pelvis, kept up by
caries of the ilium.
  A lad was kicked by a horse, and two ribs were fractured. Pleu-
risy followed, and empyema.   By puncturing an intercostal space,
I made an outlet for the matter, the discharge of which gradually
diminished in quantity;  but it was considerably more than a year
before the wound finally healed.  During the latter months, less
than a dram of maiter 'came away  daily :  it proceeded  from a ca-
rious state of the rib, which in  time got well.
  A man past  the middle age had suffered many years with a large
ulcer  on the outside of the  leg, which would sometimes  partially
heal, and then  again  spread  to its former size.  Over the fibula the
ulcer was deeper than elsewhere.   The appearance of the granu-
lations was not the same at all parts of the ulcer.  The portion of
the surface, again, which at  one time was  healthy, would shortly
after assume an  unwholesome character, while the  first  became
covered  with florid granulations.   Upon  the greater part of the
ulcer, the granulations were  generally gray and flaccid, or greenish
or yellow, and unorganised.   A probe passed into the granulations
covering the fibula, broke  easily through a soft and gritty texture,
The limb was amputated below the knee,  in the Middlesex Hospital,
in 1819.  The tibia was inflamed and enlarged.  The patient died.
The appearance of the fibula, after maceration, was the following:
—It was enlarged, and presented an irregular and  porous surface.
At the front, opposite to the  middle  of the  ulcer, there was a Ions;
and deep excavation, which, in the dry specimen—to  borrow an
expression used by Mr. Syme—looks like the surface of loaf sugar
that has been partially dissolved by  dipping into hot water, [d."62.]
  A patient past the middle age, and bed-ridden, lay for  a period on
one side.  The integuments covering the great trochanter  mortified
through the pressure, and a large ulcer followed the separation of
the slough. At the middle of the ulcer the granulations sprang from
the surface of  the bone, which was partly necrosed, partly carious.
The patient sank eventually.  The appearance of the carious tro-
chanter [d. 61.]  corresponds to a  considerable degree with that of
the fibula above described.
   A young man, from walking in a tight boot, had a blister form on
the heel, which through neglect became  an ulcer;  and as he was
compelled  to walk a great distance daily, at the end of four months 
THE BONES.
37
 he was laid up with an inflammation which spread half way up
 the leg.   The inflammation having subsided under the usual treat-
 ment, the ulcer was found to be the opening of a sinus that led  to
 the posterior part of the os calcis.  The patient upon this went to
 the seaside, and took iodine, when several minute portions of bone
 came away ; and in two  months the wound healed.  He then re-
 turned to London, and resumed his former  occupations, and for a
 time with impunity.  But three months afterwards, in consequence
 of over-walking, he  experienced a return of inflammation, extend-
 ing from the heel over the leg, attended with fever, and severe pain.
 By rest and proper remedies, the inflammation again subsided ;  se-
 veral minute portions of bone came away.  At this time  he was ad-
 mitted a patient in the Middlesex Hospital, where he remained two
 months;  by which time the sinus had healed, and the pain, tume-
 faction, and redness had disappeared.
   2. Syphilitic caries, as the name expresses, is an affection of the
 bones resulting from the poison of lues. It attacks indifferently the
 shafts of the cylindrical bones and the flat  bones; but seldom the
 round bones, or  the  articular extremities of the cylindrical  bones.
 It begins with  inflammation of the periosteum :  it does  not lead to
 much enlargement  of  bone.  The bones commonly attacked are
 those which, lying near the surface, are obnoxious to cold: the
 tibia, for instance, the ulna, the clavicle, the cranial bones.
   The swelling, by which syphilitic caries first manifests itself, is
 called a node.   It is an inflammation either confined to  the perios-
 teum, or involving at most the cortex of the bone.  The  periosteum
 becomes thickened, and is exquisitely painful.  If the integuments
 are divided down to the bone at this  period, a thick, viscid,  glairy
 matter, like honey, is often found in cells of the periosteum. A node
 is commonly oblong, from  two to three or four inches in length.
 There are generally more than one: it is not unfrequent to see two
 upon one bone.  [d. 65. 66. 67.] The surface of the bone now gra-
 dually enlarges, or is thrown up in  patches of porous bone, either
 furrowed  by longitudinal grooves, or spongy and sieve-like, riddied
 with  innumerable minute  holes.  This appearance is very common
 upon the tibia,  ulna, clavicle [d. 65.66.]; and I  have seen it upon
 the inner  table of the skull.  The outer table of the skull,  in vene-
 real caries, generally has the appearance of being worm-eaten, [d. 68.]
   Sometimes, but rarely,  the  scapulae [d. 71.] and even the verte-
 bras, and the tarsal and carpal bones  are attacked,  [d. 72.]
   While the caries of the bone is making progress, the integuments
 covering it inflame ;  matter forms below the skin, which after  a time
 ulcerates.  The  skin,  before breaking, has a livid colour;  afterwards
 the skin surrounding' the ulcer has the same hue. The edges of the
 ulcer are commonly a little raised; its outline is irregular, and its
surface is covered with unhealthy granulations and viscid ash-
coloured secretion.  A  probe pressed against the surface breaks
through the soft and gritty texture of the caries.
  Syphilitic caries is often attended with partial necrosis and ex-
       1 c  »                                    4 may 
38
MAYO'S OUTLINES OF PATHOLOGY.
foliation, [d. 69.] If left to pursue its ravages unchecked, the entire
thickness of the bone attacked is gradually involved in it.
  The coexistence of ulcerated fauces, and squamous eruption or
other diseases of the skin, generally leaves no doubt as to the nature
of the caries.   Sometimes, however, the caries, such as I  have de-
scribed it, exists  alone.
  3. Strumous caries, in  many cases, bears a close resemblance to
syphilitic caries: in  other instances it  is difficult  to draw the line
between it and simple caries.   In a third class of cases, certain pe-
culiar and characteristic features are strongly marked.
  A young lady, whom I  have attended, has suffered from inflam-
mation of the periosteum  of  the tibiae in oval patches resembling
nodes. Matter has slowly formed, and the bone has been exposed in
a carious state;  small exfoliations have then taken place, and the
wounds have healed.  Three swellings of this description have
formed in succession.  Her appearance gives evidence of the stru-
mous diathesis.
  A gentleman thirty-seven  years of age, in whom the strumous
habit is clearly marked, consulted me for caries of  the palate.  The
alveoli of the upper ja\v were  likewise carious.  He was liable to in-
flammation of the tonsils, attended with  ulcers.  The complaint,
however, was not of syphilitic origin.   The sister of this gentleman
has had caries and partial necrosis of the turbinated bones.
  A young man, twenty-five years of age, became my patient for
caries of the head and face.   A small exfoliation  had taken place
from the os malse of the left side,  and from the right superciliary
ridge.   The  integuments of the right  side of  the forehead were
swollen, puffy, and,tender : there was discharge  from the nose, and
part of  one turbinated bone was necrosed.   No  ground existed for
supposing that the disease was of syphilitic origin.
  There is not, that I  am acquainted with, any  essential difference
in the appearance of carious  bones in this form of scrofula, and in
the parallel cases dependent upon lues. Less pain,  less periosteal in-
ftammation, and a smaller extent of surface attacked, the absence of
other symptoms, and the general physical appearance of the patient,
afford a strong presumption of the scrofulous origin of the disease.
  The bones of the face are peculiarly susceptible of scrofulous in-
flammation.   The character  of the complaint is  often clearly estab-
lished by the formation of extensive scrofulous  abscesses upon the
temple or upon the cheek, or at the angle of the jaw; and by the
chronic enlargement of the lymphatic glands of the neck.
  Of the bones of the head,  the frontal and the  temporal are the
only ones which I have  known involved in this form of strumous
caries.
   The sternum is often affected with strumous caries, characterised,
as in the face, by the formation of extensive  scrofulous  abscesses.
 1 he seat of the suppuration is the anterior mediastinal cavity. The
bone may  require to be perforated with  the trephine, to awe wit
to the matter, [d. 64.]                             '    & 
THE BONES.
39
   As in the diatheses of different  persons every shade is met with,
 from delicacy of constitution to well-marked scrofula,  so  in affec-
 tions of the bones every shade is found between  simple caries and
 strumous caries.  It  is thus often difficult,  between the two, to as-
 sign their true place to instances of caries. It is probable that many
 would be disposed to class some of the cases, which I  have given
 to  exemplify simple  caries, as genuine  strumous caries.  Others,
 again, would include under the former head cases which I shall
 describe as scrofulous.  And this,  I suspect, would  be  more philo-
 sophical.   It is certain that fewer diseases are now considered scro-
 fulous than formerly; and it can only arise from an imperfect state
 of knowledge, that forms of disease, so different as the three which
 remaiu to be noticed,  should be grouped under one  head.
   The three cases to be described have, however, one point in com-
 mon ; they are affections of bones, or parts of bones, which are im-
 mediately contiguous to joints.   Through this circumstance they
 at once acquire higher importance in a practical point of view,  and
 are liable to  have their nature obscured through  the  superadded
 symptoms of articular disease.
  a. The ends of the cylindrical or round bones, which  are covered
 with cartilage, are liable to become highly inflamed and  softened
 for the depth of a  line; the adjacent bone remaining perfectly
 healthy for many months, but being finally involved in the same
 action.   The inflammation is so intense,  that the bone  is rendered
 for the depth specified of the  brightest red, when  the vessels are in-
jected with size and vermilion.  This state of the bone  leads to ab-
 sorption of the cartilage beginning on its osseous aspect, and is al-
 ways accompanied with inflammation of the synovial membrane of
 the joint.   The disease is probably most frequent in persons of the
 scrofulous diathesis.
  I amputated the leg of a patient, twenty-five  years of age,  five
 months after a compound  fracture of  the tibia  and fibula.   The
 bones  had shown a disposition to unite, but the general inflamma-
 tory swelling of the limb which supervened upon the accident, never
subsided.   Large collections of matter formed in the calf of the leg,
and about the ankle.   These were opened  in succession,  and the
 patient as many times  rallied from the hectic fever and exhaustion
 which  they produced.  At last there formed above the knee joint
an  extensive  abscess;  which was opened  ;  when  a  profuse  dis-
 charge  of  matter took place, and afterwards of blood and matter
alternately.   It was now that the limb was amputated, but too  late
to save  the patient.   In the  knee  and ankle joints the cartilages
were found partly absorbed, and what remained reduced to a thin
shell.  The articular aspect of the bone, which had become exposed,
was  highly inflamed.   The narrowed and thin shells of cartilage
which were left, were fonnd  to tear very readily from the bone:
when torn off, the detached surfaces were found to be covered with
bony particles, showing that the separation must have been effected
by rupturing the inflamed surface of the bone.   On further  ex- 
40
MAYO'S OUTLINES ON PATHOLOGY.
amination, the whole articular aspect of the condyles was found to
be highly inflamed and softened, for the depth of one to two lines.
The bone beyond was perfectly healthy,  [g. 60 J
  E. D., setat. twenty, was admitted, in November, IbdS. into the
Middlesex Hospital.   Three  years  previously, she had  been at-
tacked with pain and swelling of the left elbow joint;  which bemg
treated with leeches and embrocations,  went away in nine months.
Shortly after her recovery, the left knee began to swell at the lower
and fore part: the swelling was attended with pain, which, although
constant, was  severe at times only : she thought it  rheumatism,
and wore flannel  round the joint.   A  year  before her admission,
the disorder in the knee became more serious : at times it confined
her to her bed.  The joint  was hot,  stiff, and  painful.   Several
blisters  were then applied in succession, and with some advantage.
Leeches, fomentations, cold  embrocations, bandaging, were tried,
but were ineffectual.   At the time  of her  admission, and for a
month previously, she had been suffering the acutest pain, which
the least pressure  or  motion  aggravated to  intensity.  The knee
was hardly swollen ; it was a little bent.   There was no impedi-
ment to further flexion but the pain it gave.  The pain was severest
beneath the patella : it extended through the thigh and leg.  Hav-
ing tried local bleeding, fomentation,  a large issue, and  opium,
without any mitigation of her sufferings, I amputated the limb.
  Upon opening the knee joirfr* the capsular synovial membrane
was  found  to be inflamed and thickened,  presenting a  jelly-like
granulated surface, which extended a little way over the cartilages
of the condyles.  The cartilages were but  partially ulcerated to-
wards the joint, and for a very small extent; but they tore readily
from the bones.   There were parts at which it was  evident they
had been already discontinuous, the  surface of the cartilage being
slightly excavated, and the opposite surface of the bone ulcerated,
and extremely vascular.  At other parts the cartilage, when being
separated, tore away  with it  numerous granules of bone.  This
arose from, the surface of the bone, for the depth of a line to two
lines, having been highly inflamed, and softened in its texture.  Be-
yond the immediate surface, the bone was perfectly healthy. [g> 55.]
   The  preceding form of disease is connected with, perhaps de-
pendent upon,  inflammation of the synovial membrane.  It is ac-
companied generally with very acute pain.
  b. The common appearances denoting scrofulous  inflammation
in bone, are, softness from  deficiency of  bone earth,  increased
vascularity of the medullary membrane, and, in the place of me-
dulla, a thick reddish-brown  fluid in the cancellous structure.
   In the ankle bones of a child six years of age, examined imme-
diate y after amputation,  I found the'following appearances.   The
cartilage covering part of the posterior and upper surface of the
astragalus had been  absorbed;  the  cancellous  structure below it
was superficially ulcerated, and for a  considerable depth was soft,
as it rotten, its cells containing a thick  brown fluid.   The texture 
THE BONES.                       41
 of the anterior part of the astragalus was  healthy.  When a hori-
 zontal  section of the os calcis was made, about a third of its sub-
 stance appeared healthy; the remaining  and greater  part had the
 brown and  rotten appearance and consistence of the astragalus.
 The lower extremity of the tibia was in the same condition, [g. 67.]
   Sir Benjamin Brodie  thus describes the appearance of the elbow
 joint of a boy about ten  years of age :—
   "The cancellous structure of the articulating extremities of the
 os brachii, radius, and  ulna, was so soft, that it might be crushed
 by a very slight degree of force when squeezed between the fingei*.
 It was  of a dark red colour, preternaturally vascular, and there was
 a reddish fluid, mixed with medulla, in the cancelli."
   c. The appearance, which constitutes  the  most undoubted sign
 of strumous  action, is the deposition in the cancelli of  tuberculous
 matter—an  unorganised substance, in colour yellow, and  of the
 consistence of curd.  The  following instances are from Sir Benja-
 min Brodie's treatise on the Diseases of the Joints :—
   William Miles, aetat. twenty-three, underwent amputation  of the
 leg, for disease of the knee.   " On examining the knee, the articu-
 lating extremities of the tibia and fibula were  found so  soft, that
 they were readily cut with a common  knife : they contained  much
 less earthy matter than is usual, and their cancelli were filled by a
 yellow cheesy substance."
   Charles Miller,  astat. twenty, underwent  amputation of the foot.
 " The extremities of the tibia and fibula, all the  bones of the tarsus,
 and the extremities of the metatarsus,  contained much less earthy
 matter  than  is usual.   They were so  soft,  that  they might  be cut
 with a scalpel  without the edge  being turned.  They were pre-
 ternaturally  red and vascular, and a yellow cheesy substance was
 deposited in  the cancelli."
   Strumous  inflammation of the cancellous structure of bone, whe-
 ther attended or not with  curdy deposit, is generally characterised
 by its insidious march, the gradualness of  the local swelling, and
 the  absence  of the  pain  which  attends  common  inflammation.
 Even when the soft textures within' the contiguous joint are in pro-
 cess of secondary  ulceration, the  suffering is often  comparatively
 trivial.
   There is no reason to doubt, that the disease, in its  early  stage,
 may be arrested by judicious remedies, of which the principal local
 means is  the maintaining perfect quietude in  the affected joint;
 and the general means, the observing those  rules of diet, and medi-
 cine, and general habits, and place of residence,  which tend to cor-
 rect the strumous  diathesis.  Even when the disease has strongly
 established itself in a joint, there  is still a  remedy in  amputating
 the limb ; which is unquestionably to  be resorted to, if the organi-
 sation of the  joint  is completely destroyed, and the patient's health
 is rapidly failing, yet no vital organ seriously affected, and strength
enough left to bear the operation.   To decide upon the propriety
of operating,  in cases of less urgency, is an extremely difficult task.
Tn some cases, where the  constitutional tendency  to scrofula is 
42
MAYO'S OUTLINES OP PATHOLOGY.
slight, the  patient has been permanently restored  to  health by
losmcr a scrofulous joint.   In other cases,  the local disease appear*
to be a vent to  the specific action ; and when that vent no longer
exists, scrofula manifests itself in other more important organs, and
the patient perishes but the more rapidly.
  It may happen, however, that the organs invaded  (upon this
hypothesis) by the returning disease may not be vital parts. Mr.
Cartwright amputated  a scrofulous knee in a girl seventeen years
of ao-e.  Shortly after the stump had healed, several large strumous
abscesses formed in different parts of the body : they broke, and the
patient  was reduced to great exhaustion.  Nevertheless  she reco-
vered, the strumous action having fortunately fallen  on the  inter-
muscular filamentous tissue only.  When the disease attacks  a
small joint, it is  probable  that the patient is in less danger of a
return of strumous action on its amputation.   Disease of the join^
of the  ball of the great toe is such an instance.   In  this case the
place of the disease renders the patient particularly desirous to have
the part removed.  The operation is one often performed : besides
the joint, as much of the  metatarsal bone being taken  away as is
altered  in  structure.   A gentleman  upon  whom I performed this
operation, after recovering  perfectly, and acquiring the  appearance
of restored health, was in a few months attacked with symptoms of
pulmonary consumption, of which he died.
  It seems natural to  suppose, that if  there is a doubt about am-
putating a scrofulous joint in a patient otherwise free from disease,
it would, a fortiori, be improper to remove the  part, when  scrofu-
lous disease has  already manifested itself in  other organs.   But it
has been instructively  pointed out by Sir Benjamin Brodie, that the
removal of a scrofulous joint will sometimes palliate, or arrest, ex-
isting scrofulous disease of the viscera.  He narrates the  case, which
gave origin to this observation, in the following  words :—
   "A  young  woman  was  admitted into St. George's  Hospital,
labouring under a scrofulous affection of the ankle.   It  was of long
standing, and there were  several abscesses communicating with
extensive surfaces of carious bone.   It was evident that there was
no chance of cure for  the disease in the joint.   Nevertheless, I did
not think it right to propose to the patient thatslie should submit to
the loss of the limb, as she had a troublesome cough, with a puru-
lent expectoration, and other marks of pulmonary  disease.  She,
however, earnestly  implored that  the ankle might be  removed;
and at  her request, and certainly against my own judgment, I per-
formed the operation.   The stump healed readily. The pulmonary
symptoms almost immediately subsided.  She lived  for four or five
years in  tolerable health ; but at the end  of that period (as I have
been informed) there were  again manifest indications of disease
within  the chest, of which she ultimately died "
   It is  to  be  borne in mind, that  in  scrofulous affections of the
joints  left to pursue  their course, it is  not the articular  disease
which  is directly fatal   The patient  through  it indeed is debili-
tated and worn; but  the exhau^rr, ~f W--, £*:..* „„.i „„,n|rth has 
THE BONES.
43
 to produce disease in the  mesentery or lungs, or in both, to prove
 the immediate cause of dissolution.   The surgeon has therefore to
 consider whether the amputation of the limb is most likely to avert
 the fatal visceral disease, by saving  the patient from the exhaustion
 which promotes it, or  to accelerate its progress by removing the
 vent for strumous action, which the diseased joint affords.
   4. The instances of malignant caries  are  the ulceration of the
 bones in lupus, and in different forms of cancer.
   Lupus  commences in  the soft parts, and the bones are seconda-
 rily affected.  The ala nasi is the  part first  attacked.  The skin
 covering  the ala nasi becomes red and hard, and ulcerated, the
 ulcer presenting a yellow lardaceous surface.  The  ulcer slowly
 spreads,  the circumference of red  and hardened  skin  extending
 with its enlargement: it  gradually destroys  the  cartilages of the
 nose, the ossa nasi, the upper maxillary bones, the spongy bones,
 and finally attacks the frontal.  The  patient then perishes  of in-
 flammation  of the meninges of the brain.  The bone is not in this
 disease  merely passively absorbed: it inflames before it ulcerates.
 In  one  of two specimens in our museum [d. 7.,] there are light
 ridges of porous bone formed upon the os frontis, near the bounda-
 ries of the ulceration.
   The lower jaw is liable to ulcerate under two forms of cancer.
   True carcinoma occasionally begins in the glandular parts at the
 anglefof the jaw. When the ulcerative stage supervenes, it involves
 the bone, which is kept excavated by progressive  absorption to the
 level of the  cancer.
   There is a different disease, improperly  called cancer, which is
 produced by fretting any superficial sore upon the lip. The lip be-
 comes hard  and thickened round the sore, which turns either into
 a deeper ulcer,  or a wart-like fungus. This disease has not the ma-
 lignancy of true cancer.  When  removed by excision, it does not
 commonly return.  It  is sometimes  allowed to make  considerable
 progress, before the patient will consent to an operation ; in which
case great part of the lip may have been destroyed, and the indura-
 tion may have  extended to the gums and  periosteum of the jaw.
 As, however, the bone is  not specifically involved in the disease,
even then, at the expense of some mutilation,  a cure may be effect-
 ed; all the soft  parts attacked, including the thickened periosteum,
 being removed.
                         SECTION VIII.

                 Malignant Growths of Bone.

   By malignant growths is meant a class of affections, which con-
sist in the enlargement of parts through the production of some new
element, that has a tendency to indefinite increase;  the increase 
44
MAYO'S OUTLINES OP PATHOLOGY.
having no check but in the sloughing or ulceration of the part; and
the disposition to the new formation being so strong as to manifest
itself in different  parts simultaneously or successively, and in the
same part a second  time after temporary extirpation.
  As the subject of  malignant disease,  bone displays the following
remarkable features.  Without the introduction of a new element,
a tumour of bone may in one sense be malignant: abnormal growth
of bone from bone may be accompanied with a tendency to the de-
posite of phosphate of lime in other parts  of  the frame.  On the
other hand, when new formations appear in bone with the local cha-
racters of malignant disease;  they have not the same rootedness m
the system, as when they originate in the soft parts; so that the re-
moval of a bone attacked by malignant disease  is not in general fol-
lowed by a return of the complaint.  For example, in one who has
suffered amputation of the breast for medullary sarcoma, the dis-
ease is sure to recur; but when the leg is amputated for the same
disease originating in the tibia, the chances are greatly in favour of
the patient's permanent escape.
   The common forms of malignant tumours  of bones are six in
number, which exist either separately or in combination.   They
are,  malignant exostosis, osteo-sarcoma, medullary sarcoma, fibrous
tumour, cystlike tumour, melanosis.
   1. Of malignant exostosis, nothing  is  known  to me beyond the
facts mentioned in a former section, reference  to which is given in
the foot-note to this page.  This is probably a disease of very rare
occurrence.
   2.  Osteo-sarcoma is well described by  the term cartilaginous ex-
ostosis.  It consists in  a growth  of substance,  nearly resembling
epiphytic cartilage in texture, originating either upon the surface or
in the cancelli of bone. The form of the tumour is commonly more
or less spherical:  it may attain so great a volume as to be nearly a
foot in diameter,  [d. 78.]
   When an osteo-sarcoma is  small, the surface displayed by a sec-
tion is tolerably uniform, or differs from the most transparent carti-
lage only in  exhibiting minute oblong  or irregular cavities,  [d. 75.]
When an osteo-sarcoma  is larger, cavities of  considerable  size are
 found in  it,  which contain a reddish fluid.   In parts the  texture
grates when cut,  and contains phosphate of lime.   The phosphate
of lime is distributed so  as  to form  a  kind  of skeleton  of light
 bony plates  disposed in  a manner that looks  like a crystallisation.
 [d. 78.]  The growth of such a tumour is commonly rapid.  When
it begins in the interior of bone, the disease is attended with pain :
 when it forms on the outer surface, there is commonly no pain at
 all.   An  osteo-sarcoma has to the touch  the firmness and elasticity
 of cartilage.  This disease is ordinarily met with in the  bones of
 the  extremities, and in the lower  and upper jaw.  The cranial bones
 and the vertebrae are less frequently, if ever,  attacked by it.  The
1 The reader is referred to page 19 of the Dresent work. 
THE BONES.
45
disease does not, that I know of, invade any other texture than bone :
it bears, however, some external resemblance to gelatiniform cancer
of other parts.   It has not much malignity; so that when all the
bone involved in it, with part of the adjacent sound bone, is removed
by amputation,  the complaint seldom reappears either in the  part,
or in another bone.  If the part  is not amputated, the skin over the
tumour sloughs or  ulcerates, the tumour is  exposed, and a dis-
charge, sanious or ichorous, takes  place from it,  under which the
patient gradually  sinks.
  The following case may serve to display the leading features of
osteo-sarcoma.
  David Palmer,  at the age of eleven, when at play with other  boys,
received a  kick upon the shin,  about the middle of the leg.  The
blow was hard enough to produce  some swelling at the time  ; but
no attention was paid to it.  Gradually,  however, the tibia enlarged
at and round the part which 'was struck;  and a year after the acci-
dent, the lad was admitted into  the Middlesex Hospital with a very
considerable swelling upon the  bone.   He was at that time suffer-
ing great pain, which he attributed to a blister that had been ap-
plied, and had left the skin covering the tumour raw. The sore sur-
face was healed, when  the pain went away; but the  tumour con-
tinued slowly to enlarge.  Mercury and iodine, which were  tried,
did not check its growth.  The  tumour was eveti|, firm, and felt like
cartilage, so as to leave no doubt upon my mind as to its character.
However, to make its nature  certain, I  punctured  it deeply with a
lancet; when a brisk stream of  arterial  blood flowed from it, which
stopped, however, readily on  pressure.   The  sensation  communi-
cated by puncturing it, was the  almost  audible grating that is pro-
duced by cutting through cartilage in  which ossification is begin-
ning.   I now proposed to amputate the leg, when the boy, through
fear of the  operation, left the hospital.        i
  He then became the patient  of a very intelligent surgeon, (Mr.
Sutherland, of Hayes,) who, as  the boy  would not submit to ampu-
tation, determined to remove  the tumour by excision.   The opera-
lion was performed on  the second of June, 1832. The tumour mea-
sured in length five inches, and  at its greatest breadth two.  Its sub-
stance was cartilaginous: the base  was  bony.  It was removed very
completely.  The tibia was left of  its natural  size, the exposed sur-
face being to  all  appearance healthy.   The  soft parts were then
brought together, and  the wound  closed.   Every thing went on
well for the first  fortnight, and the wound appeared to  have com-
pletely cicatrised ; when a small opening, scarcely large enough  to
admit the end of a probe, was observed to have formed at one part
of  the  cicatrix:  this hole increased daily; and when  it was big
enough to admit the point of the little finger, a fungous tumour be-
gan to protrude through  it, the growth of which  could not be re-
pressed.  Other small  holes now formed  at different  points of the
cicatrix, through which growths of a similar appearance to the first
protruded,  and went on increasing, till  the whole became one large 
46            MAYO'S OUTLINES OP PATHOLOGY.

fungus.  The discharge was profuse ; the boy's constitution became
affected; the necessity of amputation was now strongly urged; and
the operation was performed  by Mr. Sutherland, on the  twenty-
eio-hth of July.  The limb was removed above the knee.
" &The stump healed in the  usual time, and the boy appeared to be
well.   But after some weeks,  the cicatrix became tumid, and then
broke into an ulcer over the bone.   The  boy returned to the Mid-
dlesex Hospital, and was again placed under my care.  It was soon
evident that the end of the femur was attacked  by the same disease
which had existed in the tibia.  The end of the bone was consider-
ably enlarged.  Where the character of the enlargement was most
distinct through the ulcerated cicatrix, the tumour was seen to be
bluish and  semi-transparent;  and a probe forced into  it, broke
through gritty and cartilaginous texture.  I recommended the only
course which remained; namely, amputation at the hip joint:  but
the boy would not submit, and left the-hospital.  The tumour slowly
increased, discharging daily a  considerable quantity of  ichorous
matter.   The boy died in March 1834.
   The amputated tibia [d. 76.] and the extremity of the femur pre-
sent similar appearances, being expanded into a porous and papery
growth [d. 77.] of bone, which was the basis of the osteo-sarcoma.
The practical deduction from  the preceding case  is, that, in osteo-
sarcoma, it is a degree safer to amputate at a joint, than to risk, in a
constitution  disposed to this action,  the exciting it in  another bone
by the saw.
   3. Medullary Sarcoma.—Without entering upon the question of
the minute structure and origin of this morbid growth, it is easy to
define  its physical  characters.  Medullary  sarcoma is found in
masses, generally of a rounded form,  which present two  appear-
ances: part of the  tumour  resembles  the medullary  matter of the
brain in colour and consistence; there  appear to be vessels pervad-
ing it; or it is evidently something more than a  mere secretion with-
out definite relation to vessels.   Other parts of the tumour look like
firm coagula.  Or sometimes an entire medullary sarcoma presents
the brain-like character alone, at other times the coagulum-like ap-
pearance. While in a third, and perhaps the most common variety,
the two are combined.  The term fungus  haematodes, was invented
to express the coagulum-like appearance.   It is commonly used as
synonymous with medullary sarcoma.
   Medullary sarcoma of bone generally, if not always, arises in the
cancellous structure.  It is therefore  usually attended with consider-
able pain; for the growth of the tumour is rapid, and the shell of
the bone has to be partly absorbed, partly mechanically forced open
from within.  Left to pursue its course, the tumour causes the skin
to ulcerate, and a soft dark-coloured fungus protrudes from which
blood and serum are discharged, and the^patient sinks '
   A patient  a middle-aged man, was admitted  into the Middlesex
Hospital with a swelling of the  head of  the tibia.  The enlarge-
ment had been rapid and painful: it had formed within the few pre- 
THE BONES.
47
ceding months.  The day before his admission, a surgeon had open-
ed the tumour, which felt soft and doughy, and had forced out about
a pound in weight of medullary substance.   The following day I
amputated the limb above the knee.  The  head of the tibia was
found expanded into a thin membranous shell, with very little bony
matter in its texture, the cavity being occupied partly with  soft yel-
lowish substance resembling  the  medulla of the brain,  partly with
coagulum. The-deposit of medullary substance extended some dis-
tance into the cancelli of the shaft of the bone.  [d. 79.]
  The tibia, humerus, femur, are the bones most commonly attack-
ed with  medullary sarcoma :  the other bones of the  extremities
occasionally.  The flat  bones, however, do not escape.  I have seen
the disease in the ileum and in the cranial bones, [d. 81.,] and in the
sternum and ribs.  [d. 81*.]
  I have known an instance, in which a medullary tumour in a rib
was so circumscribed and movable, as to have been supposed a tu-
mour of the breast, which the surgeon, as he told me,  would have
thought of removing by an operation, but for the evidence of other
and coexisting disease.
  4. Fibrous Sarcoma.—There  is a form of malignant disease of
bone, of which the texture is firm, white, and fibrous,   Its origin,
I believe, and its place, to be exclusively periosteal.
  This disease is met with on the tibia.   If  simply removed from
the bone, it grows again : the limb must be amputated,   [d. 83.]
  The same growth is  liable to form upon the cranial aspect of the
dura ma.ter, to push its  way through the bone by absorption, and to
project great masses of sarcomatous growth upon  the head and
face.   [d. 82.]
  5. Cystlike Tumour.—In the  heads of the bones of the extremi-
ties, and in the lower jaw, a disease, which has the general charac-
ters of malignant growth,  is found, when examined after death or
amputation, to consist in a great  cyst, or series of cysts, containing
gelatinous liquid.   It is probable  that these tumours have some re-
lation, as yet undefined, to fungus hematodes.  [d. 86.  87.]
  6. Melanosis is sometimes, but rarely,  met with in  bone.  Mr.
Langstaff has more than one specimen of this disease.  In  all  its
habitudes it resembles medullary sarcoma.
   The diseases which have been  enumerated are as often met with
combined as separately.
   Mr. Stanley possesses a specimen of ivory exostosis combined
with medullary sarcoma.                                   >
   Mr. Stanley gave to the King's  College museum a section of a tu-
mour upon the femur, which he had amputated.  It consists, at one
part, of medullary sarcoma;  at another, of fibrous sarcoma.  The
medullary sarcoma appeared to  have originated in the cancelli of
the bone,  and had caused  absorption of the cortex, which became
extenuated, and the femur broke.   The fracture is surrounded by a
large soft tumour; part  of this tumour is medullary, part consists of
a firm, white, opaque substance, not cartilaginous, [d. 88. 89.] 
48
MAYO'S OUTLINES OP PATHOLOGY.
ease
  In a leg amputated at the Middlesex Hospital for malignant dis-
use the cancelli of the tibia contained brain-like substance, or true
medullary sarcoma.  The crust of the bone was  thin and brittle.
The muscles of the back of the  leg were  externally healthy; but
near the bone, in place of their proper texture, there was substituted
a firm white substance corresponding to Mr. Abernethy's descrip-
tion of mammary sarcoma. The fore part of the leg had a remark-
able tenseness and brawny hardness :  the  skin was red and thick-
ened.  The former appearances were produced  by a very singular
lobulated subcutaneous texture,  to which  Mr. Abernethy's term of
pancreatic  sarcoma was strikingly applicable.  This part  of the
disease appeared to me a conversion of the  adipose tissue into a ma-
lignant growth,   [d. 90.]
  There is an excellent case  related  in the 120th  number  of the
Edinburgh  Medical  and  Surgical Journal,  illustrating  at  once
the connection between osteo-sarcoma and  medullary sarcoma of
bone, and a remarkable feature, which is occasionally present in
the latter disease—a pulsation, namely, as if the tumour were aneu-
rismal.  The pulsation is probably communicated from the contigu-
ous arterial trunk.
  The patient was a Ross-shire farmer, aetat. sixty-eight.  A month
after suffering rheumatism of the shoulder, he fell and  bruised the
part: some swelling ensued, which never  disappeared, but in ten
months had greatly increased.   A  pulsation was now first noticed
in the tumour; then more rapid growth, with a corresponding in-
crease of pain.   The  skin was  not discoloured ;  the tumour was
elastic, but firm;  pressure  caused  little uneasiness, but motion of
the arm gave considerable pain.  When the tumour was embraced
by the hand in all directions, there was a strong pulsation, a distinct
feeling of distention, the hand being visibly elevated.   The sensa-
tion and appearance were much stronger at the  more prominent
part, over and in the axilla. The humeral artery was distinctly felt
high up; but in the axilla the pulsation was suddenly lost, as if in
the tumour.  To the feel, the pulsation was  sawing and  peculiar.
The operation of tying the subclavian  artery was performed on the
17th  January: on the  7th February  sudden hemorrhage super-
vened:  death on the 10th.
  Upon making a section of the  tumour, which consisted  of an en-
largement of the upper part of the humerus, there  was found a con-
glomerate mass of medullary matter,  irregularly intersected with
hgamento-cartilaginous bands,  and having  intermediate  cavities
throughout, of a  dirty brown colour,  which seemed to have been
recently emptied of blood.  The bone,  in its whole diameter,  for
three inches downwards, had entirely  disappeared.  A very fewspi-
cula were felt by the knife, on making the section : these,  however,
were not visible to the eye ; and  a thin' shell of the  head, correspond-
2ft!  art,CUlaI" SUrfaCe' Tly re™ined-  On disarticulation, its
surface was sound, as  was also the scapular cavity, although  the
ligamentous structures were much thickened 
THE BONES.
49
  True scirrhus in bone I suppose to be of rare occurrence.! have
mentioned" that there exists, in the King's College museum, a sroci-
men which looks like a scirrhous tumour, which was found in *he
medullary cavity of the femur of a person labouring under cancer
[d. 91.]: and there are in London several other preparations of a
similar description.   But I am  not acquainted with an instance of
an undoubted scirrhous enlargement of bone.
  Mr.  Sweatman has a remarkable specimen of scirrhous perios-
teum.   A woman, about seventy years of age, was a patient in the
cancer ward of the Middlesex Hospital for carcinoma of the breast.
About  a month before she died, one  eye was observed to protrude ;
aud three days before her death she became suddenly comatose.
Upon examining the skull,  the dura mater and  pericranium, and
orbital periosteum, for a considerable extent on the affected side of
the head, were found to be thickened  and  hard :  the dura mater
was, at one part, a third of an inch in thickness; the arachnoid ad-
hered to it, and partook in the same thickening.   The bone is not
diseased, but is something more vascular than usual.
  In the museum of the College of Surgeons there are several speci-
mens of thickening of the pericranium and dura mater.  No. 607 is
a section  of the right temporal  and  parietal bones of a young wo-
man, twenty-five years of age.  A tumour projects externally, about
half an inch above the surface of the parietal bone ; and there is a
similar tumour situated exactly opposite, on the inside of the skull.
These tumours appear, in the preparation in spirits, not unlike that
just described, except that the part towards the skull appears opaker
than the rest.  The opposite section, however, is  preserved dried ;
by which means the opaker part is shown to consist of short bony
threads, in close apposition, which have no continuity with the cra-
nial bones, on which they rest, but must have  formed within the
tumour.  The tumour I suppose to have been malignant periosteal
growth.  The intervening portion of the cranium is sound, but un-
usually vascular.
                         SECTION IX.

                      Hydatids in Bone.

  Enlargements of the bones are liable to be produced by the growth
of hydatids in their interior.  A case of this rare affection, of which
the following is an abstract, is minutely described by Mr. Keate, in
the tenth volume of the Medico-Chirurgical Transactions.
  Maria Arnold, at the age of twelve, observed a small hard tumour,
about the size of a hazel-nut, towards the lower part of the os frontis,
over the left eyebrow.  The growth of the tumour, for three years,
was slow; for the next three, rapid: at the expiration of which time
it had the shape and size of three-fourths of a  large orange; the sur- 
50
MAYO'S OUTLINES OF PATHOLOGY.
 face, however, was  not quite  regular.  The other symptoms had
 hitherto been, uneasiness, with a sense of throbbing round the base
 of the tumour.   She now felt intense headaches, with occasional
 vertigo, dimness of sight, nausea, and tinnitus aurium.
   Under these circumstances, on the third of April 1815, Mr.Keate
 proceeded to operate on the bony tumour ; and, having exposed its
 surface, divided  one-third of its circumference with a metacarpal
 saw. A small portion of bone was then detached, when a thin trans-
 parent membrane was discovered closely lining the bony case:  this
 was ruptured in  separating the bone, and its contents, a thin colour-
 less fluid, escaped; the cyst at the same time collapsed into the ca-
 vity, which presented an irregular surface or floor, lined  by the
 membrane,  but  evidently depressed below the general or proper
 level of the internal table, which remained entire: some more small
 portions of bone  were then removed.
   Some constitutional disturbance  followed this operation ;  on the
 subsiding of which,  in the May following, in consequence of the
 exposed surface  rapidly granulating,  potassa  fusa was applied re-
 peatedly, which produced small exfoliations:  its use was discon-
 tinued after the September following, as some erysipelatous tume-
 faction had taken place.
   There had, however, already appeared  at  the left side of the
 wound, where the surface had healed quickly after the operation, a
 small puffy tumour, which had neither increased nor diminished,
 when a portion of its surface had been touched with the caustic po-
 tass. This,  by January 1817, had so enlarged, as to be nearly of the
 size of the  original  tumour.   Upon its becoming very tense,  the
 membrane and thin cuticle gave way, and the contents (the same
 sort of thin  limpid fluid that was originally discharged) were evacu-
 ated; when the cyst collapsed, the opening healed, the tumour tilled
 again, and  the same process  was repeated.  By February greater
 increase had taken place; the bony base of the tumour was elevated,
 and its circumference enlarged.  From this time till  December, at-
 tempts  were made to destroy the cyst by caustic potass, sulphate of
 copper,  arsenic ;  but these remedies  produced so much local  and
 general  irritation, that they were discontinued, and a second opera-
 tion was resorted to.
  December 5, 1817, the  integuments were turned back from the
outer surface of the prominence, so  as to expose the whole circum-
ference of the base.   The lower portion  was  then removed by a
strong metacarpal saw, and afterwards the upper portion; so that
the whole prominent bony ring was sawn through close to the sound
and healthy surface of the surrounding bone Mhe largest diameter
of the bone  bus cut through by the saw was four inches and a half,
the sma lest diameter four inches.   In the very hard and  compact
bony substance at the base of the  tumour were  found fivTor six-

pa;rr hydati,d v*\   Ti;ree °f these Xt «e ^
part of the base, were divided by th% saw through  the r centres  and
two or three ,n the lower portion of the base *s0 that the  n,dTor 
THE JOINTS.
51
sections of the cells or cavities were left as depressions of the sur-
face, and lined with corresponding portions of the cysts : these cysts
were carefully removed, and the bone exposed.  The original large
cavity, which had formed the centre and greater mass of the tumour,
from whence there had been such a rapid and inveterate growth of
hydatids, was also denuded throughout of its cysts and granulations,
and the inner table of the cranium completely exposed.  A large cell
over the frontal sinus was  similarly treated;  and lint, impregnated
with a strong solution of  sulphate of copper, was applied  to  the
whole of the denuded surfaces.
   From this time  the patient's recovery may be dated:  no new for-
mation of hydatids took place: the cells in the compact bony texture
were rubbed with nitrate of silver and with sulphate of copper. The
patient's amendment was chequered with attacks of pain in the head
and temples, considerable  disposition to diarrhoea, and inflamma-
tion of the lungs.   She was quite well by February 1818.
   I saw this patient accidentally  at Mr. Keate's house in the spring
of the  present year: there has  been no  return of disease of the bone,
nor restoration of the part removed.  The bone  is seen and  felt
through the integuments and  cicatrix to have its  outer table and
diploe irregularly  excavated.
                        CHAPTER II.

                         THE JOINTS.

   The joints are of two kinds.  In one there is  no discontinuity:
the bones which enter into the joint are united by an  intervening
layer of fibro-cartilage; and the articulation  is strengthened exter-
nally by ligamentous bands, which stretch from bone to bone over
the uniting medium.  Joints of this kind are called synarthroses.
In the other joints, discontinuity exists: the ends of the bones are
tipped with cartilage, and tied together by a capsular ligament: but
over both cartilage and capsular ligament a synovial membrane  is
reflected, which preserves and lines the articular cavity.  Joints  of
this second kind are called diarthroses.
                          SECTION I.

                       Of Synarthroses,

  Synarthroses exist between the bodies of the vertebrae, and  be-
tween the pelvic bones.   These, although the simplest joints,  are 
52
MAYO'S OUTLINES OP PATHOLOGY.
vet parts of so complicated a nature, as to render two steps necessary
[dWfek£ thei? pathology: the first of which is, he considera-
 L of the different affections to which each of the e ements of the
 ointi  table;  the second, the enumeration of the different disor-
ders  in which these affections are grouped as practical studies.
   The tissues,  which enter into the composition of synarthroses, are
three: bone, fibro-cartilage, ligament.
   1st The kind of bonef which enters into the structure of synar-
throses, has a thin external crust, and a close and strong cancellous
structure.
   a.  It unites readily when broken.
   b.  It is liable to atrophy, in the two forms of rachitis and mollities
ossium.                                      ,  ,
   c.  It is readily absorbed through pressure made by a growing tu-
 mour of the adjacent soft parts.
   d  It is susceptible of inflammation. When inflamed, it rarely be-
comes hard and compact.   It rarely is  the  seat  of abscess.  It fre-
quently becomes softened, from absorption of its earthy matter, when
it presents one of two appearances—either the internal periosteum
highly vascular, and the cancelli  filled with  brownish  gelatinous
 fluid—or with  a less degree of vascularity, the  cancelli filled with
 yellow curdy matter.  Either  of these  states is eventually followed
by caries, or ulceration ; which ordinarily commences on a surface
 of the diseased bone, not in its interior; and is liable to be attended
 with partial necrosis.
   2d, The fibro-cartilages in the synarthroses are generally not ho-
 mogeneous ; or there is every variety among them, from the sacro-
 iliac joint, in which, the medium of union is nearly uniform, a layer
 of elastic substance, between cartilage and yellow ligament in struc-
 ture,—and the pubic synchondrosis, where the  exterior  layers are
 more dense  and fibrous than the central part,—to the  fibro-carti-
 lages between  the bodies of the vertebras, of which the exterior part,
 consisting of strong, white, silvery fibres,  approaches to common
 ligament, while the interior part,  a tissue  sui generis,  is of a soft
 and  almost pulpy consistence, yet gliding,  without any  abruptness
 of transition, into the texture of the outer and ligament-like portion.
    a.  Fibro-cartilage, when torn,  is susceptible  of reparation.  In
 fracture of a vertebra,  the  adjacent fibro-cartilage is generally rup-
 tured ; if the patient lives, it unites just as bone unites.  The tex-
 ture of the cartilage of a rib is perhaps too dissimilar to that of in-
 tervertebral substance, to be used in  illustrating the properties of
 the latter; but I  may  take the  present opportunity of  mentioning
 some experiments made by myself upon reunion of these parts. The
 cartilage of a  rib was divided in several animals, which were killed
 at different periods  afterwards.  I found the initiatory stages of re-
 paration which  had been set on foot to be exactly similar to those
 in bone. The cellular  membrane surrounding the divided part was
 first consolidated into a firm capsule, which contained the cut ends
 of the cartilage.  This consolidation was produced by infiltration 
THE JOINTS.
53
with lymph ; an exudation of the same substance formed a medium
of direct union between the ends of ihe divided cartilage.  The re-
paratory capsule gradually became converted into a texture resem-
bling cartilage.  As, in the reparation of bone,  the callus changes
into'cartilage,  and then ossifies, subsequently to  which direct union
of the broken ends by bone takes  place, so,  in the restoration of a
costal cartilage, the exterior thickening becomes cartilaginous, while
the direct union of the divided ends is still by lymph alone.
  b. Fibro-cartilages are susceptible of absorption through pressure
made upon them by the growth of tumours, but in a less degree than
bone. Accordingly, in the growth of an aneurism of the  descending
aorta, the intervertebral fibro-cartilages  are found to be  absorbed
superficially  only,  when the bodies  of the  vertebrae are already
deeplv excavated,  [b. 9.]                          . .
   c The intervertebral  fibro-cartilages  probably participate in that
weakness, or  mode of atrophy, through  which, in young persons,
the vertebral column becomes laterally bent.
   d  Fibro-cartilages generally, it may be presumed, are suscepti-
ble of inflammation. The only instance, however, in which I  have
found this demonstrable, occurred in the semilunar cartilages of a
 knee-joint.  Ulceration  of the cartilages covering the bones  had
 taken place, with hHi inflammation of the adjacent surface of the
 bones, and of the capsular synovial membrane. The semilunar car-
 tilages (the knee having been  injected after amputation)  were red
 with the vermilion, swollen, and softer than natural ; and when di-
 vided, showed, upon the surface of the section, extremities ol cut
 vessels,   f^. 61*.]                         .                 T
    c  Ulceration and suppuration may occur in  fibro-cartilage.   In a
 case communicated by  Mr. Howship  to Sir Benjamin Brodie in
 which  upon  dissection, no remains were found of the intervertebral
 cartilages between the tenth and  eleventh  dorsal vertebrae, nor be-
 tween Ihe third and fourth lumbar—these  intervertebral  spaces be-
 in* filled with pus, and  the opposed surfaces of the vertebras carious,
 btit to a small extent only-the central part of the intervertebral
 cartilage, between  the  ninth and  tenth dorsal vertebrae, had been
 completely absorbed, and pus was found in its place. Externally to
 this the concentric layers of elastic cartilage  were entire, though
 somewhat altered from  their natural appearance.
    f. Portions of  fibro-cartilage sometimes  become detached  in the
  progress of ulceration ; they are then as dead  matter,  irritants to
  the'adjacent   living textures.  Like more  vascular parts, fibro-car-
  tilages are liable to mortify.
    3d  The affections of ligament will be more fully considered here-
  after.'  It is sufficient to mention at  present, that the ligaments are
  readily repaired when  torn ; that  they are susceptible  of atrophy
  and elongation-of inflammation, softening, ulceration, sl°ugh«nff.
    The diseases of the vertebral column admit of being classed un-
  der two heads-atrophy,  namely, and inflammation    rothe, first
  head belong weakness of the spine in  young  persons  the yielding
         19—a                                     5 may 
54             MAYO'S OUTLINES OF PATHOLOGY.
and curvature  in  rachitis, and  the softening in mollities ossium.
These have been already adverted to.—See Section 3,  Chapter 1.
   Under the second head may be considered the instances which
are usually classed together by the term spine  disease.   In  intro-
ducing this principle of classification, however, I am bound to state
that there is not evidence enough to authorise my asserting, as a
thing proved, that all cases of spine disease are produced by inflam-
mation, although I strongly anticipate that this will  be found to he
the fact.   Sir Benjamin Brodie,  who has contributed in so great a
degree to the elucidation of the diseases of joints, does not appear
to admit this view of the subject. After drawing an important dis-
tinction, which originated, I believe, with him, between  cases where
the vertebrae are first affected, and cases in which the intervertebral
substance is the part primarily diseased, he notices, as a third divi-
sion, "another  order of cases, but of more rare occurrence, in which
the bodies of the vertebrae are affected with chronic inflammation,
of which  ulceration of the intervertebral cartilages is the  conse-
quence."  My own impression is, that all these affections begin with
inflammatory action;  sometimes  affecting  a single bone; some-
times  two or more adjacent bones :  sometimes the whole  extent of
the vertebral bones;  sometimes affecting the fibro-cartilages alone;
sometimes  attacking both  systems at  once ;—but in every case
leading eventually, unless  checked by judicious  management, to
ulcerative disease of both, that affords  evidence by  the greater
ravage it  has  committed of one or  other  tissue, as to which was
primarily affected.
  The two following  cases exemplify commencing inflammatory
disease of the vertebral column.
  A young  lady, when wheeling a heavy garden-chair, was con-
scious of having strained her back; but  the sensation wore off.  In
a few days, however, she found that the least exercise  brought on
pain in the lumbar portion of the spine.   This was  followed by
pains  in the left thigh  and leg, and subsequenllv, but not to the
same extent, in  the right.  Two months after the complaint began,
I saw this patient: there was  no irregularity of the spinous pro-
cesses of the lumbar vertebrae,  or tenderness" on pressing  the adja-
cent region : pain  only,  and a  sense of weakness, were present.
By  perfect, quietude, and preserving the horizontal posture almost
constantly, joined with the use of caustic issues applied  over the
seat of pain in the loins, this patient in a year was entirely restored.
  A young woman was admitted an  in-patient of the Middlesex
Hospital, with  the following  symptoms.   She suffered  constant
pain in the whole length of the vertebral column, which, when
lightly struck,  communicated a sensation of  soreness through the
bones.   There  was no  projection of the spinous processes^ any
point:  her  right side and right arm and  leg were deficient in  sensi-
bility, and  were weaker than  the left. ,  There was some inconti-

oZZ/ Tle'  f^7aS keptrm the rec"'"bent posture, was
cupped on the most tender parts of the spine, and had  issues made 
THE JOINTS.                       55
on the same parts with the moxa: calomel was  likewise given to
touch the mouth.  By a long  pursuance of this plan of treatment
she eventually recovered.
  I cannot better exemplify the conditions into which the vertebral
column  falls under  spinal disease,  than  by extracting from Sir
Benjamin Brodie's work  on the Diseases  of Joints, the following
account of three dissections.
  On examining the body of a young man, " no remains  were
found of the  intervertebral cartilage between the fourth and  fifth
dorsal vertebras ;  and the opposite surfaces of these two bones
were consumed by caries  to some extent, but more upon  the left
side than upon the  right.  The intervertebral  cartilage  between
the  eleventh and  twelfth dorsal vertebrae had also entirely disap-
peared,  and the opposite  surfaces of these bones were in a state of
caries;  but this had not extended itself sufficiently to occasion any
sensible loss of bony substance.  The intervertebral cartilages be-
tween the third and fourth, fifth and sixth, seventh  and eighth,
tenth and  eleventh, dorsal vertebrae,  and also  that  between the
twelfth  dorsal and  first lumbar vertebrae, were all found in a per-
fectly natural  state  towards the  circumference, but in the centre
they were of a dark  colour; and on the surface,  towards the bones,
they, as well as the  bones  themselves, were in a state of  incipient
ulceration, but without any appearance of pus having been secreted.
All the  other intervertebral  cartilages were in a natural state, and
the bones of the vertebrae every where had their natural texture and
hardness.   On laying open the theca vertebralis, the membranes of
the  spinal marrow were found adhering together, behind the space
 between the fourth and fifth dorsal vertebrae."
   t: On examining the body of a young woman, eetat. nineteen, the
bodies  of  the  three or four inferior lumbar vertebrae were  found
 preternaturally vascular, and of a dark and almost  black colour ;
 but they retained their natural texture and hardness.  The inter-
 vertebral cartilages  were in a natural  state ;  but the body of one of
 the vertebrae was superficially ulcerated, for about the extent of a
 sixpence, on one side, towards the posterior part.   A large abscess
 communicated with this ulceration, and occupied  the situation of
 the psoas muscle of the left side,  extending  downwards  to the
 groin."
   " On examining  the body of a man, aetat. forty-five, the cancel-
 lous structure of all the dorsal and lumbar vertebrae was found of
 a dark red colour, and softer than natural, so that they might be
 cut with a common scalpel, or even crushed by the pressure of the
 thumb and fingers.  The opposite surfaces of the bodies  of the
 second  and third lumbar vertebrae, and of the cartilage between
 them, at the posterior part,  were extensively destroyed by ulcera-
 tion.   Anteriorly, the bones and the  intervertebral cartilages were
 entire, and the latter was  in a perfectly  natural  state; but the
 bones throughout were of a dark and almost black colour." •
   In the preceding dissections, as in all other instances of advanced
i 
56             MAYO'S OUTLINES OF PATHOLOGY.
spinal disease, the prominent features and differences are found in
the situation and extent of the ulcerative action : in these, as in all
others,  I  believe  evidence  may  be distinctly  traced  of  primary
inflammatory action,  [g. 45. g. 46. g. 64. g. 65]
   The  features  of spinal disease  are  the obvious  and necessary
consequences of the morbid changes which have been described.
   The vertebral  column, attacked with inflammation of the bones
or fibro-cartilages, or both, becomes, at  the part diseased, weak and
painful.
   The bodies of the vertebra? or the intervertebral substance bein<*
partially absorbed, there is loss of substance in the front of the ver-
tebral column, which causes it to bend  forwards, giving an unna-
tural projection to the spinous processes.
   The vertebral  column, being weakened by absorption of one or
other of its constituents, is  liable, on  any accidental violence, to
give way suddenly, or  to become  suddenly bent, at the ulcerated
part.  In  the  majority of instances, however, the curvature takes
place very gradually.
   The spinal  marrow, being either compressed by the flexure of
the vertebral column, or irritated by contiguous sympathy, diminu-
tion of sense  and  motion of the lower part of the frame, with
spasms, and pains of the legs, and  incontinence of urine, and con-
stipation of the bowels, are liable to follow.
   Finally, as another consequence of contiguous sympathy, there
are liable to occur in the adjacent  cellular  tissue extensive forma-
tions of matter,  which point either in  the loins or  at the groin,
under the names of lumbar or psoas abscesses.
   There is no period of these complaints so advanced as not to
admit of their being either cured or arrested.
   I have already given examples of recovery from the first or sim-
ply inflammatory stage.
   When the ulcerative stage has set up, and  the intervening fihro-
cartilages have been extensively absorbed, the bones, if  not far  ad-
T^CeillnCfarr'^dmil°f,beinff Per^nently anchylosed. fr. 52.1
IlLT     h6  fih,;o-cart»la?e necessarily causes the spine  o bend
forwards permanently at the diseased part

nla^Jen Tien maUlr haS f°rmed' ,emP°™y recovery may take
sPDina'l ditX   Thlhmy yeaFS °f a^' had a11 «he symptoms ol
sa verfebr^  Qh   " T P™ ™d ProJecti™  a< the  middle dor-
upon the  back   Sn?S  ^V" ^ a year'  »nd had *»«« ™de
exoira ion oLn  • T™** !°  haVe Perfec,,y recovered at  the
orTree sn no^'  £T  ' "°me Pru0minence on,yRemaining of two
or tnree spinous processes.   She remained well  for ten vears
Symptoms of her  former complaint thpn ?«La        Ly
admitted into  the Middl«^                  atnd s,he wf


rap'ly woTe S15?  vVrXlTZ actT'  ">  *% ^
taken place in  the back.   ^TfifflK 
THE JOINTS.
57
been left by the former attack.   Upon displaying the fore part of
the vertebral column, a strong membranous cyst was found in front
of the part  diseased.   This cyst  was full of inspissated  matter
nearly as thick as putty ;  the  matter contained fragments of bone,
which appeared  to have  been small necroses detached  from  the
vertebrce.  The  body of one  vertebra  had entirely disappeared,
with the cartilages on either side of it.   The bodies of the two ad-
jacent vertebrae had likewise lost half their volume by absorption.
They were not softened, nor had  anchylosed by bone,  but were
partially united  by firm, soft substance,  allowing  some degree of
motion.
   Disease of the pelvic joints is of unfrequent  occurrence.  At the
time  of labour, however, an#affection occasionally takes place in
these joints, which is sometimes distinctly inflammatory, while at
other times it bears the character of simple absorption of  the fibro-
cartilage.   I witnessed an instance in which,  after labour, an  ab-
scess  formed behind the symphysis pubis, which was attended by a
synse of weakness and giving of the pubic joint, which lasted seve-
ral weeks, but gradually  went away.  Cases of this description are
the most common.  But sometimes the sacro-iliac joints are princi-
pally affected ;  there  is  no suppuration,  but extreme weakness at
these joints, which lasts many months.  The  patient is obliged for
a long period to keep the recumbent posture ; and then, and after-
wards while recovering strength, derives remarkable comfort from
bandages round the pelvis.
   The following case, which was under my care, exemplifies com-
mencing disease in the sacro-iliac synchondrosis,  brought on by
external violence.
   A gentleman was  riding in Hyde  Park, when his horse reared,
and fell backwards, bearing him to the ground.  He was lifted up
by those around, when he found himself capable of walking, with
assistance.  I saw him a short time after the  accident.   The only
bruised part was the integument covering the  back of the sacrum,
and more to the right side than the left.  There was no fracture
that I could ascertain, nothing but  the bruise ;  and, as it afterwards
appeared, a strain of the right sacroiliac joint.  The patient could
bear the ileum to be pressed in any direction, and  could, as I have
mentioned,  both stand  and walk.   In  the evening considerable
pain came on : he was cupped upon the hip. and experienced relief.
The following day the cupping was repeated.  After a month, dur-
ing which this patient had kept his room, and the  pain had nearly
left him, he went, for  change of air, to  Richmond; when a child
accidentally touching his foot, as he  lay on a sofa,  he drew up the
limb  suddenly.  Upon this he experienced  a sensation,  which he
described to be like displacement of the  bones at  the right  sacro-
iliac joint; and he fancied  he recollected, that, at the  time of the
accident he had felt a similar sensation ; but certainly neither then,
nor at  this time, did pressure upon the ileum, in a direction  to
strain the sacro-iliac joint, bring on this sensation, or cause  any 
58
MAYO'S OUTLINES OF PATHOLOGY.
thin* like  sensible motion of the joint.  The pain now  became
Iraduallfvery severe, and extended down the limb, in the course

Sf It wSayearS a half from the occurrence of the accident be-
foreth?s pauent had recovered.  In this period many remedies were
 Hed  hoPse which were most beneficial were, strict observance of
rest  and the application of caustic issues over the joint.  When by
these means tfie pa* had been entirely subdued, cold sea-bathing
rapidly restored his strength.^
                         SECTION II-

                  Affections of Diarthroses.

  Diarthroses  are  those joints in which there  is discontinuity.
The ends of the bones articulated by diarthrosis are  crusted with
cartilage, and held together  by a capsular ligament, a shut  sac of
synovial  membrane being reflected over, or lining,  the articular
cartilages and  capsular membrane.  The articular cavities of seve-
ral of these  joints  are  further deepened, or their shape somehow
modified, by the introduction of a margin, or interposed plate, of
fibro-cartilage.   The tissues, therefore, which enter into  the con-
struction of diarthroses,  are bone, cartilage, synovial  membrane,
ligament, fibro-cartilage.
  I. The bones, or parts of bones, which go to  form diarthroses,
are the extremities of the cylindrical bones, the bones of the wrist
and instep and phalanges, the articular  processes of  the vertebrae,
the condyles of the occipital bone and of the lower jaw, the articu-
lar cavities  of the scapulae and ossa  innominata, the heads of the
ribs, and the edges of the dorsal vertebrae.  The affections of these
bones, in which the joints are implicated, are the following:—
   a.  Restorative action after fracture.
   b.  Atrophy.
   c.  Ebumation, or the solidifying into a texture like ivory.
   In  connection with joint diseases, this  change occasionally super-
venes in surfaces of bone from which the articular cartilage has
been  absorbed.  The ends of bones, which have  become eburneous
on their surface, are enlarged; the ebumation does not extend to a
greater depth than from two to four or five lines.   This ivory bone
resembles the dense osseous texture which forms the large and
malignant  exostoses.
   d.  Inflammation,  producing as consequences—in  the  articular
ends  of the  long bones, consolidation, and abscess which may open
into the neighbouring joint—in each  of the kinds of bones specified,
softening, with increased vascularity  of the surface of  the  bone in 
THE JOINTS.
59
contact with the articular cartilage—in each kind again, softening,
with gelatinous deposit in the cancelli-—in each again, necrosis.
  e. Deposit of scrofulous matter in the cancelli.
  2. The changes which have been observed in articular cartilages
are the following:—
  a. Cartilage is susceptible of reparation.   In oblique fractures of
the extremities  of the  long bones, and  in the fractures of several
other bones, the articular cartilages are broken or ruptured.  In a
simple fracture, which extends into a diarthrosis, as the bone unites,
so does the cartilage : the rent surfaces are  found to adhere toge-
ther by a layer of effused lymph : at the same  time the sharp edges
of the cartilage become a little  rounded by absorption, presenting
an appearance not unlike the rounding  of the edge of a fractured
cranial bone.  Whether the uniting medium finally becomes carti-
laginous is unknown to  me.   The rounding  of  sharp edges, and
deposit of lymph, are sometimes  met with, constituting reparatory
processes, after  ulceration of cartilage has been arrested: the former
occurring when the ulceration has removed  a part of the thickness
of  the cartilage only;  the latter,  when the cartilage  has  been
entirely absorbed.  The same deposit of lymph is  the medium of
union in anchylosis, or when a joint becomes  fixed  after ulcerative
disease.   Anchylosis is osseous, cartilaginous, or mixed, according
as  the surfaces which are glued together are both bone  or  both
cartilage, or one of each.
  b. Cartilage is susceptible of two forms of softening; one may be
considered true atrophy.   It  is often  met with on  the cartilage of
the patella in persons a little advanced in years.  The cartilage is
softened,  and seems split  into  soft,  thick  villi.  The change is
accompanied both  by partial absorption  of  the cartilage, and  by a
growth of the ends of the isolated villi in delicate shreddy produc-
tions, to  which the synovial membrane probably contributes.  This
condition of cartilage deserves to be viewed, not  as  disease, but as
natural degeneration of tissue.
  c. The second form of softening is of rare occurrence ; in it the
cartilage  becomes semi-transparent and gelatinous.   In a case of
severe inflammatory disease  of the knee-joint, with  caries of the
articular surfaces of the bones,  and inflammation of the synovial
membrane, I  found near the crucial ligaments, for the extent a six-
pence would cover, the synovial  aspect of the cartilage on the inner
condyloid cavity of the tibia softened and semi-transparent for two
thirds of its thickness.
  d. Cartilage is susceptible of three varieties  of ulcerative disease.
  In the first, the cartilage disappears very rapidly, the absorption
beginning upon the synovial aspect,  leaving a  surface  perfectly
healthy and smooth, either  of cartilage  or of  bone.   This change
supervenes with great  rapidity after compound dislocations, in
which the wound does not heal, and the cavity of the joint remains
exposed.
  In the second, the process of absorption is slower, and produces 
60
MAYO'S OUTLINES OF PATHOLOGY.
an  irregularly  excavated  and  ulcerated surface on  the  synovial
aspect. '  This condition of cartilage is a very common element in
chronic  articular  disease.   I  believe  it to  be generally, if not
always, preceded by synovial inflammation,  [g. 42.]
  lu'the third,  the process of absorption commences  on the aspect
of the cartilage  towards the bone.   I believe  that this kind is essen-
tially dependent upon inflammation  of the articular aspect of the
bone.  The absorption takes place with two effects : one, the dimi-
nution of the thickness of the cartilage; the other, its detachment
from the  bone. [g.  57.]
  e. I am inclined to suppose, that cartilage is susceptible of inflam-
mation, or of some change analogous to it.   In one preparation in
our museum, injected vessels are seen to pass from the bone through
the cartilage to its synovial  aspect; and one of these distinctly
anastomoses with  a vessel  on the  inflamed  synovial  membrane
covering the cartilage,  [g. 56.]
  /. The gouty concretion is met with  in cartilage.
  The components of this substance, according to M. Launier, are,
[g.  35.]
           Animal matter,.....2
           Lfthic  acid,.....2
           Lithate of soda,       ...     .2
           Water,......1
           Lithate of calcium.    ....   1
           Hydrochlorate of soda,   ...     2
           Lost,......2


  3. Synovial membrane is  liable to many changes.
  a. It unites readily when torn or divided.
  b. It is highly   susceptible of  inflammation.  When  inflamed,
where it  lines the  capsular synovial membrane, or covers  bone, it
is liable to become  thickened  by an effusion of lymph  upon its sur-
face, resembling a growth  of granulations,—at first soft and vascu-
lar, afterwards occasionally becoming hard and gristly :  where it is
reflected  over  cartilage, it is liable  to become slightlv thickened,
opaque, easily separable from the cartilage, elastic and brittle.  I
have once seen it for a small extent, thickened, firm, while, and
soft, on  the patella, in connection  with sensible vascularity else-
where on the patella and semi-lunar cartilages.  The  fluids found
in  the cavities of inflamed  synovial  membranes  are,   synovia
scarcely changed, but  in increased quantity-synovia thick, brown,
and turbid-synovia blended with pus-pus—lymph
  c.  The synovial  membrane is liable to give origin to several new
growths,  the seat of which is either in it. texture, or on its adherent
   bl,  ,C]"? 0f ,hese, ,s  a.so(t substance of a  pulpy consistence,
v»tni    '  rJ" °° °Ur' u!fersecteiJ  ^ '•""nbmmnw lines, and
intZIf     [ T format,;»' wh,ch *»«i»s tl,e thickness of a quarter
to half an inch, grows from  every part of the membrane  indiffer- 
THE JOINTS.                      61
ently.  A second is perhaps a partial developement of the first only,
and consists in a soft pedunculated tumour, which has some motion
in the articular cavity.   A third is  the  growth  of one  or  more
bodies, resembling  cartilage  in  consistence, from the  periosteal
synovial  membrane.   These are the bodies, which, when detached
by the motion  of  the  joint  or ulceration, become loose cartilages.
A fourth, a growth of similar bodies that are  ossified.  A fifth, a
growth of  soft substances iu shape and  colour resembling melon
seeds ; of smaller  size, however, but always of a soft texture, which
are liable to become detached.
  d. The synovial membrane is  liable to  be  the seat of gouty con-
cretion.
  4. Ligament exhibits the following changes:—
  a.  It  unites readily  when  divided or ruptured,  the process
being exactly analogous to that of the reparation of bone.
  b. It is liable to atrophy.  Through disuse, ligaments become
weaker, and are liable to become elongated.
  c. Ligament is susceptible of inflammation.  I cannot, indeed,
say that I have seen,  after death, what was  identified  as inflamed
ligament; but in  rheumatism, gout, and syphilis, it is impossible to
doubt  the existence  of inflammation of  this tissue.   In  joints, of
which the other tissues  have been the seat of inflammation and
ulceration, the ligaments are found softened, and less opaque than
natural.
  d. The gouty concretion is met with in ligament.
  The changes, which have been enumerated,  are the elements of
the pathology of joints.   But it  is not in this insulated state that
they form a useful or practical  study.   It is further  necessary to
consider the combinations in  which these elements of disease are
usually grouped, so as to form, if the expression  is allowable, dif-
ferent  natural families of articular affections.   These  groups of
pathological phenomena  are  governed each by its own laws, and
claim  importance each as separate studies.  They are not, how-
ever, it must still  be remarked, each  so distinct  from  the rest, but
that two  frequently coexist, and modify each other.  Thus, a sprain
is a different study from the gout; a loose cartilage from articular
caries ; but a sprained joint may pass into gouty inflammation, and
a loose cartilage may  lead to articular ulceration.
  The heads  under which I propose to  describe the  affections of
joints are the following :—
   1. Injury and reparation.
  2. Inflammation of ligaments.
  3. Heightened  sensibility of the synovial membrane, cartilages,
and ligaments.
  4. Inflammation of the synovial membrane with increased secre-
tion of synovia, from local causes.
  5. Inflammation of the synovial membrane with increased secre-
tion of synovia, produced by causes of general  or specific action on
the constitution. 
62             MAYO'S OUTLINES OF PATHOLOGY.
  6. Inflammation and ulceration of the synovial membrane.
  7. Inflammation of the synovial membrane without effusion,
attended by rapid disappearance or absorprion of the articular car-
tilages.                                    .
  8. Inflammation of synovial membrane with chronic ulcerated
excavation of the articular cartilage  beginning  on  its synovial
aspect.
  9. Inflammation of synovial  membrane with caries of the articu-
lar  aspect of the bones.
  10. Extra-articular inflammation, producing ulceration of carti-
lage arid caries.
  "] 1. Strumous caries of the  ends of bones, producing articular
ulceration.                                    o
  12. Growths from the synovial membrane.
  I. The phenomena attending injuries of joints and their repara-
tion are various.
  Simple rupture of the parts of a Joint,—from a sprain in which a
few ligamentous fibres alone  are torn, to the laceration of two
thirds of the capsule and synovial  membrane with dislocation,—
are  repaired with surprising  rapidity.   The  process of restoration
depends upon a thickening of  the parts around the torn ligament,
through effusion and infiltration with  lymph resembling the provi-
sional callus produced in the reunion of simple fractures.   If in-
flammation follows,  it  is of the  kind  specified under the fourth
head; but it is liable to be heightened by neglect  and mismanage-
ment into one of the severer forms of articular disease.
  A wound exposing the cavity of a joint sometimes heals at once,
the  integuments uniting  by adhesion.   In the greater number of
cases, however, wounds of joints are  followed by acute inflamma-
tion of  the synovial membrane, attended with rapid absorption of
the exposed cartilage, and inflammation of the articular aspect of
the bone.
  After a wound which has healed by adhesion, inflammation of
the fifth  kind  may supervene, and  the joint  become painfully dis-
tended with  fluid.   Under  these circumstances,  the  wound may
give way, and the relief thus obtained may be followed by diminu-
tion of the inflammation.
  I attended, with Mr.  Clayton, of Percy street, a gentleman, sixty
years of age,  of a  full habit, corpulent,  asthmatic, who, fourteen
days before, had fallen out of  bed, and received a severe wound of
the outside of the knee through striking a chamber-pot, which was
broken by his fall.   The integuments which  had  been cut through
for  the length of  five inches, had been brought  together by*tick-
mg-plaster; and the patient had been kept as still as an ast'lim'atic
cough  and an irritable habit would allow.   The synovial cavity
was supposed  not to have been  opened.  In the  course of a few
days the joint became swollen,  tender, and painful.   On the thir-
teenth day the wounded integuments having granulated healthily.
the granulations at the centre of the wound>ave way, a aush of
synovia took place from the joint, and the pain was relieved?  The 
THE JOINTS.
63
following day the distention and pain  had returned.   The point,
which had before given way, was now opened with a probe; when
the synovia escaped, and  the pain  was again relieved.   After this
occasion the joint did not require to be again artificially opened :
the synovia escaped spontaneously, and continued to be discharged,
lessening only in quantity (but never altering in quality) for two
months. The  joint then ceased to discharge, and what remained
of the original wound closed.                                  .
   This patient is now able to walk about tolerably well, the joint
remaining only slightly swollen and weak.
   After a small wound, which has not healed, into  a  large joint,
(the incision, for  instance, into the  knee to  remove  a  loose carti-
lage,) acute inflammation of  the synovial membrane  supervenes,
followed by ulceration of cartilage, like that described under the
eighth  head.   Such  a case often  proves fatal, unless  the  limb is
amputated.   Nevertheless, sometimes the diseased action subsides,
and the ulcerated articular surfaces are glued together and perma-
nently  united by a layer  of coagulable  lymph, or are anchylosed.
   After extensive exposure  of the cavity of a  smaller joint, (the
ankle, for instance,) acute synovial inflammation  supervenes, and
with it entire and rapid absorption of the  articular cartilage ; so
that in  three to four  weeks the bones are perfectly denuded, [g. 59.]
The exposed surfaces then inflame, and pour out lymph; by which,
under favourable circumstances, the bones become anchylosed, and
recovery with  a stiff joint follows.
   The danger which attends these cases results from the sympa-
thies of the joints with neighbouring parts,  and with the  constitu-
tion generally.   Erysipelatous inflammation, and  the formation of
deposits of matter are liable to occur in  the vicinity of the injured
joint, attended with bilious and gastric disturbance or nervous irri-
tation,  or with hectic fever.
   Such are the consequences of injuries of  joints  considered with-
 out reference to luxation of the bones.                          #
   Dislocations considered mechanically admit of being arranged in
 two classes.   In one, the difficulty is to replace the luxated bones;
in the other, to keep them in  their places when reduced.  The dif-
ficulties found  in reducing dislocations are  referable either to the
 contraction of the  muscles, or to  the resistance of the untorn liga-
 ments, or to the shape of the bones.
   The difficulty of reduction arising from muscular action is to be
 overcome  by means of continued extension, through which  the
 muscles are fatigued, and gradually yield and  are elongated, so as
 to alJttv of the replacement of the bone. The  application of this
 principle is  exemplified  in dislocations of  the  humerus, whether
 forwards or downwards, or backwards ;  in dislocations of  the hip,
 whether backwards or forwards, unless attended with elongation of
 the limb;  in compound dislocations of the tibia and fibula forwards
 upon the instep, attended with spasm  of the gastrocnemn : in the
latter  case, the  removal of one or two inches of  the projecting 
64
AYO'S OUTLINES OF PATHOLOGY.
bones becomes necessary, which  is commonly followed  by a very
favourable recovery, leaving, in some cases, motion of the joint.
  Difficulty of reduction, which  arises  from the ligaments, is seen
in dislocations backwards of the phalanges of the toes and fingers:
the difficulty, in  this instance, is to be  evaded, not overcome: the
extension to be made  must be  rotatory, not direct: by this means
the dislocated bone is carried into its place without stretching or
ruptnrinor the untorn lateral ligaments.
  Difficulty of reduction  dependent upon the bones,  or upon the
bones and'integuments,  is seen in dislocation of the patella  out-
wards, when that accident occurs to large-boned persons.  In such
there is a deep groove behind the articular aspect of the  outer  con-
dyle, in which The inner  edge of the-dislocated patella lodges.  The
only means, as I discovered," of extricating the  bone from this posi-
tion, is complete flexion of the knee, by  which  the patella is drawn
out of or below the groove described.  In  persons with small bones,
any method answers for reducing a dislocation of the patella.
   Dislocation of the knee backwards is another instance; or rather
the shape of the bones and the action of  muscles  together produce
the difficulty here,  which is only overcome  by very forcible exten-
sion.
   Dislocation of the jaw, and of the  radius  and ulna, singly or
together are referable to  the same head.   The shape of  the bones,
in  these  instances, is an element  fully as  important as the shorten-
ing of the muscles.   It  is the same  with dislocation  of the hip
attended with elongation.  A compound  force is  required ; exten-
sion alone will  not do ;  but a force  acting  transversely to direct
extension is additionally wanted.
   The cases in  which the difficulty is, not in replacing of the  bone,
 but. in keeping it in its place, are the following.
   After  dislocations with extensive rupture  of ligament, of the
ankle or elbow, the bones are sometimes not easily  kept in  their
 places, in conscience of the inflammatory swelling which super-
 venes preventing the application  of bandages.
    In dislocations  from relaxation of the ligaments without rupture
 the same difficulty occurs.
    In scrofulous children, chronic inflammation of the  knee with
 increased  secretion of synovia  is not uncommon: it  is  often at-
 tended  with  habitual displacement of the patella  flatways on the
 lateral surface of the outer condyle.
    It has been mentioned, that ligaments atrophied through disease
 of other parts become relaxed and elongated.  Mr.  Stanley showed
 to  me a patient, in whom, from this cause,  permanent dislo-|tioii
 of both  hips had ensued.  The patient had been  bedridden Wtha
 paraplegic  affection for many  months; when the capsular liga-
 ments of the hip  joints  having become relaxed  and elongated, in
 the course of one  week,  without any external violence, both thigh
 bones were drawn out of their sockets by the muscles  as he lay in
 bed, and dislocated upon the ilium. 
THE JOINTS.
65
  II. There are a variety of cases in which the ligaments appear to
be the parts exclusively or principally affected.
  A gentleman struck his knee, and neglected it.   Some  months
afterwards I saw him, when he laboured under the following symp-
toms.  He had been  now  for  many weeks confined to his bed or
his sofa; the least exertion was followed by  heat and pain in the
knee. The joint was in a slight degree larger than the sound knee :
but it contained no  fluid; and pressure  of the articular surfaces
against each other produced no pain.  It caused no pain  to re:>t his
weight upon the extended knee ; but when he stood on the  other
leg, and allowed  the diseased knee to hang or  swing, he felt uneasi-
ness in it, which was greatly increased by twisting the knee. When
he remained perfectly still, he would experience no uneasy feeling
in the joint for several days together; and then, without any visi-
ble cause, the  joint became a little heated, and the skin  slightly
reddened.  The  same effects followed any  deviation  from  the
strictest rest.
  Syphilitic pains  in  the  joints  appear to have their seat in  the
ligaments, although the synovial membrane is liable to be involved
in the inflammation.   They are accompanied  with moderate swell-
ing of the  affected joints, and  with great pain and sensibility on
pressure.  The swelling is generally external to the capsular  mem-
brane.   The knees,  wrists, and elbows, are  the joints cqmmonly
attacked.
  The ligaments are probably involved in rheumatic inflammation
of joints; although the principal seat  of articular rheumatism is
certainly the synovial membrane.        •
  The ligaments are liable to  be involved in  gouty action, as is
rendered likely by the seeming superficialness of the inflammation,
and proved by the gouty deposit being  found  in their tissue.  This
deposit,  indeed, is secreted every where: it is found in  the synovial
membrane, in  the cartilage, and in  the cancelli of the bones, as well
as in ligaments; but its principal seat is  in the latter, or rather in
the cellular tissue on its outer surface.  The threads of the  cellular
tissue in which it is engaged, instead of wasting acquire thickness,
and become highly sensible, so as to give a kind of organisation to
the chalk-stone.
  A gentleman, between forty and  fifty years  of age, was attended
by Mr. Annandale and myself for gout and gouty concretions about
several joints.   One of the tumours was situated on the posterior
surface of the  second joint of the middle finger, and was  particu-
larly  inconvenient, as our patient took pleasure in playing as an
amateur on the violoncello.   Upon this account, at his wish, I un-
dertook  to remove the tumour by an  operation.   The  operation
was very painful:  the mortar-like substance of the concretion did
not form an unorganised mass, but was penetrated every where by
live and sensible membranous threads.   The  patient recovered the
use of his finger through  the operation ;  but  the wound was long
in healing, the formation of gouty deposit going on plentifully for 
66
MAYO'S OUTLINES OF PATHOLOGY.
several  weeks after the operation, and  filling the  wound, and ex-
uding on the dressings.
  Chalk stones often  continue indolent and  painless for  many
vears- or they are painful, and the skin covering them ulcerates or
sloughs, and the deposit is discharged .vith the matter; after which
the wound often heals.                     .
  Ill There are affections  of joints, of which the symptoms are
limited to pain  increased by  motion and exquisite sensibility of the
articular surfaces to pressure.  Of the three following cases, the
two first may serve to exemplify the common features of this dis-
ease • the third may perhaps throw light upon its proximate cause,
  Lydia Drummond, aetat. thirty-one, admitted into the Middlesex
Hospital, April 21, 1835, her general health good, catamenia regular.
Six  months previously, she had struck the patella against the edge
of a pail.   The knee was painful from that time; but for a fort-
nio-ht she continued in service as a house-maid, when the increased
severity of  the  pain  compelled her to leave  her place.  The pain
extended from  the  patella down  the tibia.   Pressing the articular
surfaces of the  bones together gave  intolerable pain.  There was
no  swelling or mechanical  impediment to  motion  in  the  joint.
Leeches and a shallow issue were tried, which  rather  did harm
than good.   With time and rest, and daily fomentation of the joint,
she is now  nearly recovered.
  A young lady, sixteen years of age, had similar symptoms;  which
were not, however, attributed to any  local injury.   The right knee
joint was  painful, acutely sensible  to  pressure,  but not swollen,
The veins of the limb, ^specially upon the  ankle  and instep, were
large and full.  An eminent surgeon considered this affection to be
commencing ulcerative  disease, and  recommended a caustic issue.
The parents, however, of the patient objected to this remedy, and
a blister was applied instead; which  rather increased the pain,and
produced a crop of boils about the knee.   Medical treatment was
now abandoned; the pain continued  for some time unabated; but
after several months it gradually  went away, nothing  being em-
ployed but  fomentation of the knee with hot water.
  H. A., aetat. twenty-two, the catamenia regular, having suffered
during  four years pain in the knee joint,  which, although  some-
times greatly  mitigated,  never entirely left  her,  at  length, when
every remedy that could be thought of had been tried, and the pain
had much  increased,  underwent amputation  of the  leg.   The
symptoms  had  been pain  and increased sensibility, and nothing
more;  the joint, with the exception  of slight oedema arising per-
haps from the local remedies, had not swollen, nor had there been
any mechanical impediment to motion.   On  examining the  ampu-
tated knee, which  had been  previously injected, the capsular syno-
vial membrane  was found of a bright red. The synovial membrane
covering a  small part of the  semilunar cartilages was likewise very
vascular.   At  the  upper part of the patella, "the same appearance
was seen: towards  the lower part, the synovial membrane,  for the 
THE JOINTS.
67
extent of five lines by two, was not only red with injected vessels,
but considerably thickened, [g. 32.J
  These appearances admit of being  interpreted  in two  ways.
The increased  capillary vascularity of the joint may have been
either the cause of the pain this patient suffered, or an effect of it.
1 am inclined to adopt the latter supposition.  It is certain that in-
fluences upon the nerves are capable of producing, not pain alone,
but even swelling about a joint: it is thus, that, in hip disease, the
knee often  becomes affected with symptomatic swelling, in conjunc-
tion witji pain and tenderness.  The further progress of the present
case seemed to show, that the disease had been in  the nerves, not
in the organisation of the joint.  Soon after the stump had healed,
it was accidentally  struck.   To this  cause,  probably  without
reason, the patient attributed a return of pain exactly similar to
that which she  experienced  before the amputation of  the leg.
When  the pain had gone on several nfonths increasing in severity,
the  patient, anxious at any expense of immediate suffering to get
well, submitted  to another operation.   The  pain  and tenderness
 were seated in the last three inches of the stump, not more upon
one aspect than another, although most  acute as it seemed in the
part of the  cicatrix   covering the  bone.   The  extremity  of  the
stump  was therefore amputated, a second portion of bone sawn off,
an additional portion  of the sciatic nerve  taken off in  the operation,
 and the bone and nerve buried in  a full bed of relaxed muscle and
 integument.  On examining the part removed, the sciatic and the
 saphenous nerves were found  to  terminate in large  white  cartila-
 ginous bulbs,  behind, but not  adhering to the cicatrix.   It is  dis-
 tressing to have to  relate, that, on  the stump healing, the pain re-
 curredr  After  some months, the pain continuing, the sciatic nerve
 was divided under the edge of the glutaeus  muscle. Again, that
 is, while the wound  was green, her sufferings were mitigated ;  on
 its  healing, they have recurred.   It is needless  to say that every
 remedy, local and general, upon every plan, and the intermission of
 all  remedies,  were   tried, before  the  repeated operations  were
 resorted to.
   These complaints, it is to be concluded, are neuralgic.  There
 is  a specimen in the  museum  of  St. Bartholomew's Hospital, from
 a patient  with  parallel symptoms, where even the place of  the dis-
 ease in the nervous  system admitted of being shown.  A patient,
 after years of suffering, had her knee amputated: no appearance of
 disease was found in the joint.  Upon her death, which happened,
 if I recollect right, within two or three years after the amputation,
 the spine was examined, when the posterior or sentient surface of
 the chord was found studded with little plates of cartilaginous and
 bony deposit.
    IV.  Inflammation   of  the synovial  membrane,  with  increased
 secretion of synovia  more or less  altered  in character, and attended
 with more or less thickening of the membrane [g. 38.] is n frequent
 consequence oHnjuries or exposure to cold.   This  is perhaps  the 
08             MAYO'S OUTLINES OF PATHOLOGY.
least serious form of synovial inflammation.  The capillary action,
finding vent in increased secretion, does not, as in instances which
will subsequently be described, lead  to disease of the cartilages or
bones.   The following case may be given as  an example of this
affection.                                 .     , .  t   .   ... ,„
  Hannah Welsh, aetat. twentv-one, was  admitted into the Middle-
sex Hospital, in April  1633. 'Four years before, alter kneeling on
a stone floor, the knee suddenly swelled, and became painlul.   She
continued, however, to get about.   At one time  the  pain would
be  greater,  at another less.  At  the  time of  her admission, the
cavity  of the  knee was  distended  with  fluid, the  patella  was
lifted from the condyles, around and  above it  there was  swelling
with sensible  fluctuation ;  the form of the articulating ends of the
bones was completely lost.   The synovial  membrane could be fell,
at its  reflection from the femur to the capsular membrane, to be
considerably thickened.  The joint was  painful and  weak: the
pain was  aggravated on motion:  there was no roughness of the
articular surfaces, but  pressing  them together  caused pain.  The
patient left the hospital, in  January, 1835,  with all these symptoms
removed, the pain and the  effused fluid gone, the strength of the
joint returned, the thickening of the synovial  membrane  sensibly
lessened.  Leeches  and  fomentations, blisters,  superficial issues,
bandaging with mercurial  ointment, employed  in succession, were
each in turn  beneficial.
  A case has  been  already mentioned, in which  inflammation ot
the kind  now described occurred in consequence of injury of the
knee joint, and in which the  fluid having once escaped spontane-
ously,  was  afterwards let out, and then  continued to discharge
itself with great  relief to the  patient.   The same practice may be
resorted to where there has been no wound, if the distention of the
joint is so great as manifestly to heighten the pain and inflammation.
Upon  this subject  Sir Benjamin  Brodie makes the following re-
marks:—
  " 1st. In a  thin person,  if a few punctures be made with an in-
strument a very little broader  than a couching  needle, by means of
an  exhausted  cupping  glass  applied over the punctures, a large
quantity of fluid may  be  easily abstracted without the  smallest
danger, and with no inconsiderable relief to the patient.  But while
inflammation exists, the relief  is  not permanent,  the  fluid  being
rapidly regenerated; so that in  a  day or two, or perhaps in a few
hours, the swelling  is as large as ever.  If, on the other  hand, the
inflammation be already subdued, the absorption of the fluid usually
goes on so rapidly,  that any more expeditious method of  removing
it is unnecessary.   2dly,  If  suppuration   has taken  place in the
joint, (not in consequence of ulceration, but from the surface of the
synovial membrane,) a free opening made into it with a lancet will
often be attended with the best effects.   I  have known, under such
circumstances, anchyloses to become established almost immediately,
and the patient to  obtain  a speedy cure with an anchylosed  joint
 1 he most orudent method of proceeding is to make a  puncture 
THE JOINTS.                      69
with a needle first, and allow a  small quantity of fluid to escape,
so as to ascertain its nature.   If  it be not simple turbid serum, but
actual pus, the lancet may be used afterwards."
  In case  XIV, in Sir Benjamin  Brodie's work, in a patient, aetat.
thirty,— in whom both knee joints had been swollen and painful in
October, 1S27, on the subsidence of an inflammatory affection of the
chest, but had nearly recovered,—in December the right knee became
inflamed.  On the 21st of February, the knee was much distended
with fluid.  The patient complained of constant  pain in the joint,
and of painful startings of the limb at night, by which he was fre-
quently awakened from his  sleep.   The pain was aggravated by
every motion of the joint, and by pressing the articulatory surfaces
against each other.  The pulse beat  100 in a minute.  Blood  was
taken by  cupping, and the pulvis ipecacuanha compositus  was
directed to be  given every  night.  Afterwards  the cupping  was
repeated;  and 3ss of  the vinum radicis colchici was  administered
three times daily for three successive days when it was discontinued
on account of its having acted considerably on the bowels.  Under
this  treatment,  however,  little or no  amendment took place with
respect to  the local disease, and the pulse rose to 108.
  March  17.  On the supposition that the fluid in the joint might
be purulent, and to ascertain the fact, the knee was punctured with
a narrow  sharp-pointed instrument;  when a cupping-glass being
applied  over the  puncture, between two and three  ounces were
drawn off, not of pus, but of turbid serum, with small  flakes of
coagulated lymph floating in it.
  March 20.  The fluid  had become again collected  in the joint,
so that the swelling was as large as ever.  The pain, however, had
been manifestly relieved  by the puncture.  Pulse 110.  The  man
complained of  pain, referred to the right ulna, and to  the forehead,
which he said he had felt for the last week.  Calomel with opium
was then  given to touch the gums ; upon which all the symptoms
were much relieved.  The mercury was continued till the 28th of
April; and, shortly after,  the patient was dismissed as cured. But on
the 10th of April, it is to be mentioned, that, having been already quite
free  from  pain in the knee, he had a slight recurrence of it;  on ac-
count of which it was thought advisable to apply leeches, and after-
wards a blister.
  This  case partakes of the nature of one class of those affections
which are considered under the next  head.
   V. Inflammation of the synovial membrane  with  effusion  into
the joint, is an occasional result of general or specific constitutional
disturbance.
  A sort of ataxic fever occasionally follows surgical operations, in
which the synovial membrane lining one  or  more joints, becomes
acutely inflamed, and pours out a semipurulent fluid.
  Rheumatic inflammation often has  its  seat in  the synovial mem-
brane.  In a patient under Mr. Cassar Hawkins, in' St.  George's
Hospital,  who  died  of inflammation and gangrene of the  lungs,
       19—b                                    6 may 
MAYO'S OUTLINES OF PATHOLOGY.
with pericarditis  and  hypertrophy of the  heart, one knee  had
continued  swollen  from  an  attack  of  rheumatism  that  had
settled in it five months before death, after involving for a lew days
nearly all the joints.   The state of the knee was the following :-
" The synovial membrane was full of <r dark fluid, not  purulent,
but having the appearance  of  a  thick synovia tinged with blood.
The synovial membrane was  every where  of a red colour, as if
stained by this secretion ; and the cartilages of  the joint had the
appearance of having been stained in the same manner.  There
were some small extravasations of blood in the cellular membrane
external to the joint."                       • , • «
  Inflammation, resembling rheumatic synovial inflammation,occa-
sionally follows gonorrhoea! inflammation of  the  urethra,  and is
liable to be combined with ophthalmia.  The following case from
Sir Benjamin Brodie's work upon the joints,  may be  adduced to
exemplify this important variety of joint disease.
  " A gentleman forty-five years of age, in the middle of June, 1817,
became  affected with symptoms resembling those of  gonorrhoea.
There was a purulent discharge from the urethra, with ardor urina
and chordee.  On the 23d of June he first experiencfd some degree
of pain in his feet.   On the 24th the pain in the feet was rather
increased, but not in a sufficient degree to prevent his walking four
miles.  There was some appearance of inflammation of his eyes,
  "June 25th, the pain in  his feet was more  severe:  the  tunica
conjunctivae of his  eyes were  much  inflamed, with a  profuse dis-
charge of pus.
  "These symptoms increased in violence, the pulse varying from
80  to 90  in  a minute; the tongue being furred; and the patient
being restless and uncomfortable during the night.  The whole of
each foot became swollen ; there was inflammation of the synovial
membranes  of the  ankles; and  it   appeared that  the affection
of the  feet themselves arose from inflammation of the synovial
membranes belonging to the joints of the tarsus, metatarsus, and
toes. He said that he could compare the pain which he experienced
to nothing else than that which might  be supposed to arise from the
feet being squeezed in a vice.
  " On the 27th of June the left knee became  painful,  and  on the
following day  the synovial membrane of  this joint  was found
exceedingly  distended with synovia. He  was now completely
crippled ;  compelled to keep his bed, and  scarcely able to vary his
position in the smallest degree without assistance.  The  inflamma-
tion of the eyes and urethra was somewhat abated.
  " June 30th, the inflammation of the eyes and urethra had much
subsided, and the purulent discharge was diminished.   The pains
of his joints were less severe ;  and the feet were less swollen.  On
the following day the knee  was less swollen also
  "He continued to mend, and on the 10th of July the swelling of
the feet was still further diminished, and that of the knee had almost
wholly disappeared.   His pulse continued to vary from 80 to 90 in
a minute, and his tongue was still furred.   He had pain  in the feet 
THE JOINTS.
71
and knee, but less severe than formerly, and  he was restless at «
night.
  " July 13th, he complained of pajn in the right knee, and on the
following day there was pain also of the right elbow and  shoulder.
  "The'right knee afterwards became swollen from fluid within the
cavity of the synovial membrane, but not in  the same degree with
the other knee,  and the swelling soon subsided.  There was never
any perceptible swelling of the shoulder and  elbow.
  " August 1st, all his pains were abated.  The eye and the urethra
were  nearly free from inflammation, and the purulent  discharge
was scarcely perceptible.                                  .  .
  " August 5th, he was free from pain except on motion;  the joints,
which had been affected, were stiff; but he was able to move about
on  crutches.                                             c .
   " From this time he progressively mended.  The stiffness oi the
joints diminished very slowly; but he was free from all uneasiness.
He was longer in recovering the use of  the shoulder than that of
the other joints.                                             .
   "In the following December, 1817,(at which time he had nearly
but not completely,"recovered the use of his  limbs,) he had another
attack of the complaint.  The symptoms were the same as formerly,
taking place in the same order, and  pursuing the same course, but
with  a  much less degree of violence.  This second attack lasted
about six weeks, and left him again considerably crippled.
   "In March.  1818, he. became affected with an ophthalmia, but ol
 a different nature from that which he  laboured under in  the pre-
ceding summer.  The inflammation was seated in the proper tunics
of  the  eye ; and it appeared probable that  it would speedily  have
 terminated in adhesions of  the iris, and  destruction of the powers
 of vision, if its progress had not been arrested by repeated blood-
 lettings and the use of  mercury.  He had  another attack of oph-
 thalmia of the  same kind four years afterwards (1822.)
   " In  order that the history of the  disease  might be rendered as
 simple as possible, the symptoms in this  case have been described
 without the treatment which was employed. Leeches, and blisters
 to  the  knee;  liniments  rubbed on the knees and shoulders; and
 fomentations when  there  was severe pain, formed  the principal
: topical remedies.   Of the various medicines which were exhibited
 none seemed to be productive of  benefit, with the exception of the
 vinum  colchici.  It was under the  use  of  this medicine that not
 only the pains and swellings of the  joints but that even the ptiru-
' lent  inflammation of the eyes and urethra, first began to ^bside
    It has been  mentioned, that the gouty  concretion is found in tne
- cartilages of joints, and  without and upon the synovial  membrane^
 The gouty action, however, is certainly determined more frequently
 and  to a much greater extent, upon the ligaments, and the adjacent
 cellular tissue.                                  ,.      «.„„„„
i    VI  Inflammation of the synovial membrane, leading to suppu-
 ration and ulceration of that membrane, is  an extremely rare form 
72
AY07S OUTLINES OF PATHOLOGY.
of articular disease.   The two following cases to exemplify lt are
taken from Sir Benjamin Brodie's treatise  already referred to
  " A vZn* lady nine years of age, being at play on the 1st of
JanuarV  1808, feil and wrenched her hip.  She experienced so little
uneasiness, that  she walked out on  that day as  usual   In the
evenino- she went to a dance : but while  there was seized with a
rio-or : was carried home, and put to bed.  Next  morning she was
much  indisposed, and complained  of pain in the thigh and knee.
On the following day she  had pain  in the hip, and was very fever-
ish   These symptoms  continued ;  she became delirious ; and she
died just a week from the  time of the accident.
   "On inspecting  the  body the following day,  the viscera of the
thorax and abdomen were found in  a perfectly healthy state.  The
hip joint on the side of the injury contained about half an ounce cf
dark-coloured pus ;  and the synovial  membrane, where it was re-
flected over the neck of  the femur, was  destroyed, by ulceration,
for about the extent of a shilling.
   "A middle-aged  man,  who  had met with a  contusion of one
shoulder,  was admitted into St. George's Hospital in the winter of
1812.  He complained of pain and  tenderness of the shoulder, and
a very slight degree of swelling was observable ; but his principal
disease was a fever, resembling typhus in  its character, of whichhe
died in a  few days after his admission.
   "On inspecting the body, about half an ounce of thin pus was
found in the shoulder joint.  The synovial membrane bore marks
of general inflammation ; and in one  spot, where it was reflected
over the neck of the os brachii, it  was destroyed by ulceration for
about the extent of a sixpence."
   VII. A different class of cases, likewise of rare occurrence, was
first described by myself,  in a paper in  the eleventh volume of the
Medico-Chirurgical  Transactions.
   The disease consists in acute inflammation of  the synovial mem-
brane, with rapid absorption of the  articular  cartilage, attended,not
with effusion into the joint, but with considerable oedema or suppu-
ration external  to  it.   The attack begins with  sudden pain in a
joint, and swelling round it, not attended  with much  symptomatic
fever: and it frequently, in twenty-four to forty-eight hours, entirely
 leaves the joint  first attacked,  and settles in another.   The pain
 continues for several weeks with hardly abated severity, then goes
 away, and the joint is found to be anchylosed.   Leeches repeatedly
 applied,  and superficial  caustic issues,  have appeared  to  me of
 manifest  utility in lessening the pain.
   A young woman twenty-seven  years of age, six  months after
 labour, was seized  with pain and swelling of the wrist.   The next
 day, the right knee was attacked in the same manner.  The follow-
 ing day, the pain and swelling left the joints  first  affected, and
 attacked  and settled in the left knee.  Six  weeks after the com-
 mencement of her  illness, I saw this patient.  At that time  by her
 account no material change had taken  place in the  limb; the tbigh 
THE JOINTS.                       73
 and leg were swollen with serum effused in the cellular membrane ;
 the joint contained no fluid :  the pain in the knee was very acute
 and constant, and increased by the least motion ; the patient lay on
 her back, with the knee straightened.   The  application of leeches
 to the part gave no relief; cold applications  and fomentations were
 equally inefficient; repeated  blistering appeared, at one time, to be
 of  service; small doses of calomel and  opium were administered
 frequently, during a few successive days, with  no advantage. At
 length the pain seemed to abate spontaneously, the swollen state of
 the limb gradually subsided, the patient recovered the  appearance
 of health, but the joint was wholly immovable.
   A female, seventeen years of age, was seized with pain and swell-
 ing of the  thumb, which she conceived she had sprained.  The fol-
 lowing day the pain had shifted to her elbow, where it rested, being
 exceedingly severe,  and consequently throbbing.  The  arm was
 swolleu  above and  below the elbow, and  the  skin was slightly
 reddened and heated ;  leeches were applied to the arm without any
 benefit, and subsequently a blister, in the vicinity of the joint, which
 was kept open with  the savine cerate.  Under this treatment, the
 pain in the elbow was beginning to be relieved, when it  suddenly
 returned with increased violence, the arm becoming more swollen,
 and the skin covered with a bright blush of inflammation. Leeches
 were repeatedly  applied without any relief.   An erysipelatous in-
 flammation now  extended itself up the arm, and spread  over her
 neck and chest;  the stomach  became remarkably irritable, so that
 for  several days  she vomited every thing that  she took, and she
 became greatly reduced.  A  fluctuation could now be  felt  on the
 outside of  the forearm, near the elbow joint.  On puncturing this
 part a small quantity of pus  escaped ;  the wound was not long in
 closing.   The patient  now regained her strength ;  her  arm gradu-
 ally returned to its former size, but the elbow joint was completely
 anchylosed.
   In both  these cases, the  period between the commencement of the
 attack and the completion of the  anchylosis was something  more
 than two months.
   Soon after the cases which I have described occurred,  1 had an
 opportunity of making the following dissection.
  A boy, fourteen years  of age, died of an affection of the brain,
 connected  with   fracture of  the skull.   He survived  this  injury
 about  three weeks.  Four days after the accident, a joint of one
 finger and one ankle joint appeared swollen  and painful; the swell-
 ing extending some distance  above and below the affected joints.
 There was no discoloration of the surface, which might lead to the
 supposition that these  parts had  been bruised.   The swellings sup-
 purated,  and were opened previously to the boy's death.
   Upon inspecting the parts,  it was found that the abscesses, which
 had been  extensive, did  not  communicate with the neighbouring
joints, the capsular synovial membranes of which were highly iu-
 flamed, but contained no fluid.   On opening the articulation of the 
r|4            MAYO'S OUTLINES OF PATHOLOGY.

affected finger, the extremities of the bones were found wholly bared
of cartilage; in other respects  quite  healthy.   On  exposing the
cavity of The ankle joint, the surfaces of the astragalus and tibiaand
fibula were found almost wholly stripped of their cartilage;  what
remained  was  extremely thin, but seemed in other respects tin-
changed and healthy, and it adhered  firmly to the bone.  [g. 39.]
The °same alteration was  found  in the other joints, of which the
astragalus forms part: the exposed bone was perfectly healthy.
   The resemblance of the case last described, as far as the symptoms
of articular affection were  concerned, to the two preceding, led me
to conjecture that  the  morbid change in all three was the same.
Four years afterwards, I had an opportunity of  verifying the cor-
rectness of this supposition.  For it  happened,  that  the second
patient died under circumstances which enabled me to examine the
elbow joint which had been diseased.   I found in it, as I had anti-
cipated, bony anchylosis between the humerus and ulna. [g. 40.]
   A young woman  was admitted into the Middlesex Hospital in the
summer of 1829, four or five weeks after her confinement, inastate
of great emaciation,  with a large abscess below the fascia of the thigh,
extending from the  knee more than half way to  the groin.  The
abscess did not communicate with the joint, which contained no
fluid, but was contracted.  The tibia was drawn backwards upon
the condyles of the femur.  In six weeks this patient sank and died.
Upon examining the knee joint, the cartilage of the condyles of the
 emur was found  to be entirely absorbed towards the edge, the bone
exposed being  healthy.  The cartilage covering the condyles at
other parts was  uniformly attenuated, but smooth  and strongly
adherent to the bone, which was healthy, [g. 41.]
   F. W., astat. eighteen, previously in  good health,  in the night of
the 28th of January, 1835, awoke from  sleep with  severe pain in
the joint,  accompanied  with swelling  of the knee,  leg, and foot
The pain, the character of which  she described  as  shooting and
gnawing, continued  to increase  for a fortnight, and then remained
stationary for six weeks  to two  months.   For this period, foment-
ing and leeches only appear to have been used.   Small superficial
issues were now tried; and at the same time the pain  began to abate,
and with  it the cedematous swelling.   When  the pain was at the
worst, the  knee was drawn to semiflexion: on  its subsidence,the
joint  became  nearly straight, in  which  position anchylosis has
taken place.  Now, (June  27,) for  two montlis, the  joint has  been
entirely free  from pain during the greater part of the  twenty-four
hours;  but still no  day has  passed without occasional fits of the
original pain.
   VIII. Chronic articular disease, of which the principal- and early
feature  is ulceration of the synovial  aspect of the cartilages, was
first correctly described  by Sir Benjamin Brodie; and shown to be
a very frequent form of disease, and one which, at an  early stage,
yields readily to appropriate treatment.
   In  this  disease,  the  cartilage  presents some slight  varieties  o( 
THE JOINTS.                      75
 appearance: there is either  an irregularly excavated ulcer, [g. 42.J
 or  the  synovial  aspect of  the cartilage appears in  parts simply
 absorbed, leaving a smooth surface; in other parts split into fibres,
 or  short brush-like projections, or thick short villi of cartilage and
 synovial membrane, the bone and the layer of cartilage adhering to
 it being healthy.
   The  disease commences insidiously;  for  several  months the
 patient  experiences occasional pain only in the joint after exercise;
 the pain then increases in severity, and becomes constant; the joint
 finally  swells, often  suddenly, and with  great  increase of local
 pain.
   Sir Benjamin  Brodie  distinguishes  two periods in this disorder:
 the first, unattended by enlargement of the joint, when he supposes
 the ulcerative state alone to exist;  the second attended with swell-
 ing, when inflammation  and  effusion  have supervened.   My own
 impression  is, that, from the first,  inflammation of the  capsular
 synovial  membrane exists,  as the cause of the ulceration of carti-
 Iige ; and that, in  the second stage, the action previously existing
 is only  heightened.
   Mr. Key, who  has written more than one paper of great interest
 on this subject, holds  the same opinion as myself as to the general
 inflammatory character of this affection.  But he entertains notions
 respecting the absorption of the  cartilage, which I  think there are
 strong grounds for not admitting.   Mr. Key doubts the self-absorb-
 ing powers of cartilage,  and supposes that this texture disappears
 in  this  and other articular diseases, either through being absorbed
 by the vessels of the natural synovial membrane, or of an organised
 false membrane formed previously within  the joint.  Many cases,
 however, are mentioned in  this volume, particularly that of a boy
 who died of hernia cerebri, the details of which positively establish,
 that cartilage may disappear by spontaneous or self-absorption, like
 other more evidently vascular tissues.
   The  following cases may serve to exemplify the form of disease
 under consideration.   The  second presents features of unusually
 aggravated  sulfering, considering the small extent of diseased car-
 tilage found in the joint after amputation.
   Mary Cole, aetat. twenty-seven, was  admitted  into the Middlesex
 Hospital, January 16,  1834.   The left knee was nearly motionless
 through anchylosis of the  patella to the outer condyle: it was
 swollen, but in a trifling degree.   The position of the knee was
 nearly straight.  When the  limb was at rest, she was generally free
 from pain ;  which, however, was invariably brought on by motion
 or  pressure.   The complaint had commenced a year before, and
 she attributed it to an accident: her  foot had slipped through a
 hole in  the floor, and the joint might have been sprained.   But
 three  months  elapsed between the occurrence of this accident and
 any symptom  which she distinctly remembered.   The joint at that
 period became suddenly swollen and painful: but leeches, cupping,
fomenting, blisters, and an issue, had in four months nearly removed 
76
MAYO'S OUTLINES OF PATHOLOGY.
 the pain and swelling, when she fell again and  struck the knee.
 The  symptoms immediately returned  with aggravation, and the
 knee  was drawn into a semiflexed position.   The  treatment which
 had before been of service was again resorted to successfully;  after
 persevering in it for some time, bandaging, with mercurial ointment,
 was used.   The knee  became nearly free from pain, and straight,
 but the joint was stiff.
   She  now ventured  to walk,  when the pain, which had never
 wholly gone, increased. Soon after this  period, she came into the
 hospital.  A few days  after her admission she was taken with ery-
 sipelas, and died.
   Upon examining the diseased joint, bony anchylosis was found
 to have taken place between the patella and outer condyle.   The
 inner half of the cartilaginous  surface of the  inner  condyle  was
 ulcerated;  the ulceration was shallow,  the  excavated surface was
 irregular, and uneven rather than rough.  It gave  me the idea that
 it was a surface, which, having been ulcerated in the former attack,
 had subsequently healed.  The capsular  synovial membrane was
 inflamed and thickened, especially at the front of  the joint, and a
 layer  of false membrane partially covered both condyles.
  Jane Dean, cetat.  seventeen,  was  admitted  into the Middlesex
 Hospital, June  18, 1833.  The  preceding  April,  the lower  outer
 and anterior part of  the left knee became  full and painful, which
 she attributed to cold  from  kneeling upon the stones.  Cupping,
 poultices, and a liniment were used.   The  slight  fulness went
 away, but  a  pain,  which she had felt from the first, deep  in the
joint,  now increased.   The  application of  a blister  mitigated the
pain for a time; afterwards, cupping twice repeated, leeches, and
the use of a cold embrocation, had nearly removed it, when, upon
 using the joint in walking, the symptoms became aggravated.
  At  her admission,  but for  a slight  fulness to the outside of the
ligament of the patella, the knee had the appearance of being free
from disease; but she was never without throbbing pain under the
knee-pan, which was increased  by motion or pressure.   The posi-
tion of the greatest ease was slight flexion of the  joint.   There
 was no mechanical impediment to perfect flexion or extension.
  From the period of  her admission, the 18th of June, to the 7th
 of February following, when the limb was amputated, this patient,
 with  one  brief  intermission, became progressively  worse.   The
 pain became, during the  last two months/insupportable; and she
obtained very short intervals of broken rest at  night throuo-h lar^e
doses  of laudanum.  The  pain  in the  knee did not alter its place
or character; but  latterly, with the violent  sense of throbbin-r the
patella  felt to  her  as if lifted up.  The leg wasted, the ankle'and
instep became osdematous. The slightest touch on the knee a^ra-
vated  her suffering.                                       "°
  Many remedies,  in  the  mean time,  were  ineffectually used-
leeches, cupping upon the knee and upon  the loins, blisters' caustic
issues, tartar emetic ointment, hot fomentations, steamino-  ice  opium
 with calomel to touch  the gums, belladonna  and thS' acetate of 
THE JOINTS.                       77
morphia applied to a blistered surface, mercurial ointment  and
bandaging, bandaging to a light splint to prevent motion, carbonate
of iron, arsenic, colchicum, iodine, and an intermission of all reme-
dies, were in succession tried.   Of the means  described, the only
one which produced a marked effect was constant hot fomentation:
there  was a week, during the early period of her illness, when the
pain was  materially lessened by this means.   The applications of
ice, and of pressure with mercurial dressings, were discontinued as
soon as tried; they aggravated  the symptoms.   Of the other reme-
dies,  each, when  first tried, appeared of service, and afterwards
became wholly nugatory.   During the last two months, any local
treatment invariably produced an aggravation of pain.
   Upon  examining  the knee joint, which was previously injected,
the capsular synovial  membrane was found  highly vascular, but
not thickened.  Upon  parts  of the cartilage of the patella, of
the inner condyle of the femur, and of the semi-lunar cartilages,
there  were  vessels in the  synovial membrane  filled  with injec-
tion.   Upon  the patellar surface of the inner condyle, the cartilage
was superficially absorbed  for  a small extent, presenting the cha-
racteristic excavation  and fibrous  or  brush-like processes.  The
synovial membrane  adjacent to this, and, which is singular, cover-
ing a part of the  ulcerated surface, was highly injected,  [g. 42.]
The  texture of the  cartilages  of the joint was otherwise natural,
and their adhesion to the  bone perfect.  But they had a slightly
greenish tinge, which presented  a remarkable contrast  with the
clear  bluish whiteness of the cartilages of the ankle joint.
   In  the case  which  has  been described, the  suffering  was far
greater than  usually attends so small an extent of ulcerative disease.
I am  therefore disposed to think that there existed, combined with
the ulcerative disease,  the neuralgic  affection described under the
third  head.   The  patient, however, recovered well from the opera-
tion, and has had  no neuralgia of the stump.  But she has suffered
partial paralysis of both arms, produced, as it was evident, by the use
of crutches, yet marking, perhaps, a disposition to disease in the
nervous system.   To this part  of the present case  I shall revert on
a future occasion.
   The following case, in which the patient has recovered,  bears a
great  resemblance to  the first of the two which have been just
narrated.
   Elizabeth  Higgin, aetat.  thirty, was  admitted into the Middlesex
Hospital in  August, 1833.   The right knee  was  a  little  swollen,
but the synovial cavity contained no sensible quantity of fluid; the
knee  was bent, the tibia retracted, the foot everted.  The joint was
hot and painful ; the pain was  seated  in the  front of the knee;  it
was  much increased  by motion:  when  the  patella  was moved
upon  the condyles, roughness  was indistinctly felt.  The  tongue
was white, the pulse frequent,  the skin dry and heated.  The com-
plaint had commenced ten weeks  before, with  fever and pains in
the limbs generally, and pain and  swelling of the knee: the pain 
78
MAYO'S OUTLINES OF PATHOLOGY.
 lay on  each side  of the patella.  The knee  continued to swell
 during the first fortnight; from that time till  her admission it had
 been getting better.  Leeches were  applied, and the joint  was fo-
 mented at the commencement of the attack, without influencing in
 any degree its progress.  Afterwards, two  blisters and the ointment
 of tartarised antimony had  been prescribed,  from which sensible
 relief was experienced.
    Upon  her admission, leeches and frequent fomentations  were
 ordered, the diet regulated, and  opening medicine with  calomel re-
 peatedly gi^en.   Afterwards, a caustic issue was made on each side
 of the patella; the knee was bandaged to  a splint having  a joint
 capable of extension by means of a  screw, and gradually straight-
 ened.  In about  ten months, when this patient left the hospital, the
 pain and tenderness had entirely disappeared;  the skin  had  re-
 gained its natural hue ; anchylosis  had taken place between the
 patella and femur.   The  recovery of this  patient was in the mean
 time occasionally interrupted by sudden increase  of pain and heat,
 which in each  instance was relieved by leeches.
   Whether chronic ulceration of cartilage  be or be  not always pre-
 ceded by inflammation, certain it is, that" neglected inflammation of
 a joint will produce this  form of disease.  ^The  features, again, of
 the advanced stage of ulcerative articular disease, whatever  its
 commencement may have been, are the same, comprising—effusion
 of purulent fluid and lymph  into the joint,—caries of the articular
 ends of the bones,—suppuration in the cellular texture  external to
 the joint,—permanent  flexion of the joint  through  muscular con-
 traction,—increasing pain, and hectic fever.
   At this extreme period  the  patient's life may yet be saved by the
 amputation of the limb, unless his strength has been suffered to fall
 so low that he has not force to rally after the operation,  or the joint
 be one, beyond which there is not room for amputating.
   In studying the  progress of these affections,  the surgeon will
 remark the following points.   Often, when the complaint, upon
 being first submitted to proper treatment, has appeared  to  yield,
 and the pain and swelling have materially abated, suddenly with-
 out any evident cause the symptoms will  return with aggravation,
 compelling in a few weeks some decisive step to be taken.   Of all
 the remedies used simply or in combination with others, rest is the
 most  efficient.  Of  the others,  fomentation is the next in  value.
 Yet there is uncertainty as to the effect even of this simple remedy.
 I met with an instance in  which fomentation aggravated  the arti-
 cular pain, which was only allayed by the application of ice, that
 was \is?.d for a fortnight together.  Leeches and  caustic  issues
 again, which are  so generally useful in  these complaints, are ser-
 viceable for a period only, ater which they often  irritate.  The
 articular action,  when at its  greatest  height, and  untouched by
every  remedy, and threatening  the destruction of the  joint  will
occasionally spontaneously become mitigated, and rapidly diminish
and finally  subside.  The symptoms  wifi sometimes  be greatly 
THE JOINTS.
79
aggravated by collections of turbid synovia, or pus, in  the  bursae
adjacent to  the  affected joint: the pain resulting from this cause
may be removed by puncturing the  cyst, and letting out the dis-
tending fluid : it is easy to ascertain  that the fluid  in the adjacent
bursa  has no communication with  the  articular  cavity.   1 have
opened, with great relief to the patient, collections of turbid synovia
in the  sheaths of the tendons of the inner hamstring muscles, and
abscesses external to  the capsular  membrane  of the  knee joint
formed in the cellular tissue.
   It is to be suspected that  some form  of  articular ulceration  is
commencing, when, with little or no  fluid  in the synovial mem-
brane,  there is pain of  the joint, attended with acute sensibility  to
pressure or motion of the articular cartilages on each other.  The
conjecture becomes certainty, when the surfaces, on being moved
over each  other, communicate the sensation of  grating.    After
ulceration of cartilage  has existed a considerable length of time,
the joint is seldom perfectly restored.  But recovery may take place,
either  by partial  or complete  anchylosis:  the  former  is often a
troublesome feature when it occurs in the knee joint, the patella be-
coming fixed to  the condyles, without the tibia and fibula being
united.  The joint is then infirm and unsteady, the quadriceps ex-
tensor  cruris being unable to act. Recovery, again, sometimes takes
place in another manner after complete absorption of the articular
cartilage, the exposed  bone becoming hard, dense, compact, and
polished, for the depth of two or three lines, and presenting a strong
and smooth surface, which moves  upon a corresponding surface  of
the bone articulated  to it.   This case, however, is of rare occur-
rence,  [g. 53.J   The process of anchylosis,  in some cases, may be
promoted by  freely opening the disorganised joint.   Of excision  of
the articular ends of bones in joint disease, what I have seen of it
leads me to speak with no approbation.   I  suspect that, where it
has been performed successfully, it has been performed  before the
degree of exhaustion which renders an operation decidedly neces-
sary has arrived.   When an  operation is clearly required, the con-
stitution has generally no longer force enough to support the tedious
process of that restoration which follows  excision.  It is better, in
my opinion,  to wait till all chance of other cure has failed, and
then to amputate.  The shoulder joint appears to me the only one
in which, from the inapplicableness  of amputation to the case, ex-
cision of the articular ends may be recommended.
   IX.  Under the head  of strumous caries, 1 have described inflam-
mation of the articular surface of bone, accompanied with  inflam-
mation of the capsular  synovial membrane, and  leading to absorp-
tion and ulceration of the cartilage commencing upon  its osseous
aspect.   I have likewise given a case, in  which all the  features of
the complaint are strongly and characteristically  marked, and  to
which  I beg to refer the reader.  It is not, however, an easy matter
to identifvthis disease ; the less so, that it is often accompanied by
the ordinary form of ulceration and  excavation  of the synovial 
80
MAYO'S OUTLINES OF PATHOLOGY.
aspect of the cartilage.  This had partly been  the case in the in-
stance above referred to: the cartilage was  found to be partially
ulcerated on its synovial surface, both upon the  femur, patella, and
tibia; and near the crucial  ligaments, for the  extent  a sixpence
would cover, the  synovial surface of the  cartilage,  on the inner
condyloid hollow  of the tibia, was softened and semitransparent for
two-thirds of its thickness.
  In the following cases, the same complication of different features
is still more pronounced.
  Benjamin Cockerell,  Eetat.  fifteen, was admitted into  the Middle-
sex Hospital in January, 1834.   Three years and a half before, he
had  fallen out  of a stable  loft, and struck  his knee.   The knee
swelled  during  the night, and became  stiff and painful; but, not-
withstanding this, he continued to walk upon  it for three weeks,
during  which  it  became worse.   Leeches,  fomentations,  lotions,
and  blisters were  then  used; and in  six months, being much re-
covered, he  began again to walk.   After a short period a  relapse
took place, when  the same treatment was gone over again with the
same advantage.   This recurred more than once.   The  relapses
generally happened in  the winter.  When at the worst, the knee
was not greatly swelled : there was pain  all over it:  its  position
was moderate flexion.  The sensations in the joint were of shooting,
pricking, or throbbing.
  The last summer he was  for a period better than he had been
since the first  attack;  but.  at Christmas he again became worse.
Upon his admission into the hospital,  the knee was more  swelled
than ever;  the form of the articular  ends  of  the bones was lost,
through effusion  of fluid into the joint. Leeches and fomentation,
blisters  and caustic issues, and bandaging over strips of mercurial
dressing, were used ineffectually. The limb was amputated on the
12th of March :  the boy speedily recovered.
   On examining  the knee, which had  been  injected, much lymph
was found effused into it, part half coagulated, part an organised
false membrane.   The synovial  membrane was  inflamed,  and
thickened.
   The  marginal  parts of the cartilages of the  femur,  patella, and
tibia had wholly  disappeared, leaving rough and highly vascular
surfaces of  bone  exposed.   The vascularity of the bone was super-
ficial: its structure beneath the surface was healthy: the rough-
ness arose from a partial, superficial,  and irregular absorption  of
the crust of the bone for about the depth of half a line : the carti-
lage which  remained was in parts ulcerated upon its synovial sur-
face; in parts was attenuated, through ulceration upon its o<seous
aspect—as  it was proved by the synovial  surface  being perfect  at
those parts.  The adhesion of the attenuated cartilage to the bone
appeared to be very slight.   Most part of it, however, did not sepa-
rate cleanly from the bone,  but brought away with it thin  particles
of the inflamed surface of the bone.   At the posterior part of the
inner condyle, the vascularity and softening of the  bone  extended 
THE JOINTS.
81
further, but to no great extent into  its substance.  The semilunar
cartilages were partially ulcerated, softened, and distinctly vascular.
[g. 58.]
   I amputated the leg of a patient, aetat. twenty-eight,  for disease
of the os calcis and os cuboides.   The cartilages had disappeared
from the corresponding surfaces of  the two bones.  The surface of
the os cuboides was covered with lymph ; that of the os calcis pre-
sented in parts its proper hard shell of bone :  in parts the shell was
ulcerated, and exposal the cancelli, which, to the depth of a third
of an inch, were highly vascular.
   The surfaces  of the astragalus were in an earlier stage of dis-
ease, and presented the following remarkable appearances.  The
tibial and  navicular surfaces were  not denuded  of cartilage; but
the synovial membrane covering each was in parts highly injected,
and was every where  easily separable from  the  cartilage.  Upon
the  middle of the tibial surface, the synovial membrane was  so
much thickened as to be semi-opaque, and to resemble a thin sepa-
rable layer of caitilage.  On both of these surfaces several  vascular
points were seen;  the  greatest number were on  the tibial aspect.
On  making sections of the  cartilage  on this surface,  the  points
were found to be the terminations of numerous vessels  which had
pierced the cartilage from the bone.  One of these  anastomosed
with vessels of the inflamed synovial membrane.  The bone below
its vascular surface was perfectly healthy.
   X. Under the head of strumous caries I have described as a
different affection  scrofulous disease, involving the whole  or the
greater part of the  cancellous structure  of the articular ends  of
bones, leading eventually to ulceration of the  cartilage,  beginning
on its osseous aspect, and synovial inflammation. The characteristic
features  of this form  of articular  disease are the slowness of its
progress; the general absence of the pain which  attends ulcerated
articular disease from other causes; the extent of external swelling;
the strumous abscesses which often form  in the neighbourhood of
the joint,  leaving sinuses through which the probe reaches and
penetrates  the  softened cancellous structure  of  the  bone ; and,
finally, the general marks  upon the patient of the strumous  dia-
thesis, [g.  66. g. 67.]
   XI. There are affections, in which the joints are not primarily
affected, but in which,  through contiguous sympathy,  they become
gradually invaded by destructive disease of one or  other of the
forms already described.
   A lad was a patient in the Middlesex Hospital, under  the care  of
Dr. Watson and myself, for what I  may describe as a suppurative
fever. ' After cold  in the head and suppuration of the  ear,  a return
of rigor took place, and increase of  fever; and abscesses formed in
succession  over the great toe, over one shoulder,  in  the  loins, and
behind both hip joints.   He sank under the profuse discharge.
   The abscesses  were found to communicate with the  different
joints, the synovial membranes  of which were in  great  part ulcer- 
82
MAYO's OUTLINES OF PATHOLOGY.
 ated away, and the cartilages of all the articular surfaces absorbed.
 Yet I am certain, from careful observation of the case at its com-
 mencement, that the joints were not affected in any way when the
 matter was first formed in their vicinity.   The joints at that time
 contained no fluid, and were not painful, not  put in pain by rub-
 bing the articular surfaces against each other.
   Fractures near a joint are liable to be followed by inflammation,
 suppuration, and ulceration of the articular cavity.
   I amputated the leg of  a patient, twenty-five years of age, five
 months after  a compound fracture of the  tibia and  fibula.  The
bones had united, but the swelling, which had  succeeded the frac-
 ture, had led to repeated large collections of matter  in the calf of
 the leg and about the ankle joint.   These had  been opened in suc-
cession, and the patient had as many times rallied  from the  hectic
fever and debility which they occasioned.   At last  there formed,
 above  the  knee joint, an  extensive abscess, which  was opened;
 when profuse discharge, alternately of blood and matter, took place
 for several days.  The limb was  amputated too late to  save the
 patient.
   The knee and ankle joints were  examined after they had been
 injected : the appearances were much the same as in the two pre-
ceding instances: the bones were sound, all but the surface towards
 the cartilages, which was  highly inflamed : the articular cartilages
were in  part  entirely absorbed, in parts remarkably attenuated by
absorption upon  their osseous aspect; at other parts, but to a small
extent, ulcerated upon their synovial aspect.   The attenuated car-
tilages appeared to be readily separable from the  bone; but, when
torn off, their  under surfaces were found covered with  bony par-
ticles, showing that it was the line of inflamed and  softened bone
which gave way, not the adhesion of the cartilage to the bone.
   The capsular synovial membrane was inflamed, and the carti-
lage of the patella was partially absorbed  on its  synovial surface.
[g 60.]
   XII.  The  alterations of structure of the synovial  membrane
would  perhaps  be  described  with  more  propriety as  peculiar
growths, which form upon its outer or attached surface : they pre-
sent four varieties.
   a. The first is the rare and peculiar change of structure de-
scribed originally by Sir Benjamin Brodie.  The  following is  a
description from his treatise of the appearance of a knee joint affect-
ed by it.
   " The cavity of the joint contained about four ounces of  a pale
yellow fluid, having flakes of coagulated lymph floating in it: the
synovial membrane, where it formed the  loose folds, extending from
one bone to the other, where it was reflected over the bones them-
selves,  the crucial  ligaments, and the fatty substance of the joint,
had completely lost its natural appearance.   It was converted into
a pulpy substance, in  most parts about a quarter, but in  some parts
nearly half an inch in thickness, of a light brown colour, inter- 
THE JOINTS.
83
sected by white membranous lines, and with red spots  formed by
small vessels injected with their  own  blood.  The synovial mem-
brane on the edge of the cartilaginous surfaces had  undergone a
similar change of structure, but only for a small extent: the semi-
lunar cartilages were entire,  but in a great  measure "concealed by
the pulpy substance projecting over them: the cartilages covering
the bones, in a few places, were in a state of incipient  ulceration."
  The first symptoms of this affection are  slow, firm, elastic,  and
painless enlargement of the joint.  After the lapse of two, three, or
four years, articular inflammation  and ulceration commence with
their customary features.  The new  texture has  to perish by the
ulcerative process; and in the cases which have been observed, it
has  been found  necessary to amputate  the limb, lest the patient
should die before the joint has cleared itself  of the new growth,
and attained a state  proper  for  anchylosis.   This affection  com-
mences sometimes  in  childhood, always before the middle of life.
It is rarely met with, except  in the knee.  It has not  been known
to exist in the hip or shoulder; but it has been found in the ankle,
and in a digital joint.   *
   6. The synovial membrane lining the capsular ligament of the
knee joint has been found covered with innumerable little processes,
something like melon seeds in shape and colour, some  larger, others
smaller,  pendulous into the cavity of the joint.  Of this affection I
have met with but oue instance.
   A patient, between thirty and  forty years of age, laboured under
inguinal aneurism: the artery was tied, but ulcerated above the
ligature.  I tied the common iliac, but he sank.   He  had suffered
for several years with  occasional attacks of  what was considered
rheumatic gout  in the knees; that is to say,  with pain, swelling,
and weakness. After a time these symptoms would get  better ; but
the  knees always  remained a little enlarged:  they presented the
appearance described above,  [g.  86.]   The joints  contained a few
drams of synovia.
   Sir Benjamin Brodie adverts to three preparations of this disease,
which he has examined; one purchased at Mr. Heaviside's  collec-
tion ; a second in that  which belonged to Sir Charles Bell, in Great
 Windmill Street: the symptoms were unknown.  He describes the
morbid growth as consisting of a great number of small pendulous
excrescences connected  with the synovial membrane,  having  a
 smooth external surface, and  bearing a resemblance  to the appen-
 dices epiploic* of the great intestine.  The  third preparation  is,
 with the first now mentioned, in the museum  of St. George's  Hos-
 pital :  in it, there is reason to believe that the excrescences were the
 result of long-continued inflammation of the synovial membrane.
   c. In the knee joint of the body of a female examined at  King's
 College in the last season, a flattened tumour was  found attached to
 the  ligamentum mucosum,  immediately below the  patella:  it is
circular, an inch and a half in diameter, and  half to two thirds of
an inch in thickness.  It is covered by synovial membrane: the 
84
MAYO's OUTLINES OF PATHOLOGY.
peduncle of the tumour is little more than areduplicature of syno-
vial membraue half an inch in breadth :  the articular cartilages are
partially ulcerated.  The tumour consists of two substances; a
nucleus" of the size of a small bean, of a gristly or fibrocartilaginous
texture, contained in a softer membranous substance, [g. 90.]
  In a very similar case, mentioned by Sir Benjamin Brodie, occur-
ring in a young man, the tumour used occasionally, in walking, to
slip between the articular surfaces. This accident always produced
considerable pain at the time, and an inflammation of the synovial
membrane afterwards.  He said that these  symptoms had been gra-
dually coming on for two or three years;  that he had worn band-
ages without experiencing any good effect; and that, as the disease
interfered very much with  his comfort and occupations,  he was
desirous of submitting to any operation which afforded him a pros-
pect of relief.  An operation  being therefore determined  on,  the
tumour was fixed, by the finger of an assistant, over the. inner con-
dyle of the femur, and an incision being made down to it, was ex-
posed ; when it was found  not  to  be  a loose cartilage,  but of a
fleshy structure,  connected  to the synovial  membrane below  the
patella by a broad  adhesion.  This was  divided,  the tumour re-
moved, and the edges of the wound brought together by a sectum;
and the joint secured by a splint from motion.
  " About twenty-two hours after the operation, symptoms of vio-
lent inflammation began to  show themselves.  There was almost
insupportable pain  ; the joint became  rapidly swollen ; the pulse
rose to 90 in  a minute,  and was hard  and  strong.  By means of
very active antiphlogistic treatment,  however,  the  inflammation
subsided, without producing any  bad  consequences.   On the 27th
of June he was able to undertake a journey to a considerable dis-
tance from London ; at which time the knee was neither swollen
nor painful, but it was still incapable  of perfect  flexion and exten-
sion.
  " On examining more accurately the tumour which had been re-
moved in this case, it was found to be about  two inches and a half
in length, and one inch and  a half in breadth, and somewhat less
than half an inch in thickness in the thickest part; convex on one
surface, and somewhat flattened  on the other.  It was of  a firm,
fleshy structure: the general appearance of it a good deal resembled
that of the coagulum which  was found  in the sac of aneurism;
but it was  not laminated: it had a smooth  membranous surface,
and it was manifestly organised,  as vessels might be distinctly
traced ramifying through its substance."
  I have at present under my care a patient, in whom I suppose
that a tumour of a similar description has formed  upon the inner
surface of the head of the tibia, immediately below the edge of the
cartilage.  The patient is rather  a nervous female, thirty-six years
of age, who three months ago, having previously observed the right
knee to snap  on moving it, was taken  with acute pain at the place
of the present tumour.  There was no swelling of the knee, nor 
THE JOINTS.
85
pain at any other part of the joint.   She was desired to apply a
blister at that time, which considerably increased the pain.   When
the skin had healed after the blister, she first observed a tumour as
big as a large pea, but flatter, on the inner  surface of the head of
the tibia; it was at  first, and continues to be, tender on pressure.
The tumour occasions her great  inconvenience.  She  can only
walk with comfort by  placing the outer  edge of the  foot on the
ground.   If she inadvertently rests upon the sole of the foot, she is
seized  with sickening pain in the joint, and  falls down : the same
pain is brought on when the knee, being bent, is rotated inwards.
The tumour is situated immediately before the internal lateral liga-
ment;  and every motion which brings the edge of that ligament a
little more forward, causes it to compress the tuuiour, and pain is
produced.  This patient derives great comfort from a bandage, which
confines the motion of  the joint, and prevents the ligament sliding
over the tumour.
   d.  Loose cartilages in  joints have exactly the  appearance of
the texture from which their name  is taken.   Sometimes there  is
one only, in other cases there are several.   They grow upon the
attached surfaces of the synovial membrane, and principally upon
that part of the membrane which  is reflected  over the bone: they
are covered by synovial membrane, and for  some time continue ad-
herent by a pedicle formed of it: the texture of these growths is
occasionally bony:  they become detached through  the accidental
rupture of the slender pedicle, which joined them to the surface on
which they grew.
   When  detached,  they  are  a source  of  perpetual trouble and
anxiety to the patient,  since they are liable at any time to get inter-
posed  between the  articular surfaces, in which situation they pro-
duce severe and sudden pain, so as  to throw the patient down  at
the time, and afterwards to bring on synovial inflammation.
   " My own experience,"  says Sir Benjamin Brodie, ,: is much in
favour of the removal of these loose cartilages by an incision of the
joint, provided that this be done in a cautious and prudent manner.
The patient should  be  kept in a state of the most perfect quietude
for two or three  days preceding, and for several days after, the ope-
ration.   The cartilage having been  well fixed, the different parts
over it should be slowly and separately divided until it is exposed :
the wound of the synovial membrane may be dilated by means of a
probe-pointed  bistoury, until  it is of sufficient size to allow of the
cartilage being extracted with a tenaculum ;  and the cut edges of
the skin should be  instantly replaced in contact with  each other,
and secured by means of adhesive plaster.
   "I attended a gentleman who laboured under this troublesome
disease, and in whom the loose bodies not unfrequently slipped be-
tween  the articulating surfaces of  the knee,  occasioning an  almost
immediate swelling of  the joint, with the most excruciating pain
and tenderness,  and much symptomatic  fever.  In one instance,
more than a month  elapsed  before these symptoms  had subsided.
       19—c                                     7 may 
80             MAYO'S OUTLINES OF PATHOLOGY.

These circumstances are noticed, because they prove that in this
patient there was a considerable disposition  to inflammation ; yet,
by attending to the precautions  above mentioned, as many as five
loose cartilages were extracted by three different  operations, with-
out the slightest inconvenience from any one of them.
  On the other hand, it occasionally happens  that  the joint is de-
stroyed, and even the life of the  patient lost, through inflammation
set  up by the extraction of these bodies.  And therefore I consider
that the operation is  not to be recommended, if by means of band-
aging the joint the patient can be rendered tolerably secure against
the loose substance slipping between the articular surfaces.  What
renders this palliative  practice  the  more advisable is, that loose
bodies in a joint, which  for several  years  have caused  repeated
attacks of pain and inflammation, occasionally from some cause or
other cease to do so; either they get impacted, and adhere perhaps
to some part of the joint where their presence does not signify; or,
as  the nature of these  bodies varies, they may sometimes be of a
looser and more membranous character, or, possibly, but  portions
of  firm,  coagulated  lymph,  in which case they may admit of re-
absorption.   In all cases in which the loose substance can be fixed
between the condyle and  the capsular membrane, its nature can be
determined with tolerable certainty by its greater or less hardness.
                         SECTION III.

                  Diseases of Bursal  Mucosa.

  Bursas mucosa) are small  sacs of sinovial membrane, which are
interposed as joints either between the periosteum and the skin, or
between the periosteum and either muscles or tendons, or between
tendon and tendon.
  1. The subcutaneous bursae are either natural,  like those upon
the patella or the olecranon, or are developed in the common cellular
membrane by pressure.
  The subcutaneous bursae are met with in various  states  of dis-
ease, all of which depend  upon different degrees of inflammatory
action.
  The bursa of the patella is sometimes distended with synovia,
without pain, or tenderness, or thickening of the membrane.  Rube-
facient applications are sufficient, in most of these cases, to produce
absorption of the fluid.  If they fail, the bursa should be punctured,
the synovia let out, and the wound healed : the operation  should
be  repeated, if, or as often as, the fluid  reaccumulates.
   Increased secretion of synovia in a bursa is liable to be combined
with considerable thickening of the membrane.  In this case, like- 
THE JOINTS.                       87
wise, puncturing the sac is available ;  but the fluid is more certain
to reaccumulate afterwards; so that if the tumour is  small, it an-
swers better to remove it,—any accidental  attack, or  increase, of
pain and tenderness having been first subdued  by proper treat-
ment.
   If the thickened bursa is of considerable size, (as large as a small
orange for example,) it still maybe removed.  The alternative is
to puncture it;  when suppuration will probably follow.  A middle
aged  woman  was admitted into the  Midulesex  Hospital with a
large bursal tumour in front of the knee.  Upon puncturing it, eight
ounces of a dark-brown turbid liquid escaped.  The cyst then in-
flamed and suppurated, not  without considerable pain: therefore,
although  the  first puncture  had not closed, I made three other
opening  at different corners of the synovial sac,  which gave free-
dom to the discharge; the inflammation speedily subsided, and the
patient recovered.  There is  never occasion  to  lay  an enlarged
bursa extensively open, or to pass a seton through it, or to apply
caustic:  if the fluid will not disperse by common means, it is only
necessary to puncture  the sac  several  times,  when it will  either
cease to secrete an  undue quantity of fluid, or suppurate, and so
get well.
   Acute  inflammation of the bursa of the patella is not unfrequent,
when the sac becomes an abscess.  Upon puncturing it the inflam-
mation subsides, and the complaint is cured.  If the puncturing is
delayed, the inflammation  and suppuration  spread, so  as to form a
large  abscess in front of the  knee, the  walls of  which  are partly
cellular membrane, partly the synovial sac.
   These suppurations, external to the  joint, are liable to be mis-
taken by a superficial observer for collections of fluid in the articular
cavity.
   Pressure will cause the  developement of subcutaneous bursas in
the cellular membrane, where they previously had no existence. I
have removed a small bursa with a thick cyst from the posterior
annular ligament of the wrist, and another from the lower and
outer part of the  knee joint, points where  naturally there are no
bursas.  After the excision of the bursa of the patella, the skin and
cicatrix are fixed  for a time to the bone; afterwards they become
again movable.
   2. The bursa situated between  the latissimus dorsi and the infe-
rior angle of the scapula is liable  to become distended with a very
considerable quantity of fluid.  In this state it should be punctured,
and the puncture  healed, if possible: the fluid is to be again let out,
on its reaccumulating.  But the bursa, if greatly enlarged, is more
likely, upon being opened, to suppurate.  In the  latter case, after
discharging  for some weeks, it  will probably dry up, and the case
terminate favourably.
   3. The sheaths of the tendons are liable to the same affections as
the subcutaneous  bursae :  the most frequent place of their enlarge-
ment is at the wrist, in the hand and fingers, and at the ankle. 
88
MAYO'S OUTLINES OF PATHOLOGY.
  The swellings which are thus formed have either an acute or a
chronic character.  In the former case, they often have a rheumatic
origin;  sometimes  they occur in connection with synovial  inflam-
mations of the joints, produced by gonorrhcsa. They are generally
extremely painful:  they are to be cured by general or constitutional
treatment.  Swellings of this kind, that were originally acute, are
liable afterwards to persist in a  chronic form, when they yield to
local remedies.   The vinum seminum colchici, so useful internally
in the first stage, is an excellent local application in the second.
  Chronic swellings of tendinous bursae  are either diffused or cir-
cumscribed :  they are very troublesome : with rest and cold lotions
they are commonly lessened ; but they increase upon the part being
used again.   A patient was under my care, in the Middlesex Hos-
pital, with considerable and painful enlargement of the lower three
fourths of the forearm : the swelling was elastic, and evidently con-
tained fluid.   I  punctured it twice with  advantage, when some
synovia containing numerous little  portions of coagulated lymph
escaped from the sheaths of the  tendons. No suppuration followed,
and the wounds healed: the patient, however, left the hospital, and
I lost sight of him.
  Circumscribed swellings of tendinous bursae  are  produced by
effusion between  partial adhesions of the synovial  membrane.
[g. 100.]   There must be less risk of extensive and serious inflam-
mation in opening these,  than  in opening the  diffused swellings.
A middle aged woman was under  the care of Mr. Keate, with  a
bursal tumour on  the back of  the wrist,  of the size of a double
walnut, containing fluid.   The inflammation which had caused  it
had subsided, and the tumour was not tender or painful.  After
 having punctured it without effect, for the fluid reaccumulated, Mr.
 Keate  made a  longitudinal  incision  through  the skin over the
 tumour, and dissected  out as much as possible of the bursa which
 formed it, leaving only that part which  immediately enveloped the
 tendons.   The  wound suppurated, and gradually healed ;  but after
 a few weeks another tumour, of  half the size of the original one,
 formed in its place.
3, 
VOLUNTARY MUSCLES AND THEIR TENDONS.
89
             CHAPTER  III.

VOLUNTARY MUSCLES AND THEIR  TENDONS.
                          SECTION  I.

                    The Voluntary  Muscles.

  The study of the voluntary muscles in health comprehends two
different inquiries; the first relating to  the structure of muscular
tissue, and to the endowments which it possesses independently of
the brain and spinal cord; the second relating to phenomena which
are produced by influences  originating in those organs.   The same
distinction may be made with advantage in the pathological study
of the voluntary muscles.  Their powers of self-restoration after in-
juries, their liability to hypertrophy, atrophy,  inflammation, and
malignant disease, had better be considered apart from the  phe-
nomena of palsy and anaesthesia, muscular neuralgia and spasm.
  1. Injury and Reparation.—In injuries of muscles, the same
distinction is to be drawn as in  injuries of bone.  Muscular tissue
may be torn without, or with, an open wound.   The process of re-
paration is different for these two cases.  In the former case, the
torn fibres are united by a sort of callus, which is formed through
the infiltration of the cellular membrane with lymph.  In the latter
case, the  divided or  lacerated muscle inflames and granulates, the
granulations forming a means of union equivalent to  the  infiltra-
tion of the cellular membrane in simple muscular rupture.   The
uniting medium subsequently contracts in volume by a process of
modeling  growth, and is finally either converted into muscular
tissue, or absorbed, leaving  the muscle perfectly restored.
  The muscles are interested in surgical operations.
  In operations for tying arteries, or for the removal of tumours, or
in any other case in which the bottom of a wound is not intended
or likely  to  close by adhesion, it is  generally  preferable to divide
any portion of muscle which intervenes between the incision of the
skin and the bottom of the wound.   If the edge of the muscle is
drawn aside only, in the first place it may still embarrass  the ope-
rator ; in  the second place,  after the operation, it has a tendency to
prevent the  free escape of matter from  the interior of the wound,
and to retard  the process of  healing.  The  promptness and com-
pleteness  with which a divided  muscle unites, renders  the above
rule entirely unobjectionable.
  If a muscle has to be divided in an operation in order to reach a
part below  it, it  is better  upon the same  reasoning  to divide it 
00
MAYO's OUTLINES OF PATHOLOGY.
transversely, than to make a longitudinal section, or one parallel to
its fibres.
  In dividing parts in an amputation, to secure a fleshy stump, a
certain proportion must be kept between the quantity of integument
and muscle left, and the length of bone.  But at the time of an
amputation, a limb may be  in  one of two different states ; it may
be either in full muscular strength, or it may be wasted and ex-
tenuated.  A different  calculation is  required for the  two cases.
For, in the first, the muscles retract very little on division; while
in the second, they retract to  an extraordinary degree.  The re-
verse holds with the integument.  In a strong and large limb, over
which  the integuments are already stretched to the  utmost, they
fly back to a remarkable extent upon division.  In an  extenuated
limb, in which it has already shrunk to the utmost, the skin hardly
retracts at all.
  The clean  oblique sections  of the flesh produced by flap opera-
tions unite more  readily, or to a greater extent by adhesion, than
the separately divided skin and muscle in the circular operation.
  To produce  union by adhesion of the muscular substance in a
stump, it is better, as it  has been recommended by Mr. Hodgson of
Birmingham, not to close the wound directly, but  to leave the cut
surfaces of the muscles exposed for twenty minutes or half an hour,
when their  surface is seen to be  glazed with an  exudation wof
lymph : they should then be gently laid together, adhesive piaster
applied, and the wound lightly dressed.
  2. Hypertrophy.—The voluntary  muscles are rarely affected
with hypertrophy.  I  have seen,  however, one instance, in which
the tongue was so affected ; and  the following is  the account of a
similar case,  treated by Mr. Hodgson  for the same disease success-
fully by ligature.  I transcribe it in  the words of my pupil, Mr.
William Tarleton, who communicated it to  me.
   " A child, when about two months old, was first observed to pro-
ject its tongue beyond the gums, and to sleep with the mouth open.
After a time, the mother became alarmed  by a very sensible in-
crease of the size of the tongue, and applied  for advice to  many
medical  men.  Its  tongue  [now  at four months]  was at least as
large again as natural,  and  always protruded.   The child took the
breast with difficulty;  but it grew, and looked in health.
   " The growth of the tongue still advanced with disproportionate
rapidity.  When eighteen months old [July  1832,] the tongue was
very large and thick, projecting more than  an inch  and  a half be-
yond the teeth, and served  to widen the mouth  considerably.  The
incisor teeth had  formed a deep furrow  upon the upper and  under
surface of the  tongue, but ulceration  had not taken place.  The
protruded surface of the tongue, from  being constantly exposed,
was covered  with a coat of dried mucus.  There was no appear-
ance of diseased structure in the part.   The  child was weaned, and
fed as other children of the same age (with spoon  meat.)   She was
always pleased with animal food, and experienced no difficulty in 
           VOLUNTARY MUSCLES AND THEIR TENDONS.        91

 tearing it to pieces with the upper teeth pressing upon the tongue.
 There was no pain in the part.  About three months since, leeches
 had been applied without advantage.
   "April 20, 1833.—The  child's health is  good.   Since  the first
 part of these notes was taken, the tongue has grown in proportion
 with the rest of the body.  The protruded part of the tongue is the
 size of a small orange.   Mr. Hodgson determined upon removing
 it.   Accordingly, the tongue  being drawn  out of the  mouth as
 much as  possible, a needle with  a double ligature was passed
 through the fraenum, just beyond the part of the tongue  where the
 teeth pressed  upon it.  The ligatures were carried one on each
 side of the tongue, as near its root  as possible, and  tied very tight.
 There was very little blood lost, and the child did not appear to
 suffer much  pain from the operation.  In a short time  after  the
 operation,  the tongue became cold ;  but on the following day (21st)
 the tongue became rather warm ; and when Mr. Hodgson scratched
 it with his nail, it bled.   He then tightened the ligatures :  again, in
 a short time, the tongue  became cold;  but  on the following day
 (22d) slight warmth returned, and  Mr.  Hodgson once more tight-
 ened the ligatures.  The tongue became cold, and in places black;
 and remained so until the following day, when Mr. Hodgson re-
 moved it with a pair of scissors.
   "June, 1833.—The child is  in  good health, the  tongue is quite
 within the mouth, the incisor teeth are gaining their proper posi-
 tion.   They were pushed forwards by the tongue.
   " May, 1835.—The child is in good healthfhas learned to read,
 and can articulate very well."
   3.  Atrophy of  the voluntary muscles  presents itself under seve-
 ral forms.
   a.  In simple atrophy, the  muscles  become  small,  shrunken,
 flaccid, pale, and devoid of irritability.  Such is  the appearance
 common to limbs that have wasted from long disuse, in joint dis-
 ease, or in ordinary palsy, or through palsy from lead.
  b. Another form would admit of being termed rigid atrophy. In
 this  case  the  proper  muscular structure  wastes,  and  the tissue
 which remains is tense and hard and inextensible.   The common
 seat of this affection is the sterno-cleido-mastoid muscle ;  the distor-
 tion which it produces is termed the wry neck.  But obliquity of
 the neck may be  produced by  the  same disease in other muscles;
 it may likewise, when it has existed for many years, prove to have
 been merely spasmodic, and spontaneously go away.
   Dr. Mott mentioned to  me, that  he had seen three cases of rigid
 atrophy in  the  muscles which raise  the lower jaw : the effect of the
 change of structure had been  gradually to fix  the mouth in the
 closed position.   He had  succeeded however, by means of a suita-
 ble instrument, in forcing the jaws gradually  to unclose.
  c.  There is  another form of atrophy, in which a  rapid and total
absorption of the muscular structure takes place.  The attack has
an acute character, and is  attended with great  pain, which looks 
92             MAYO'S OUTLINES OF PATHOLOGY.

like inflammation :  yet it certainly is not inflammation of the mus-
cle, though it possibly may be accompanied by, or even result from,
inflammation of the membranes of the muscular nerve.  1 he dis-
ease is brought  on by long exposure to cold.  I have witnessed the
two following cases.
  Thomas Styles,  aged twenty-seven, a  carver and gilder, four
years  ago, when heated with  exercise, and in perspiration,  was
obliged in his business to keep the right hand in water for an hour;
to which  he attributed what shortly followed.  He was  attacked
with pains in the arm, which were  considered rheumatic; and the
arm was rubbed with stimulating  applications, and kept warm in
flannel.  Weakness of the arm however, and wasting, ensued. The
arm and hand gradually became tremulous, and have continued so.
He cannot raise his hand to his head, nor extend the arm horizon-
tally,  nor supinate the wrist: he has, however, the use of  his hand
and can write.   The  muscles of the arm and  forearm  generally
are extenuated  ; but the latissimus dorsi and serratus magnus are
completely gone.
  John Jeremy, aged forty-five, a  farmer's workman, accustomed
to frequent exposure to wet and to let his clothes dry upon him,
four months ago was seized with pain in the left  shoulder, which
lasted, almost  without intermission, for  six weeks: it was most
severe a fortnight after its  commencement: it was  at times as vio-
lent, he said, as if his arm was coming off. There  was no swelling
or redness, no  numbness,  no general tenderness  on pressing the
shoulder, but great pain was felt on lifting the arm by means of the
other hand.   The arm he  could not lift by its own efforts.  About
a week from the  beginning of the illness,  he observed that the
shoulder had lessened : the extenuation continued progressive after
the pain had ceased ; and  now the deltoid, supra and infra spinati,
and the teretes, appear to  have been wholly absorbed, or reduced
to thin  layers of membrane.   The shoulder is  free from pain, the
joint undiseased, but he has no power to lift the arm : the forearm
and hand  are not wasted.  Pressure on  that  part  of the  deltoid
which covers the  circumflex  nerve is now attended with pain;
and at the height of the attack, when the suffering was the greatest,'
used to aggravate it.
  4. Steatosis.—The muscles are  liable to fatty degeneration.  In
this affection they sometimes,  but not always, diminish in  volume.
The altered muscle is sometimes the seat of severe pain, which has
led to amputation of the limb.  Vicq d'Azyr, in  an  old subject, saw
the psoas and  iliacus, the glutafcus medius and minimus,  the ad-
ductors, the deep posterior muscles of the leg, and  the plantar mus-
cles, completely changed  into fibro-cellular fat, without traces of
remaining muscular fibre.   The fat, into which  these muscles were
changed,  is described as white, firm,  and contained in numerous
minute cells ; the uniting  cellular tissue, whitish,  looser, and  more
separable than  usual: the fat is not deposited between its  filaments,
but forms part  of their substance.  Examined  by a good glass, it 
            VOLUNTARY MUSCLES AND THEIR TENDONS.        93

(  presents a mass of soft  transparent fibres of various diameters in
  different parts of their length.1
     5.  Ossification of muscle has been already adverted to under the
  head  of exostosis.
     6.  Inflammation of the voluntary muscles  may be acute or
\  chronic, circumscribed  or diffused;  or  it may be rheumatic or
  gouty.
     In  acute inflammation  the muscular tissue softens, and suppura-
  tion or gangrene follows.  Inflammatory softening and suppuration
  of the tissue of several muscles is liable to occur  in puerperal fever.
     When affected with chronic inflammation, entire  muscles some-
  times disappear in  abscesses.   In  psoas  abscess, the membranous
  sheath of the psoas  has  been  the  only trace  of the muscle rc-
"  inaining.
     In  rheumatic inflammation of muscles, increased  vascularity of
  the muscular texture has been  found, and a deposit of gelatinous
:  .fluid among the fasciculi.
     The gouty deposit is found between  the fibres of  voluntary
■•  muscles.
    7. Every variety of malignant growth, with the exception of
  osteo-sarcoma, js found to implicate the muscles.
:    8. Entozoa.—The  cysticercus  cellulosa is found in the volun-
!'  tary muscles.
    The trichina spiralis, recently described by Mr. Owen, is an
:  entozoon which appears to infest the voluntary muscles exclusively.
  The flesh of bodies beset  by trichinae spirales appears studded with
  minute whitish specks, which are of an elliptical figure, one-fiftieth
  of an inch  by one hundredth, and contain a minute coiled-up worm.
  A few of the  cysts  contain two worms.   The cysts are supposed to
:  be cellular membrane condensed around the entozoon.  The worm
  is disposed in two to  two and a half spiral coils.  When straight-
  ened,  it measures from one twenty-fifth to one thirtieth of an inch
  in length, and from one seven-hundredth to one eight-hundredth of
  an inch in diameter.  It is round and filiform, terminating obtusely
  at both extremities,  which are of unequal sizes,  and tapering
  towards one end for about a fifth part of its length.  At the larger
  extremity,  Mr. Owen  observed a large, transverse, linear orifice or
  mouth.
    The two patients,  in  the bodies of whom these  entozoa were
  identified, died in St. Bartholomew's Hospital, "after long and de-
:  bilitating illness, producing great emaciation; unaccompanied, how-
  ever, with any eruption on the skin, or any greater loss of muscular
  power than would probably have arisen from the diseases of which
  they died."
    Mr. Wormald  mentioned to me,  that the trichinae- were found in
  the  sphincter  externus ani, but  not in the muscular fibres of the
  rectum.  They were, however, found in the fibres, which that ex-

     1 Craigie's Elements of General and Pathological Anatomy, p. 500. 
94             MAYO'S OUTLINES OF PATHOLOGY.

cellent anatomist, the  late Mr. Wilson, described, under the name
of compressor  urethrae—a  circumstance  which  strongly  corro-
borates his opinion, that these fibres are muscular, and constitute a
voluntary muscle.
                         SECTION n.

                       Of the Tendons.

  Tendon, when  divided, readily unites : the surrounding cellular
membrane  is thickened by  an infiltration of coagulable lymph,
which  forms a bed that contains and adheres to the divided ends.
This bed of thickened membrane shapes itself into a callus,  which
gradually coheres inseparably with the ends of the  tendon; and
acquiring strength and firmness, after a time shrinks to the  size o{
the neighbouring tendon, and assumes its white colour and fibrous
character.
  It is  probable that tendon is susceptible of simple, and  of rheu-
matic, and of gouty inflammation.   The  tendons are liable to be-
come ossified.
  Small  painful swellings are liable to  form  upon the tendons. A
gentleman, thirty-two years of age, after taking more exercise than
usual, observed a swelling of the size of half a bean on the inner
and anterior surface of the tendo Achillis, which occasionally
caused pain in walking. Haifa year afterwards, a similar swelling
formed in the other tendo Achillis  at the same place : the tumours
were situated about two inches above the os  calcis.  He applied a
solution of the oxymuriate of mercury in alcohol, which produced
soreness of the skin, without  making at the  time any sensible im-
pression upon  the swellings; and  then he thought no more about
them.  They still continue, but are something  less in  size; and
although sensible, so as to be  rather  painful if pressed, they are
otherwise without sensation. 
CELLULAR TISSUE:
fasciae:
ADIPOSE TISSUE.
              CHAPTER IV.

CELLULAR TISSUE: FASCI/E : ADIPOSE TISSUE.
                          SECTION I.

                        Cellular Tissue.

   The cellular tissue owes its importance in pathology to its me-
 chanical  properties.  It  is made of elastic threads and laminae,
 which form a network that covers the flesh of the body, and dips
 into all its interstices,' the intervals of the network  being one con-
 tinuous series of cells  lubricated by serum, which  extend through
 the whole frame.
   The simj lest alterations of this  tissue are  its  infiltration with
 fluids, either unusual in quantity or in kind.
   1.  Emphysema.—The cellular tissue may  be  distended  with
 air,  which causes a uniform  swelling,  crepitating or emitting a
 crackling sound  when  pressed.  The  situations, in which this
 swelling may begin, vary with  the cause by which it is produced.
 It may take  place  spontaneously,  when- it is  commonly general,
 and  is supposed to be  a  product of secretion.   It  may arise from
 rupture or laceration of (he mucous membrane of the  larynx or
 windpipe, when the swelling  appears chiefly over the face, neck,
 and  upper part of the chest.  It  may succeed a broken  rib, or any
 injury of the luu^s, when it appears sometimes over the neck, face,
 and  chest ; sometimes over the chest and side  only. It may arise
 from rupture of the bronchial  membrane  during violent efforts;
 and  in tin's  manner emphysema  happens in  puerperal women.
 Lastly, it may appear as an effect of gangrenous inflammation and
 mortification, when it  is confined solely  to the affected  limb.  In
 the latter  case, air is produced by the decomposition of the serum of
 the bk od  in the morbid parts.   In examining the body of a person
 who died after injury of the lungs, with emphysema, on  dissecting
 back the integuments and adipose tissue of the chest and abdomen,
 the celltihr membrane appeared like bubbles  upon the muscles,
 from  which, when pressed, the air  partly passed on into the adja-
 cent cells,-partly escaped.
   2. Serous  Infiltration,  (Edema, Anasarca.—Under the opera-
 tion  of various causes, of which the commonest is delay of the cir-
 culation  from disease of tho  valves of the heart,  the quantity of
 serous fluid in the cellular tissue maybe considerably increased;
 and ihis increase gives rise to a pale, white, or  wan-coloured and
 cold  swelling of the skin, which is distinguished by receiving the
impression of the finger, or of any other substance forcibly applied. 
96
MAYO's OUTLINES OF PATHOLOGY.
 When this swelling arises from a cause of such general influence
 as obstruction in the heart, the effect is necessarily general likewise;
 but from the free communication of the cells of the tissue, the fluid
 gravitates to the lower part of the person.
    3. Ther^ are occasions on which the fluid with which the cellu-
 lar tissue is infiltrated is not simple serum, but has an acrid and
 stimulating quality.  This is  observed in the fluids of the cellular
 membrane  adjoining  a part bitten by  a  venomous serpent; or in
 the swelling which, in unwholesome constitutions, follows a severe
 injury, such as  a  compound  fracture; or in phlegmonous erysi-
 pelas.
    There is nothing  more formidable  in surgery than the second
 case  to which I have adverted.  An instance is now before me.  A
 labourer, of a full, gross habit, yesterday morning  early, was
 thrown down by a wagon, the wheel of which passed over his
 knee,  causing a compound fracture of the inner  condyle  of the
 femur, and  opening the  knee  joint.  He refused to have the limb
 amputated.   At  this time, thirty hours after the accident, the thigh,
 nearly  to the hip,  is  swollen to double its natural  size, the veins
 full, and the skin mottled with large patches of red : the ordinary
 hue of the skin which  attends  this form of swelling, when its pro-
 gress is something less rapid, is a pale coppery tint.
   In  the third case, or whenever the cellular membrane is filling
 with fluid, and the  skin is tense and  inflamed over it, incisions are
 useful.   The most striking  instance of their  efficacy  which I re-
 collect is the following.  'A medical  student,  then an assistant at
 the Marylebone  Infirmary, had poisoned a wound on his finger in
 examining a body.  The worst form of symptoms supervened : he
 was attacked with shivering, with fever  of a low  character, and
 nervous irritability; there was no affection of the lymphatic sys-
 tem, but some tumefaction of the arm, and a large  swelling upon
 one side of the body.  The patient's breathing was oppressed ; the
 celluar membrane on the side  was  swollen, without  fluctuation;
 the skin was hard,  brawny, and of a dark red colour.   I therefore
 made an  incision through the skin and  the thickened subjacent
 membrane;  some serum  and about six ounces of blood  escaped;
 the tension of the side was lessened, and  the patient mechanicallv
 relieved   From  that  period he improved, and finally recovered';
 but such had been the diffusion  of acrid humour through the cellu-
 lar t'.ssue  that abscesses  formed not  only in the shoulder and on
 the side which had been opened, but below the  pectoral muscle and
 the integuments of almost the whole back.
   4 The cellular tissue  in phlegmonous  ervsipelas constitutes a
 medium along which an  acrid  humour rapidly finds  its way, the
 presence of which contributes to excite suppuration  and sloughing.
 The cellular membrane is no  less the ordinary seat  of common
phlegmon.   Phlegmonous or  circumscribed inflammations  often
occur immediately  below  the  integuments of the arm and of the
 thigh.   The same often form in the nates, and about the anus   A 
         CELLULAR TISSUE :  FASCIAE : ADIPOSE TISSUE.       97

common boil is a small phlegmon, with a central slough of cellular
membrane—a carbuncle, a large and virulent boil.
  5. Chronic abscesses  have  their seat in  the  cellular membrane,
both below the skin  and in the intermuscular and interfascicular
spaces, the  muscular fibre being absorbed to make room for the. en-
larging abscess.  Such  abscesses forming without pain, contain
vast collections of fluid, which is  commonly  serum,  containing
flakes of lymph.  Sometimes the serum is deeply tinged with blood.
Abscesses of this kind often form in the thigh; and with proper
care, they  commonly do well.  It  has been  mentioned, that the
chronic abscesses which form in the loins,  and which usually point
above the posterior part of the crest of the ilium, or below Poupart's
ligament, are often connected with disease of the vertebral column.
It is not, however, to be overlooked, that chronic abscesses perpetu-
ally form in these parts without vertebral disease, and  get  well
with ordinary care.
  Another  kind of chronic abscess occurs in the cellular membrane.
The two following cases may serve to exemplify this  disorder.  In
the first of the  two, the inguinal lymphatic glands participated in
the disease.
  A middle aged  man  had for several months a tumour  in the
groin,  which had formed very slowly :  it was about the size of two
half oranges, but presented three or four rounded elevations : he
had experienced little pain  in it.  Shortly  before his admission into
the Middlesex Hospital, the skin had become red  and softer at one
part of the tumour.   The  swelling had greatly the appearance of
malignant  disease.   The soft and red integument now threatened
to slough:  I punctured  it, when a little air and foetid ichor escaped.
The integument, by sloughing and ulceration, in a few days gaped
for some extent, and nodular granulating masses were seen within.
No further unpleasant feature, however, presented  itself; and with-
out  any great quantity of discharge taking  place, the swelling
slowly subsided, and the part healed.
   There is a middle aged man now in the  Middlesex Hospital, who
was admitted eight  weeks  ago, with the calf of the leg immensely
swollen, the skin of  a dark red, with  a small  hole in the middle,
through which some thin pus found  vent.  Some months  before,
he had been kicked  by a horse on the calf of the leg, to which he
attributed  the swelling. Placed in bed, and the  leg poulticed, the
swelling diminished at  first rapidly; the  discharge,  however, was
very inconsiderable in quantity.  A  probe being introduced passed
below the gastrocnemii: the external wound was  enlarged a little;
the abscess got well.  But  at the same time this patient showed me
a swelling on the back of the forearm, as large as. and much  of the
figure of, two half walnuts :  it had been  a year forming, and lat-
terly had become painful: it adhered to  the periosteum covering
the posterior edge of the ulna, and to the  aponeurosis.   My  atten-
tion was now drawn to the  general health  of the  patient, and I
found that he had had for many months a scaly eruption upon the 
98
MAYO'S OUTLINES OF PATHOLOGY.
 skin ;  and he said that a year before, a tumour like the present,
 only less, had formed at the corresponding part of the other arm.
 I gave him, upon this, the decoction of sarsaparilla,  with the oxy-
 muriate  of mercury: his  health  began to improve, and the scaly
 eruption to die away ;  but the lump'below the elbow increased in
 size.   I therefore punctured it with a lancet in three places,  where
 it was most elastic;  it bled freely, and at one part small fragments
 of lymph escaped with  the blood.  The swelling was poulticed,
 and is now beginning to suppurate, and lessens daily.
  6. The  cellular  tissue,  when  divided,  readily  unites.  I have
 aheady adverted to its efficiency in uniting other parts.   In  the re-
 storation of a broken  bone, a  divided fibro-cartilage, a ruptured
 ligament, a divided tendon, muscle, or nerve, it is the surrounding
 cellular tissue, which, becoming infiltrated with lymph, forms the
 firm glue-like capsule,  in which the divided  parts are contained,
 and the process of organised reparation commenced.
  7. All the morbid deposits, but osteo-sarcoma,  are met with in
 the cellular tissue.
  8. The filamentous tissue is a frequent seat of encysted tumours.
 These are membranous sacs, which contain a  substance either like
 honey in colour  and consistence, or like tallow : in the former case
 they are  termed meliceris,  in  the  latter steatomatous.   These
 tumours are movable, tense, elastic, and disposed to  indefinite in-
 crease ; and the  sooner  they are  removed the  better.  It is conve-
 nient in their removal, first to open them, and to squeeze out their
 contents, when the cyst  may easily be dissected out.   Its entire re-
 moval is necessary, as any part of it will serve to reproduce the
 tumour.
  9. Another growth, and which  is perhaps confined to the cellular
 tissue,  may  be  termed fibro-albuminous  tumour.   It  sometimes
occurs in the cellular tissue of the breast, and grows to a considera-
ble size, having  much of the external character of malignant  dis-
ease.   In  the following  instance, this growth  occurred in  the
 cellular tissue of the parietes of the abdomen.
  William Latham, astat.  forty-seven, was admitted  into the Mid-
 dlesex Hospital,  in  July, 1835,  with  a tumour upon the umbilical
 and  left iliac region.  It  is twenty years since he first noticed a
 small lump below the skin, of the size of a pea, which gradually
 enlarged, but was not painful.  Six months ago, it was as large as
 a small egs; ; and a surgeon, whom he  consulted,  tried  to break it
 by pressure.  The skin then gave  way, when the swelling enlarged
 rapidly ; at the time of his admission, the swelling looked a great
 fungoid tumour, five inches in diameter, an  inch and a half in
 thickness, and adhering by an oval pedicle three inches in its long
 diameter.   The surface of the tumour was lobulated, and covered
 with large  flat granulations, of a pale red  colour, which secreted
 matter.  The tumour had bled  frequently and profusely, not from
 the whole surface, but from two or three points.  Since it had been
 broken, the patient had frequently experienced shooting pains in it, 
         CELLULAR TISSUE : FASCIAE: ADIPOSE TISSUE.      99

which lasted two or three minutes.  He was greatly reduced by
the bleedings and the discharge.   The skin round  the pedicle of
the tumour  was mottled of a dark red,  and several tortuous and
swollen veins extended from it in different directions.  The ingui-
nal glands were not enlarged.
  I removed this tumour on the  23d of July.  It was situated upon
the external oblique muscle and its tendon, from which I dissected
it:  two vessels only required to be tied.   The wound granulated
healthily; and a few days made a  remarkable improvement in the
patient's appearance  and strength, who is  now [August 10] all but
recovered.
   On examining the tumour, it  was found to consist of two distinct
masses; one of the size of a walnut, seemingly of later formation,
contained in a clean membranous capsule, firm, of no great vascu-
larity, gray, semi-transparent, elastic, easily breaking down  with
pressure.  The other, which had formed the more prominent and
larger mass, was of much greater size : its base was  covered by in-
tegument, the giving way of which, six months before, had allowed
of or given rise to its rapid increase, and exposed it as a vascular
and secreting surface.  In one part of the larger mass, and inclosed
in  it, there  was a  second growth, opaquer in colour,  and  more
fibrous in character, not unlike,  though less  firm than, the ordinary
fibro-cartilaginous tumour of the uterus,  [h. 6.]
   I assisted Mr.  Broughton in removing  a  large tumour  from the
thigh of a female, which had very much the character of the smaller
and more fibrous portion of the tumour  described  above.  But it
was of a more gristly texture, or more closely approximated to the
fleshy tumour of the uterus. It appeared to have formed in the in-
termuscular cellular tissue, [h. 7.]
                         SECTION II.

                 Of Aponeuroses and Fascia.

  The principal part which these  textnres play in disease is me-
chanical.  They are tense, strong, and unyielding; and they bind
the flesh of the limbs.  But what is salutary support in the healthy
condition of a limb, is liable to  produce painful and  mischievous
tension and confinement in disease.
  Aponeuroses are liable to simple and to specific inflammation.
  The first is the most frequent untoward consequence of ordinary
bleeding.  The wound  festers; the arm  and forearm adjacent  to
the elbow are swollen and painful, and the skin has a slight blush
upon it.   Rest, cooling medicines, fomenting, and a raised position
of the limb, in a few days relieve the inflammation.
  The aponeuroses are a principal seat of rheumatic inflammation.
  They are likewise occasionally affected with lues.   I have seen, 
100
MAYO'S OUTLINES OF PATHOLOGY.
in connection with syphilitic periosteal  inflammation and suppura-
tion on the tibia,  inflammation  with suppuration on the aponeu-
roses  of the arm and  leg, bearing a close affinity to the periosteal
nodes.
                         SECTION III.

                     Of the Adipose Tissue.

   The most remarkable circumstance with which I am acquainted
respecting this texture, is  its increase in animals after the removal
of the spleen.   This increase begins in dogs as soon as the  wound
has healed. • I have twice  repeated this experiment.  The duration
of the obesity is temporary:  before a  year  is passed, the  animal
returns to its former  weight and degree of spareness.
   The adipose tissue readily unites  when divided;  and if the
wound heal by  granulation, presents, in the process of restoration,
granulations as florid as, and at first of rapider growth than, those
of the adjacent muscle.
   The adipose tissue is liable to general or partial hypertrophy.
   Common fatty tumours result from  partial  hypertrophy of this
texture.   They require to be removed  by an operation ;  which
occupies  very little time,  and is easily performed, if  the surgeon
lays open the sac of  cellular membrane that immediately contains
the tumour.  Adipose tumours consist of large lobulated masses of
coarse membrane and fat.  They grow to a considerable size.  The
largest which I have removed weighed thirteen pounds two ounces.
[h. 30.]
  Continued  pressure on an adipose tumour will  sometimes cause
the absorption of the oil, and convert it into a dense  membranous
sarcoma.
  In hypertrophy of the breast, the principal source of the enlarge-
ment is increase of the adipose tissue.
  The following case, communicated to   me by  Mr. Samwell,
exemplifies a peculiar affection of the subcutaneous adipose tissue.
  A female, aetat. thirty-six, after suffering  from  rheumatism, had
a swelling of one instep, which, however, went away; but  shortly
after, the leg began to enlarge, and became painful.   The increase
in size was very gradual;  but in four  years the  leg  had become
twice as  large  as natural. The  swelling  was diffused  over the
whole leg, but was greatest upon its outer aspect: to the touch it felt
elastic, like Indian rubber.  The skin  was  not discoloured.  Mr.
Samwell  punctured  the swelling, when a  thick, semi-fluid  sub-
stance, like grumous blood, escaped  ; upon which he  enlarged the
puncture  to a long incision, and squeezed  out more  of a Similar
nature.   The wound healed readily.  But the swelling, at the side
where it had been opened, filled again, and the skin began'to ulcerate. 
THE NERVES.                     101
The limb  was then amputated above the knee;  the patient re-
covered, and has been four years well.
  Upon examining the swelling, it was found to be exterior to the
fascia, and situated in the adipose tissue ; which, where the enlarge-
ment was  greatest, was three inches in  thickness, soft, grumous,
and  red.   At the  extremities of the  swelling, the adipose tissue
seemed infiltrated with a gelatinous substance only. Intermediately,
there was a transition in colour between the pale gelatinous swelling
of the adipose tissue near the knee and ankle, and the sanguinolent
and grumous effusion in the middle of the tumour.  No other tissue
appeared to be diseased.   Mr. Samwell has  an excellent model of
the recent appearance of the parts, and has given to King's College
a specimen [h. 32.] of the  disease.   The  gelatinous infiltration
extended above the knee to the parts divided in the amputation.
  The malignant growths invade the adipose tissue; especially
scirrhus, the spread of which often gives a gristly character to the
fat about a carcinomatous mamma, or uterus, or rectum.
                     CHAPTER  V.

                       OF THE NERVES.,£ V

  The nerves have two functions:  by the one they minister  to
consciousness;  by the other they regulate nutrition, secretion, and
involuntary muscular action.  In their first office, the nerves appear
to be channels of communication, or media of transmission only: in
their second, they not only convey impressions, but are capable of
originating or  determining effects, independently of or in addition
to the impulses proceeding from the brain and spinal cord.
                          SECTION I.
           Of the Nerves as Organs of Consciousness.
  Modern  physiology has  established, that, in reference  to con-
sciousness, the nerves are  of  two classes;  the one  sentient, the
other voluntary.  This  distinction is constant, and is the only one
which has been proved to exist.
  The sentient and voluntary nerves distributed to  any segment
of the frame are sometimes separate through their course;  as, for
example,  the  facial  branches  of the  fifth and  seventh cerebral
nerves: more generally they are bound up in one sheath, as is the
case with  the sentient and voluntary fasciculi of the spinal nerves,
of the pneumogastric, of the glossopharyngeal.
       19—d                                    8  may 
102
MAYO's OUTLINES OF PATHOLOGY.
   The  sentient nerves are  the first, second, ganglionic portion of
the fifth, soft portion of the  seventh, certain  fasciculi of the pneu-
rnogastric, glossopharyngeal, and  spinal accessory;  and  the  pos-
terior or ganglionic roots of the spinal nerves.
   The voluntary nerves are  the  third, fourth, ganglionless portion
of the fifth,  hard portion of the seventh, certain  fasciculi of the
pneumogastric, glossopharyngeal, and spinal accessory;  and the
anterior or ganglionless roots of the spinal nerves.
   As the nerves,  in reference to  consciousness, are channels of
transmission or communication only to and from the central organs
of the nervous system,  two consequences follow in  pathology. One
is,  that division, or in general  any considerable mechanical  or
chemical alteration of the texture of a nerve, suppresses its  function
beyond the point of injury.  The other is, that the proper disorders
of nerves are much less numerous than might at first be imagined;
so many of the phenomena  of disordered sensation  and muscular
motion depending, not primarily upon the nerves, but upon affec-
tions of the central organs, in conveying the influence of which the
nerves are passive agents.
   The effects which  result  from  disturbance, whether direct or
indirect, of the animal  functions of the nerves, have the characters
either of depression or  of excitemeut.
   Muscular weakness,  and palsy or paralysis, numbness, and entire
loss of sensation  or anaesthesia are the degrees in the  first class of
affections.  Increased sensibility and pain, spasm, or uncontrollable
muscular action,—whether tonic or sustained,  as in  locked jaw,—
or clonic or  intermitting, as in repeated convulsions, belong to the
second head.
   The pathological phenomena displayed by the nerves  may bo
arranged under the following heads:—Injury  and reparation,  in-
creased vascularity, inflammation, and ulceration, hypertrophy and
atrophy, tumours, neuralgia  and spasm from irritation.
   I. Injuries of nerves present different features, according to the
nature of the violence done.  The  consequences of simple  division
of nerves, of the section of nerves in amputations, of  ligatures on
nerves, of the laceration of nerves in contused wounds, of  pressure
on nerves, require to be studied separately.
   When a nerve is entirely  divided, or a  small portion removed,
complete restoration ordinarily takes place in a  brief  period.   This
has been shown by the experiments of  Dr.  Haighton  and Mr.
Cruickshank on the pneumogastric, published in the  Philosophical
Transactions; by experiments of my own on the reunion of the fifth
and seventh, published in the Medical and Physical Journal; and,
finally, by some very elaborate experiments on the  spinal nerves,
published by Mr. Swan in his valuable work on  the Disorders of
Nerves.
   I found that a divided  nerve unites like a divided  tendon.  The
adjacent cellular  tissue becomes  infiltrated with lymph,  which
forms a  sort of callus that  incloses and unites the  divided ends. 
THE NERVES.
103
After some days this callus appears like a pearly nodule upon the
joined nerve.  I found that sensation  returned more quickly than
voluntary motion, sensibility beginning to appear early in the third
week; while motion did not recommence till after the fourth.
  The facts which  Mr. Swan has added to those which were pre-
viously known, are  the following:—
  1. In twenty-four hours after division, the extremity of a nerve
becomes enlarged, and more vascular.
  2. Iu four months after the division  of a nerve, [in a rabbit,] the
union  is sufficiently  perfect for considerable  return of voluntary
motion.
  The sciatic nerve of the right leg of a rabbit was divided July
17th, and the animal was killed November 22d.   On  the  11th of
September it could  make much use of its leg.  From this time it
kept gradually improving; and, before it was  killed, it had nearly
the perfect use of the limb.
  3. The function  of a voluntary nerve may be restored, after it
has been divided by a ligature.
  "The sciatic nerve of a rabbit was tied with a ligature of thread
on the 7th  of August. The ligature came away on the 30th.  The
animal  was  killed  on  the  22d of November.  The nerve was
completely united.   The portion of the  nerve above the part where
the ligature had been applied  was enlarged: below this, the nerve
was smaller.  The skin about the os calcis was ulcerated, and part
of that bone  was dead;  but the animal had improved in the use of
the limb, though it was by no means perfect."
  4. The formation of new nerves, after excision  of part of the
trunk of a nerve, appears to be to a certain degree possible.
  Half an inch of the sciatic nerve of a rabbit was  cut out on the
16th of July, and the animal was killed on the 22d of November.
  The  extremities  of the divided portions were separated  from
each other eight twelfths of  an inch.  There  appeared  several
small branches  arising from the superior portion:  but there were
three very remarkable;  one was continued down into the nerve,
passing to the outside of the  heel,  which in this case was larger
than ordinary:  the other two appeared to be newly-formed  nerves;
one went from the superior portion to the popliteal nerve, the other
went from the same place to the fibular nerve.  The integuments
of the heel were in  an ulcerated state,  and part of the os calcis was
dead ; but these diseased appearances  had not increased in the last
two months.  The  rabbit was certainly much improved in the use
of its limb, which was, however, very far from being perfect.
  5. The restoration of nerves,  after complete  or partial division, is
in general accomplished  as  perfectly in  animals  as  in  human
beings: the reunited nerve slowly resumes its functions.
  For example :—In  a case mentioned by Mr. Swan, " in which
the nerves  of the thumb were divided, sensation kept gradually re-
turning ; but though it is now nearly a year since the accident, it is
not quite perfect.  In a case of  tumour of the median  nerve, Sir 
 104           MAYO'S OUTLINES OF PATHOLOGY.

 Astley Cooper removed two thirds of the thickness of the nerve,
 leaving one third :  tingling of the fingers with some partial numb-
 ness followed, but  no constitutional irritation ; and the patient did
 very well."  But the progress of all cases is not equally favourable.
   In a small  portion of instances, no restoration whatever takes
 place.   A patient consulted  me, in whom, three years before, the
 median nerve had been divided above the  rist: the  wound had
 healed readily ;  but the part of the hand supplied by the nerve re-
 mained without  feeling or voluntary power.  The  cause of the
 non-return of nervous power  in such cases is explained by what
 happened in  the following experiment.  I divided  one pneumo-
 gastric nerve  in the neck of a dog: the animal recovered. A month
 afterwards, I  divided the nerve of the other side : the animal died.
 Upon  examining  the state of the nerve which had been first
 divided,  I  found that  no  union had taken  place;  the  cerebral
 portion of the divided nerve terminated in a thick white bulb that
 had no union with the distal portion, which  was wasted and dimi-
 nished in size, and  semi-transparent.
   In a large proportion of the unfavourable cases, a more or less
 perfect union  takes place ; but it is attended with a train of symp-
 toms of various degrees of severity, but partaking of one character.
 These symptoms are, pain extending along the injured nerve, which
 is  described as aching, gnawing, thrilling,—muscular weakness of
 the limb,—clonic and tonic spasms of the muscles,—fits  of total
 insensibility.
   It is of  importance in a practical view of these cases, to distin-
 guish between those in which the symptoms supervene within a
 few hours of the injury, and those  in which they manifest them-
 selves after cicatrisation of the wound.
   In the former case it is presumable, that the symptoms result from
 the manner in which the nerve is injured, which may  possibly have
 been lacerated, or its fibres left partially upon the stretch through
 an incomplete division ;  the practice which must be  resorted to is
 the division of the nerve above the wound.
   Dr. Wilson, of Grantham, was called to see the housekeeper in a
 family, who had been let blood two days before by a gardener. The
 wound which had  been the seat of pain, that had extended to the
 shoulder, was not healed, was inflamed, and a thin liquor oozed from
it.  The patient had been in strong convulsions, which, having sub-
sided, returned on the examination of the wound by Dr. Wilson. A
 tourniquet being now applied, a remission of the spasms followed,
 when an anodyne was administered: but  the convulsions, after a
 short interval, recurred ;  and the application of the tourniquet being
 tried again produced no effect.  A transverse incision was then
 made above the puncture of the vein, in order to divide the nerve
 which  was supposed to be injured ; no mitigation of the symptoms
 however, followed.   But  upon another incision being made deeper
 and longer, the patient cried out to the astonishment of the attend-
ants, "I am well! I am quite well! I can stir my arm!" when she 
THE NERVES.                     105
 began to move, and continued to do so with great delight for some
 time in various ways.  She had no return of the spasms, and very
 soon got well.
   In  connection with the preceding  case, in  which the greatest
 benefit ensued upon the immediate division of the nerve, the three
 following, from  Mr. Swan, are  of great interest.  In the first the
 nerve  was not divided, and  the patient died;  in the second the
 nerve  was not  divided, but the attendant circumstances were less
 unfavourable, and the patient lived, her health slowly but gradually
 improving.   In the third, the nerve was divided on the twenty-
 second day; it was then too late. The  irritation had extended from
 the wound, and invaded the injured nerve above.
   " Immediately after opening a vein in  the right arm of a woman
 there came on  the most excruciating pains, which could not be
 appeased  by any  remedies;  violent inflammation  followed; then
 spasms; at length, being weakened by  pains,  watching, and want
 of food, she  fell into  epileptic fits, brought forth a dead foetus, and
 died at the end of a week."—Bonetus.
   "A  female was bled in the foot.  This slight operation was very
 painful,  and  was soon  followed  by convulsive motions,  which
 extended themselves through the whole of the wounded extremity,
 and then through the rest of the body.   These symptoms were un-
 accompanied by any tumefaction, and  were very often renewed.
 The patient could neither walk nor ride in a carriage.  This state
 having continued a long time, notwithstanding the use of anti-
 spasmodics  and  quieting  remedies, I  advised a division  of the
 saphenus nerve ;  but it was not  consented to: nevertheless, the
 nervous symptoms gradually diminished, and the  patient  partly
 recovered her  health,  after five or six  years  of almost continual
 suffering."—Sabatier.
   A young lady, when cutting an orange, wounded the digital nerve
 on the ulnar side of the second finger of the left hand.  She was
 immediately  in great pain, which extended over the hand, and up
 the arm :  and, after some days, was continued to the centre of the
 left breast, and up the left side of the  neck  to the face along the
 branches  of the facial portion of the seventh nerve.  Without
 detailing  the progress of the symptoms more minutely, it will be
 sufficient  to  mention,  that the  nerve was divided  on the  finger
 twenty-two days after the accident.  The consequence was  imme-
 diate  relief;  but in  two  days  nervous  symptoms  again showed
 themselves; and their gradual  aggravation finally  led, after two
 months, to the amputation of the finger at the metacarpo-phalangeal
 joint.  The impression on the nervous system, however, had been
 too deeply made to be retrieved ;  and the patient, although benefitted
 by the operation, continued for eleven years (the date when the last
report of the case is given) to suffer from nervous irritation.
   In describing the appearances on the amputated finger Mr. Swan
remarks, that "at the original wound, a small  fibril  of  the digital
nerve was found divided ;  the end  of  this, next the tip, was incor- 
106            MAYO'S OUTLINES OF PATHOLOGY.

porated with the cicatrix, the other was formed into a small bulb
At the place of the division of the nerve at the first operation, both
extremities of the divided nerve were incorporated with the cicatrix;
and  likewise those of the dorsal  branch, which  had also been
divided."
  When nervous symptoms supervene after cicatrisation of a wound,
division of the branch of the nerve above becomes a less certain and
less advisable remedy.  It is true, indeed, that the source of  irrita-
tion may even then be confined  to the cicatrix, in which  case an
operation will remove it.   Dr. Mott told me, that, in three  cases of
nervous irritation coming on after bleeding, he had  [not divided the
nerve, but, which is evidently finer practice] dissected out the cica-
trix ;  and that,  in two of these cases the operation was followed by
the patient's direct recovery. In the third no benefit resulted.  And
it is always to be feared, where the nervous  symptoms have been
slow in coming (and therefore have been present for many days,)
that they are dependent, not more upon  the  injured point of the
nerve than on an irritation involving its whole  length ;  which of
course can  be little affected by a section of the nerve or the removal
of the cicatrix.   Time and general treatment are to be relied upon
in such cases more than operative surgery.
  The following case I select, to exemplify the general inutility of
the division of  a nerve under these circumstances; it exemplifies,
besides, the return  of sensibility  through anastomosis with other
nerves.
  Matilda  Fuller, a?tat. twenty-five, a  fortnight before Christmas
last, was cleaning  a table knife, when it slipped, and cut a deep
oblique wound  on the outside and to the  back of the base of the
first phalanx of the fore-finger of the left hand. The wound healed
in a  week.  In another  week  the hand swelled,  and she then
observed that the  back of the  fore-finger, beyond  the  scar, was
numb : a cicatrix itself was very sensible on pressure : at the same
time the arm began1 to be painful, and her hand became  weak and
powerless; the  fingers were half bent;  she could bend  them  a
little more, but  could not  extend  them, except by using the other
hand.  The pain she described  as a  gnawing  pain ; it extended
along the radial branch of the spiral nerve, then along the trunk of
that nerve  to the shoulder : moving the hand or arm increased the
pain.   Having  tried various remedies ineffectually, on the 26th of
March I divided the radial branch of the spiral nerve, where it lies
on the back of  the  wrist; a third of  an inch was then  removed
from the lower end of the nerve.   The patient seemed to feel pain
(but it is hardly credible that she did so) at the second  section of
the nerve.  The effect of the division of  the  nerve  was  to remove
instantly the former pain, and to restore a great  deal of freedom
and power  to the motion  of the hand and fingers :  but it produced
a very disagreeable  sense of numbness in the back of the thumb
fore and middle fingers, and  the corresponding surface of the hand!
  The relief thus  obtained  was  not permanent.  After  four days 
THE NERVES.
107
some  swelling took place around the wound, which was unbound
and poulticed ;  the gnawing pain, too, returned, but it was not so
severe as before, and did not extend higher than the elbow.  Six-
teen days after  the operation, I noticed  the following singular cir-
cumstance, which  perhaps existed from  the first.  The outer part
of the back of the hand was of course  perfectly numb ; and like-
wise the back of the thumb, and of the  middle finger, so that the
patient could not tell when these surfaces were touched : the back
of the fore-finger over the first phalanx was equally numb, as far
as to the original cicatrix : but the cicatrix was tender on pressure,
and. all the back of the fore-finger, from the cicatrix to  the tip,
had feeling.   The  feeling there appeared to be as perfect as that of
the back of the other fore-finger.  It is evident that the only means
of accounting for this  phenomenon is to  suppose, that, in  the in-
terval between the accident  and the  operation, being a period of
three months and a half,  sensation  had  made its way through the
junctions of the index branches of the median nerve with the index
branches of the divided digital branch of the spiral, circuitously to
the back of the fore-finger.   The  patient now (IVJay 21st) is im-
proving.  There is less pain  in the arm, and rather more strength
in the" hand.   The cicatrix  of the operation  remains, however,
tumid and acutely sensible when touched. The back of the middle
finger and thumb has regained some sensibility.
   The  nerves, after amputation, are liable to become  irritable;  in
which case there are pains in the stump, and spasmodic twitchings
of the muscles.  The seat of  the irritation  may either be  the ex-
tremity of  the divided nerve, or the whole length of the nerve, or
even  its origin, or all three together.  When the seat of irritation is
in the extremity of the nerve, it is supposed to depend upon a pecu-
liar change of structure, which is conjectured to be favoured by the
proximity of the divided end to the  cicatrix.  The change of struc-
ture is the formation of a large bulb, of the consistence of cartilage,
on the extremity of the nerve.  Mr. Langstaff, who has written an
interesting paper on  this subject,  in the  sixteenth  volume of the
Medico-Chirurgical Transactions, recommends, as a means of pre-
vent ino- the ends  of nerves becoming enlarged after  amputation,
the removal of a  second portion of each nerve which may have
been  left so long that it would not otherwise be well buried in flesh
on bringing the parts together. The patient hardly feels the second
section of the nerve.                                         .
   When nervous irritation has been set up from this cause, and is
exclusively dependent upon the bulbous enlargement of the end of
the nerve,  it  may be relieved either by reamputation of the stump,
or excision of the extremity of the nerve.   The latter operation is to
be preferred, if the symptoms are clearly attributable to an affection
of one nerve.  The following case  is an example in point.
   A  man, about thirty-five "years  of age, was admitted into the
Middlesex Hospital in the course of the last autumn,  whose leg I
had amputated below the knee, for compound fracture, about two 
108           MAYO'S OUTLINES OF PATHOLOGY.
years before.   It was, to the best of my recollection, half a year
before the re-admission of this  patient that the stump began to be
painful.  The pain was described as a constant and  severe gnaw-
ing pain : it  was principally felt at  the end of the fibula, from
whence it extended to the knee and ham.  The cicatrix covering
the end of the fibula was exquisitely sensible, and the  muscles of
the stump were in  a state  of perpetual quivering  : the cicatrix
appeared to grin, from the successive traction of different packets
of the muscles.  Supposing  the symptoms to depend upon an en-
largement of  the end of the superficial peroneal nerve, I cut down
to the fibula,  and removed about the half  of  a square inch of
integument and cicatrix covering it, with half an inch of the fibula,
and some thickness of the flesh attached to it, including the super-
ficial fibular nerve.   The end of this nerve was found to terminate
in a small bulb behind the cicatrix, [i. 20.]
   The severe pain which the patient had suffered for months, was
instantaneously removed by this operation.  While the wound was
healing,  however, some  pain  and tenderness reappeared in the
direction of the fibular nerve: but on applying leeches, and admi-
nistering calomel every night for  a  week, these symptoms  went
away, and the patient left the hospital almost free from pain  in the
stump;  but a little of the quivering remained, with a slight tender-
ness of the original  cicatrix opposite to the situation of the tibial
nerve.
   To exemplify painful affection of a stump, in which the source
of irritation was not confined to the cut extremity of the nerve, I
may mention  the  conclusion of the case of Hannah Allen, which
has been already adverted to under the head o  neuralgic affection
of joints.
   In October last the extremity of the stump was reamputated, for
return of intolerable pain diffused over its extremity.   On examin-
ing the amputated part, the sciatic nerve  and the saphenus  nerve
were  found to terminate in large callous bulbs.  In  the second
operation care was taken  to  draw out and remove a considerable
portion  of the  sciatic  nerve, which  retracting  lay  well covered
among the muscles.   Nevertheless, when the stump had  nearly
healed, the old pain  again appeared.   The  patient was now sent
into the country. After some months  she  returned, unrelieved.
The pain, however,  this time was more circumscribed ;  and  if not
limited to the termination and course  of the sciatic nerve, was cer-
tainly most severe at the outer and back part of the stump.  Sir
Astley Cooper, who  saw the patient at her request at this period,
recommended  the division of the sciatic nerve.  Accordingly, I cut
down upon that nerve, where  it is covered by the lower  fibres of
the glutasus maximus, and divided it: a portion was  then removed,
taken of course from the lower end.  The patient appeared  to feel
pain at the second section of the nerve.  This operation was per-
formed  on the 1st of May.  The immediate effect was, that the
morbid sensibility of the posterior part of the stump was removed 
THE NERVES.
109
but the advantage was temporary; and this patient is now suffering
as acutely as ever.
   I suppose it to be possible, that, in this case, the seat of irritation
may be confined to the trunks of the nerves in the limb, and  that
their origins may not be engaged.  If it were so, amputation at the
hip joint might cure this  patient.  But 1 am loath to recommend
this formidable operation, as it  might  prove as  useless as those
which have been  already sustained.  My reason  for conjecturing
the seat of the irritation may possibly net extend beyond what
remains of the limb,  is the following case.
   I had about three months ago under my care, as an out-patient
of the Middlesex  Hospital,  a  woman  whose  arm Mr. Bransby
Cooper had amputated at the shoulder joint for neuralgia, which
had followed  an  amputation above the wrist, and had returned
after a second amputation above the elbow.  She told me that she
was perfectly cured, by the third operation, of the pain she had
undergone so much  to get rid of.
   The extension of nervous irritation from the stump to the origins
of the nerves may be exemplified by the  following case, in which
the symptoms, decided in character, but of no great severity, spread
secondarily from the spine down the other leg.
   Susan Briggs, aetat. thirty-five, was  admitted into the Middlesex
Hospital, in February last, with neuralgia.   Eight years  ago, Sir
Benjamin  Brodie had amputated the left leg  below the knee, for
disease of  the ankle joint.   For the seven  ensuing  years, this
patient remained well;  but, during the last twelve months, she had
experienced pain and tenderness of  the stump, pain extending up
 the thigh to the sacrum, accompanied with pains of the right leg,
 occasional cramp  of the muscles of the right leg, and a remarkable
 and permanent retraction of the toes, and occasional numbness and
 thrilling sensations extending to the sole of the right  foot.  The
 tenderness  and the principal  pain were diffused over the extremity
 of the stump.   On  examining  the back, I thought that I detected
 some tenderness at the upper spinous process  of the  sacrum :  an
 issue was accordingly made at  this part, and five grains of Pluai-
 mer's pill  given  each night.   These remedies were apparently
 of no service.  Afterwards, strips of  belladonna plaster were ap-
 plied round the stump, and carbonate  of iron was given in  consi-
 derable  doses.  The patient stated  that  she derived benefit from
 this  treatment; and certainly  her  general appearance improved.
 She  left  the  hospital  after two months, as she said, in much less
 pain, and evidently  in better health.                     .
    It has  been mentioned, that, in  experiments upon animals, a
 nerve divided by a ligature will  reunite, and its function be restored.
 It is equally well authenticated, that,  in  human bemgs, the  same
 things may happen.   No  case,  however, can present itself in dis-
 ease" which would authorise the placing a ligature upon  an undi.
 video nerve, nor indeed  upon one that has been divided, unless
 (which  is hardly conceivable) hemorrhage  should  follow  unre- 
110           MAYO'S OUTLINES OF PATHOLOGY.
strainable by other means.  Where nerves have been unintention-
ally included in ligatures,  it has occasionally happened that the
severest symptoms of nervous irritation have supervened.  They
may be allayed  by the removal of the ligature.
   What has been said of the  consequences of intentional division
of nerves  is of course equally applicable to those cases in which
nerves are partially torn by accidental violence, whether attended
or not by laceration of the integuments and an open wound.  The
occurrence of very severe nervous symptoms in a limb, in conjunc-
tion with fracture of a bone in a direction to injure a nerve, might
in certain  cases give rise to the question, whether the nerve ought
not to be divided above the point of local injury.
   Pressure upon nerves is liable  to produce  permanent or tempo-
rary interruption or disturbance of their functions.
   A case  was  communicated to me, in which  a gentleman lost
entirely the use of his  arm  through falling asleep with the arm
over the back of his chair.   The effect was described  to  me as
perfect palsy and anaesthesia, produced by the mechanical  com-
pression of the axillary nerves.
   I have witnessed several cases, in which weakness and numb-
ness and thrilling pain of the arm have been brought on by the use
of crutches.  The symptoms have come on gradually,  and have
been slow to give  way.  Blisters over the affected nerves,  and
mercury to touch the gums, I have found of use in the most obsti-
nate of these cases ; leading me to suppose the affection  of a con-
gestive or inflammatory nature.  Nerves in  such  cases are tender
on pressure.
  Strains, or forcible extension of nerves, have given  rise to symp-
toms of a yet more serious character.
  In a case described  by Sir Everard  Home, a gentleman received
a violent sprain of his  thumb by the weight of his body being
thrown  upon it, in saving himself when nearly thrown off by a
sudden  motion of his horse.   He  was afterwards  liable  to pa-
roxysms, in which his thumb was first bent in towards  the palm
of his hand; spasms then took place  of the muscles of the arm,
after which he became insensible, and continued  so for about a
quarter of an hour.   The attacks returned frequently in the arm;
but it was found that the  pressure of a tourniquet prevented the
insensibility.  A nerve  in this case was divided without success.
The tourniquet lost its effect in arresting the spasms, and he died
suddenly after three months ; but there was no examination of the
body.1
  II. In many of the  cases already given, the immediate cause of
the nervous symptoms may have been increased action or inflam-
mation of the vessels of the injured nerve.
  In the case of Matilda Fuller, page 106, the divided nerve was
larger and more  vascular  than  usual.  What is  supposed to be
' Phil. Trans. 1801. 
THE NERVES.                      Ill
 inflammation of the sheaths of nerves is no unfrequent consequence
 of exposure to cold.  I have seen it in the nerves of the arm, and it
 is perpetually met with in the form of sciatica.   The symptoms of
 the  affections are, pain, numbness, and  thrilling sensations in the
 course  of the nerve,  occasionally combined with spasms of the
 muscles supplied by it, and tenderness on pressure over its course.
 The following case,  where the  disorder was brought on by vio-
 lence, may serve to exemplify this affection.
   Luke Reany, aetat. thirty-five,  on the 11th of March, 1835, fell
 backwards,  striking  his loins against  a low iron rail.   He  was
 raised up by the bystanders, when he  contrived, though in much
 pain, to walk home.  The pain  increased, and extended to the
 groin,  which  was swollen ;  and to the testicle,  which was re-
 tracted:  the bladder  became affected,  and he  passed  frequently
 small quantities of  high-coloured urine"  Purging and cupping on
 the  loins greatly mitigated  these  symptoms, and gave prominence
 to  others which had existed  from  the first twenty-four hours:
 these were pain and tenderness in the course of the sciatic nerve,
 muscular weakness and occasional spasms of the thigh and  leg,
 numbness and thrilling, which, below the knee, took the course of
 the  fibular nerve.   With rest, cupping  on  the back of the  thigh,
 blisters, and  issues  over the sciatic nerve, each of which remedies
 gave in its turn distinct relief, the patient recovered, and left the
 Middlesex Hospital the 25th of May.
   Dr. Abercrombie, in the conclusion of his profound and masterly
 work on  Diseases  of  the Brain and  Spinal Cord,—from which I
 shall frequently borrow in the succeeding chapters,—has  put toge-
 ther some instances  of affections of nerves,  from which I extract
 the  following as illustrating the present  subject.
   Martinet found in a case, in  which there had  been violent pain
 of the  fore-arm followed by palsy (and  in which repeated blisters
 suspended for the  time  the paralytic affections and the  palsy), a
 uniform dark red  colour of the  substance of the median nerve,
 occupying a  defined  space,  perhaps an inch or  two in extent.   In
 a similar affection of the right  sciatic nerve, accompanied by palsy
 of the limb,  he observed a diseased  portion of nerve involved in
 a quantity of gangrenous cellular  tissue.  In another  case he found
 a diseased portion  of the crural  nerve, which was an inch and a
 half in extent, enlarged to about  double its natural size: this  por-
 tion was of a violet-red colour, and strewed throughout with ecchy-
 moses, each about the size of a  pin's head.
   Serous or  bloody effusion within the sheath  of the nerve, pene-
 trating  the substance  of the nerve, and separating its fibres from
 each other, Martinet found in the sciatic nerve of a man (he  had
 died of pneumonia) who had been affected with violent pain in the
 posterior part of his thigh, aggravated by the least  motion, so as to
 make hiui cry out.
  Pus  effused among the fibrils was  found by Martinet in  the
sciatic nerve, in a man who died  of disease in the head and abdo- 
112            MAYO'S OUTLINES OF PATHOLOGY.
men, and who had been affected during the latter part of his ill-
ness with violent pain in the course of the sciatic  nerve.   The
cellular texture surrounding the diseased portion of the nerve was
also penetrated by pus.
  Ulceration of the substance of the peroneal nerve was met with
by Mr. Swan in connection with a fungous ulcer of the leg:  there
had been violent pain of the whole leg and  thigh, which had ren-
dered amputation  necessary: in many parts of the limb, the nerves
were found considerably enlarged.
  Inflammatory swelling and suppuration near the ear, from ex-
ternal violence  or otherwise, are liable to  produce  palsy of the
portio dura.
  III. It is analogically probable that nerves are subject to hyper-
trophy and atrophy.   In  the case last  described, it is mentioned
that the nerves of a diseased leg were found enlarged.   When an
organ of sense  is destroyed, its nerve  wastes  [i.  20.]: the  same
happens to the distal part of a divided nerve, when no union  takes
place.
  IV". Tumours are liable to form in the  nerves: they either are
solid, or are cysts containing liquid : their common  situation  is
between the nervous  fasciculi: the pressure which they make upon
the  nerves sooner or  later gives origin to local pain and numbness;
in severer cases,  to convulsions and epilepsy;—in short, to the
whole train  of symptoms which have been already enumerated as
consequences of a local irritation  of a nerve.
  In a remarkable case by Portal, a woman was cured of epilejfcy
by the removal of a tumour which had formed on one of the nerves
of the thumb.  The slightest pressure upon it had  given pain, and
frequently brought on epileptic convulsions.
  The practical questions which present themselves in connection
with this subject are various.
  Suppose that a  patient suffers a train of  symptoms referable to a
single nerve, and  that a lump is to be felt at one part of the course
of that nerve, pressure upon which aggravates the symptoms: the
following alternatives present themselves.
  The tumour may not be in the nerve, but  resting upon it.
  The tumour maybe implicated with the superficial fasciculi only
of the nerve.
  The tumour may be intimately implicated with all  the nervous
fasciculi.
  In either of these cases, the tumour may be a solid or a cyst.
  The tumour again may be upon a small nerve; as, for example,
the  internal cutaneous nerve of the arm, the  division  of which
would not materially interfere with  the  functions of the limb;  or
on a great trunk,  as  the sciatic,  after the loss  of which the limb
would, in the most favourable event, remain a troublesome incum-
brance.
  It is evident  to what practical conclusions the preceding con-
siderations point.  Supposing the remedies by which swellings are 
THE NERVES.
113
dispersed to have been properly but ineffectually tried, there remain
the following measures.
  The exposure of the tumour, which—if separable from the sur-
face of the nerve, or from the body of the nerve at the expense of a
few fibres,  should be removed,  whether solid or a  cyst;—if com-
pletely implicated with the whole structure of the nerve, and that
nerve a small one, should be removed with the portion of nerve in-
volving it;—if so  implicated, and the nerve the sciatic, and the
tumour a cyst, the cyst might be punctured, and the fluid evacu-
ated, every precaution being subsequently taken to unite  the wound
by  adhesion, leaving  the chance of the fluid not reaccumulating.
In  the last case, supposing the tumour to prove solid, another ques-
tion might still arise;—whether,  the nerve  being first divided
above the tumour, the latter would not admit of being dissected out
of the so palsied  nerve, with more probability of safety to the pa-
tient, than  if the nerve  to  be operated on  were  left  in communica-
tion with the brain.  Of course, if in such an operation the tumour
should be found to  implicate the nervous  structure, or to leave no
separable  and wholesome  fasciculi,  the operation  must be aban-
doned.
  V.  When the varieties of nervous affections, which  have been
described, have been  separated  from the mass, there is  still left  a
class, which, from  its obscurity and difficulty of treatment,  has  a
yet higher  interest.    The cases of this class are the intermittent
pains in the direction of particular nerves, which bear the name of
tic  douloureux.  What is considered with  or without justice as the
distinguishing character of these cases is,  that the symptoms flow
from nervous irritation, determined by no lesion of,  or tumour in,
the nerve, but  proceeding from a variety of causes, acting  by re-
mote or contiguous  sympathy,  the nature of which regulates the
treatment of individual  instances.  It is probable,  that, with im-
proving medical science, tic douloureux will eventually disappear
in nosology, as in  the pathology of the joints the  vague term of
white swelling is already falling into disuse, now that the different
individual  affections which used to be grouped under it are classi-
fied with pathological precision.  And even in the history of the
different shades of tic, which I have now to enumerate, the basis of
such a distinction may be traced, and the  general and vague cha-
racter which I have assigned to the complaint, already begins  to
shape itself into groups of features, some of which show  a near
alliance to  the definite forms of disease which have been recently
described.
  The intermittent and even periodical character  which attends
pain from  any affection of the  nerves is often well  marked, even
when the cause is constant, definite, external, and mechanical.
  Mr. Swan  mentions a case of popliteal  aneurism, in which vio-
lent pain of the leg  used to come on every night at half past ten,
and go away about  two in the morning.  The  pain  was never felt
after the operation. 
 114            MAYO'S OUTLINES OF PATHOLOGY.

   Disorder of the  digestive  organs is  one of the causes of  tic
 douloureux.
   A gentleman was taken ill through having eaten hashed  hare
 cooked in a  brass pan which was covered with verdigris.  Some
 months afterwards, having not been well since, he had an affection
 of the nerves of the back" part of the head, which  caused excru-
 ciating pain.  He had become weak and  extenuated. He recovered
 through the application of a blister to the back of the neck, the free
 use of bark, joined  with  a dose of laudanum at the period of the
 morning  when the pain was commonly most severe, and wine and
 malt liquor.—Swan.
   The commonest seat of tic  douloureux is the facial branches of
 the fifth nerve, especially the infra-orbital: in this case the cause is
 often in the state of the  teeth, which either are diseased, or  have
 been broken  with violence.   The removal of the diseased teeth,
 and the use of tonics afterwards in the  first case, and  the use of
 tonics alone in the second, are often  successful in remedying the
 complaint.
   In a lady, aged forty, who suffered severely with tic douloureux,
 it was observed that the  attacks were  frequently preceded by an
 uneasiness in  one tooth, which exhibited, however, no signs of un-
 soundness.    The tooth  being extracted,  a large  exostosis  was
 observed  at its root; and the lady never  suffered more than slight
 attacks, and those very seldom afterwards.—Halford.
   In another case mentioned by the president of  the College of
 Physicians, recovery took place after the exfoliation of a portion of
 bone from the antrum.
   Sometimes  the complaint is produced by thickening of the cra-
 nial bones.
   On examining the head of  the late Dr. P. after death, there was
 found an unusual thickness  of the os  frontis where it had  been
 sawn through above the  frontal sinuses, and at its juncture  with
 the  parietal  bones.    He had twice suffered  suppuration  in the
 frontal sinuses.   There was discovered,  also,  in the falciform pro-
 cess of the dura mater, a little distance from the crista galli, a small
 osseous substance, about three eighths of an  inch in length, rather
 less in breadth, and about a line in thickness.—Halford.
,  In another  case, an enormous thickening was observed of the
 frontal ethmoidal  and  sphenoidal  bones, in  one part to the extent of
 half an inch ; and the anterior lobes of the brain  were curiously
 moulded  and  indented by the  thickened bone.—^Halford.
   Tic douloureux is occasionally produced by a congestive state of
 the vessels of the brain.
   Sir Anthony Carlisle described  the case of a lady who had tic
 douloureux in the infra-orbital nerve.   The pulse was very full
 therefore  sixteen ounces of blood were taken from the arm.  Three
 days after, she thought herself relieved;  but as the pulse continued
 still  very full, twelve ounces more of blood were taken away.
 Three days after the last bleeding, she was bled again to sixteen 
THE NERVES.                     115
ounces.  She was now entirely free from pain, and never had any
return of it.  She died two years after this period of apoplexy.—
Swan.
  In one disposed to this affection, it will attack first one part, then
another.   I attended, with Dr. Nicholl, a gentleman  who laboured
under  neuralgia of the bladder.   He had formerly suffered from tic
douloureux  in  his eyes.  In another patient the  pain was situated
in the  perineum.
  A gentleman, about forty years of age, had pains in various parts
of his  body, but most frequently in his limbs.   These resembled
tic douloureux  in violence, and were sometimes confined to a small
spot in one leg, sometimes in the other, or in the  arm or shoulder;
and when in the latter, he was usually very sallow.  His complaints
arose from a disordered  state of the digestive organs; they were
brought on by anxiety of mind  or  improper diet.  By the  use of
blue pill and  aperient  and  tonic medicine, he  was always very
much  relieved,  and for some time remained  quite  well.  When the
pain was in the lower extremities, the cause  was generally a col-
lection of faeces in the larger intestines,  and he was  relieved by
purging.—Swan.
  Where the affection  is fixed to one nerve, the division  of the
nerve generally gives temporary relief.  The nerve, however, re-
unites, and the  pain returns.  What is remarkable is, that the union
of the nerve, or at all events the return of pain, is more rapid after
each successive division; so that a  briefer  interval  of ease is ob-
tained  through  each repetition of the operation.
  Sometimes in conjunction  with neuralgia, without any apparent
cause,  muscular spasms occur.
  A young lady, trientioned  by Mr.  Pearson, was seized with pain
in the  thumb, for which no reason could be assigned, accompanied
by a morbid sensibility of the part:  the affection  gradually spread
over the arm, and was accompanied by the loss of nearly the whole
muscular power of the extremity, with morbid sensibility of the in-
teguments, and a strong contraction of the  fingers,  so  that the
points of the nails were forcibly pressed  against the palm  of the
hand.  The fingers were not under the  control of the will, and
every attempt  to extend them was  accompanied by insupportable
pain.   The joint of the elbow also was contracted.  After some
time the other arm was slightly affected in the same manner, and
she had likewise pain and great debility of both the lower extre-
mities.  After this affection had continued about  a year, it got well
under  the use of a liniment composed of olive oil, turpentine, and
sulphuric acid.   This produced most severe erysipelatous inflam-
mation, which, beginning upon the affected arm, extended  after-
wards over the whole body. 
116
MAYO'S OUTLINES OF PATHOLOGY.
                         SECTION II.

      Of the Nerves in reference to Nutrition and Secretion.

  Very little is known of the pathology of  nerves, in relation to
their automatic functions.  It is, however,  well  established, that
parts  from  which the nervous influence is withhheld have  less
vitality, and are more disposed to inflame and suppurate and slough
than other parts.
  The limbs of animals, iu which the principal nerves have been
divided, frequently mortify ; and in human beings, whose limbs are
completely paralysed  by disease, the skin is  found to  inflame  and
vesicate through  slight causes, such  as a moderate  heat, which
would not blister  the skin in health.
  It has been  further  rendered probable, by the experiments of
Magendie, that the nerves of touch are  those upon which the sup-
port of healthy nutrition  mainly depends.  He  found that,  after
dividing the fifth  nerve within  the cranial cavity of rabbits,  oph-
thalmia supervened, which left partial  opacity of the cornea.
  It likewise appears  that the principal  organic effects of division
or disease of nerves result in part only from the interruption of
continuity with the brain.   In some of his experiments, Magendie
divided the fifth nerve further from its  origin, interrupting, not only
the connection with the brain, but by destroying it, the influence of
the ganglion of Gasser besides.  The consequence of this injury is,
that not the surface only of the eye inflames, but  its whole interior
structure ; it suppurates and perishes.
  Instances are not uncommon  of the  combination of anaesthesia of
one side of the face produced by disease, involving the origin of the
fifth nerve,  with  ophthalmia.  I  have  seen several  cases of this
nature, upon which  the experiments of Magendie not only have
thrown a clear pathological light, but have likewise led to an im-
proved and  efficient treatment.
  The following case exemplifying  the  disease, occurred to Dr.
Alison, of Edinburgh.
  The patient had  loss of common sensation in the left side of the
face, the left nostril, and left side of the  tongue;  with sensibility of
the ball of the eye, and occasional bloody discharge  from the left
nostril; and was  liable to attacks of pain occasionally accompanied
with fever, during which the pain was  principally referred to the
sensible parts.  There were frequently  attacks of inflammation of
the left eye, with  dimness of  the cornea, which was relieved from
time to time by the usual antiphlogistic  means; but at the end of
two months, a line formed round the base of the  cornea, which at
length sloughed out,  and the  contents of the eye  were entirely dis-
charged.  The muscles of the  left side of the jaw were paralytic,
and felt  quite flaccid when the patient chewed or clenched his
jaws;  but the motion of the muscles of  the cheek was unimpaired. 
THE SPINAL CORD.
117
After the destruction of the eye, the paralytic symptoms remained
stationary for a year or more:  there was then a  violent return of
headach, with fever; and death, in a state of coma, after an illness
of a fortnight.   On inspection, there was found considerable soften-
ing of some of the central parts of the brain.  The fifth  nerve of
the left side,  on being traced  backwards from the ganglion, was
found close to the  ganglion to  be of a  very dense texture ; but be-
yond this, it was much wasted ; and at its junction with the tuber
annulare, nothing  but  the membrane seemed to remain.—Aber-
crombie.
  A patient was  under my care,  in  the Middlesex Hospital, for
fracture of the middle lumbar vertebra:  he had palsy and anaes-
thesia of the left leg. Before his death, inflammation of the mucous
membrane of the bladder supervened ;  the urine had an ammoniacal
odour, and was loaded with viscid  mucus.   The  left nerves of the
cauda equina had  been  bruised, and adhered together and to the
theca through effused lymph,  [i. 10.]
  The inflammation of the lungs and of the stomach, which follow
division of the pneumogastric nerves,  are phenomena of the  same
nature with the preceding, and result from interruption of the ner-
vous influence.
  Dr. Abercrombie supposes,—and the same conjecture had occur-
red to myself,—that the  painful wasting of muscles which has been
described in a previous chapter as the occasional result of exposure
to cold and damp, may  depend upon  affection of the  nerves.  In
one of the two cases which I have given, and in  which the deltoid
wasted, the principal pain was constantly felt in the situation of the
circumflex nerve.
  Of the affections and pathological influence of the visceral nerves,
nothing can yet be said to be sufficiently established. It is  probable
that enlarged glands, or morbid deposits pressing  upon the  pneumo-
gastric nerves,  may derange the functions of the  larynx, the lungs,
and the stomach.  It is likely that diseases of the sympathetic nerve,
and the semi-lunar ganglia, may cause or be produced by diseases
of the heart and bowels.  The evidence,  however, as  yet elicited
upon this subject  is of so doubtful  a character, as only to render the
obscurity of the subject more visible.

                                       '/
                       CHAPTER VI.

                     OF THE SPINAL CORD.

  The spinal cord is that portion of the central organs of the
nervous system which is situated below the decussation of the an-
terior pyramids, or which is contained in the vertebral canal.
       19—e                                     9 maV 
118
MAYO'S OUTLINES OF PATHOLOGY.
    The spinal cord, like the nerves, both ministers to consciousness,
 and exerts an influence over vegetative life.  Like the nerves, it has
 distinct fasciculi for sensation and volition.   Like the nerves again,
 in reference to consciousness, it may be considered, in part at least,
 as an organ of transmission,  and altogether as exercising a de-
 pendent function.  The  division or crushing of the spinal  cord
 palsies the portion  of the frame supplied with nerves from below
 the injured part, as certainly as a parallel effect is produced by the
 division of the trunk of a nerve.
   But the dependence of the spinal cord upon  the enkephalon is
 not exactly of the same nature with the dependence of the  nerves
 upon the cord.   The spinal nerves arise—that is, begin or end—in
 the spinal marrow, and have no power independently of their con-
 nection and continuity with it.   The spinal cord in  the same way
 is a production of the enkephalon, and has no part in consciousness
 but when  in continuity with it:  stiil it possesses  forces which  are
 not derived from the enkephalon.   The spinal cord with the spinal
 nerves  forms thirty-one separate organs; each organ consisting of
 a segment of the gray  and white matter of the spinal cord, and'the
 pair of nerves originating in it.   Each of these organs in one sense
 is independent of all the rest; one of the sentient nerves belonging
 to it being irritated, the impression which it conveys to the segment
 of the cord in which it rises is capable of exciting there an impulse
 to motion, which is transmitted by the voluntary  nerve to the mus-
 cles.  Each of these thirty-one  organs is to its corresponding seg-
 ment of  the  body,  the  organ of sensation, volition,  and the com-
 monest instinct.  It is true that the white fibres which communicate
 with the enkephalon, carry upwards the impressions of sensation,
 and bring downwards the  cerebral impulses either of deliberate de-
 sign or  passion.   But  the organs below are  already perfect to the
 extent assigned to them, although incapable of ministering to con-
 sciousness, unless when continuous with the enkephalon.   Accord-
 ingly, in some cases of privation of  sense of motion  in  the le^s
 through disease affecting the middle of the spinal  cord, I have seen
 so much independent power remain in them,  that pricking or tick-
 ling the  foot, which yet excited no sensation,  and  was unknown to
 the patient, was nevertheless followed by its retraction.
  Again, as the segments of the cord may be perfect, yet excluded
 from consciousness, through interruption of their continuity with
 the enkephalon, so on the  other  hand that continuity may be per-
 fect, but one or more of the segments themselves  be  diseased and
 unable to execute their function.
  Thus the arms have  been palsied and  contracted in consequence
of disease in the cervical portion of the spinal cord, while the legs
have retained feeling and voluntary muscular power:  the fasciculi
of communication between the lower part of  the cord and the en-
kephalon having remained perfect, while the interior structure of
the cervical portion, which originates the brachial nerves,  had be-
come disorganised. 
THE SPINAL CORD.
119
   These physiological principles as to  the uses of the spinal cord
being admitted, it is easy to deduce from them the symptoms which
must attend its pathological affections.
   An affection of one side of the cord  may produce either anaes-
thesia, or paralysis separately, of one side, or both together, that is,
either anaesthetic,  or paralytic, or complete  hemiplegia.  An affec-
tion extending its influence to both sides of the cord, may paralise
and deprive of sensation more  or  less  completely the part of the
body supplied with nerves below the place of lesion, that is, it may
produce either paralytic, or anaesthetic, or complete paraplegia.
On the  other hand, pains and spasms and  cramp may flow from
affections of the spinal cord.
   Concussion, compression,  division of  the cord,  produce as their
immediate consequences complete paraplegia. Inflammation of the
substance of the cord and of the membranes produce local pain,
palsy, and spasm,  but in  general palsy predominates in the former,
spasm in the latter.  Constipation of the bowels, and incontinence
or retention of urine, are usual attendants of disease of the spinal
cord.
   The following cases will  serve to exemplify the  principal fea-
tures in the pathology of the cord.
   a. Concussioti of the spinal marrow may produce complete sus-
pension of its functions.   In a case given by Boyer, complete para-
plegia had been instantaneously produced by a fall  into a ditch :
the patient died.   On dissection, no disease could be  discovered
either in the  head  or spinal canal.  Frank mentions four fatal cases
of concussion of the spine, on the post mortem inspection of which
no change in the spinal marrow  was detected, or injury of the ver-
tebral column.   Instances of this description throw light upon the
nature of those  cases of more frequent occurrence,  in which per-
sons recover after  all varieties of palsy and anaesthesia, that have
instantaneously followed blows or falls upon the back.  In all such
cases, however, there is a threefold  risk—first, of the palsy being
quickly followed by death; secondly, that the concussion (having
been attended or  not by ecchymosis of the  nervous  substance)
[k. 10.]  may give rise to disease of the  spinal  marrow, vertebral
column, or both; thirdly, of the palsy being permanent.
   There are some remarkable instances of wounds  of the spine
with recovery.
   A young man was struck on the back of the neck with a poniard,
three fingers' breadth below  the  left ear, the wound penetrating
obliquely towards the right.   Immediate loss of sense and  motion
of the whole body ensued, the head alone feeling.  During the first
few days there was retention of urine and constipation; afterwards,
involuntary discharge of urine.  Towards the eighteenth day, feel-
ing began to return on the left side;  on  the twentieth, the  patient
could move the digits of the left hand and foot; and feeling and
motion of the left side increased daily. On the thirtieth day,  feeling
began to  reappear on  the right  side; shortly after,  motion.  In 
120
MAYO'S OUTLINES OF PATHOLOGY.
three months  he was  so  recovered that he could walk  a  little;
the  left side,  however, having kept in  advance of the  right.—
Morgagni.
  A drummer  of the National  Guard of Paris was struck on the
back of the neck with the  point of a sabre, which was thrown at
him: his limbs bent under him, and  he fell.  The  left arm was
palsied: this effect  was permanent.  The  left  leg  was  likewise
affected with weakness: but this disappeared on the fourth day.
On the thirteenth day it was accidentally discovered  that  he right
side of the body, from the fourth rib downwards,  had lost  its feel-
ing: this anaesthesia was permanent.—Boyer.
  The  following cases exemplify effects of simple concussion of
the spinal marrow;  in  the second, strong threatenings  of inflam-
matory softening of the cord manifested themselves.
  A man, aged fifty, was admitted between four and five years ago
into the Middlesex Hospital, having fallen out of a loft into  a stable,
in such a manner as to pitch upon the juncture of his neck and
back.  He did  not lose  his  senses, but on being lifted up, his arms
and legs were  found to be numb and powerless.   In a few days he
recovered the feeling and use of his legs; the numbness and  weak-
ness likewise gradually left the arms ; but his hands  remain  affect-
ed,  and continue so still.   The hands  are  numb and weak; the
thumbs and  fingers are drawn inwards, and are incapable of com-
plete extension.  The treatment employed was cupping, blistering
on  the  neck, and calomel.  About six  months after the  accident
strychnine was used, but without advantage.
  James Jacob, aged thirty-nine, was admitted into the Middlesex
Hospital in May, 1835.  On the 1st of March, he was turning to
speak to some  one at the top of a flight of  seventeen stone steps,
when he slipped and fell backwards to the bottom. He was stunned
by  the fall, but knows that he pitched upon  the  upper part  of the
back, because his coat was cut through  at this part, and his  shoul-
ders and back  were bruised.  He was lifted up, and soon recovered,
and walked  to his room.  No  symptoms supervened for a month,
during which  he recovered from the bruise, and lived  heartily as
before the accident.  He was  then, without any warning,  seized
with spasm  in the left foot and hand:  the spasm  went off in a few
minutes; but  the left hand and arm  remained weak and  numb.
This was attended with pain of the back part of  the head, and oc-
casional confusion of thought,  and aching and shooting pains be-
tween the shoulders; he had also frequent  desire to make  water,
which came on  suddenly  with great urgency.   He  continued in
this state about a fortnight, when he had twitchings in the arm and
leg, and gradually recovered the use first of the arm, and then of
the leg.  A  fortnight after  the restoration of his arm and leg, his
right side was taken much as the left had  been.  This again cot
better.  At  the time of, and for six weeks after,  his admission, he
was liable to spasmodic seizures of the hands and feet, which lasted
a few minutes; the pulse  during the  seizure was  frequent and 
THE SPINAL CORD.
121
 feeble; the skin cold and inclined to rigour ;  his limbs were weak,
 and he had pain at the back of the head, and occasional confusion
 of thought.  On striking the upper dorsal vertebrae, an obscure and
 deep-seated  pain was felt in  the  part.  He  has now for several
 weeks been entirely free from symptoms, (August 17.)  He has re-
 mained in the hospital; been cupped upon  the back, had issues
 applied over the part which  was struck; and for six weeks the
 mouth was kept slightly affected with mercury.
   b.  Simple pressure or  division of the spinal  cord above the
 origin of the phrenic nerves, is  instantaneously fatal.  The lower
 the injury, the longer is the period  the patient may survive,  and
 the greater the small probability of ultimate recovery, [k.  15.]
   When the spinal marrow is cut across,—as by a musket ball, or
 lance, or sabre wound, at or below the lowest cervical  vertebrae,—
 or is  torn in fracture of the vertebrae, the patient may live from two,
 three, or four days, to several weeks:  if the  injury is at the lower
 part of the back, it is possible that  he may recover, but with  per-
 manent paraplegia.   The fatal turn of such a case is  marked by
 the lining membrane of the  bladder  becoming inflamed and se-
 creting a  thick ropy mucus, which imparts a strong ammoniacal
 quality to the urine: this change is followed  in a few  days by the
 patient's death.
   Inflammation of  the bladder is liable to occur in any form of
 paraplegia.
   Pressure upon the spinal marrow operates in two  ways:  one
 resembles the effect of a  ligature, or any strong compression made
 upon  a nerve.  It is probable that pressure of this kind made upon
 the spinal cord by fracture and depression of  the  bony arches of
 the vertebrae, would sometimes admit of being relieved by an ope-
 ration analogous to trephining.  But it is no  less  probable, that  if
 the injury in such a case is so great as to require the operation, it
 is likewise too great to be relieved by it. The other mode in which
 pressure operates is less  explicable ; there must be some additional
 element besides pressure to concur in producing the effect.
   A woman, aged forty-eight, was attacked, twelve years ago. with
 pain and weakness  in the middle of the back.   There were no pa-
 raplegic symptoniS, but the spinous processes  of three of the dorsal
 vertebrae became prominent backwards.  She was received into St.
 George's Hospital, and was kept in bed a year,  with issues to the
 side  of the projecting spinous processes.   She recovered.   Six
 months ago, this patient having enjoyed good  health in  the interval
 was  gradually attacked with paraplegia: after a  few weeks there
was total loss of voluntary power in the legs and thighs, and numb-
 ness from the loins  downwards.   This was unattended with  pain
of the part of the back before diseased. Nevertheless, it was  thought
right to apply caustic issues on either side of the projecting spinous
processes, and she was kept perfectly still.   A little fever gradually
supervened : the belly was hard and  obstinately costive ; the urine
was passed involuntarily; the thighs were frequently drawn spas- 
122
MAYO's OUTLINES OP PATHOLOGY.
  modically to the belly, the knees  being at the same time strongly
  bent.   She sank rapidly.
    On examining the body, the spinal  marrow and its  membranes
  were found free from disease;  but there existed in front of three of
  the dorsal vertebrae a thick sac, covered by the pleura, which con-
  tained about two ounces of what  I suppose was inspissated pus : it
  had the appearance and consistence of putty.  This  rested upon
  the anterior surfaces of the bodies of the vertebrae, which, with the
  intervertebral substance, had been partially absorbed in the former
  attack, but now were remarkably  hard  and firm, and their surfaces
  covered with strong fibrinous membrane.  There was nothing in-
  dicative of recent disease.
    The preceding case, with so  little  apparently to produce  the
  symptoms that attended it, may be  contrasted with the following,
  which exemplifies the opposite extreme.
    Renee Aleyon, aetat.  thirty-eight,  had experienced,  for a long
  period, pain at the upper and back part of the neck : any motion,—
  that of swallowing, or even breathing,—increased it.  The neck
  became drawn backwards, and fixed by the instinctive action of its
  muscles.   She  died  gradually of  phthisis, the cough attending
  which added to her suffering.  Some little difficulty of swallowing
  and of breathing she had experienced, but no palsy or anaesthesia.
    On inspection, the odontoid  process and the transverse  ligament
  were found to have perished by caries and ulceration.   A displace-
  ment forwards of the  atlas upon  the dentata had  taken  place to
 such an extent, that the articular surfaces of the latter were covered
 on their anterior half only by those of the atlas.— Ollivier.
   c.  Inflammation of the  substance of the cord.—A  gentleman,
 who was liable to epilepsy, complained*of uneasiness ofthe throat'
 with difficulty of swallowing,  accompanied by acute pain in the
 neck and occiput,  followed  by fever, embarrassed  breathing, and
 vomiting;  he  then was  seized with  numbness  of the  left  hand
 which  speedily extended up the arm:  the right  was immediately
 atter affected in the same manner;  and  on the following day they
 were both paralytic.  The  legs were not in  the least  affected, nor
 the functions of the bladder or the bowels.  He died on the eighth
 day, having preserved  his intellects to the last.               b
   Inspection.—There was extensive softening of the upper part of
 the cord, chiefly of the gray matter, which was of a  rose colour
 with a highly vascular state ofthe  membranes. - Ollivier
   In another case, with extensive softening at the  upper'partof the
 cervica  portion, extending  nearly through the whole thickness of
 the cord, there  was palsy of all the limbs—Ollivier
   In  a case described  by Dr. Abercrombie, the process  of the dis-
 ease was slow,  and lasted from  October  to the  July following • the
 symptoms being coldnessand numbnessof the feet, with diminished
 power of motion: after several  weeks, complete palsy of  the leg,
and,nab..ty to empty the bladder; tightness across the  abdomen'
spasms like opisthotonos.  In the intermediate April, some amend- 
THE SPINAL CORD.                   123
 wient occurred, with the power of moving the legs when supported
 by crutches.   Two days before death, the right arm became  para-
 lytic, and his speech impaired.  The loss of sensation was never
 complete.
   Inspection.—The whole cord was of a pale rose colour, and was
 in every part entirely diffluent.  The medulla oblongata was soft-
 ened on its anterior part, as well  as the adjacent portion of the
 annular protuberance.
   A young soldier,  after  recovering  from a petechial fever,  was
 affected with pain in the  back, difficulty of moving the legs, reten-
 tion  of urine, involuntary discharge of  faeces.   The weakness of
 the  legs increased to perfect palsy, in which the  upper extremities
 were shortly  after  involved: he then lost his speech;  and after
 lying a fortnight in  this state, but in  possession of his intellects, he
 died suddenly.  At the lower  part of the  back  the cord  was in a
 state of suppuration, dissolved, and disorganised.—Brera.
   A woman, aetat.  fifty-six, was seized with loss of power of the
 limbs of the  left side, without  anaesthesia: voice feeble ; speech
 embarrassed;  pulse natural; respiration frequent. Death in a week
 from the seizure.
   Inspection.—The brain sound, but the  pia mater injected.  In
 the  centre  of  the right half of the cervical portion of the. spinal
 cord there  was a cavity, three inches long, by two or three inches
 in diameter, full of soft matter like pus;  this became more consist-
 ent towards the parietes ofthe cavity, which were about a line and
 a half in thickness, and  formed  by the healthy white matter.  In
 the  left column of the same  portion of the cord  there was a like
 disease, but less extensive, being about one inch long, and one line
 in diameter:   its  contents  were less purulent, rather resembling
 softening ofthe cord.   The membranes ofthe cord  were thickened
 at this part.— Velpeau.
   It  is difficult to preserve, in preparation, the appearance of soft-
 ening of the spinal  marrow.   In [k. 20.]  it is seen in combination
 with deposit of cartilaginous flakes in the pia mater.
   The additional features of  inflammation  of the  spinal marrow
 are, contraction of the  limbs, (either tonic or clonic,) sensation re-
 maining,—or  with palsy, the  sensibility heightened (hypertrophy
 ofthe posterior fasciculi ofthe spinal nerves being sometimes added,)
 —the extent and character of the symptoms being dependent on
 the part of  the cord attacked, and on the limitation  of the changes
 to one half,  and either to the anterior or posterior fasciculi.
   Portal describes the case of the Marquis de Causan, in whom, in
 the space of a  year,  a gradual palsy of the left side commencing in
 a prickling of the fingers, had supervened.  Palsy of the right side
 gradually followed;  sight, hearing, speech, deglutition, in  succes-
 sion  failed.   On dissection, the cervical part of the spinal  cord was
 found to  be as hard as cartilage, and its membranes were red, as
 if inflamed.
   d.  Inflammation of the membranes of the cord.—A gentleman,
aetat.  twenty-six, had been liable for  several years  to suppuration 
124            MAYO'S OUTLINES OP PATHOLOGY.

from the right ear, with occasional severe headachs, which were
temporarily followed  by a considerable  increase of the  discharge.
The first week in April, 1817, he  became ill, with  headach,  dis-
turbed sleep, loss of appetite,  but little or  no increase of pulse.
About  the 7th, the pain left the head,  and attacked the neck; it
gradually moved down the spine, at the lower part of which, after
several days, it became fixed, being more severe at  this part than it
had before  been when  occupying the upper part of the neck,  and
extended round the crests of the ilia, with great uneasiness of the
belly,  and  pain  and difficulty in passing the urine.  On the 15th,
great increase of suffering, under which the patient  was continually
walking about, grasping the lower part of the back  with  his hands;
repeated rigours.   On  the 17th, convulsive  twitches,of the face;
difficulty of swallowing; squinting, not permanent; pulse from  120
to 130. After bleeding from the arm,  he appeared relieved,  and
lay down in bed; he soon rose, and became delirious and unman-
ageable; then threw his head  back, fell into a state of  coma,  and
died in two hours.
  Inspection.—Brain healthy; gelatinous deposit  under  the  me-
dulla  oblongata;  the spinal  cord  covered  with  purulent matter
which lay betwixt it and its membranes—the matter most abundant
near the foramen magnum; substance  of the cord itself soft,  and
in some places much divided into filaments.—Abercrombie.
  The preceding case is valuable from the general absence of
symptoms, which  are thus shown to be in some sort accidental to
the inflammation.
  The symptoms commonly present are—strong  extension or in-
curvation  backwards of the spine, with retraction  of the head, the
spasm  sometimes  extending to the  limbs; pain in the back, some-
times  a prominent feature, sometimes developed on motion only;
pain and difficulty in passing the urine:  paraplegia  is an  occasional,
but by no means a common attendant, [k. 30.]
  A child, between three and four years of  age, died with symp-
toms of opisthotonis, difficult deglutition, and a coma.   There  was
found, on  the post-mortem inspection,  a deposition of a red  and
very consistent fluid in  the cellular texture, between the  dura mater
of the cord  and the  canal  of the vertebrae in- the dorsal region;
serum within the membranes;  and the arachnoid of the  cord
covered with albuminous secretion for four inches.— Ollivier.
  The following  case, which  presents some unusual  features,  I
suppose to  have  been  threatening inflammatory  affection of the
cord or its membranes.
   Mrs. H.  B., aetat. thirty-four, married, mother  of three  children,
while suckling the second, more than two. years ago, first  observed
a quivering in  the flesh of the right fore-linger, which came  and
went: after two or three months the left  hand  was similarly affected.
Not many weeks after  the first attack, the hands would  swell  then
become numb, with a gnawing pain extending to the elbows: these
attacks lasted for several hours.  In one seizure, the hands were in 
THE SPINAL CORD.
125
addition spasmodically contracted, being bent backwards at  the
wrists, and the  fingers stiffened and drawn together.  In April,
1834, two or three days after menstruation, the pain and all sud-
denly and entirely went away; she did  not at the time conjecture
that she  had then become pregnant: but she did not again men-
struate, and was confined exactly nine  calendar months from the
termination of the  period which  was followed by her  temporary
recovery.  A week after confinement, now suckling her  infant, she
observed the quivering in  the hand recommence.
   A few weeks  later [March 21st] I was asked by Mr. Angus, of
Greek street, to  see this patient.   The  disorder had extended its
sphere.  The  muscles of the  great toe  on  each  foot had fits of
quivering,  sometimes  attended with pain, like those of the thumb
and fore~-fingers; the quivering, however, occurred occasionally in
the feet  only, and equally in both;  but  was constant in  the hands,
and worse  in  the  right:  the cheeks, eyelids, and tongue,  at times,
to use her own expression, were likewise "on the work."  She was
otherwise in perfect health; yet had experienced,  in addition to
these slighter  symptoms,  one attack of spasm of the hands only
slighter  than  before.  The  spasm and pain displayed  different
features in  the upper and lower extremities.   In the lower, the pain
and sensations and action seemed to strike from the toe upwards to
the knee, where the effect became most feeble, and ceased: so for-
merly had  it been with the arms:  but  when the pain in the arms
had by slow  degrees  extended to the elbows  and then to  the
shoulders, and afterwards to the neck, in its subsequent attacks, it
seemed to  stretch downwards from the neck, as if  it sprang from
thence.  Upon  examining the cervical  vertebrae, some deep-seated
 tenderness was discoveredabout the fourth cervical spinous process.
 An issue was made  to one side of this spinous  process. It.was
 likewise thought advisable to give mercury.  The effect of the
 two remedies has been greatly to relieve this patient: her amend-
 ment  has  not, indeed, been uniform; one attack  of violent spasm
of the arms, preceded by shivering, occurred a few days after the
 application ofthe  issue, which Mr. Anaus relieved by bleeding, and
 administering a purgative enema; but, with this and  one or two
 lesser interruptions, the state of the patient has been bettering, and
 continues  to improve to the present time.   The pain in the feet is
 gone, but  slight numbness  is felt occasionally: there is no pain in
 the hands, and much less quivering, and longer intervals of perfect
 health.  The mercury was given in the expectation, that, as preg-
 nane had diverted the complaint, another general alteration of the
 state'of the frame, and derivation of blood to new channels, might
 produce a  like result.                             .    ,
    This  report of  the case goes to May  23.   The patient  has now,
 \ucrnst  18, no symptom remaining,  except occasional painless
 working of the  muscles of the right thumb, which comes on when
 she has°over exerted herself, or been worried.             .
    Serous  effusion in the spinal  canal.-The observations of 
126            MAYO's OUTLINES OF PATHOLOGY.
Magendie have taught pathologists, that a sensible quantify of serum
exists in the space between the arachnoid and pia mater ofthe cord
in health.  An increased secretion of this fluid is not a common
form  of disorder.   The  following cases,  however, may serve to
exemplify it.
  A man, aged forty, was affected with acute pain and weight in
the lower dorsal vertebrae, the pain occasionally extending upwards
or downwards to the top and bottom of the spine.  After eleven
days, he was seized with palsy of the right lower extremity; and,
in three days more,  with retention of urine.  The pain was now so
acute as  to prevent him from lying  down; and  was soon  after
accompanied  by dyspnoea, vomiting, and tonic convulsions of the
trunk and arms,  which recurred at  intervals, and continued for
about fifteen minutes.  The left inferior  extremity  then became
paralytic, and he died  suddenly.  His intellectual  faculties had
continued entire, except during the paroxysms of convulsion.  On
inspection, much fluid was found in the cavity of the spine, but the
cord was sound:  there was also  fluid on the surface of the brain,
but none in the ventricles.—Morgagni.
  A child, aetat. twelve months, after appearing to be in much pain,
lost the  use of the inferior extremities, and died in three days.  The
spinal canal was found full  of bloody serum.—Chevalier.
  Spindl apoplexy, or hemorrhage ofthe spinal m,arrow.—A man
received a violent blow on  the three inferior lumbar vertebrae from
a log of wood which fell upon him.  He died in four hours.  Ex-
travasated  blood was found in the spinal  canal, but the vertebras
were entire, and the cord was healthy.—Morgagni.
  A lady, aetat. forty, had headach and pain of the back.  After a
few days, the pain of the back became very acute, and violent con-
vulsions took place, which  were fatal after continuing five or six
hours.  All was sound in the brain; but extensive extravasation of
blood was found  in the  spinal canal,  which was most abundant
about the seat of pain.—Ollivier.
  A gentleman, aetat. sixty-one,  had just arrived in Paris from a
long journey, when he  complained of pain  of his back, extending
from the cervical vertebrae  to the sacrum.  After  a few hours, he
was seized with  paraplegia and incontinence  of urine, and  fever;
and he  died while the physician  was talking to him, who had been
sent for on the occurrence of the palsy.  There was extensive ex-
travasation of blood  in the spinal canal, under the membranes of
the cord.  At the lower part it formed a rhass like  a bouillie of
bullock's  blood, in which the substance of the cord could not be
distinguished as  far as  the  third dorsal vertebra;  and above this,
where the cord was entire, it was of a deep colour, and verv soft.
   Of deposits between  the  membranes of the cord.__These con-
sist of small thin flakes of cartilage, or phosphate of lime, which form
in the  cellular membrane  between the arachnoid and pia  mater.
[k. 40.]   They are often met with where no symptom  of  spinal
disorder has occurred.   They are likewise occasionally met with 
THE SPINAL CORD.
127
 in combination with the most severe symptoms.   To this subject
 I shall  presently recur: in the mean time, let me give an instance
 of this  deposit complicated with a growth of another kind in the
 same situation.
   Velpeau relates the  case of a woman, aged thirty-six, who had
 first some convulsive motions, which soon ceased; then acute pain
 of the left arm, with  headach: the arm became weak,  and gradu-
 ally completely paralytic.  She then had convulsive motions ofthe
 lower extremities, which also became completely paralytic.  The
 right arm next became painful, and the motion of it wal impaired,
 but  not entirely lost.   The  inferior extremities became cedema-
 tous; the inferior half  of the thorax, and all the parts below, were
 completely deprived of sense and motion ;  and the right  arm at last
 became entirely paralytic.  Sloughing of the integuments of the
 sacrum then took place, and death ensued at rather more than three
 months from the commencement of the paralysis.
   On inspection, there was found between the body ofthe cord and
 the arachnoid a tumour of a reddish-yellow colour;  it was about
 three lines in thickness at the thickest part, and covered the ante-
 rior  surface of the cord, from the sixth cervical nerve to the third
 dorsal;  the cord  was  flattened by it.  The tumour was of a firm
 fleshy consistence, and of  a yellowish-white colour.  On many
 parts of the  arachnoid  of the cord, cartilaginous  scales were
 observed.
   Tumours exterior to  the the theca.—There are three preparations
 in the King's  College museum of tumours external to, and pressing
 on, the theca.  In two of these the morbid deposit looks like tuber-
 culous matter;  is oblong, about two inches in length, half an inch
 in breadth, and a quarter of an inch in thickness,   [k. 45.  k. 46.]
 In the third,  the tumour is somewhat longer,  of a white  colour,
 and  half an inch in thickness: it was situated at the upper part of
 the  back; the  spinal cord, otherwise healthy, is narrowed at this
 part. [k. 47.]  In  each of the  three cases, there  was  more  or less
 complete paraplegia.
   An interesting case, in which the presence of a fatty  tumour in
 the vertebral canal  had caused the entire  absorption of  an inch of
 the cord, leaving the membranes only, is given by Mr. Robarts, in
 the Medical Gazette for  March 22, 1834.
   The fatty tumour lay beneath  the bony rings of  the  tenth,
 eleventh, and  twelfth dorsal vertebrae, was about the tlfickness of
 the middle finger, and between two and three inches in length.
   Aneurism of the aorta is liable, after producing  partial absorp-
 tion  of the vertebral column, to press as an external tumour upon
 the theca.   Dr. Abercrombie  describes a  case something of this
 description, in  which  the arms, for a short period before  death,
 were entirely deprived  both of motion and feeling, the head and
 legs  being in  constant  motion.  There is  in this case  a want of
agreement between the  part of the spinal marrow softened from
• 
128
MAYO'S OUTLINES OF PATHOLOGY.
 inflammation, excited by the carious vertebra, and the parts affected
 with palsy.
    Malignant disease of the spinal cord.—A youth, aged fourteen,
 fell from a window in the second story of a house into the street;
 his back was bruised,  but without fracture; but he afterwards con-
 tinued to  walk with  his body  bent forwards.  After three years
 and a half, he was seized with violent pain in the back, thighs, and
 legs;  and  a  tumour began to form on the lumbar vertebrae, which
 increased gradually, till  it  attained to a very great size.   The pro-
 minent part of it was red; and repeated attacks of hemorrhage took
 place  from the  apex of the tumour.   He  was then affected with
 complete paraplegia, incontinence of urine and faeces, and extreme
 emaciation;  and at length died, gradually exhausted, about six
 years  from the accident.  On dissection, the tumour was found to
 consist of a large fungous mass, resembling the medullary substance
 of the  brain, which  took its origin fronTthe spinal cord, and had
 extended itself upwards and downwards from the third dorsal ver-
 tebra to the coccygis.  Many of the vertebrae, both dorsal and lum-
 bar, were extensively  carious on the posterior part;  and some  of
 the lumbar vertebrae had nearly disappeared.—New  London Medi-
 cal Journal,  1792.
   Having thus given  an outline of the principal affections which
 can be brought home to the spinal cord, either through mechanical
 injury having fallen  there, or alteration of structure being found in
 it, I shall briefly advert to other cases, in which the whole evidence
 of their dependence  on the spinal marrow consists in the character
 of the previous symptoms.
   1. It sometimes happens, that symptoms, and indeed a whole
 course of disorder and death, take  place, closely resembling those
 which  commonly flow from organic lesion, and yet no organic
 lesion  can be found.  I quote as examples the two following cases
 from Dr. Abercrombie.
   A medical gentleman, aged  thirty, who  had been  for several
 years m the navy, returned home in perfect health, and was livino-
 in  Edinburgh,  when he was observed by his friends to drag his
 legs awkwardly in walking.  He was not himself at first sensible
 of it;  but soon perceived a weakness and want of command over
 both his legs, which gradually increased to nearly perfect paraple-
 gia   Some time after the affection of the legs took place, he began
 to lose the power of his arms: and this also increased till he retained
 in them only a  very feeble  and  unsteady power of motion: thev
 were also frequently seized with  convulsive starlings, so that any
 article which  he  attempted to hold was  thrown from him with
 violence.  The legs  often started in the same manner, and were
 thrown about  with  considerable violence,  especially  when  he
 attempted to  move  them while  he  was sitting  up.  No disease
 could be discovered  in the  bones of the spine* and he was other!
 wise in good health until about two years after the commencement
of the  cemplamt, when he was seized with  phthisis, of which he 
THE SPINAL CORD.
129
died in September 1822.  Dr. Abercrombie examined the body with
the utmost care, and could not discover a vestige of disease either
in the brain or spinal cord.
   A woman, aged thirty-five, was first affected with numbness of
the thumb of the left  hand, which  gradually extended over the
whole  hand and arm.   The limb was thus partially paralytic, and
was likewise affected with involuntary motions, exactly resembling
those of chorea: this continued several weeks, and then gradually
ceased, and the arm recovered its healthy state.  Almost  imme-
diately after this, the right hand and arm were affected in the same
manner, and after some time also got well.  Thl legs then became
affected with starting, involuntary twitches, and a feeling in walk-
ing  as if  they would fly from under her to one side.  The com-
plaint went on  in this manner for some time, and then terminated
in complete paraplegia, with retention of urine, requiring the con-
stant use  of the catheter.  She was  now confined  to bed for nine
months, and died of extensive gangrene of the sacrum and tops of
the thighs.  For some  time before her death she had recovered the
action of the bladder.
   No disease could  be discovered in the brain or spinal cord,  except
that the cauda equina  was  of a very dark colour, as if it had been
soaked in venous blood;  and there was some bloody fluid round it.
   Dr.  Abercrombie gives several parallel cases  to  the preceding,
where  death ensued ; and others, bearing a strong analogy to them,
in which the patients recovered.
   2. In chorea, or St. Vitus's dance, the symptoms are exactly such
as should flow from an affection of the spinal  marrow.  They con-
sist  in jactitations of  the  head  and limbs and trunk, of every
degree of irregularity and violence, from occasional twitches ofthe
features and neck, to such a tumult of motion, that the patient is
lifted off her legs, and  thrown  upon the ground by uncontrollable
muscular  action.  The jactitation is sometimes constant, in other
cases intermittent, but  always aggravated when the patient makes
any voluntary effort.
   A step  is made towards  explaining the phenomena of this dis-
ease, by considering the  spinal marrow (with of course the conti-
nuous  structure ofthe medulla oblongata and  the nerves) as  organs
of sensation, volition, and the simple impulse which connects them,
separately from  the hemispherical masses of the enkephalon; and
by supposing that the  segments in which the nerves originate are
capable of being rendered, by impressions conveyed from the brain,
preternaturally irritable for  a longer or shorter period.  The ordi-
nary jactitation of chorea might then  result from common sensation
telling upon  the irritable points of origin of the voluntary nerves:
as  the extraordinary violence would  come on when the tame seg-
ments  are stimulated doubly, that is, by the impulse to deliberate
action  transmitted from the brain, superadded to  the  stimulus of
ordinary sensation. 
130
MAYO'S OUTLINES OF PATHOLOGY.
   Chorea is commonly produced by fright.  In the following case,
an impression of this kind made upon the mother appears to have
given rise to chorea in a foetus in the womb.
   Mr.  Reid, of Bloomsbury Square, lately showed to me  the fol-
lowing case in the St. Giles's workhouse.  The mother who now
attends her child, stated to me, that, having borne children, she was
in the  fourth month of another pregnancy, when there was thrown
upon her bosom  a frightfully disgusting object.  She was, for two
months, in a state of extreme nervous illness from this cause; but
she  recovered, and went her full  time.  She  remarked,  however,
that the child was  extraordinarily lively  in the womb, so that at
times she was overcome by the  sensations she experienced.  The
ehild, a female, at the instant of its birth, displayed the writhing
motions of chorea:  they have continued  ever  since.  She is now
thirty years of age, yet  looks but an elderly child.  Her  head is
remarkably small  and narrow; she is thin and emaciated; the mind is
hardly removed  from complete idiocy: she says  nothing but an
ill-articulated yes and no, and is continually twining and writhing
herself about, except when asleep.
   3. The nervous system of infants is particularly excitable.  Den-
tition,  fever, abdominal or  cerebral irritation,  perpetually produce
in infants sudden and repeated seizures,  characterised by spasms
of the  hands and  feet,  the  fingers straight,  the thumb  pressed
rigidly against  the palm of the  hand  and fingers;  spasm of the
glottis, characterised  by the crowing inspiration which attends its
departure;  spasmodic tension of the back  and neck;—symptoms, to
discriminate the causes of which is of the greatest practical conse-
quence.  Symptoms of this nature perpetually result from fulness
of the  cerebral vessels,  to  be relieved  only by local detraction of
blood.   On  the other hand, they frequently result from simple irri-
tation  of  the  spinal  marrow and  medulla oblongata, for which
opium  is the appropriate  remedy, as bleeding is destructive.
   4. Several pathologists of  the present  day concur in  viewing
hysteria as a nervous affection, produced indeed in many instances
by uterine causes,—but directly seated in the spinal marrow.  This
view assumes a practical character, when  it classes a proportion of
hysterical attacks as the results of a congestive  state  of portions
of the spinal cord.
   5. It is difficult not to consider tetanus and trismus to be affec-
tions of the spinal cord.   But as in the majority of cases of  these
diseases, no preternatural appearances are met with in the spinal
marrow, the affection, if there seated, must be classed as  nervous.
Tetanus in its acute traumatic form is almost invariably fatal.  I
treated  successfully a case in  a boy, in  which the symptoms super-
vened  rapidly,  and were of the severest  character.  He  began to
mend on the third day of the attack, the  mouth becoming affected
at that period with calomel, which had been profusely administered
for that purpose.  A very philosophical experiment  made by Pro-
fessor  Sewell  on this  disease is  well  worthy of  being recorded. 
THE SPINAL CORD.
131
Viewing the disease in horses as  the  resrflt of  irritation  on the
nervous system, Mr. Sewell conjectured, that if a horse in tetanus
were  destroyed  by a poison which  acts by suppressing nervous
power, and life were then to be restored by artificial respiration, the
nervous system on reanimation taking place, might possibly be free
of the original morbid irritation. Reasoning thus, Mr. Sewell tried
the following singular practice.
   A  horse,  suffering from  a severe  attack of tetanus and locked
jaw, the mouth being too firmly closed to admit the introduction of
either food  or medicine, was  inoculated on the  fleshy part of the
shoulder with an arrow-point coated with the wourali poison.  In
ten minutes apparent death was produced.  Artificial respiration
was immediatly commenced, and  kept up about four hours,  when
reanimation took place: the animal  rose up, apparently perfectly
recovered, and eagerly partook of corn and hay.  He was unluckily
too abundantly supplied with  food during  the night.  The conse-
quence was over distension of the stomach, of which the animal
died  the following day, without, however,  having the slightest re-
currence of tetanic symptoms.
   6.  The symptoms of hydrophobia, place this formidable disease
likewise among  affections of the nervous system.   Cases of hydro-
phobia are luckily so rare, and unluckily so seldom treated by sur-
geons prepared with a well-weighed  plan to try upon them, that no
progress has been made towards a  theory of its treatment.  Morbid
anatomy exhibits in this disease a  great variety of inflammatory or
congestive  action.   The mucous membrane of the trachea and
bronchi is uniformly inflamed; that of the oesophagus and stomach,
 variably and  capriciously; congestive patches and actual ecchy-
 mosis are met with sometimes on  the lungs, sometimes beneath the
 peritoneum, sometimes  on the  medulla oblongata. Viewing the
 disease as a specific irritation of the medulla oblongata and  spinal
 marrow, produced  by inoculation  with a morbid  poison,  I would
 try in human  beings  in  whom  the  hydrophobic symptoms had
 appeared the  following remedies.
   a.  The removal of the cicatrix.  In one case, which I witnessed
 and -examined after death, the inner part of the cicatrix  was blood-
 shot, and a gland  in the axilla had swelled at the coming on  of the
 hydrophobic symptoms.
   b.  A free opening  into  the larynx.  The painful character  of
 the disease, and the rapid exhaustion which attends it, appear  to
 depend  in  great part upon fits of spasm and closure of the glottis
 brought on, not merely by the attempt or idea of drinking, but by
 any  sudden impression upon the senses.  Now it is clear, that, as
 far as the  distressing  feelings in the throat  consist in a sense of
 suffocation, they would be put an end to, or relieved, by the estab-
 lishment of a free opening in  the windpipe.
    c.  The administration of narcotics in conjunction with the two
 preceding remedies.
    In rabid dogs, the experiment  of injecting water into the veins, 
132            MAYO'S OUTLINES OF PATHOLOGY.
either pure, or with some neutral  salt and narcotic drug mingled
with it, deserves repetition.   And  it would certainly be highly in-
teresting to  try upon any animal affected with this disease the re-
markable experiment made by Mr. Sewell upon horses in tetanus.
   CHAPTER VII.

OF THE ENKEPHALON.
   The enkephalon is divided into three parts;—the medulla oblon-
 gata, the cerebellum, the cerebrum.
   The medulla oblongata, by which  is commonly meant the  part
 which intervenes  between the spinal marrow and the annular pro-
 tuberance, has  three offices.  First, it is a channel of communica-
 tion  between  the spinal marrow  and  the brain;   Secondly,  it
 originates nerves in the same manner as the spinal cord;  Thirdly,
 it  is the vital centre of the whole system, and the immediate  link
 between  consciousness, and our bodily frame.  When any part of
 the brain above, or of the cord  below, is separated  from this organ,
 the function of the separated part is obliterated.  The removal of
 portions of the nervous system above and below this organ leaves
the animal still in possession of partial consciousness, sensation and
volition temporarily persisting in it, and in the parts  supplied with
nerves from it.  On the other hand, all the rest of  the frame being
entire, the mutilation  of the medulla oblongata at the origin ofthe
eighth pair of nerves, produces total extinction of consciousness.
  The use of  the cerebellum is  unknown, except conjecturally;
but there can  be little doubt that it is the material organ of some
important mental affections.
  The use of the cerebrum is equally a matter of  conjecture with
that ofthe cerebellum.  The former is a more complex organ than
the latter; for  it comprehends,  in addition to parts comparable to
the entire cerebellum, in the tubercles, corpora striata, and  gray
matter ofthe crura, a continuation of parts resembling the segments
of the cord which give origin to nerves in the parts below
                          SECTION I.

           Pathological Anatomy of the Enkephalon.

  The textures, of which  the  morbid alterations  are now to  ba
considered, are—1, the cerebral  tissue, including both the medul- 
THE ENKEPHALON.
133
lary and cineritious substances of the enkephalon; 2, the pia mater;
3, the  arachnoid membrane;  4, the dura mater.   In speaking of
the pia mater  separately from the brain and spinal marrow, the ex-
ternal  layer only of that membrane is referred to.  The innumer-
able productions from it, which, entering the cerebral substance, form
sheaths to all  the nervous fasciculi, cannot be considered apart from
the cerebral substance itself; nor would it even  be proper to treat
as a separate subject  the external  layer of the pia mater,  but that
this  portion of the membrane is at particular parts gathered into
detached folds, or reduplicatures, which contain  in them  no cere-
bral substance, and that elsewhere the free surface of the pia mater
constitutes the organ of a special secretion.
   1.  Of the cerebral tissue.
   a.  The cerebral  tissue,  from its softness, is  easily injured:  it
possesses considerable powers of reparation.
   The braiu and spinal marrow may be  bruised, without fracture
of the bony chamber  in which they are lodged:  concussion alone
will produce  this effect.   The cerebral  tissue, if  examined after a
recent bruise, appears bloodshot with spots of extravasation, result-
ing from rupture of the small vessels.  [/. 10.]   Under favourable
circumstances,  the' bruised cerebral substance  may recover itself,
the blood effused becoming absorbed.  A more severe concussion
causes either  rupture of the larger vessels, with considerable extra-
vasation of blood, or  complete disorganisation  of the bruised part,
 which appears, when examined, like a mixture of blood and brain.
 The last cases are necessarily fatal: but it will be seen, that when
blood has been effused from the giving way of a  vessel (within the
cerebrum and  cerebellum at least,) without external violence, the
 parts  have a power of self-restoration.
   A  different instance of cerebral restoration  occurs after hernia
 cerebri.  [1.  35.]   When  the extruded part  has  separated, and
 healthy action supervenes, the  exposed  surface becomes covered
 with  granulations, resembling those which form on  other tissues,
 which coalesce with the granulations ofthe dura  mater and integu-
 ments, to form a cicatrix.
   b.   When a considerable vessel gives  way within or  upon the
 cerebral substance, blood is freely poured  out.   It may escape upon
 the external surface, or into the ventricles, or into the cerebral sub-
 stance.   The two former  cases are necessarily  fatal; the third is
 not so.   Blood effused into the substance of the  brain is  generally
 collected into an irregularly round mass, varying from the size of a
 pea to that of a hen's egg, or orange.1   It is either of dark red, or
 almost black; coagulated wholly or in part. [1. 20.]  The cerebral
 substance in contact with the clot is always more or less ragged,
 and portions of it are sometimes broken down and  mixed with this

   1 In  this account of cerebral hemorrhage, and afterwards in that of soft-
 ening, I have principally followed Dr. Carsvvell, with whose beautiful fasci-
 culi on Morbid Anatomy the reader is or ought to be familiar.
        19—f                                    10 may 
 134           MAYO'S OUTLINES OF PATHOLOGY.

 fluid.  The lacerated cerebral substance forming the walls of the
 excavation which contains  the blood  presents a number of dark
 points, or dots, of coagulated blood,  many of which  indicate  the
 orifices of ruptured vessels.
   The blood which has been effused gradually changes in colour:
 the red deepens till it amounts to black: the colour then successively
 passes to brown, dull green, orange, pale yellow, or yellowish white.
 When the latter changes of colour have taken place, and the fibrin,
 separated from the other constituents of the blood, has assumed a
 fibrous laminated appearance, blood-vessels are observed to form in
 it.  The subsequent  changes are of two kinds: the structure may
 either retain for  a  long time its  primitive arrangement,—that of
 fibrin,—and afterwards become converted into a firm fibrous tissue,
 which, gradually diminishing in bulk, is at last reduced to a small,
 circumscribed, thin portion, which constitutes  the  cicatrix of  the
 original lesion of the brain; or the  organised  fibrinous substance
 may be converted into  a loose cellular tissue, filled with a serous
 fluid, and is generally traversed by a considerable number of blood-
 vessels.  As the quantity of the serous fluid increases, that of  the
 cellular tissue diminishes, as well as the number and size of  the
 blood-vessels with which it was before  provided.  In this manner
 a  cavity of considerable extent is formed, filled with serum of a
 citron colour, and bounded by the  remaining cellular tissue in con-
 tact with the substance of the brain. [I. 21.]  It is this portion of
 the cellular tissue which appears to be transformed into the yellow-
 ish serous  membrane, which  afterwards lines the entire surface of
 the cavity, and which converts it into  the apoplectic serous cyst.
 [/. 22.]   The obliteration of this cyst is  the  next circumstance
which takes  place in the progress of cure.  This is accomplished
by the gradual removal of the serum contained in the  cyst, and
the consequent approximation of its walls, which become united,
 and form a cicatrix.  Lastly, the cicatrix itself, whether formed in
this manner or in the manner previously described, disappears; such
 at least seems to have happened in cases of paralysis from extrava-
 sation, which have undergone a complete cure.
   c. The quantity of blood in the brain, or  its degree of vascularity
under different circumstances, has peculiar interest upon  two ac-
 counts.   As  many of the gravest cerebral symptoms sometimes
occur without any evident organic lesion, physicians are accustomed
 to suppose, that they result from  an altered state of the cerebral
 circulation.   On  the other  hand, there  is  this peculiarity in  the
 condition of the brain, enclosed as it is in a hollow sphere of bone,
 that the  quantity of blood in it does not admit of the same facile
alteration as in  parts which are  not thus encased.  Dr. Kellie of
Leith, made some interesting experiments, to show that the healthy
 brain cannot be drained of blood.   In  animals bled to death  the
 cerebral  blood-vessels remained well filled.   In one  the sinuses
were  loaded with dark blood, and the vessels of the pia mater were
delicately filled with florid  blood.   In  another,  the sinuses were 
THE ENKEPHALON.
135
loaded with blood, the veins of the pia mater were well filled, and
the choroid plexus was remarkably turgid.  The converse facts [or
that the healthy brain cannot  be made  to hold more blood] were
made  out  in  observations  by  Dr. Monro  and  Mr. Kellie con-
jointly, upon the  brains of two men who had  been hanged.   On
dividing the scalp in these cases, the blood flowed in such quanti-
ties as  to afford ample proof of the congestion of the vessels exte-
rior to the cranium;  but no  turgescence was observed in the brain.
The sinuses contained blood, but in no extraordinary quantity ;  the
larger  vessels on the surface, and betwixt  the  convolutions, were
but moderately  filled; and  the pia mater was, upon  the whole,
paler and less vascular than we often find it in ordinary cases.
   The facts which have been thus quoted exemplify what is cer-
tain a priori—that as the cranium is  unyielding, if the brain  re-
main  unchanged,  the pressure of the atmosphere  upon the Eoft
parts of the body will always  keep within  the  cranium the  same
quantity of blood,  and allow neither its  increase nor diminution.
So an  alteration  of the quantity of blood  in the  brain can never be
a simple phenomenon.
   There cannot be less blood in the vessels, unless the area ofthe
cranium is  partially occupied by some substance  not there before.
Accordingly, in  some examples given by  Dr. Kellie  in his experi-
ments, in  which the vessels of the brain contained sensibly less
blood than in the other cases, serous effusion was found.  Extra-
vasated blood,  a tumour, the skull  driven in, or  cerebral hypertro-
phy, answer the same purpose as effusion of serum, and allow  the
brain to hold less blood in its vessels. There cannot again be more
blood than before, unless the mass of cerebral substance is through
some cause diminished.
   But  although  alteration of the quantity of blood in the brain is
necessarily a compound phenomenon, it is not so with the relative
proportions of arterial and venous blood.   When the circulation is
loaded, the brain may be gorged with venous  blood, and  arterial
blood find no entrance in adequate quantity; and thence stupor may
supervene: on the other hand, when the system is  drained of blood,
the arterial flow  upon the head  may be in excess from the want of
venous distension to  retard it; and giddiness,  tinnitus aurium, and
violent throbbing in the head, may ensue  from this cause.
   d. Hypertrophy.—The cerebral substance is susceptible of hy-
pertrophy.   The following  instance, which I quote from Andral,
describes the appearance of the brain when in this state.  The age
ofthe patient at his death was twenty-nine.   On opening the head,
the membranes did not  present any unusual  appearance;  but  the
character of the upper surface of the brain was strikingly peculiar:
the intervals between the convolutions had disappeared; there was
no fluid between the arachnoid and pia  mater, nor in the ventricles.
Upon  a section, the brain  appeared bloodless: it was singularly
firm, having the  consistence and elasticity of white of egg:  the
cineritious substance of the convolutions, and ofthe striated bodies 
136
MAYO'S OUTLINES OF PATHOLOGY.
and thalami, had lost its  natural colour, so as to be distinguishable
with difficulty from the medullary  substance.   The convolutions
at the base of the brain, the cerebellum, and the annular protuber-
ance, presented a healthy appearance.
  e.  Atrophy.—The cerebral substance is liable to atrophy.   This
is shown  by diminution  of the brain in size and  weight, without
further alteration.   To the same head should probably be referred
the white softening originally described by Rostan, and found in
connection with disease ofthe arteries ofthe brain, and obliteration
or obstruction of their channels.   The softened condition in this
instance (when not resulting from inflammation) is most likely to
be produced by partial absorption, and to be analogous to the thin
and pale and wasted state of the flesh  ofthe  heart, which occasion-
ally attends ossification of the coronary vessels.
  /  Inflammation of the cerebral substance.—The universal effect
of acute inflammation is to diminish the consistence of parts.  This
effect is primarily  produced by effusion of serum from  the capilla-
ries ; afterwards the deficient nutrition of the inflamed part contri-
butes to deprive its elements of their natural cohesion.
  The effects of inflammation upon  this tissue are the following:—
The degree of softening of the cerebral  substance from  this  cause
may vary, from a slight diminution  of the natural consistence of
the part affected, to that of cream or milk.   The first stage of the
softening is often so slight as to be hardly perceptible to the touch,
so that even when considerable, if not accompanied by some  pecu-
liarity of colour, it may be easily overlooked.   A gentle stream of
water allowed to fall upon suspected  surfaces of the cerebral sub-
stance, is the best means  of ascertaining whether a portion of  it has
undergone a diminution  of  its  natural  consistence.   As yet the
cerebral  substance is not broken down ; it has  only lost a certain
degree of its cohesion : it  is still continuous with the firm substance
by which it is surrounded.  In the second stage, the diminution of
consistence is so great as to be  recognised at first sight.  Upon a
section being made through it, the softened  substance  sinks  by its
own weight beneath the  level of the rest of  the cut surface;  while
parts that  are  naturally  prominent, such as the thalami, corpora
striata, and  convolutions, being involved in the softening, are sen-
sibly flattened.  In the  third stage,  a  solution of continuity has
been effected by the separation and partial removal  of the soft-
ened cerebral  substance.   The dissolved texture, now of the con-
sistence of cream or milk, is contained in an excavation of variable
extent, situated in  the substance oft the brain, or confined between
the membranes and convolutions of this organ.   The colour  ofthe
softened part is liable to be  modified by an admixture either of
blood or pus ;  and its consistence, at the same stage ofthe disease,
by the greater or less proportion of membrane  which remains un-
dissolved in the softened  cerebral substance.  [/.  30.]
  The nervous matter adjoining the softened part presents  traces
of increased vascularity, often  in  a very high  degree;  it is occa- 
THE ENKEPHALON.
137
sionally found hardened at different points.   Abscess in the cere-
bral substance presents every intermediate grade between softening
mixed with matter, matter contained in an irregular cavity of, and
in contact with the nervous substance,  and matter  inclosed  in a
circumscribed membranous cyst. [I. 33.]
  g.  Of Hardening.—It  has been  already mentioned, that in the
neighbourhood of a softening of the brain, the inflamed texture is
sometimes, at one or more points, preternaturally hard.  In an in-
stance of hernia cerebri which was  under my care, the cineritious
matter of a portion  of brain, which  protruded and  was removed,
had acquired an almost cartilaginous hardness:  it was of a bluish
gray  colour.   The  medullary matter, though hardened, was less so
than  the cineritious.  Diminution of a part ofthe enkephalon  from
pressure is liable to be attended with hardening.
   h.  Strumous and scirrhous tubercles, melanoma, medullary sar-
coma, and cysts containing gelatinous fluid, form in the cerebral
substance.  [I. 41. I. 42. I. 43.]
   II.  Ofthe Pia Mater.—The external surface of  the pia mater
naturally secretes a certain quantity of transparent  liquid, the use
of which  is to keep up an equal pressure upon all the irregular
surfaces of the brain and  spinal marrow.  Its abnormal increase is
very  frequent: sometimes it may arise from obstruction of the cere-
bral veins ; sometimes, as it is  possible to imagine, from feebleness
of the cerebral circulation; but in general it is the consequence of a
low degree of inflammation.
   Sometimes small lymph tubercles form in vast  numbers upon
the outer surface ofthe pia mater, a consequence of continued sub-
acute inflammation ofthe membrane.
   In a higher  stage of inflammation, the pia mater secretes semi-
opaque or lactescent serum, containing albuminous flakes, purulent
serum, pus.  [I. 46.]  These deposits are more  frequent upon the
surface ofthe brain than  in the ventricles.
   Cysts containing serum are found in  the  pia mater, both ofthe
chorioid plexuses, and on the surface of the brain.
   Flakes of semi-transparent elastic substance, resembling cartilage,
varying in size and number, are found  between the pia mater and
arachnoid.  It is conjectured  that they  are formed in the cellular
tissue, which unites the two membranes.
   Deposits of tuberculous matter, and of white  matter of the same
consistence, are  met with singly, or in  groups—as miliary tuber-
 cles ofthe pia mater. [I. 48.]
   III. Ofthe Arachnoid  Membrane.—Alterations of the arachnoid
 are less frequent than those of the pia mater.  The arachnoid,
 however, is  liable  to  be  inflamed—to  become  slightly thickened
 and opaque—to secrete a  viscid serosity—to secrete pus—to secrete
 lymph [/.  50.] which forms layers of false  membrane that  lor a
 time  remain nearly unattached, but subsequently become organised.
 The  opposed surfaces ofthe two layers of the arachnoid are  liable 
138
MAYO'S OUTLINES OF PATHOLOGY.
to  contract strong partial  adhesions  [I.  51.] malignant growths
occasionally form below the arachnoid.  [I. 52.]
   IV.  Ofthe  Dura Mater.—The dura mater has two important
relations—one to the cranial bones, of which it constitutes the prin-
cipal periosteum:  through this  relation, it becomes the seat of all
those alterations of structure which originate on the superficies of
the  bones.  These changes  have been already  adverted to.  To
follow its  second relation—upon its inner surface the dura mater
adheres to the reflected arachnoid, and rests against  the  soft sub-
stance of  the brain, between the  divisions of which it sends falces
and tentoria.   The habitudes under disease of its  cerebral surface
and productions  are now to be considered.
   The dura mater is susceptible of inflammation.   Blood is some-
times found  effused  between the dura  mater and the arachnoid
lining it, which  that effusion has detached.  Small collections of
pus  have  likewise been found in  the same situation.
   Fibrous tumours, of the size of a nut, and larger, and of a tissue
resembling that  of the dura mater, sometimes grow from  its inner
surface: they  commonly adhere  to it by a narrow pedicle.
   Tumours of  a similar  appearance are occasionally met with,
which contain  deposits of phosphate of lime, constituting osteo-
fibrous tumours. [I. 55.]
  Phosphate of  lime is frequently deposited, in flattened masses,
between the layers ofthe processes ofthe dura mater, especially in
the falx cerebri.  [I. 57.]
  In the vertebral canal, the external surface of the dura mater has
not a periosteal  character.  In  this situation  it is liable to  give
origin  to deposits of the consistence of tuberculous matter, either
white or yellow,  with which melanoma may be mixed.
                          SECTION  II.

                 Classes of Cerebral Affections.

  The disorders of the cerebral functions are so far from bearing
an  exact  relation  to  the structural  lesions which have been de-
scribed, that to convey a true idea of their  character and causes, it
is necessary to give up the  attempt to arrange them upon anatomi-
cal  principles; and to be satisfied with grouping  them in natural
families upon resemblance of symptoms alone ;" examining after-
wards with how various conditions of the brain, each disease may
be associated ; and endeavouring to  trace the connection between
its mental features and the physical condition ofthe organ.
  The heads under which  cerebral affections may  be conveniently
arranged, are apoplexy, palsy, epilepsy, derangement, inflammatory
disease, concussion, compression from injuries. 
THE ENKEPHALON.
139
                       § 1.  Apoplexy.

  Apoplexy is a more or less sudden and permanent oppression of
the mental functions, varying in degree in its mental features from
confusion of thought to complete stupor or coma.  The following
cases may serve to exemplify slight forms of apoplectic seizure.
  A gentleman, fifty years of age, of a full  habit, accustomed to
live  beyond moderation, had been  harassed by business: in the
afternoon while conversing with his lawyer, he  stooped to pick up
a pen that  had fallen ;  when  his senses seemed to leave him, but
he knew that he went on talking: he recovered himself instantly,
and  stood upright; his face was pale ; shortly afterwards it became
strongly flushed.   He took opening  medicine for some days, and
has had no other  symptoms.
  A gentleman, aged seventy-nine, was at dinner and  in conver-
sation  with .his wife, when  he seemed to have some difficulty in
swallowing, and his speech became confused : he recovered a little,
but  became drowsy and disposed to sleep;  the following day he
appeared unable  to collect his  thoughts ;  when attempting to ex-
press himself, he  used one word for another, and in attempting to
find appropriate language, forgot the idea he was striving to ex-
press.  There was slight pain  at the  back  part of the head, the
pulse was rather more frequent than  usual, and  unequal and occa-
sionally intermitting.  The symptoms did not  become worse, but
it was ten days before any amendment began to show itself; and
the recovery has been very gradual.
  A boy mentioned by Zitzilius had drawn his neckcloth remarka-
bly tight, and was whipping his top, stooping and rising alternately,
when after a short time he fell down apoplectic.  The neckcloth
being unloosed, and blood being drawn from the jugular vein, he
speedily  recovered.
  Dr. Abercrombie has powerfully drawn the two severer forms of
pure apoplexy.
  In one form the patient falls down deprived of sense or motion,
and lies like a person in a deep sleep: his face flushed, his breath-
ing stertorous, his pulse full and not frequent, sometimes below the
natural standard.   In this state of profound stupor the patient may
die after  various intervals, from a few minutes to several days ; or
he may  recover  perfectly without any bad consequences of the
attack  remaining.  Such a  seizure may take  place  suddenly, or
after premonitory  confusion  of thought, imperfect articulation and
deglutition, sense  of weight,  fulness, or beating in the head, and of
flashes of light before the eyes.   It may be unattended with  other
symptoms,  or palsy and convulsions may be present in addition.
  In the other,  the disease begins with a sudden attack of  pain in
the head, the  patient becomes giddy, sick, and faint, often with
slight convulsions: the face is pale, the body cold, the pulse feeble.
In a few minutes  he  recovers; but the pain  remains, and after an
interval of  a few minutes to  several  hours, he becomes oppressed, 
140            MAYO'S OUTLINES OF PATHOLOGY.
forgetful, incoherent, and then sinks into coma, from which he never
recovers.  Palsy and convulsions may or may not be present.
  The appearances which are found upon inspection after apo-
plexy, are of three kinds:  a. A  natural  state of the brain; b.
Serous effusion into the ventricles or upon the surface ofthe brain;
c. Rupture of vessels and extravasation of blood.
  a. A man, aged fifty-four, of a plethoric habit and short-necked,
was admitted into the clinical ward of the Edinburgh Infirmary,
under the care  of Dr. Duncan on the 31st of May.  He was in a
state of nearly perfect coma, speechless, and with  palsy of the right
side to such an extent that even the intercostal muscles of that side
did not act.   The leg and  arm of the left side were occasionally
affected with convulsive motions.  Breathing stertorous, deglutition
much impaired, pulse 74.   The affection was of three days' stand-
ing, and  had come on with  vertigo, loss of vision, violent headach,
and vomiting.
  All the usual remedies were employed in the most judicious and
active manner without benefit; on the 1st of June there seemed to
be a slight return of intelligence, but he soon relapsed into coma,
and died on the 3d without any change of symptoms.
  A most minute and careful examination was made of the brain,
without  discovering any  appearance of disease, except that [the
phorioid  plexus seemed rather darker than usual, and the basilar
artery was diseased at one spot.  By the  side of the artery, there
was a spot of the cerebral substance, no larger than a barley-corn,
which appeared  somewhat softened,  but  even  this  Dr. Duncan
considered as extremely doubtful.—Abercrombie.
  b. A gentleman, aged seventy, of a florid complexion, but rather
infirm in his limbs, had suffered repeated attacks  of loss of recollec-
tion, which  were  said by his family to resemble  fainting fits.  At
the commencement of the illness, of which he died, he  fell  down
suddenly deprived of sense and motion.   After  some time  he re-
covered from this state of perfect insensibility, but his speech was
now inarticulate; he had lost the  power of his limbs, and his right
eye was  distorted outward.  He was then confined to bed;  at times
incoherent,  at  other times  more distinct, but always  much op-
pressed,  bordering upon coma;  his speech continued very inarticu-
late, and  his pulse was  generally about 100.  His strength sank
gradually without any particular change in the symptoms;  and he
died at the end of five  weeks.  The  ventricles of the  brain were
found distended with colourless fluid,  and there was a considerable
quantity  under the  arachnoid.  There was no other  morbid ap-
pearance.—Abercrombie.
   c.  A gentleman aged eighteen,' previously in good health, after
using rather violent exercise in the forenoon, had returned home
before dinner,  and was sitting near  the  fire, when without  any
warning, he started up, pushed his  chair backwards with violence,
exclaimed, " Oh,  my  head !" and  instantly fell on the floor insen-
sible  and slightly convulsed.  Dr. Abercrombie saw him within ten 
THE ENKEPHALON.
141
 or fifteen minutes after the attack.  By that time he had recovered
 his recollection, was sitting on a chair, and was quite distinct.  His
 face was extremely pale, and his whole  body cold and shivering:
 he  complained  of  severe  headach, and  his  pulse was weak  and
 rather frequent.  Blood-letting was immediately employed, and his
 pulse improved under it.  It was repeated after a few hours with
 the  addition of purgatives, and  the  other usual remedies.   The
 coldness and  paleness went off after some time, and he then com-
 plained  only of severe headach,  with a  feeling of stiffness of his
 neck, and pain extending downwards along the cervical vertebrae ;
 his pulse was rather frequent and of good strength.  He continued
 in this state for two days,  the headach varying very  much  in de-
 gree, and frequently complained chiefly of his neck : his pulse was
 frequent, 120  or more, and of good strength ; the other functions
 were natural; he was quite distinct;  had the use of all his  limbs,
 and could get out of bed with little assistance, and sit up for  a con-
 siderable time.  On the third day he  began to be more oppressed,
 and a little confused and  forgetful; the other symptoms as before.
 On the fourth he sunk very gradually into coma, and  died on the
 fifth.  His pulse had continued from 120 to 140: there had been
 no  paralytic  symptoms; bnt on  the  fifth day there was repealed
 convulsion.  Blood-letting and all the other usual remedies had
 been employed without benefit.
  All  the ventricles of the brain  were completely filled with coa-
 gulated blood.   In the substance of the left hemisphere there was
 a cavity  formed  by laceration of the cerebral substance filled also
 by the coagulum, and communicating with the ventricle:  there
 was  no other morbid appearance.—Abercrombie.
  The cases, which have  been detailed,  if they exemplify the  fea-
 tures of apoplexy, exemplify no less the extreme difficulty of assign-
 ing their physical cause.   In cases of sanguineous, or  serous effu-
sion, it appears natural to consider the mechanical pressure as  the
 cause of stupor.  But the stupor is often slow in coming on, and
often does not manifest itself till some time after the  effusion  has
taken place ;  nor is it necessarily permanent, although  the effusion
remains  : for it  may be temporarily relieved  by  bleeding, or with-
out any apparent cause gradually wears off.  And, if it would  not
encumber this volume by too many  illustrations, cases might be
adduced, in which large extravasations of blood have existed  with-
 out  any  degree of coma ; and still more numerous and striking
cases of  enormous  accumulation of water in the heads of adults,
 without a single apoplectic symptom.   The extravasation,  or pres-
sure of effused fluid, where it exists in apoplexy, is probably there-
fore  a part only of  the physical cause of coma ; something  there
must be  in addition, some change either in the condition of the
nervous substance, or in the cerebral circulation, that is brought on
by, although, as in the first instance quoted, capable of existing in-
dependently of, any effusion, to constitute the immediate cause of
the mental oppression. 
142           MAYO'S OUTLINES OF PATHOLOGY.

  The symptoms of apoplexy bear, if not a certain, at all events
the most definite relation  to  the organic lesion,  when they  flow
from sudden extravasation of blood.  In the third ofthe cases last
cited, the inward sensation attending the giving way of the vessel
and first  burst of hemorrhage,  and the subsequent invasion  of
coma, were so decisive of the nature of the attack, that its origin
could not have been mistaken during life.
  It is possible even  to distinguish when the effusion is upon the
surface of the brain, in contradistinction from the cases in which it
is confined to the medullary  substance, and to  the  cavities of the
ventricles.  In the former case it is uniformly characterised by the
attendance of convulsions.
  A man, aged  about thirty-five, keeper of  a  tavern, and addicted
to the constant use of ardent spirits, had been drinking to intoxica-
tion during the  night betwixt the 12th and 13th July, 1816 ;  and,
about seven o'clock in  the morning, was found lying in a state  of
violent convulsion.  No account could be obtained of his previous
state,  except that during the  evening  he  had drunk a very large
quantity of whisky, and that when he was last seen, about three
o'clock in the morning, he was walking about his house, but una-
ble  to speak.  He  was seen  by Dr. Hunter at a quarter before
eight.  He was then  lying on his left side,  in a state of perfect in-
sensibility, with laborious breathing ;  saliva was  flowing from his
mouth ; his  eyes were much  suffused, and greatly  distorted—the
cornea of both being completely concealed below the upper eyelid;
pulse 120, full and soft.   While Dr. Hunter stood by him, he was
again seized with convulsions ; it began in the muscles of the jaw,
which was drawn from side to side with great  violence, producing
a loud jarring sound  from the grinding of the teeth.   The spasms
then extended to the body and extremities, which were first thrown
into a state of violent  extension and  then convulsed for. one or two
minutes ;  they  then  subsided, and  left him as  before in a state of
perfect insensibility.   Similar attacks took place  four times while
Dr. Hunter remained in the house, which was about half an hour;
and he expired in another attack of the same kind about ten minutes
after.  Blood-letting, and  every other remedy that the time ad-
mitted of, were employed  in the most judicious manner.
  Inspection.—On removing the skull cap an appearance was ob-
served on the surface of  the dura  mater, of coagulated blood  in
small detached portions.   These appeared to have been discharged
from small glandular looking  elevations on the outer surface ofthe
dura  mater, which were  very vascular,  and highly gorged  with
blood.  There were depressions on  the inner surface of the bone,
which corresponded with these bodies. On raising the dura mater,
there came into view a coagulum of blood, covering and completely
concealing the  right hemisphere of the brain ; it was about two
lines in thickness  over the   middle  lobe, and became  gradually
thinner as it spread over the anterior  and posterior lobes, and
dipped down  below the base of the brain.   The  coagulum being 
THE ENKEPHALON.
143
removed, measured about gv.  On the  surface of the left hemi-
sphere, the veins were turgid with blood; on the surface of the right,
they were entirely empty; but the source ofthe hemorrhage could
not be discovered.  There was no  fluid  in  the ventricles, and no
other disease was discovered.  The stomach being  carefully ex-
amined, was found to contain  nothing but air  and some  healthy
mucus.—Abercrombie.
   It  is remarked that effusion in the cerebellum, or  near the base
ofthe skull, is more  certainly and  rapidly fatal than in the upper
parts of the enkephalon.
   A woman, aged about seventy,  a midwife, of a full habit and
short stature, while sitting by the bed of a lady whom  she was at-
tending,  suddenly exclaimed, "I am gone!" and  almost immedi-
ately fell down in a  state of coma, with  some vomiting.  She lay
in a comatose state, without any change in the symptoms for forty
hours, and then died.                                    .
   A coagulum of blood, the size of a pigeon's egg, was found in the
right lobe of the  cerebellum.  There was no other morbid appear-
ance.—Abercrombie.
   A private in the 10th hussars, of a spare habit, about a month
before his death was attacked with a pain in the back of his head,
for which a blister was applied, and the pain  soon  went off.  On
the 22d  July, 1819, he was  seized with giddiness and fell down;
on being raised  he vomited,  and complained of  violent  headach
and  faintness, but was  quite  sensible;  he was very pale, and his
pulse was slow  and languid.   Being carried to  the  hospital, he
 continued in the same state: asked for cold  water, which he swal-
 lowed, and seemed relieved of ihe faintness, but continued very
 pale.  In a few minutes his eyes became fixed ;  he  drew deep  in-
 spirations, and in two minutes more was dead.   From the moment
 of seizure, he did not move either the upper or lower extremities
    Nothing  unusual was discovered in  the brain.   On raising the
 tentorium, the vessels of the cerebellum  appeared very  turgid.  Un
 removing the cerebellum, a coagulum of blood of about two ounces
 was found under it, and surrounding the foramen magnum.—Aber-

    Some'symptoms  have been  described  as precursors of, or at-
 tendant  on  apoplexy,  which deserve   independent considera ion.
 These are headach, vertigo, vomiting.  There are cases, in which.
 the disease being certainly cerebral, these  symptoms  predominate
 over the strictlyapoplectic symptoms ; and there  is a  singular alli-
 ance between them, when  proceeding from any cause, which it is
 interesting to investigate.

           Vertigo depending upon Cerebral Congestion.

    Wepfer mentions the case of a woman, who was  recovered after
 hano-ing by frequent bleeding: she  was for some time afterwards
 affected with vertigo, which subsided gradually. 
144            MAYO's OUTLINES OF PATHOLOGY.

Headach, Vomiting, Instability, depending upon the softening of
                         the Brain.

  A gentleman, aetat. twenty-six, of a plethoric habit, had suffered
occasionally for two or three years from  headach  and vertigo,
which were always relieved  by depletion.  On 12th April, 1827,
while walking out, he was seized with  confusion and giddiness,
embarrassed speech,  and a considerable degree of paralysis of the
right leg.  He was rather  pale;  his pulse was 70 and soft; and
he did not complain of any  headach.   The usual treatment was
adopted with activity by Dr. Combe of Leith, without much relief.
On the contrary, after several days he began to complain of acute
headach, accompanied  by vomiting and hiccup; and the other
symptoms continued nearly as before—his speech being laboured
and slow, and his memory  very defective.  After some weeks those
symptoms subsided, so that he was able to walk out; but the head-
ach continued with frequent vomiting.   The pain was chiefly re-
ferred to the left side of the  head, sometimes to  the occiput, and
there was occasional numbness of the right arm.   When Dr. Aber-
crombie saw him, along with Dr. Combe and Dr. Kelly, in July,
his chief complaint was of frequent and irregular attacks of vomit-
ing, occurring daily,  or repeatedly during the day.  It came on
very suddenly without  previous  nausea, and  he  was often awak-
ened in the night by the sudden attack of vomiting.   He had now
a pale sickly look ; there was no paralytic affection, and little com-
plaint of headach ;  though he still had occasional uneasiness in the
head, sometimes referred to one part of it and sometimes to another.
When he did refer it to a particular part as the principal seat ofthe
pain, it was either the left temple or the occiput.   But the headach
at this time was slight and transient, and the symptoms in the sto-
mach were so  much the more  prominent, that it was a matter of
much doubt whether there was now any fixed disease in the head.
The vomiting was much  relieved by the oxyd of bismuth, so that
he was free from it several days. But it soon returned  and went
on as  before, with increasing debility, great  listlessness, and bad
appetite; pulse little affected.   He had  now  a peculiar unsteadi-
ness of his limbs, so that on first getting up into a standing posture,
he staggered very much, and required some time and attention to
steady himself.  When he had accomplished  this he walked with
tolerable firmness.  The symptoms went on in this manner till the
27th of October, when  he was  suddenly seized with violent and
continued convulsions, and died in nine hours.
  Inspection.—In  the substance of the  middle lobe of the left
hemisphere of the brain, about the  level of the lateral  ventricle,
there was a portion in a state of complete ramollissement, about an
inch and a half in length, and an inch in its other dimensions, and
the  neighbouring parts appeared unusually vascular.  The tuber
annulare and  pons Varolii were softer than usual,  but  otherwise 
THE ENKEPHALON.                  145
healthy.   No other morbid appearance could be discovered in the
head, and all the other viscera were healthy.—Abercrombie.

          Headach, ending fatally, allied to Apoplexy.

  Tissot mentions a woman, who, after complaining for some time
of headach. was attacked with  a great and sudden increase of pain,
accompanied by loss of sleep, and died in  a short time.  On dissec-
tion  no  morbid appearance could be detected.   A young woman,
mentioned by the same writer, having, during the flow ofthe men-
ses, suffered from  a fright, the discharge stopped, and she became
liable to frequent leipothymia.  After suffering from this and vari-
ous other symptoms for several   months, she fell into  a profound
sleep, from which nothing could rouse her; this continued  four
days ; she then came out of it and appeared to be recovering, when,
after several  days, she  was  seized  with  severe  headach, anxiety,
and  convulsions,  and died.   No morbid appearance could be de-
tected in any ofthe viscera.
  In the cases last quoted (curiously analogous to simple apoplexy,)
the headach was  not connected with any sensible cerebral  lesion,
or alteration in the state of the  circulation.   We may, however,
reach to a further point still in this path  of inquiry.   Headach
alone, or with giddiness, is  liable to be produced by a condition of
the brain the most remote from that congestive state, which is the
common attendant of apoplexy.   When much blood has been lost,
the  balance in the cerebral circulation between the quantity and
force of the arterial and venous circulation is disturbed, and the im-
petus of the arterial circulation  seems to produce the symptoms
which are referred to ;  in other  instances they  may rather be re-
ferred to simple nervous cerebral exhaustion.
  The  following cases and observations from  Dr. Abercrombie,
are replete with pathological and practical value.
  A gentleman, aetat.  about forty, had  been for  some time losing
considerable  quantities  of blood  by arterial  hemorrhage  from the
rectum.  Considering it as merely hemorrhoidal, he had paid little
attention to it, until his friends became alarmed by his altered ap-
pearance.  From being strong and rather plethoric, he had become
weak, exhausted,  pale, and haggard. He had anasarca of his legs,
his pulse was  frequent and feeble, and much excited by the  least
exertion.  Along with these symptoms, he was liable to strong and
irregular action of the heart,  and complained of giddiness, tinnitus
aurium, violent throbbing in the  head, and frequently of throbbing
headach.  On examining his rectum, a fungous tumour was found
within the sphincter, on the  apex  of which a  small  artery was
bleeding per saltum.   This was tied,  and there was no return of
the hemorrhage ; and under the  use of nourishing diet, and a libe-
ral  allowance of wine,  all his other complaints disappeared. He
made up  so rapidly in flesh and  blood, that not long after, appre-
hensions were entertained that he was becoming  too plethoric, and 
146
MAYO'S OUTLINES OF PATHOLOGY.
it became necessary to reduce his regimen ; but under these  cir-
cumstances he had no return of the symptoms in his head.
  A lady,  aetat.  twenty-five,  had been  frequently bled on account
of symptoms in  the head which had supervened upon an injury.
Considerable relief had followed each bleeding; but the symptoms
had soon returned, so  as to lead to a repetition of the bleeding at
short intervals,  and this  had been going on for  several  months.
When Dr.  Abercrombie saw her, she  was stretched upon a couch,
her face of the most death-like paleness, or rather  of the paleness
of a stucco figure, her pulse very rapid  and as  small  as a  thread,
her general weakness extreme.   The mass of blood appeared to be
reduced to  the lowest point that  was compatible with life, but she
still complained of frequent headach, violent throbbing in the head,
confusion and giddiness.   It was  evident that evacuations could
be carried  no further,  and, in consultation with a  very intelligent
medical man  who had the charge of her, it was agreed as a last ex-
periment to make trial of the opposite  system, nourishing diet and
tonics.  In a fortnight she was restored to very  tolerable health.
  " I have been  repeatedly consulted under the following  circum-
stances.  A gentleman accustomed to  very full  living,  is seized
with an  apoplectic  attack, or with symptoms indicating the most
urgent danger of apoplexy; he is saved  by bleeding and other free
evacuations, and is kept for some time upon a very spare diet.  His
complaints are relieved ;  and as  long as he keeps quietly at home,
he goes on without any uneasy feeling.   But when  he begins to
go abroad,  he becomes liable to attacks of giddiness and confusion,
generally accompanied by palpitation of the heart, and an uneasy
feeling about the praecordia.  His pulse is now  soft and rather
weak,  and his general appearance indicates the  very reverse of
plethora; and these  symptoms are removed by a cautious improve-
ment of his  regimen.   This curious fact Y have repeatedly had
occasion to attend to in the treatment of cases of this kind, and it
has  always appeared  to ine to be one of very great interest in
reference to the pathology of the brain.
  " Various other facts will present themselves  to  the  practical
physician, which bear upon this  curious subject.  In the last stage
of diseases of  exhaustion, patients  frequently fall  into a state
resembling coma, a  considerable  time  before death, and while the
pulse can  still  be felt distinctly; and  I have many times seen
children  lie for  a day or two in this kind of stupor, and recover
under the use of wine and nourishment."
  In the following case, the symptoms experienced have probably
been the result of cerebral exhaustion joined  to  derangement of
stomach.
  A gentleman,  between  his thirty-fifth and  fortieth years, of a
temperament inclining  to nervous, but stout and muscular, habitu-
ally taking considerable exercise, and living heartily, and engaged
in  an active profession, has experienced, on  different occasions,
when exhausted by days of previous fatigue, the following attacks. 
THE ENKEPHALON.                   147
After partaking early of a hearty breakfast, and travelling twenty
miles, he was seized with vertigo, and inability to stand, and slight
nausea:  he  took  two glasses  of brandy without any effect; but
became relieved upon producing vomiting, by means of salt and
water, and lying perfectly still.   On another occasion, he awoke in
the night, low, depressed, shivering violently, with a sense of failing
power, like approaching dissolution ; this was relieved by applying
hot  bottles to the feet, and administering brandy.  On another
occasion,  when exhausted by over-exertion, he  was taken with a
sense of feebleness joined to imperfect vision ;  in which, at first, he
could see only the objects to which the optic axes were immediately
directed ;  in  half an hour afterwards, this was changed to vision of
the  half  of objects:  with quiet and  stimulants,  in another half
hour the sensations wore off.   These seizures were followed by
slight headach.  He is now in  perfect health; but  feels on going
through  much excitement or exertion, that he might bring on a
return ofthe feelings described.
  The alliance between vertigo and sickness is remarkable.  In
injuries and diseases of the head, these  feelings perpetually accom-
pany each other; and there are curious instances which even go to
show that the one has a necessary  connection with  the other.  In
persons sick at sea, it is very certain  that  the  shifting motion of
visible objects, and the  instability and want of support felt, or, in
other words, the disturbance of the sense of  equilibrium, and  the'
giddiness  so produced, are the  causes  of the sea sickness.  If a
person on ship-board, with feelings  of  nausea coming on,  lie down
and close  his eyes, the nausea is wonderfully diminished; yet  the
only difference which he has made,  is excluding impressions which
favour the production  of giddiness.   When  a  person has drunk
immoderately of wine, on the  contrary, if  he shuts his eyes he
experiences a  strong  vertigo or sense of  whirling, followed by
nausea;  but if, instead of giving way to this sensation, he fixes his
sight on  a stationary object near him, the vertigo is corrected by
the  steadiness  of the visible object; and as the vertigo disappears,
the  nausea wears off.   The mitigation of the nausea is in both
of these dissimilar instances the effect of getting rid ofthe vertigo.

                        §11— Of Palsy.                   J'

  Palsy, from a single lesion of the brain,  affects one side of the
body only; the proper term for this disease is  therefore hemiplegia.
  Hemiplegia is either general or partial; that is, it invades either
the whole, or part only, of the  side attacked.  Hemiplegia is alter-
nating, when it invades one side of the face, and the opposite side
ofthe trunk and limbs.
  Hemiplegia  is either paralytic, anaesthetic, or complete; that is,
it may extinguish  either voluntary motion alone, or sensation alone,
or both at once.  Hemiplegia, again, is either  perfect or imperfect; 
 148            MAYO'S OUTLINES OF PATHOLOGY.

 that is, it may either suppress or only weaken voluntary power and
 sensation.
   The following cases will serve to exemplify the principal varieties
 of hemiplegia.  I have selected such as were to  a considerable
 degree unconnected with apoplectic syaiptoms, to  the relation of
 which with palsy I shall afterwards advert.
   Paralytic hemiplegia of the face.—A gentleman, aged forty-six,
 after suffering pain above the right eyebrow, was taken with con-
 fusion of thought and staggering: his face was flushed, and shortly
 afterwards was drawn to Ihe right side.  With proper treatment he
 entirely recovered.
   Paralytic hemiplegia of ihe face and arm.—A gentleman, aged
 eighty, who had experienced, in May, 1834,  an attack of confusion
 of thought and drowsiness, was taken in December  last with palsy
 of the right side of the  face  and right arm.   His mind had not
 completely recovered  from the former attack, but did not appear to
 suffer  through the present. He again slept a great deal. The pulse
 was more frequent than natural, weak, irregular, and  unequal.
 There was considerable difficulty in deglutition and  in articulating.
 The right leg was not paralytic, but it was cold, the left  having a
 natural heat.   There was no pain of the head. I ordered a blister
 to  the back of the neck, and opening medicine.   For the two
 following days there was no change; but it was observed,  that each
 evening a slight flushing ofthe countenance  took place. I therefore
 applied six leeches to the right temple, watching the effect of the
 small abstraction of blood: it evidently did harm; the pulse became
 feebler and thready.  The remaining treatment was nutritive diet,
 and occasional opening medicine.  The patient recovered the use
 of the  arm completely, and there are hardly any remains  upon his
 countenance of the palsy.

                General Paralytic Hemiplegia.

   " A gentleman, aged sixty, had been liable, for two years before
 his death, to attacks of giddiness, accompanied  by complete  loss of
 all muscular power,  in which, if not prevented,  he  fell  to  the
 ground.   In  these attacks he did not lose his  recollection, and he
 recovered completely in a few minutes.  Before the commencement
 of this  complaint, he had been liable to severe pain in the head, and
 giddiness, the attacks of which generally went off with vomiting.
 He was sound in his mind, but had considerably fallen off in  flesh
 and strength: he felt an unsteadiness in walking, which made him
 afraid of going alone;  and, for some months before his death, he had
 perceived an increasing weakness of both his  lower extremities. On
 the 1st of August, 1816,  he was attacked with hemiplegia ofthe left
side, accompanied by headach and giddiness;  the pulse\vas natural,
and his mind was not affected.   For four days  he continued to be
affected with the most complete hemiplegia: he then began to recover 
THE ENKEPHALON.
149
a little motion ofthe parts, and about the 15th was able to raise his
arm to his head, and to walk a little with  assistance:  he still  com-
plained of giddiness, and noise in his ears, but had little headach.
Bloodletting and the other usual remedies had been employed.  On
the 19th, there was considerable headach; on the 20th,  he became
incoherent;  and on  the 21st, fell  into perfect coma,  with some
convulsion.   On the 22d, he was considerably recovered, so as to
know those  about him, and to answer questions rationally; but at
night he relapsed into coma, and died on the 23d.   For the last
three days his pulse had been from 112 to 120.
   " Inspection.—Along the upper part of the right hemisphere of
the brain there  lay a remarkable tumour five and  a half inches
long, two and a  half broad, and about half an  inch in thickness ;  it
was formed  by a separation of the laminae of the dura mater, and a
deposition of new matter betwixt them.  This uew matter was, at
the posterior part, white and firm; in other places, especially about
the centre ofthe tumour, it was more like recent coagulable lymph,
firm, yellow, and semi-transparent;  and, at the anterior part, there
was  a cavity containing yellowish serous  fluid.   The  tumour
lay from before backwards along the upper part of the hemisphere,
—the inner  edge of it being about an inch from the falx; the  dura
mater  all around it was considerably thickened, as were also the
coats of  the longitudinal  sinus.   The surface of the brain, where
the tumour  lay  was depressed so as to retain an impression of its
figure; and, on  the anterior part of the  brain, the substance was
considerably softened, with some appearance of suppuration. There
was very little serous effusion, and no disease in any other part of
the brain.—Abercrombie.

Ancestlietic Hemiplegia  of the left side of the Body, with Para-
                lysis of the right side of the Face.

   Thomas Embury, aetat forty-two, one  morning after breakfast,
now seven weeks ago, on stooping to open a plate-chest  which had
been made of green wood, and kept closed some time, was so pow-
erfully affected"by the close smell which issued from it (such  is his
account) as  to  fall backwards, but without  losing his senses, or
striking  his head.  On recovering, he found he had undergone a
paralytic seizure:  the left side of the face and head, and body and
limbs were numb; the left arm more so than the left leg:  he believes
that no muscular weakness of the left side was combined with the
anaesthesia; but the leg, he thinks, dragged a little during the next
two or three days.  In four or five days, however,  the leg, whether
paralysed at first or not, had recovered both  strength and feeling.
The arm has been slower in recovering feeling; and even now the
little finger and ulnar edge ofthe hand and forearm are in a degree
numb. The sensibility of the left side of the face is entirely returned.
What may have been the state of the right side of the face on the
day of the seizure he does not know j but the following morning he
       19—g                                  11 may 
150
MAYO'S OUTLINES OF PATHOLOGY.
observed that it was paralysed : he could not close th e right eyelid
the mouth was drawn to the left side;  the sensibility of the right
side  was  unimpaired.   The first day  he  had some difficulty o
swallowing;  and for three or four days his speech was thick and
imperfect.  After a few days he felt a pain, for an extent which a
shilling would cover, deep-seated on  the right temple, midway
between the eye and upper part ofthe ear. This pain has continued,
though  now considerably mitigated, to  the present time.  He had
occasionally confusion of thought.  He experiences at times sensa-
tions like life-blood in the arm and legs, but no spasm.   The right
eye is weak, but not inflamed:  when  it  is unclosed, he sees double,
owing to a slight deviation ofthe right optic axis outwards.  [July,
1835.]
  Hemiplegia is found  to be produced by any variety of cerebral
lesion, from slight serous effusion,  or  inflammatory softening, to
tumours or thickening ofthe membranes, or masses of extravasated
blood.   The  proximate cause, therefore,  of this  affection is, if
possible, in still greater  ambiguity than that of apoplexy.   At the
same time, I think it is possible to explain  (passing  over the ques-
tion, what is the  physical  cause of  hemiplegia) many  of the
phenomena of the disease, the nature of which has hitherto been
thought obscure.
  The most remarkable phenomena in hemiplegia are the following:
—Disease of  one hemisphere of the  cerebrum or  cerebellum pro-
duces hemiplegia of the opposite side of the body:—in general
hemiplegia the palsy of the leg is  less complete, and capable of
being more quickly recovered from  than palsy of the  arm:—in a
gradual attack of hemiplegia, the weakness and numbness are first
felt in the hands and feet, the parts nearest the trunk being the last
affected:—paralytic hemiplegia is more frequent than anaesthetic
hemiplegia.
  The preliminary question to be settled is, what is the nature of
the impression, which, being made by the diseased or injured brain
upon  the medulla oblongata and spinal marrow, produces palsy?
An idea  commonly entertained upon  this subject is, that palsy
results from  the  interruption  of  the ordinary  supply of nervous
stimulation furnished by the brain: this idea, however, is certainly
erroneous; for, experiments made  on animals, and  instances of
acephalous human infants that have survived their birth, abundantly
show that the  medulla oblongata and  spinal cord are sufficient,
without the brain, for sensation and  voluntary motion.  The notion
that most commonly prevails perhaps is, that pressure on the brain
is the cause  of palsy:  this, however, if it were true, would only
shift the difficulty to another point;  for it still would remain to be
asked, how does cerebral pressure produce palsy ?  But the truth is,
that in many cases of hemiplegia from cerebral disease there is no
pressure: softening of a part of  the brain for  instance, in which
there is no increase of volume, will as effectually produce palsy as
an  apoplectic  clot.  The  solution  of the question which I am 
THE ENKEPHALON.
151
disposed to adopt, and which I believe not to have been previously
entertained, is the following:—I  conjecture the immediate cause of
hemiplegia to be a depressing influence or shock, originating in the
brain when in certain states of lesion, and propagated from it to the
medulla oblongata and spinal marrow.
  It may be asked, whether it is reasonable to suppose that the
brain, when in a state of lesion, can originate any such depressing
or palsying shock 1 Reasoning upon analogy, it is probable that the
brain may possess  this property.  It is certain, that, upon other
organs than those of animal life, the brain does exert such disastrous
and depressing influence.   For example, in persons of a nervous
temperament, sudden and overwhelming intelligence will sometimes
temporarily stop the heart's action.   Physical  impressions, again,
such as crushing a part of the brain or spinal marrow, will  tempo-
rarily palsy the heart;  an experiment the more conclusive, that the
heart's action will continue undisturbed during the entire removal
ofthe brain and spinal marrow, if the abstraction of these parts be
made with  gentleness.  Is  it surprising that lesion of  the brain,
which can palsy the heart, the action of which is not derived from
the nervous system, should throw palsy upon the voluntary muscles,
that in so many ways are habitually influenced through it?  Such
a force of depression, similar in kind, although much less in degree,
mental  affections alone have the direct power of temporarily pro-
ducing: the "genua labant, tremor  occupat artus," the weakness
of terror, is probably an instance of imperfect or temporary palsy
so produced.
   Upon these  and other grounds, which will be presently  men-
tioned, it appears reasonable to believe that a lesion of the  brain  is
capable  of originating  a  depressing force, which can strike with
palsy the organs in the cord from which the nerves arise;  or  that
palsy from  cerebral disease is  not caused by the  interruption  of
an  accustomed stimulus, but by the  production  of a new and
withering influence, transmitted  from thence to  the  origins  of
the nerves.
   I. How does it happen that  a lesion of one side of the brain
invariably produces palsy of the opposite side of ihe body ?
   The entire analogy of the nervous system leads us  to suppose,
that the influences which  pervade it move in the  direction of the
threads or filaments.of which the medullary substance is composed.
Anatomists therefore look with curious interest to the construction
 of the enkephalon, in the expectation of discovering some transpo-
sition  or crossing over of nervous filaments from one side to the
other, through which  the  crossing of the depressing influence,  or
 palsy-shock, may  be supposed  to be  conveyed.  After the most
 careful research, it appears that such a transposition or decussation
 of nervous threads is  to be found in the medulla oblongata alone.
 Where the medulla oblongata joins the spinal marrow, the anterior
pyramids throw their fibres downwards, in oblique decussation,
each to the opposite side, in such a manner that the right anterior 
152
MAYO'S OUTLINES OF PATHOLOGY.
pyramid plunges into the centre of the left half of the spinal mar-
row, while the fibres of the left anterior pyramid plunge  into the
right half of the cord.
  I concur with those who think that these decussating filaments
are the channels through which the palsying influence is conveyed
from a  diseased cerebral  hemisphere to the opposite side of the
frame, upon several grounds: first, because these decussating fasci-
culi are the only ones which have been discovered in the enkephalon;
secondly,  because  the  position of these decussating fasciculi  is
exactly that which experiment and observation lead us to expect to
be the place of the transposition of palsy; thirdly, because all the
phenomena of hemiplegia, from lesion of the  opposite side of the
brain, may be explained upon  this supposition; fourthly, because
even the  remarkable cases in which partial  hemiplegia  of the
opposite side is combined with partial  palsy on the side of the
cerebral lesion, admit of a perfect explanation  on the same hypo-
thesis.
  The most conclusive facts with which I am acquainted,  to show
that the crossing of palsy  to the opposite  side  is effected in the
region of the medulla oblongata, are given  in a very interesting
paper by Dr. Yelloly, in the second volume of the Medico-Chirur-
gical Transactions.
  Dr. Yelloly describes  an experiment  upon a dog, in which Sir
Astley Cooper divided the right half of the spinal marrow, at the
iuterval between the occiput and atlas:  the dog became  palsied on
the injured side.   It may be inferred from this experiment, that the
seat ofthe transmission  of palsy is to be found above the atlas.
  Dr. Yelloly afterwards describes a case of hemiplegia, in  which it
was found, after death, that a tumour, of the size of a filbert, had
been imbedded in, and had made pressure upon, the right side ofthe
annular protuberance. The hemiplegia in this case had affected the
left, or opposite side of the body.
  It may  be confidently inferred from this case, that the  seat of the
transit of palsy is behind or below the pons Varolii; but the experi-
ment by Sir  Astley Cooper, previously mentioned, establishes  that
it is above the spinal cord.  The two  instances, taken together,
render it  almost certain  that the place of the transit of palsy  is
somewhere in  the  medulla  oblongata, or its  junction with the
spinal cord;  and it is evident how much additional  force  is given
to this conclusion  by the fact previously  mentioned, that no decus-
sation  of nervous  filaments  has been found, except at the latter
point.
  We  may now inquire whether the decussation of the  anterior
pyramids  is sufficient to account for all the  phenomena of hemi-
plegia.
  Will, in the first place, the course of the decussating fibres
account for the production  of numbness, or anaesthesia,  as well as
of muscular palsy; for the former, although not a constant attend-
ant ofthe latter, maybe combined with it, or even exist without it? 
THE ENKEPHALON.
153
Upon this question no one, who has well examined the anatomy of
these parts, will entertain a doubt.  The decussating fasciculi of
the anterior pyramid, on plunging into the opposite column of the
spinal marrow, strike into its centre, and implicate themselves nearly
as much with the posterior as with the anterior fasciculi;  that is
to say, with the sentient as well as with the voluntary portions of
the  cord: so  that the wonder is, not  that anaesthesia should  be
produced through their agency, but that it should be so seldom
produced, compared with the frequency of simple  muscular palsy.
   Again : it is evident  that palsy of all the  spinal nerves of the
opposite  side  of the body may be sufficiently accounted  for,  as a
consequence of  lesion ofthe cerebrum, if the anterior pyramids be
supposed to transmit the palsy-shock; for the fibres of the pyramids,
which are continuous upwards, on the one hand, with the cerebral
hemispheres ofthe same side, or with the seat of lesion on  the other
hand, are continued downwards into the upper part and  centre of
that tract, from  which the whole of the spinal nerves are derived.
But how is it possible to account  for  palsy of the opposite  side of
the face through the same channel, for palsy of the opposite side of
the tongue, and  ofthe opposite facial and auditory  nerves?  These
phenomena may, I think, be  thus explained: Where the decus-
sating fasciculi  of the  anterior pyramid plunge into the opposite
half of the spinal marrow, they  are  implicated,  in a wonderful
closeness of intertexture, with fibres, which, in their upward course,
bend towards the places of origin of the ninth and seventh, and of
the  eighth and  fifth of the palsied side.  May it not be  supposed
that this interlacement may be a sufficient means of communicating
the  palsying  influence to the ascending fibres, which are in  close
relation'to the  affected cerebral nerves?   Thus,  the palsy-stroke
transmitted to the junction of the spinal cord and medulla oblon-
gata, might spread its influence in either direction separately, or in
both together, according  to laws which may possibly be  hereafter
rigorously determined;  sometimes striking  the body  alone  with
palsy, sometimes  the  face, sometimes  both;  sometimes palsying
speech, sometimes deglutition, sometimes hearing.
   But the fifth  nerve, why is it so rarely affected  in  hemiplegia 1
and the orbital nerves, why do they so frequently escape the palsy-
ing influence?  These phenomena, it will be  evident, are highly
consistent with the  supposition  that the palsying force strikes
exactly at the point where  the  decussating  fibres of the anterior
pyramids terminate.   Supposing the paralysing impression  to be
received  on  this  part, its force upwards should  be weakened in
proportion to the distance of each cerebral  nerve from  that  part.
But  the fifth lies further off than the seventh, the third than  the
fifth; and something  in  that proportion is the infrequency of the
palsy of these nerves in hemiplegia.
   But if the phenomena of hemiplegia dependent upon cerebral
lesion are thus sufficiently explained, how is the fact to be accounted
for  that  hemiplegia of the opposite side is produced by lesion of 
154
MAYO'S OUTLINES OF PATHOLOGY.
one hemisphere of the cerebellum ?   I have little  doubt that the
following explanation ofthe phenomenon will eventually be proved
to be correct.  The fibres of the anterior pyramids pass through the
pons Varolii.  The pons Varolii consists in great part of filaments,
which issue from each hemisphere of the cerebellum.  These fila-
ments  may easily be  supposed  to convey a depressing influence
from the diseased hemisphere; but in their course they come imme-
diately upon the  filaments of the anterior pyramid of the same side;
and  they are so implicated with  the latter, with such a  singular
closeness of reticulation, and often with so much that looks like an
actual interchange of filament, that it is far from unlikely that they
may transmit to the descending fasciculi of the pyramid a shock,
which  may thence be communicated to the same part at which a
cerebral lesion exerts its paralysing force.
  But why does  it  happen  that the  diseased hemisphere does not
strike with  palsy the cerebral nerves  of the same side, the fifth, the
seventh, and the  ninth? It is not impossible that the ninth, which .
rises close to the side of the pyramid, may be so affected.   But the
fifth and seventh are so remote from  the pyramid of the same side,
that it could not be expected to extend its influence to them.
  But  it has been mentioned that there are cases in which hemi-
plegia of the opposite side  to the seat of cerebral affection may
coexist with partial palsy ofthe same side; both phenomena being
produced by one cerebral lesion.  How are such phenomena to be
brought under the same hypothesis?  The following case, which
is under the care of Dr. Hawkins, in the Middlesex Hospital, and
is of remarkable interest, may serve at once to exemplify and to
explain the apparent anomalies to which I  now advert.
  The  patient, a female, twenty-eight  years of age (I  omit the
symptoms of general disorder under'which she has laboured) expe-
rienced, in December last, pains deeply seated in the left side ofthe
head ; she became afflicted, at the same time, with palsy ofthe right
side ofthe body.   Under appropriate treatment, the pain in the left
side of the head has subsided, and the hemiplegia has much dimin-
ished.  But  another symptom supervened soon after  the appearance
of the hemiplegia:  the sight of the left eye has become  dim, the
pupil is dilated, the upper eyelid has  fallen, the eye  is more promi-
nent than the other, is habitually directed outwards, and can by no
effort be  directed inwards.  It is evident, from the latter train of
symptoms, that the second  and third nerves of the left side have
become partially palsied.  Through  palsy of the second, her sight
is dim;  through  the same cause, joined with imperfect palsy of the
third, again, the  eyelid droops,  the  levator having feeble  action;
through the same cause the eye protrudes,  for there is no sufficient
force in the weakened recti to overcome the traction forward  which
is produced by the unpalsied superior oblique.   The eye is habitu-
ally turned  outwards through the infiuence ofthe fourth and sixth
nerves, that are unaffected ;  and when, by a painful effort, the eye
has been slowly drawn to a  central position, which the feeble action 
THE ENKEPHALON.                  155
excited through the imperfectly palsied third can gradually effect,
the contrast is  remarkable of the rapidity with which it is thrown
outwards, the moment the patient is desired to look  in that direc-
tion.
   But what is the seat ofthe lesion which has produced this com-
plicated paralysis?   It appears to me impossible to doubt that the
disease is situated in or near the left optic thalamus ;  it has palsied,
though not perfectly, the second and third nerves of the same side,
which rise in its immediate vicinity; it has then thrown its palsying
influence down the fibres ofthe crus cerebi to the anterior pyramid
of the same side:  the fibres of the pyramid having no communica-
tion with the fourth, the  fifth, the sixth, the seventh, or the  eighth,
of the same side, these have escaped unharmed.  Below their origin
is the decussation, at which it  is certain that the palsy-shock has
been  transmitted to the opposite half of the spinal cord.
  What maybe the nature ofthe disease in this  case is by no means
so certain as its place.  Palsy follows various kinds of lesion: san-
guineous effusions, softening,  abscess,  tumours, or pressure from
substances external to  the meninges of the brain, may frequently
produce it. In the present instance,  the gradual supervention of the
symptoms renders it probable that they are  caused either by soft-
ening or by  the growth of a  tumour.1  The diminution  of the
hemiplegia under the treatment employed, and the increase  of the
palsy ofthe parts in the  orbit, lead me  to suspect the latter.
  2.  What reason can be assigned for the facts, that in general
hemiplegia from cerebral lesion, the palsy of  the leg is less com-
plete, and capable of being more quickly recovered from, than the
palsy of the arm ?
   If  the  supposition, which I have advanced, be  admitted, that
hemiplegia results from a depressing influence transmitted from the
brain to the cord through the anterior pyramids, the answer to this
question is easy.   Thepalsy-shock, if shock it  be, would naturally
act with most severity, where it is first delivered; that is, upon the
upper part of the spinal  cord, weakening with  the greatest depres-
sion the voluntary powers of that part; it would naturally affect
with  less intensity  the inferior  and remoter part of the cord.  But
it is worth while to consider all the phenomena ofthe class together,
as they are repeatedly exemplified in  disease:—a slight attack of
hemiplegia paralyses the  arm;—a severer, the arm and leg together,
but the arm is  more numb and feeble than the leg;—on  recovery,
the leg improves before and faster than the arm, and is often  per-
fectly restored,  when the arm is yet feeble:—on the other hand, if
the attack from a slight one  becomes more severe, it is first the arm
which is taken (generally together with the face) and as the arm
gets worse, the leg gradually becomes attacked.  These striking

  1 These remarks were made in March ofthe present year.   The patient is
now well of the hemiplegia  of the right side of the body ;  but the left eye is
protruded and  its sight lost. The  case, the event has shown to have been
one of the softening of the brain, with recovery.  [August 25.] 
156            MAYO'S OUTLINES OF PATHOLOGY.
facts may be used in two ways; cither they may be explained upon
the theory of the palsy-shock which I have advanced, supposing it
otherwise established; or that theory remaining in doubt, they may
be adduced in proof of its validity.
  3.  Why, in a slow attack of palsy, are the muscular iveakness
and the numbness first felt in the extremity of the affected limb ?
 Why in the hand before the forearm,—in the forearm before the
upper arm ?
  In  this instance  it may be presumed that a diminution of the
usual quantity of stimulus  or energy, transmitted  along the nerves
from the organs in which they rise, is the cause ofthe effect observed.
A part of the cord is smitten with an imperfect palsy-stroke: it can-
not energise as before, or throw along the nerves which arise from
it the usual quantity of nervous  force.  Upon this supposition it
would follow, that the defect of stimulus should first become sensi-
ble at the extremity of a limb.  The weakened segment of the cord
might be expected to be  unable to  throw out energy enough to fill a
long nerve, while it yet  might supply with adequate force of stimu-
lation the shorter nerves of the portion of the limb nearer the trunk.
The fact presents a remarkable contrast with the last class of facts
adverted to, and shows at  all events that the two are not referable
to one principle.   In slow  hemiplegia, the arm is struck before the
leg; but the hand is struck before the arm.
  4. How is it to be  accounted for that muscular palsy is more
frequent than anesthesia ?
  The reason  may be this: the office of the sentient  nerves is
probably an easier function than that of the  motor nerves. In some
experiments which  I made upon the mode and quickness of repara-
tion of both classes of nerves after their division, I found that the
sentient nerves resumed their functions in a shorter time than the
voluntary nerves.   I divided  the facial branches of the seventh and
ofthe fifth nerves on one side in a cat: in the third week sensation
had returned, but no sign  of returning motion appeared  till after
the fourth.  If this principle be true, it will solve the present ques-
tion.   The sentient nerves, it would appear, require a harder blow
to palsy them than the voluntary.  It deserves besides to be pointed
out, that, as the office ofthe former is to transmit towards the centre,
not from the centre, it is natural  to expect that they would be less
susceptible of a force proceeding against the habitual course of these
motions.  The connection of the decussating fibres of the pyramid
with  the posterior part of the opposite half of the spinal cord, is
likewise not quite as extensive as with the anterior.
   The relation of palsy to apoplexy is close  and remarkable.  Rup-
ture  of vessels  with extravasation (no less than serous  effusion)
produce each of these seizures indifferently, singly or together.  It
appears, however, that as a general rule, palsy after rupture of ves-
sels is the consequence  of a lesser effusion than apoplexy.  Or the
 cause which  produces palsy is  a lesser lesion  than that which
 produces apoplexy.  Accordingly,  it  occasionally happens, when 
THE ENKEPHALON.
157
bleeding is employed in simple apoplexy, and the mental oppression
becomes sensibly less trre cerebral circulation being relieved, that at
thje same instant hemiplegia developes itself.  It is, indeed, difficult
not  to  pause upon  this Yact, and to take a different view, and to
question the absolute expediency of large abstractions  of blood in
apoplexy; it is certain that bleeding cannot  remedy  palsy; is it
possible, that by  disturbing the  circulation, when the brain  is
recovering  from the apoplectic shock,  it may  promote its  occur-
rence ?
   A middle conclusion may be safely adopted; bleeding is not to
be employed as a practice  of routine,  but only when rendered
imperative by peculiar features in  the attack.   The following case
will serve to show its temporary usefulness even in a desperate case;
it exemplifies likewise another' curious and unexplained feature of
the gravest  and most  complicated apoplexy,—the  occurrence  of
convulsions 077, the  same side  with the cerebral lesion, in conjunc- '
tion with palsy of the opposite.
   W. Tucker, aetat. forty-two, brought into the Middlesex Hospital,
and supposed to be intoxicated: he\vas drowsy, heavy, stupid, not
insensible, answered some  questions; the pulse small and  slow.
 The left arm and leg powerless, face drawn to right side.  When
 put to bed, he was seized with rigor, and  complained of pain in
 the right side of occiput: in an hour afterwards the  pulse rose, and
 the right side ofthe body became  convulsed :  v. s. gxviij:  the con-
 vulsions ceased for a time, then  returned with extreme violence
 threatening  to suffocate him: v. s. §xl:  the respiration became
 more free, but the convulsions  remained :  he then became comatose.
 He continued insensible during the night, the breathing stertorous,
 right pupil dilated, left contracted, no  pulse at the  wrist: he died

    A  large  cavity filled  with blood, partly  clotted,  occupied the
 centre ofthe ri*ht hemisphere ofthe brain : it did not  communicate
 with the lateraf ventricle, but  opened between the sulci of the con-
 volutions,  which for.a large  extent were lined with it;  between
 their summits streaks of clotted blood lay, resembling  veins.
    There was slight sanguineous  effusion on  the surface of the an-
 terior lobe ofthe left hemisphere.  It is possible, but very unlikely,
 that  this may have caused the convulsions ofthe right side of the
 body.

                       ^l\l.—Of Epilepsy.

     In the immense digest of scientific and practical  observations on
  cerebral disease, with which Dr. Bright  has  enriched English me-
  dical literature, no subject is  treated more luminously and instruc-
  tively than that of epilepsy.  To  convey an  idea of the general
  features of this disease, I cannot do better than extract the following
  graphic account from  the volumes to which I refer. 
158
MAYO's OUTLINES OF PATHOLOGY.
  " The first paroxysms of epilepsy very frequently occur during
the night; and when accidentally discovered, it is quite uncertain
whether something of the kind  may not have taken place before,
and passed unobserved.   The first fit often comes without a warn-
ing, and if it do not occur in the night, sometimes takes place with
most, inconceivable suddenness : the patient, while dressing himself
in apparent health, falls to the floor senseless : or, in  the very act
of putting a morsel into  his mouth, loses his recollection, and is
stretched convulsed upon the ground; while at other times the first
attacks are of the slightest character.
  " It sometimes happens, though  comparatively seldom, that a
single paroxysm occurs, and is never repeated during life; some-
what more frequently the paroxysm is repeated at very long inter-
vals, several years intervening between the attacks;  still more fre-
quently  the fits return at irregular intervals of a few months or a
few weeks; sometimes they observe nearly regular periods; some-
times  they return daily  or nightly; and I  have known twenty,
thirty, or more renewals of the paroxysm within twenty-four hours.
This variety in the frequency of repetition depends occasionally on
explicable causes, but is  often totally  unaccountable; when each
night brings back the fit, we naturally account  for  it  by the  con-
gestion attendant on the state of sleep; where in females the fit ob-
serves a monthly period, we trace it  often to  nervous irritation in
sympathy with the uterus ; and when long periods have intervened,
we may usually  trace each distant paroxysm to the repetition of
some excess, or to a neglected  state of the  bowels; but where it
occurs less regularly, we often seek in vain for a probable exciting
or favouring cause.
  " The phenomena preceding,  accompanying,  and  subsequent to
each paroxysm,  present a wide variety.  In  some, the fit is imme-
diate, without the slightest warning: in other cases, previously to
a fit we  find a considerable influence excited  over the whole dispo-
sition ofthe mind: in some instances an unusual flow of spirits for
a day or two is the constant forerunner of the attack ;  in others, a
depressed, almost a sullen state of mind mark the approach of a pa-
roxysm; sometimes an unusual drowsiness is the precursor of the
fit.  In  some cases certain feelings are  experienced,  which at  once
give the alarm,—a tingling, or slight spasmodic action of the mus-
cles,—sensations, which the patient often calls  "a working:" this
may continue for a whole day or more, and may even subside with-
out the fit coming on ; or it may scarcely afford time for the patient
to prepare the attendants for the threatened event.  At other times
a very peculiar sensation, not unlike a creeping or a cold air pass-
ing over the skin, is felt  in some distant part  of the  body, as the
hand or the foot, or a single finger, and this  seems to  advance by
quicker  or slower steps towards the  head, sometimes affecting the
cheek, and then  the violence of  the paroxysm often comes  on" but
it sometimes even then again subsides. 
THE ENKEPHALON.
159
   " The character of the fit itself varies as much as the premoni-
tory symptoms; often, it is simply a momentary absence of mind,
the eye fixed as in thought, yet gazing vacantly, no convulsion, no
sound, the occupation of the  hand ceases, while the mind  for a
moment is annihilated;  the cloud passes off, the intellect returns,
and often, unconscious that its operation  has been  suspended, the
patient resumes the occupation in which he was engaged. At other
times, this loss of mind  is  connected  with a slight appearance  of
convulsive or  involuntary action;  the fingers, generally of one
hand, sometimes of both,  are moved irregularly, and without ob-
ject ;  the eyes are rolled from side to side, or drawn under the eye-
lids, or some catching motion is seen in the muscles ofthe face. In
other cases,  again, the  convulsion  is more obvious; the  head is
drawn forcibly to one side, and the hand sometimes follows in such
a way,  that  at first  it appears to be  seeking  something towards
which the eyes are directed.   This may be the whole fit, but more
commonly is only  the commencement of a much more violent and
appalling paroxysm, in  which the whole frame is agitated, drawn
together, and thrown into tremulous  motion,  as by the excess  of
muscular contraction.  Sometimes the fit commences by a sudden
cry, uttered as the patient falls senseless  to  the ground, and there
either lies motionless, or more frequently agitated with such power-
ful muscular contortions,  that two  or three  attendants scarcely
suffice to prevent his suffering injury from the objects around; the
teeth are gnashed, lacerating the tongue, and the saliva, frothy with
air and red with blood, flows from the mouth.
   " The duration of these attacks, even in their most violent  form,
is often only a few minutes, seldom above half an hour,  unless,  as
the first fit is obviously going  off, a second succeeds, and in that
way the paroxysms may be repeated through several  hours.  The
paroxysm past, some few recover as if awakening from a slumber,
and  return at  once  to their  former   health; others suffer severe
headach for a few  hours; the majority become drowsy and  fall into
a deep sleep, or pass info that state without having recovered  to
consciousness after the convulsion was passed.  In this state a few
hours are passed, and then apparent  health  is restored.   In  some
cases, however, this sleep is a death-like sopor,  a state of  insensi-
bility rather than of  sleep.  When the paroxysm has passed away,
there is very frequently not the slightest knowledge  of  what has
happened; so that in some cases it is only from the urine having
passed unconsciously, or from some other accidental circumstance,
that either the patients or the attendants are made acquainted with
the fact."
   The characteristic features of epilepsy are insensibility and con-
vulsions.   The latter symptom leads us to expect, on the analogy
of apopleetic  cases  attended with convulsion, that the surface ofthe
brain is the part immediately disordered.   And  such is frequently
ascertained to be the fact.  Common causes of epilepsy are, growth
inwards of the skull; thickening of the membranes  of the brain ; 
 160           MAYO'S OUTLINES OF PATHOLOGY.

tumours pressing upon the surface of the  brain, or implicating the
 cineritious substance.
   Instead, however, of making additional  extracts, I shall refer the
 reader to Dr. Bright's original work  for examples of what is  here
 stated.   When studying his views, the reader  may be disposed  to
 class some of the slighter  cases, which I have placed in alliance
 with apoplexy, as partaking more of the nature of the disease  now
 under consideration.  Epilepsy, however, is closely allied to  apo-
 plexy ; and it is often not less difficult than important to distinguish
 in the combination of symptoms  presented by individual cases  to
 which character they most incline.
   Epilepsy, again, is so nearly allied to hysteria, that it is equally
difficult  in other cases  satisfactorily to discriminate between these
affections. The most severe epileptic fits, which I recollect to have
 witnessed, were at once of  uterine origin,  and,  singularly enough,
combined with temporary hemiplegic seizures.
   A woman, between thirty and forty years of age, laboured under
obliteration ofthe canal of the vagina, that had been caused by in-
flammation following a miscarriage.   I believe that the  cavity  of
the womb was obliterated  likewise: at all  events  there was  sup-
pression ofthe catamenia.  It happened, that this patient had from
puberty menstruated regularly every three  weeks.   When, there-
fore, the  catamenia were  suppressed, the disorder which thence
arose manifested  itself periodically at  this short interval. Every
three weeks this patient was seized with pains in the head, which
became gradually more acute; after a day or two epileptic seizures
took place, two or three or  more recurring at each  catamenial pe-
riod ; when the seizures were  the severest, they were attended by
numbness and weakness of one side of the body.
   This patient for a time had the severity of these attacks much
mitigated by small bleedings  immediately before the expected re-
turn ofthe symptoms.  Afterwards, with Sir Charles Clark's advice,
and hoping that  the operation  might bring back  the  catamenial
secretion, I divided the adherent parts, and so restored the canal of
the  vagina.  And as I then found  no opening leading into the
uterus, I cut the cervix half through, and  tried with a probe to find
a passage; I could not,  however, discover any uterine  cavity, and
I believe that it had closed.  The suppuration from the wound for
a time relieved the  patient of  her epileptic  seizures; and I heard
that she did not suffer so severely afterwards.

                  § IV.—Mental Derangement.

   Mental derangement,—whether shown in partial delusions, or in
the attaching undue and irrational importance to particular objects,
or in profound  melancholy and wayward  impulses  to extravagant
actions, or in habitual suspiciousness, or in  uncontrollable irritability
and violence of disposition, or  in indifference to moral restraints  or
in total disorganisation of  the understanding and  incoherence of 
THE ENKEPHALON.
161
 thought ending in fatuity,  or in  several of these elements com-
 bined.—is either more a mental than  a corporeal disease, or else
 has to do with finer  shades of alteration of structure than  anato-
 mists can yet appreciate.
   I think it is practically more useful  to view this disease as a dis-
 ease of the  mind.   Ample experience has shown that the most
 powerful  effects are produced  upon it through  what is called moral
 treatment, the essence of which is,—the seclusion of  the deranged
 person from the pociety of his friends, whose injudicious attempts
 at controlling and managing him serve but to  irritate his mind and
 increase his malady;—and the impression quietly conveyed to him
 and quietly acted on,  that he is placed  under  restraint, for want of
 self-restraint in conduct, and irrational  views in thought, under the
 influence of which  he cannot  be trusted  to his own  guidance.
 Quiet, and gently enforced obedience,  joined with a moderate and
 wholesome exercise  of the undiseased  portions of the  mind, are
 more important to the recovery of insane persons than all schemes
 of medical treatment, beyond those which common sense dictates,
 namely, abstemiousness in diet, bodily  exercise, medicine  to move
 the  bowels if necessary, and sometimes but rarely to compose the
 nervous system.
   On examining the  brains of those who have died insane, no con-
 stant appearance is met with.   When  the complaint  has not been
 of long standing, or modified by phrenitic attacks, no change at all
 is observed.  The  commonest appearance, after  continued mania,
 is thickening of the arachnoid ; this is indicative of former vascular
 action, which, however, has not attended the  ordinary course, but
 the occasional parexial exacerbations of the  malady.
   The more rare appearances, such as cysts and tumours of vari-
 ous  kinds in  the brains of maniacs, may be viewed rather as causes
 which have disposed  the brain to the disease, rendering it unusually
 irritable, than as themselves the sources of it.
  Or, in a brain disposed  by other circumstances to insanity, it is
 possible that these  may act as exciting causes.   There are some
 persons strongly disposed to mania, whom fermented liquors render
 for  the time insane;  and others in whom bodily injuries  produce
 the same effect.  What  is mere  insanity is then liable to be mis-
 taken for phrenitic delirium. It is, perhaps, in cases of injury  of the
 head alone that this mistake is likely to  be made:  but in these cases
 the supervention of temporary mania is just uncommon  enough to
 lead the practitioner not to expect it, while  the  error, if acted on,
 might prove of serious or fatal consequence.

          § V.—Inflammatory Affections of the Brain.

  It is easy to make or to find a vigorous outline of apoplexy, palsy,
and epilepsy, but the  characters of inflammatory affection of the
brain present such endless and important varieties, that it is hardly 
162            MAYO'S OUTLINES OF PATHOLOGY.
 possible  to group their features with any thing like  correctness
 under a few decided heads.
   Cases, which hava been already given, exemplify the production
 of palsy from inflammation of the  brain, when thickening of the
 membranes, or effusion, or softening has taken place. Convulsions,
 again, are, from what has been already stated, natural consequences
 of inflammatory action upon the surface of the brain ;  and coma
 will supervene from the excited state ofthe circulation alone, inde-
 pendently of the compression resulting from the fluids poured out.
 So insidious again is the progress of these disorders,  that the first
 symptom which  conveys an idea of cerebral mischief, often has one
 of these startling characters.
  In other cases, fever, watchfulness, acute headach, impatience of
 light, suffusion of the eyes, and delirium, stamp a decided character
 on the attack.
   In other cases, when the attack is masked by fever, on the sub-
 sidence of the latter, the tongue being clean, ths pulse  reduced in
 frequency, at  the time when decided improvement  should be no-
 ticed, in its place headach, squinting,  and a disposition to coma
 supervene.
  It is, again, difficult to localise by symptoms the seat of cerebral
 inflammation.
  Inflammation ofthe dura mater is generally characterised by less
sensorial disturbance than  inflammation of the deeper parts.   It
necessarily implicates the  bone; and its existence often becomes
suspected through the presence of caries evinced in the os temporis
by discharge from the ear,  in the ethmoid by suppuration in the
nose.  In the following remarkable  case,  the  first clear light as to
the nature of the disease seems  to  have been thrown by the con-
dition of the cranium.
  " A lady, aged twenty-two, in the evening of 16th March, 1820,
was  suddenly seized with severe pain in the left temple.  I saw her
for the first time on the following morning, when I found the pulse
about 100,  the tongue white and moist; some pain continued  in
the left temple, but it was not severe;  and her whole appearance
corresponded with that of mild continued fever, though  with some
characters of an affection of the brain.   After general and  topical
bleeding, with purgatives, &c., she was very much  relieved; she
occasionally complained of pain in the head, but at other times was
entirely free from it, and  mentioned only  a feeling of confusion.
 The pain when present was occasionally referred to the left temple,
and  at other times was more general, extending over the  upper part
of the head.  Amid these  changes the first week  of  the  disease
passed, with much ofthe character of continued fever;  the tongue
white, the  pulse varying from 96  to 110, the nights  sometimes
quiet,  and  sometimes restless.   In  the  beginning of the  second
week, a swelling appeared in the left upper eyelid;  her look was
now more  oppressed, the pulse varying from 96 to 120; the pain 
THE ENKEPHALON.                   163
varying as before, sometimes a good deal complained of, and some-
times quite gone; and one day she complained of acute pain in the
right ear.   On the 27th she began to have severe shiverings, fol-
lowed by heat and perspiration, for which an eminent physician
ordered her the bark in large doses.  For two days  after  this she
seetned much better, the pulse from 90 to 96, and every symptom
greatly relieved.  The swelling on the left eyelid was punctured,
and discharged a good deal of purulent matter;  and a probe intro-
duced by the opening passed to a great depth along the upper part
of the orbit, where the bone in some places felt bare.  On the even-
ing of the 29th she was seized with slight convulsion, but it soon
subsided, and after it she seemed quite as well as on  the  two pre-
ceding days, all  the previous  symptoms being very much relieved.
On  the 30th there was  more complaint of headach, with  an op-
pressed look, and the pulse  varied exceedingly, being sometimes
very rapid, and nt other times little above the natural standard. On
the 31st there was no particular change;  she was quite intelligent,
and all her senses were entire.   When she was last visited, about
nine o'clock at night, she complained of some uneasiness across the
crown ofthe head, but no other change was remarked in the symp-
toms.  Between one and two in  the morning, she was observed to
be slightly incoherent, and soon after sunk into  a state of lowness;
did not speak, but seemed quite sensible, and  died at three.  Very
slight delirium had been observed on a preceding night, about the
28th, and once she had complained of dimness of sight, but none of
these symptoms had been again taken notice of.
   " Inspection.   On raising  the skull-cap, a good deal of purulent
matter escaped, which had been collected betwixt the bone and the
dura mater.  The space in  which it had been contained was de-
fined by an irregular elevated margin of adventitious membrane, by
which the dura mater had adhered to the  bone,  the included space
being about the size of a erown  piece : it was on the anterior part
of the right hemisphere.  The dura mater  included within this
space was depressed ; its surface  was in some places ulcerated, and
in others black, but the membrane was quite entire,  and  the bone
was sound.  On raising the dura mater, the inner surface  of this
portion had the  same irregular ulcerated  appearance as  the outer
surface, and when held up to the light, the membrane  at the part
appeared to be  in some places considerably thickened,  in others
 very thin.  The right hemisphere of the  brain, over all that part of
it which  is usually exposed  in the ordinary way of opening the
head, was covered by a thin uniform layer of very thick purulent
 matter, spread over it with great  equality, and this being removed,
 an extensive stratum of adventitious  membrane was found under
 the arachnoid.  It was irregular  in thickness, being most remark-
 able on the anterior part of  the  hemisphere, and disappearing on
 the posterior part. It followed the course of the arachnoid, covering
the openings of the convolutions, but not dipping  between them.
 The pia mater betwixt the convolutions was highly vascular, but 
164            MAYO'S OUTLINES OF PATHOLOGY.

without any deposition.  On cutting into the substance of the right
hemisphere, the cerebral matter was  to a  slight depth of a dark
livid colour, but without any change of structure.  There was no
effusion in the ventricles, and the brain, in all other respects,  was
quite healthy.   The suppuration in the left orbit was confined  to a
cavity betwixt the orbit, and the ball of the eye, without any dis-
ease of the bones, and without any internal disease  on that side of
the cranium."—Abercrombie.
  The following case  exemplifies extensive inflammation of the
arachnoid and pia mater. It is remarkable for the exclusive locality
ofthe disease, and the obscurity of the symptoms.
  " A child, aged between  three and four, had scarlatina mildly in
the middle of June, 1824,  having been confined only  four or  five
days.  He had  been down stairs for several  days, and once or
twice out of doors;  when, on the evening of the 23d, he became
feverish, and complained of his bowels.  After the operation of some
laxative medicine  he was  much relieved on the 24th ; his pulse,
however, continued frequent.  On the 25th he again complained of
his bowels, and was feverish ; but in the evening he was again re-
lieved, and no symptom was remarked, except that  his pulse con-
tinued slightly frequent, and at one time he complained of uneasi-
ness  in his eyes.  In the night he was restless, but still complained
only of his belly; his bowels had been freely moved, and the  mo-
tions were natural.  On the 26th he had frequent vomiting, and in
the evening became oppressed; pulse 120.   I saw him for the  first
time at  night.   He was then in a state of oppression,  evidently
verging towards coma; could be roused, but without taking much
notice of objects; pulse 120; countenance and eye natural. Topical
bleeding, purgatives, cold applications, &c. were employed.   In the
night there was frequent vomiting, every medicine  being brought
up, and  the bowels were not moved.   On the 27th the coma  was
increased,  and  there were through  the day  frequent convulsive
affections  of the face  and arms;  pulse  120,  and weak; pupil
dilated, and the eye insensible;  died  early in the morning of the
28th.
  " Inspection.—On removing the dura mater, the whole surface
of the brain was found to be covered by a continued stratum of
yellow adventitious membrane,  deposited  betwixt  the arachnoid
and pia mater.   It was thickest above the openings betwixt the con-
volutions ;  in npny places it was traced dipping betwixt them to
the depth of half an inch; and in some places, on the right side of
the brain, it followed the course ofthe pia mater through the whole
depth of the convolutions.   The deposition was  general over the
whole brain, and on the upper and anterior parts of the cerebellum;
and there was  a good deal  of it about the optic nerves.  The  pia
mater and the arachnoid adhered every where  very firmly together
by means of it; when they were separated, the arachnoid  presented
no unusual appearance, but the pia mater showed throughout the
highest degree of vascularity; the deposition was entirely confined 
THE ENKEPHALON.
165
to the space betwixt the membranes, for no vestige of it could be
traced either  on the outer surface of the arachnoid,  or the  inner
surface of the pia mater.  There was no serous effusion, and  the
brain and the cerebellum were perfectly healthy;  the bowels were
in many places irregularly distended with flatus."— Abercrombie.
  By the term acute hydrocephalus, a disease is  understood com-
mon in infancy, yet occurring occasionally  Inter in life, the nature
of which is inflammation of the brain and  its membranes, with  a
tendency to terminate in serous  effusion,  and  characterised by a
combination of all or several of these symptoms,—pain in the head,
sensibility to light, restlessness, starting  from sleep and screaming,
squinting, convulsions, dilatation of the pupils, coma.
  Attacks  corresponding to  this description are frequently fatal,
without  having gone beyond  the inflammatory stage.
  "A child, aged two and a half years, affected with hooping-cough
in a very mild form, was attacked, in the end of May. 1822, with a
convulsive twisting of the hands, to which she had  been formerly
liable at  an early period of life;  this excited  no alarm till the 4th
of June, when she was seized  with  general convulsion, accom-
panied with fever, headach, and  an obstinate state of the bowels.
All  the  usual remedies were employed with activity, but the con-
vulsions continued to recur several times in the day, and she died
on the 8th.   The cough had  gone on, but in a mild and favourable
form.
   "  Inspection.—There  was  slight increase  of vascularity  of the
pia mater, with numerous red points throughout the medullary sub-
stance of the brain.  No other disease could be discovered on the
most careful examination, and all the other organs were healthy."—
Abercrombie.
   "A child, aged five, affected  with hooping-cough, on the 5th
June, 1822, was seized  with headach and fever; had afterwards
irregular motion ofthe eyes, with occasional squinting, then violent
convulsions, which recurred  frequently and alternated with coma;
and  he  died in  three days.   After death,  nothing  could  he  dis-
covered, on the most careful  examination,  except increased  vascu-
larity ofthe  pia mater in several places."
   In the following cases, serous effusion, identifying the hydroce-
phalus, had taken place.  It is evident that the term hydrocephalus
applies to an occasional  and almost accidental  consequence of the
real disease ofthe brain.
   "A boy, aged twelve, (August, 1818.) had been for several weeks
observed to be languid and declining in strength, with some cough
and pain in his breast.   A fortnight before death  he  began to com-
plain of his head, and was then first confined to bed. After a week,
when he was first seen by a medical man, he still  complained much
of his head, was oppressed, and answered  questions slowly and
heavily; had some diarrhoea and frequent pulse.  The oppression
increased,  and four days before his  death he lost his speech and the
power of the right side.   This was followed by blindness and per-
       20—a '                                  12 may 
106
MAYORS OUTLINFS OF PATHOLOGY.
feet coma, and  he died about the fourteenth day from the com-
mencement ofthe affection ofthe head, the pulse having continued
uniformly frequent through the whole course ofthe disease.
   Inspection.—All the ventricles were distended with  fluid;  the
septum and fornix were so completely broken down,  that,  the two
lateral ventricles and the  third  ventricle  seemed  to  form one
cavity; there was also extensive  ramollissement of the  cerebral
substance on  the anterior part, so that the cavity thus  formed by
the ventricles extended within half an inch of the anterior part of
the brain.
   "A boy, aged seven, (October, 1818,)  had fever, and headach,
which was referred chiefly to the  back part of  the head,  and  the
bowels were obstinate.  After six  or  seven  days the pulse came
down to the natural  standard.  The headach  continued  without
any remarkable symptom till a few hours before his death, when
he fell into a general state of tonic spasm of the whole body.  He
died, after continuing in this state two or  three  hours, about the
fourteenth day of the disease. There had  been in this case no coma,
but he had continued quite sensible till the attack ofthe convulsive
affection.
   " Inspection.— The  ventricles were distended  with   fluid, and
there was extensive ramollissement of the septum and fornix, and
ofthe cerebral matter immediately surrounding the ventricles."
   -------,  aged nineteen.   May  5th, having previously  enjoyed
good  health, was seized suddenly with intense pain over the eyes,
which continued very severe:  the following morning sickness and
vomiting supervened.  He retained his  intelligence till the 10th,
after which he scarcely spoke till the  17th, when for a  short time
he appeared  more sensible:  he was  delirious  during  the night:
latterly evacuations passed unconsciously. On the 20th  of May he
was  admitted  into Guy's Hospital under Dr.  Addison.  At that
time, face flushed, eyes suffused and fixed, yet seeming occasionally
to follow objects; pupils rather dilated, and  nearly insensible;
breathing sonorous; deglutition imperfect; power of motion in the
extremities perfect, but feeble; pulse 140:  became  convulsed to-
wards the evening, and died.
   Dura mater natural; arachnoid  dry ; veins of pia mater turgid;
convolutions ofthe brain flattened. Bloody points in the substance
of the hemispheres.  Corpus callosum arched  by fluid  beneath, of
which there were three ounces in the ventricles: parietcs of the
ventricles soft:  vessels ofthe chorioid plexus turgid.—Bright.
   Delirium tremens appears to be the supervention of inflamma-
tory action in a brain already weakened by over-excitement, gene-
rally from drinking.   It  is attended by delirium of more or  less
violence, out of which the patient may be temporarily roused, by
vascular action greater or less in degree, which sometimes admits
of reduction by purging and bleeding; by an enfeebled and tremu-
lous character of the  expression and gestures, continued from the 
THE ENKEPHALON.                  167
previous state of health.   In  as  far as the disease depends upon
previous over-excitement, it is remarkably benefited by opium.
  A. B., a butcher, aged forty-three, stout and broad built, addicted
for twelve years to drinking: stomach disordered; had taken little
solid food for three weeks.   On the 17th he  found  great difficulty
in swallowing a cup of coffee, from the tremulous state of his handa
and from sore throat: this was quickly followed by cerebral excite-
ment, with delirium  and violent muscular exertion.   He died on
the 19th.
  The  dura mater  firmly adherent to the skull:  several small
cauliflower-shaped ossific patches on the dura mater, and especially
on the falx,  and a considerable quantity of serous effusion  beneath
the arachnoid.  The veins of the pia mater  turgid.   The cerebral
matter generally pale, and the incised surface exhibited few bloody
points.   Part ofthe right lung was inflamed.—Bright.
  A gentleman of intemperate habits had become suddenly delirious
the day before.  Leeches had been applied to his temples; and his
delirium so far from being relieved seemed to  be greatly aggravated,
so that he passed the night in most violent agitation, requiring the
strength of two or three persons to hold him.  On his expressing a
desire for a  mutton chop and some porter, they were given him, and
he was better for them.  His mind  became calm and  collected:
when Dr. Bright saw him shortly afier, little but general  nervous
agitation and a hurried manner of speaking  remained; and a few
doses of opium with calomel were all  that there was occasion  to
recommend.   He afterwards said that the state of his mind during
his delirium was such  as to make him believe himself two persons;
one of which, as in a dream,  had committed  murder,  was tried and
condemned ; while the other  was alive to real persons  and thing*
arouyd him.—Bright.

                § VI.—Concussion of the Brain.

  The direct effects of violent concussion of  the brain are syncope,
and something more.   The syncope results  from'the physical in-
fluence which the brain exerts upon the heart, independently of the
mind.   The heart is struck with feebleness,  the pulse is hardly to
be felt, respiration scarcely takes place, the limbs are relaxed,  the
countenance and lips are pale and bloodless.  As the heart rallies
and its action returns,  the effect of the concussion upon the con-
dition ofthe mind becomes apparent. Its associations  are unhinged
and disjointed; one thought  fails to  suggest another; and the pa-
tient, although  recovering, perpetually  loses himself.
  A lady, who was thrown from her horse and  stunned, yet reco-
vered enough to be seated again upon her horse, and to ride home.
She told me, that though able to keep her seat  and  to guide  the
horse,  she was perpetually lost, and  seemed every  instant to  be
waking and collecting herself, and recollecting where  she was. 
168            MAYO's OUTLINES OF PATHOLOGY.             £P|

  It is sometimes  many days before the brain  rallies its powers^
A boy was brought into the Middlesex  Hospital labouring  under
concussion : for three weeks he continued in a state of remarkable
insensibiliiy, at times only, or when  roused, screaming aloud:  his
pulse was extremely slow and languid all  this time:  he gradually
recovered.
  In other cases the mind recovers in a few hours, but not without
falling into excitement, and trouble of thought, and slight delirium.
In such a case, the patient requires the most careful watching and
treatment,  to ward off cerebral inflammation, which in any of its
forms is liable to ensue.
  It has  been mentioned that simple concussion of the brain may
bruise the cerebral  substance; which, if  examined shortly after the
injury, presents the common appearances of ecchymosis.  There is
no reason to doubt that the brain may recover from this state; but
if the bruising be considerable, it greatly increases the risk of sub-
sequent inflammation.
  Concussion of the brain is constantly attended with  vomiting.
The instance  in medical  pathology to which it  is most parallel, is
the  first stage of apoplexy from rupture of a vessel, which  is cha-
racterised by paleness, feebleness of the pulse,  and vomiting.  In
that case, in truth, the cause of the symptoms  is equally mecha-
nical—a  blow from the gush of blood upon the brain.

    § VII.—Compression of the Brain from external violence!

  The medical pathology  of the brain throws  the clearest light
upon every part of its surgical pathology: the practical conclusions
are  the same for both; with this addition, that as the cause in  the
latter is external and  mechanical, it is  often possible to give me-
chanical  relief: compression of the brain from an injury differs in
the  symptoms which attend it  in  no  respect  from  compression
caused by spontaneous extravasation.
  I  attended, with Mr. Stevenson of Edgeware  road, a publican,
about forty years of age, who had been  thrown  out of a gig when
driving at a rapid  pace.  In falling  he had received a severe blow
upon his head behind the left ear.  He was stunned for an instant,
but quickly recovered his senses, and answered questions  put to
him; his  mind, however, was not collected;  he was sick and
vomited,  and in about an hour fell into a  state of stupor.   There
was no depression  or fracture of the bone.   It was evident that by
the shock a vessel had been ruptured within the skull, from which
effusion had gradually taken place.   This patient continued in a
state bordering upon coma  for several  days, when he became more
sensible and finally recovered.   But for a long time he had  double
vision: he has permanently lost the sense of  smell; and  is  not
capable ofthe same bodily or mental exertion as formerly.
  A young man had a small portion of the left  parietal bone  de-
nuded by a blow;  it became necrosed, and was already beginning 
THE ENKEPHALON*
169
to loosen, when he observed  that the thumb and fore-finger of the
right hand  were weak and numb: in a day or two  he was taken
with a slight epileptic seizure, which lasted four or five minutes: a
similar fit recurred a few days afterwards.  This 1 attributed to the
confinement of matter between  the bone and  dura mater; but as
the bone was loosening, it was evident that there would shortly be
a free  escape  for the matter; so that I thought  it better not to
apply the trephine, unless the symptoms became more urgent.   As
the ulcerated groove around  the dead portion of bone enlarged, the
palsy of the thumb went away, the patient had no  return of the
epileptic seizure, the dead bone separated, and he recovered.
   " The following case occurred in  St. George's  Hospital, under
the care of Mr. Keate.  A man was admitted who had fallen from
the top of a coach, and  had struck his head.  He was stunned, and
continued  insensible after being brought to the hospital.  At the
end of two days, when he had begun to recover from this state of
stupor, he  was seized  with  violent  convulsions, affecting not only
the muscles of his limbs, but also those of his face. The first attack
of convulsions continued about six minutes, but this  was succeeded
in the course of an hour and a quarter by four similar  attacks, and
in spite of  a considerable quantity of blood being taken  from  the
arm.   At the end of this time Mr. Keate saw him.  and  made an in-
cision  through the scalp  at  that part which had received the vio-
lence of the injury.  A fracture about an inch in length was dis-
covered at the posterior part of the left  parietal  bone, extending
into the lamboidal suture  with a slight depression. At this part Mr.
Keate applied a saw, and removed the depressed portion of bone.
A small coagulum of blood  was found lying on the surface of the
dura mater, and this having been exposed, there was no recurrence
of the convulsions."
   A patient under  the care of Sir  Benjamin  Brodie,  after a blow
upon the head, experienced  intense pain :  he  had no other symp-
tom, except that  the pupil of one eye was preternaturally dilated.
There was a fracture, with depression of a very small portion of
one parietal bone:  immediately that it was elevated, the pain in
the head was completely relieved.
   Sophia  Pennett, aetat. sixteen, was admitted into the  Middlesex
Hospital under  the care  of Mr. Joberns,  on the  19th of October,
 1815   She  had been knocked down in  the street by a carriage,
the wheel  of which had grazed the left  temple  and denuded the
parietal bone.  She had  lost a considerable quantity of blood from
 the temporal artery, was low and weak, and vomited.   Ihe par
 exposed did not recover:  about a third ofthe surface ofthe parietal
 bone was  necrosed.  November 9th, having gone on favourably in
 the interval, but complaining occasionally of pain in the nacK ot
 the head,  she was taken with shivering, and sickness.   Nov. 10,
 she could  not articulate: pulse CO, and irregular;  at times insen-
 sible   12th. cannot put out her tongue:  right side  of the lace and
arm paralytic.  Nov.  14, Mr. Joberns trephined the parietal bone, 
170
MAYO's OUTLINES OF PATHOLOGY.
 when about a teaspoon fill of matter escaped, which had been con-
 fined  between the bone and  dura mater: the latter  was covered
 with a layer of organised  lymph.  The operation was performed
 about one o'clock; it was followed  by an immediate  amendment.
 Nov.  15: now quite sensible;  her speech  in great  measure re-
 turned; she  can move her arm.  From  this period her recovery
 was rapid.
   Thus as long as effused fluid (or, which  is the same  thing in
 effect, a portion of depressed bone) is exterior to the  dura mater,
 the various cerebral symptoms, convulsions, pain, stupor, or palsy,
 admit of being relieved by its removal.  There are even on record
 cases, in which blood  effused [in consequence of an injury] within
 the dura mater has been let out successfully; but such cases are
 necessarily of  extremely rare occurrence, as  they presuppose an
 injury so violent as to have menaced much greater mischief than
 the superficial extravasation.
   "The late Mr. Chevalier was called to a child  a  year and a half
 old, who had received a severe blow on the head.  The child  lay
 in  a state of  insensibility, and  was  affected with  convulsions.
 There was no  wound ofthe scalp, but on an attentive  examination
 of the head the fontanel appeared to  be somewhat elevated.  Mr.
 Chevalier was  led  therefore to make a crucial incision  of the scalp,
 by dissecting up the corners of which he exposed the  fontanel.
 He then made an angular incision  of the right side of  the fontanel,
 and raised the  membrane forming it so as to  expose the surface of
 the dura mater, beneath which the purple colour of extravasated
 blood  was plainly to ^e seen.  A puncture  being  made carefully
 with  a lancet,  the  blood issued  at first with considerable  force,
 spouting to the distance of a foot.   Three or  four ounces of blood
 escaped;  the symptoms were  immediately relieved, and the child
 recovered without any further unfavourable symptoms.
   "The following case, which is  still more remarkable, occurred
 to Mr. Ogle of Great Russell street.
   "A woman, who kept a cellar  in Monmouth street for the sale of
 second-hand linen, &c. fell  from the street,  head foremost, to  the
 bottom of the cellar.  When taken up she was  in a state  of total
 insensibility.   Mr. Ogle  being immediately  sent  for, found her
 lying as if in a  fit of apoplexy.  He ordered her head to be shaved,
 and, on examining it afterwards, discovered no wound  of ihe scalp,
 but observed  that she  flinched very much when pressure was made
 on  one spot  near  the  anterior and  superior  angle of one of  the
 parietal bones.  Having made an incision  of the  scalp at this part,
 he could perceive no appearance of fracture.   Nevertheless as the
 woman was manifestly in imminent danger, he thought it expedient
 to remove a portion of the bone with a trephine,   immediately on
 the bone being  removed, the dura mater of a dark colour rose "into
 the opening nearly as  high as the external  surface of the cranium.
 Convinced from its appearance, and  from the feeling of tension
communicated  to the  fingers, that a fluid was interposed between 
                      THE ENKEPHALON.                  171

it and the brain, and that that fluid was blood, Mr. Ogle ventured
to puncture the dura mater with  the point of a lancet.  The
puncture was instantly followed by a stream or jet of blood, which
spirted out to the  height of some feet.  Immediately on the blood
being discharged, the  woman, who till that moment had continued
totally inseusible,  opened  her  eyes.   After  looking  about  her,
apparently amazed, she exclaimed, ' What is the matter? what are
yon doing with  me??  and was able  to give a clear account of the
manner in which the  accident had occurred.  From this time she
recovered without  any untoward symptoms.  It was impossible to
ascertain  the precise  quantity of blood which escaped through the
opening of the dura mater, but Mr. Ogle supposes it to have been
about- three quarters of an ounce."— Brodie.
  When, after the  removal of a portion of bone, the dura mater
sloughs, a new feature presents  itself.   The brain is assailed from
within by an increased force of the  circulation, at a time when its
usual external  support is  wanting.   Under  these circumstances
there gradually protrudes from  the cranial cavity a rounded mass,
partly consisting of the proper cerebral substance, partly of effused
lymph and  clotted blood.   This  protruded substance  cannot be
returned; nor even can its increase  be  strongly repressed, lest
symptoms of compression should  supervene.   On the other hand,
the tumour  must  be  supported, or there will be more, and rapid,
and  destructive escape  of cerebral substance.  The  art  of the
surgeon is here directed to removing what has already escaped,
and making afterwards just as much pressure as may be maintained
without injury, to prevent any additional extrusion of brain.

  The ideas generally entertained respecting the symptoms of con-
cussion and compression of the brain  are  that the former are no
more than syncope; and that the latter consist of stupor, with one
or both pupils fixed, stertor, laboured pulse and  breathing, and
commonly partial hemiplegia.
  The remarks aud instances above given tend, however, to show,
that in concussion  an effect of greater or less duration is traceable
on the mind after the syncope has passed away:  and that by com-
pression,  not only the commoner symptoms  adverted  to  may be
produced, but all the others which medical pathology makes out to
flow  from the apoplectic states ofthe brain.
  The different effects of compression, are—
  I.  Coma without stertor:  commonly resulting from  extensive
cerebral laceration  and  hem>rrhage;  but  sometimes from remedi-
able  extravasation.
  2.  Coma with stertor, and partial  hemiplegia: often resulting
from depressed bone,  or circumscribed extravasation, or suppura-
tion, upon the dura mater.
  3.  Coma with violent, convulsions;  resulting from extravasation
on the surface of the brain, sometimes situated without the dura
mater. 
172            MAYO's OUTLINES OF PATHOLOGY.

  4.  Epileptic seizures;  from  small circumscribed effusion  [or
depression of bone?] upon the'dura mater.
  5.  Acute pain in the head, from depression of bone.
  6.  Sudden and great decline of frequency in  the pulse.  This I
witnessed in a child, supervening several days after fracture of the
skull.  The symptom was followed  in a few hours by coma and
hemiplegia: there was extensive suppuration between the bone and
dura mater.
                      CHAPTER VIII.

                          THE SKIN.

  The pathology of the  skin, from its  numerous divisions, from
the minute and trivial character which attaches to many of them,
and the vast importance and extent of investigation which others
claim for themselves, is hardly a fit subject to  be  included  in the
present treatise. I have, however, ventured to compress within a few
pages a sketch ofthe affections ofthe skin, in the belief that, imper-
fect as the following outline is, it may not be unacceptable or use-
less to the reader.
  I have divided the subject into three sections.  In the first, I have
included affections ofthe skin, which  have points  in common with
the pathology of other organs: in the  second, I have given the pe-
culiar diseases, principally of an inflammatory nature, and constitut-
ing eruptions, which so singularly characterise this organ:  in the
third, I have enumerated the principal forms of ulcers in which the
skin is involved.
  In  the second section,  I have closely followed  and adopted the
descriptions of Rayer, from  Dr. Willis's excellent translation, re-
placing only, which 1 think he has unwisely"separated,  the  notice
of the syphilitic eruptions among the  others.   In  the  first, 1 have
borrowed many parts from Rayer.  In the third, what I have stated
is the result of my  own  observation,  concurring, I suppose, with
that of other surgeons.
                          SECTION I.

  1. Injuries and reparation of the skin.—No  texture in the sys-
tem unites by adhesion with such  promptness as the skin. The me-
dium of union is a thin layer of lymph, which in coagulating glues
together the opposed surfaces, and afterwards becoming penetrated
by the blood vessels, is finally absorbed.   Union of a section ofthe 
THE SKIN.
173
skin of small extent is established in less than twenty-four hours.
The reparation, however, has at that time little mechanical strength,
and the divided part is easily forced open.   In incisions of any ex-
tent, union  is determined  by the fourth day.   About the third  or
fourth day succeeding a wound, unless adhesion  has taken  place,
inflammation supervenes; upon which serum  is poured  out  from
the swollen  edges, and the intervening layer of lymph is either de-
tached or absorbed.
   When the injury ofthe skin is  superficial only, and  parallel to
the surface, the cuticle is liable to  be razed and rubbed off; or se-
rum being poured out below it, it  may be elevated so as to form a
blister.  In either case the cuticle is quickly regenerated.
   Or the entire thickness ofthe cutis may perish,  through a bruise
for instance, or a severe burn.   In this case the mortified part be-
comes detached by the process of ulceration :  the subjacent cellular
tissue pours out lymph, which coagulates, and becoming organised
forms granulations.  When th-se  have acquired  a certain height
and firmness, their surface upon the edges ofthe healing sore, or at
its centre, or  in both places, becomes  opaque, smooth, and white;
the denser texture thus produced gradually spreads over the whole
wound, and forms the cicatrix.  In time a cicatrix becomes harder
and firmer than the adjacent skin : at  the same time it draws toge-
ther from the circumference, stretching the surrounding sound  in-
tegument.  A cicatrix is covered  with a  cuticular  surface,  which
however cannot be detached from  it.  In the coloured races of man-
kind, a cicatrix is at first white ; but  it gradually becomes darker
than the adjoining skin.
   When the cuticle  has been raised by blistering, the application of
irritants to  the skin causes the  exposed surface ofthe chorion to
granulate and suppurate.   The irritant being removed, the inflam-
mation subsides, and cuticle is again formed.
   Continued exposure of the feet and  hands to cold, causes the in-
tegument to inflame, producing chilblain.  In this affection the skin
is at first white, then becomes red and  swollen, tingling and itching
when warmed.  The red colour afterwards changes to a leaden hue.
In a severer form, the cuticle is raised in  blisters, leaving indolent
excoriations; or gangrene may take place.
   White gangrene is an affection ofthe skin, in which, without any
assignable cause or preliminary symptom, patches of skin, of the
area of one, two, or three square inches, suddenly die.  White gan-
grene occurs sometimes on the breast.   In the museum of  King's
College there is a model of white gangrene, in which the disease at-
tacked the arm, several patches of cutaneous gangrene successively
forming: the sphacelated  parts were  while "from  the commence-
ment ofthe process to their  separation, when  healing and healthily
granulating sores were left.  [A. 1.]
   2. Hypertrophy of the skin presents several forms.
   Hypertrophy  of  the chorion.—The skin over subcutaneous tu- 
174
MAYO'S OUTLINES OF PATHOLOGY.
mours grows with their  growth: hence  in  their extirpation it is
generally necessary to remove part of the integument covering them.
  The skin, in a person whose arm is modeied  in the King's Col-
lege museum,  is thickened upon  the  back part  of the limb, of a
brown colour, and hangs in a thick pendulous flap several inches
in length.  The hypertrophy was congenital.
  The integuments of the nose  are  particularly liable to enlarge
and thicken. After the removal of a part of the hypertrophied mass,
the wound cicatrises wholesomely.
  The extension or thickening of the  integuments is a prominent
feature in the elephantiasis Arabica and Barbadoes leg ; but the skin
and epidermis in these instances  partake only of a general enlarge-
ment, the result, as it seems, of obstruction ofthe absorbents.
  Hypertrophy of the papilla..—Ulcers of the legs, chronic eczema,
impetigo figurata, and blisters, are occasionally accompanied or fol-
lowed by  an unusual developement of the papillae:  these become
particularly apparent when the part affected is  plunged  in water,
and look mammillated and uneven, like the pile of coarse plush or
velvet.  The skin in these cases is habitually covered with  scales
of epidermis, sometimes micaceous in appearance, generally brown,
and easily rubbed off.
  Hypertrophy of the epidermis.—Ichthyosis  is the name  given
to this affection, which is generally congenital, sometimes acciden-
tal, and is met with in  various degrees of intensity
  The^cuticle  in some instances looks only dry,  rough, and dirty;
the dark colour or greatest thickness of cuticle being  in those parts
where the epidermis is naturally disposed to be rough,  as  at the
knee, the elbow, the fore and outer part ofthe leg.
  In other cases, the thickened epidermis has an appearance resem-
bling that  ofthe legs of fowls.
  In a few cases, as in the family of Lambert, the porcupine man,
the entire  skin, with the exception of the face, the palms of the
hands, and soles  of the feet, is covered with small brown excres-
cences, in  the shape of pimples, so hard and elastic as to rustle and
make a noise when the hand is passed over them.
  In ichthyosis, the skin, divested of the  scales, is not unusually
vascular.  The scales are often shed at regular periods, and recur
again. Irritants applied to the skin, or inflammation casually super-
vening,  will detach them; but they grow  again.
  Hypertrophy of the papilla and epidermis.—Warts or verrucae
are fringes of elongated and vascular papillae encased in epidermis
of variable thickness.
  3. Discoloraliens.—Stains of the skin, or alterations of the colour
ofthe rete mucosum, depend on various causes.
  a. Pigmentartt navi are congenital stains of different colours.
  b. Ephelis.   The browning produced by the sun.
  c. Lentigo, freckles: small yellow spots, appearing from the  pe-
riod of infancy in persons with light or red hair and light blue eyes. 
THE SKIN.
175
  d. Chloasma, [pytyrlasis versicolor.] characterised by  one or
more  accidental spots or patches, from  ihe size of a millet  seed to
that ofthe palm of the hand : they are dry, generally without pru-
ritis. and of a pale or brownish  yellow colour, which are  seldom
developed but in the trunk. Spots of chloasma are more particularly
observed among  persons whose skins are fine and  delicate,  and
among pregnant women.  Their duration is very variable.
  e. Melasma, [pytyriasis nigra,] temporary blackness, with rough-
ness ofthe skin, and furfuraceous desquamation.
  /. Nigrities, change of colour to blackness.
  A lady, says Lecat, about thirty years of age, became  pregnant.
About the seventh month the forehead assumed a dusky hue, of the
colour of iron rust:  by  degrees the whole face became  entirely
black, except the eyes  and the edges of the  lips, which retained
their  natural colour.   The hue was deeper on some days than
others.   This lady being naturally of a very fair complexion, had
the appearance of an  alabaster figure with a black  marble bead.
Her hair was naturally exceedingly dark ; but the part of it which
grew from the dark-coloured skin appeared coarser, and  filled with
a blacker sap than the rest, to the height of  about  a line or two
above its roots.  She did not  suffer from headach ; the appetite was
good ; the  face after becoming black was very tender to the touch :
the black colour disappeared two days after her accouchement, with
a profuse perspiration, by which the sheets were stained black.  The
child  was of a natural colour.  In the following  pregnancy, and
even  in a third, the same phenomenon reappeared in the course of
the seventh month : in the eighth month it disappeared ; but during
this month the lady became  subject to convulsions,  of  which she
had an attack each day.
  g.  Leucopathia.  The conversion of the  skin  to a colour  as
white as snow, takes place not onlv in  blacks, but in Europeans.
  h.  Slate colour from nitrate  of silver.  The skin  and acciden-
tal  cicatrices, the conjunctiva, and  the mucous membrane of the
fauces and stomach and intestines,  are susceptible of this  change.
The dark slate or bronze colour is deepest  on the surfaces  exposed
to the light and air.  With years, it gradually becomes  paler.  Its
place is found to  be the chorion, and membranous tissue: the colour
remains in these tissues after boiling.   Mr. Biande assures us, that
he  detected oxide of silver in the stained organs,
   4.  Hemorrhages.   Under this lit!e are classed extravasations of
blood deposited in the texture ofthe skin,  which  when small circu-
lar spots are called petechiae, when  larger marks are  calhd ecchy-
moses.  They'occur in attacks presenting the following differences.
   Purpura  simplex.—The eruption  commonly petechial, some-
times mixed with ecchymoses. with  little or no disturbance of the
health ;  the spots on the arms,' legs,  neck ; sometimes in the face :
period uncertain.
   Purpura urticans.—The extra vasal ion preceded  by  the forma-
tion of reddish oval or circular-shaped spots, prominent, and accom- 
176
MAYO's OUTLINES OF PATHOLOGY.
panied by smarting or tingling sensations.  The little spots, usually
ofthe size of a lentil, sink at the end of two or three days to the
level of the surrounding skin: their colour, which was pink at first,
becomes at the same time deeper and livid. New spots appear while
the first are going off.  They appear most frequently upon the legs,
and sometimes in other regions ofthe body, mixed with true  pete-
chias: the lower extremities in  these cases  are often cedematous.
The eruption is generally  of a month's duration, or longer.
   Purpura hemorrhagica.— Externally the same features as pur-
pura simplex, but characterised  by attendant hemorrhage from some
of the mucous membranes;  epistaxis in children, menorrhngia in
females,  pulmonary and intestinal in  adults: the circulation  ex-
cited at the commencement; afterwards supervention of fever, and
typhoid symptoms.
  Purpura febrilis.—Purpura simplex preceded by two or three
days of  fever: ordinary duration from two to three weeks.  There
is likewise a purpura urticans febrilis. When purpura exists, trifling
pressure upon the skin produces ecchymosis.
  Purpura senilis.—Spots the colour of wine lees, lasting a  month
or more, on the hands and arms of elderly people, without attend-
ant symptoms.
  Petechial spots occur incidentally in typhoid fevers ofthe gravest
class.
  5. Alterations in the condition of the blood vessels.—Of these
there are two principal.
  a. A varicose state of the minute veins.—This is often seen in
the skin ofthe thighs, legs, and insteps of persons in whom the ve-
nous  trunks  are varicose.   One of these  minute veins will some-
times give way, and bleed with surprising violence.  The remedy
is to destroy the vessel with caustic potass.
  6. Vascular  navus.—This affection  is  congenital.   At birth it
looks like a fleabite, but growing rapidly  it becomes a raised and
highly vascular tumour ofthe skin ; generally circular, but often of
an irregular figure,  from the junction of two  or three adjacent naevi.
Left to itself, a vascular naevus  enlarges and ulcerates, and bleeds,
and the infant sinks.  These tumours, when very minute, may be
cured by vaccinating upon them; if larger  they  require  to  be re-
moved by the knife, the ligature, or the caustic,  [m.  6.]
  The texture of which they are composed does not appear to me
to deserve the name of erectile tissue. The vascularity I believe to
be arterial, not  venous.  When divided in an operation, these tu-
mours pour out arterial blood  profusely.   When  removed and ex-
amined, they  are found to  be lobulated. of a firm  texture, and of a
pink colour from the blood they have contained.  The ed<re ofthe
morbid structure is clearly defined.
  This structure is not confined to the skin ; I  have seen it in the
parotid gland, in the lymphatic glands, in the gland ofthe breast in
an infant, in the subcutaneous cellular membrane in  different parts. 
THE SKIN.                      177
Large subcutaneous naevi  are often combined with small  nasvi of
the integuments.
  6. Morbid growths.
  Chehtid tumour.-— A reddish  point, of the form and dimensions
of a grain of barley, rising on some point of the healthy skin, or on
the cicatrix  of a smallpox pustule or burn, is first observed, which
slowly enlarges, its surface covered with numerous transverse wrin-
kles, but smooth.  Increasing, it preserves its redness and hardness,
and shapes itself either as a broad  cylindrical crest or ridge, or as a
flattened tumour, sending off prolongations from its  circumference
having some resemblance  to the claws of a crab.  This growth is
of rare occurrence ; it does not  ulcerate :  when removed, it has re-
turned :  left to itself, it has after some time been found to shrink.
   Cartilaginous tumour.— 1 removed from the ham a painful  tu-
mour, of the size of a  chestnut, which had been long in forming.
[rn. 10.]  It  was seated in  the texture of the skin, and its firm and
uniform  texture, with very slight transparence, more resembled car-
tilage than any other tissue.  This tumour was of the texture, but
not of the form, described by Rayer as mollusciform cancer. Rayer
describes a case, in which many hard lenticular tumours formed on
the trunk, limbs, and face.   They were not painful when handled;
were of a deep red colour,  and very much  raised above the level of
the skin.
  True carcinoma occurs in the skin,  adjoining a  glandular can-
cer. It occurs  likewise primarily.   Elizabeth Taylor, aetat. seventy.
Three years ago the skin ofthe left heel was made sore by a  brass
nail in her shoe, and a tumour  formed, which gradually increased,
and for the last year was the seat of constant intolerable pain.   She
was admitted into the Middlesex Hospital, in June, 1835, when I re-
moved the tumour.  It was a large oval disk, four inches in its long
diameter, and  more than half an inch thick in its middle, adhering
by a short thick pedicle to the outer edge ofthe foot: the  incision,
which was free ofthe pedicle, left an oval wound two inches by one
and a half. The skin cut through was red, but not indurated. The
wound healed by granulation, and there has been subsequently no
pain or thickening. It is remarkable that she has a mass of harden-
ed glands, as big as an orange, in the left groin, which had  given so
little uneasiness, that  before the operation, she said  there was no
swelling there. They show no present disj osition to enlarge.  The
tumour  removed  was of a white,  dense, crisp texture, with mem-
branous bands intersecting it.
   Melanosis.—Melanosis  may  be deposited in grains within the
substance ofthe skin, or may form true tumours in its substance, or
upon  its surface.  Deposits of the same description  almost always
take place at the same time in one or more ofthe internal organs.
   The skin  is sometimes black  with numerous melanotic tumours,
like black currants or juniper berries.  They are black throughout,
and when cut through, preseut a great resemblance  to the paren- 
178            MAYO'S OUTLINES OF PATHOLOGY.
 chyma of a truffle. In other cases, a single large cutaneous melanic
 tumour presents itself.
   Melanic tumours  rarely inflame.  Messrs. Breschet and  Femes
 have, however,  met with ulcerated melanosis several inches in ex-
 tent; and situated in the right groin,  in an old woman, at the Sal-
 petriere. This sore discharged a kind of blackish fluid, which stain-
 ed paper and linen in  the same manner as nitrate of silver.
   Medullary sarcoma.—In the neighbourhood of medullary sar-
 coma ofthe breast, fungoid tubercles continually form in the skin.
   7. Disordered transpiration.—The  perspiration varies in quan-
 tity, in  quality, in place, in odour, in different complaints; and it is
 capable, probably, were its differences well ascertained, of throwing
 light upon the nature and progress of various diseases.
   Blue sweats.—Victorine Rutland, aged sixteen,  (in  a case  de-
 scribed by M. Ballard,) stout in person, pulse regular, catamenia na-
 tural, strength and appetite good, but with a loaded  tongue and dry
 cough ; presented on the neck, face, and  upper part ofthe chest, a
 beautiful blue tint ofthe skin, principally spread over the forehead,
 alae nasi, and round the mouth.  When these parts were wiped with
 a white towel, the blue colouring matter was. detached from the in-
 tegument, and stained  the towel, leaving the skin white.   She had
 been engaged as a laundress for  the last two  years;  from the time
 she began this occupation she had  perceived a blueness  round  her
 eyes, which disappeared, however, on going into the air.   It reap-
 peared when she worked in a hot and confined place. After repeated
 venesection, sulphur with sarsaparilla was given. But this course,
 which was continued  for  twelve days, far from being useful, only
 occasioned profuse perspiration, a  material diminution ofthe quan-
 tity of urine, and a considerable increase  of the blue discoloration.
 The forehead, face, neck, and belly now became shaded with azure
 blue, which spread like clouds,  and appeared  deeper or paler,  ac-
 cording as the cutaneous circulation was  accelerated or retarded;
 when for example the  patient should have blushed, the face became
 blue instead of red.  The face, the fore part ofthe trunk, the shoul-
ders, the arms, and a portion of the thighs were alone coloured. The
linen ofthe patient was stained blue.   Shortly  after this the urine
became  very  scanty, and for three  days the patient did not pass a
drop: the blue colouring matter became more abundant:  there was
profuse  perspiration at night. This patient experienced great amend-
ment when taking several doses  of  bicarbonate of soda, which had
been found by experiment  to neutralise the colouring matter.  At
length the face only retained a slight blue discoloration, which was
increased by exposure to heat, agitation of mind, fatigue, or the cata-
menial period.  The blood that was taken from the  arms had the
usual appearance.  Some that she vomitetl contained a sufficient
quantity of blue colouring matter to stain the sides ofthe  vessel.
  8. Diseases ofthe sebaceous follicles.
  a. Sebaceous flux.—In  one form, the increased  secretion con-
tinues soft; the skin is not sensibly red or altered;  but the hair of 
THE SKIN.
179
the part affected is liable to be lost.  The complaint, more commonly
partial, may yet occur over the whole body.  In the other form, the
common seat of which is the face, the skin of the  cheeks, nose, or
eyebrows, appears covered with a kind of yellowish scurf, nearly of
the colour and consistence ofthe cerumen of the ears.  The skin
looks thickened and unctuous around this deposit, which in some
points is moist and oily, and in others of the consistence of yellow
wax.
  b.  Follicular elevnt'mns and  tumours.—When  the orifice of a
sebaceous duct becomes obstructed, the secretion is liable to accu-
mulate in a small  round sac, of the size of a pin's head.  Or it may
acquire considerable  magnitude, the size for instance of a chestnut,
and the secretion retains its peculiar odour and character ; and when
punctured or squeezed, shows no disposition to reaccumulate in un-
due quantity.
  It  has been supposed that the encysted tumours ofthe scalp, face,
and neck, have no other origin than obstructed sebaceous follicles.
Sir Astley Cooper showed,  that the horns which  grow upon  the
head and eyelids and forehead, are growths from the lining follicular
membrane.                                      ♦
   Calcareous matter is liable to form in  the sebaceous follicles.  I
removed from one ofthe meibomean ducts a  small calculus which
projected from it,  and by scratching the surface of the cornea, had
for several days kept  up inflammation of the  conjunctiva.
                         SECTION II.

                      § I. Exanthemata.

  Inflammatory affections of parts or the whole surface ofthe slain,
in which the highest point of developement is the local accumulation
of blood.
  1. Erythema.—An uninfectious exanthema, occurring without
fever, characterised by one or more red blotches, varying from a few
lines to many inches in diameter; confined to one, or scattered over
several  regions ofthe body, the duration of which in the acute state
varies from one to two weeks.
  a. Erythema intertrigo.  Redness ofthe skin, arising where two
surfaces in contact are chafed, liable to be attended with slight thick-
ening and itching, and serous or purulent discharge.  The skin after-
wards rough and chapped.
  b. Erythema pepulatum.  Small red spots not exceeding the size
of a split pea, irregularly rounded ; occurring on  the backs of the
hands, on the neck, face, breast, arms, and forearms, in females and
young people, slightly prominent, .of a bright red at the commence-
ment, afterwards of a violet hue:  sometimes occurring in rheumatic
fever. 
180            MAYO'S OUTLINES OF PATHOLOGY.

  oi  Erythema tuberculatum.
  d. Erythema nodosum. With fever preceding or accompanying,
on the arms and fore part of the legs, are eruptions of red oval spots,
slightly elevated in the centre, varying in extent from a few lines to
an inch and a half in their greatest diameter: instead of suppurat-
ing,  which they seem to threaten, they diminish, become from red
bluish,  and are resolved in ten or  twelve days, leaving bluish or
yellowish stains.
  e.  Erythema marginatum. Circular patches  of livid  red, from
half an inch to an inch  in diameter, the circumference raised, pro-
minent, and slightly papular.
  /.  Erythema circinnatum.  Patches of erythema,  forming com-
plete circles, involving healthy skin.
  g. Erythema fugax.  Diffused redness, of different  degrees of
brightness, without appreciable swelling; spread unequally over dif-
ferent regions ofthe body: the skin dry and heated : in a weak or
fortnight after its appearance, desquamation ofthe cuticle.
  h. Chronic  erythemata.—The skin  first red, then dry and scaly,
becomes hard, chaps, and is never stretched without increasing the
cracks : affecting the hands, feet, the nipples, &c.
  2.  Erysipelas.—Diffused redness, with slight swelling, increased
heat, and sense of pricking ofthe skin ; attended with fever, termi-
nating  in  resolution and desquamation,  in vesication,  sometimes
with suppuration or sloughing.
  a. Erysipelas rarely or never attacks any part but the head or
face, except in consequence of a wound, or irritated state of the sur-
face. It is preceded or accompanied by symptomatic fever.  In idio-
pathic erysipelas ofthe head and face, the symptoms increase to the
third or fourth day, remain stationary for the same period, and then
decline. When the inflammation is  highest, the skin rises into small
or large, single or conglomerated bladders, which  break, and the
fluid they contain dries and forms thin, hard, yellowish crusts, which
afterwards blacken.  When the inflammation  is less severe, the skin
on recovering desquamates.
   6. Phlegmonous erysipelas,  is  the complication  of  cutaneous
erysipelas with spreading inflammation  and infiltration of  the cel-
lular membrane. This complication is rarely met with in erysipelas
of the  head  and face, except about the eyelids where suppuration
and sloughing occasionally take place.   It is common in the extre-
mities  alter slight  injuries of the skin.   It is attended with great
swelling; and unless incisions are made to let out the acrid hutnonr
 with which the cellular membrane is loaded, it suppurates, and, the
 skin being isolated,  sloughs in large patches.
   c. Erratic erysipelas.   Erysipelas that has been excited by any
 local  cause will  often, when  the skin  first attacked is recovering,
 spread over the adjacent surface ofthe body, one edge beino- yellow
 and  desquamating; while the oppbsite and spreading side, having
 an irregular but definite margin, is of a bright red.  This affection
 often continues with very little  constitutional disturbance. 
THE SKIN.
181
  3. Rubeola, or measles, an exanthernatous and contagious in-
flammation, preceded by chills and  shivering; accompanied by
watering of the  eyes, sneezing, and hard dry cough ;  and charac-
terised externally by an  eruption of small red spots of the size of
fleabites, prominent  at the  points, where the cutaneous  follicles
surpass the general level, separated by irregular narrow interstices,
in which  the skin seems  healthy:  forming afterwards by their con-
junction small crescent-shaped patches, which decline towards the
seventh or eighth day ofthe attack, and are commonly followed by
bran-like desquamation.
  Rubeola  vulgaris.  A week to a fortnight after  exposure to
infection  fever  supervenes, with  nausea;  tongue white, tip and
edges scarlet.   Second day: fever aggravated, sneezing, eyes suf-
fused and watering, cough.  Third : fever aggravated, eyes swollen,
voice  hoarse,  cough, constriction  of the  chest.   Fourth;  after
vomiting, diarrhoea, or sweating, an eruption of small red spots on
the forehead, chin, nose,  cheeks, mouth, gradually by the next day
extended  over  the  neck, breast, and limbs; itching  and heat of
skin: other spots appearing, form by their conjunction small cres-
cent-shaped patches: spots on  the  soft palate.  Fifth:  the  red
colour ofthe patches at its height upon the face.  Sixth : the erup-
tion begins to decline there;  on other  parts of the body becomes
more abundant.  Seventh and eighth: the patches begin to die off
in the order of their appearance, and then assume a pale-yellowish
colour.
  With the completion  of the eruption, the general symptoms
decline in intensity.  The sense of pectoral oppression and cough
alone continue in some individuals: the nausea and vomitin^ have
ceased from the  fourth day; and the sense of heat, oppression, and
restlessness, generally vanish about the sixth.
  The patches of measles convey an impression of a rough, uneven,
or prominent surface.  They disappear on stretching the skin: the
yellow spots into which they degenerate do not.  On their decline,
the epidermis roughens, separating in  a minute bran-like  scurf,
attended with itching, that lasts till the tenth or twelfth day.
  Rubeola sine catarrho.— Vide Roseola.
  Rubeola nigra.   In persons of a weakly constitution, the erup-
tion towards the seventh or eighth day becomes bjack.
  Rubeolae  anomala.  The eruption appearing on  the  third, or
delayed to the sixth day; or sudden secession; or appearing on the
arms before the face.
  Scarlatina.—A contagious exanthernatous disease, which,  after
one or two days' continuance of fever, is announced by an eruption
of small red points, which  are soon replaced by large irregular
patches of a scarlet  or strawberry-red colour, extending to almost
the whole  surface of the  body,  accompanied by sore throat, and
ending in  desquamation at the end of the first week.
  Scarlatina simplex.  Four  days after infection, fever,  nausea,
drowsiness.  Second day: face swelled, small spots, not prominent
       20—b                                   13 may 
  2            MAYO's OUTLINES OF PATHOLOGY.

nor bright at first, but subsequently of the most vivid hue, separated
by intervals  of natural colour, appear in great numbers on the face,
neck, and breast; and  within twenty-four hours over  the  whole
body, the lips also, the  tongue, the palati, and pharynx.  Third:
the eruption becomes  continuous on the cheeks and limbs,  and
becomes scarlet.  A few papular elevations on the hands, the chest,
and  extremities.  The  skin burning, itching, parched,  tender; its
surface in some places rough: hands and feet swelled and painful.
The eruption deepest towards evening ;  in the morning less vivid.
The efflorescence rarely general:  on the trunk in large  patches,
dotted as it were around their margins, and very various in their
outlines.  Fifth or sixth day: the eruption  begins to  grow pale.
Seventh : its character indistinct.   Eighth to ninth : desquamation.
On the second or  third day of the  eruption,  remission of general
symptoms, when  a second crop of efflorescence sometimes appears.
   Scarlatina anginosa.  Preliminary symptoms more severe.  Stiff-
ness of the  muscles of  the throat.   Second day; inflammation of
the fauces, with thick viscid secretion.  Eruption often a day later;
not so general; vanishes sometimes and reappears, and is of longer
duration.  Tumefaction of the subcutaneous cellular membrane in
the face and fingers.
   Sarlatina  maligna.   The attack as in the preceding, leading to
cerebral and typhoid symptoms.  The efflorescence tardy, colour
pale and livid, sometimes mixed with petechiae; may appear and
disappear once and again.
   Scarlatina sine Exanthemata.
   4.  Roseola.—This class comprehends several eruptions acute in
their nature, not contagious, transitory, characterised by red spots
variously figured, slightly or not at all prominent, and usually pre-
ceded and accompanied by febrile  symptoms.
   a.  Roseola astiva.  Small distinct patches, separated by numer-
ous  intervals,  larger,  paler,  and  more irregular than  those of
measles, sometimes preceded by  slight  fever.  First  and second
days' eruptions a lively red.  Third: declension, the colour a dull
red.  Fifth: disappearance, and return  to health.   The  pharynx
has  the same  light redness as the  skin, and  is dry.  At times the
eruption limited  to slightly raised and itching patches on the face,
neck, breast, and shoulders, something  between urticaria and ery-
thema.
   b. Roseola aulumnalis. A variety of erythema, attacking children
in distinct  circular or oval spots, of a dusky red, which gradually
increase to  the size of a shilling:  principally situated on the arms.
   C. Roseola annulata.  Rosy rings enclosing areae of the natural
colour, spreading from a line  to  an inch  and a half in diameter:
duration indefinite without fever, brief with fever.
   d. Roseola infantilis.  The spots have smaller intervals  than
roseola aestiva.  It  sometimes exists for a single  night, or comes
and goes during  several days: liable to be confounded with measles.
   e.  Roseola variolosa.  An almost generally diffused efflorescence, 
THE SK1X.
slightly prominent in some points, occurring once in  fifteen cases
on the second day of the eruptive fever of small pox, commencing
on the arms, breast, and  face: it lasts about three days.
  /. Roseola vaccina.  Either small confluent patches, or generally
diffused, coming  on from the ninth to the tenth day after"vaccina-
tion, spreading from around the vesicle over  the  entire surface of
the body:  commonly accompanied with acceleration of the pulse,
and slight anxiety.
  g.  Roseola febrilis.   Occurring in continued or typhoid fever.
  h.  Roseola rheumatica.   Small, round, isolated  spots, ofthe size
of a  millet seed, rarely prominent,  of  a violet or blackish red ;
breaking out in  the legs, and attended with gastric disturbance or
considerable fever;  connected with rheumatism and gout.
  i.  Roseola colerica.  Bright red patches, of an irregularly circu-
lar shape,  appearing on  the body, chest, hands, and'arms, in  the
stage of reaction  of cholera.
  6.  Urticaria.—An exanthernatous  non-contagious inflammation,
characterised by  an eruption of  prominent spots or wheals paler or
redder  than the surrounding skin,  rarely of  long continuance,
appearing  after febrile symptoms, often  recurring at intervals,  or
becoming aggravated  by fits, and always attended by the burning
and itching sensation that follows  the sting of a nettle.
  Urticaria acuta.
  U.  A. ab ingestis.   In an  hour or two after the food that disa-
grees, (especially shell fish,)  nausea,  sinking,  giddiness; then  hot
skin : and  the eruption on the shoulders, loins, fore-arms, thighs, of
irregularly shaped  wheals.   When they are  numerous, the skin
has generally a red tint,  and the limbs are swollen  and stiff.   If no
severe gastric  symptoms supervene,  at the end of twenty-four  or
thirty-six hours, the eruption declines.
  U.  A. febrilis. Slight  febrile attack of at least a  week's duration,
with  urticaria during the greater part of it.
  Urticaria chronica.
  U.  C. evanida.  Wheals  like  those produced  by flagellations,
that   come  and  go, and are generally  dependent on  disturbed
digestion.
  U.  C. tuberosa.  Wheals  of various magnitudes,  hard, deep-
seated, extending to the subcutaneous cellular  texture, with a tense
and sore state of  the skin;  attended with great itching, coming on
at night, and disappearing before morning, leaving the patient weak-
ened, restless, depressed, languid.  The  attack is commonly  de-
veloped in a febrile paroxysm.    The disorder is irregular in its
progress, leaving  and returning, and lasting often with intermissions
for many months.

                        § II.—Bullae,

Are inflammations of the skin, characterised when at their  height
by small bladders, varying in size from that of a pea to that of a 
184
MAYO's OUTLINES OF PATHOLOGY.
goose's egg, generally transparent, and formed by the effusion of a
serous or sero-purulent fluid between the chorion and cuticle.
   1. Pemphigus, an eruption on  several regions of the body, of
one or more large yellowish and transparent bullae, which break,
and are followed by a scab or superficial excoriation.
   a. Acute pemphigus.  After one, two, or three days of fever, one
or more  circular or oval  red spots appear on the trunk, limbs, and
face, most commonly on  the lower extremities.  These spots are
slightly prominent, and vary from a few lines to several inches  in
diameter.  They are at first of a bright red, but soon  turn  to a
more dusky hue.   They are then  transformed, and  often  very
rapidly, into  bullae.  The number is variable, from  a single one to
many: the greater  number  contain a transparent yellowish green
serum.   Coagulated lymph  is sometimes deposited in the chorion.
They reach  their  acme  in  three days,  after which they  become
flaccid, wrinkled,  and half full; and, breaking, lamellar incrusta-
tions form on the inflamed skin, which, being detached, leave spots
of a dusky red hue.   The duration of each extends  to about seven
days: that of acute pemphigus varies from one to two weeks when
the eruption is simultaneous, and from three to four weeks when
it is consecutive.
   b. Chronic pemphigus : pompholix diutinus.  Bullae succeeding
each  other at various intervals, during from ten weeks to seven  or
eight months, and  occasionally during several years.   The  near
bullae arise in the neighbourhood of the old ones, and are sometimes
preceded by a febrile paroxysm and lancinating pain. [A. 3.]
   2. Rupia.  Small, isolated, flattened bullae, filled with a serous
fluid, which  soon becomes opaque, puriform, or sanguinolent; and
to which  succeed black,  thick, and prominent scabs, whose bases
conceal ulcers of variable depths.
   a. Rupia simplex is  more common  on the lower part of the
body and limbs than on the upper.  The circumference  of  each
flattened bulla is from a sixpence to a shilling.   The fluid becomes
purulent, and then  crusts ;  the crust thickening, and being highest
in the centre.  On detaching the crust, the cutis is found  red and
thickened, ulcerated,  and honeycombed.  The crust forms again
as long as the disposition to the disease lasts. [A. 4.]
   b. Rupia prominens.  The ulcer larger, the crust thicker, form-
ing a cone.  In each form of rupia, the ulcer and crust enlarge
after their first bullous formation.
   c. Rupia  escharotica begins  by one  or two red and livid spots,
over which the cuticle is soon raised by the effusion under it of a
serous or sero-sanguinolent fluid.  The bullae go on increasing in
an irregular  manner: the serum they contain becomes turbid, and
acquires  a  blackish  colour. By-and-by they give way,  and the
skin exposed appears ulcerated, softened*or gangrenous, in different
parts; a bloody and offensive sanies bathes the surface of the sore,
the edges of which are livid, and not very painful.
   I  have seen each of these forms of rupia occur In succession, in 
THE SKIN.
185
a patient who had  taken  mercury for syphilitic sore throat at the
appearance of the first: they continued to develope themselves at
intervals.   She died, having  never  thrown off the disposition to
rupia. in about eight months, of phthisis.

                       § III.—Vesicul^e.

  This group is characterised  by vesicles,  or small  serous and
transparent elevations,  differing from bullae  in nothing but their
smaller size, and formed  by a globule of serum with  or without
coagulable lymph effused beneath the cuticle.  These minute drops
of serum  may either be reabsorbed, or the vesicles burst; desqua-
mation, superficial excoriation, or small thin crusts, following.
  1. Herpes.—Clusters of distinct vesicles inflamed at their bases,
not contagious.
  a. Herpes zoster.  With or without previous fever; but after
smarting and  local pain,  irregular  blotches of a  rather vivid red
appear, upon which are formed several oval groups of silvery-gray
vesicles, mixed with irregular bullae,  surrounded by a red crust.
The vesicles are of the form  and  size of seed  pearls:  in three or
four days  they acquire the volume of a large  pea.  The patches
upon which they are clustered then  become more florid.   At the
end of five or six days the fluid contained in the vesicles becomes
opalescent,  then  sero-purulent; and when the inflammation runs
high, true  pus.  The greater number ofthe vesicles dry and crust;
some, from which the cuticle is detached, suppurate.  The greater
number of the vesicular groups appear in succession:  while those
first observed are drying off, new  clusters occur in the  intervals
between them.   After the lapse of  from eight days to three  weeks,
dating from the period of the attack, the whole of the incrustations
are detached. [A. 10.]
  The  eruption  does not  terminate  so speedily  when the vesicles
are confluent.  It sometimes happens that part of the skin sloughs.
  b. Herpes phlyctenodes.   Characterised by clusters of globular
and transparent  vesicles, as large as  millet  seeds  or the smallest
peas, which appear  in invariable numbers upon red patches, usually
of a circular  form, and disseminated over different regions of  the
body.
  c. Herpes labialis.  An irregular ring of vesicles, forming round
the lips, after a feeling of burning and'tension, and in  twenty-four
hours becoming pustular.   When occurring as a symptom of fever,
being of favourable augury.
  d.  Herpes praputialus.  A crop or crops of vesicles, on a more
or less inflamed  base, which break and dry in a few days.
  e. Herpes vulvaris,  auricularis, palpebralis;  of each  a like
history.
  /. Herpes iris.  Occurring in conjunction with  other varieties
of herpes,  or alone.  This variety is  distinguished  by four concen-
tric erythematous rings of different shades of colour. 
186
MAYO's OUTLINES OF PATHOLOGY.
  2. Eczema.—A non-contagious inflammation of the skin, cha-
racterised at its commencement by an eruption of very minute and
non-prominent vesicles, commonly crowded together, which termi-
nate either in the absorption of the fluid, or in superficial excoria-
tions, to which succeeds furfuraceous desquamation.
  a. Eczema  simplex.   The skin of a natural  colour, without
heat or tumefaction, becomes covered with  minute  vesicles, the
principal place of which is round the apertures for the  hairs.  The
eruption  drying off is often succeeded by another.
  b. Eczema rubrum.  The skin hot, red, and shining, before the
vesicular eruption.
  c. Eczema impetiginodes.  In  its acute form, the tension, heat,
and redness considerable; and not tingling  and itching only, but
shooting and  violent smarting pain.  The  vesicles  pass readily
into the  purulent state: the cuticle raised in large flaps, is impreg-
nated with the fluid effused, and acquires the appearance of green-
ish  coloured laminated scabs, which being before long detached, a
surface is exposed of as bright a red as carmine.   When the erup-
tion is considerable, there  is  profuse secretion of fluid.
  These forms of eczema, especially the two last, are liable to per-
sist in a chronic character, the irritation, however, rather increasing
when  the vesicles have  burst  and the skin is partly dry and
chapped; and fresh eruption ensues.
  d. Eczema of the scalp.   Heat, swelling, redness, vesicles, with
a sort of cheesy or  sebaceous exudation, attended  with violent
itching.
  e. Eczema of the face.  Liable to crust in thin greenish yellow
scabs, between which fresh vesicles appear.
  /. Eczema aurium, mammillarum, umbilicalis, &c.
  3. Hydrargyria (eczema mercuriale).—A cutaneous inflamma-
tion, excited by the internal or external use of mercury, character-
ised by an evolution of vesicles with or without fever, upon red
and inflamed patches of various sizes.
  a. Hydrargyria mitis.  A slight rosy efflorescence,  which upon
looking  narrowly is seen  to be covered with  exceedingly minute
vesicles,  generally appearing about the upper and inner part of the
thighs, the scrotum, and  lower parts of the abdomen, and attended
by  violent heat and smarting.
  b. Hydrargyria febrilis.   After fever, an eruption  like that  of
measles; but at the end of  the  second  day the patches unite into
larger patches than the morbillary, and are not arranged in arcs of
circles.  On  the  third and  fourth days the greater part of the sur-
face of the body  is covered.   The  vesicles" are larger  and more
distinct than in hydrargyria mitis;  they become as  big  as pins'
heads, and purulent.
  c. Hydrargyria maligna.  Great heat of skin ; the throat and
tonsils painful;  the eruption  of a deep  or purple red colour; the
face and eyelids swollen;  the vesicles larger and crowded together;
the discharge offensive. 
THE SKIN.
   The epidermis is thrown off at a much later period in this tha
 in the  two former varieties;  and  it scarcely  happens before  the
 fortieth day from the date of the eruption.  The cuticle occasionally
 falls entire from the hand like a glove.  Thick yellow scabs follow
 the detachment of the epidermis, which peel off in layers; a fresh
 incrustation succeeds a fresh flow of serum, and each new desqua-
 mation discovers a surface less and less red.
   4.  Scabies.—An inflammatory affection of  the skin, unaccom-
 panied with  fever, contagious, and  characterised by an eruption o
 pointed vesicles, transparent on their summits, filled with a viscid and
 serous fluid, and constantly attended with pruritus.   The eruption
 usually takes  place in children four or five days after exposure to
 contagion;  in  adults from the  eighth  to the fifteenth day; in  the
 aged occasionally a month : the  disease  left to itself never gets well.
 The character ofthe disease is modified by the effects of scratching
 the vesicles, among which accidental pustules and lichen  make
 their appearance.
   5.  Miliaris  sudatoria.—An  eruptive and contagious febrile dis-
 order, which almost always appears as an epidemic, and is charac-
 terised  on the exterior  by a copious  and continued sweat, and
 generally by the eruption  of small rounded  vesicles, the size of
 millet seeds.  It assumes two principal forms, the benign and  the
 malignant.
   6.  Sudamina.—Minute permanent  vesicles, round, transparent,
 of the size of millet seeds, without accompanying redness of  the
 skin ; a symptom occasionally attendant on the progress of severe
 febrile disease.

                       § IV.—Pustule.
   Pustules consist of small collections  of matter enclosed between
 the  cuticle and  a  circumscribed spot of inflamed and thickened
 skin.
   Seven forms of pustular inflammation of the skin are reckoned;
 variolae and its modifications (varicellas ;) vaccinia and its modifica-
 tions  (vaccinellae ;) acne;  rosacea;  mentagra or sycosis; impetigo;
 favus ;  ecthyma.   Of these I necessarily in the present work pass
 over the two first.
   3. Acne.—Chronic inflammation  of the sebaceous follicles, com-
 mon in youth  and manhood, characterised by  isolated acuminated
 pustules, most  usually developed  on  the  shoulders, sternal, and
 scapular regions, the skin of which looks dense and unctuous, and
 more rarely on  the face.   These pustules are succeeded by livid or
 violet-coloured  spots, by tuberculated indurations of the same or of
 a milky white hue, almost always intermingled  with the accumula-
 tions of sebaceous matter  with black points, vulgarly called worms,
 and with follicular enlargements.
  4. Rosacea.—A chronic non-contagious inflammation, affecting
 the follicles of the skin of the  face,  characterised by the successive
eruption of small isolated and  acuminated pustules, the  bases of 
188
MAYO'S OUTLINES OF PATHOLOGY.
which, indurated in different degrees, are surrounded by an inflamed
areola.  These pustules appear dispersed especially over the cheeks,
nose, and forehead, and occasionally extend to the ears and upper
parts of the neck.  To these pustules succeed a dilated and arbores-
cent state of the superficial blood-vessels in their vicinity, or small
hard, red, circumscribed, and excessively indolent tubercular indu-
rations, the  resolution  of which  is always brought  about with
extreme difficulty, if ever  it can be accomplished entirely.
  5. Sycosis is characterised  by the successive evolution of a
number of small pointed  pustules, similar to those of rosacea, and
scattered singly or clustered together over the chin, upper lip, sub-
maxillary region, and lateral parts of the face.
  6. Impetigo  is a cutaneous  affection, unaccompanied by fever,
characterised by the eruption of one or more crops of pustules, dis-
seminated or collected in  clusters,  the contents of which  dry up
before  long, and assume the form of yellowish, rough, and  perma-
nent incrustations.  It  may invade every part of  the  body.   It
appears under  two principal forms.  The small pustules that cha-
racterise it being in the  one disposed in  circular or  oval groups
(impetigo figurata,) in the other disseminated  over a surface  of
variable extent  (impetigo sparsa.) [A. 20.]
  Each of these forms ofthe disease is acute or  chronic, according
as it consists in a single crop, or in successive eruptions of pustules.
  7. Favus  (porrigo favosa, tinea favosa).—A cronic inflamma-
tory affection of the skin, essentially contagions in its nature, and
principally characterised  by the appearance of its scabs, which are
of a clear yellow  colour,  very dry, strongly adherent  to the skin,
circular and cupped, and  either isolated or agglomerated into con-
tinuous masses with raised and inverted edges, the surface of which
presents numerous characteristic depressions.  It principally occur-
in those regions of the body where  piliferous follicles abound.
  a. Favus dispersus.   The  complaint begins under the form  of
very minute  pustules, scarcely  rising  above the skin, and from the
first covered with  a small yellow scab.  The dimensions of these
crusts  increasing, the cup-like  character of the  scab becomes dis-
tinct, and continues.
  b. Favus confertus.  The cup-shaped crusts arranged in such a
manner as to form circular clusters and regular rings.
  The hair is affected in favus: it becomes dry, and falls off.  The
hair reproduced by the bulbs that have been affected are thin, white,
and woolly.  If the disease continue long, it may produce perma-
nent baldness.
  8. Ecthyma.—A non-contagious inflammation of the skin, cha-
racterised by largish prominent pustules, seated on a  hard, circular,
bright  red base.   It occurs under  two forms, the acute and chronic.
  a. Acute  ecthyma, the  rarest form, is manifested on  some region
or regions of the body (the neck and shoulders most  frequently)  by
large distinct,  hard,  conoidal,  red elevations,  the  size of which
varies  between  that of a lentil and a large pea.   Their base, which 
THE SKIN.
1S9
is of a vivid red, spreads as their prominence increases.  A puru-
lent point is before long seen in their  centre.  In this state the
larger pustules bear a resemblance to small boils.   The eruption of
the pustules of acute ecthyma is completed in a few days.  The
developement of acute ecthyma is characterised by lancinating pain
in the part.
   b. Chronic ecthyma, differs from the preceding in the continued
succession of pustules.
   c. Syphilitic ecthyma, is generally distinguished by less inflam-
mation, and a more coppery hue at the base of the pustule.

             § V.--FURUNCULAR INFLAMMATIONS,
Have their seat in the chorion, and subcutaneous tissue.
   a. Furunculus, or  boil.  A hard  conical tumour, of a livid or
violet-red colour, at first of minute size, enlarging afterwards to a
considerable size.  From the fourth to the eighth day it rises to a
point;  the apex becomes white,  softens,  and finally gives  way,
when a small quantity of sanguinolent pus escapes, and the top of
a sloughy substance is  exposed, which is a small  piece of cellular
membrane infiltrated  with  pus: this  is thrown out between the
tenth and the twelfth day.
   b. Anthrax,  a large  hard painful boil, of a deeper red, with  a
larger slough, commonly situated  upon the nape of the neck, the
back and shoulders.
   c. Anlhracion.  A large  vesication  or bleb, full of a sero-san-
guinolent  fluid:  under  this a  small  lenticular  inflammation is
formed, which  is itself speedily surrounded by a phlegmono-erysi-
pelatous areolar swelling, a larger or  smaller portion of which is
before long stricken with  gangrene.

                        § VI.—Papula.
   Papulae or pimples  are hard  and  solid elevations, attended with
pruritus, terminating by resolution and furfuraceous desquamation.
   I. Lichen.—A simultaneous or successive eruption of itching pa-
pulae, reddish in their colour, or of the natural  hue of the skin, most
commonly clustered together, but occasionally scattered, and occupy-
ing a particular  region, or disseminated over  the whole surface of
the body.  I believe that the first three forms occur as syphilitic
eruptions.
   a. Lichen  simplex.   Often ushered  in by febrile symptoms, con-
fined  to one part, or  spreading  from thence over the whole body:
small solid elevations, red, not transparent, frequently acuminated,
containing neither pus  nor  serum, and seldom exceeding a millet
seed in  size. [A. 30.]
   b. Lichen  pilaris.   Differing  from  the preceding only in the
place of papulae being at the points of escape of the hair.
   c. Lichen  circumscriptus.  One or several  clusters  of papulae,
pretty regilarly circular in  their shapes, and bounded by a well
defined  edge. 
190
MAYO'S OUTLINES OF PATHOLOGY.
  d. Lichen  agrius.   The papulae  prominent, acuminated, of a
vivid red  colour, running one  into another, over an erythematous
surface, attended with a febrile state, and intolerable burning and
itching.   Duration, with remissions, for months.
  e. Lichen urticatus.
  f. Lichen luridus.
  g. Lichen  tropicus.  Sensations of pricking, itching, tingling,
suddenly brought out in tropical climates, by exercise, or any source
of stimulation, and often attended with vivid red pimples, not larger
than a pin's head.  It subsides with quiet and coolness.
  2. Strophulus is the lichen of infants:  the varieties are stro-
phulus intestinatus. s. albidus, s. confertus, s. volaticus.
  3. Prurigo.  An  eruption  of papulae, nearly of the colour of
the skin, attended with intense pruritus.  The papillae larger than
those of lichen, after having been torn by the nails, are replaced by
small black and circular scabs.
  a. Prurigo  mitis.   Papulae  softer and broader than those of
lichen.
  6. Prurigo formicans.   Papulae larger than in  prurigo mitis,
intense tingling and burning itching.
  c. Prurigo senilis.

                       § VII.—SouamjE.

  Red elevations, spots, or blotches, from which laminae of cuticle,
altered in different degrees, are formed, thrown off, and incessantly
renewed.
   1. Lepra.   Scaly patches of different dimensions, of round or
orbicular  shape, slightly depressed in the centre, surrounded by a
red and prominent circle, disjointed, or united with other patches.
  a. Lepra vulgaris.  Small  solid  elevations first appear, round
which numbers of other  reddish coloured  prominent spots, about
a line  in  diameter, of a  circular form and  firm  consistence, are
observed.   The summits of these elevations, smooth in  the earlier
stages, become some few days after covered with a small epidermic
scale,  white,  transparent,  smooth,  and polished.   This  minute
spangle-like scale is detached before long, and its fall is announced
by  a feeling of tingling or pruritus.   The scaly spots, having shed
their covering once, enlarge  rapidly, until they measure an inch
and even  more in diameter, but always  preserving a circular shape,
They  are speedily again  covered with squamae,  which are  dry,
glistening, sotHewhat opalescent, tough, and of a pearl gray or pale
yellow tint.  They are bounded by a rosy, or purplish, and slightly
elevated margin, so that the centre of each patch appears somewhat
depressed.
   Lepra is very seldom seen exclusively on the hairy scalp.  When
it occurs  in  that  situation, the squamae are commonly  yellow and
furfnraceous; and want the glistening micaceous appearance which
they present on the knees and elbows. 
THE SKIN.
191
   The spontaneous or artificial cure of lepra begins in the centre,
 and extends towards  the circumference.   After the detachment of
 the squamae from the patches, the skin, when they are not renewed,
 first acquires a  grayish tint  with  a shade of yellow; at a  later
 period the ring which  bounds the patches is narrowed progressively
 from within  outwards, the circle breaks at length in one or more
 places, and the  spot subsequently disappears entirely.  Upon some
 regions, and in  particular individuals, the squamae of lepra remain
 of inconsiderable size, never exceeding a few  lines in  diameter:
 they also increase very slowly, and are but little prominent, rarely
 run into one another, are developed almost exclusively on the ex-
 tremities, and differ from the patches of lepra vulgaris by the white-
 ness and small size of the squamae:  this constitutes the variety
 called lepra  alphoides  [A. 33.]; when  the hue is livid, the disease
 is called lepra  nigricans. [A.  34.]  Lepra sometimes forms in arcs
 of circles a few lines  in diameter, red, prominent, devoid of scales,
 and bounding surfaces of various  extent, occasionally as much as
 five  or  six  inches  across;  the enclosed skin rather healthy or
 yellowish.
   b.  Lepra syphilitica.
   A variety of lepra forms the most common form of syphilitic erup-
 tion. It  is.characterised by a coppery colour, thin and soft squamae,
 a tendency to ulcerate, and, on disappearing, to heal from the edges.
 [A. 35.J   The spots are commonly of  small diameter: they occur
 either singly, or in  groups.   In the axillae and around the anus
 they become tuberculous, and discharge a  moisture from their sur-
 face. [A. 36.]
   2.  Psoriasis.  Solid inflammatory elevations of the skin, which
 change  into  squamous patches of different sizes, not depressed in
 the centre :  the  edges irregular.
   a.  Psori'asis discreta.  Small distinct elevations, each from two
 to four lines in diameter, irregularly circumscribed, forming scales;
 sometimes of syphilitic origin.
   b. Psoriasis confluens.   Many  elevations evolved  so close to-
 gether, that the  squamous patches which succeed them meet and
 blend at their edges.   They may extend continuously over a large
 surface.
   Psoriasis discreta, on the trunk, is often combined with psoriasis
 diffusa of the extremities.  The patches of psoriasis are character-
 ised by the chapped  lines  which intersect them. [A. 40.]
   c. Psoriasis inverterata.  The primary  patches  no longer dis-
 tinguishable.  The skin ofthe entire body and limbs often involved
 in continuous psoriasis.  The skin  becomes hard, thickened, tense,
 and elastic; disposed  at the natural  folds to chafe and crack, and
 covered with a general incrustation of hard, dry, white scales. The
joints are fixed  by the rigidity of the skin.   The quantity of des-
quamation in this complaint is sometimes enormous.
   d. Psoriasis gyrata.  The eruption disposed in curling lines. 
192            MAYO'S OUTLINES OF PATHOLOGY.
Sometimes syphilitic; in that
  case often  combined  with
  psoriasis ofthe tonsils.
  Psoriasis ofthe scalp: the discrete form, the squamae yellow and
pulverulent.
  Psoriasis of the scrotum.
  Psoriasis palmaris ; one or more
inflamed and desquamating patches,
of an irregular outline, forming on >
the palm ofthe hand, and spreading
from  two  lines in diameter to  half
an inch and upwards.
  Psoriasis palmaris centrifuga, in which ring after ring forms
regularly beyond the  surface  last attacked.  It is  attended with
troublesome pruritus.   It is principally observed in washerwomen,
and among coppersmiths, silversmiths, and tinsmiths. The variety
of psoriasis, known by the  name of grocer's itch, occupies the back
ofthe hand, wrist, and fingers.
  3. Pityriasis.  An evolution of red points, and more frequently
of red spots  or  patches, from which  a  mealy, or pulverulent, or
foliaceous desquamation soon  commences,  and continues till the
disease is cured.

            § VIIT.—Tubercular Inflammations.

  Tubercular inflammations are characterised by the occurrence of
tubercles,  or small, solid, circumscribed, indurated, and enduring
tumours, which, after continuing for some months, often for several
years, almost uniformly end by ulceration.
  1. Syphilitic tubercle. Broad, red, inflammatory tubercles, form-
ing at the alae of the nose, or on the cheeks; after a time running
into deep irregularly-excavated ulcers,  which, on  healing, leave
disfiguring cicatrices.  Syphilitic tubercles  occurring upon the back
and legs are harder, more prominent,  and  deeper; and "of a violet
or livid colour.   After remaining stationary for  some time, jthey
inflame and suppurate, and are replaced  by deep and foul ulcers.
  2.  I have met with three cases exemplifying uncommon varieties
of simple tubercles, of which the two first occurred in habits tainted
with syphilis. The third, with no suspicion of syphilis, went away
under the use of mercury.
  a.  Soft, smooth, round tubercles, of a dull red colour, very promi-
nent, of the size of  peas [the complexion otherwise clear] scattered
upon the chin.   When pricked with a lancet they bled freely, and
healed.  They were not at any  time squamous,  or pustular,  or
ulcerated ; but gradually subsided under the use of mercury, when
sarsaparilla and other remedies had failed.
   b.  In a young man, after recovery  from  syphilitic lepra, treated
with mercury, there formed, in three  months, large, oval, soft, but
solid tubercles upon the back  and shoulders, at  points where the
leprous spots had been. Some of the tubercles were an inch  in their
long diameter: they were of a very light  purple red : when punc-
tured, they bled and healed.   No  other   symptom was  present. 
THE SKIN.
193
Mercury,  arsenic,  iodine, were tried  in  succession without any
effect.  Afterwards, in four or five months, these tubercles sponta-
neously disappeared. [A. 45.]
  c. A respectable woman, about  forty years of age, had a crop of
tubercles slowly form upon one instep: they were from a third to
half an inch in height and diameter. They were of a copper colour,
soft, bled  freely when cut through, and then healed.   They disap-
peared with the internal use  of mercury.   Two or three, which  I
touched with  potassa fusa, ulcerated :  they shrank and went away
with the rest.  [A. 47.]
  3. Lupus.—Two diseases fall under this head, which  have not
much alliance.  The cases which 1 have witnessed have had the
following characters:
  a. Lupus exedens.  Inflammatory tubercles forming at the alae of
the nose,  ulcerating and scabbing, and capable of being arrested by
escharotics;  otherwise spreading and destroying  the nose, the
cheeks, the floor of the orbits, and penetrating the ethmoid bone to
the  dura mater.   The  ravages  not  uniformly  progressive: the
ulcer sometimes spontaneously cicatrising at parts  of its surface.
[A. 50.]
  b. Lupus non exedens.  Inflammatory tubercle, scaling  and  occa-
sionally exuding serum and  matter, commencing about the mouth
and nose, and gradually spreading in a circle, the interior of which,
or the part  of the skin over which the lupus has passed, remains
hardened, and like a cicatrix ; the  mouth contracting to a small rigid
aperture; the soft  part ofthe nose shrinking to two cicatrised holes;
the tubercular circle spreading over the cheeks to the eyelids and
causing ectropium, and to the temples.
   4. ^Scrofulous  tubercle.—Thickenings  of  the skin,  inflamed,
chapped,  and ulcerated, occurring in persons of a marked scrofulous
diathesis.
   5.  Chimney-sweep's cancer.—A disease originally beginning as
an indolent warty excrescence of the scrotum.   The skin is thick-
ened and tuberculous: after  some period, ulceration supervenes;
and, as it spreads, a reddish-gray ulcerated surface  is formed, and
the nodular  redness and thickening of the adjoining skin extends
itself. The disease differs externally from true cancer in the doughy
softness of the parts, which  yield in some degree on pressure, and
want the cartilaginous hardness ofscirrhus: neither, if taken  early
and extirpated, has  it an equal tendency to  return.   Chimney-
sweep's cancer is liable to commence in the skin and glands of the
groin.
   6.  Elephantiasis; lepra taurica.—Chronic tuberculous disease,
characterised externally by shining and oily-looking dark patches;
to which succeed  irregular, slightly prominent, softish, and  at first
red and livid tubercles, which by and by assume a dusky or bronze
colour: these  usually continue long indolent; they may terminate
in  resolution or ulceration.   Their most common seat is the face,
but they  occur, though less  numerously, upon the  shoulders, but- 
194
MAYO'S OUTLINES OF PATHOLOGY.
tocks, and  limbs.  They also often  appear on the  palatine arch;
but the nose and ears, swelled and hideously distorted, are the parts
of all others which suffer most frequently.
                         SECTION III.

  I propose, in the present section, to enumerate different descrip-
tions  of ulcers  in the following order:—1.  Primary  syphilitic
ulcers;  2. Secondary  syphilitic  ulcers; 3. Ulcers  having  other
origins.
  I. Primary syphilitic ulcers present four varieties.
  a. A  circular ulcer  with raised edges, the  base  and edges soft,
commonly preceded by a pustule.
  A Frenchman consulted me for an ulcer corresponding with this
description on the inner surface ofthe praeputium, and for two large
flat pustules on the body ofthe penis, which, breaking, assumed the
same  character.  He took  mercury, but  irregularly, and the sores
healed.   A few weeks afterwards he returned, with  a general erup-
tion of copper-coloured spots  four to  five  lines in diameter. On
taking a proper course of mercury, he recovered.
  b. A  circular ulcer, raised above the  level of the skin, without
hardness.
  A gentleman consulted me for a sore of this  description on the
praeputium: its surface was of a  gray colour, and flat, soft but firm;
the edge neither raised nor hard  : there was a fine red and vascular
line round it.  The black wash  was applied,  which  seemed to irri-
tate it.  A saturnine and opiate  lotion  was then used, under which
the sore healed in  a  fortnight, but left a hard cicatrix.   Three
weeks afterwards  the  cicatrix ulcerated: the sore so formed was
level  with, or very slightly below the adjacent surface ;  the surface
red, without granulations.   The black wash was again used, when
the sore began to  cicatrise from the  edges  and from the  middle.
Before the cicatrisation was completed, a crop of copper-coloured
spots  appeared on the forehead, chest, hands, arms, and legs.   Mer-
cury  was then given, when he recovered.
  c. Excavated ulcer: the base and edge hard, as if formed of a
cup of thin cartilage; commonly surrounded by a red vascular line;
with little secretion.  Hunterian chancre.
  A middle-aged man  became a patient of the Middlesex Hospital,
with  a sore of  this description,  situated  on the praeputial surface,
adjoining the corona glandis.  The sore  had existed several  weeks.
A  complete course of mercury was given;  but  the sore  healed
slowly  and unwillingly,  considerable general  thickening  of the
adjacent parts of the prepuce and glanstaking place:  the cicatrix,
however, was not indurated.  Decoction of sarsaparilla with soda
was  now prescribed.  In  a little time  one  testicle swelled; and
shortly afterwards, elevated copper-coloured  eruptions  made their 
THE SKIN.                       195
appearance about the body.  They were a quarter of an  inch  in
diameter, collected in four or five close groups, with a few scattered
ones in the neighbourhood of each group.  Upon  this the patient
has resumed the  use of mercury, and the spots, and the  chronic
inflammation ofthe testis are subsiding.
  A young man  had had an ulcer near the corona glandis, which
had healed, and left a  horny nodule ofthe size of a pea.   He was
in perfect health,  but the nodule rather increased than lessened.  It
was much larger than any hardness that I  had seen from imper-
fectly-cured chancre.  I therefore passed  a  tenaculum through  it,
and with a lancet cut it out.  The wound healed readily.  In a few
weeks a crop of copper-coloured spots appeared, which were cured
by sarsaparilla and mercury.
  d. An ulcer spreading rapidly in circumference and depth, the
surface soft and yellow, with red points showing through the secre-
tion, the base and edges soft.: the edge of the skin red and inflamed,
and often hard.  Phagedenic ulcer.
   The phagedenic  ulcer, like sloughing  phagedena (in which the
appearance is only  changed from that of  a yellow lardaceous ulcer
to that of an  ashen  slough) presents itself in two forms, the sthenic
and the asthenic.   In the former the habit is inflammatory, and the
pulse  strong  and  frequent; the latter occurs  in feebleness and
extenuation of the system.   In the former case, bleeding rarely fails
to arrest the progress of the disease; in the latter, cauterisation  by
nitric  acid.
  A patient, aged sixty-eight, of a hale constitution, became a patient
at  the Middlesex Hospital with  a phagedenic ulcer of  the  glans.
Mercury was given for three weeks, and the  sore  continued to
spread, making its way under the prepuce,  which became  thick-
ened.   The  patient was now admitted into the hospital; the mer-
cury discontinued ; and after a few days, the thickened foreskin was
divided;  when twenty  ounces of blood flowed from the incision, in
which an artery had  been cut.  The sore now put  on over the
greater part of its  surface a healing appearance;  at parts the pha-
gedenic character remained : these parts  were touched with  strong
nitric  acid more than once;  the ulceration then stopped, and  the
sore healed permanently.
   This  patient, however, was subsequently attacked with small
oblong tuberculous inflammations on the arms,  chest, and face,
which ulcerated : he recovered under the use of iodine.   He sub-
sequently had iritis, which resisted the most active mercurialisation,
and periosteal swellings of the arm and forearm.
   A  gentleman, fifty-four  years of age, had a phagedenic ulcer of
the glans penis.  It was healed with great difficulty, after repeated
applications of nitric acid, the free division of the foreskin, a month's
course of mercury, and iodine.  He has  since had glandular swel-
lings in the thigh, the groin, and the upper part ofthe neck; at first
indolent and slow, the skin gradually reddening, then  ulcerating
and sloughing, and exposing deep, foul, excavated  wounds. On  his 
196
MAYO'S OUTLINES OF PATHOLOGY.
face, one or two tubercular thickenings with superficial ulceration
formed, as in the preceding case.
  II.  Of secondary venereal ulcers.
  a. Circular superficial ulcers, spreading from three or four lines
in diameter  to two, three, or four inches ; the central part cleaner,
granulating; the edge ofthe ulcer yellow, with  red points showing
through the  yellow  surface;  the'edge  of  the surrounding skin
raised and red.
  A patient, who had taken mercury for secondary syphilitic dis-
ease,  came  into the  Middlesex  Hospital with an  ulcer  of this
description on the instep: upon his legs, arms, and face, there were
leprous spots, which  on the face  were  thick and  tuberculous, and
on the limbs crusted with thick white squamae : these successively
ran into ulcers corresponding to the description.   Iodiue has been
of singular efficacy in this case. [A. 60.]
  b. Narrow ulcers, with a yellow surface, and sharp irregular mar-
gin, the skin  around red and tumefied.
  A patient, who  had been long treated for  secondary syphilitic
symptoms, had a puffiness on the  forehead, and at the eyebrow, and
on  the  lower eyelid.  The skin at these parts gradually became
red and thickened, and then ulcerated; the ulcers had the  appear-
ance  described above.   [A. 65.]  This affection  bears  a close
relation  to,  or is  identical with, the syphilitic  tubercle  already
described.
  c. Narrow ulcers spreading  as segments of circles, leaving in
their  hollow a healed and cicatrised surface:  the spreading edge
of the ulcer  yellow with red  points, alternating  sometimes with a
livid hue: the edge of the skin adjoining the ulcer raised and red.
  A lad was a patient in the Middlesex Hospital, with syphilitic
ecthyma, followed by nodes on the tibia.  The pustules were large
and flat, with little redness round them.  The left ulcers, which in
their progress assumed the character above given. The same form
of  ulcer sometimes  follows venereal tubercle on the  trunk, arms,
and legs.
  III.  Ulcers  proceeding from other sources,  may be thua ar-
ranged.
  a. Healthy ulcers.  The surface covered with small,  pointed,
florid granulations, rising a little  above the level ofthe surrounding
skin, the edge changing into soft, whitening cicatrix: the secretion,
healthy pus.
  b. Indolent  ulcers.  The surface sunken, pale, with yellowish
and gray imperfectly organised  gfanulations,  or with  none; the
edge raised, thick, white: secretion of pus, small  in quantity.  The
ulcer is sometimes deeply excavated.
  c. Inflamed ulcers.  The surface red, at  parts of a remarkably
dark crimson, with streaks of effused  blood ; the skin around, hot
and red ; the  secretion  thin  and  sanious.  Irritable ulcers are a
modification of this kind ; the inflammation less; parts of the ulcer
often of a greenish colour. 
THE SKIN.                      197
  d.  S'/fi^\iii? ulcers.   The surface of the ulcer sunk and  livid,
or ashen:  the  surrounding margin of the skin  blue  and gan-
grenous; generally attended with'pain.
  c.  Cachectic ulcers.
  1. Circular  ulcers from  half an inch to  an  inch and  a half in
diameter,  the  following tubercular  inflammation of the skin  or
crops of pustules; at  first foul, often  sloughing  to some depth
gradually cleaning and healing.  The number commonly one, two,
or three, on each leg.
  2. Numerous small  ulcers from two  to four lines in  diameter:
generally upon both  legs.
  The common seat of the five  preceding  forms  of  ulcers is  the
legs.  The cause of this circumstance is mechanical, and the same
which renders  inflammation ofthe tibia more, frequent than infiam-
maiion of other hones.   When we  are on our legs, the  weight of
the  column of venous blood keeps the capillaries ofthe extremities
in a congestive state, which is equally  prejudicial to  nutrition and
reparation.   Thus a broken shin does not heal so readily as a  cut
on the arm; and when  there is a  disposition to ulcerous complaints
from a loaded state ofthe system, it shows itself on the legs.  The
rules derived from this principle  in practice are obvious.
  f.  Scrofulous ulcers.   The ulcer generally of small extent, and
shallow, with  a pink or whitish secreting surface;  the skin red,
soft, and undermined, with an opening large enough to display part
only* ofthe  subjacent ulcerated surface: commonly succeeding sub-
cutaneous scrofulous abscess round lymphatic glands.
  g. About the knee or the heel  ulcers are  met with ofthe follow-
ing  description.   The skin  is puffy,  raised, and of a dingy red  for
an extent of several square inches.  In this reddened skin  there  are
several oblong irregular ulcers, some of which are spreading  while
others are healing; and one part of one ulcer is yellow, angry, and
enlarging, while the  opposite extremity presents healthy granula-
tions,  and the skin surrounding it is becoming firm and pale.
20-c
14 may 
198
MAYO's OUTLINES OF PATHOLOGY.
                       CHAPTER IX.

                   THE DIGESTIVE ORGANS.

  The pathology of the digestive organs will be considered under
the following heads:—fauces, salivary glands, and nasal  cavities;
pharynx and oesophagus: stomach; small intestines; great  intes-
tines; peritoneum;  hernia;  liver; pancreas; spleen.
                         SECTION I.

          Fauces; Salivary Glands;  Nasal Cavities.

  I.  The fauces comprehend the tongue, the gums, the cheeks, the
tonsils and soft palate, and the lips.
  A.  The different appearances of the upper surface of the tongue
in health form three varieties.
  1. The surface of a reddish gray, moist and soft, conoid papillae
distinct:—the common appearance in children and adults.  2. The
surface inclined  to roughness, with a thick and semi-opaque epithe-
lium, conoid  papillae  distinct:—not unfrequent in men.  3.  The
surface red. as  if raw, and  firm, traversed  by  irregular fissures:
conoid papillae not distinguishable :—frequent in elderly persons of
both sexes.
  The morbid conditions ofthe tongue are more numerous.
  a. The state ofthe  surface changing with the stale of health fur-
nishes important pathognomonic signs ; the value  of which,  how-
ever, is more in  their successive alterations than in the appearance
presented  at  any single period : there  are varieties in  the appear-
ance ofthe tongue in  the same disease, as well as in perfect health,
that are dependent upon idiosyncrasy.  The differences observed
are in the degrees of thickness of the epithelium, and  in the charac-
ter ofthe secretion covering it.
   Debility caused by  disease without fever, produces the following
change :  the epithelium disappears; the tongue is soft, red, raw,
cleft, and  unusually  sensible;   or, feverishness supervening, be-
comes dry and glazed.
   The epithelium sometimes becomes  opaque,  thick, rough, like a
blanket.   The most remarkable instance  of this variety that I have
seen, occurred in a strong, middle-aged man, who  laboured  under
an obscure rheumatic or nephritic  attack.
   When the stomach is foul  and the system heated,  the upper and
back part of the tongue  is covered with a thick, brownish, viscid
secretion, which may be scraped off, leaving the epithelium opaque
and white.
   Mercury produces a thick, white, viscid secretion upon the upper 
                    THE DIGESTIVE ORGANS.                199

surface of the tongue, which is easily scraped off.   If salivation is
present, the sordes are washed off by it, leaving the tongue moist
and flibby, and flattened by the teeth at the sides.   The tongue is
liable to become swollen through mercurial action; I have seen the
swollen tongue protrude beyond  the teeth, requiring to be mecha-
nically forced back, to prevent its strangulation.
   At  the commencement  of  inflammatory fever,  the  tongue is
covered with  a brown secretion, which, when scraped off, is rapidly
reproduced:  towards the edge, the secretion  is white:.   Both the
morbid secretion and the epithelial thickening  in  general occupy
the middle of the dorsum  of the tongue, and diminish towards the
tip and edges.  It is again  the middle of  the same surface which
becomes dry in fever, the dry part often  having a  definite edge.
The drying of the middle part  is assisted by the air in breathing
passing over  the middle of the tongue ; the sides  and tip are kept
moist  through contact  with the gums, and their vicinity to the
openings of the salivary ducts.  The cleaning of the tongue com-
mences upon the  edges.
   Sometimes in febrile disorders—in acute rheumatism for instance
—a streak of fur is seen  on each half of the tongue, the  middle
being clean and glazed.
   In typhoid fevers, the tongue covered with sordes becomes black
and dry.
   In scarlet  fever the tongue is at first white, the vascular fungi-
form  papillae  showing  red through the  white secretion:  on the
eruption declining, the tongue cleans, and  becomes wholly of a
bright scarlet.
   In a gentleman between  sixty and seventy years of age, who  had
abscess in the prostate, and became in three or four months from a
stout man thoroughly emaciated, the tongue was constantly covered
■with a thick, moist,  coherent,  greenish-black  secretion,  which ad-
hered to the surface with great tenacity.
   b.  Aphtha, a vesicular  eruption upon  the  tongue, palate,  and
pharynx: common in children:  occasionally occurring  in adults:
frequently  combined with  gastric  and  intestinal  irritation  and
ulceration.
   c.  Psoriasis of the rd'jes and sides of the tongue is  character-
ised  by patches of whitish, sore, excorhued surface, about half an
inch in diameter.   It is  most common  where slight degrees of
syphilitic taint exist, but it occasionally occurs in cachexia from no
specific cause.
   d.  Hypertrophy of the mucous membrane.   A lad is  at present
under  my care, as an out-patient  of the. Middlesex  Hospital, with
this complaint.   It has existed three years.  The middle half of
the left side ofthe upper surface of the tongue is the part affected ;
it is elevated  to the height  of a quarter to a third of an inch where
it  is  thickest.   The prominence  is not uniform, but towards  the
back part is  divided  by two or  three  fissures into separate emi-
nences.  The surface is soft, moist, and of a reddish gray, but has 
200            MAYO'S OUTLINES OF PATHOLOGY.
more  of gray in it than the opposite side of the tongue.  There is
no pain or soreness of the part, or sense of taste m it.  H he swell-
ing lessened under the daily application of  hydrargyrum pirn
crela, and shrank a  little upon two or three applications of the
nitrate of silver.   The first was discontinued, when it atieoled the
mouth : and the lunar caustic, because it began to irritate.  1 have
prescribed nothing recently for the part, as the patient has phthisis.
  Circumscribed tumours "sometimes form upon the surface  of the
tongue, which  are probably  partial hypertrophy  of the mucous
membrane.  They may be'removed either  with scissors, or with
the ligature.
  e. Hypertrophy of the substance ofthe tongue.  This affection
has been already described.
  f. Inflammation and suppuration ofthe substance ofthe tongue.
The tongue swollen  and  painful, so as to obstruct deglutition  and
breathing;  at  last communicating a sense of fluctuation  on pres-
sure: the distress relieved, when the abscess is opened.
  g.  A peculiar disease of the  tongue was met with  in.'a boy by
Mr. Eurle.   Clusters of very minute transparent vi sides pervaded
the whole thickness of the tongue, occupying  nearly one half,  and
projecting considerably both on the upper and under surface. The
slightest  injury caused them to bleed  profusely.  In some places
the clusters  were separated by deep clefts, which discharged a felid,
irritating sanies.   This disease, which had resisted various plans
of treatment,  both local  and  constitutional,-gradually yielded  to
quiet,  cleanliness, and large  doses of hyoscyamus,  which  wore
increased to a dram ofthe extract daily.
  h.  Ulcers. The tongue is liable to several  forms of ulceration.
A young woman was seen  by  me, with  Mr. Parsons, of Mew
Cavendish street, with  two shallow flat ulcers on the left side  of
the  upper  surface of  the  tongue:  the substance of the tongue,
around the ulcers was  hard  and thickened; the tongue  foul, with
whitish secretion ; the gums  spongy,  and" disposed to  ulcerate  at
their dental edge.  The complaint has existed five mouths; about
the middle  of which period  it had got well  under the ui>e of the
liquor arsenicalis, with occasional aperients.   This medicine was
again tried,  when  one  of  the ulcers healed ;  but the oilier spread,
putting on  the appearance of the secondary syphilitic ulcer de-
scribed at a, p. 199; and a patch of psoriasis formed on  one  eye-
brow.
   Foul excavated ulcers of the tongue,  wiih induration,  I have
seen put on a  healthy character, and get well  under u.eicury and
sarsaparilla, joined with the local use of hemlock.
   i.  Cancer.  True  carcinoma, originating  in  the tongue, com-
mences with  tubercular induration :  the ulcer  which  follows is
excavated ;  its surface foul, or red ; the base and surrounding sub-
stance hard as cartilage: the  edge thickened  and contracted, part
inverted, part everted ; pains shooting and lancinating;  the neigh-
bouring lymphatic glands gradually  becoming  affected.   In  the 
                    THE DIGESTIVE ORGANS.               201

 progress  of cancer, here, as  in other parts, sudden hemorrhage is
 liable to supervene  from an artery oar vein giving way.   The
 actual cautery is the best remedy for this bleeding.
   B.  The gums.   The  gums are liable to become soft, spongy,
 and  disposed  to bleed,  in scorbutic habits; to  become  red and
 swoMen. and finally to ulcerate at their dental edge, when the sys-
 tem is loaded with  mercury; to become indurated  by the spread of
 caneer from  the lip.  They are further liable to  the following spe-
 cific malignant disease.
   Epulis. The gum enlarged and redder than natural, growing in
 parts over the sides of the teeth in irregular processes, and at the
 same time ulcerating.   This state of the gum is commonly found
 around one or two decayed teeth.  The cure for it is the removal
 ofthe decayed tooth or teeth, and the excision of the whole of tho
 diseased portion  of the gum.   If a part is left, the disease returns,
 and requires a fresh operation.
   C.  The cheek.   The inner surface ofthe cheek becomes swollen
 during an excessive use of mercury, and is liable to ulcerate against
 the edges of the molar teeth.
   Ulceration  of  the cheek, again, is liable to take place from foul-
 ness ofthe stomach and  bad  teeth.   In some persons with decayed
 molar teeth,  a cold is often atlended with abscess ofthe cheek, that
 should be opened from within.
   Vascular tumours are  liable to form upon  the inner aspect of the
 cheek.  A young woman, who three years before had first remarked
 a fulness of her right cheek, was sent to ihe Middlesex Hospital by
 Mr. Lipscomb, of St. Alban's in April, 1S35.  The swelling gradu-
 ally increased, but  was unattended with pain.  It was produced by
 a circular  vascular tumour, covered by the  mucous membrane of
 the fauces, somewhat more than an inch in diameter, and* half an
 inch  in  height:  at times it was  more foil  and  prominent.   The
 surface was mottled, as if a  cluster of veins of the size of crow-
 quills were knotted together under the mucous membrane.  There
 was no pulsation in the tumour:  it was situated below and free of
 the  opening  of the Stenonian  duct.   I  removed  the tumour by
 passing two  tentacula from the fauces below it, and so making a
 base, round  which  a strong ligature was wound.   The  ligature
 came away on the  eighth day, and the  ulcer speedily contracted
 and  healed.
   D.  The tonsils  are liable to various affections.   One of the
 commonest effects of cold is inflammation ofthe mucous membrane
 of the tonsils and soft palate, attended with more  or less swelling,
 and  a thickened yellowish-white secretion, which, collecting in the
 excretory orifices of the  gland, gives it  the appearance  of  being
 covered with small  ulcers.  The same parts are the seat of putrid
 sore throat.
   a. Acute inflammation ofthe tonsils, or quinsy, is attended  with
 rapid and  excessive swelling, with  difficulty of  breathing and of
deglutition,  with a tendency to form abscess,  that puncturing 
202
MAYO'S OUTLINES OF PATHOLOGY.
 relieves, when suppuration has commenced.  Quinsy sometimes,
 it is said, is of a gouty origin, and has been known to spontaneously
 subside on the appearance of gout in the, extremities.  Abscesses
 about the mouth are remarkable for their fetor.
   b.  Chronic enlargement after  inflammation ; sometimes capa-
 ble of being reduced  by astringents or the application of caustic;
 at other times obstinate, and requiring excision or  the ligature : the
 latter easily applied, when  the tonsil is drawn out and held upon
 two tentacula introduced at right angles.
   c. Syphilitic psoriasis.  The  tonsil more or  less inflamed and
 swollen, with one or two whitish excoriated  patches upon it.
   d.  Syphilitic  ulceration.    Excavated  lardaceous  ulcer;  the
 surrounding mucous  membrane  of  different  shades of  red, and
 degrees of swelling.   In general, syphilitic  ulcers are less painful
 than  would  be expected from their  appearance.   Sometimes the
 ulcers slough, and present an ashen flocculent surface :  the slough-
 ing spreads over  the side of the pharynx ;  and there is danger of
 arterial hemorrhage taking place, either  from the lingual artery,
 the facial, the superior thyreoid, or the internal carotid.  For vio-
 lent and repeated hemorrhage  from the posterior fauces in slough-
 ing venereal ulcer, I tied the  common carotid with success.   The
 patient between three  and  four years afterwards was admitted into
 the Middlesex Hospital, in  the last stage of consumption ; through
 which circumstance the parts identifying the  lingual artery as the
 source of the hemorrhage  came into my possession, [s. 51.]   The
 use of mercury sometimes gives rise to ulceration ofthe tonsils.
  E.  a.  The soft palate, liable to common inflammation, syphili-
 tic psoriasis,  syphilitic  ulceration and sloughing, like  the tonsils, is
 often left after the latter complaint with a large perforation through
 its centre, which  I have seen an inch in length and half an inchln
 breadth.   Ulcerated holes  of this description, when the specific
 action  has been  subdued,  will in every  case draw  together and
 close, if the edge  is prevented cicatrising by the use of escharotics.
 Sometimes nearly the  whole  of the soft palate is  destroyed, at the
 same  time that the posterior  surface  of the  pharynx  is  attacked
 with sloughing or  ulceration.  In this case  a singular restoration
 takes place ;  the remaining flap of soft palate adheres to and forms
 one cicatrix with  the back  of the pharynx, leaving two small cica-
 trised apertures into the  nostrils.  The  restoratTon  thus accom-
 plished is sufficient for  deglutition, but not for the voice.   The flap
 so stretched behind the posterior openings of the nostrils  prevents
 the food iu the act of swallowing getting into the nose ; but it does
 not prevent the air passing in speech  through  the nostrils, so that
 the voice has always a  nasal quality.
  b.  In weakly infants, sloughing of the soft  palate, ofthe lips and
cheek,  occasionally supervenes.  It is commonly fatal.
  c. The soft palate is liable  to congenital fissure.  In this case
there is no deficiency of substance, but the raphe is ununited •  the
halves ofthe soft  palate hang receding from each other at an an^le
                                                            t5 
                   THE DIGESTIVE ORGANS.                203

of about thirty degrees.   The voice is nasal, and the articulation
of several  letters imperfect.  The infant is unable to suck, being
incapable of exhausting the air from its mouth.   When grown up,
the patient learns to swallow tolerably perfectly ;  for the" action of
the circumflexus palati becomes  gradually strengthened and im-
proved to that degree, that in the act of deglutition  the lower half
of the sides of the  halves of the soft palate and uvula are brought
towards each  other so as nearly  to meet.   This I observed in "the
first case in which I operated for fissure ofthe soft palate; and cal-
culated that  it  would contribute to  support  the sutures during
deglutition.  The case to  which  I refer did favourably,  but the
upper half only  of the surface  united  by the first operation ;  a
second was necessary for joining the lower half.
   The  method which  1 recommend for this operation is, first, to
remove the edges of the  fissure with a cataract knife and curved
scissors; secondly,  to pass silk ligatures, the first near to the hard
palate, tying that, and each, before the next is introduced: the next
is thus introduced all the more easily.  The operation should not be
done in childhood.   In  two children, one eight, the other eleven
years of age, in whom I performed it, it failed.   The cause of failure
in children is  the narrowness of.the en tire* so ft palate ; from which
it follows, that if the ligatures  are  passed sufficiently far from the
cut edge to hold, there is not  left  on their  outside breadth of sub-
stance enough to stretch  easily to the extent required: the  liga-
tures therefore have  to  be drawn  with such tightness as causes
them to cut themselves out in forty-eight hours, leaving the parts
ununited.
   d.  Polypi sometimes grow from the soft palate.
   A Spanish gentleman consulted Sir Astley Cooper for a polypous
excrescence of the colour of the  mucous membrane of the fauces,
which grew from the fold  over  the palato-pharyngeus, and hung
down like a sausage into the pharynx.  By great efforts he could
regurgitate it into his mouth.  Sir Astley Cooper passed a ligature
round the  root of the  tumour,  which separated in  eight days.  A
second was removed by Sir Astley, similar to the former in appear-
ance, but not quite  so large, which grew more  from  the root of the
tongue.   Both cases succeeded.— Cooper's Lectures, by Tyrrell.
   E. The lips.
   a.  A lady and her infant suffered at the same time with a similar
attack: the lips and cheeks were  swollen ;  and patches of inflam-
mation occurred  upon the mucous surface, which  formed  painful
oblong ulcers.   The infant recovered in two or three weeks.  The
mother suffered for several months.  Iodine appeared to have  more
cobfrol than any other medicine on the complaint.
   b.  When the orifice of one ofthe labial glands becomes accident-
  ly closed, mucus accumulates  in  it, converting it  into a  tense
encysted tumour.   It should be punctured, and a small piece of the
cyst cut out. so as to leave a permanent opening.
   c. A middle-aged woman was an  out-patient of the Middlesex 
204            MAYO'S OUTLINES OF PATHOLOGY.

Hospital upwards of a year.  A part of one side ofthe upper lip,
for the extent of a square  inch, was full, thick, and  red, mottled
with streaky vessels.  This complaint  had supervened gradually.
It had  made no progress,  when  I lost sight of her.
  d. Cancer of the lip has been already noticed.
  e.  Hare-lip is a parallel  defect to congenital  fissure of the  soft
palate.  It is generally single, sometimes double.   in the latter
case, the central part, if  disposed to project, should  be ren.ovid;
otherwise  it should be united  by one operation  to  the  two lateral
portions.  The pins may be  removed on the third or fourth day.
I operated, in the  presence  of Mr. Travers, for  hare-lip in a child
thirteen years of age, on  whom the operation had been  twice  per-
formed without success.   On the fifth day, till when  /// this rase I
delayed removing the pins, organised union certainly bad uoi tit ken
place;  but the edges were yet raw, and had a gelatinous adhesion :
by keeping them together with sticking plaster, they united.
  11.  Of the salivary glands.
  a. Cynanche parotidaa. An infectious inflammatory complaint,
taken  but once in  life,  attended with  considerable synq ton atic
fever, and painful swelling of the lower part of  the face, coifs.sling
in inflammation ofthe salivary gl.lnds.
  b.  Ranula.   A large cyst containing  mucus,  situated under the
side  of the  tongue, and covered by the  mucous membrane of the
mouth : supposed to  be a dilatation ofthe duct of the submaxillary,
or of one of the  ducts of the sublingual.  The best practice is,
having opened  the cyst, to  pinch up a small  portion of it with  for-
ceps, and  cut it out.   The  fluid then continues to flow  through the
opening.
  c.  Medullary sarcoma is liable to originate in the parotid gland,
or in a lymphatic gland embedded in it.   The removal of the gland
is useless.
  d. Vascular  subcutaneous  navus often occurs towards the angle
of the  jaw, involving the parotid and sometimes the submaxi.lary
gland.
  In one case  of  this affection, in  a healthy infant a  ft>w months
old,  I  applied a ligature, which was tied round two  strong  pins
passed at a considerable depth through  the parotid.  The part  that
was  strangulated came away, and the wound healed ;  but the  vas-
cular growth had  not been  extirpated, and the disease relumed.
  In another infant, in which the disease was still more extensive,
I first  passed setons through  the parotid without advantage, and
then tied the common carotid artery.  The temporary elfect of ihe
second operation was considerable;  but after two mouths, the uas-
cular structure became  again  distended, and on  the increase:
secondary hemorrhage took place through an unhealed sinus lead-
ing  to the  point where  the  artery had been tied, and the child
shortly afterwards sank.   If a similar case again presented iiself in
a strong and healthy infant, I should be disposed to tie the external
or common carotid, and to extirpate the  tumour, at one operation. 
                  THE DIGESTIVE ORGANS.                 205

  III.  The nasal cavities.
  A. a. The pituitary membrane is the common seat of inflamma-
tion from exposure to cold.   Chronic defluxion from the no>e, with
sense of stuffing and fulness, occasionally attends cerebral conges-
tion.
  A gentleman of a remarkably large person, fifty-five years of pge,
when dressing in the morning,  dropped in a state of insensibiliiy:
after lying, how  long he does  not know, upon  the  floor, he reco-
vered ; hut  he experienced for a day or  two, pain in the  head,
Three years afterward*, having in the mean tim- been in perfect
health, he again experienced pain in  ihe head, wilh disturbed  sleep;
every morning he awoke heated and unrelreshed, the nose stuffed,
with  much  defluxion.   After  these symptoms  had  lasted  some
weeks,  he was  cupped to twenty  ounces on  the back of  the
neck.  The symptoms, all  but the defluxion from  ihe nose, then
went away, and that was much ameliorated : afterwards, by purging,
and the u-ie of the sulphur-bath twice a week, this symptom  disap-
peared.
  b. In children, a perpetual and troublesome defluxion  of  trans-
parent mucus  of a peculiar odour occasionally occurs, which lasts
for  years, and is  with great  difficulty  repressed by  the use  of
astringents.
  c. Eiiis/axis.    Hemorrhage  from the exhalent  vessels  of the
nose is a symptom of either general  or local fulness, or ol general
debility and  vascular atony.  In the'first case  it may give relief;
as, for instance, in the yellow fever, or in an apoplectic  habit: in
the second it  may be injurious, and  require  to be mechanically
suppressed.    The mechanical suppression of  epistaxis  is  easily
accomplished  by stopping the  nostrils  at once from the toft  paiate
and from the nose.
  d.  The  pituitary  membrane is liable to be  thickened over  a
greater or less extent,  secreting viscid mucus  causing nasal ob-
struction.   In one case, t broke off, with  polypus forceps, a portion
of the upper  turbinated  bone,  on which the membrane was thick-
ened.   The patient,  a young lady, felt no uneasiness afterwards,
and was quite relieved.
  e. Common polypi. Thin, smooth, elongated, pendulous tumours,
of a greenish-white colour,  slightly iransparetit,  and  of a gelatinous
softness,  which  grow from the pituitary membrane co\eiuig ihe
turbinated bones.  They require to  be pinched off at their roots
with polypus  forceps.  They have a strong disposition to return,
which may be obtained by applying escharotic or astringent lotions
to tiie surface, from which  they have been removed.
  / Hydatid polypi.  Collections of mucus contained in pendu-
lous membranes, resembling wetted bladders, hanging within the
nose like  the  preceding, unattended with pain,  but  producing ob-
struction of the nostrils'.   When  pressed with   forceps, thev burst
and discharge mucus.   The cysts may be removed  by the forceps ;
but they grow again, unless checked by astringent  applications to
1 
206
MAYO's OUTLINES OF PATHOLOGY.
the surface.   Their origin is probably the obstruction ofthe orifice
of one or more of the mucous follicles ofthe pituitary membrane.
  g. Fungoid polypus.  A  young gentleman consulted Sir Astley
Cooper  for a large purple excrescence projecting from the nostril,
which completely obstructed the  passage on that side.  There was
a copious discharge of sanious fluid  from it; but the disease was
little painful,  and the general  health was at first but  slightly
affected.  Sir Astley Cooper passed a ligature round the  highest
part ha  could reach towards the root of the tumour, which sloughed
away without  hemorrhage.  The patient appeared to be greatly
relieved:  but some time" afterwards the disease returned, and was
again removed.  It grew again, and ultimately destroyed life.  The
head was examined,  and the  disease was found to have grown
from a  very small surface of  the  pituitary membrane.—Cooper's
Lectures, by  Tyrrell.
  h. Syphilitic ulceration is liable to commence upon the septum
narium, through which it eats.   The fore part ofthe septum being
destroyed, the cartilaginous part  ofthe nose sinks down and is flat-
tened,   bieffenbach,  in cases  of this deformity, recommends the
cutting  down upon and removing a portion of the  ossa nasi,  so as
give a straight outline to the profile ofthe nose.   The cartilages of
the nose are liable to be  eaten away by  venereal ulceration  com-
mencing in the integuments.  The turbinated bones  are  liable to
be the  seat either of syphilitic or strumous caries, attended with
discharge of matter from  the nose, and exfoliation.
   B.  The antrum.
   a. Inflammation of the mucous membrane not depending  upon
evident  local  causes.  A  young man complained of excessive and
constant  pain  in  the left maxillary antrum.  There was  some
degree,  but not much, of tumefaction of  that side ofthe. face ; ten-
derness in the situation of the antrum every where ; the pain aggra-
vated by pressure.   In addition to these local symptoms, there was
a good  deal of febrile excitement.   The  disease had existed and
been on the increase for two or three weeks.  Sir Benjamin Brodie
opened  the antrum by perforating it, after dividing the membrane
which covers tho jaw bone just above the alveolar  processes of the
molar teeth, with strong  sharp-pointed scissors used as a chisel.
No fluid, however,  of any kind escaped.   The patient was then
ordered to take two grains of  calomel and half a grain of extract
of opium three times daily.  In about  three days the gums were
a little  sore, the pain began to  abate, and at the end of three or four
days more the symptoms had entirely subsided.
   b. Necrosis of the antrum from injury.  A person was  admitted
into St. George's Hospital, who eight years before had fallen on the
pavement, and bruised his nose and the whole left  side of his face.
Ever since he had pain  of  these parts.   The left side of the face
beea u ' swollen, the pain  increased, and  matter was  discharged
from the nostrils.  Matter also  occasionally made its way through
one^of  the alveoli of the superior maxillary bone.   After dividing 
THE DIGESTIVE ORGANS.               207
the membrane covering the outside of the antrum, the probe intro-
duced appeared to come in contact with  dead bone.   The antrum
was opened, when small fragments of dead bone were felt, some of
which were extracted.  On the following day. other small portions
passed through the nose.—Brodie.
   c. The ordinary cause of inflammatory disease and suppuration
in the antrum is caries of a molar tooth.   The symptoms are, pain
in the situation of the antrum,—acute when matter  is pent up,—
oedema and inflammatory discoloration ofthe cheek ; in some cases'
occasional discharge  of matter from the nostrils.  The disease is
slow in its invasion and course:  it is often attended with partial
necrosis.   The local  treatment consists in establishing a sufficient
opening into the antrum, which  may be afterwards  plugged,  and
the  plug  removed and  the cavity syringed  when necessary : the
opening is to be made in the manner described above, unless the
extraction of a carious tooth has left a free channel into the cavity.
   d.  Collection of transparent fluid in ihe antrum.   A lady had
a large projection of one cheek, looking  as though she had a plum
in her mouth.  On holding  up the cheek, a  projection was seen in
the situation  of the antrum as  large as a pigeon's  ego;.   The  sur-
face, where it was covered by the mucous membrane, gave way a
little under the pressure ofthe finger.  There was no distinct fluc-
tuation, but a kind of crackling sensation was communicated to the
fingers, as if you  pressed upon very thin bone or dry parchment.
To open  this tumour, Sir Benjamin Brodie used a strong curved
scalpel bent upon the  flat, introducing the point into  what seemed
the thin bony parietes  or boundary of  the  tumour: immediately
there escaped a large quantity of transparent fluid  like very thin
mucus, something like that in ranula. The cavity being examined
with a probe, proved to be enormously dilated, but did not contain
either dead bone or a tumour.  The opening was  then  enlarged,
by the removal of a circular portion of  the  thin bony shell of the
expanded antrum.  After the operation,  the tumour subsided ;  and
in the course  of a few weeks  the cheek was not  larger than the
other.   The aperture made by the scalpel has continued pervious
to this day, though it is ten years  since the operation  was  per-
formed.   The lady wears a plug, which she takes out night  and
morning, and with her own hand introduces  the point of a syringe,
and washes out the antrum.                                    A
  e.  Malignant tumours of the antrum.  Of these, the commonest
are medullary sarcoma  [q. 10.]  and  osteo-sarcoma ; of which the
former originates in the mucous membrane,  the latter in  the bone.
In the  progress of either disease, the cheek becomes frightfully
swollen and prominent, the  integuments ulcerate externally, the
mucous membrane gives way towards the nostrils, and the patient
gradually sinks.   It is peculiarly important to distinguish  between
these two  complaints.  The  removal of the former is probably
never successful;  while that  of the latter, if the operation is per-
formed sufficiently early to  allow of the excision of the whole, 
208            MAYO'S OUTLINES OF PATHOLOGY.
ought to be permanently effectual.  The only criterion that I am
acquainted with for determining  the  nature  of  the swelling, is to
plunge a lancet into it;  when  if the  disease is  osteo-sarcoma, the
peculiar crisp sensation of cutting that texture will !~e perceived.
  I have known medullary sarcoma commence in the membrane of
the palate,  and spread upwards  into the antrum  by absorption of
the bone.  [q. 15.]
                         SECTION II.

                  Pharynx and (Esophagus.

  A.  Pharynx.
  a. The difficulty of deglutition, which  is a common feature of
cerebral  and spinal disease, results from  complete or incomplete
paralysis ofthe pharynx and oesophagus.
  b. The pharynx  is frequently  the  seat of syphilitic  ulceration
and sloughing,  which extends to that part from the tonsils and soft
palate.
  c. Common inflammation  and suppuration are liable to occur in
the membrane ofthe pharynx and cellular tissue external to it.  In
a patient of Dr.  Watson's, in  the Middlesex  Hospital, after sore
throat, an  abscess formed external to the pharynx, in  which the
cornu of the os hyoides lay carious, and the lingual arteiy became
ulcerated.   The  abscess had both an outward and a pharyngeal
opening; the latter was nearly half an inch in diameter, and situated
just above and to one side of the aperture of the glottis.  This patient
die! suddenly,  being suffocated  by a sudden gush of arterial blood,
which filled the  windpipe, and choked  him. [s. 50.]   Suffocation
sometimes takes place from inflammation of the mucous membrane
at the root of the tongue  and pharyngeal margin of the  larynx,
with suppuration under,it.  The latter case will be again  adverted
to, in connection  with disease of th° larynx.
  d. Acrid  liquids produce  two effects upon the  pharynx.  The
slightest  degree, is the detachment of  the  cuticular lining [a. 20.];
the greater,  effusion, of lymph [q. 30].
  e. Solid  bodies are liable to  stick  in the pharynx.   They may
commonly be extracted either by the finger, or with the assistance
of long curved  forceps.  A small pointed  substance, as  a fish-bone
sticking  in  the pharynx,  is best removed by swallowing  large
mouthfuls of chewed  bread, which first detach it, and then sheath
it in its descent.  After the removal of a  sharp-pointed  substance,
the part remains sore for some hours,  as  if the  irritant  were there
still.  The principal danger from foreign  bodies  in the  pharynx is
immediate suffocation, eiiher through the mechanical obstruction of
the opening of the windpipe  or spasm.   A large morsel hastily
bolted, a clot of blood even, has thus  proved fatal.  If  the foreign
1 
                    THE DIGESTIVE ORGANS.               200

substance cannot readily  be extracted, and suffocation  threatens,
laryngotomy should be performed without delay.
  /. The pharynx is liable  to become sacculated at its junction
with  the oesophagus, a blind pouch  being produced  fiom it either
behind or to one side  of  the gullet.   In  this disorder the evil is
aggravated by each meal ;  part of which is forced into the sac, and
by its pressure contributes to extend it.
   g.  Scirrhus of the  pharynx I have seen in  two forms : one, a
large hard  fungus, growing from  the  laryngeal surface of the
pharynx, gradually obstructing  the  passage, and producing death
by inanition [q. 2o.]; the other,  several small  scirrhous tubercles
on different aspects of the pharynx, causing spasmodic difficulty of
swallowing, [y. 2b.]
   Dr. Monro gives a case of polypus growing from the fore part of
■the pharynx, which, on the patient retching, was thrown forward
into  the mouth, and was so long as to touch  the front teeth, but
otherwise lay in ihe oesophagus.
   h.  Simple but fatal ulceration sometimes takes place at the lower
 part ofthe pharynx, [q. 23.]
   B. (Esophagus.
   a.  Spasmodic difficulty  of deglutition,—Spasmodic stricture.
 This affection is produced by a variety of causes.
   A  young man applied to me, at the Middlesex Hospital, for relief
of difficulty of swallowing; he could get down liquid  food only,
 and  that, not without an effort.   A bougie I eing introduced, some
 resistance was found at the upper opening ofthe oesophagus, but it
 yielded; the resistance  was  spasmodic,  and depended  ujon  the
 irritation caused by ulceration of the interior of the  larynx.  The
 use of the bougie a few days, joined  with appropriate remedies to
 the larynx, removed the difficulty of swa'lowiug.
   A  gentleman, about sixty years of age,  consulted me for spasmo-
 dic stricture of the oesophagus.  On a sudden, at dinner, be used
 to be seized  with a sense of stoppage in tie throat; he  felt as if
 choked  by what he attempted to get down, and was  compelled to
 discontinue  his meal.   I passed a large oesophagus bougie into his
 stomach without finding any obstruction.  1 prescribed  for him an
 alterative course of blue  pill, combined will) warm aperients.   He
 has had no return  ofthe attack.  A brother of this gentleman, who
 has lived freely, and suffered severely from gout, had at one period
 of his life similar seizures.
    A lady consulted Sir Benjamin Brodie, who was unable to swal-
 low the smallest morsel of solid, food, and  swallowed liquids not
 without great difficulty.  The symptoms had been coming on up-
 wards of three years.' A full sized oesophagus bougie being intro-
 duced entered the stomach without meeting the slightest impediment.
 This lady's  face was pale and bleached, her feet (Edematous.   She
 had  long laboured under internal piles,  from which repeated dis-
 charges of blood had taken place. Under the use of remedies which 
 210            MAYO'S OUTLINES OF PATHOLOGY.

 relieved the piles and the bleeding, the difficulty of swallowing went
 away.
   A female between  fifty and sixty years of age consulted me for
 difficulty of swallowing, attended with a sense of obstruction and
 uneasiness in  the oesophagus at the lower part of the throat.  She
 could  only swallow liquids or sopped  bread ; the obstruction or
 difficulty appeared  to her  always to  occur at the same point.   I
 passed a middling-sized bougie, without meeting with any impedi-
 ment, into  the stomach.  On further  inquiry,  1 found that she
 laboured under symptoms of inflammation ofthe peritoneal covering
 ofthe liver; and  the treatment which removed this complaint, took
 away the spasmodic difficulty of swallowing.
   b. Rupture of the oesophagus.   Baron Von Wassanaer, healthy,
 robust,  but subject to attacks of gout, was  accustomed to  take an
 emetic every time he  thought he had eaten  too much. His stomach
 being out of order  on one  occasion, after a day of abstinence that
 followed on a  preceding excess, he remarked, that he felt something
 disagreeable at the upper part of his stomach,  which he  proposed to
 wash away (as he had often successfully done before) by swallow-
 ing three or  four  cups of carduus  benedictus  tea,  and exciting
 himself to puke.  While endeavouring to vomit, he suddenly cried
 out with sudden and excessive pain, and declared that he had burst
 something  at the upper part of his stomach,  and  that the anguish
 was so great that he must be near his last hour.  The pain did not
 relax  a  moment, but gradually spread  to  his back,  and through
 every part of his breast.  When he felt  an  inclination to eructate,
 or tried to sit upright, the pain was aggravated.  He was taken at
 nine in  the evening, and died at nine the following morning. The
 oesophagus was  found to have been torn asunder a little above the
 cardia ;  and there was a rent an inch and a half long through the
 pleura, forming the  left boundary of the posterior mediastinal  cavity,
 that had allowed the escape of the contents  ofthe stomach into the
 left cavity of the chest, in wh.ch  the lung  lay collapsed and com-
 pressed. —Boerhaave.
  c. Foreign bodies in the oesophagus.  If a large or angular and
 pointed  solid substance is swallowed inadvertently, and passes the
 cervical portion ofthe (Esophagus, it commonly makes its way into
 the stomach, although eases have been known to the contrary. The
 OBSophagus does not become narrower in its descent. The resources,
when a  foreign body is fixed in  the cervical  portion ofthe oesopha-
 gus, are its retraction, excision, or detrusiou into the stomach. The
 preference of either  ofthe three  methods must be determined by the
nature of the  obstructing body.  If eesophagotomjuis requisite, it
 should be performed without delay ; which, if indulged in, turns the
 scale—as I have seen  it happen—against the patient.
  d. Effects of corrosive liquids.  The effect of corrosive 1 iquids on
 the oesophagus is to produce in the lowest degree separation  of the
cuticle [q. 2S.]  in a higher degree effusion of lymph [q.  c0.]  in the
highest, sloughing of the lining membrane to  a greater  or less ex- 
THE DIGESTIVE ORGANS.
211
tent;  which, being  thrown off, leaves a granulating surface, that
cicatrising, contracts and narrows the canal, establishing permanent
and fatal constriction.  A  most remarkable case of this  description,
which 1  witnessed,  was under the care  of Dr. Wilson  in the Mid-
dlesex Hospital.  \q.  33. q. 34.]
  Hannah Powers, ageel twenty-one, was  admitted on the 4th of
January, 1834, at eleven o'clock at night, half an hour after she  had
swallowed about a table-spoonful, as she supposed, of oil of vitriol.
There were marks of the action  of the acid on her chin, where it
had destroyed  the cuticle; also on the fore-arm and fingers of the
left side.  The parts thus injured were of a dark colour.  She  was
restless, and almost incessantly retching and bringing up a dark
reddish-brown fluid. She stated,  that, upon swallowing the poison,
she was  instantly seized with vomiting.  There  appeared to be
extensive abrasion ofthe membrane lining the interior ofthe mouth,
and  of the  tongue: both these parts were white, apparently from
magnesia taken before she was brought to the hospital.  Two hours
after her admission,  her lips began to swell; and she complained of
much pain in  the throat, in  the  course of the oesophagus, anel in
the stomach, with a sensation of constriction and choking about the
pharynx; and her  voice was greatly affected, and at  length  was
reduced  to a whisper.
   Two  days afterwards, she began  purging a thick  ropy mucus
resembling boiled isinglass: this  continued for a week, and ceased
gradually. It was attended with some general pain of the abdomen.
On the 11th, having previously vomited some membranous shreds,
she was  attacked with  an unusually violent fit of coughing  and
choking, and appeared  to be  in  danger of immediate  suffocation.
Mr. Lonsdale, then house-surgeon, who was called to her assistance,
perceived a long, white, flocculent mass hanging out of her mouth,
which he took hold of, and then  drew from the ihroat; it appeared
to be an almost entire slough of the membrane lining the oesophagus,
having ragged extremities.   Some of the circular miucular fibres
ofthe oesophagus were plainly visible on the exterior ofthe tubular
slough.   She  suffered much  pain after this along the course ofthe
oesophagus, especially whenever she  swallowed : but,  upon  the
whole, her sufferings diminished from that period.   At the time of
her admission it was  found impossible  to get any  thing down  her
throat, except a little gum, or  honey, or thick arrow root; and these
seemed to be of some use in lubricating and soothing the parts.
Leeches were  applied  in  largo numbers and frequently along the
course of the pharynx, oesophagus, and stomach.   She was bled
also during the first four days to upwards of thirty ounces.
   She mended slowly after the expulsion of the  slough, and  was
able  by degrees to get down more nourishment; but was often
checked for twelve or fifteen  hours  together by incessant sickness,
and a discharge of tough, ropy, frothy mucus. The weather had a
marked  influence upon her:  she was much more free from pain
and sickness during warm, dry, and clear weather, than  when it 
212           MAYO'S OUTLINES OF PATHOLOGY.

was nnist, cold, and  foggy.  She always suffered pain during the
descent of food and drink into the  stomach; and  pointed to the
upp;r  bone of the  sternum as  the part behind which  the  most
uneasiness lay.  She  became able to take soft eggs, beef  tea, wine,
ale,  and porter; and  she mainly subsisted  on  these things,  and
really gained some flosh by the summer, and went out of tue hos-
pital very much recovered.
  She  was readmitted in September of the same year, and  improved
greatly in h u!th and spirits, and gained flesh, taking an abundance
of sops an 1 the nutriinent already mentioned.   But on the 14th of
November, at  five  in  the morning, she was suddenly seized  with
severe  rigors and sickness, and her countenance altered greatly, and
assumed a  death like appearance.  In  the course of the day pain
cam; o i  over the  general  surface of the body, so thai (as  she
expressed herself) not an  inch of her frame was free from exquisite
soreness:  the wrists, and  in a les- degree the other joints, became
piinftil  and swelled, but were not red: towards night she became
covered with  a clammy warm sweat ;  and from that time, till  her
death, at seven p.  m. of  the 17ih, nothing whatever was received
into the, sto inch.  The only  thing which seemed to relieve her was
lumps of sugar saturated  with  laudanum  placed upon the tongue.
Towards the close, she did  not  complain of any particular pain.
Sh; survived, after swallowing the acid, forty-five weeks  and three
days.
  Inspection.—The oesophagus for the lower two thirds was thick-
ened and narrowed, the inner surface an  irregular cicatrix. There
wn5  an opening in the  fundus  of  the stomach of the  size of  a
crown-piece, the edges of which  were  soft and flocculent; a large
quantity of dark fluid was found in the abdomen.  It was thought
dou'.tful, whether the perforation ofthe stomach had not preceded
death,  [q. 34.]
  e. Dilatation of the oesophagus. Mary Blores. aetat. thirty-three,
was admitted  into the Middlesex Hospital, November 16, 1829, in
a state of extreme debility and emaciation, produced by her con-
stantly throwing up the  food she took.   She swallowed liquids
more easily than  solid food.   When she took a small quantity of
fluid, it seemed to her not to reach the stomach : in this case vomit-
ing did not follow so soon, and some part of the draught was  per-
manently retained.   She  craved  for food and drink, and seemed
literally dying of starvation.  The vomiting was not preceded by
nausea, although in its progress it had the appearance of ordinary
retching.   The matter vomited was not thrown up  at once, but by
successive-efforts: it consisted of ihe food she had last taken, mixed
with colourless mucus.  The complaint, she said, had begun ten
years ago, during pregnancy ; since when she had never  been  free
from it, although at times her suffering;; had been less, and she had
been able to retain some portion of her meals.  The belly was so
shrunk, that the umbilicus was not more than an inch distant from
tho spine: there was no enlargement or hardness about the stomach, 
THE DIGESTIVE ORGANS.               213
no particular tenderness on pressing  the epigastrium, or general
sense of heat or uneasiness there.  This patient died sixteen days
after her admission, utlerly extenuated.
  Inspection.—The stomach was smail, and contracted at its mid-
dle to  the breadth of  an inch and a half.   The upper part of the
duodenum  was  but half the  ordinary  size of the ileum.  The
oesophagus from its junction with the pharynx, which was perhaps
rather  less  capacious  than usual, enlarged to an  extraordinary
degree of dilatation.   The greatest breadth  which it attained (ex-
ceeding  two inches and a half, when  distended) occurred about
four inches above the cardia : the tube then narrowed more abruptly,
so as  to render  the cardiac  termination, like the pharyngeal, of
nearly the usual dimensions.   The structure ofthe cardiac end for
about  an inch, and that of the pharyngeal  end for  about an inch
and a half, "were  healthy.  Intermediately, the lining tunic was
thickened and opaque; the mucous membrane had the appearance
of having yielded or  opened into  flat shallow depressions, which
above  followed  a longitudinal direction, below formed irregular
pits.   At the depressed surfaces, the membrane  had the  natural
colour ;  between them, it was opaque and whitish.   The muscular
fibres  were  of the natural colour and thickness:  they had  grown
with the expansion of the canal. [(/. 37.] ,
  /. Permanent stricture.  The canal of  the oesophagus may be
permanently narrowed, as it  has been already shown, by contrac-
tion ofthe cicatrix following the sloughing  ofthe inner membrane.
But by permanent stricture of the oesophagus is properly meant the
narrowing  of its channel from inflammatory thickening of  the
mucous and submucous coats, by which  a  sort of firm  ring of
variable depth is formed, encroaching  upon  and straitening  the
canal.  The symptoms  are, difficulty in swallowing, which pro-
gressively  increases, and is liable to occasional paroxysmal exacer-
bations from spasm.   In the early stage, the disease is curable by
the  use of  bougies: if neglected, the  stricture becomes narrower,
the cesophagus ulcerates above the stricture, and finally opens into
the  cellular membrane, or the trachea, [^.42.], or  the lungs; or
abscesses form in the adjacent parts, and with  increasing difficulty
 of swallowing  and  symptomatic fever, the patient sinks.  The
ordinary place of stricture of the oesophagus  is where  the latter joins
the pharynx: sometimes stricture occurs lower down: sometimes
 there are more than one.
   g.  Ulceration.  Ulceration  of the cesophagus most frequently
occurs at  its upper part [q. 23.]; sometimes lower down, when it
 may open  into the lungs, [o/.  44.]  The symptoms are not distin-
guishable from those  of aggravated stricture.  But the obstruction
in ulceration proceeds entirely from spasm ; in permanent stricture,
 partly only.  In each, the food, even when liquid,  will sometimes
 be arrested above the diseased part, and  after a few seconds or
 minutes be returned into the mouth.
   h. The  oesophagus is liable to  be contracted through  partial
        20—d                                   15 may 
214
MAYO'S OUTLINES OF PATHOLOGY.
hypertrophy of the cellular coat, producing a mass of dense white
substance penetrating between the  muscular fibres, which is  com-
monly called scirrhus [q.  39.]: whether it be ever truly of that
nature, I do not know.  The symptoms are  the same as in common
stricture, and the occasional use ofthe bougie is beneficial.
  Pressure upon  the oesophagus  from  tumours external to it will
interrupt deglutition; such as  maybe caused by enlargement of
the thyreoid gland, of the bronchial glands, or of the glands in the
posterior mediastinal cavity; by aneurism of the aorta, or  abscess
upon  the dorsal vertebras ; or even, according to Abercrombie, by
abscess betwixt the coats of the oesophagus.  Dr.  Abercrombie men-
tions, that he has seen several examples of the latter affection in the
upper part, ofthe cesophagus [pharynx?] so situated, that they could
be reached by the  point of the finger, and opened by a curved instru-
ment.  They all  did well; but "from the  quantity of matter dis-
charged from one of them, the disease must have been of immense
extent.  The breathing was much affected in this case, and swal-
lowing was almost impossible.   A remarkable case occurred to Mr.
George Bell, in which the dysphagia had existed  so long that it was
considered as an example of stricture of the oesophagus, and  a
probang was introduced.   When this reached the part, which
was very low down, it  ruptured the  abscess, and an immense dis-
charge of matter took place with immediate and permanent relief.
   It has been mentioned, that the pharynx is sometimes palsied in
head disease: the cesophagus is then probably palsied likewise. The
cases given by Dr. Monro  of paralysis of the oesophagus appear to
me to have been varieties of spasmodic stricture.
   Inflammation of the cesophagus from  irritant or corrosive poisons
has been  already adverted to.  Two other  forms of oesophagitis
have been  met with.  1. In hydrophobia a considerable patch of
the mucous surface ofthe  oesophagus, or of the pharynx, or of the
stomach, is occasionally found of a bright red.  2. In inflammation
of the throat from cold, the inflammatory action may extend down
the whole  of the tube  of  deglutition.  Dr. Abercrombie describes
the case of  a gentleman, who, on his  journey  to consult him for
complaints in the head, caught cold in crossing the Frith of Forth.
He complained of his throat, and there was a glandular swelling on
the right side of  his neck.  His voice was hoarse, with a  peculiar
husky sound.  The fauces were of  a  bright red colour  without
much  swelling, but were  covered in some places with aphthous
crusts. He was  at this time not confined, and there was no fever;
but after a few days he became feverish, the other symptoms con-
tinuing as before.   He was now confined  to   bed, and  actively
treated ; and after eight or nine days he was much better, so as to
be able to be out of bed :  but there was still some rawness of the
 throat, with small aphthous crusts, and a husky sound ofthe voice.
 After  a few days  there  was a recurrence  of  fever, which soon
 assumed  a  typhoid character, with  considerable  appearance  of
 exhaustion.  He had some dyspnoea, with considerable difficulty of 
THE DIGESTIVE ORGANS.
215
swallowing.  The attempts to swallow excited sometimes  cough
and sometimes vomiting, and  by both he brought  up considerable
quantities of a soft membranous substance.  He became more and
more exhausted, without any remarkable change in the symptoms,
and died at the end of about three  weeks from the  commencement
of the  disease.  For twelve  hours  or  more before  his death, he
swallowed  pretty freely.
  Inspection.—The whole ofthe pharynx was covered  by a loose,
soft, adventitious membrane, which also extended over the epiglot-
tis : a portion of it was found lying in small irregular masses within
the larynx at the upper part.  A similar membrane was  traced
through  the whole extent of  the inner surface of the oesophagus
quite to the cardia.  Near the cardia it lay slightly attached, form-
ing a soft  continuous  mass about a third of an inch in diameter,
and with the oesophagus closely contracted around it.  The other
parts were healthy.
  Dysphagia sometimes  results from displacement of the  os hy-
oides.
                         SECTION III.

                        The Stomach.

  The disorders of the stomach may be arranged under the follow-
ing heads :—hemorrhage; acute inflammation ; indigestion, whether
functional only, or from chronic inflammation, or from hypertrophy
of one or other or of several of the gastric tissues or of the muci-
parous glands, or from simple  ulceration; gelatinisation? ;  malig-
nant disease, whether carcinoma, medullary sarcoma, or gelatiniform
cancer.
  The coats of the  stomach and of the intestines are, first,  the
mucous: secondly, the submucous—these two  membranes  cohere
firmly, and are generally spoken of as one  tunic, then  called  the
mucous or villous; their joint folds form  the rugae ofthe stomach ;
the muciparous glands are sacs of mucous tissue embedded in the
submucous: thirdly,  the cellular coat—a lax and plentiful tissue
intervening between the submucous and muscular coats, and allow-
ing the former to project in coarse rugae during the contracted state
ofthe latter; the cellular coat is continuous with the cellular mem-
brane which intervenes  and connects the fibres of the muscular
coat, whereby disease readily spreads from the  one to  the  other:
fourthly, the peritoneal.
  There is a habit of the stomach rather  than a disease,  which has
been observed in a small number of individuals, of throwing off
part of its contents almost regularly after a full meal.   I have no
doubt that a case given by Dr. Abercrombie, as derangement ofthe
stomach from a tumour attached to it, was of this nature. 
216            MAYO'S OUTLINES OF PATHOLOGY.
   A lady, aged about seventy, had  been afflicted with periodical
vomiting, which occurred so regularly a few hours after meals, that
during the whole  of the period she had  vomited a part of almost
every  meal.   It was brought up ivithout  nausea, and  the affection
had never injured her general health. She fell off rather suddenly,
and died after a shorMllness with  diarrhoea  and rapid failure of
.strength.   The only morbid appearance  discovered was a tumour
the size of a hazel nut or very small walnut, resembling an enlarged
gland.  It lay in contact with the outside of the stomach near the
pylorus, and was  slightly attached  to its outer  coat, but  without
any appearance of disease in the stomach itself.   This habit ofthe
stomach is a variety doubtless, grafted on  the impulse to rumination,
which, although extremely rare, exists in some persons.
   A.  Hemorrhage.  The mucous surfaces  are constantly pouring
out one secretion or another. By the same channels, through which
their  customary sections find vent, blood  may transude.   At all
events, blood transudes from the surface  when no  cognisable alter-
ations from healthy structure can  be discovered.  In cases in which
death  has followed immediately upon gastric hemorrhage,the mem-
brane  has  again and again been  found entire, and of its  natural
consistence and texture throughout; sometimes partially  red, and
pulpy, and  vascular;  sometimes universally so, the submucous
capillary  network of vessels being still gorged with  blood ; some-
times quite pale, the same system of vessels having been completely
emptied  by the last  hemorrhage; and  sometimes studded  with
minute dark points, which could be made by slight pressure to start
from the surface, and looked like grains of black sand.1
   Hemorrhages from the stomach, as from other mucous surfaces,
present themselves under  three  different characters.  One in  its
origin is  salutary, and has a manifest tendency to relieve the sys-
tem ;  a second partakes of some of the features of inflammatory dis-
ease ;  a third proceeds from relaxation and debility.
   Gastric hemorrhage of the  first kind offers two varieties: first,
when  it  is vicarious  of  some other habitual  hemorrhage; se-

   1 See Dr. Watson's instructive Lumleian Lectures upon this subject.
Medical Gazette, vol. x.  The skin, which has so strict an analogy to the
mucous membranes, is capable of exuding  blood.  Cutaneous hemorrhage is
generally partial: the face, the fore part ofthe chest, the region ofthe liver,
the fingers, the toes, the palms ofthe hands, the soles of the feet, have occa-
sionally been known to be the seat of this affection, which consists in the
skin becoming covered with a dew of blood:  if this is wiped  away, no un-
natural appearance of the skin is perceptible, but the blood presently exudes
afresh.  Sometimes  the hemorrhage is accompanied by redness and  slight
pain.   Rostan describes two cases of females, in whom from terror [in one
there  was  concomitant  suppression  of  the  catamenia] the  skin became
altogether and almost suddenly black.  In  the same  one, ^fter death, Rostan
ascertained the change of colour to hav,ebeen  in the rete mucosum, probably
from  ecchymosis.   Cutaneous hemorrhage is most frequent in hysterical
girls.   It is commonly supplemental of some  other  habitual hemorrhage, of
the catamenia especially, and then periodical. 
                  THE DIGESTIVE ORGANS.                217

condly, when it proceeds from accumulation of blood in the abdomi-
nal glands.
  Among the patients of the celebrated Hoffman was a woman of
Amsterdam, who for  eight years remained subject to  a bleeding
from the  nose, which came  on regularly every month a few days
before  the menstrual period, and  ceased  upon the flowing of the
catamenia: then the  locus of this periodical  hemorrhage  was
changed; and for  six months  more, instead of epistaxis, she suf-
fered haemoptysis, occurring  under exactly similar circumstances:
every month she had slight cough, and expectorated blood.  At the
time when she was  under Hoffman's care, the  haemoptysis had
ceased  for six months; but it had been  replaced by vomiting of
blood, which returned every month a little while before the appear-
ance ofthe menses, and ceased when the natural discharge became
fully established.   This woman was plethoric, lived fully, and led
an indolent life.
   Gastric hemorrhage vicarious of the catamenia is genera1 ly not
dangerous.  Mr. North however has stated, that  he has met with
two  instances, in which suppressed menstruation was followed by
repeated and at length fatal vomiting of blood.
   Hemorrhage of  this class sometimes takes place at advanced
periods of pregnancy; sometimes  as supplemental to  habitual he-
morrhage from the rectum.
   The following case, given by Latour, exemplifies hemorrhage in
relief of glandular congestion.   A person who had been living in  a
malarious district had laboured the greater part of two years under
obstinate ague.  This was followed by an immense enlargement of
the spleen, which came to occupy almost the whole ofthe abdomen.
One night this patient vomited an  enormous quantity of blood ;  a
good deal passed  away by the bowels also.  This recurred  from
time to time, till in the course of  a month, the spleen was so far
reduced in bulk that it could no longer be felt  in the abdomen, and
the patient  lived  and enjoyed good health for twenty-five years
afterwards.  It must  however be borne in  mind, that the abdominal
congestion in parallel cases may proceed from more than simple
glandular turgescence.  The accumulation of blood-in  the abdomi-
nal veins, which leads to this  form of gastric  hemorrhage, is  more
commonly a result of hepatic obstruction, sometimes of a remediable
nature, but in other cases irremediable.
   Sthenic gastric hemorrhage.   One form of hemorrhage from
mucous surfaces partakes of the inflammatory  character.  Purpura
hemorrhagica, which is often  attended with  gastric  hemorrhage,
occasionally displays this feature, and is benefited by abstraction of
blood.                                                    .
   Asthenic gastric hemorrhage.   In the greater number ot in-
stances the secretion  of blood in purpura coexists with want of tone,
vascular relaxation, and debility.
   Gastric hemorrhage taking place to any considerable extent pro-
duces a sense  of weight and pain  at the stomach, and is followed 
218            MAYO'S OUTLINES OF PATHOLOGY.

by nausea and vomiting of blood.  The blood thrown up is of a
dark colour, and more or less coagulated.  Sometimes the coagula
have evidently been moulded in the stomach ; and sometimes clots
are thrown up, partially deprived of colouring  matter, and  re-
sembling the fibrinous polypi so often  met with  in the cavities of
the heart.
  Blood  changed in its  physical and chemical qualities is occa-
sionally thrown up  from the stomach.   The coffee-ground vomit-
ing which  attends  the advanced stage of cancer  of the stomach,
and the black vomit of yellow fever, are  blood more or less altered.
  It is not always easy to determine that  gastric hemorrhage has
taken place.  If small in quantity, the blood may pass off by stool,
and no means present themselves of determining its source. There
is a case related by Franck, in which death took place from hemor-
rhage of the stomach without haematemesis; when both the stomach
and the intestines were found distended by an enormous coagulum
of blood.  On the other hand, when haematemesis takes  place, we
cannot infer with certainty that there has been gastric hemorrhage.
The blood vomited  may have first been carried into the stomach
from  the  nostrils or  fauces, or even  from the lungs, having been
unconsciously swallowed when it  has reached the pharynx ; or it
may even have been intentionally taken  into the stomach for  some
purpose of deception.
   Blood is liable to be poured directly into the stomach from other
causes than hemorrhage  without alteration of structure.
   a. Bleeding by way of exhalation,  is often  one of the earliest
declaratory symptoms  of cancer of  the stomach, occurring long
prior to ulceration.
   b. Corrosive or irritant poisons, taken into the stomach, produce
hemorrhage.
   c. Ulcers of the stomach occasionally, although very rarely, open
a considerable coronary vessel, when  serious and even fatal hemor-
rhage is likely to ensue.
   d.  Aneurism ofthe aorta, or ofthe coeliac artery, may burst into
the stomach.
   e. Medullary disease of the liver may open into the stomach, and
discharge blood into  its cavity.
   B.  Acute inflammation of the stomach rarely  occurs as an
idiopathic complaint. As the effect of corrosive and irritant poisons,
it is  frequently met with.   The symptoms which attend gastritis
are, local  pain and tenderness, vomiting of the  ingesta, of mucus,
and of blood.  The appearances  which characterise it upon inspec-
tion are, redness of the mucous membrane, softening of its texture,
extravasation of blood in minute or larger spots into the submucous
tissue.  These appearances may be accompanied by sloughing and
ulceration ofthe stomach from the corrosive effect of the poison, by
ulceration from the irritating effect, by blackening  and charring
from the action of mineral acids upon the blood, by induration of
the  rugae  from the combined chemical  and inflammatory agencies 
THE DIGESTIVE ORGANS.
219
of the  poison.  The following instances, quoted from Dr. Christi-
son's valuable Treatise on Poisons, will serve to exemplify the prin-
cipal appearances met with.  In Dr. Ron pell's beautiful illustrations
of this  subject, the reader may turn to figures which have the truth
and colours of nature.
   But  before describing the effects of poisons on the stomach, let me
take occasion to advert  to the effects of coarser irritants on this
organ.   For  this purpose I select two cases, one to show how won-
derfully impassive the stomach often is to the  contact and attrition
of solids introduced into  it [sharp or pointed  solids do not indeed
generally let the  stomach escape  so easily]; the second, to exem-
plify destructive  lesion caused by an accident, the  possibility of
which is hardly conceivable.
  A young German nobleman tried to kill himself in a fit of insanity
by swallowing different  indigestible  substances, but without suc-
cess.   He  never suffered any particular inconvenience, except  a
single  attack of vomiting daily; though, in  the course of seven
months after he  was  detected, he passed the following articles by
stool—one hundred and  fifty pieces of sharp angular  glass, some of
them two inches long; one hundred and two brass pins; one hun-
dred  and  fifty iron  nails; three large hair-pins, and  seven  large
chair-nails;  a pair of shirt-sleeve buttons, a collar-buckle, half of a
shoe-buckle,  and three  bridle-buckles;  half  a  dozen six-penny
pieces  ; three hooks, and a lump of lead ; three large fragments of
a currycomb, and fifteen bits of nameless iron articles, many of
them two inches in length.— Christison, from  Schmucker uber den
Selbstmord,  p. 168.
   When boiling liquids are attempted to be swallowed, they seldom
pass beyond the  pharynx ; and their injurious effects are exercised
upon  the  aperture of the  glottis, which closes spasmodically, and,
swelling with rapidity, threatens instant suffocation.
   A man,  while gazing up at the burning of  the Eddystone light-
house, received  a shower of melted  lead  from the building, and
expired after twelve  hours of suffering.   Seven ounces and a half
of lead had entered  the stomach,  which was severely burnt and
ulcerated.—Phil. Trans., vol. Ixix, p. 477.

           Effects of Corrosive and Irritant  Poisons.

   a. Mineral  acids.  The stomach is often  found  to  contain a
quantity of yellowish-brown or black matter, and is sometimes lined
with  a thick paste,  composed of disorganised tissue, blood  and
mucus.  The pylorus is contracted : the mucous membrane is not
always corroded;  but there is  excessive injection, gorging, and
blackness ofthe vessels,  general blackness of the membrane, some-
times  even  without softening.   More commonly, however, along
with the blackness, there is softening of the rugae, or actual removal
of the villous coat, occasionally [but  this supposes some period  to
have elapsed before  death]  regularly granulated ulceration with 
220
MAYO'S OUTLINES OF PATHOLOGY.
puriform matter in it.   The stomach is not always perforated : but
if it is, the  holes are circular, and the coats thin  at the margin,
coloured, disintegrated, and  surrounded by vascularity and  black
extravasation.  In some rare cases there is  no mark  of vital re-
action, except in the neighbourhood of the aperture.  A case of this
kind  is  related  by Mertzdorff.   The margin of the  hole  was
surrounded to the distance of half an  inch with apparent charring
of the coats, and this areola was  surrounded by redness;  but the
rest ofthe stomach was of a grayish white.   In the body of a child
two years old, which died in twelve hours [the stomach having been
protected or the injury limited by a full meal of porridge] on the
posterior surface ofthe fundus ofthe stomach, towards the pylorus,
there was a  hole as big as a half crown, which was surrounded  to
the distance of an inch with a black mass formed of  the  disor-
ganised coats and of incorporated charred blood.  The inner coat
of the duodenum often  presents appearances closely resembling
those of the stomach.—Christison.  The blackened colour results
from the agency ofthe acid on the blood : where this cause does not
interfere, nitric acid has a characteristic effect in giving a yellow
tint to the animal textures on which it acts.
  b. Corrosive sublimate.   Dr. Christison observes, that the local
effects of this poison are twofold—corrosion namely, and ulceration ;
and that the former is seldom witnessed in man,  on account of the
solubility ofthe salt, its easy decomposition,  and  the violent vomit-
ing it occasions.  In a young woman who died in the  Middlesex
Hospital,  forty-eight hours  after  swallowing corrosive  sublimate,
there was an oblong slough at the inferior part  of the stomach
towards  the fundus; and the surrounding mucous membrane for
the left two thirds of  the organ was of a deep rose-red colour,  [q.
50.]  The pharynx and oesophagus  were lined with a  layer of
lymph, [q. 30.] The epithelium of the tongue was black, and par-
tially detached. [^. 1.]  Immediately upon taking the poison, she had
vomited ; the fauces swelled directly, and profuse salivation super-
vened.   Thirty hours after taking the poison,  the disposition to
vomit had ceased: she drank porter  with eagerness, and  retained
it: towards the second night she became delirious.   In a man who
survived  nine days, Dr. Christison  narrates, that numerous  large,
black, gangrenous ulcers, like those observed in bad cases of dysen-
tery,  were scattered over the whole colon and rectum: the stomach
was also ulcerated, but the small intestines were not.
  c.  The fixed, alkalies.  In a  boy who died in  twelve  hours, Mr.
Dewar found the inner membrane of the throat  and gullet almost
entirely disorganised and reduced to a  pulp, with blood extravasated
between it and the muscular coat.  The inner coat ofthe stomach
was red, in two round patches  destroyed, and the  patches covered
with a clot of blood.
  d.  Acetic acid.  In a case of poisoning, in which the examination
ofthe contents ofthe stomach seemed to establish  that this substance
alone had been taken, MM. Orfila and Barruel describe, that  the 
THE DIGESTIVE ORGANS.
221
 stomach presented internally several large, black, firm  elevations,
 owing to the injection of coagulated blood  into the submucous cel-
 lular tissue; and elsewhere it  had a grayish-white tint, with here
 and there  a reddish  colour: but the mucous membrane was  per-
 fectly entire.
   e.  Oxalic acid.  In a case given by Mr. Holt, the mucous  coat
 ofthe throat and gullet looked as if it had been scalded, and that of
 the gullet  could be easily scratched off.   The stomach contained a
 pint of thick fluid : this is commonly dark,  like coffee-grounds, as it
 contains a good deal of blood.  The inner  coat of the'stomach  was
 pulpy, in many parts black, in  others red.  The inner membrane of
 the intestines  was similarly  but less violently  affected.   In  Mr.
 Frazier's patient, the whole villous coat of the stomach was either
 softened or removed, as well as the inner membrane of the gullet,
 so that  the muscular coat was exposed ; and this coat presented a
 dark  gangrenous-like  appearance,  being  much thickened,  and
 highly injected.  Although  these  signs of  violent irritation are
 commonly present, it must at the same time be observed, that some
 cases  have occurred, in which the stomach and intestines were
 quite healthy.   In a girl who died about thirty minutes  after swal-
 lowing an ounce ofthe  acid, no morbid appearance whatsoever was
 to be seen  in any part ofthe alimentary canal.— Christison.
   f. Nitre.  The appearances observed in  man after poisoning by
 nitre are solely those of violent  inflammation of the stomach and in-
 testines.   In Lafleze's case, which proved fatal in three hours, the
 stomach was distended, and the contents were deeply tinged  with
 blood ; its peritoneal coat of a dark red colour, mottled writh black
 spots ; its villous coat very much inflamed,  and detached in several
 places.  In Souville's patient, who lived sixty hours, the stomach
 was every where red, in many places chequered  with black spots,
 and at the centre of one of these spots the  stomach was perforated
 by a small aperture.  The whole  intestinal canal was also red.—
 Christison.
   g. Arsenic.  The effects of arsenic on the stomach are purely in-
 flammatory, the poison being supposed to have no corrosion or che-
 mical action.  Every variety of inflammatory redness may be pro-
 duced  in the mucous  membrane, modified by more or less extrava-
 sation of blood  into it.   The villous coat  is  sometimes softened;
 sometimes,  on the other hand, it is strong and firm, and the rugae
 thickened,  raised,  and corrugated,  as  if seared   with a hot iron.
 Sometimes the villous, and also more rarely the other coats of the
 stomach  are found actually destroyed,  and removed in scattered
 spots and patches.   This loss of substance is occasionally owing to
 the same action which causes softening and brittleness ofthe villous
 coat; the action, however, having been so intense as to cause gela-
 tinisation.  That such is the nature ofthe process,  appears from the
 breach in the membrane  being surrounded by gelatinised tissue, and
not by an areola of inflammatory redness.  In other cases  the loss
of substance is owing to a process ofordinary ulceration, as is proved 
222            MAYO'S OUTLINES OF PATHOLOGY.
by the little cavities having a notched irregular shape, and being
surrounded both by a red areola and a margin of firm tissue.  Va-
rious secretions have been found in the inner surface of the stomach:
the mucous secretion increased in  quantity—sometimes thin  and
glairy—sometimes abundant and solid, as an attached pellicle, or
loose shreds floating among the contents.  Sometimes the matter ef-
fused  is true coagulable lymph: this is distinguishable from tough
mucus by its reticulated appearance, and by the threads of the  reti-
culation corresponding with inflamed lines in the stomach beneath.
Another and very common appearance is the presence of a  sangui-
nolent fluid, or  even of actual  blood in the cavity of  the stomach.
The signs of inflammation are  seldom to be seen in the small intes-
tines much lower down than the extremity ofthe duodenum ;  and
they do not often affect the colon.  But  it is a curious fact, that the
rectum is  sometimes much inflamed, though the colon, and more
particularly the  small intestines are not.   Dr. Baillie  notices  two
cases in which the lower end of the rectum was  ulcerated.—Chris-
tison.  [q. 62.]
  C. The affections of the stomach which are practically of the
greatest interest, from  their frequency,  the severity of their  local
and sympathetic demonstrations, and the  moderate amount and of-
ten curable kind of organic lesion which produces them, are usually
grouped under  the title of dyspepsia,  or indigestion.  The local
symptoms of dyspepsia are, pain  and distention, lieartburn and py-
rosis, nausea and vomiting.  In  individual cases, one  or other of
these symptoms is generally more prominent than the rest.   The
sympathetic affections which attend dyspepsia are, disordered action
of the heart, oppressed breathing and cough, headach, giddiness,
confusion of thought, melancholy, fits of every character, neuralgia,
alterations ofthe urine, rheumatic pains, swollen joints, and swell-
ings ofthe bones: there is therefore hardly a single  class  of com-
plaints, which  may not exist sympathetically excited by,  and de-
pendent for its continuance upon, disorder ofthe stomach.
  Inspections after death lead us to suppose that the symptoms of
dyspepsia may result either from functional disorder of the stomach,
or from chronic inflammation  of the mucous membrane, or from
hypertrophy ofthe mucous coat, or of  the submucous, or ofthe fol-
licular structure, or ofthe cellular coat, or from two or more of these
affections combined, or from ulceration beginning in the  mucous
coat or mucous follicles.   In  practice,  it is seldom possible to dis-
tinguish between these  different causes of dyspeptic symptoms.
The best mode of treating the subject  which occurs  to me is, first,
to give  cases of dyspepsia which have got well, describing  their
symptoms and management;  secondly,  to describe  particular  le-
sions which dissection has shown to be occasionally associated with,
and to have caused, these symptoms.
   A gentleman, aged sixty-three, from a boy has suffered fits of in-
digestion, which have lasted several weeks at a  time, and which
have come on and left him gradually.   During  the attacks, he has 
THE DIGESTIVE ORGANS.
223
been free from pain as long as the stomach has been empty ;  and
the immediate effect of a meal has been to produce comfortable bo-
dily feelings.  This state he can protract, by continuing  to drink
wine, or by taking hot tea ; but as soon as the stomach is quiet, and
digestion commences, intolerable pain and distention and flatulence
supervene, which last during the whole process.  On one occasion,
in September last, having risen from table after partaking sparingly
of boiled turbot and roast partridge,  he felt a numbness and weak-
ness of both his arms, and immediately after dropped in a state of
insensibility: he recovered in  a few minutes, and has had no return
of such a  seizure : he slept tolerably well, but the following morn-
ing was taken with sickness, and vomited  a large quantity of mucus,
with a few fragments of the undigested repast, after which he be-
gan to mend of  this attack.  Being a chemist, he is  averse from
taking medicine: but a few grains of magnesia, which he constantly
uses, "allay the  pain a little ; and a  mustard plaster applied on one
occasion to the  pit of the stomach produced a temporary  improve-
ment during one ofthe attacks.
   A gentleman accustomed to moderate but very comfortable living,
had been  for many years what is called a martyr to stomach com-
plaints, seldom a day passing in which he did not suffer greatly
from pain in the stomach, with flatulence, acidity, and the usual
train  of dyspeptic symptoms; and in particular he could not taste a
bit of vegetable, without suffering from it severely. He had gone on
in this manner  for years, when he was seized with complaints in his
head,  threatening apoplexy; which after being relieved  by the
usual means, showed such a constant tendency to recur, that it has
been necessary ever since to restrict  him to a diet almost entirely of
vegetables, and in  very moderate quantity.  Under this regimen, so
different from his former manner of living, he has continued free
from any recurrence of the complaints in his head, and has never
been known to complain of his stomach.—Abercrombie.
   A lady, aged  about thirty, laboured  under the following symp-
toms in the summer of 1818.  She  was affected  with violent  pain
in the stomach, which seized her immediately after dinner, continu-
ed with  great violence  during  the  whole evening,  and gradually
subsided about  midnight: it sometimes occurred after breakfast, but
more rarely. The complaint was of two years'  standing,  during
which time a great variety of practice and every variety of diet had
been tried, but with very slight and transient benefit.   The parox-
ysms occurred  with perfect regularity:  she  was considerably re-
duced in  flesh and strength, and had a sallow unhealthy look; and
her whole appearance gave strong  grounds for suspecting organic
disease.   In the epigastric region no hardness could be discovered,
but there was  considerable tenderness  on pressure at  a particular
spot.   Various  remedies were employed  during  the summer,  with
little advantage : at last, however, she appeared to derive  some be-
nefit from lime water, and returned  home in the autumn rather bet-
ter.  But the affection soon recurred, and she returned to Edinburgh 
224            MAYO'S OUTLINES OF PATHOLOGY.
as bad as ever.  After another trial of various remedies, this severe
and intractable  affection subsided under the use of the  following
simple remedy.  She took two grains of the sulphate of iron  three
times a day, combined with five grains of the aromatic powder, and
one grain of aloes, which was found enough to regulate the bowels.
Under the use of this remedy she  was soon free from complaint, and
has continued to enjoy good  health.—Abercrombie.
   A protracted case of vomiting is mentioned by Dr. Parry, in which
the vomiting was in such a degree that every thing was rejected,
even a teaspoonful  of water.   The case  had gone on in this manner
for several weeks, and the patient was reduced to the last degree of
emaciation ; when Dr. Parry ordered half a grain of aloes to be given
every four hours, moistened only with a few drops of liquid.  This
was retained, and acted gently on the bowels; and in less than two
days the complaint entirely subsided. The bowels had been  freely
moved during the previous treatment, and other remedies in great
variety had been employed without any benefit.
   A female had for a considerable time laboured under  symptoms
which were supposed  to indicate scirrhus  of the  pylorus, and  her
case had-been regarded as entirely hopeless.  She suffered severe
pain in  the stomach when the smallest  quantity of food was  taken,
with great tenderness upon pressure, and constant vomiting, which
occurred regularly about the same  period after eating at which it
usually takes place in  affections  of the  pylorus.   A variety of treat-
ment had been employed without  benefit, when Dr. Barlow deter-
mined upon trusting entirely to regimen, by restricting her to a diet
consisting wholly of fresh-made  uncompressed  curd, of which she
was to take but a table-spoonful at a time, and to repeat it as often as
she  found it advisable.  On  this article  she subsisted  for several
months, and recovered perfect health.
   A young woman in the family ofthe English  consul-general at
the Hague, in the  spring of 1818, was  subject to intractable  vomit-
ing, which had gradually supervened in three months.  At first the
vomiting took  place occasionally only: after a short time she ob-
served that it occurred after those meals in which she took meat: in
time, after every meal, and occasionally when nothing had been taken
into the stomach.   She threw up no blood or  coffee-ground fluid:
there was pain at the praecordia, and tenderness on pressure,  but no
hardness: the emaciation was very considerable: the usual remedies
had been tried, and had proved ineffectual.  I therefore recommend-
ed that she should take, three times a day, a quarter of a grain of su-
gar of lead with a third of a grain of opium, and  that a blister should
be applied to the pit of the stomach. On the following day  the vo-
 miting ceased, and did not return: the lead and opium  were con-
 tinued for a week, and a second  blister  applied.
   a. To instance  by dissection disorders of the stomach  purely
 functional, or unattended by alteration of structure,! must select a
 case in which  the affection was  probably the sympathetic result of
 neighbouring disease.  Dr. Abercrombie examined the body of a wo- 
THE DIGESTIVE ORGANS.
225
man, who died gradually exhausted by daily vomiting, which had
continued more than a year, and discovered no morbid appearance
except  the gall-bladder filled with biliary calculi.
  b. As evidence of  chronic inflammation  of the mucous mem-
brane of ihe stomach, there is found, according to Andral, a brown
or slate colour of the  membrane,  sometimes spread over  a small
number of points forming  isolated stains, either circular, or of a
more or less irregular outline. In the interval of these gray or brown
or black stains, the mucous membrane may preserve its whiteness.
Sometimes the appearance is as if drops of colouring matter had
been diffused through the membrane, and the stain is uniform: at
other times with the naked eye, or under a glass, the discoloured
patches  appear formed  of an  agglomeration of infinitely  minute
vessels filled with black blood.  In place of spots so stained again,
large portions, strips, or  the entire inner surface ofthe stomach may
present discoloration.  Frequently in chronic  inflammation, how-
ever,  the mucous membrane is neither  slate-coloured, nor brown,
nor black, but red.
   The body of a young man was opened at La  Charite,  who  for
more than eight months had presented all the symptoms of chronic
gastritis—vomiting, sense of weight at the epigastrium after taking
food, total loss of appetite: the tongue was natural. In this subject
the mucous membrane of the stomach  was of a bright  red  colour
[rouge vermeille] for a great extent of its surface.
   The mucous with the submucous membrane is sometimes swollen,
soft, and lax, in chronic inflammation ;  sometimes attenuated to the
thinness ofthe tissue which lines the antrum in conjunction with
inflammatory vascularity.
   c. When chronic inflammation has existed for some time, it is  lia-
ble to  produce thickening and  opacity of the mucous and submu-
cous tissues. Or thickening, or hypertrophy ofthe mucous or sub-
 mucous tissues, or of both, are  met with ;  which, it certainly is  not
unlikely, and which Andral conjectures,  are consequences of chro-
nic gastritis.  The preparation  [q. 72.] presents thickening of these
tissues for nearly the  whole extent of the stomach.  The symptoms
 were those of cancer ofthe stomach.
   In a case  which occurred at La Charite, the local and general
symptoms were so decided, that it was believed the patient laboured
 under cancer of the stomach. Among other symptoms, coffee-ground
 vomiting often occurred.  On examining the body, the stomach pre-
 sented at its middle a surface something larger than the palm of the
 hand,  of milky whiteness, from manifest induration and thickening
 of the mucous membrane: the  latter, for the same extent, was  co-
 vered with a sort of opaque, white, membraniform layer, resembling
 the epidermis ofthe cesophagus when of unusual thickness.
    d. Sometimes the  hypertrophy or enlargement particularly  at-
 tacks  the follicular structure, giving a mammillated fulness to  the
 interior surface of the stomach, the  enlarged orifices of the glands
 identifying the seat of the affection. A woman mentioned by Andral 
 226            MAYO'S OUTLINES OF PATHOLOGY.

 vomited every day about four pints of white glairy mucus like the
 white of eggs; and she never vomited either food or drink.  On dis-
 section,  no other morbid appearance could be discovered than a
 general thickened  state of  the  mucous membrane of the stomach,
 which was of a brownish colour, and the follicles  were remarkably
 developed.  This case throws light upon the source of pyrosis.
   e. The cellular coat ofthe stomach is liable to be hypertrophied.
 In this affection, the cellular membrane between the muscular fibres
 is commonly involved; while the muscular fibre itself is either atro-
 phied, or undergoes apparent increase.
   The hypertrophy of the muscular coat, observes Andral, to which
 several authors, and  in particular M. Louis, have  drawn attention,
 is seldom an isolated phenomenon ; such at  least is the result of my
 observations. It is especially associated with hypertrophy of the cel-
 lular membrane  in both its aspects, and between its fasciculi.  On a
 section, the interfascicular layers of membrane appear of a harder,
 more dense, and  brilliant texture than natural: they extend  from
 the peritoneal to the submucous coat, and form membranous inter-
 sections, between which the divided ends of the muscular fasciculi
 slightly project like glandular lobules.
   In a patient who  died with symptoms of cancer of the stomach
 in the Middlesex Hospital, the pyloric extremity of the stomach was
 externally enlarged, white,  and firm:  on a section, it presented ex-
 actly the appearance just described; but the hypertrophy involved,
 in addition, the submucous tissue. The mucous membrane was full,
 soft, and velvety, [q. 74.]
   To complete this  series  of examples, the  following dissection,
 quoted from Andral, exhibits the additional complication of the mu-
 cous membrane ulcerated on the hypertrophied tissues.
   The internal surface of  the stomach was white over its whole
 extent.   At the pyloric extremity there was manifest induration of
the submucous tissue, with hypertrophy of the muscular coat. These
tissues, as they receded from the pylorus, regained their natural ap-
pearance ; but towards the middle of the stomach the coats present-
ed a second thickening, with an almost cartilaginous hardness.  The
 induration occupied the different  tissues exterior  to  the  mucous.
 For the  whole extent of the  thickening, which was about the size
of a five-franc  piece, the mucous membrane  had disappeared.  The
 result was a superficial ulceration, the edges and surface of which
 were white, so that it at first escaped observation : the surface ex-
posed by the ulcer was cellular membrane  remarkably thickened.
 The patient had been attacked three years before with fever thirst
pain in the epigastrium, vomitings: these symptoms had gradually
amended; but the digestion had always been bad from this time,
and attended with occasional vomitings. His death was hastened by
chronic  peritonitis.
  /.  Ulcers.   One or more  chronic ulcers,  often attended with ex-
tremely  mild dyspeptic  symptoms—the  consequence  probably  of
very partial chronic inflammation—are liable  to form in the inter- 
THE DIGESTIVE ORGANS.
227
nal surface of the stomach:  there is, however,  generally but one
such ulcer at a time, and that circular and of small extent; the edge
not remarkably raised or hard. Sometimes the formof the ulcer is less
regular; and it may be larger, and the edge thickened. The termi-
nation of this complaint is various : the ulcer may either cicatrise
and heal;  or may perforate  the stomach, and allow its contents  to
escape into the peritoneal cavity; or adhesion having taken place
before the perforation is completed, a neighbouring viscus may form
a temporary wall for the stomach on that side; the ulceration  may
then eat its way  through, and  produce a fistulous opening either
into another viscus, or through  the parietes ofthe belly.
   a. In  a preparation in the King's College museum, the stomach
is shaped into two cavities, with a narrow communication: this hour-
glass contraction of the stomach had evidently been produced by
the cicatrisation of an ulcerated surface or surfaces which had gra-
dually extended round the stomach, [q. 80.]
   b.  A lady towards thirty years of age had been attended several
years by Mr. North for frequent attacks of pain at the  stomach, and
flatulent distention. One evening, having suffered rather more than
usual pain and distention of the stomach, she went  early to bed.
On her mother going into her room at  nine the following morning
to inquire after her, she raised herself in bed, and then dropped back
and expired.   I assisted  in examining the body, and found in the
stomach, as Mr. North anticipated, a circular perforation about half
an inch in diameter, which looked externally as if punched ;  inter-
nally, the muscular and mucous  coat were evidently eaten through
by ulceration.  The contents of the stomach  had escaped into the
peritoneal cavity: no adhesions  or reaction had taken  place, fa. 81.]
   A strong and healthy-looking servant girl, aged about twenty-one,
while engaged at  her work between seven and eight in the morning,
was suddenly seized with excruciating  pains in the abdomen, sick-
ness, and  vomiting.   About ten  she  was bled  to  fainting, and
twice afterwards  in the course ofthe day.  The bowels were freely
moved by an enema, and she took purgative medicine, which did
not operate;  but  there was  no alleviation of the  symptoms.  The
belly became tense, tender,  and  tympanitic;  the pulse feeble and
rapid; every thing she took  was vomited; and she died in eighteen
hours from the attack.
   Inspection.—The  cavity of the abdomen was distended with air
and the liquids that had been  swallowed: the peritoneum was highly
inflamed, and coated on the  bowels with puriform matter.   In the
middle ofthe smaller curvature of the stomach there was  a  round
opening about one third of an inch in diameter.  At the part where
it was situated, the coats ofthe stomach were in some places nearly
half an inch in  thickness, and the thickening extended in a greater
or less degree over a portion  five or six inches  in extent. The inner
surface at the place of the rupture presented a deep excavation with
rounded  and smooth  edges, like a deep corroding ulcer which had
cicatrised.  It was fully half an  inch in diameter, and  a third of aa 
228            MAYO'S OUTLINES OF PATHOLOGY.
 inch or more in depth.  This patient had been residing in the same
 family the preceding four months, and was never known to comp^m
 of he? stomach, or to  have the smallest deviation *om *"™**J°
 bust health. Six months before, she had had ^--J*™?^
   D.  Gelatinisation of the stomach.  The fund"%°f^r&X0
 is often met with in a half dissolved state;  or a ^e°t greater o
 less dimensions is found in it, the edges of which are a soit,, irregu
 lar, and flocculent fringe. The mucous membrane surrounding the
 perforation is pulpy, generally white, sometimes bluish oi Mac£sh.
 Very rarely vascular? and when it is so, the blood ™y ^^m*
 out of the loaded vessels.  The organs in  contact with the d. so ved
 part of the stomach are often found softened.   Sometimes it ha ca-
 priciously happened, that the solution has been principally external,
 ?he peritoneum being extensively softened,  and partly dissolved, so
 as to lay the muscular coat bare on its outer  surface.
    Partial solution  of the stomach was observed by John  Hunter
 and considered by him to be the effect of the gastric juice^acting
 after death.   The uncertainty of its occurrence has been explained
 through the researches of Tiedemann and Gmelin, who have estab-
 lished that the gastric secretion  is then only acid and a solvent,
 when the villous coat of the stomach is subjected to some stimulus.
 It is still an undecided question, whether gelatinisation of the sto-
 mach can take place during life. fa. 84.]                    Ki
    E. Malignant  disease.   The expected publication of Mr.  rUer-
 nan's reseafches relating to the structure and growth of carcinoma,
 medullary sarcoma, gelatiniform sarcoma, and melanoma, will throw
 new and important light upon the nature of these diseases. 1 shall
- therefore speak of them  in the present treatise very briefly. In tne
 stomach, the symptoms  which these diseases produce  are  not dis-
  tinguishable with certainty from those of chronic gastritis or simple
  ulceration.                                 .         . f.QOt_tp
     Carcinoma fa.  89.] affecting the cardiac region, partly in the state
  of cancerous ulceration.
     Medullary sarcoma,  fa. 88.] Extensive growth of medullary sar-
  coma to the height of three quarters of an inch from a-large extent
  ofthe pyloric portion of the stomach, projecting inwards, [q. yu.J
   Medullary sarcoma rising from the pyloric  surface of  the stomach,
   projecting as a great tongue several inches in length  through the
   pylorus into the duodenum.
     Gelatiniform cancer.  A beautiful specimen of this disease was
   recently purchased, with other specimens, of Mr.  Langstaff for the
   College of Surgeons.   It has attacked  a considerable  extent ofthe
   stomach, which is full half an inch in thickness;  the  natural tex-
   ture  being no longer discernible, but in its place a semitransparent
   tissue of little semitransparent  gluelike lobules, with  membranous
   septa interposed.                             .
     There is considerable difference in  general  in the  symptoms of
   disease ofthe stomach when situated near the cardia, and when situ-
   ated near the pylorus.  In the  latter case,  the symptoms are more 
THE DIGESTIVE ORGANS.
229
insidious, and even to the end less severe.  In the former  there is
more ofthe distressing vomiting of stomach disease, and that so im-
mediately after taking food as to lead to the suspicion of stricture of
the lower part of the cesophagus: spasmodic strictu re of the oesopha-
gus sometimes attends it.
  Melanosis has not  been met with in  the  stomach, cesophagus, or
pharynx;  but extravasated  blood in  the tissues of  the stomach,
blackened by the gastric acid, has produced appearances which have
been mistaken for  it.
                         SECTION IV.

                     The Small Intestines.

  It is impossible in a treatise like the present,—in  which at once
so wide a range of disquisition is embraced, and the subjects treated
of have such varied and intimate alliances,—on the one hand to
proceed a step without a most carefully considered and digested me-
thod and order,—and on the other, to contrive a  method in which
important natural affinities are  not frequently severed, and the ar-
rangement occasionally based upon relations which  are slight and
arbitrary. Nevertheless, I trust that the reader will absolve me from
having sacrificed much  to the wish to  preserve  the appearance of
system in this treatise,  and will rather give  me credit for having
preferred the substance to the shadow, and while violating the com-
mon rules of systematic arrangement, for having availed myself of
the most important affinities in  pathology, or at least for having de-
scribed the diseases of parts in  those sequences which render their
study pregnant with most instruction.  In the present section I find
it convenient to exclude the subjects of suppression of secretion, pe-
ritoneal affections, and abdominal hernia, which  naturally claim to
be considered here: while I pass under separate  review,—affections
ofthe duodenum—affections originating in the muscular coat of the
jejunum and ileum, conjointly with other causes of obstruction ori-
srinatingf in their interior—inflammation of the bowels—affections of
the villous coat.
  A. Affections ofthe duodenum. The affections ofthe duodenum
deserve to be considered alone,  as they are repetitions ofthe pheno-
mena which are observed in the stomach.
  a. Duodenal hemorrhage  may occur  under  the same  circum-
stances as gastric hemorrhage:  the blood may be poured out by the
exhalent vessels, as in purpura hemorrhagica; or from an ulcerated
artery, as it  happened in a case recorded by Broussais, of  fatal he-
morrhage from the hepatic artery, opened  by a duodenal ulcer. The
blood effused, if the patient lives, may be part vomited, but the greater
part is generally discharged by stool,  presenting different appear-
ances, as it has  undergone mixture or other alteration in its descent
       20—e                                     16 may 
230
MAYQ'S OUTLINES OF PATHOLOGY.
along the intestines.  The term melana is given to the discharge of
altered and pitchy blood voided by the bowel.
  b. Inflammation ofthe lining membranes of the duodenum is an
occasional  effect of the corrosive and irritant  poisons.   See the
preceding section.
  c One or more small ulcers are liable to originate in the mucous
membrane of the duodenum, or in the follicular structure, and to run
the same course as simple gastric ulcers.  It is presumable that such
ulcers may heal.  On the other hand, the ulcer may perforate the
coats of the intestine, and the contents of the latter  escape into the
peritoneal cavity, fa. 100.]
  In a very singular case described by Dr. Streeten, (Midland Medi-
cal and Surgical Reporter, Nov. 1829,) a communication took place
between the duodenum and an external opening on the side ofthe
thorax,  at  the interval of the seventh  and eighth ribs, and articles
of food or drink were frequently discharged by it.  The duodenum
was found greatly contracted  beyond the  seat of this communica-
tion, which was  produced  by means of a  canal two  inches and a
half in length passing from the opening in the duodenum through
thickened cellular texture to the external aperture.   The affection
was complicated with extensive disease ofthe liver and of the tho-
racic viscera. The patient appears  to have lived about a month after
the communication  took place between the duodenum and  the ex-
ternal parts.
  d. There is a duodenal indigestion,  which, as on the one hand it
may be functional only, or may depend upon chronic inflammation,
or upon simple ulcers, so it  may be the result of every form of ma-
lignant growth: it is rare, however, to find the duodenum thus af-
fected alone.
  The leading peculiarity of disease ofthe duodenum, as far as we
are at present acquainted with it, seems to be, that the food may be
taken with  relish, and the first stage of digestion be unimpeded'; but
that pain begins about the time when  the food is passing out ofthe
Stomach, or from two to four hours after a meal. The pain then con-
tinues, often  with great severity, sometimes for several hours, and
generally extends obliquely backwards in the direction of the right
Icidney. In  some cases it gradually subsides after several hours, and
in others is relieved by vomiting.   The peculiar characters of dis-
ease ofthe  duodenum are  well illustrated by a case related by Dr.
Irvine in the Medical Journal of Philadelphia, for  August, 1824.
The patient was liable to  attacks of pain  and  vomiting, which at
first recurred at long intervals, but gradually became more frequent,
until they occurred regularly every day.  His appetite was good, and
the functions of his stomach were unimpaired for two, three, or foui
hours after  a meal.  He was then seized with violent pain followed
by vomiting, and the pain did not cease till the stomach was com-
pletely emptied. He died, gradually exhausted, in about six months
from the time when the attacks began  to occur daily.  About three
«'eeks before his death, a tumour was felt in the right hypochon- 
                   THE DKiESTIVE ORGANS.                231

drium, which after eight or ten  days subsided.   On inspection, the
stomach was found distended but healthy, and the liver was sound.
The duodenum was enlarged and hardened, and internally showed
an extensive surface of ragged ulceration. It was also studded with
tubercles,  varying in size from that of a hickory nut to a hazel nut.
In the largest there was a soft  white matter, and  the cavity ofthe
duodenum contained about four ounces of pus.—Abercrombie.
  Vomiting is not so simple a consequence of duodenal  as it is of
gastric disease: it is here  a symptom in some sort transitional be-
tween the effects of gastric and of intestinal disorder. Vomiting from
duodenal disease  either may be the result of irritation, like vomit-
ing from affections of the stomach, or it may be the result of obstruc-
tion.   The Calibre of the duodenum is  liable to be contracted by
thickening of its coats toi  a degree which practically obliterates the
cavity, when vomiting ensues as in strangulated hernia.
  The duodenum closely adjoins the stomach, liver, and pancreas:
it is situated before the spine, the psoas muscle, the right kidney, and
ureter, and behind the ascending portion ofthe  colon.  There are
few occasions for finer diagnosis than this complicated region af-
fords. Disease can hardly exist in one of these parts without through
contiguous sympathy implicating in a greater or less degree those
adjacent to it. It  is thus often extremely difficult in individual cases
to identify the organ primarily attacked.
  B.  a. The mnscitlar coat of  the jejunum and ileum is the  part
principally affected in ileus. Great ambiguity exists as to the nature
of this complaint; its characteristic features in their simplest form
are given  in the two following cases.
  A patient, after a short febrile illness, during which there were na-
tural stools,  was taken with  pain in  the belly, want of passage
through the bowels,  and  vomiting, which became stercoraceous.
Death ensued in two days.  The jejunum and upper  portion of the
ileum were  distended, and two or three feet  of the latter dark co-
loured and vascular.  The portion which succeded was contracted
and pale.  The peritoneum was not  inflamed, fa. 110.]
  A woman, aged twenty, was affected with  violent pain at the up-
per part ofthe abdomen, extending towards the left side, and at times-
increased  by pressure; frequent and violent vomiting, and obstinate
costiveness.  The belly was distended and tense, the  tongue white,
pulse 76 and small. On the 16th she had got wet during the flow of
the catamenia, which ceased, but returned at night. Pain about the
umbilicus began on the 17th, and increased gradually.  Vomiting be-
gan on  the 21st,  with hiccup.  Blood-letting, with various purga-
tives, injections, warm bath, &c. were actively employed.   24th. In-
cessant screaming, from the violence ofthe pain ; frequent hiccup;
no stool;  pulse 88 and small;  frequent vomiting; belly distended
and tender: every medicine  Was  instantly vomited.  25th.  No
stool;  every thing vomited ; pain almost gone ;  pulse very feeble.
26th. No  stool; free from pain ; vomiting" continued, with hiccup.
Died in the night.—Abercrombie. 
232            MAYO'S OUTLINES OF |ATHOLOGY.

  Inspection.—The whole ofthe colon, and about twelve inches of
the lower extremity ofthe ileum, were empty, contracted, of a white
colour, and seemingly perfectly healthy.  The  remainder of the
small intestine was distended to  its  greatest degree, so as to appear
thin  and  transparent: its contents were chiefly watery matter and
air.  On the surface ofthe distended intestine, there was in several
places, especially at the lower part near the contracted  portion, a su-
perficial blush of vivid redness, but without any appearance of exu-
dation.  There was a small abscess on the right ovarium.  All the
other parts were healthy.
  The preceding cases  exemplify  the simplest form of ileus;  in
which theessential symptoms are vomiting, want of passage through
the bowels, and tenderness of some  part ofthe belly:—the common
attendant, twisting pain and tormina.  While the essential appear-
ances on inspection are, great distention of a  large portion of the
small intestine, with contraction of the part below;—and the com-
mon attendant, more  or less discoloration and congestion of the dis-
tended portion.
  The Varieties ofthe complaint are, in the symptoms, a higher de-
gree of fever, and greater frequency of the pulse: in the appearances
after death, a leaden colour ofthe intestine, great congestion, inflam-
mation ofthe intestine and of the peritoneum, or partial or extensive
mortification.
  The ambiguity which attends these cases  is brought out  by the
following question,—on what does the prominent  feature,  the ob-
struction, depend ?  Does a spasmodic contraction of some portion
of the ileum cause it; and is the intestine above this portion large
and  congested, and the source  of pain, vomiting, depression, and
death, only because its  action cannot overcome the  spasm of the
part below? or is a congested and  weakened state of the muscular
coat of some part of the  bowel the means of interrupting the mecha-
nical function of the intestine?  It is not contrary  to analogy to
suppose that the latter condition of the parts  constitutes ileus: and
if the effect, which will  be  afterwards adverted to,  of the secre-
tion  of gas into the intestine,—calculated as  it  is to impede and re-
sist the action of the  muscular fibres, already weakened through
congestion or a low degree of inflammation,—be taken into the ac-
count, one may thus  form a very plausible solution  of the  pheno-
mena of ileus, without having recourse to the hypothesis of spasm.
My own  impression, however, leans towards the first solution given.
I am disposed  to conjecture, that spasm and contraction ofthe mus-
cular fibres of one portion ofthe intestine are the primary source of
the disorder; the symptoms and the varied appearances'of the di-
lated part ofthe intestine above  being so much  the same with those
which are met with in different  cases of fatal  strangulated  hernia.
  The remedies, which  are beneficial in ileus, appear  to me to
countenance the theory of the disease which  I have adopted.   The
priucipal  of these are  blood-letting,  the tobacco injection,  and
opium, which  might well allay and remedy spasm of one part, and 
THE DIGESTIVE ORGANS.                233
a consequent  stale  of distention, congestion, and inflammation of
the portion above it;  but are hardly calculated to relieve any sup-
posed state of distention of a part ofthe intestine  merely dependent
upon weakness of its muscular structure.
  Dr.  Abercrombie, from whose work on the diseases of the ab-
dominal  viscera—rivaling, in scientific and practical interest his
Treatise on the Brain—I have largely borrowed,  is not disposed to
admit the hypothesis of spasm: yet among his numerous illustra-
tions of the subject there are many which seem to me to favour it.
  b. There  is an affection,  the  symptoms of which are  identical
with those of ileus, which may occasionally  originate  in the same
condition of the intestine.   This affection is the intussusception,
or invagination with inversion, ofthe intestine.   The common seat
of the disorder is the small intestine.   But the part, which invagi-
nates, is often the caput coli; and sometimes the  disease altogether
originates in and is confined to the great intestine, fa.  120.]
  A woman aged  thirty-two, [9th November, 1818,] while sitting
dressing  her child, was suddenly seized with vomiting and pain at
the stomach, which soon after moved downwards, and fixed  with
intense severity at  the region ofthe head ofthe colon.  The whole
abdomen then became painful and tender.  10th.  Urgent vomiting;
violent pain over the whole abdomen, with frequent paroxysms of
aggravation which produced screaming;  abdomen  tender;  pulse
120, small and feeble; countenance exhausted.  She  lived in ex-
treme distress, without any particular change in  the symptoms, for
three days more, and died on the 13th.
  Inspection.—The small intestine was greatly distended.  About
three inches from the lower  extremity ofthe  ileum there began an
inversion of the intestine to such an extent, that more than eigh-
teen inches of the  ileum had passed into the cavity of  the caput
coli.   The inverted parts were inflamed and  extensively gangren-
ous, some portions being reduced to the state of a soft pulp.   The
colon was healthy.—Abercrombie.
  A young  man, aged  nineteen, awoke in the night of the 23d
October, 1819, complaining  of violent pain in the abdomen, with
urgent vomiting.   Pulse at  first natural, but in  the course of the
day became frequent: pain little increased by pressure.   All the
usual remedies were  employed  without relief.   25th. Pulse  120,
and feeble ;  urgent  vomiting ; belly not tumid, and little or no pain
on pressure ; no-stool; features collapsed.  He died in the night.
  Inspection.—The small intestine  was considerably distended,
with inflamed portions and spots of gangrene.  Near the lower end
of the ileum there  was an intussusception, in which the included
portion, about eight inches in extent, was very soft and gangrenous.
Below this  there was, in the cavity ofthe  ileum, a considerable
quantity of coagulated blood.—Abercrombie.
  The cause  of intussusception has not yet been made out very
satisfactorily.  In the bodies of infants, in whom  there  has been no
abdominal disease,  partial  invaginations ofthe bowel are often met 
234
MAYO'S OUTLINES OF PATHOLOGY.
with; and no doubt through the lively peristaltic action of their in-
testines frequently occur, and are again drawn out and righted. In
a preparation of the small intestine of an  adult, belonging to Mr.
Caesar Hawkins, an invagination of a few  inches of the jejunum is
preserved, which had been brought on by the irritation of atsenia
lumbricoides, which adheres to the inverted part.
  Who can say, in  fatal intussusception, whether the first step is
invagination, or whether it consists in inflammation and contraction
of the part afterwards invaginated;  or whether invagination and
inflammation must accidentally coincide, in  order to  produce  the
disease ?
  One of the most remarkable circumstances in intussusception is
the restoration  which occasionally  takes  place when all hope is
seemingly gone, and  the  patient has fallen into that prostration
which attends sphacelus ofthe intestine, and is then the forerunner
of death.   It sometimes happens, that the patient, instead of dying,
lives on ; the obstruction, tension, pain, and vomiting, subside;  the
strength  rallies gradually ; and after a few days several inches of
the bowel which were invaginated, are  passed by stool: the part
having sloughed, and  become detached in  the  cavity of the living
bowel by ulceration, while the edges from which the separation  has
taken place, have  been glued together  by peritoneal  lymph, and
grow together and permanently cohere by granulation.
  c. I am tempted  by the  similarity of the symptoms to throw  un-
der the same head with the disorders enumerated, in which the
muscular coat of the intestine is to so great an extent  primarily or
secondarily implicated, some cases of rare occurrence, in which the
similar symptoms of obstruction result from some mechanical  cause
not external  to the intestine.   These are  either foreign bodies in
the cavity ofthe intestine,  or else membranous  narrowing.      '
   1.  A man, aged forty-five, had been repeatedly affected with vio-
lent paroxysms of pain, followed by jaundice, which had been sup-
posed to  indicate the  passage of gall stones.   On 3d June,  1822,
he was seized with one of these paroxysms in the usual manner;
and the pain continued in great violence through the whole day,
accompanied by vomiting.  On the 4th, the violent pain in the re-
gion  of the gall-ducts had subsided ; but he  now complained of
more general pain over the abdomen : his pulse was  becoming
frequent, and his bowels had not  been  moved.   On  the 5th, the
symptoms were those  of complete ileus, and he died in the night.
   Inspection.—The upper half of the small intestine was distended
and inflamed, with considereble exudation.   The lower half  was
collapsed, empty, and of a healthy appearance.   At the place where
the distention ceased,  there was found a large biliary calculus, four
inches on  its larger  circumference, and  three and  a half ou its
smaller.  The  common duct was enlarged so  as easily to admit a
finger.   The gall-bladder was in a state of inflammation, and  was
softened and partially disorganised.—Abercrombie.
   2.  Narrowing of the small intestine is extremely rare: the growth 
THE DIGESTIVE ORGANS.               235
of malignant disease occasionally produces it; or it may arise from
hypertrophy or inflammatory thickening of the  submucous and
mucous coats.  One instance of  contraction  of the duodenum has
been already given : the following exemplifies the same occurrence
at the termination ofthe ileum.
  A woman, aged  sixty-three, had enjoyed  tolerable health till
within three months  of her  death.  She  then had  vomiting and
costiveness for a week, and was relieved by purgatives.  After this,
she complained of  nausea without vomiting, and without pain:
the  abdomen was at first tumid, but afterwards subsided.   After a
month she was confined to bed,  with  constant nausea, and an ob-
stinate state of  the bowels; and she had frequent attacks of vomit-
ing, which sometimes  continued for several days.   In the intervals,
she complained onlv of nausea and want of appetite.  Purgatives
Were vomited, but the bowels were kept open by  injections.  She
died, gradually exhausted, about three months from the commence-
ment ofthe disease.
  Inspection.—There was great thickening  and induration of the
coats ofthe ileum at its termination in the colon ;  and the opening
was so narrowed, that it only admitted the point ofthe little finger.
The ileum was distended and dark coloured.—Abercrombie.
  C.  Enteritis.  The acute disease, called inflammation of the
bowels, is generally not distinguishable from that form of ileus in
which inflammation is joined with the characteristic cause of ob-
struction, whatever  that cause may be.  Inflammation of the bowels
is characterised by pain and tenderness of the belly,  vomiting, and
want of passage.   But the vomiting may cease, or never be a pro-
minent feature; and  the passage through the bowels may be re-
stored  or never have been interrupted, and  yet the  patient die of
inflammation.  The  inflammation attacks all the tissues of the
bowel, but its principal seats are the muscular and peritoneal coats.
The pulse may be frequent and small, or frequent  and full, or vary
little from the  natural standard ; and  the pain and tenderness of
the belly,  which are  the  most constant symptoms,  may  be  occa-
sionally intermittent, or occur in paroxysms, leaving long intervale
of comparative easet
  u A boy, aged ten (10th May, 1832,) who was out  at play in the
morning before breakfast  in  perfect health,  returned home about
nine,  complaining of pain in his  belly.   Laxative  medicine was
given him, and was repeated at intervals throughout the day  with-
out effect.   In  the  evening he began to vomit, and passed a rest-
less night with  frequent vomiting, the pain in his belly continuing.
11th. Pain continued in the early part of  the day, but subsided in
the afternoon :  be was seen by a surgeon, who ordered a succession
of purgatives, but they were  constantly vomited.  I saw him late
at night, and found the pulse  120, and of tolerable strength.  The
pain had in a great  measure subsided, but great tenderness of the
whole belly continued, with frequent vomiting: and  there had been
no stool.  Bleeding from the  arm  was employed with much  appa- 
236            MAYo's OUTLINES OF PATHOLOGY.

rent relief, followed by leeches, &c.  The bowels were now moved
by a mild enema, and he had afterwards one or two motions;  but
he continued very restless, and died about five in the morning, not
more than forty hours from the first complaint of pain.
  " Inspection.—The upper part of the small intestines was much
distended :  on  the lower part there was  high  inflammation, with
extensive  adhesions.  By the distension of the upper portion, a
great part of the ileum was pressed together into the cavity of the
pelvis, forming a mass of disease, the different parts of which ad-
hered extensively to each other, to the rectum, and to the sides of
the pelvis ; much force being required either to separate them from
each other, or to raise them out of the pelvis.  The inflammation
extended over  a great part ofthe small intestines, but the principal
seat of it was the ileum;  and the bladder also seemed to be affected.
In the cavity of the pelvis  there was  a considerable quantity of
puriform fluid."—Abercrombie.
  D. Inflammatory and ulcerative affections of the mucous coat.
The ordinary and common symptom of these affections, as it might
be anticipatecf from physiology, is purging ; that is to say, increased
secretion, with increased action of the muscular fibres, which sur-
round and are under the control of the mucous membrane.  But
many circumstances may occur, to prevent this symptom  having
any prominence ; such as debility, a tranquil state of the great in-
testines, and probably violence of inflammation.
  a.  Acute  inflammation of the mucous coat is extremely rare.
The following case, which occurred in the practice of Dr.  Alison,
may  exemplify some of its features, modified perhaps by  the de-
pression following fever.
  A woman, aged about thirty, in  November, 1827, was received
into the clinical ward of  the Royal Infirmary of Edinburgh, affected
with symptoms of continued  fever in a very mild form ;  and after
five or six days she was considered as convalescent. She recovered
strength so slowly, however, that she was allowed to remain in the
hospital; and she went on for ten days without any symptom, ex-
cept  weakness.  She then seemed to relapse, complaining chiefly
of headach, and pain ofthe back.   After this she had sickness and
a good deal of vomiting,  and complained of pain, with some tender-
ness, referred to the region ofthe liver, which was relieved by topi-
cal bleeding.  She still had sickness, with  occasional vomiting; the
pulse continued frequent and weak;  her strength sank rapidly;
and she died in four days from the  commencement of this  relapse.
There had been no diarrhcea; stools had been produced  by ene-
mata, and they were tolerably healthy.
  Inspection.—-In the lower end ofthe ileum, a portion ofthe mu-
cous membrane, eighteen inches  in extent, was covered by a thin
uniform film, like the crust of aphthae;  beneath it, the membrane
showed a high degree of redness.  The  peritoneum covering this
portion of intestine showed some minute flakes of coagulable lymph 
THE DIGESTIVE ORGANS.               237
for three or four inches.  All the other parts were healthy.—Aber-
crombie.
  A woman, aged  twenty-five, was affected with pain over the ab-
domen, tenesmus, and diarrhoea.  The  pain intermitted occasion-
ally, and was most severe on going to stool and on passing urine.
The concretions were free from scybalae or blood.  She had head-
ach, thirst, some cough,  nausea, occasional vomiting, and a pale
emaciated look : pulse 72.  She ascribed  her complaints to cold,
and they had been gradually  increasing for three weeks.   Various
remedies were employed without benefit, consisting  chiefly of
opiates, absorbents, and calomel.  The disease went on for eight
days more, during which  time the state of the bowels was as fol-
lows.
  2d day.  Two stools, severe  tormina, which  were relieved by
fomentation.
  3d day.  Nearly free from tormina ; one stool, which seemed to
consist of broth, which she had recently taken, little changed.
  4th  day.  Two  scanty evacuations, without griping;  abdomen
hard and  painful; vomited once : a mild enema produced a copi-
ous discharge, and relieved the pain.
  5th day. Less pain ; vomited several  times ;  one stool thin  and
fecal; pulse 78 : took six grains of calomel.
  6th day.  Two  stools,  one of them thin and fecal, the other
much tinged  with blood; much pain before the evacuations ; ab-
domen tense and painful;  pulse 80;  vomited a considerable quan-
tity of slimy  matter tinged with blood, and having some purulent
matter mixed with it: took eight grains of calomel.
  7th day.  Two  stools, thin, fecal, and of a  natural appearance,
but preceded  by much pain ;  vomited repeatedly some greenish
slimy matter mixed with  bloody pus ; less tension of the abdomen ;
pulse from 60 to 70: took some calomel, with opium.
  8th day.  No stool, and no vomiting.  Died in the  night.
  Inspection.—The  vessels  in  the stomach, duodenum, and jeju-
num, were unusually distended with  blood.  The ileum was livid,
with sorne  adhesions;  its internal surface  was quite  black, and it
contained dark-coloured slimy matter mixed with very fetid pus.
The colon on the left side was found livid, with adhesion to the ab-
dominal parietes and to the lower part ofthe omentum, which  also
was of  a  livid colour; and  between these parts there  was much
fetid pus.
  The  appearances of the mucous surface showing effects of dif-
ferent degrees of inflammation are,—
  1. Portions  of the  membrane red, with  flakes or  a continued
coating of lymph upon it.
  2. An extensive portion of the mucous  membrane exhibiting a
soft consistence of  a uniform black colour—gangrene  of the mem-
brane—sometimes  implicating the muscular fibres.
  3. Inflammation in patches confined to the muciparous glands;
which  are either thickened and covered  with tenacious mucus, or 
238            MAYO'S OUTLINES OF PATHOLOGY.
with lymph, or present a dark-gray surface of a soft pultaceous
consistence ; the slough separating leaves an ulcerated excavation.
Sometimes the obstructed follicles, distended with mucus, present
the appearance of vesicles.
  4. Ulcers of various appearances—either simple excavations as
imder the preceding head;  or from chronic disease, joining to a
surface  either preserving the  character of  ulceration, or covered
with an ashen slough, edges raised,  hard, and  ragged;  the ulcers
differing in  number and size ; the intermediate surface  generally
healthy, sometimes partially thickened into red fungous elevations.
fa.  130, <fec]
  Where  ulcers exist, danger likewise exists of perforation of the
intestine from  the giving way of the peritoneum.   There is like*
wise danger of hemorrhage, from the  possibility of a large  vessel
being opened.
  Where ulcers ofthe small intestines attend phthisis, the follicular
thickening which precedes them is often scrofulous.  On making
sections of the not as yet ulcerated but swollen  follicles, tubercular
matter is found in them.
  b. The subacute or protracted forms of inflammation of the mu-
cous membrane  of  the small  intestines which are concentrated in
the follicular structure, and  lead  to  thickening  and ulceration of
the muciparous glands, exhibit three varieties.
  1st. Where the local inflammation is the primary disease.
  2d. Where ulceration follows fever.
  3d. Wrhen it is attendant on phthisis.
  1. A  girl  aged three  years, about three weeks before her death,
was attacked with vomiting, frequent calls to stool, and pain in the
abdomen.   The evacuations were reported to have been frequent,
slimy, and fetid.   After eight or ten days, when she was first seen
by the late Dr. Oudney, she had frequent, irregular, febrile parox-
ysms.   She had vomiting and  frequent stools, which were of a clay
colour ;  and the  abdomen was tender upon  pressure.  Her tongue
was white, and there  was urgent thirst, especially during the feb-
rile paroxysms.  In this  state  she continued until  a few days be-
fore her death, when she became oppressed and  partially comatose,
with frequent  screaming, and  great unwillingness to be moved.
The pulse varied from 130 to  150, and she had frequent stools,
which were now of a dull green colour mixed  with specks of yel-
low.  The pupil was natural,  and continued sensible to  light until
a few hours before death.
  Inspection.—The ileum,  from its termination  in the colon to
near the jejunum, was highly  vascular, its  minute vessels appear-
ing as  if injected.   The  mucous membrane was covered with nu-
merous  inflamed patches, which  had a fungous appearance : they
were considerably elevated above the level of the sound parts, and
were covered with minute ulcerations.  Some of these patches were
the size of a shilling, others smaller:  they were generally  at the
distance of an  inch or two from each other, and the membrane in 
THE DIGESTIVE ORGANS.               239
the intervals was  healthy.  The mesenteric glands  were greatly
enlarged, and very vascular.—Abercrombie.
  2. A girl, aged nine, was seen  by Dr. Alison, in December, 1819,
affected with the usual symptoms of contagious fever, which was.
very prevalent in a narrow and crowded lane where she resided,
and had affected a person in an  adjoining room.  From  the com-
mencement of the disease she  had  diarrhoea,  with  griping, and
considerable tenderness of the abdomen ;  and the concretions were
thin,  fecal, and  of a  healthy appearance.  These symptoms con-
tinued, with frequent pulse and foul dry tongue, till about  two days
before her  death;  when  the diarrhoea suddenly subsided, and was
succeeded by violent  pain, acute tenderness of the abdomen, and
every symptom  of peritoneal inflammation.  The duration of the
case was about five weeks.
   Inspection.—There was  considerable  peritoneal  inflammation,
especially in the ileum, where  there was  extensive adhesion, with
considerable deposition of flocculent matter.  The intestine was
also seen  to be  in several places perforated by small ulcerations,
through which fecal matter  had  escaped into the cavity ofthe peri-
toneum.  The ileum  being laid  open, discovered  a most extensive
tract of disease on its inner surface, the  mucous membrone  being
extensively corroded,  and in many places completely destroyed, by
round well-defined ulcers, many of them  as large  as  a shilling.
This state of disease  extended over the  greater part of the ileum,
and  in several  places its coats  were considerably thickened.  It
contained a considerable quantity of fluid fecal matter of  a natural
appearance.  The higher parts of the small intestine were healthy,
and contained  a small quantity of a dark-green  viscid fluid,  like
inspissated bile.   The colon was collapsed,  and externally healthy;
internally there were in several places, especially on the left side,
patches of redness on its mucous membrane, but without any ap-
pearance of ulceration :  it contained only a small quantity of mu-
cus.  The other viscera were healthy.
   3, A gentleman, aged  nineteen,  about four  months before his
death began to  be affected with slight febrile  paroxysms, and an
unhealthy state  of the bowels.   His motions were in general not
above two in the day; but were always thin, light coloured, and
remarkably fetid.  This went on for  two  or three  weeks, when,
under some treatment which was adopted, his stools became formed,
and  more natural; but they were often slightly tinged  with'blood.
Soon after this,  he was exposed  to cold, and was seized with much
griping and frequent  watery stools, which continued for two days.
This attack left him  weak, and  he  had feverish paroxysms in the
 evening.   He had still  generally no more  than  two evacuations
daily, but they were always thin and remarkably fetid.   He took a
good deal of food,  but wasted progressively.   He had slight cough,
 which  was chiefly observed during the night, and seldom  in the
day; his  pulse  was constantly quick and small, with flushings in
the evening, and perspiration  at night;  but the latter afterwards 
240            MAYO'S OUTLINES OF PATHOLOGY.
ceased. Dr. Abercrombie saw him about a month before his death;
he was then weak and much emaciated, with a small rapid pulse,
slight cough, and  very little expectoration.  There was some dis-
tention of the  abdomen, with considerable tenderness:  he  had re-
gularly about two motions daily, which were sometimes thin and
fecal, without  anything  unnatural  except a remarkable fetor; at
other times there  were mixed  with them flakes of a yellow curdy
matter.   He died, gradually exhausted, without any change in the
symptoms, except considerable oppression  of his breathing.  His
cough was never severe, and there was very little expectoration to
the last.
  Inspection.—The lungs were most extensively tuberculous, with
numerous cornuae.  In the upper part of the left lung there was an
abscess larger than  an orange, full of a sanious fluid  mixed with
broken-down   tubercular  matter.  The  bowels were externally
healthy:  internally, nearly the whole tract of the small intestine
was covered  by a series  of ulcers.  They  were in some  places
small and distinct, being scarcely larger than the diameter, of split
peas: in  other places, many of  them  had run together,  forming
considerable  spaces  of continued  ulceration.  The  colon  was
healthy.—Abercrombie.
   The last case  which I shall quote under this head exemplifies
the spread of ulcerative  disease throughout the whole tract of the
alimentary canal ; the principal  seat, however, being the small in-
testine.
   A lady, aged thirty-five, died in April, 1818, had  suffered for
nearly four years from  a diarrhoea  which  had  resisted  every
remedy.  Dr.  Abercrombie saw her only  a few days before her
death ; when she was pale, withered, and emaciated, with frequent
pulse, slight cough, and considerable uneasiness in the abdomen.
The diarrhcea occurred  several times every day;  and the evacua-
tions were thin, fecal,  and of a healthy appearance.  The abdomen
was to the feel soft and  natural; she had no vomiting; the cough
was not severe, and  had commenced only within the last year.  At
the commencement of the complaint she had suffered much from
pain in  the bowels,  and occasionally through the whole course of
it; but it was not constant, and was not confined to any particular
part.  For some time before her death she had aphthae ofthe throat.
   Inspection.—The bowels were externally healthy, except in seve-
ral places ofthe  small intestine,  where  there were  large spots of a
dark-red  colour,  which  seemed to be deep-seated, as if  shining
through  the  peritoneal  coat.  At the  places corresponding  with
these spots, the mucous membrane was elevated into  patches of a
fungous  appearance and  deep-red colour; and in these portions
there were numerous  small oval  ulcers, the bottoms of which were
smooth and pale, while the parts around were of a dark-red.  At
these ulcers, the intestines, when held  up to the light, were semi-
transparent:  they were  found  wherever the dark fungous appear-
ance existed, and this was over a  considerable part of the small 
THE DIGESTIVE ORGANS.
241
intestine, in irregular portions, some of them s'x or eight inches in
length, the intervening membrane being healthy.  The colon was
externally  healthy;  internally, there  were manv  small  ulcers,
which had a different character from those in the small intestine.
They were more distinctly ulcerated at the bottom :  few of  them
were larger than the diameter of a split pea ;  but each of them was
surrounded by a firm ulcerated margin, without  any discoloration
ofthe surrounding parts.  They were chiefly observed  in the as-
cending  colon, and  on the arch.  On the  inner surface of the
stomach, near the  pylorus, and of the oesophagus through its whole
extent, there  were  numerous very minute superficial ulcers, of an
oval shape, and scarcely larger  than  the diameter of a pin's  head.
The lungs were tubercular, and in the left there were several  small
abscesses.  The other viscera were healthy.
   c. The mucous  membrane of the small intestines is the principal
seat of three disorders, of very different degrees of importance, in
the first of which analogy, and in the last direct observation, shows
nothing more than hyperaenia of the  mucous tissues and follicular
structure, and in a less degree ofthe outer coats ofthe bowel.
   The diarrhaa,  which commonly prevails in this country during
the latter end of August and beginning of September,  is seldom at-
tended with  symptomatic fever.   It lasts from three to  ten  days.
The stools are frequent and watery, with a slightly fecal character;
or more solid and  clayey, from the absence of bile.  There  is  com-
monly little griping,  but some obscure tenderness on pressing the
belly.  There can be no doubt but that this affection depends  upon
an unusually irritable state of  the mucous lining of the small  n-
testine.   The same affection occurs sporadically at every period of
the year ; the evident cause frequently being exposure to wet and
cold, or unwholesome food.
   Ordinary cholera differs  from the preceding complaint in being
attended with bilious vomiting and purging, joined with cramps of
the legs and  abdominal muscles.  The same state of the mucous
membrane of the small intestine is probably present as in diarrhcea;
but the irritation upon it is aggravated or excited  by a profuse flow
of bile into the duodenum, part of which makes  its  way into the
stomach.   This disease is rapid in  its course:  in a few hours it
produces extreme prostration ;  and if the purging and vomiting are
not stopped, the  patient is in danger from this cause, not to  men-
tion  the various  inflammatory affections which so much irritation
ofthe bowels may set up.
   Asiatic cholera.  The symptoms are, after diarrhoea, or sometimes
no premonitory symptom having occurred, sudden vomiting ofthe
contents  of the stomach  with  little nausea, and  sudden purging
without pain;  the vomiting and  purging frequently recurring,
the liquid discharged being like rice-water or water gruel.    With
this, spasms of the muscles ofthe extremities and belly. In a  short
time—from one to  three or four hours—collapse supervenes;  urine
is not secreted ; the pulse is  extinguished ; the eyes are sunk  ; the 
242           MAYO'S OUTLINES OF PATHOLOGY.

eyelids are surrounded by a dark circle ;  the voice is hardly audi-
ble ;, the  tongue is cold; the skin cold and passively shrunk, with
a dirty look, or Livid and bluish, particularly on the extremities;
cramps ofthe limbs constant;  vomiting and purging cease;  death.
   In the bodies of those who  have died of asiatic cholera one in-
variable and characteristic appearance presents itself.   On opening
the cavity of the belly, the alimentary canal looks as if it were pre-
ternaturally healthy and fleshy, of a light pink colour mottled with
gray: the  secretion  on the surface  of the peritoneum is slightly
viscid.  On opening the small  intestine, the mucous  membrane is
found to have the same pink tint as  the outer surface, as if it had
been the  seat of an unusual flow of blood;  but without the redness
of inflammation, or the dark vascularity to which the term venous
congestion is often applied.  The mucous follicles are remarkably
full, large, and prominent.  These appearances are most striking in
the small intestines, but they extend to the stomach and great in-
testines ;  and  the  whole length of the tube contains the gruel or
ricewater-1 ike liquid, which has been passed during life.
   Upon the true nature of this tremendous malady, it is difficult to
come to  a satisfactory conclusion*   The  analogy of the lowering
effects of common  cholera would lead us to suppose, that the spasm
and prostration which characterise Asiatic cholera  result from the
violent action and exhausting discharges of the stomach and bowels
that attend the majority of cases of this disease.  The appearances
which alone are  observed with  uniformity after death favour this
supposition ;  which  is additionally supported by the remarkable
fact, that in the greater number of cases in this country, the disease
has been immediately preceded  by  simple diarrhcea.  When the
intestines have been under the irritation of that disorder for some
hours, they have  directly passed  into the state of cholera.  It may
even be confidently asserted, that many who have died of cholera
in this country, would not have  had cholera at all, if the premoni-
tory diarrhoea had been arrested.
   The next characteristic circumstance  to the spasm, prostration,
and copious  mucous discharges in Asiatic cholera, is the state of
the blood, which  is  deficient of its due proportion  of serum and
saline  ingredients.  But this  alteration  is  intelligible enough, on
the supposition that the abstraction ofthe fluids vomited and purged
would reduce  the  blood to the condition in which it is actually
found.  It is evident, likewise, that such  a condition  of the blood
so produced might be expected neither adequately to stimulate the
heart, nor—this deteriorated blood being  thrown with  feeble im-
pulse along the circulation—to  animate the nervous system to its
functions.  How  much of the  prostration of asiatic cholera depends
upon the quality of the blood, is shown by the marvellous effects
of injecting hot water, containing a small  proportion of sea salt and
carbonate of soda, into the veins.  After  the temporary utility of
this expedient had been made known, I had an opportunity of try-
ing it upon a patient of Dr. Hawkins's, in the Middlesex Hospitalr 
THE DIGESTIVE ORGANS.
243
who was in a state of complete collapse.  Upon two pints of water
at \15 degrees of Fahrenheit, containing half a dram of carbonate
of soda and a scruple of sea salt, being slowly injected into one of
the veins ofthe arm, the patient recovered some warmth of skin, a
sensible pulse, his voice (before a whisper) acquired some tone, his
eye was less sunk, he raised himself and sat up, and expressed  him-
self as wonderfully revived.  However, as it usually happens, this
patient in two hours fell  back into the state of collapse : the injec-
tion of hot salt and water  was then repeated, but with much less
effect, and that of shorter duration.  In two hours  afterwards death
took place, leaving it doubtful whether life had  been at all  pro-
tracted by the treatment.
■, Such is the argument, which may be used to  show that Asiatic
cholera bears a close  affinity  to  our indigenous cholera, and in-
volves no new and  peculiar element.   The  principal objection to
this view rests upon the fact, that, in some of the most rapid and
hopeless cases,  the vomiting and purging have been extremely mo-
derate.  Nevertheless, the peculiar  derivation of blood to the st©*-
mach and bowels was  probably present; and such is  the powerful
sympathetic influence  of these organs, that  it would be bold  to
assert that when in this state of altered circulation  they may not
actively depress the other organs ofthe frame, and even change the
blood.  The easiest mode of escaping the difficulties of the ques-
tion, is to admit the operation of all the influences which I  have
enumerated ; and to suppose in addition another cause, some  pow-
erful agency, producing a specific effect upon the  vital frame.  Ma-
gendie  antithetically observed, that asiatic  cholera begins where
other diseases end—in death.   And certainly many of its features
impress us with the idea of some extraneous and peculiar force of
prostration that directly extinguishes life;  and,  which is indeed
most wonderful, seems to act  upon life by depressing, without ex-
hausting  the  vitality of the  organisation.   This language,  I am
aware, is  too fanciful for sober physiology ; but it is suggested by
certain remarkable features of the disease yet unadverted to.  It is
 well attested, that  in  many cases of the most formidable type of
cholera, when  the patient  for two or three hours before death has
lain cold, blue,  motionless,  the limbs stiffened with cramp—upon
death taking place  the limbs and  the jaws have begun to  move in
slow convulsions, the  skin has become sensibly warmer, and the
blue tinge has  gone off, changing to a mottled  red ; as if the or-
ganisation, which had been borne down during the  struggle  be-
tween life and the disease, could  temporarily re-exert its forces,,
when the pressure which extinguished life had ceased.
   But what is the external influence that excites cholera? or as that
question cannot be answered, is cholera infectious, or simply epi-
demic ?   Judging  from  its  progress, when it  first  invaded this
country, lam disposed to consider  the disease as simply epidemic.
I witnessed the complaint as it occurred in Lambeth and St. Giles's
in the midst of a very  poor and crowded population.  The disease 
 244            MAYO'S OUTLINES OF PATHOLOGY.

 attacked here and there a few persons only. A typhous fever in the
 same neighbourhood would have seized ten in a  house, where the
 cholera found but one victim; and would have invaded every house
 in a street, where the cholera appeared but in two or three.  On the
 other hand, the fact that cholera arrived in England at two of our
 ports, appears to favour considerably the idea of its propagation by
 infection ;  but it still must be borne in  mind, that these ports were
 on the eastern coast, the coast by which the disease, if epidemic,
 and not iufectious, should analogically of its former route  have
 arrived ; and that if arriving as  an epidemic on the eastern coast of
 our island, the disease  should   again  analogically have  broken
 out in crowded populations by the water side.
   It must however be admitted,  that a number of individual cases
 have been recorded, in which the disease seemed  to be conveyed by
 personal infection; and it certainly is not disproved that cholera may
 be communicated by the exhalations from cholera patients.  Practi-
 cally, therefore, the disease ought to be considered of  this nature ;
 and where  it prevails the usual precautions against infection—so
 that they do not interfere with the offices of humanity—should be
 resorted to.  Admitting  the  conclusion, that the disease is  really
 infectious, the following positions require to be additionally assumed.
   1. Cholera has a less  force of infection than  any other  known
 infectious disease.                                              .
   2. More predisposition is required to take the infection of cholera,
 than to  take other infectious diseases.
   3. A peculiar constitution of the* air and season, or an epidemic
disposition,  is more necessary for the spread of cholera than for that
 of other infectious complaints.
  4. Local peculiarities and habits of diet are of unusual influence
 in promoting the  invasion of cholera.
   5. As a practical corollary from the preceding conclusions, more
 care is advisable during the prevalence of  cholera to avoid  predis-
 posing causes, than to avoid infection.
  How, finally, is malignant cholera to be treated ? Every remedy
 that has been tried, has failed in most instances, and has been success-
 ful in some.   The various remedies which have  been used may be
classed as the empirical, the rational, and the paradoxical.
   1. The empirical.   When an English  practitioner  is at a loss
 his resource is calomel and opium, or bleeding. Calomel in  greater
or less doses alone, or combined with more or less opium, is the
favourite treatment for cholera  in  this country.  Bleeding in the
stage of collapse  is impossible; in general, before collapse super-
venes, it is injurious;  but when  occurring  in strong and plethoric
persons, and attended with violent spasm, the complaint thus treated
at the outset, is believed to have been mitigated.
  2. The rational.  Cordials, with stimulants  and opiates.   This
practice, in the stage of collapse,  has proved wholly inefficient.
Opium in large doses has gained general condemnation ; it has been 
THE DIGESTIVE ORGANS.                215
thought to give an unfavourable character to the secondary fever, if
the patient  survives the stage of collapse, and  with some  rare
exceptions has been of no service in that stage.  The saline treat-
ment, so well advocated by Dr. Stevens, has had very ambiguous
success.  The external application of heat has proved useless.0 The
injection of  hot salt and water into the veins in some instances has
been followed by recovery, and is certainly  not the  worst practice
that can be tried in the most serious half of cholera cases.
  3.  The paradoxical.  Cold affusion.  It  is certain, that, in some
instances, salutary reaction has been produced by this means.—Ex-
citing vomiting by salt and water.   This practice often arrests the
vomiting belonging to the disease, and sometimes the other symp-
toms.— Purging by croton oil.  I am assured,  by an Indian prac-
titioner, that he has known this  practice  successful.  Repeated
small doses of nitrate of silver, or sulphate  of copper.
                          SECTION V.

                     The Great Intestines.

   The disorders which I have placed under this head and in which
 the great intestines are exclusively or to a great extent  involved,
 will be treated of  in the following order.   First, suppression of in-
 testinal secretion ;  constipation :  tympanites.   Secondly, diseases of
 the colon analogous to ileus, internal obstruction, and inflammatory
 affections of the mucous membrane ofthe small intestines.  Thirdly,
 diseases of the rectum.
   I. a.  Suppression of  intestinal secretion.  I  attended during
 several  weeks a tall, extenuated child,  aged sixteen, who a  year
 before had  had scarlatina;  which left her debilitated, and liable to
 an occasional spasmodic difficulty of swallowing.   She was ex-
 tremely thin and weak, and food  went against her,"so that she  took
 very little daily : once in a week or ten days she  passed a minute
 quantity of dark-green faeces.   Dr. Merriman afterwards saw this
 patient.   She  died after being  reduced  to the utmost degree of
 emaciation.  On the inspection of the body, as it was reported to me
 by Mr. William Hawes, no appearance of disease was found ;  but
 the intestines were  remarkably thin. The following case exemplifies
 the connection of thinness of the bowels with the same tendency.
 li A lady, aged about thirty, had been in bad  health for  four or five
 months;  and was  wasted like a person  in an  advanced stage of
 phthisis.  She had a small frequent pulse and bad appetite, but com-
 plained of nothing except some undefined uneasiness in the abdo-
 men.  The bowels were slow, requiring the constant use of medi-
cine ; the motions were consistent and formed, but always of the
deep brown colour of dark mahogany or  rose wood, and  no treat-
ment had any effect in correcting that colour.  The abdomen was
      20—f                                   17 may 
246
MAYO's OUTLINES OF PATHOLOGY.
collapsed, and nothing  can be discovered by examination.   Some
time afterwards, she began to have uneasiness in her chest, with
slight cough ;  she then became liable to fits of  coma, in which she
lay with  her eyes open, but unconscious of anything: at length
she had repeated paroxysms of convulsion,  and she died in  a state
of the most extreme emaciation, after an illness of eight or nine
months' duration.
  "Inspection.—No disease could be discovered in the brain, and
the lungs were quite healthy, except some very old adhesions ofthe
pleura.   The  intestinal canal was throughout so thin,  as to be
transparent like goldbeater's leaf.   On the mucous membrane there
was in many places a tenacious mucus of a dark brown  colour; but
no disease could be discovered in the membrane itself, and no mor-
bid appearance could be detected in any organ."—Abercrombie.
  I was  requested to see a young medical man, who I heard was
in a fit.  I  found  him lying on the floor,  sensible, but exhausied
with suffering: the flexor  muscles of the limbs and the muscles of
the abdomen were in strong spasmodic action.  He had been in this
state for several hours.  Ammonia and hot  brandy and water were
given him, and he gradually  rallied.  This  I  learned was not the
first seizure of the kind which he had experienced.  Attacks of a
similar description, but of  less severity, would come on several times
in  the year:  they  were preceded  by obstinate costiveness.  This
patient, now twenty-eight  years of age, up to the age  of fifteen
enjoyed excellent  health.   At that age his  bowels fell  into  a state
of costiveness which has continued since.   He grew  up of a slight
and delicate frame, physically incapable of much bodily exertion,
and indisposed to it by a  languor and drowsiness which probably
arose from the imperfect action of the bowels.  The bowels now
act once in  five or  six days only :  what is  then passed is healthy;
it is only extraordinarily deficient in quantity.  With  this he has
little appetite; and even that he is afraid of indulging, lest it should
lead to one of the attacks  which 1  have described. These attacks,
it has  been  mentioned, recur when the bowels have been confined
for an unusually long period.  The belly then becomes hard, and
a little swollen : there  is  sickness, but nothing is thrown  up but
what  has been recently taken  into the stomach : there  is a sense of
uneasiness and pain above the umbilicus.   When at the close of
such an attack the  bowels are relieved, the  motions which pass are
still extremely scanty.
  b. Constipation.—Two of the preceding cases exemplify nearly
total suppression of intestinal secretion.  From this state  there is
every  intermediate shade to regular  and  healthy  action of the
bowels.  But there are two  principal varieties: in one, the entire
quantity of  feces is insufficient;  in the other,  the quantity is con-
siderable : but owing either to torpor of the intestine, or deficiency
of fluid, or of stimulating quality in the feces, they are retained and
accumulated.
   Torpor and deficient secretion from spinal disease.   I was con- 
THE DIGESTIVE ORGANS.                247
suited  in the case of a young  lady, one of whose symptoms was
obstinate constipation ofthe bowels, requiring that she should take
nightly from twenty to thirty grains of  the compound extract of
colocynth, to produce an action of the bowels the following day.
She had been ill four years,  and her sufferings had  commenced
with severe  pain across the belly, and obstinate costiveness.   After
a fort night's illness the constipation yielded ; but one leg became
feeble, and the knee  of that side was frequently spasmodically bent.
This complication of palsy and spasm soon after affected the  oppo-
site leg: afterwards  one hand became feeble and contracted. These
symptoms grew  upon  her;  but she retained a  remarkably fine
complexion, and had the appearance, when making no exertion, of
perfect health.   The vertebral  column was perfectly straight and
even ;  but she  often experienced pain at  the lower part ofthe dor-
sal  portion,  and pressure there gave her uneasiness.  This circum-
stance, coupled  with the  other symptoms, led me to recommend
that issues should be  made  at the lower part of the back.   Tho
remedy was followed by great relief  The legs seemed less weak,
the knees were not so frequently or  so painfully contracted, and the
bowels acted with half the usual dose of drastic purgatives.   But
the improvement was temporary;  and, disappointed of obtaining
permanent relief, this patient consulted other surgeons.  She died
six months  afterwards.  On  the examination of the spinal cord, it
was found for the length of two inches in a state of softening  at its
lumbar poition.
   Torpor from paint.—A gentleman bad been under the care of
the most eminent  physicians in England and Ireland  for an  obsti-
nate state of the bowels, which was originally ascribed to having
slept in a newly-painted room.  From being of a full  habit, he be-
came greatly ertiaciated, and  the complaint went on in this manner
for two years.  Dr.  Cheyne  then recommended galvanism, which
in about three weeks restored the natural action ofthe bowels, and
he  soon recovered perfect  health.—Abercrombie.
   Accumulations of hardened feces take place in the caecum, in
the sigmoid flexure ofthe  colon, and in the rectum.
   Mr. Lamb, of York Square, Regents Park, communicated  to me
the following instances.  He was present at the examination  ofthe
body of a middle-aged person,  who had  died of obstruction of the
bowels, having  pieviously suffered from constipation.  There had
been an inward swelling, which was felt externally above the right
groin, and to which (he pain  and distress  which the patient suffered
was referred.  Upon opening the abdomen, this swelling was dis-
covered to be the caecum, enormously distended with scibalae.
   A publican, aetat.  fifty-five, had  been  bed-ridden for six months,
He lay supported in his  bed in an inclined position.  If he lay
down, he was oppressed and uneasy; if he stood  up, he vomited.
He was corpulent, and ate voraciously.  The bowels never acted
without medicine.   It had been ascertained that there was  no ob-
struction in the rectum, and the most powerful purgatives had been 
 248            MAYO'S OUTLINES OF PATHOLOGY.

 restorted to without giving relief.  The remedy which  led to the
 cure of this patient, was the injection of nine pints of water into the
 great intestine.  The injection brought away an immense quantity
 of scibalae.  The injection was repeated daily, but not in the same
 quantity,  for a  week ;  and for that  period accumulated  scibaia;
 continued to be discharged.  When the colon  had been thoroughly
 emptied, an alterative course  of medicine and regulated diet  en-
 tirely restored the health of this patient.
   Accumulations  of feces in the great intestine often exist a long
 time unsuspected, in consequence of small quantities of liquid mat-
 ter occasionally passing.  When complete  obstruction from  accu-
 mulated feces has  taken place, a month  has been known to elapse
 without the passage of  any thing—distention, pain,  vomiting, gra-
 dually  supervening; yet the  patient has recovered on  the bowel
 being mechanically cleared out. In such cases, acute inflammation
 or ileus are in the mean time  liable at any moment to develope
 themselves ;  or ulcers may form, at one or more of which the peri-
 toneum may give way and the intestine be perforated.   The latter
 fatal accident has singularly happened at the appendix caeci vermi-
 formis,  through a cherry-stone becoming impacted in it.
   c. Tympanites.—In  tympanitic distention,  the flatus either is
 confined within the  canal of the intestine,  or  has escaped  into the
 peritoneal cavity through a perforation of the bowel.  Distention
 ofthe stomach and intestines with wind causes extreme suffering,
 and greatly aggravates, or contributes to the fatal event  of, several
 diseases.
   The pain of indigestion, and the rupture ofthe peritoneal coat in
 simple ulcer of the stomach—the second probably no less than  the
 first—are immediately dependent on distention ofthe stomach with
 wind.
   In ileus and in strangulated hernia the distention ofthe intestine
 which accelerates or determines the mortal progress of the disease,
 is caused by accumulation of  wind.   It is even possible  that in
 some cases of ileus the original obstruction may be entirely or m a
 considerable degree dependent on palsy of the bowel  from disien-
 tion by wind thrown out by the mucous membrane when under
 certain states of irritation.   The re-protrusion of an old  reducible
 hernia is often caused by wind in the bowels; and the accumula-
 tion of flatus in the portion of intestine in  the sac is certainly one
 of the  causes which prevent  reduction by the taxis, and  tend to
 establish strangulation.
   There can  be little  doubt, that, in  ordinary cases, flatus  is a
 secretion.   This appears to me sufficiently proved by the fact of its
 formation  when  the alimentary canal is perfectly healthy, on some
 neighbouring viscus being diseased.  Inflammation of the  neck of
 the bladder  fills the rectum with flatus.  Inflammation «or  conges-
 tion of the uterus swells up the whole abdomen with  intestinal
distention.   The sympathetic influence of the womb in producing 
THE DIGESTIVE ORGANS.
249
wind in the bowels, is one of the causes which  render women so
subject to this disorder.
   In the Edinburgh Medical Essays, Dr. Monro  has described the
case of a young  woman, whose abdomen became so  enormously
distended that it often seemed in danger of bursting.  This affec-
tion continued three months, and then disappeared by a prodigious
discharge of flatus both upwards and downwards.
   Several  years  ago, a  gentleman consulted  Dr. Abercrombie re-
specting a tumour in the right side of the abdomen.  It seemed as
large as the head of a child ;  and, when examined  while  he  was
in the  erect posture, felt quite hard and  unyielding: but on laying
him in *he horizontal posture, and  making pressure  upon it, the
whole  swelling disappeared suddenly with a gurgling noise.   It
appeared to be the caput coli in a singular state of distention. The
affection had existed for  a  considerable  time; and though he was
subject to flatulence and indigestion, his general  health was little
impaired.
   A lady, aged twenty-three,  had  been long affected with  pain in
the right  hypochondrium, and a very confined state of the  bowels,
for which a great variety of treatment was adopted with little bene-
fit.  In the autumn of 1822, the abdomen became greatly enlarged,
tense, and painful.   Some relief was obtained from topical bleed-
ing, blistering, and  purgatives;  but after a severe  pulmonary
attack in winter, the pain  and weight  were  aggravated, and ex-
tended into the left side in  the direction of the  arch of the colon,
with increased tenderness of the  abdomen.   In  spring, 1823, she
was somewhat improved, but  in June and July there was again an
increase of the abdominal  pain, which  became very severe in the
course  of  the transverse colon,  with obstinate  costiveness,  dry
tongue, and thirst.   Some  relief was again obtained from topical
bleeding, purgatives, and enemata;  the latter bringing off frothy
discharges and much flatus.   In the  beginning of winter,  1823-4,
she had  two  pulmonary attacks, after which the  abdomen  became
again  very tumid and painful.  In April, 1824, she bad pain in the
right shoulder, pain and  numbness of the right thigh and leg, and
she often complained of a feeling as if scalding water were  passing
along  her  right side.  In  June, the abdominal pain and  tension
being very great, a caustic  issue was inserted on the right side of
the linea alba ; purgatives  were persevered in ;  and she  went to
the country, where she remained during the summer and autumn,
and  improved considerably in strength.   From this  time her com-
plaints continued to abate, and she has since enjoyed very tolerable
health.   The uterine functions had been, through the whole course
of this  affection, quite natural.
   A sister of this lady was  affected in a  similar manner, suffering
most intense pain in  the abdomen, and such tumefaction  that she
was supposed to have ascites, and was several times on  the point of
being tapped.   She died after protracted suffering, which continued
for several years; and on  examination  the disease was found to 
250
MAYO'S OUTLINES OF PATHOLOGY.
consist entirely of an enlargement of the colon.  A  portion of it,
forty-four inches in length, is preserved ; the largest circumference
of which  is twenty-five  inches, the smallest sixteen.   It was in
many parts ulcerated.—Abercrombie.
  II.  a. The colon is liable to the same affection, which under the
name of ileus has been described as attacking the small intestines.
The following case exemplifies its  localisation  here ;  it often hap-
pens, that  both small and great intestines participate in this affec-
tion.
  "A boy, aged twelve (26th Oct. 1S13,) was affected with violent
pain ofthe belly, chiefly round the umbilicus, urgent vomiting, and
costiveness for  two days ; abdomen distended,  pulse 50.  Various
remedies were employed  without benefit.   On  the 27th the pulse
rose to  120, with  increase of  the pain, tension, and  tenderness of
the abdomen.   Blood-letting was used in the morning, and again
at 3 P. M., after which the pulse  fell to 112.    The "other usual
means were employed without procuring any evacuation from the
bowels ; the pain  continued  unabated ; sinking took place,  with
coldness ofthe body  ; and he died between  seven and eight o'clock
in the evening, having continued in violent pain until immediately
before death.   1 did not see this case during the life ofthe patient,
but was present at the examination of the body.
  " Inspection.—The stomach was healthy ;  the small intestine
was a little distended and slightly inflamed, especially at the lower
part,  where it had contracted some  adhesions.    The whole  right
side of the colon was in  a state of gangrene, especially the caput
caecum, which had burst  and  discharged into the cavity ofthe peri-
toneum a  large quantity of  fluid  feces.  The  diseased parts ap-
peared to  have been  much distended; and,  after  being emptied by
the  rupture, had not contracted, but had fallen  flat,"presenting a
very broad surface like an empty bag. There was no inflammatory
exudation : and at the upper part of the  ascending colon  this dis-
eased part terminated at once  in  healthy intestine,  which  was
while, collapsed, and empty.   This was the state of the remainder
of the colon,  except  the sigmoid flexure, which,  with the rectum,
contained  much consistent feces."—Abercrombie.
  The great intestine is liable  to intussusception.
  "A boy, aged two years and five months, (7th May,  1812.) had
vomiting,  pain  in the lower part of the belly, and tenesmus, by
which he  passed small quantities of bloody mucus, and some pure
blood. Pulse  very frequent: abdomen, to the touch, natural; much
restlessness;  countenance depressed and  anxious.  On the  8th,
while he was straining at stool, a tumour of a  dark  bloody colour
protruded from the anus  to  the bulk of an egg.  It was easily re-
duced, but on examination was distinctly ascertained to be inverted
intestine; and a probang heing introduced, passed to a great depth
by  its side, without  reaching  the commencement of the"inversion.
The  child died on the following morning.
   " Inspection.—A most remarkable inversion  ofthe intestine was 
THE DIGESTIVE ORGANS.
251
discovered, which began at the middle of the arch of the colon ;
and the parts concerned in it, including the remainder ofthe colon
and  a  corresponding portion of the  ileum, measured thirty-eight
inches.   The part that had protruded at the anus was the inverted
caput coli.   The inverted portion of the colon was of a dark livid
colour, very  soft, and in some  places thickened.   The portion of
the ileum included within this was tolerably healthy.  Besides the
mesentery connected with the inverted intestine, a portion of omen-
tum was included."
   b. Narrowing  of  the colon  by hypertrophy or  inflammatory
thickening of the mucous and cellular coats is rare, but neverthe-
less of more  frequent occurrence than similar disease in the small
intestine.   The  following case exemplifies stricture of the colon.
At the sigmoid flexure, permanent stricture is  more common.  Ma-
lignant disease of the colon  producing narrowing  and obstruction,
is more frequent than simple stricture.
   "A man, aged  twenty-four, had an attack of cholera about a  year
before his death,  and from that time was liable to uneasiness in his
bowels, with costiveness.  After some time, he had great enlarge-
ment of the abdomen, which however subsided after some weeks;
and the only symptoms then were, progressive loss of strength and
most obstinate  costiveness.   When I saw him, a few weeks before
his death, he was much wasted, had a very small  pulse, his  belly
was tense and a  little tender, his bowels were obstinately costive,
and the strongest medicine and injections often failed in producing
the smallest  evacuation.  He  had occasional  vomiting, but it was
not urgent:  he died, gradually exhausted, without  much suffering:
his abdomen had been tense, but not  remarkably distended.
   " Inspection.—In  the centre of  the arch ofthe colon there was a
remarkable stricture, which only admitted the point of a very small
finger from  the left  side.  On the right side, the opening was co-
vered across its centre by a flap apparently composed of fibres  from
the  mucous  membrane, which  were attached at the  upper  and
lower parts of the opening, and left  only a lateral  passage on  each
side of it. The left side  ofthe colon,  from the stricture downwards,
was completely  collapsed into a cord  not  larger than  a finger.
From the stricture, the  right side  became immediately distended to
upwards of twelve  inches in  circumference: it continued of this
size to the caput  caecum,  and the whole was completely impacted
with firm consistent  feces.  A great  part of the small intestine was
also distended with consistent feces."
   c. Inflammation of the mucous membrane ofthe great  intestine,
leading to enormous pulpy thickening of the mucous and cellular
coats, to ulceration, and to sloughing, is either acute or  chronic,
and constitutes dysentery.   This disease forms one of the scourges
of Europeans in  hot climates.   Even in its acute form  it generally
begins  insidiously:  after a day ofordinary  purging, mucus  and
blood are  passed, with straining and tenesmus; there  is extreme
sensibility  to pressure in the  entire course of the  great intestine 
252
MAYO'S OUTLINES OF PATHOLOGY.
and in no other part of the abdomen, with symptomatic fever, and
generally a frequent wiry pulse.   The  remedies which  have been
found  most successful are  calomel  in  large and  repeated  doses,
bleeding, and the injection of iced water and of a weak solution of
creosote into the bowel.  The disease is strictly limited to the great
intestine, of which it pervades the whole.  The disease has a re-
markable tendency to recur :  it is probable, that when the symptoms
of a first attack disappear, the membrane is often left  permanently
thickened, and affected with  chronic inflammation  and even ulcer-
ation.
  "A gentleman, aged sixty, had been for some years liable to an
irritable state of bowels, which affected  him chiefly after exposure
to cold, and  was generally accompanied by mucous discharges
tinged with blood.   He was seized with one of these attacks, while
he was at a distance from home, in September, 1827,  which seems
to have been more protracted than usual ; and on his return home,
in the end of September, he was again seized in a still more violent
degree. When Dr. Abercrombie saw him, about the third or fourth
day of this attack, he  had a look of  much exhaustion and  febrile
anxiety: his tongue was parched, and his pulse frequent and rather
small.  He complained of much general uneasiness  of the  abdomen,
especially across the epigastric region,  where  there was some de-
gree of tension and considerable tenderness.  He had frequent calls
to stool, and the evacuations consisted of small quantities of mucus
deeply tinged with blood, and  sometimes almost entirely of blood.
He had occasional hiccup, and some vomiting.   All the usual reme-
dies were employed without benefit;  the symptoms continued una-
bated ;  the vomiting  became  more  urgent;  his strength sunk
rapidly; and he died  in four days more, being about the eighth
from the commencement ofthe disease.   The evacuations retained
throughout the same character,  without the least appearance of
feculent matter even when laxative medicine was given.
  " Inspection.—The whole tract ofthe colon appeared moderately
and uniformly distended. Externally,  it presented no morbid appear-
ance,  except  some degree  of that softened and slightly thickened
state  which  has  been compared to boiled  tripe.  Internally, it
showed most extensive disease of the  mucous membrane.   This
consisted of portions ofthe membrane, of various forms and degrees
of extent, being of a fungous appearance and bright red colouiyand
sensibly elevated above the  level of the  more healthy  portions  that
were interposed between them: this morbid appearance, in patches
separated by  healthy portions of the  mucous membrane, extended
through the whole course ofthe colon and rectum;  and it preserved
throughout nearly the same character, without any appearance that
could  be considered as ulceration  or even abrasion  of  the mem-
brane.  The small intestine and all  the other  parts were entirely
healthy; and  there was no  appearance of feculent matter in  any
part ofthe canal.
  " A man, aged fifty, (7th October, 1827,) was seized with general 
THE DIGESTIVE ORGANS.
253
 uneasiness over the abdomen.  On the 8th he took castor oil, from
 the operation of which he had  numerous evacuations consisting
 almost entirely of blood.  On the 9th he was seen by Mr.  While,
 who found him complaining of great  uneasiness  in the bowels,
 chiefly referred to the lower part, but without much tenderness.  He
 had frequent calls to stool, with scanty discharges which seemed to
 consist almost entirely of blood.   His tongue  was parched, but  his
 pulse was little affected.   10th. The pulse was still  nearly natural,
 but there was  much  pain and tenderness of  the lower part of the
 abdomen, with  some dysuria.  The evacuations were  now more
 abundant in quantity, and were remaikably changed in their cha-
 racter, being watery,  dark  coloured, and with  a remarkable and
 peculiar fetor  comparable to the washings of putrid flesh.  For
 several days from this time there was little change.  The  evacu-
 ations continued watery, of a dark brownish colour, and remarkable
 fetor, and without any appearance of feculent matter. They varied
 much in frequency, sometimes occurring every ten minutes, and
 sometimes leaving him quiet for  several hours.  There was much
 thirst, and the  tongue was parched ; but the pulse continiud little
 affected till  an  advanced period of the disease.  He had some hic-
 cup, and  vomited  a few times, but it was not urgent.  Dr. Aber-
 crombie  saw him for the first time  on the  15th.   He was then
 languid  and exhausted, with an  anxious typhoid  look, a small
 frequent pulse, and a parched tongue.  He had  much uneasiness,
 with some tension and tenderness ofthe abdomen, especially across
 tke epigastric region :  there were frequent painful calls to stool, with
 scanty discharges  of  dark watery matter, some vomiting, and con-
 siderable hiccup.  He died early on the  16th.
   "Inspection.— On  laying open the abdomen, the  whole tract of
 the  great intestine, from  the  caput coli to the extremiiy  of  the
 rectum, was found to be greatly and uniformly distended.  From
 the extremity ofthe rectum to nearly the middle ofthe arch of  the
 colon, the intestine was of a uniform black colour, as if completely
 gangrenous.  From the middle of the arch to the  caput coli,  the
 appearance  was more healthy, but was  variegated by numerous
 patches of a deep red or livid  colour.  These seemed to be deep-
 seated, and were seen shining through the peritoneal  coat,  which
 appeared to be  healthy.  The large intestine being laid open,  the
 mucous  membrane at the black parts was throughout of a deep
 uniform black colour,  very soft, and easily separated ; the muscular
 coat was black and easily torn;  the peritoneal  coat was healthy.
 These appearances were continued from the extremity of the rectum
 to nearly the centre of the arch of the colon : the mucous membrane
 then assumed an appearance more  resembling that described in the
 former case, being elevated  into  irregular patches of a dark red
colour, with interspersed portions in a more healthy state.  Towards
 the lower part of the  right side of the colon, there was an appear-
ance of erosion or superficial ulceration ;  and on the inner surface
ofthe caput  coli  there  were several distinctly-defined ulcers.   The 
254
MAYO'S OUTLINES OF PATHOLOGY.
ileum, for a few inches from its junction with the caput coli, was
slightly distended, and its  mucous membrane  was reddened; the
other parts of the canal were healthy.   The  inner surface  of the
urinary bladder, at its posterior part, showed a considerable degree
of increased vascularity."
   Chronic dysentery is well exemplified in the following case.
   " A young lady, aged seventeen, had been  liable, from an early
period of life, to an  irritable state  of her bowels;  but the affection
had assumed a more  fixed  and alarming character about the begin-
ning ofthe year 1827. She at that time became affected with more
constant  uneasiness  in the abdomen, and a tendency to diarrhoea,
with  considerable  irritation; and after  some time, the motions
began to  exhibit a very unhealthy character.   She became  feeble
and  exhausted, with a quick pulse and  hectic paroxysms;  and a
great variety of treatment  was employed through the spring and
summer without benefit.   Dr. Abercrombie saw her in September.
She was  then much exhausted; had a feeble and rapid  pulse, little
appetite,  and disturbed feverish nights, with considerable perspira-
tion.  She had much uneasiness extending over the whole abdo-
men, with some tenderness, and frequent calls  to stool, accompanied
by much  pain and  irritation.  The  motions  sometimes consisted
almost entirely of a tenacious puriform  matter streaked with blood;
at other times of thin feculent matter with  much  of this puriform
discharge mixed in it, and occasionally there  was healthy feculent
matter "of considerable  consistency.   After using some remedies
without  benefit, she began to take a strong decoction of cusparia
combined with nitric acid, and small doses of  laudanum ; under the
use  of this, the puriform  discharge entirely ceased;  but she con-
tinued to have much uneasiness in the abdomen, with frequent
stools, which were thin, feculent, and healthy.  Her strength sunk
gradually, and she died in October.
   " Inspection.—The colon  externally  had   a  soft and  slightly
thickened appearance, and  there were patches of a  deep-seated
redness shining through its peritoneal coat.   On laying it open, its
inner membrane presented one continued diseased surface through
its whole extent.   There  were deep abrasions in some places, from
which portions of  the mucous membrane appeared to have been
entirely  removed :  at others, more superficial  irregular ulcerations
of various extent; and in many places, round well-defined  ulcers;
and the  whole was interspersed with  portions  of a dark reddish-
brown colour in a state of fungous elevation.   Through the whole
extent of the colon and rectum, there was  no spot that presented a
healthy appearance ; but the small intestine and all the other viscera
 were entirely healthy.  In the sigmoid  flexure of the colon, there
 was a small  portion  where the intestine was considerably thickened
 in its coats, and of almost cartilaginous hardness."
   The  occurrence of inflammation ofthe mucous membrane in the
 small and great intestines at the same time has been already exem-
 plified.    But in general, the attack is  confined to the one or to the 
THE DIGESTIVE ORGANS.
255
other;  and shows itself, if extending from either to their junction,
by very inferior  action,-and that  to a very small extent, upon  the
second part.
  The point has been already several times adverted to, of rupture
of the intestine taking place as a consequence of ulceration of the
mucous surface.  When perforation  of the commencement of the
colon takes place, it is not necessarily fatal : the ulcer may open
into  the cellular membrane in the fossa of the ileum, and give  rise
to an abscess that may point either in the loins or at the groin.  A
patient was in the Middlesex Hospital with  an abscess which  had
broken  above Pouparl's ligament, and discharged feces:  after a
considerable period, the abscess closed.  After  ten years, it again
opened:  it continued to discharge for  some months, when I  lost
sight ofthe case.   It is not less possible for abscesses originating in
the right iliac fossa to penetrate  the colon, than for ulceration of
the colon to work outwards into the iliac fossa.
   A fistulous  opening sometimes takes place from the arch of the
colon through the  parietes of the abdomen.  An  elderly woman
was in St. George's Hospital with pain and tenderness of ihe belly
below and  to  the left  of the umbilicus.  Leeches were applied to
the part; when one of the leech-bites festered, and in a few days
fecal matter was discharged  through the ulcer: this  continued till
the  patient's  death, which  happened in a  few months.   The fistu-
lous opening  [q. 80.] is seen to communicate  with  the great intes-
tine, which adhered to  the  front  of  the belly: the great intestine
had  likewise  adhered  to  a portion  of the  small intestine,  and
between  the two a second ulcerated communication had formed.
   The  great  intestine  when inflamed and  ulcerated  is liable to
become extraordinarily dilated.
   A naval officer,  aged fifty-three, in  the beginning of the year
1821, fell in  walking  down some steps, and "struck his left  side
against the corner of one of them, about halfway betwixt the ribs
and the spine  of the ileum.  No  violent symptoms followed at the
time, but he continued to feel some  uneasiness at the part, which,
though it varied very much in degree at different times, was never
entirely gone.  After some time,  he  began to have dyspeptic com-
plaints, with loss of flesh, and his general health was considerably
impaired. He then went to Cheltenham, where he got considerably
better, but  returned home, and having lived rather freely, became
worse again.   After a  considerable time had passed in this manner,
a swelling  was perceived in the  left side of the abdomen, which
was by some  considered as an enlargement  of the spleen, and by
others as a disease  of  the  liver.  He now went through  several
courses  of mercury,  by which  his  strength was considerably
reduced, but  without  any  improvement in  his complaints.   His
bowels had hitherto been in general  pretty natural, but sometimes
rather loose;  and occasionally he had passed by stool considerable
quantities of  coagulated blood.   These discharges had generally
been preceded by a good deal of pain in the left side.   The disease 
256            MAYO'S OUTLINES OF PATHOLOGY.

had gone on in this  manner for about eighteen months, when he
came to Edinburgh in the beginning of September,  1823, and was
seen by Dr. Abercrombie.   He  was then much emaciated, with a
sallow  complexion, a small frequent pulse, great weakness, and
considerable anasarca of his legs.   His belly was tumid, and there
was considerable  but not  severe uneasiness in the left side, imme-
diately above the crest of the ileum.  At this place a firm, defined,
deep-seated swelling was perceptible, which did not extend into the
region  of the spleen, and  was evidently too low  down to be con-
sidered as a disease of that organ ; and, on  repeated examination, it
was  distinctly perceived to vary sensibly in size on different days.
It was, however, so firm as to convey the  impression of a mass of
organic disease.  His bowels  were moderately open ; the  stools
were thin  and very dark  coloured, with an occasional  mixture of
blood.   After he had been in Edinburgh for ten or twelve days, he
was  seized with vomiting, which had never  occurred before his
bowels became confined, with great pain in the left side, and much
uneasiness  extending over the whole abdomen.   His strength now
sunk rapidly, and he died  in three days.
  Inspection.—The  swelling in the  left  side was  found to be a
disease of  the descending  colon, a portion  of which  was dilated so
as to form a large  irregular cyst, and the parietes of the cyst were
thick and very hard, so as to be at some places almost cartilaginous.
Externally the  cyst  adhered extensively  to  the parietes of the
abdomen ;  internally, it  presented  a  continued  surface  of dark-
coloured fungous ulceiation, with many elevations and depressions.
The disease was entirely limited to the part forming the cyst, which
was between four and five inches in diameter.  The intestine, both
immediately above and immediately below, was entirely  healthy,
and  communicated  freely with the diseased cavity.  The spleen
was quite healthy: the  liver was tubercular, but not  enlarged.
  III.  The diseases which affect the colon and rectum in  common,
—namely,  suppression  of secretion, constipation, inflammation of
the mucous membrane and its sequelae,— have  been  already ad-
verted  to.   But there remain others,  which either  are peculiar to
the termination of the  intestinal canal, or from their greater fre-
quency at  that part deserve to be made a separate  study.   These
diseases are, simple ulcer, or fissure ofthe rectum—indurated ulcer—
carcinoma—gelatiniform  cancer—medullary sarcoma—permanent
stricture—spasmodic stricture—irritable sphincter—hemorrhage—
piles — prolapsus   ani—polypus—abscess  and  fistula — lacerated
sphincter.
  a. Simple ulcer or fissure ofthe rectum commonly forms imme-
diately  above  the sphincter: its usual place is at the  posterior
surface of  the gut;  but  I have  known the complaint occupy the
fore  p irt.   It  is  frequently produced by a mechanical cause, the
mucous membrane being torn  by hardened feces,  and the crack
becoming an ulcer.  In the following case the disease had a differ-
ent origin. 
THE DIGESTIVE ORGANS.
257
    James Farrant, aetat. forty-five, was admitted into the Middlesex
  Hospital on  the  9th of October.   Fifteen months previously, he
  first experienced a sensation  of heat and pain at the anus, which
  would last  a few hours  and  then  subside, leaving a feeling  of
  numbness.  While the pain  lasted, the anus was  strongly drawn
  inwards.  The  pain extended  to  the hips and  to the sacrum.
  Ihese symptoms recurred daily: they were  always  brought on
  when the bowels acted.  About a month  after  the  commencement
  ot the complaint, something appeared to him to give way in the
  bowel, and a slight discharge of mucus took place, which continued
  afterwards.   Other  symptoms  were present, which  led  me  to
  suspect that the prostate gland was the seat of the  disorder.   The
  patient made  water  more frequently than before  ; and after the
  water had passed, some pain or uneasiness was commonly felt  deep
  in the perineum, and  of the  same  description  with  that  which
  attended  the evacuations of the bowels: mucus was likewise often
  discharged from  the urethra after the urine  had  passed.  Upon
  examining the rectum, the prostate gland was found to be  larger
  than usual, and tender on pressure; to this organ the treatment first
  employed was directed.  Leeches were applied  to the perineum,
  and the hip bath was used.  Blood was taken by cupping from the
  sacrum :  an opiate suppositorv was used at night, an enema of tepid
  water in  the morning.  The bowels acted regularly, but the patient
  did not  improve in  other respects.   Upon  the  rectum  being re-
  examined, the seat of pain, at  least  of soreness, was discovered not
  to be towards the prostate, but at the posterior surface ofthe rectum
  within the sphincter.  The bowel at this part was extremely loose
 and flaccid: but there could be distinguished upon it  an oblong ulcer
 with a hardened edge.   After trying several remedies ineffectuafly
 in this case, I divided the sphincter: the  wound was made to heal
 by granulation  and  slowly, through the introduction of a  few
 threads of lint between  the edges.
   The patient was sensible of immediate relief.  The pain which
 he experienced for several days afterwards he felt  to be the soreness
 of the wound, not the  original pain of the ulcer.  He was  then
 ordered to introduce a mercurial ointment at  night into  the gut.
 When  the part was examined a fortnight after the operation, the
 ulcer was  found  to have much improved, although  it was still'dis-
 tinct;  it had lost  much  of its sensibility together with its hardened
 edge.  By continuing the use of the mercurial ointment, the patient
 entirely recovered.  As the ulcer healed, the pain in  making water,
 with the  discharge of mucus from the urethra,  and the 'swollen
 state of the prostate, equally subsided.
   6. Spreading ulcer of the mucous membrane, with  induration
 ofthe muscular coat, is a disease extremely prevalent  among women
 in this  country; and, unless taken  early, it commonly proves in-
 curable. The condition of the parts is the  following:—the mucous
membrane entirely disappears for the extent of  from two or three,
to thirteen inches from the rectum, and, if it extend as far, from  the 
258            MAYO'S OUTLINES OF PATHOLOGY.

sigmoid flexure of the colon ;  the muscular coat which is exposed
does not granulate, but  is to th.; touch hard and rough, and when
cut through is dense and firm and almost gristly, but little if at all
thickened": the muscular  fibres are pale and atrophied, and the
cellular texture indurated.   The  disease generally commences
about  half an inch within the anus:  at  the  upper part it ter-
minates very abruptly, the mucous membrane  being eaten away
at an uneven line extending round the gut.  There is little or no
thickening at either end of the ulcer.   The ulcerated part of the
intestine has a disposition to contract.
   The symptoms of the disease are, pain and difficulty in passing
the feces,  which, when not liquid, consist of small fragments ac-
companied with blood and mucus, sense of weight in the  part,
and  confinement and soreness aggravated by  the  action ot the
bowels, pain  down  the thighs, bearing down of  the womb, irritable
bladder, no ease but in the recumbent posture.
   c. Carcinoma [q. 100.],  gelaliniform  cancer [q. 101.], medullary
sarcoma [q. 101.], have  the same anatomical characters in the rec-
tum as iu the stomach or sigmoid flexure of the colon.  Their mass
and projection into the bowel enabled  the  surgeon to distinguish
them during life from indurated ulceration, but not from each other.
The symptoms attending them are the same with those ofthe latter
disease.
   d. Permanent stricture of the rectum consists in  a partial thick-
ening of  the submucous  coat of  the  bowel and of  the adjacent
cellular texture; through which means a  smooth ring is  formed,
generally from a third to half an inch in depth, which projects into
and narrows  the channel.  Sometimes the thickening does not in-
clude  the whole circle of the intestine, but a segment only.  It  is
presumable that this thickening results  from chronic inflammation.
   The ordinary seat of stricture of the rectum is from two and a
 half to four inches from the orifice of the gut.  But sometimes it
 occurs at a greater  distance, at  six to seven inches for example ; and
 a contraction of the same nature is occasionally met with in different
 parts of the colon.
   The symptoms, with  the exception of purulent discharge,  in
 place of which there is mucus, are the same in  kind  but less severe
 in degree than those ascribed  to indurated  ulcer.   The nature of
 the disease  can be  ascertained by examination with  the finger,
 when, as it  usually happens, it is seated in  the lower part of the
 rectum.  When a similar disease occurs higher up in the gut, it is
 very difficult to distinguish  it from malignant disease.  The pain
 and difficulty which, if the instrument is  rudely used, attends the
 passing a bougie into the sigmoid  flexure of the colon, is sometimes
 mistaken or misrepresented to  be stricture.  At this  natural turn of
 the intestine, the bowel is occasionally torn through  by instruments
 used by the  unskilful, when death ensues.
   e. Spasmodic stricture.   What part of the  rectum is the seat of
 spasmodic  stricture?   From my own experience, I am disposed to
 think that no single point is  more liable to this affection  than an- 
THE DIGESTIVE ORGANS.
259
other.  The  cases, however,  which I have  met with, and have
considered of this  nature, have  been  any thing but satisfactory.
They have left me with the impression that the upper part of the
rectum, and the sigmoid flexure ofthe colon, are liable to irregular
contractions of their  muscular tunic, capable  of obstructing the
passage of the feces and of making resistance  to the introduction
of instruments.   This irregular action is generally dependent upon
a vitiated  state of the secretions; and  is more  frequently relieved
by a regulated  diet and alterative medicines, and the use of injec-
tions, than by the  employment of instruments.  Nevertheless, the
use of the  bougie is sometimes beneficial in spasmodic  contraction
of the rectum.
  One of  the best instances which I can  give of this disorder is
the following:  it contains a very useful lesson as to its treatment.
The patient is a physician, who is now through  his  judicious self-
management at length  restored  to perfect health.  The extract
which I shall  quote from  a  letter, in which  at my  request he
favoured me with an  outline  of  his case,  that  had several  times
been  the subject of communication with me before,  will convey to
the reader an idea of  the suffering which  may attend this kind of
disorder.
  "In my life," says  the writer  of this communication, "I  never
knew what it was  to  have a  single action of the bowels without
the aid of medicine, or to be fiee  for many hours together from all
the wretchedness of disorder and of remedies in conjunction, ex-
cepting for two short  intervals of time, during one of which  I
trusted simply to the use of injections of warm  water,  and during
the other when  I  took the white mustard seed, and that with so
singular  an effect that for a while I thought I had quite got rid of
my complaint.   With  the exception of these two intervals, I have
never been able till lately to say there  is in life that which is  worth
living for, or in other and more proper  words, I  did not  know what
it was to wish to live.   To say nothing of the  medical discipline
which I have  undergone again  and  again, I have been examined
and treated for stricture of the rectum and of the sigmoid flexure
of the colon for years, and for years  never passed any thing from
my bowels larger than a horse-bean, if solid, or of the little finger,
if of a softer consistence.  Oftentimes have I beenquife in capaci-
tated for exertion,  and never  able  to  enter upon my professional
duties with any  thing like alacrity  or  cheerfulness.   It is now
nearly two years ago since I came to the resolution of abandoning
all  remedial measures; to  leave off at once physic,  injections, and
the bougie; to  take nothing in  the shape of food  that could by
possibility irritate the stomach or bowels, and to leave  them to act
of and for themselves, when they could no longer retain their con-
tents.  I had, as you may suppose, difficulties in bringing about so
entire a  change.   At  first I suffered  much inconvenience from  a
sense of fulness in the bowels and in the head.  But this I contrived
to obviate by the very  occasional  use of an  injection  of  warm 
260            MAYO's OUTLINES OF PATHOLOGY.

water, determining with myself to overcome the disposition to con-
traction by making the contents  of the lower bowels the means of
dilating them.  By a steady perseverance in this course of discipline,
I have perfectly recovered;  know nothing  now of that distress of
feeling, which  for at  least twenty years made life burthensome to
me; I have seldom or never occasion to have recourse to  medicine,
and then  only as a man in perfect healih would do.   I should tell
you, that  at  one time such was  the  state of the stricture in  the
rectum, that the largest sized urethra bougie alone would  pass, and
that at another the contraction was so far in the intestine that a
bougie of three feet in length was  considered necessary to  reach it."
  f. Spasmodic contraction  of the sphincter  is a kind of cramp.
It often comes on suddenly.  The patient  who has gone to  bed
quite well, awakes in violent pain.  The sphincter muscle is hard
and in  strong  action, so that the finger cannot without great diffi-
culty be passed into it. In some cases these paroxysms  recur daily,
in others only two or three times a year. In  some the attack comes
on  gradually, and after producing uneasiness for several  days gra-
dually wears off; in  others it is sudden in its invasion,  and sudden
in leaving the patient.
  There are cases in  which this disease produces long continued
and most serious suffering; in which the anus becomes permanently
contracted  and hardened, constituting therefore a permanent stric-
ture, and generally combining both permanent and spasmodic con-
traction.   The motions are passed with an effort and with pain,
and all the  common  symptoms of stricture  of the  rectum  are
present.
  In this  more aggravated form, the complaint will  yet often yield
to simple  treatment;—such as the observance of a regulated diet,
the use of gentle aperient medicine,  the daily use of  the bougie,
and of lavements of tepid water.   If  these means  are  insufficient,
the sphincter must  be divided, and the wound made to  granulate
and heal from the bottom by the introduction of lint  between its
edges.
  g. Hemorrhage from  the rectum, without  other  disease,  not
uncommonly takes place as a mode of relief to an overloaded or
obstructed abdominal circulation.   In some persons it is of frequent,
even of periodical recurrence, and amounts to no prejudicial quan-
tity.  In others the  hemorrhage  is excessive  and relaxing, and
requires to be arrested  by astringents or  purgatives.
  Arterial  hemorrhage is sometimes met with, that  is  traceable
to a single vascular  and  fungous point: the remedy for this com-
plaint is the application of a ligature round the bleeding tubercle.
  h. Piles are small tumours, which project either from  the mucous
surface  of  the  intestine [inward  piles], or from the margin of the
anus [outward piles.]  They are  formed originally of one or more
tortuous and dilated veins, the cellular membrane around which
becomes  thickened  by infiltration with lymph.  They  are alter-
nately quiet and irritable.  In the first state,  they sometimes shrink 
                     THE DIGESTIVE ORGANS.                261


  itch ar7£b ^T^6 'f^; ,h7 ar° tUmid' heat^ ™« -he and
  eelrt T~     ,,nw1ard p,leS  frcfl"ently bleed profusclv.  Thev

  C'otaa^-   t,eatme,,t-  THe diff*nM™»«« wlS

  trud'ir!"^''3^1 i,,'War<1 Pi,e,5' dark' firm' wi,h li'tle sensibility  pro-
  truding at each motion, w.th discharge of mucus.          ** P



  favTurable!"0 *"* *"* ^  **  ^ other ^"^nces being
    3. One or more round blue knobs exactly at the man*, of the

  K^r^rh^h  h?lr™ered, 1>y  8kin» !'a'f b>'  ^ous  men,
  eXmelvSr?   ^J     i^ a,0!,e'U,,less °ne of them l^omes
  owned vi/h   I and d,ste«lded ™d Panful, when it had  better be
  opened with a lancet.

  nJLPend,nl°MS °r rid"y folds of thickened skin around the  anus
  oc asiona ly or constantly causing uneasy sensations, heat, itching
  P%  w          Uld be removed by the knife or scissors.       *
    *' Wa»y excrescences occur  round the anus, which should be
  caustic            SCUlpe''  and  the  bases of cach  t0»cI,ed with.
   t. Polypus  of the rectum.  I have met with two different dis-
 eases to which this  term would  be applicable;  the  first I suppose
 to  be not malignant, and to have some affinity to common inward
 piles, which often waste spontaneously, sometimes remaining thin
 pendulous, membranous folds.                            b     '
    1.  A little girl eleven years of age was  brought to  the Middlesex
 Hospital by her mother.  She had~ during the preceding half year
 repeatedly lost blood by stool, and  at each motion something pro-
 truded.   Upon  examining the part after the bowels had acted, a
 small pile not bigger than a large pea, of a red colour, and sup-
 ported upon a long narrow pedicle which had not much appearance
 of  vascularity, was seen.  The  child appeared  to be perfectly in
 good  health, and no objection  presented itself to tyino- the hemor-
 rhoid at once.  Accordingly I applied a ligature to  the sllnder pedicle
 of the hemorrhoid;  but being drawn too tightly, the thread cut
 through the part, and the pile came away at once.  No disposition
 to bleed showed itself  at the time;  but  the following ni<rht the
 child lost a profuse quantity of blood, and came  to the hospital the
 following day faint and pale and  reduced from the bleeding.   The
 hemorrhage did not recur.
  2. William  Bond, astar. thirty,  was admitted into the Middlesex
 Hospital in December,  1828.  He stated,  that as long as he could
 recollect, a protrusion had taken place from the  rectum whenever
 the bowels acted, and that expulsion of the feces was always pre-
 ceded by a discharge of mucus.  Until  four months before  his
admission, the complaint had been unattended with pain.  During
the  latter  period he had continually experienced  a sense of numb-
ness and  aching within the rectum, with  variations only' in  its
      20—g                                   18 may 
262            MAYO'S OUTLINES OF PATHOLOGY.

severity.  When  the bowels acted, a  substance invariably came
down, which consisted of a pedicle about an inch and a half  in
length, attached to the fore part of the rectum, and terminating in
an "irregular hemispherical mass, the under and detached surface
of which was not flat but nodular.   Its texture looked not unlike
that of a common polvpus of the nose, but it had greater firmness.
The disc of the tumour was more vascular than the pedicle, and it
bled readily upon being handled.   It was quite insensible.   Upon
examining the rectum,  the pedicle of the  tumour was found at-
tached to°the fore-part of the bowel, behind the prostate  gland.
There was  some  little hardness of the rectum at this  part.  I re-
moved  the  protruding tumour by the ligature, which gave  little
pain, but caused  some irritation of the bladder.   In a fortnight the
patient  left  the hospital, having got rid of the tumour, but with
some hardness remaining where  it had been attached.   He came
back again after three months, complaining of a sense of obstruction
and uneasiness in the rectum.  I now found  the fore part of the
rectum occupied  by nodular masses, which to  the touch appeared
of the same substance with the original tumour.  They were in-
creasing rapidly.  By drawing them out with the tenaculum, and
making an  incision at their bases, I contrived to include the whole
in three ligatures.   They came away, but the malignant  growth
returned.   The tumour now grew rapidly, and the patient gradu-
ally sank.   At three  inches from  the  orifice of the gut,  the bowel
was perfectly sound.
   k. Prolapsus  ani.  The protrusion of two to five or six inches
of inverted  rectum through  the  sphincter, produced by straining,
from  pain or costiveness, or by weakness of the  sphincter ;  often
attending piles, and  cured by their removal; sometimes  inveterate
and irremediable.
   /. Abscess arid fistula.  By a fistula is meant a narrow channel
or sinus,  secreting purulent or serous discharge,  and having  an
external opening near the anus, through which the matter has vent.
The  opening of a fistula is often extremely small, so that  there is
difficulty  in^  finding it.  The channel itself, or fistula,  is usu-
ally a little  larger than a common probe:  it is sometimes straight,
sometimes  crooked; its  length  may  vary from half an  inch to
several inches.   Towards its inner extremity a fistula reaches  the
coats of the rectum:  it may terminate inwards  by a small aperture
of communication with the  intestine, or  blindly as  a  cul  de sac.
There may be one fistula, or there may be several; and in the latter
case the fistulae may or may not communicate.   A fistula is a con-
sequence of an abscess, which, when  it has broken  or been  punc-
tured, contracts  to such a  narrow channel as has been described,
which continues  permanent.
   Abscesses near the rectum either are superficial and small, which
is the character  of  those that lead to fistula ; or they are deep-
seated,  when they often contain large accumulations of matter,  but
rarely produce the secondary complaint.  The latter kind, if  not 
THE DIGESTIVE ORGANS.
263
opened, spreads within  the pelvis, isolating and enclosing the rec-
tum in a vast bag of matter,  producing low fever and delirium.
  m. Lacerated  sphincter.  The perineum is liable to be torn in
labour, either superficially or through the sphincter into the vagina.
In the former case, the laceration  heals spontaneously :  in the latter,
in general it  will  not heal, unless the following practice is employed,
The sphincter  must be cut through on each side, and  the wounds
prevented healing by the introduction  of a few threads of lint.  The
patient's knees in  the mean time should be fastened together with a
roller, and the  laceration be kept  repeatedly cleansed/whcn it will
granulate  and draw together: the lateral  sections  may then be
allowed to close.
                          SECTION VI.

                        The Peritoneum.

   The leading pathological relations of this important membrane
 are the following:—its influence in repairing lesions: its liability to
 acute inflammation, to chronic inflammation, to malignant disease,
 to be the locus of effusion from obstruction ofthe abdominal circu-
 lation.
   A. It is the common tendency of all the serous membranes, upon
 slight irritation,  to throw out lymph; by which,  in a  very brief
 period, the  parts of their surfaces, which are in contact,  become
 glued together.   Mr.  Travers has shown how effectual this process
 is in  repairing wounds of the  bowels.  As soon as an opening is
 made in an intestine,  either by a stab in the belly or through a blow,
 the wound of the intestine gapes, the divided muscular fibres re-
 tracting.  If it happens  that the wounded portion is empty,  the
 peritoneal surface lying  next against  the opening  into the bowel
 becomes then glued by lymph to the peritoneal surface surrounding
 the wound, which under favourable circumstances  is thus perma-
 nently secured.   The great extent of this power of  restoration Mr.
 Travers exemplified,  by  tying a ligature round the  small intestine
 of a dog: the ends of the ligature were cut off,  the bowel was re-
 placed, and the wound closed.  The coils of intestine adjacent to
 the tied part  then adhered to  it, enclosing the ligature, which sepa-
 rated with the circle  of dead  matter  enclosed within it  into the
 cavity of the divided intestine, the extremities of which finally
 united by granulation, being  in the interval securely held together
 by the original adhesion.  This process, however, is to be relied on
as little as possible in human surgery.  Thus, a single wound of
an intesiin^ had  better be temporarily maintained as an artificial
anus.  But if there are several, nothing remains but to sew them 
264
MAYO'S OUTLINES OF PATHOLOGY.
with a fine continued suture, cutting the end close to, and returning
the wounded portions into the belly.
  B. Acute peritonitis. This inflammatory disease is often ushered
in by bold and well-marked  general and local symptoms.   Often,
however, its progress is  insidious; the pulse being little affected,
and the pain occurring in paroxysms, as the portion of intestine in-
vaded by it is now distended and in motion, now at rest, and for a
similar reason occasionally shifting its place; the stomach not irri-
table, the passage of the  bowels free.  The following cases will ex-
emplify some of its most important features.
  A girl, aged fifteen, on Sunday, 2d March, 1817,  was at  church
in her usual health.  In  the evening she  complained of some pain
in the abdomen.   3d.  Had pain of the belly,  and  some vomiting;
took castor  oil, which operated  copiously.   4th. Pain continued,
with some vomiting, but not urgent, and the  complaint excited no
alarm ;  bowels quite open ; was seen by a surgeon,  who found her
pulse 116 and very small,  and the belly painful on  pressure.   5th.
Belly tense and tympanitic;  other symptoms  as before; was bled
without relief, sunk rapidly, and died at night.
  Inspection.—The whole  tract  of the small intestines presented
one smooth uniform surface, being firmly glued together, and the
interstices filled up by an immense deposition of coagulable lymph,
which was quite soft and recent; and the mass likewise adhered to
the parietes of the abdomen.   There was  a similar  deposition,
though in smaller quantity, on the surface of the  great intestine;
and  it was  traced nearly to the extremity of the rectum : it  also
appeared on the surface  ofthe liver.  The omentum was inflamed,
and dark coloured ; and there were considerable marks of inflam-
mation on the peritoneum lining  the parietes of the abdomen.
  A young lady,  aged  twenty,  was seized (July  9,  1822) with
symptoms of peritonitis,  which were relieved  by blood-letting, and
the other usual means;  and on the 12th she appeared  to be con-
valescent.  At night she took some pills of aloes and colocynlh,
which  operated  frequently with much irritation.   After  this the
pain of the bowels  returned,  and  continued through the  13th.
14th.  There was some pain ofthe bowels, with tenderness, and the
pulse was again  becoming frequent: she  was now bled from the
arm, and a second time a few hours after;  and, after the second
oleeding, she became faint and  low. Dr.  Abercrombie now saw
her for the first time, and found the pulse extremely frequent and
small: she had a look of extreme exhaustion ; but there was still
much pain  ofthe belly, with great tenderness: there was no vomit-
ing.   She was now treated by weak tobacco injections, cold appli-
cations to the abdomen, followed by blistering; and small doses of
aloes, with extract of hyoscyamus, repeated every two or  three
hours.   Under  this plan she gradually improved: the pain and
tenderness  subsided;  the  pulse  came down ; the bowels  were
moved freely and without irritation ;  and after three or four days 
THE DIGESTIVE ORGANS.                265
 she appeared to be convalescent.   About the 20th she complained
 of some pain  in the region of the liver, which was quite removed
 by topical bleeding; and from this  time she appeared to be reco-
 vering perfect health :  the pulse and functions ofthe stomach were
 natural,  the bowels easy or  easily regulated by the mildest  medi-
 cine, and her strength improved daily.
   About the  25th she began to be troubled with a parotid swelling,
 which gave  her a good deal  of  uneasiness; but in other respects
 she was  well.  She was in  the  drawing-room the greater part of
 every day, and every function was natural.  The swelling advanced
 slowly to suppuration,  and  was  of  very considerable size:  it dis-
 charged  a little matter by the ear, but she would not submit to have
 it opened.  On the night of the 2d of August she went to  bed in her
 usual health, having been in the drawing-room during the day, and
 without any complaint  except  the parotid swelling.   Early in  the
 morning of the 3d she awoke in great distress,  with cough and op-
 pressed breathing.   When Dr. Abercrombie saw her, about eleven
 o'clock,  her  face was  cadaverous;  her breathing frightfully  op-
 pressed,  with  a  rattling sound:  the pulse was very frequent, and
 there was in the room an  intolerable fetor.  The first impression
 was, that the parotid swelling had burst into the larynx ;  but upon
 opening it healthy  pus  was  discharged; while small quantities  of
 frothy fluid, which she coughed up, were  intolerably fetid.   She
 died about twelve.
   Inspection.—Betwixt the diaphragm and the  upper surface of the
 liver there was formed  a distinctly-defined cavity, lined  by a cyst
 of coagulable lymph, and contained at least a  pound of  thin puri-
 form matter of intolerable fetor.   The right lung adhered exten-
 sively to  the diaphragm; and the diaphragm was perforated by a
 small opening, by which the matter from the  abscess  had passed
 freely into the bronchial canals, and it was traced  as far as the
 trunk of  the trachea.  The liver was sound  in its internal  struc-
 ture, but  in its peritoneal coat there were some marks of inflamma-
 tion.   The  intestines adhered to each other, through almost  their
 whole extent, to the omentum, and to the parietes ofthe abdomen;
 so that no portion of intestine could be traced without tearing these
 adhesions, which were soft.  Throughout  this mass  of disease
 there were in several places cavities of various  sizes  containing
 purulent matter:  one of these, on  the right  side,  seemed to com-
 municate  by a small canal with the great abscess above the  liver.
 On the posterior part ofthe pelvis, behind the uterus, another great
 abscess was discovered,  containing  nearly a pound of thin  fetid
 pus.   It was circumscribed by adhesions betwixt the intestine, the
 uterus, and the ovaria, so that it was completely cut off  from the
other parts, and remained entire, after the examination of them had
 been concluded.
  The following case is  too important to be passed over, when  1
am borrowing so freely from Dr. Abcrcrombie's  treatise. 
266            MAYO'S OUTLINES OF PATHOLOGY.

  "A lady, aged  about  thirty-six, a few days after her accouche-
ment, was seized with symptoms of peritonitis, which was treated
in the usual manner by a judicious practitioner.  The activity of
the symptoms was subdued by two  bleedings: the bowels yielded
to laxative medicine, which, in fact, operated rather fully and with
irritation.  This was followed by a state of exhaustion, in  conse-
quence of which I saw her.   I found  her with a haggard and ex-
hausted look; the skin  clammy; the pulse feeble and  rapid; the
whole abdomen tympanitic, and  enlarged to  the size of the last
period of pregnancy.  Wine was now given her at short intervals,
with injections of beef tea containing assafoetida and sulphate  of
quinine.  Under this treatment she improved rapidly, and in a few
days was in her usual health."
  There is a form of acute peritonitis connected with  erysipelas, in
which the effusion has less of lymph, but is  either sanious or puru-
lent.   The proportion of pus  in common  inflammatory effusion  is
very variable.
  C. Chronic peritonitis.  The  obscure and  insidious nature of
this disease is well shown in the following case.
  A  young lady,  aged  sixteen, (April 5,  1816.) for several  weeks
had been observed to lose flesh and  strength,  with lisllessness and
impaired appetite,  but without making any complaint.   She was
now  a good  deal debilitated, and  easily fatigued ;  had  a  hectic
look; pulse 120; tongue  rather  foul;  appetite bad; abdomen
tumid and somewhat tympanitic ;  made no  complaint of any pain;
she only said that she  felt "stuffed in  the belly."   She had not
menstruated.
  Such was the first report,  Dr. Abercrombie remarks, of  one of
the most insidious cases of this affection that has  ever occurred to
me.  The patient was put upon  the use of gentle laxatives, with
tonics, and the tepid bath. The bowels were found in  a very  loaded
state, and for about a fortnight she combined without any change:
she was restless and hot in the night, and languid through the day.
with bad appetite and quick pulse, but made no complaint of any
uneasiness.  In the middle of April she  seemed to  improve con-
siderably: her appetite was much better,  and she slept well in the
night.  She also improved in  looks, in spirits, and in strength ; but
the pulse continued frequent, being generally from 100 to  120, and
the abdomen retained a considerable degree of tympanitic fulness.
The bowels were  open,  sometimes  rather  loose,  with occasional
griping pain, but no fixed uneasiness, and the  motions were quite
natural. In May she began to  decline again, without any particular
change  in  the  symptoms,  except progressive  Joss  of flesh  and
strength.  There was still no complaint of pain, except at times a
little griping;  and the  bowels were natural.   In the end of May
she began to  have some vomiting, and  occasional diarrhcea; the
vomiting became more and more  frequent, until at last she could
retain nothing.   She died early in June,  having been confined  to
bed only  two or three days before her death. 
THE DIGESTIVE ORGANS.
267
   Inspection.—-The whole contents of the abdomen presented one
 solid mass of adhesion, in which  it was  impossible to distinguish
 one intestine from another.   The mass  likewise adhered exten-
 sively to the parietes of the abdomen; and in  various parts  of it
 there were cavities containing purulent matter, and presenting on
 their internal surface unhealthy scrofulous ulceration.  There was
 also much purulent matter in the cavity of the pelvis.  There was
 much disease of the mesenteric glands, and the liver was consider-
 ably enlarged.  The lungs were sound.— Abercrombie.
   Dr. Barron has  described a form of this affection under the title
 of tubercular accretion of the peritoneum.  The symptoms of the
 disease  present no essential difference to those of ordinary chronic
 peritonitis.   Upon dissection, the bowels are found  glued together
 by  lymph, which is studded with lymph tubercles, in  some  of
 which scrofulous matter is deposited, [q. 150.]
   In chronic peritonitis, when matter is formed in the abdomen, it
 sometimes makes its way along the spermatic  passage, and points
 externally: the patient may live a  considerable  period, with a dis-
 charge of pus from the peritoneum.   It is to be recollected, that
 extensive abscesses sometimes form between  the  anterior parietes
 of the abdomen and the  peritoneum,  from which, when opened,
 matter, often mixed with air,  is thrown out; with an impulse upon
 coughing, as when it proceeds from the peritoneal sac.
   One kind of chronic peritonitis gives origin, not to adhesions, but
 to gradual and unequal  thickening  of the membrane, which ac-
 quires iu parts a depth of a third of an inch.' [q. 152.] This change
 is ordinarily  confined to  the  reflected peritoneum;  and the func-
 tions of the bowels are in  this case materially less likely  to be dis-
 turbed,  than when  the inflammation  leads to general  adhesion,
 which has a direct tendency to obstruct the passage of their  con-
 tents.
  Partial peritoneal adhesions occasionally lead to serious and  fatal
 results.   They are liable to produce obstructions of the bowels  in
 several ways.  A  band of lymph may form a noose, into which  a
 coil  of intestine may slip; or the omentum, or the appendix caeci
 may be so fixed as to form a ring;  or two  portions of intes iue may
 be  glued  together  at  one  point, while a third  may accidentally
 wed^e itself  between them close  on the  adhesion ; or one  con-
 tinuous portion  becoming inflamed while lying abruptly bent,  may
 be fixed by adhesion in such a position, that when distended it  may
 obstruct its own channel.   But  for inward mechanical causes of
 obstruction,  such  adhesions  are not necessary: the bowel  will
sometimes knot with itself.  To exemplify this unlikely accident, I
shall finally  add another case from  Dr. Abercrombie, which will
 form at the same time a natural transition to the subject which will
 next be presented to the reader.
  A  man, ag^d sixty, (23d April, 1815,) had  been ill for a week,
 with the usual symptoms of ileus, which had resisted all  the ordi-
nary remedies.  He was now  much exhausted;  and  his  belly was 
268            MAYO'S OUTLINES OF PATHOLOGY.

enlarged and  tympanitic, with  frequent  vomiting.  He lived in
great distress till the 28th, and the  swelling of the abdomen pro-
gressively increased until it resembled the  abdomen of a woman at
the most advanced period of pregnancy; yet  to the last he could
bear pressure  upon every part of it: his pulse varied from  108
to 116.
  Inspection.—On opening the abdomen a viscus came into view,
which at first appeared to be the stomach enlarged  to three  or four
times it  natural size.   On  more accurate examination, however,
this  turned out to be the sigmoid flexure of the colon, in such a
state of  distension that, it rose up into the region  of the stomach,
and  filled half the  abdomen.   The stomach  was  contracted and
healthy.  The small intestine was healthy at the upper part:  lower
down it became distended, and of a dark colour; and at the  lowest
part  it was much distended, with some  spots of gangrene.   The
colon was greatly distended, being in some  places not less than five
or six inches in diameter; and the sigmoid flexure was also enor-
mously  enlarged in the manner already mentioned, and of a dark
livid colour: it contained only air and thin  feces.  The rectum was
collapsed and healthy.   The  following appeared to be the cause of
this remarkable state of disease.  The sigmoid flexure was found
to have  taken a singular turn upon itself, so that the rectum lay to
the left,  in contact with the descending colon  ; and  the  ascending
portion of the  sigmoid  flexure passed in  front  of this portion, and
lay on the right.  In consequence of this transposition, the rectum
as it descended passed behind  the lower curve  of the sigmoid
flexure,  where it takes the  first turn from the descending  colon;
and the  rectum itself at this part received a twist, as if half  round.
Exactly at the point where this twist had taken place, the  disten-
tion  and dark colour of the diseased intestine terminated abruptly,
and the  remainder ofthe gut became v/hite and collapsed.  At this
point, however, there was no mechanical obstruction, for the part
was  quite  pervious,  and, excepting the slight twist,  perfectly
healthy.
  In this singular case, also, Dr. Abercrombie says, I had an  oppor-
tunity of ascertaining the state ofthe part  during life.   For on the
25th, three days before  the man's death,  having exhausted  all  the
usual means, I was  induced to examine the  rectum  with a large
ivory-headed probang; when 1 found at a certain depth, which
was  afterwards seen to correspond with the point where the rectum
was  twisted, a very slight obstruction to the passage of the  instru-
ment, which, however,  passed with very little difficulty, and was
withdrawn without  any.  A piece  of the  intestine of  an  animal,
tied at the end,  was  now carried up bevond this point, and filled,
by forcibly injecting  water  into it.  This  was  retained for some
time in  the  distended state, and then slowly withdrawn ;  but no
discharge followed, though, as I  have already stated, the distended
intestine  contained only air and fluid feces. 
THE DIGESTIVE ORGANS.
269
  D.  Malignant disease.   Where the  disposition  to medullary
sarcoma, melanoma, or gelatiniform sarcoma  exists, these different
growths accumulate in clustered nodules of various sizes upon all
the peritoneal surfaces.  The omentum thus,  or even a single mas-
sive growth from the abdominal parietes, may form a  sensible
movable tumour in  the abdomen.   The functions of the bowels
are not usually deranged.
  Medullary sarcoma, [q. 160 to q.  165.]  These preparations are
from the body  of  Elizabeth Taylor, whose case is given  at page
177.  This patient gradually sank, and died on the 9th of October,
1835.  The peritoneum was covered with nodules of medullary
sarcoma, here  and there mixed with melanoma.   The pleura re-
flexa was in the same  state.  In the  lungs were many small  tuber-
cles, the largest of the size of a hazel nut, some  of medullary sar-
coma, others of  melanoma,  others of the  two structures mixed.
Upon the  fore part of the  heart, a mixed tubercle was found.  In
the spleen  another.  In the liver two.  There were many  below
the integuments  of the chest and belly, and a  few on  the  back.
The inguinal  glandular swelling was" partly medullary sarcoma,
partly melanoma.  There was no disease or induration ofthe cica-
trix at the part where  the tumour had been removed. The tumour,
which has been described as of a dense, white, crisp texture, with
membranous bands intersecting it. had the peculiar fetor of a can-
cerous ulcer, and exuded  matter from its surface.  There were
parts, however, in which upon a section of it being made, a grayer
colour showed itself between the white bands, which was probably
melanotic.
  Melanoma,  [q. 170. 171. 172.] Black nodular masses of various
sizes growing immediately behind the peritoneum.
  Gelatiniform  sarcoma,  [q.  180. 181.]   Nodular masses of the
colour of size,  in disposition like the preceding; and on a section
looking like little agglomerated spheres of glue in cysts of a  mem-
branous substratum.
                         SECTION VII.

                           Hernia.

  An abdominal hernia is the protrusion of part or parts of one or
more viscera through some outlet in the walls of the abdomen, the
reflected peritoneum being pushed before the protruding viscus, so
as to form a sac, which immediately contains it.  The force, which
extrudes the viscus through  the walls  of the belly, is the pressure
of the abdominal muscles and diaphragm.  The extrusion is some-
times sudden and instantaneous; generally, however, it takes place
by slow and almost insensible degrees.  The weak part of the ab- 
270           MAYO'S OUTLINES OF PATHOLOGY.

dominal wall is commonly slow to yield, so that at first a fulness
only is observed;  which, however, gradually becomes a circum-
scribed tumour, the contents of which receive an  impulse on the
patient coughing.   As  the  bowels are perpetually  shifting their
place, the same viscus is not always opposed to the yielding part of
the parietes.   Even in the first stage of an abdominal  hernia, the
viscera feel the disorder: a sense  of weakness and internal uneasi-
ness,  with flatulent  distention and  pain,  frequently recur  at the
part which is in  progress of  yielding.  In general, the patient first
learns  the existence of a hernial tumour through his attention being
directed to the part by the recurrence of these feelings.
  The differences  in  herniae are  founded upon—the place of pro-
trusion—the nature of the sac and  its contents —the  variable con-
ditions of  the contents ofthe sac.
  I. Heruise are divided from  the place  of their escape into oblique
inguinal, direct inguinal, crural, umbilical, ventral, perineal, vagi-
nal, pudendal, thyroideal, ischiatic> diaphragmatic.
  1. An oblique inguinal hernia escapes from the abdomen l>v the
internal ring, and  descends along the spermatic passage.   Wrhen
not of length enough to pass  beyond that passage, it is termed a.
bubonocele; when extended considerably beyond the outer ringj it
is called scrotal or  labial.  There are naturally two narrowings in
the parts  which form the spermatic passage, one situated at each
ring: the  neck ofthe sac may therefore be compressed, or stricture
be produced either at the inner  or  outer  ring,  or at both.  The
common seat of  constriction is the internal ring.
  The epigastric artery is situated in the inner pillar of the internal
ring.
  The spermatic cord is commonly situated behind the hernial sac,
but occasionally it has been  found before the sac.   In these in-
stances its component parts have been separated by the tumour, the
vas deferens has passed on one side of the  sac, while the spermatic
vessels ran on the  other: or the former has been  on the anterior
and inner, while the vessels were placed on the posterior and outer
part of the swelling.  In other instances the vessels have been be-
fore, and the vas deferens behind  the sac.   "The separation of the
vas deferens and spermatic vessels," observes Mr. Lawrence, "is
seen on both sides, in a case of old double scrotal hernia now lying
before  me.  They  arc about two inches apart, and at the  back of
the sac on one side ;  and more considerably separated on the other,
where the middle of the tumour has penetrated  between them, so
that they  run quite laterally. Lower down  they advance anteriorly
to the testicle, so that they would  probably have been  divided by
prolonging the incision  through the  whole length of the sac, parti-
cularly if  it had  been directed  a little to one side."
  Oblique inguinal  hernias are  more  frequent in  men than in
women, and on the right side  than the left.
  Oblique ingujnal hernias, that are down  frequently, or for a con-
siderable period  at once, gradually  render the spermatic passage 
THE DIGESTIVE ORGANS.
271
less oblique,  so  that they come externally  to resemble the next
kind.
  2. A direct inguinal hernia escapes through  the abdominal
walls behind  the external ring, and  protrudes directly through  the
latter.   This kind of hernia  is of rare occurrence, owing to  the
strength which the parietes ofthe abdomen derive at this part from
the insertion  of the tendon of the transversus  into the linen ileo-
pectinea.  But this attachment is sometimes  congenitally deficient;
and when it  is perfect, it is liable to  be forced through by j ressure
from within,  or to be gradually extended and elongated so as to
protrude as a fibrous membrane  covering the sac through the ex-
ternal  ring.  In direct  inguinal hernia  there is but  one  parietal
stricture.
  3. Crural, or femoral hernia.   The crural  opening,  or that
through which crural hernia descends, is situated immediately be-
hind the inner part of Poupart's ligament, which forms its  anterior
boundary : the  inner  boundary is the ligament of Gimbernat:  the
posterior boundary the  body of the  os  pubis and the pectineus
muscle: the  outer boundary the iliacus internus and psoas  mngnus
with the external  iliac vein  and artery lying upon  the  surface of
the latter.  The crural opening is the channel for transmitting the
femoral vessels, which with adipose tissue  and one or iwo lymphatic
glands naturally fill it.   A hernia finds passage  here through the
displaceableness or compressibility of these substances, while it ex-
tends or breaks through  the fascia that stretches  from  the ligament
of Gimbernat to the sheath of the vessels.  The  crural opening is
considerably  narrower than the inguinal opening.  The  sharpest
edges of the  opening are the anterior and the inner; or are formed
by  Pou part's ligament and Gimbcrnal's ligament.  When  an ope-
ration  is necessary, the surgeon has his choice of dividing either of
these  ligaments: a section backwards would reach the-bone, a sec-
tion outwards would endanger the femoral vessels.
  The division of Pou part's ligament is thought  to weaken the in-
guinal parietes; nor can it be made without some risk of the sper-
matic cord.   The division of Gimbernat's ligament close upon,  and
in a direction parallel to Pou part's ligament, is preferable:  the  sec-
lion need not exceed a third of an inch in length.  This operation
is not, however, wholly free from objections: when the obturatrix
artery  takes its origin (which happens once in five times) from  the
common femoral, it would wind half round the neck ofthe  sac of a
crural  hernia: generally, indeed, it is  found to pass behind  the
hernia, and then is safe; but sometimes  it lies before the  neck of
the sac, and  is  liable to be divided  even  by the most skilful  and
cautious operator.   In strangulated  crural hernia there is  but  one
stricture, as far as the abdominal parietes are concerned.
  4. Umbilical hernia are either congenital or otherwise.
  Congenital umbilical  hernise protrude through  the navel, or
more strictly through the umbilical  ring,  or  passage for the navel
string  through  the abdominal parietes.  The umbilical ring con- 
272            MAYo's OUTLINES OF PATHOLOGY.
sists in its upper half of strong, semicircular, tendinous fibres, with
a well-defined margin,  forming an  arch  under which the vein
passes, connected to it by loose cellular tissue:  the lower half is
not so strong or well defined, and its tendinous fibres are  attached
to the umbilical arteries, so  that  these parts cannot be separated
without cutting these fibres.   The tumour in  congenital umbilical
hernia appears as if formed by the dilatation of that extremity of
the umbilical cord which is  connected to the child's body.  Gene-
rally it has a more or less conical figure: the  basis  is attached  to
the abdomen, and the  round tendinous opening by  which the vis-
cera protrude, occupies  its  centre:  the  umbilical cord  appears  to
arise from the apex of the swelling.   The coverings are thin, soft,
and seem transparent, so that, the contents can be readily perceived
externally.  The external surface is polished, and  externally re-
sembles, both in  appearance and structure, that of the cord.  The
base ofthe swelling is covered, for a short extent, by integuments.
Internally  the cavity presents a smooth peritoneal  production,
which lines  it throughout.   The umbilical vessels are generally
divided by the swelling; the vein  going above, and the arteries
below or on one side.
   Umbilical hernias that are not  congenital occur eiiher soon after
birth, or later. In the former case they commonly protrude through
the umbilical ring, and are to be attributed to its closure not being
sufficiently rapid  and perfect.  In the latter  case they commonly
escape on one side of the obliterated umbilical ring.  The causes
which lead to their occurrence are, distention of the jsaiietes of the
abdomen through adipose enlargement ofthe mesentery and omen-
tum, or by pregnancy.
   Iu strangulated umbilical hernia there is but  one parietal stric-
ture.
   5. Ventral hernia are such  as protrude through  the anterior or
lateral parietes ofthe belly at any openings besides the specific pas-
sages separately enumerated.  The last described kind of umbilical
hernia is therefore properly a ventral hernia.
   The most frequent seat of ventral hernias is at the interval  be-
tween the recti abdominis above the navel.  They have been seen
in this situation from the size of an olive to that ofthe fist, or even
of a man's head.  The smaller ones occur in the  scrobicnlus cordis,
or at the sides of the ensiform cartilage.   Protrusions through  the
linea alba are much less frequent below than  above the umbilicus.
The linea semilunaris, the hypochondria, the  sides of the  belly be-
tween  the ilea and the last ribs, or the lumbar regions, may be the
seats of ventral ruptures ; but such cases are rare.   The opening
through  which the  parts are protruded is usually considerable in
venttal hernia, more particularly in such as do not  happen in  the
linea alba.  Hence the tumour is broad and flat, the basis being the
largest  part: hence also it  generally disappears, or is very easily
reduced  in the  recumbent  posture,  and  is very seldom  strangu-
lated. 
                    THE DIGESTIVE ORGANS.               273

   6. Perineal hernia escape from the pelvic boundary of the ab-
dominal cavity  between  the  rectum and bladder, rupturing  or
stretching the fascia which extends from the  one to the other and
to the sides ofthe pelvis, and protrude between  the fasciculi of the
levator  ani, or between that muscle and the  sphincter, forming  a
tumour in the perineum generally to one side of the raphe.   Most
of the examples have occurred in the male sex.
   7. Vagi'ial hernia is opposed by or escapes  through  a produc-
tion of  fascia referred to in the preceding instance, and  which is
reflected, where the peritoneum is reflected, from the vagina to the
rectum.  The hernia forms a  tumour  projecting into the vagina,
either at its back or lateral part, and covered  by its proper tissues.
   8 Pudendal hernia.   Tumours of  similar  origin  or place of
escape with  the preceding, but which,  instead  of projecting towards
the vagina, descend parallel to the vagina, and make their way be-
tween the vagina and the ascending plate ofthe ischium to protrude
in the external labium.
   9. Thyroideal hernia, or hernia  at the foramen  ovale.  Du-
verney  found on both sides ofthe pelvis  of a female the peritoneum
had been forced through  the openings at which the obturator ves-
sels pass, so  as to form swellings each of which was about the size
of an egg.  These contained intestine,  were placed  between the
anterior heads ofthe triceps, and formed an external tumour.
   Not to mention other instances, a case is minutely described by
M. Cloquet,  in which a thyroideal  entero-epiplocele caused death.
It produced no visible external swelling.   The  tumour was about
the size of a small  hen's egg, and  contained  sphacelated intestine
and omenlum.  It  was  covered  by  the  pectineus and  adductor
longus,  and rested on the vessels and nerves.
   10. Ischia'Ac hernia.   A case in which a  fatal strangulation of
the small  intestine took place in this  situation  is recorded by Sir
Astley Cooper. The swelling was small, and its existence not sus-
pected during the patient's life.
   11. Diaphragmatic hernia may be either  congenital, from par-
tial deficiency of the diaphragm, or result from accidental separa-
tion ofthe fasciculi.
  The comparative numbers ofthe different kinds of ruptures may
be seen  in the following particulars, extracted from the report  of
the City of London Truss Society, 1814.
  Of 7599 cases, 6458 were males, 1141 females.

 Males.  Females
1469     14 left inguinal
2567     20 right inguinal
  38    246 left femoral
  46    264 right femoral
2182     10 double inguinal
  36    139 double femoral
  92    387  umbilical.
4070 inguinal
595 femoral
► 4665 single.


 2367 double. 
274
MAYo's OUTLINES OF PATHOLOGY.
Males.  Female*
  10    34 ventral.
         I obturator.
  17    26 operated on.

  The ages of persons relieved with trusses were as follows:—

                 524   under  10 years.
                 384  between 10 and 20
771	c<	20	" 30
1286	(!	30	" 40
1471	<>	40	" 50
1420	(;	50	" 60
9S8	i:	60	" 70
347	i;	70	" 80
38	t<	SO	" 90
2	(<	90	" 100
   The cases of congenital hernia were 454.
   Two patients  had  each double  inguinal and double femoral
hernia.  Sixteen had three ruptures each ;  and forty seven had two
of different kinds.
   II.  Of the constituents of a  hernia.—The constituents  of  a
hernia are  the sac and its contents.
   1. The hernial sac.   The protruding viscera, as  a  general rule,
are contained in a special sac of peritoneum.  The points of inquiry
are, in what respect  is the protruded peritoneum altered in its na-
ture ; and what arc the cases in which a special peritoneal sac is
not found?
   a. The peritoneum  which forms  a hernial sac is  altered  from
its natural character at what is called its neck only; that is to say,
at that point which is contained in the narrowest part of the  pas-
sage through the abdominal  parietes.  There  the  peritoneum be-
comes thickened in consequence ofthe pressure of the tendinous or
ligamentous or fascial fibres around  it, and that to a degree which
renders it inextensible and undilatable.  There  is but one kind of
hernia in which the passage through the abdominal parietes occa-
sionally presents a second separate narrowing;  that kind, as it has
been already explained, is oblique inguinal hernia. In this instance
there may likewise be two peritoneal contractions, one correspond-
ing with  each narrowing of the external parts.   But it is most im-
portant to  bear in mind, that the hernial sac is movable in the
canal which contains it, so that the thickened ring  or neck of the
peritoneal sac may either be forced from within  further  out, or by
pressure from without may be forced back behind  the  parietes of
the abdomen :  a new ring or segment of the  sac then  becomes ex-
posed to the thickening pressure.   It is  thus  always possible, that
there may exist upon every hernia several narrowings or strictures.
There may be one, the  last formed,  in  the  immediate grip of the 
THE DIGESTIVE ORGANS.                275
narrowest part of the passage; there maybe additionally one, or
even two or more, simply peritoneal.  I have never seen more than
one peritoneal stricture, in addition to  the  stricture dependent on
present external pressure.
  b. The cases in which a special or a perfect peritoneal sac is not
found are the following :—
  Congenital oblique inguinal  hernia:  in  which a  portion of
omentum or intestine  has accompanied the testis in  its descent, or
has foHowed it before the peritoneal canal  has closed,  preventing
its closure.  In this case  the sac  of the hernia is at the'same time
the serous covering of the testis.
  Hernia of the  caput coli.   The beginning  of the  colon is not
covered  by peritoneum  for its posterior third : hence, when  pro-
truded, it is liable to have a partial peritoneal  sac only; or, in one
aspect, the muscular coat of the bowel may directly present below
the integument and  superficial  fascia?, while on the  opposite it
would have a  proper and ordinary sac.
  Hernia without a sac.  There is a cast in the  King's College
museum, taken from a body which was brought into the dissecting-
room in Great Windmill  street,  in 1829.  An  oblique  inguinal
hernia had  existed on each side: on the  right, the  appearances
were as usual : on the left, a portion of intestine was  down which
had no sac ; but it was not ascertained whether the want  of a sac
proceeded from the adhesion of a thin peritoneal sac to  the intestine,
or from  original  protrusion through  ruptured peritoneum.  The
former is a more  likely occurrence than the latter.
  2. The  ordinary  contents  of  hernial  sacs are either  intestine
(and then most commonly  ileum) or omentum, or both  ; which
cases are respectively denominated enterocele, epiplocele, entero-
epiplocele.
  The usual parts in hernial sacs are,—
  a. The bladder.  This viscus has been found in inguinal, crural,
perineal, and vaginal herniae, combined or not with enterocele, occa-
sionally producing, sometimes following the latter.  Vesical hernia
has in general a  partial  sac only; and when  the anterior part of
the viscus is protruded, without the fundus  being drawn  into  the
ring,  it will be every where  adherent by cellular substance,  and
possess no sac at  all.   This was the case in an instance  recorded
by  Mr.  Pott,  where, however, the bladder had descended  to  the
bottom of the  scrotum.  When the fundus or  side  has been  pro-
truded, the .posterior  part of the  swelling only adheres to the sur-
rounding parts, and  there is  a bag formed by the peritoneum in
front.  The cellular adhesions in both cases are such as to render
the return ofthe  protrusion impossible. Although the natural con-
nections might be expected to oppose any considerable  displacement
of this bag,  we find that a very large portion of it may quit the  ab-
domen,  descending to the  bottom of the  scrotum, and  forming,
when full of urine, a very considerable tumour.  The part under-
goes further changes after it has passed through the  ring.  It be- 
276            MAYO'S OUTLINES OF PATHOLOGY.

comes contracted in the opening, and  expands again below.   Mr.
Keate found it contracted  at the ring, dilating itself again in the
abdomen and pelvis, and forming a kind of double bag divided  by
the ring.  And the same change had occurred to a still greater ex-
tent  in  an instance operated on  by Mr.  Pott.   He discovered  a
membranous bag, growing narrower as it proceeded upwards;  and
a membranous duct, about the size of a large wheatstraw, was con-
tinued from its upper  end  through the ring.  The urine flowing
through this, when it was  divided, proved the case to  be a hernia
of the  bladder.   Stones have been contained in the protruded por-
tion  in many instances.
  b.  The ovaries were found by Pott, each contained in an inguinal
hernia; and by Camper the ovary was found in  an indurated rup-
ture.   The uterus, Fallopian tubes, ovaries, and part ofthe vagina,
were found, together with some  omentum, in a large crural hernia
in a  patient who died  in the Saltpetriere, at the age of eighty-two.
  c.  The stomach, spleen, and  part of the liver, have  been  found
in diaphragmatic hernia.
  III.  Of the different conditions of the contents of  the hernial
sac,  or of the hernial protrusion.   A hernia  may exist in one of
these states, it may be reducible, or simply irreducible,  or strangu-
lated.
   1. A hernia is reducible, when the stricture  upon it is inconsider-
able, and it admits of  being returned within the limits of the abdo-
men.  The constant use of a truss  is requisite,  to prevent the  re-
protrusion of reducible hernia.
  2. A hernia is said to be simply irreducible, when without  any
constriction ofthe neck of the sac sufficient to prevent its return, or
to impede the free passage of the contents of the incarcerated bowel
to and from the bowels in  the belly, the contents of the sac are pre-
vented  from  being replaced within the abdominal walls  through
some other cause.  The causes which produce the simply irre-
ducible hernia are,—1. Adhesion of the contents of the sac to the
sac; 2. Their reciprocal adhesion, so as to form a mass  too great
to be returned at once, though  separately each part might have ad-
mitted it; 3.  The increase of one part—the omentum nau.-ely—by
excessive growth of adipose substance  and induration of the  fila-
mentous tissue, rendering it too large and firm to be pressed back.
An irreducible  hernia requires  to be strongly supported  by a sus-
pender that fits tolerably closely, with the view  of preventing the
viscera already down  from dragging more after them.
   3. Strangulated hernia.  Obstruction  of  the  bowels has been
already described, as it occurs in ileus,  in  intussusception, in stric-
ture or malignant disease of the great or small intestines, or when
caused  by peritoneal  adhesions within the belly.  The  common
features of all. these cases  present themselves  again in strangulated
hernia; the mechanical cause alone is different,  which in  this in-
stance consists  in the neck of the hernial sac being so narrow as
to obstruct the passage  of the contents of the  intestine, when 
THE DIGESTIVE ORGANS.
277
intestine is down ; or so to compress the omentum, when that viscus
alone protrudes, as symptomatically to derange the functions ofthe
alimentary canal, and give rise to temporary symptoms of obstruc-
tion.
  The phenomena and management of strangulated hernia, as they
relate to the condition of  the  protruded  intestine, may be con-
veniently  arranged under  the  following  heads:—symptoms of
strangulation—cause of strangulation—reduction without an ope-
ration—fallacious appearances of improvement in unreduced stran-
gulated  hernia—operation—management of protruded intestine—
omental hernia.
  a.  The symptoms  of strangulated  hernia  are  three: —1. A
tumour at one of the  known regions of hernial  swellings, the pro-
trusion of which or  a  change in  which  will  have taken place
shortly before the supervention of the other symptoms; the tumour,
more or less tense, and incapable of diminution  by pressure, gene-
rally receiving an impulse when the patient coughs, and apparently
continuous with the abdominal walls; the  tumour generally tender
or uneasy on pressure, the tenderness being commonly the greatest
at the point  where the protrusion begins,  and diffusing itself from
thence over  the adjacent part  of the belly.   2. Want of passage
through the bowels.  3. Vomiting, at  first of the  contents of the
stomach, then of mucus, finally of liquid  having a fecal smell and
colour. At the commencement, the tumour is often devoid of pain ; its
very existence even may be doubtful, from its  small size and depth,
or from its lying behind another tumour, such as a second and not
strangulated hernia. The lower bowels sometimes act once or twice
unloading their  contents, at the commencement of strangulation.
The vomiting at first  may be  occasional only, and attended with
little distress.
  b. Causes of strangulation.
  One kind  of strangulated hernia may be called acute, in  which
the protrusion takes place suddenly in consequence of some violent
muscular exertion, the walls of the abdomen not having been pre-
viously weakened.   In this case the pressure of  the small aperture
through which the hernia  has  been forced, directly grips the neck
of the sac with force enough to obstruct the passage.
  But in chronic cases,  in which the protrusion has been gradual,
the ring-like aperture, in which the neck of the  hernial sac lies, is
large enough to  permit in general a  free communication between
the belly and the sac.   And this is equally the  case, whether the
hernia is reducible or  otherwise.  It is indeed  true,  that the worst
part ofthe constriction often arises  from thickening of the neck of
the sac; but even this often exists to a very great  extent without
the hernia being strangulated.   A certain  narrowing of  the abde-
minal aperture,  and a certain thickening and loss of extensibility of
the part of  the peritoneum forming  the  neck of the sac may be
viewed as  constant  qualities,  which are present  as well  before
strangulation as during its continuance.  In such cases—and they
      21—a                                    19 may 
278
MAYO'S OUTLINES OF PATHOLOGY.
are by far  the  most numerous—the strangulation depends upon
something added to the usual narrowness of the abdominal aperture
and neck of the hernial  sac.  What that something is, is a matter
of doubt.
  First; Is it spasm?  I am persuaded  that spasm of the parietes
of the passage through  which  the  hernia  protrudes, is not  the
source of strangulation.  In no case, except  in  oblique inguinal
hernia,  do fibres exist by which spasmodic contraction  could  by
possibility be produced;  and in  that case I believe they commonly
take no part.
  Secondly; Is it a straitening of the passage and of the neck of the
sac,  produced by determination  of blood  and congestive turgor!
It is far from improbable that this  condition of the  parts  may con-
tribute to strangulation.
  Thirdly; The principal  cause of intestinal strangulation appears
to be distention ofthe intestine with air and  liquid ; the traction so
produced  of the  distended  part upon the narrow aperture of the
neck of the sac giving a tightness  to the portion of intestine lying
in it, which produces perfect obstruction.
  The  second cause adverted to  must be  supposed sufficient in
strangulated omental hernia; the second and  third probably com-
bine to produce strangulation in  intestinal rupture.
  But under the head of causes  of strangulation another question
has to be considered.  How is it that a  person labouring under re-
ducible hernia incurs an  attack of strangulated hernia? It happens
every now and then that a person, who has been for some years
afflicted with reducible hernia for which a truss has been worn,  on
making an accidental exertion  suddenly forces down the rupture
anew, when the case presents the features ofordinary acute hernia.
But in the  majority of instances, the circumstances of the attack
are different: nothing precedes it,  but either an  indigestion, irre-
gular action  of the bowels  and  flatulency,  attended by a sense of
 ressure on and  fulness at the old seat  of protrusion,  or  slight
 iarrhoea, or smarter bilious disorder: in  the  midst of which  the
hernia  comes down, often  without the patient  observing  it till
strangulation has taken place.  The cause of the protrusion  is dis-
tention of the bowels with liquid and flatus; no wonder,  therefore,
that strangulation should ensue, considering how much that state
of the bowel depends  upon  distention.  Many persons who have
chronic hernia, and who have once or twice experienced strangu-
lation, are perfectly aware when they are  threatened with another
attack,  by  uneasiness in the region of the rupture accompanying
some  form  of bowel disorder; by  lying in  bed a  few hours, ana
taking some  warm aperient medicine, they  commonly succeed in
allaying abdominal irritation and the threatening feelings, of which
they know the nature.
  c.  Reduction without an operation.   The first impression upon
viewing a strangulated hernia is, that as it has been forced from with-
in the abdomen by pressure outwards, it may be returned by pressure
 
THE DIGESTIVE ORGANS.
279
in the contrary direction.  And in a large majority of cases, the
practice founded upon this idea succeeds.   The process is termed
the  taxis.   The patient  or  the surgeon  gently  compresses  the
tumour, and works it in the direction of the opening through which
it has escaped.  By continued, gentle, and varied compression, and
urging the tumour backwards, the rupture is often reduced.  One
constant phenomenon attends the success of this process; the intes-
tine is emptied before it is returned ; the patient hears and feels a
gurgling sensation of air and liquid  passing  from  the hernia into
the belly ; the  passage through the strangulated part of the intestine
being now restored, and the intestine itself passes easily back through
the stricture.
   The taxis is not to be attempted, if it gives pain.   In that case,
supposing  the attack recent, and  these means not  to have  been
already tried,  bleeding and the warm bath are to be used, which
are sure to lessen the tenderness ofthe hernia and  ofthe abdomen,
after which the taxis may be safely employed..  Under these cir-
cumstances I have gone on for half an hour with the  taxis, without
producing  any effect; and in  another  quarter of an hour have
succeeded in reducing the rupture.
   If the taxis  has once been well tried and has failed, what is to be
done? This question  is  decided by the rapidity and severity of the
symptoms, by  the  probable contents of the sac, and in part by the
place ofthe protrusion.
   1. If after bleeding and the warm bath, and the taxis ineffectu-
ally employed, the symptoms are not aggravated, and are not severe,
there may be tried,—a purgative injection, the effect of which is  to
excite an action of the  bowels  that  draws the strangulated intes-
tine back into the belly;—the application of pounded ice  over the
tumour.
   2. It is particularly expedient to wait—the symptoms not having
become worse—if the hernia is an oblique inguinal hernia conjoined
with an imperfect  testis, which is sometimes  in the upper part  of
the scrotum, sometimes drawn within the ring, and now so retracted.
In  this instance something  like an effect of spasm  is traceable.
Certain it is [the case has occurred to myself] that in such  a patient
left for three or four hours, the common remedies having failed, the
two changes have simultaneously supervened, ofthe descent ofthe
testis, and the  retrocession  of the hernia.
   3. If the hernia is  omental only, it is expedient to wait.  It is
indeed  difficult to determine with  certainty, that an hernia  is
omental only.   That  it  contains omentum, may be known  by the
doughy feel it  presents, and the indistinguishableness ofthe impulse
on coughing.   But it is hardly possible to be certain, that behind
or within that  protruded omentum, no  portion of intestine is  con-
cealed.   Nevertheless, if the  tumour  is doughy to the feel, if no
impulse is communicated on coughing, if the patient is rather better
than worse after bleeding  and the warm bath and an  injection, the
presumption is very strong that the hernia is merely omental; and 
280
MAYO'.S OUTLINES OF PATHOLOGY.
the surgeon is usually safe  in administering opening medicine by
the mouth, which, acting, relieves all the symptoms.
  4. If the hernia  is umbilical, it probably contains great intestine
only, [with or without omentum,] and the ring is probably of large
size.  The symptoms not being aggravated in such a case, almost
indefinite delay maybe allowed, or even bolder practice. I attended,
with Dr. Stewart, an elderly lady, who had long laboured under a
large umbilical hernia.  It had been strangulated more than once,
and as often relieved without  an operation.   For the last four or
five years, it had been constantly down. The attack of strangulation
for which I was consulted, had lasted several hours; the vomiting
was constant, with  tormina, and considerable  tenderness of the
abdomen and umbilical ring.   1 recommended that the  operation
should  be  performed,  which,  however,  the patient  would not
accede to.   Under  these circumstances, Dr.  Stewart and myself
determined to give  a drop  of  Croton oil  every two hours, to force
a  passage.  The practice was successful; and after  two  doses the
bowels were completely relieved, without however the hernia re-
turning.
   In strangulated hernia, if a  surgeon is  in  doubt, he had better
operate.  Many lives are lost by delaying the operation ; but I never
saw an instance in which life was endangered, or any serious symp-
tom produced, by the performance of the operation.  There exists,
however, no end to the varieties of the features of hernia; in some
cases, it is bad practice to delay the operation three hours from the
commencement of the attack:  in others, it has been delayed many
days without detriment to the patient.
   But another important question demands consideration,  when the
use ofthe taxis is spoken of. Has this process not its own hazards,
even when employed at a seemingly fitting time?   The surgeon
must always bear in mind, that, if he use  too much violence with
the taxis, he is in danger always of either rupturing the intestine,
or  returning it in a state otherwise unsafe into the belly, or of re-
turning  together with  the  intestine the  sac, and the peritoneal
stricture of the neck ofthe sac.
   The following case I did  not witness, but I was assured it hap-
pened  as I shall describe.   A patient laboured under strangulated
inguinal hernia: the symptoms not being very urgent, and  the
tumour  not very tender, considerable pressure  was used, and at
length the greater  part of the  tumour disappeared.  The  patient,
however, was not much better,  became  worse, and died.  Upon
examination, it was  found that the bowel had indeed been  pushed
back, but that the sac had also been pushed back with it; the neck
of the returned sac, formed of thickened peritoneum, had  been
sufficient to keep up the strangulation,
   A patient (a recent case in  the Middlesex  Hospital) had all the
symptoms of strangulated hernia: there was a small tumour, feeling
like an  omental hernia, at  the crural arch.   The patient had  a
swollen  and  tender  belly, and  stercoraceous  vomiting.   Repeated 
THE DIGESTIVE ORGANS.
281
 attempts  had been  made to reduce the rupture, which the patient
 said was  considerably larger before these attempts had been  used.
 The  bowels had acted twice with  enemata.  I did not attempt to
 return  the  tumour, but  operated  immediately, when I found an
 empty sac:  I divided the nee ofthe sac.  The patient died in thirty
 hours.  On  opening the abdomen,  the  upper part  of the  small
 intestine was found distended, swollen, and inflamed.   A segment
 of a  portion of the ileum, which had been down, was deepfy dis-
 coloured,  and retained  the impression of the close grip of the neck
 of the sac.   It had been forced back into the belly, before the per-
 formance of the operation, by  the  taxis,  too  much  injured  for
 recovery,  through the length of time it had been strangulated. The
 tumour upon which I operated was the sac, with thickened adipose
 substance partially  surrounding it.
   4.  Fallacious appearances of improvement in unreduced stran-
 gulated hernia.
   a.  Diminution in  tenseness and volume of the tumour, the  other
 symptoms remaining.   I have  repeatedly seen  inguinal  hernial
 tumours become  less in volume, and less tense,—without  the  ur-
 gency ofthe more important symptoms being suspended,—through
 the water of the hernial sac being forced by the pressure used into
 the abdominal cavity.  When the operation has been subsequently
 performed, the serum, which had  been forced into the abdomen, has
 poured out  through the neck of the sac, upon the  division of  the
 stricture.
   6.  Disappearance of the tumour, the otWor symptoms remaining.
 I  recollect seeing the body of a female examined, who had died of
 crural hernia.  She was not my patient;  the surgeon,  under whose
 care she had fallen several hours after the invasion of symptoms of
 strangulation, had resorted  to the taxis:  he had compressed  the
 tumour till  it  had  disappeared,  and in  his opinion  had been re-
 duced.  A small segment of the  circumference of the bowel,  how-
 ever,  had  remained  nipped in the sac, and caused death.  Whether
 the diminution and  supposed return ofthe tumour in this case was
 produced  by forcing the serum of the sac into the belly, or by  the
 actual reduction of a part of the protruding bowel, I had no means
 of ascertaining.
   Another suspicious improvement in strangulated hernia, which
 is  the more  likely to prove delusive that it very rarely occurs, is
 the action of the bowels eiiher not being suspended, or returning :
 this circumstance is not incompatible with total obstruction.
   A patient  was admitted into the Middlesex Hospital,  with sterco-
 raceous vomiting, and  with frequent purging.   His  belly  was
 swollen, and tense, and tender; and there was a large swelling of
 the right side ofthe scrotum.   The lower part of the swelling was
 distinctly a  hydrocele;  but the upper part, though to all appear-
 ance it was  continuous with the tumour, I thought,  must be an  in-
guinal hernia : but  it had  little tension and tenderness, and a  very
obscure impulse was alone communicated to it on coughing.   The 
282
MAYO'S OUTLINES OF PATHOLOGY.
purging  continued, and  the stercoraceous vomiting, and the pa-
tient grew worse.   On the second day I operated ; a portion of in-
testine was found strangulated.
   What then  are  the symptoms on which the surgeon  must de-
pend?—unrelieved vomiting, and uneasiness, and tenderness ofthe
abdomen : with which there are gradually associated, distention of
the belly, a frequent and  wiry pulse, hiccup, a haggard expression
of countenance.
  5.  The operation.—The first object ofthe operation is to relieve
the constriction, wherever it exists,  that causes the strangulation.
In cases of strangulated  hernia, that were  previously irreducible,
nothing more is contemplated.   The protruded part is net returna-
ble, but the passage through it may be restored.   But in cases of
strangulated hernia before  reducible, there is a second object,
namely, to ascertain by inspection whether the part protruded is in
a fit state  to be returned.   For both these objects, it is essential, as
a general  rule, to  lay open  the sac.   The place of the stricture is
often not  discernible till  the sac is opened.   The stricture itself is
often entirely  peritoneal, and  cannot be divided without  opening
the sac.   And  it is evident that the state of  the bowel cannot be
seen, till it is exposed to view.  I am aware that cases occasionally
occur, in  which a surgeon  may hazard with  tolerable security the
not opening the sac—1 allude to those cases of inguinal  hernia in
which the strangulation has existed  a very short time, and the grip
of the external ring upon the sac is strong and close.  I have in-
deed seen this done with success; but I  am  sure that it is unsafe
practice, for the reasons which I have assigned.
   Is the surgeon, then, to lay the sac entirely open ? This is by no
means to  be done : an incision into the sac three inches in length,
beginning from the ring at which it  protrudes, is sufficient even in
a  large hernia to allow the surgeon  to examine the contents ofthe
sac ;  at the same  time that the  moderate size of such an incision
prevents the bowels falling out upon his hands.
   Let me now enumerate the difficulties which the  surgeon may
encounter in attempting to open the  sac, and to divide the stricture.
   a.  If the integument and subcutaneous layers of fascia are  unu-
sually thin, and the intestine in the sac is  distended with flatus, the
intestine may be cut into  in the first incision.   I have seen this ac-
cident happen. It is  hardly attended  with danger to the patient,
who may almost be viewed in a state of greater safety in conse-
quence of the immediate relief of  the distention of the bowels
through the wound.  If the wound  is  a  puncture  merely, it may
be secured with a knot of fine silk, the ends  cut close off.  When
larger, I have seen the intestine returned all but the cut part, which
is to be fastened by a suture to the integuments.   The artificial
anus closes in from six to eight weeks.
  b. If the sac contain no water, either because none  has  been
formed, or that it has been  pressed into  the  abdomen, and if the
surface of the  bowel has lost its polish from slight effusion or 
THE DIGESTIVE ORGANS.
283
lymph, the. surgeon  may  be in doubt whether he has yet reached
the sac, when he has already divided it.  I have seen the peritoneal
coat of the intestine punctured under these circumstances, in the
expectation that it would  prove the sac.  It is hardly necessary to
observe in this place, that the  water  of the sac, which is so con-
stantly met with,  results  from the impeded return of the venous
blood of the strangulated part.
   c. I met with, in  the dissecting-room, an old  hernia, which ap-
peared to  have no sac.  On the opposite side there was an ordinary
hernia.  A model  of the appearance presented is in the museum of
King's College.  It  appeared  to me that there had been a hernial
sac, the identity of which  was lost, through its having become uni-
formly adherent to the intestine which it contained.   If such a case
occurred in practice, the surgeon would be  almost excusable  if he
opened the intestine  by mistake.
   d.  It happens occasionally, that an old hernial sac lies  conti-
guous to  that which contains the  recent and strangulated hernia.
An appearance similar to  this  is sometimes produced through con-
densation ofthe filamentous tissue ofthe groin by pressure. Layers
of membrane, closely resembling peritoneum, are  liable to be thus
formed.   I have, however, seen this  appearance  in  crural hernia
alone.  I recollect  a case, in  which a sac of this kind  was supposed
to be the hernial sac, which it contained, and the  ligament of Gim-
bernat was divided, before the mistake was discovered.  This mis-
take is the more easily made, that in  such  a case the finger  intro-
duced within the factitious sac passes under the inguinal arch, and
seems to be contained in the narrow neck of a true sac.
   c. A circumstance, which, when it occurs, contributes  to
strengthen this  deception  is, that  the  serous cyst  occasionally con-
tains liquid,  the absence of which would otherwise  lead the sur-
geon to suspect that he had not yet opened  the sac.  It has not
happened to me to meet with an  instance where the  whole hernial
sac has been  contained in such  a false sac;  but I have known a
false sac, attached  to the outside of a hernial  sac, convey the idea
that a hernia ofthe head of the colon, with  the characteristic par-
tial sac, presented.
  /. There is a  complication of these serous sacs with condensed
adipose tissue, which completely deceived  me.  In  the first case
which I  witnessed  of this  description,  the  hernia  was a crural
hernia, and  extremely  small.  After dividing  several layers  of
fascia,  I  exposed  a membrane resembling a hernial  sac:   upon
opening it, I came  upon what I conceived to be a nodule of omen-
tum.   This I  cut  through, in  the expectation of finding intestine
contained within it; instead of this, I came upon  the true hernial
sac, of remarkably small  dimensions, and which  I had not before
reached.  There was strangulated  bowel  within it.
  g.  But  it is possible that the hernial sac may be properly opened,
and yet the neck of the sac escape division.
  It  is difficult to conceive  how the following  accident should 
284            MAYO'S OUTLINES OF PATHOLOGY.

arise, but I saw a case  in which it  had actually  happened.  The
case  was strangulated crural hernia in a man.   The surgeon  laid
open the sac :  the gut was already mortified : there was a question
of returning  it; but it was necessary to divide the stricture, in
order to allow of the free escape of the contents  of the bowel at the
wound. The surgeon divided what  he supposed to be the stricture.
The following day nothing had escaped through the wound, and
when the finger was passed towards  the belly  from the cavity of
the mortified intestine, it was found  that there was no passage; the
stricture still existed.   Upon carefully  examining the  wound, it
was found that the division of Gimbernat's  and Poupart's ligament
had been made external to the sac.   Upon then  dividing the true
neck of the sac, the  finger could be  passed from the opened and
mortified gut into the sound intestine within.
  The case is more likely to happen, although it is an extremely
rare case, in which a surgeon  may  have to  operate upon a stran-
gulated hernia  which has already been  half forced back, sac and
all, within  the abdominal parietes.   In this case it is obvious, that,
upon opening  the  hernial sac, and  passing  the finger  towards its
neck, the surgeon will  feel the narrow ring in the abdominal walls
at which the protrusion took place : this he will probably be satis-
fied with enlarging by a slight division; and, unless he is singu-
larly  circumspect, and has been quite alive  to  all the previous
circumstances of the case,  he may  leave  within  the  abdominal
parietes an undivided peritoneal stricture.
  I recently witnessed a case of scrotal hernia, in which, when the
sac had been laid open, the bowel disclosed appeared nearly healthy,
and  the finger could  be passed  easily into the abdominal  ring.
There  was  no stricture in the spermatic  passage, or  behind it.
Upon further examination of the part, it was found that the stric-
ture was a peritoneal one, and situated in the middle of the scrotum,
the lower part of which alone contained  strangulated intestine.
This stricture  being divided, some length  of mahogany coloured
small intestine was drawn from the  bottom of the scrotum, and  re-
turned into  the belly.   The stricture in this  instance had  been
formed, I  have little doubt, at the inner ring, through  its pressure
on the  peritoneum, and afterwards  had been pushed forwards out
of the grip of the ring and  into the scrotum finally by additional
protrusion from behind.
  6. Management of protruded intestine.
  a. The intestine may be nearly healthy in  appearance, or but
slightly if at all darker than natural from congestion.  In this case
it is to be returned.
  b.  The peritoneal surface may have lost its glossiness, and be
inflamed, with here and there small  patches of lymph upon it. The
prognosis in this case  is unfavourable,  but the best practice is to
return the bowel.
  c.  The intestine may here and there exhibit a black patch, from
extravasation of blood  beneath  the peritoneal  coat produced by 
THE DIGESTIVE ORGANS.
285
 pressure on the previous taxis.  This is no impediment to return-
 ing it.
   Before returning protruded intestine, it is of the highest import-
 ance to draw down a small additional portion at eiiher end, to see
 whether the part gripped by the stricture be  in a state threatening
 gangrene.  I have seen a patient die through  neglect of this pre-
 caution.
   d. If the intestine be partially sphacelated, of a greenish black or
 brown, or ashen, in patches, or the  whole of it, whether  already
 burst or not, it must  not be returned   But the stricture having
 been set free, and  the  intestine opened, it  is to be attached by a
 suture to the  adjoining skin.  The contents of the bowel will then
 freely pass out of the wound, which becomes an artificial anus. The
 patient's life being  preserved, the next thing is to close this tempo-
 rary aperture.  Under some circumstances this is easy. Supposing
 that of all the intestine in the sac one small part only threatened to
 be gangrenous, this part  alone  is opened and retained in the sac,
 the rest  replaced in the belly.  Such  an  opening—there being little
 lost ofthe parietes  of the bowel—will spontaneously close in from
 six to eight weeks, if the wound is only kept clean, and encouraged
 to granulate and draw together.  If the loss of substance is greater,
 the two  portions of intestine on  either  side the slough meet at an
 acute angle at  the artificial  anus, their adjacent sides  forming a
 septum down to the opening. To this case the instrument invented
 by M. Dupuytren, for nipping and strangulating  a small portion of
 the septum, is still applicable, and when used with caution  I should
 think perfectly safe.
   e.  But the  intestine may be neither sphacelated, nor yet so free
 from discoloration  as to make  the surgeon confident what would
 be  its progress if replaced.   It is not possible to express in  words
 the  differences of appearance which  will decide the  practical sur-
 geon in one of these middle cases to  return the bowel, in another
 to open it.  It is not, however,  the colour ofthe  intestine alone by
 which the surgeon  ought on this occasion to be guided :  he must
 likewise  take  into consideration  the  quantity of discoloured intes-
 tine ; the age of the patient; the condition of the h: wels within
 the abdomen ; the length of time the  strangulation has existed.  I
 have seen patients die at different periods—from two to seven days
 —after  the operation  for  strangulated hernia,  in whom, upon a
post-mortem examination, the intestine that had been returned has
 been  found either  to have mortified subsequently to its  replace-
 ment, or  not to have recovered its colour from the dark and suspi-
cious hue it presented in the operation.   These  patients have died
of peritonitis;  and although several  would  in all probability have
died if the unhealthy intestine had not been  returned  into the belly,
I am convinced that others would  have lived, if, instead of the
whole, the healthiest part only of the protruded bowel  had been
reduced,  and the most discoloured part opened and retained in the
sac.   In  a small proportion  of these serious cases,  the  scale is 
286
MAYO'S OUTLINES OF PATHOLOGY.
probably turned against the patient by the bowel being called upon,
and being unable at once to recover its healthy state, and to con-
tinue  its functions.   Relieve  it by a  direct outlet of its contents,
and the chance of its self-recovery ought to  be, and (I think I have
found it so practically) is considerably  increased.   The artificial
anus is of no consequence : it will close in a  few weeks.  This
important question, which  has seldom  to  be discussed except in
hospital  practice, applies only  to cases which have become aggra-
vated through delay and neglect before a surgeon is consulted.
  7. Of omental hernia.
  When a strangulated hernia is merely omental, the patient ordi-
narily has less pain and distress in the belly and  in  the tumour,
than when the hernia contains intestine : the symptoms are slower
in their progress ; the bowels are easily unloaded by enemata ; the
patient is then sensibly relieved; and opening medicines, adminis-
tered  by the mouth, complete his recovery.
  There are two reasons  for operating in omental  hernia:  first,
although a surgeon can determine by the touch when a hernial
sac  contains omentum, he cannot tell that it does not contain intes-
tine besides :  secondly, a patient may die of strangulated omental
hernia alone.  I operated in the Middlesex Hospital  upon  an  old
man with strangulated omental hernia: there was vomiting, hiccup,
and tenderness of the belly.   He sank,  and died of the peritoneal
inflammation, which had been established before the operation was
performed.
  But what  is to become  of  the omentum,  exposed  in operating
upon  either an epiplocele or an entero-epiplocele?
  If the omentum is in its natural state, it is to be returned.  If, as
more commonly  happens, the omentum is  found  enlarged, thick-
ened, and  firm,  it cannot  be returned.  In the latter case three
modes of practice have been employed, each of  which I have tried
with success.
  1. The omentum may be left in the wound to slough or granu-
late, when it will cohere with the sac. and  plug up the opening.
This  is perhaps the safest practice; and  in an aged person I should
again  employ it.
  2. The protruded  part may be cut off  by a clean section, and
each  bleeding vessel  tied with a small knot of  the finest thread of
silk, the ends cut close to the knot.   This  practice I believe to be
perfectly  safe if the  surgeon  secures  all  the  vessels,  which he
may do.
  3. The protruded  part may be cut  off,  and a  double ligature
passed through the abdominal  end, tied round it, and  then attached
by a suture to the integuments.  This method  I adopted in a gen-
tleman about thirty years of age.  He has had no return of hernia,
nor at any time any sense of dragging or traction of the stomach
or colon towards the groin, nor any kind of abdominal uneasiness.
But I am informed, that, in  other cases where this practice has been
employed, it has been followed by grave inconvenience of the kind
adverted to. 
THE DIGESTIVE ORGANS.
287
                        SECTION VIII.

                          The Liver.

  The affections of the liver may be arranged under the following
heads:—injuries and hemorrhage—hyperaemia—anaemia—inflam-
mation—abscess—hydatids—atrophy—hypertrophy—steatosis—tu-
berculous  deposit—malignant  tumours—biliary congestion—gall-
stones—jaundice.
  1. A  violent blow upon  the praecordia is instantaneously fetal:
but it is uncertain to  what extent the injury of the liver contributes
in such  cases to the fatal result.  Pressure upon the liver, when in
its healthy slate, produces a painful and subduing sensation.
  I was called to see a gentleman who was shot through the side:
he lived about  eight  hours  in  intolerable pain.  The ball had tra-
versed the long diameter ofthe liver.
  Blows on  the right hypochondrium are liable to produce  rupture
of the liver, when the patient dies in from twenty-four to sixty
hours, the period being determined by the quantity of the  hemor-
rhage into the peritoneal cavity, [r. 1.]
  A  man sitting carelessly upon the  edge of a cart was  thrown
from  it by a sudden  jerk upon the road.   He immediately got up
and scrambled  into the cart, which was still in motion, and he did
not appear to a person who was along with him to have received
any injury ; but he soon became faint, and in  a few minutes  was
dead.  On inspection,  the  liver was found to have been ruptured
through a great  part  of the  right lobe, and there was extensive
hemorrhage in the cavity of the abdomen.—Abercrombie.
  Sometimes a violent  blow upon the region ofthe liver is followed
immediately by pain and extreme depression ;  but  the  patient re-
covers, beginning slowly to mend after twenty-four or  forty-eight
hours have past.  In such cases I have felt persuaded that the liver
has been superficially bruised,  or perhaps slightly lacerated.
  A branch  ofthe vena portae  sometimes spontaneously gives way,
producing a sort of hepatic  apoplexy.
  A gentleman mentioned by Andral, previously in perfect health,
on getting up one morning  complained of  some uneasiness in the
abdomen,  and  returned to bed, where  he was left  alone for some
time: when  his attendants came again into the room, he was dead.
On inspection, there was found in the cavity of the  abdomen much
extravasated  blood,  which  appeared  to  have proceeded  from a
lacerated opening in the substance of the liver; this led to  a small
cavity full of coagulated blood, and the hemorrhage was distinctly
traced to the rupture of a branch ofthe vena portae.
  2. The different appearances ofthe liver, in respect to the quan-
tity of blood contained in its vessels, are the following.
  a. Hyperamia of the hepatic veins.  Mr. Kiernan has  shown,
that the usual appearance in a healthy liver, of darker spots mottling 
288            MAYO'S OUTLINES OF PATHOLOGY.
a yellow parenchyma, results from  congestion of the  intralobular
hepatic veins.   The congestion beyond a certain limit constitutes,
an abnormal state, or a state of disease. [R. 1.]
  b. Hyperamia of the portal veins.  When congestion  of the
portal system alone is present, the peritoneal surface ofthe liver, or
a section of the  liver, displays the appearance of yellowish spots
mottling a dark  parenchyma.  In the former  case the  central ves-
sels ofthe lobules are congested, in the latter the vessels in the inter-
lobular spaces.  [R. 2.]
  c. Hyperamia of both systems.  In this case the yellow colour
disappears  from every part of the liver, from the lobules, as well
as from the interlobular spaces, the vessels of each being congested.
  d. Anamia.   The liver of a pale yellow.   It is commonly at the
same time firmer than in health.
  The preceding appearances may be general or partial.
  3. Inflammation.
  a. Acute inflammation ofthe liver is a disease of rare occurrence
in this country.   The appearances which it produces are increased
vascularity accompanied with softening, as if the tissue had  been
macerated  in  serum.
  A lady,  aged twenty-eight, suffered a  sudden cessation  of the
menses  from a violent  mental  emotion.   She  was  immediately
seized with severe vomiting, and  complained  of acute pain  in the
epigastric region extending along the right hypochondrium.   After
a few hours, deep jaundice took place, with fever, distention of the
abdomen, hiccup, and very difficult breathing; and she died on the
following day.   The liver appeared much  enlarged, and when cut
into seemed to be infiltrated  with a bloody serous fluid.  Its  upper
surface was covered with false membrane,  and the right side ofthe
diaphragm was inflamed. The lungs were much gorged with blood.
The other  viscera were healthy,
  b. Chronic inflammation of the liver.   The appearances which
denote this affection are, increase  in firmness ofthe structure of the
liver.  The ramifications of Glisson's capsule in  the interlobular
spaces are  more or less thickened and  indurated, having the ap-
pearance of  being infiltrated with  semitransparent lymph.  The
lobules  themselves are  compressed, firm, and generally pale. [r.
4.]   In  the following case the quantity of lymph  effused appears to
have altered the character of the entire structure  ofthe liver.
  A man,  aged  forty-five,  in the  beginning of May, 1813, was
affected with  severe pain in the region of the stomach, which soon
shifted into the  right hypochondriac  region among the lower false
ribs: it was much increased by respiration  : there was some  couch:
pulse 120.   In  the course of two days and a half, he  was  bled* to
the extent of £145 : the symptoms then yielded,  and soon after  he
went to  the  country.  But  he did not recover  sound health :  he
had some  cough and dyspnoea, with  much debility.   After  some
time he became dropsical: the dropsical symptoms increased with 
THE DIGESTIVE ORGANS.
289
pain in the right side, and he died in the beginning of August.—
Abercrombie.
  Inspection.—There was extensive effusion in the abdomen.  The
liver was completely changed  in  its texture, being,  through its
whole structure, of a dull  white  colour, and very hard, in many
places almost  cartilaginous.  There  was not the  smallest portion
of it that retained the healthy structure or colour, but it was en-
tirely ofthe natural size.  The lungs  and all the other viscera were
healthy.
  c. Adhesions of the peritoneal surface of the liver to the  perito-
neal covering ofthe diaphragm are frequently met with. It is more
than probable, that many cases considered to be chronic inflamma-
tion ofthe liver are chronic peritonitis.
  4. Abscess of the liver.
  a. Abscess occurring in acute hepatitis fatal in ten days.
  A gentleman, aged twenty-two,  (15th June, 1817,) was affected
with pain .across the epigastric region, increased  by pressure, and
accompanied by vomiting and frequent pulse.   The case was  con-
sidered by an intelligent surgeon as gastritis, and was actively treated
by repeated blood-letting, blistering, purgatives, &c. Under the use
of these means the pain was very much  relieved, and the vomiting
subsided ; but on the 18th, being the third day from the commence-
ment ofthe symptoms, he was seized with very deep jaundice.  Dr.
Abercrombie saw him on the 20th.  His pulse was then from 90 to
96, and soft; the bowels were open : very deep jaundice continued;
but there was little complaint  of pain, except some uneasiness on
very firm pressure in the region ofthe left lobe ofthe liver. On the
21st, there  was no change, and very little complaint; but on the
22d, the pulse rose suddenly to 140, without any  other change in
the symptoms.  It subsided at night, but  on the 23d was at 160:
there was  much  febrile oppression, and very deep jaundice, with
restlessness, slight pain upon' pressure,  and some tension  in  the
region ofthe left lobe of the liver.   The usual remedies were per-
severed in,  without any effect  in controlling the disease.   On the
24th this patient  continued  in  the  same state, with an anxious
febrile look, and died on the 25th.
  Inspection.—The left  lobe  of the liver contained several small
abscesses, full of purulent matter;  and there were also several ab-
scesses in the right lobe in the part most contiguous to the left. In
other respects, the whole substance ofthe liver, except a small part
at the lower extremity of the great lobe, was very much softened and
broken down, and of a very dark or nearly black colour.  Both the
hepatic duct  and the ductus communis were obstructed by large
calculi ; and a large accumulation of bile appeared to have taken
place in the substance  of the liver, which  flowed  out freely when
the ducts were laid open.  The other viscera were healthy.
  b. Abscess produced by acute hepatitis, the patient surviving the
attack in which the abscess originated.
  A lady, aged fifty-one, (23d October, 1816,) was affected with in- 
290            MAYO'S OUTLINES OF PATHOLOGY.

cessant vomiting, and  severe  pain  in the region of the stomach,
much increased by  pressure,  and extending downwards towards
the umbilicus ; bowels open ; pulse 84 : the symptoms had continu-
ed twenty hours. She was treated by repeated blood-letting, blister-
ing, full doses of calomel, &c. In the evening of the 21th there was
considerable relief of the  pain,  but it returned  on the  25th  with
much severity : it was fixed in the region of the stomach, and was
increased by inspiration ;  and  tenderness  on pressure extended over
a great part of the abdomen ;  there was  less vomiting; pulse 120,
and small; bowels open:  after  further bleeding there  was again
much relief of the pain ; she breathed with more freedom, and was
free from vomiting;  pulse  108. On  the 26th the pain returned with
much severity, and continued  with little abatement on the 27th and
28th.   It was chiefly referred to a spot immediately below the ensi-
form cartilage, and extended into the region of the left lobe of the
liver,  where there was some tension and tenderness on pressure.
She was now free from vomiting; the bowels were quite open, and
the motions dark-coloured ; the pulse varying from 100 to 120.  She
was now chiefly treated with calomel, digitalis, and blistering.  On
the 29th the symptoms began  to subside; and in a short time she
was able to be out of bed, and seemed to be convalescent.  But it
soon appeared that she was not free from the effects of the attack.
She had occasional  uneasiness in the  region of the stomach  and
liver,  with severe  nausea, occasional vomiting, and  oedema of the
legs:  pulse sometimes natural, and sometimes rather frequent. The
pain recurred  in  paroxysms, which  often extended through the
whole abdomen ; and she  was liable to attacks of vomiting, which
continued severe for a day or two at a  time, and then subsided.
Her most permanent and uniform complaint was of constant and
severe nausea; and  her general aspect was pale and exhausted, but
without any appearance of jaundice.  Some tension was felt in the
region of the liver,  but it was very obscure.  With various remis-
sions and aggravations of the symptoms now mentioned,  the case
was protracted for four months, and she died, gradually exhausted,
on the 27th of February.—Abercrombie.
  Inspection.—On the upper  surface ofthe liver, towards the left
side, there was an abscess,  covered by little more than the peritoneal
coat, and containing about a pound of thick purulent matter.  The
greater part ofthe liver was much softened and broken down  ; and
the gall-bladder contained a great number of biliary calculi of va-
rious sizes.   There were some small abscesses in both kidneys. All
the other viscera were healthy.
  c.  Abscess originating in chronic inflammation.
  A  gentleman aged  sixty-seven, and previously enjoying  good
health, except frequent dyspepsia, had  occasionally complained for
some time of a pain  in his right side, which affected him chiefly
when he walked quickly.   But he made little complaint, and was
not confined to the house until about three weeks before his death,
when he had some irritation of the bowels, with loss of appetite, and 
THE DIGESTIVE ORGANS.
291
 an obscure uneasiness  across the  epigastric region.  After another
 week he was confined to bed, his chief complaint being the frequent
 irritation of his bowels: the stools were scanty, and composed chiefly
 of bloody  mucus. Dr. Abercrombie saw him only a few days before
 his death : he wac then considerably exhausted;  the pulse feeble,
 but little increased in frequency ;  the bowels still  troublesome, but
 kept in check by opiates. There was obscure uneasiness across the
 epigastric region, but without tenderness; and no fulness or hard-
 ness was to be discovered either there or in the region ofthe liver.
 There was an aphthous state of the mouth, with great difficulty of
 swallowing, a great deal of hiccup, but no vomiting and no jaundice.
 From his  exhausted state, there was no  room for active treatment:
 he died, gradually exhausted, a fortnight from the time when he was
 first confined to bed.
    Inspection.—The liver appeared to be considerably enlarged, and
 the right lobe was found to have almost  entirely degenerated, into a
 large abscess, containing fully three pounds of thick purulent mat-
 ter, the proper substance of the liver merely forming a very thin cyst
 around the cavity. At the cardiac orifice of the stomach there was
 evident inflammation ofthe  mucous coat, with a deposition of floc-
 culent matter; and this appearance extended along the whole course
 ofthe cesophagus, with much deposition  of flocculent matter in thin
 layers in different places.  There were various  adhesions of the in-
 testines to  each  other: internally, the small intestine was healthy;
 but in the mucous coat ofthe colon there was extensive ulceration,
 mixed with fungous elevations, which extended in a greater or less
 degree along the whole course of  it, and even  into the rectum.
    Abscess ofthe liver may break  into the stomach,, [r. 5.] or into the
 great intestine, and, having a free  vent, gradually contract and heal:
 or the abscess may point externally, either through the  abdominal
 walls, or in the right hypochondrium between the lower  ribs, [r. 6,]
 or it may  break through the diaphragm into the lungs.   In the lat-
 ter case, the presence of bile in the sputa is not necessary, or likely;
 as, on the other hand, a yellow tinge resembliug bile in  the expec-
 toration, has sometimes existed, when after death it has been ascer-
 tained that  no communication had ever  taken place between the
 liver and  lungs.   Abscess of the liver is liable  to be produced  from
 the lungs.  The preparation [r. 9.]  is from a boy, who died of abscess
 of the lungs coming on after an ear of  rye had slipped down the
 trachea :  the ear of rye was found lying in an abscess common to
 the right lung, the diaphragm, and the liver.
   d. Numerous small abscesses are liable to occur, either in groups
' of five or six small adjacent irregular cavities, [r. 10.] or dispersed
 singly through the liver.   I met with the latter appearance in the
 liver of a man about fifty years of age, who died, after three days' ill-
 ness, of suppression of urine.
   5. Hydatids.
   Hydatids are of frequent occurrence in the  liver, and are found
 either in cysts attached to its outer surface, or imbedded in its sub- 
292
MAYO'S OUTLINES OF PATHOLOGY.
stance. The cysts in which they are contained are sometimes lined
with a thick coating of false membrane, and not  nnfrequently there
are found in them portions of bone. A liver which contains hyda-
tids may be enlarged and  otherwise diseased, or  it may be  quite
healthy with  the exception of the cyst which  is  imbedded in it.
There are no symptoms which mark the presence of hydatids in
the liver, distinct from those of the other  chronic  affections; and
they have been found where patients have died of other diseases
without any symptoms referable to the liver.
   In  a case which occurred in the Middlesex Hospital, under  the
care of Dr. Macmichael, a cyst in the liver containing hydatids burst
into the lungs ; and for a long period the hydatids, with a yellowish
mucus, continued to  be  expectorated.   All doubts as  to the nature
ofthe case were removed by the post-mortem examination, which I
witnessed.
   Cysts  containing watery matter confined under the  peritoneal
coat of the liver  are occasionally met with.  These cysts may  ap-
pear either upon the convex or concave surface ofthe liver.  The
following remarkable example is related by Dr.  Abercrombie.
   A man, aged thirty-two, was affected with an  immense tumour of
the abdomen, which  filled the greater part of it,  extending from  the
region ofthe liver considerably below the umbilicus, and into  the
left side. At the upper part, near the ribs on the right side, there was
an evident fluctuation.  This was most remarkable  when he was in
the erect posture ; in the horizontal posture it seemed as if the fluid
retired under the ribs: no fluctuation was perceived in  any other
part ofthe mass. His breathing was much oppressed and laborious,
especially when he attempted to turn on the left side; he then seemed
in danger of instant suffocation ; for several minutes gasping in the
utmost agony before he  recovered his breath : similar attacks were
produced by other causes, especially any bodily exertion.  He was
much emaciated ; and the  complaint was of about a year's standing.
A puncture  was made on the spot where the fluctuation was felt;
clear  serous fluid was drawn off to the amount of nine or ten pounds,
and the opening continued to discharge freely for a good many days.
By this evacuation he was very much  relieved; but his strength
continued to  sink, and he  died about ten days after the operation.
   Inspection.—The  liver was very little enlarged.  The tumour was
found to consist of an immense sac formed on the  convex surface,
under the peritoneal coat; it was of such a size that it had, on  the
one hand,  pressed down the liver below the  umbilicus, and on  the
other had pressed the diaphragm upwards as high as the second  rib.
The right lung was  consequently compressed into a small flaccid
substance less than a kidney; the left lung also was  much dimi-
nished in size, and the heart was as small as that of a child of  five
or six years.   This immense  cyst adhered firmly to  the  posterior
half ofthe diaphragm; but betwixt it and the anterior part of  the
diaphragm there was a distinct cyst, containing a watery fluid.  It
was this which had been opened in the operation ; the  great cyst 
THE DIGESTIVE ORGANS.
293
was entire, and contained 18 lbs. of transparent colourless fluid.  Its
parieles were firm and dense, like the peritoneum very much thick-
ened.   In the bottom  of the cyst there were found two singular bo-
dies, consisting of flat cakes of a soft gelatinous matter rolled up into
solid cylinders :  when unrolled, they were about ten inches in dia-
meter, and about one eighth  of an inch in thickness,  and had the
appearance of a deposition which had been separated from  the inner
surface ofthe cyst. The liver was not diseased in its structure, and
the other viscera ofthe abdomen were healthy, but remarkably dis-
placed, the stomach being on  the left side and the  pylorus towards
the left os ilium.
   A remarkable circumstance in this case was the uncommon firm-
ness ofthe tumour, which imparted the idea of an  immense mass of
organic disease, without any fluctuation, except at the part which
was opened.  A case considerably similar occurred in the Infirmary of
Edinburgh many years ago,  under the care of the late  Dr. Gregory.
It was supposed to  be an immense enlargement ofthe liver; but one
day the whole hardness suddenly disappeared, with a  feeling to the
patient of something bursting internally.  Fluctuation then became
evident,  though none had been  perceived before.  The patient died
next  day, and it was found that this remarkable change had taken
place  by the cyst bursting into the cavity of the  peritoneum.  Mr.
Annesley mentions a case in which there was attached to the con-
cave surface of the liver a cyst containing  a quart of watery fluid,
 with  a hydatid floating in it.  Dr.  Hastings has described a similar
 case, in  which, a week before the death ofthe patient, nine pounds
 of fluid were drawn off from a cyst of this kind. Sir Benjamin Bro-
 die has described two cases which were supposed  to be of this na-
 ture, but which were relieved by the evacuation of the fluid.  In the
 one, a young lady of twenty, the relief was permanent; the quantity
 of fluid evacuated was three  pints. The other was an hospital case,
 a boy, who  was dismissed in good health after the evacuation of a
 pint and a half.
   6.  Atrophy.  In those who habituate themselves to the use of ar-
 dent spirits the liver is found contracted, while its surface and edges
 are furrowed and notched.  These appearances result from wasting
 ofthe liver.  At the lines,  where the surface is furrowed, the lobular
 structure has partially  disappeared, and the  interlobular  tissue is
 unusually distinct.   Atrophy of the liver is  liable to  be  combined
 with inflammatory thickening of Glisson's capsule, [r. 34.] and with
 partial biliary congestion,  [r. 35.]
   Diminution ofthe size of the liver, with induration, is liable to
 occur where the use of ardent spirits has not been indulged in.
   7.  Hypertrophy ofthe liver.  In a case by Andral, of disorder of
 the liver connected with disease of the heart, the liver would dis-
 tinctly enlarge during the cardiac paroxysm, and  subside when the
 attack was relieved by  blood-letting.  Cases  of this description be-
 long more properly to the head of hyperaemia.
   a.  Simple permanent enlargement of the liver is an extremely
        21—b                                   2° may 
294
MAYo's OUTLINES OF PATHOLOGY.
rare affection in adults.  The following case serves to exemplify this
disorder, as it occurs in young persons of a scrufulous habit.
   A boy aged eleven, in the winter of 1811-12, was seized with
great enlargement ofthe glands under the jaw, his neck being com-
pletely beset with a chain of them of a very large  size, extending
from ear to ear.  He improved considerably during the summer; but
in the following winter he became, languid and impaired in strength,
with variable appetite and irregular attacks of fever.  In the follow-
ing summer he  was affected with cough and dyspnoea, and it  was
now discovered that his liver was so much enlarged, that the edge of
it was distinctly felt as low as the umbilicus.  He had a wasted and
withered look,  with cough, frequent pulse, enlargement of the ab-
domen,  and anasarca of the legs;  the latter increased to  a  prodi-
gious degree, and he died after protracted suffering in October, 1813.
   Inspection.—The liver  extended rather below the umbilicus, and
so much into the left  side as to fill the upper half of the abdomen.
It was a little paler than natural in its colour, but in other respects
was scarcely altered from  the healthy structure.  There was exten-
sive disease ofthe mesenteric glands.  The lungs were slightly tu-
bercular, and there  was  a  chain of enlarged glands, some of them as
large as walnuts, extending behind  the lungs from  the bifurcation
of the trachea to the diaphragm ; some of these were of cartilaginous
hardness, others contained thick purulent matter,  and in  others
there were hard calcareous particles. There was considerable effu-
sion in the abdomen.—Abercrombie.
   b. Hypertrophy, with induration, is the consequence of slow in-
flammatory action, and perhaps would find its proper place under
the head chronic hepatitis.
   A lady,  aged  forty-five, had  long been liable  to  dyspeptic com-
plaints ;  but she was often for a considerable time together entirely
free from them, so that no suspicion had been ever entertained ofthe
presence of organic disease. She also frequently complained of pains
in the back, neck, and shoulders, which had merely  a rheumatic^
character.  In autumn,  1818, she went to Harrowgate, and seemed
to derive much benefit from  the use ofthe water.  In the following
winter she was again a  good deal confined, complaining chiefly of
wandering rheumatic pains, with bad appetite, very bad digestion,
and a feeling of oppression across the region of the stomach. On ex-
amination, the liver was now found to be  much enlarged and very
hard, but without pain or  tenderness.  In January, 1819, she began
to lose flesh and strength  ; the pulse became small and frequent,
with difficulty of breathing,  and effusion in the abdomen ; and she
died, gradually exhausted, iu the end of February.
  Inspection.—The liver  was very much enlarged,  so as to extend
quite into the left side of the abdomen, and to descend three or four
inches beyond the line of the ribs:  in the epigastric region, its mar-
gin formed an adhesion to the parieties ofthe abdomen. Internally,
it was entirely changed from the healthy structure, being of  a pale
or ash colour, and very firm in its texture;  in  many places nearly 
THE DIGESTIVE ORGANS.
295
 cartilaginous: scarcely any part of it retained the healthy appear-
 ance.  There was considerable effusion, both in the abdomen and
 the thorax, but the intestines and the lungs weie healthy.—Aber-
 crombie.
   8. Steatosis of the liver.   A substance resembling wax or adipo-
 cire  is found in  the. liver, producing what on the analogy of a like
 disease in the voluntary muscles  may be termed steatosis  of that
 organ.  This  substance is  sometimes found  in irregular portions
 mixed with the healthy structure, and sometimes in small nodules
 like  peas dispersed through the substance  of the liver [r. 39.]: in
 some cases the whole liver, or a large part, is found changed into an
 uniform mass of this appearance, [r. 40.]
   9. Scrofulous deposit is of rare occurrence in the liver.   Some-
 times it  forms small tubercles, which slowly suppurate [r. 50.]; in
 other instances it exists in longer round masses, with general en-
 largement ofthe organ.
   10. Malignant  tumours.
   a. Medullary sarcoma,  [r. 58. 60. 61. (fee]
   A  gentleman, aged sixty-seven, had been for many years dyspep-
 tic, but without any affection of his general health till the spring of
 1820, when he began to decline considerably in flesh and strength,
 and complained chiefly of a feeling of oppression about his chest.
 He went to the country and improved  considerably, but in May he
 became worse.  His chief complaint was  then of a fixed pain in the
 lower part of his back, with restless nights : he  was able to take a
 good deal of exercise on horseback; but complained that,  after
 riding, the pain in his back was increased.  He came to Edinburgh
 in June.  He  was then a good deal fallen off in flesh and strength,
 and his pulse was a little frequent;  but his appetite was good, and
 he made no complaint of his digestion: his chief complaint was
 still of a fixed pain  in the lower part of the back.  On examination,
 nothing was discovered in his back; but  a mass of disease was felt
 in the abdomen, extending from the ribs to near the  spine of the
 ilium, chiefly on the left side.  It was not  at all painful on pressure,
 and he could give no account ofthe origin or progress of it, having
 never taken notice of it until it was pointed out to him.  There was
 now a gradual failure of strength,  without  any urgent symptom.
 His appetite and digestion continued tolerable until eight  or ten
 days  before his death, when  he began to have nausea  with thirst,
 foul tongue, and impaired appetite; and he died, gradually exhaust-
 ed; in the beginning of August.  His bowels had been  throughout
 natural or easily regulated, and the motions quite natural.
  Inspection.—The whole liver  was  enormously enlarged, espe-
cially the left  lobe, which descended  nearly to the spine of the ilium.
Externally it  was of a very dark colour, variegated with light ash-
coloured  spots.  Internally it was composed  chiefly of numerous
round tubera, ofthe size of small oranges ; they were generally of a
white or ash colour, some of them approaching to a scirrhous hard-
ness, others of a softer consistence,  and some of them contained a 
296
MAYO'S OUTLINES OF PATHOLOGY.
fluid of a puriform character.   In the interstices betwixt these tu-
bera there were portions which retained the appearance of the pro-
per structure of the liver, but they were of very small  extent, dark
coloured, and of a soft consistence.
  It appears that the  form of disease which occurred in this case is
sometimes much more rapid in its progress.  A man mentioned by
Andral died with fever, vomiting, and pain in the right hypochon-
drium, having  begun only about a month before to  complain of
some uneasiness in the region ofthe liver. The liver was much en-
larged, and presented a mixed mass of disease, scirrhous, encepha-
loid, and tubercular.
  b. Melanoma,  [r.  70. r. 71. r. 72.]
  c. Gelatiniform sarcoma.  This appearance is described by Por-
tal as occurring both throughout the substance of the liver, and on
its surface, raising the  peritoneal coat into irregular soft tumours,
accompanied with great enlargement ofthe liver.  The case was of
several months standing, and was distinguished by pain in the epi-
gastric region and vomiting, at  first occasional,  but becoming gra-
dually more frequent: there was progressive wasting, and at last
dyspnoea and anasarca.
   11. Biliary congestion.   This occurred in a case  by Boisment
to such an extent as  to make the liver resemble a large undulating
cyst.  The appearance  was found to. depend upon a remarkable dis-
tention of all the biliary  vessels with dark-coloured bile, and was
accompanied by wasting ofthe  proper substance ofthe liver.   The
distention had been caused by an obstruction ofthe common duct
through a membranous band which passed over it.
  A lesser degree of biliary congestion is more frequently met with,
invading a part or a whole of the liver.
  Preparation [r. 35.]  exemplifies partial biliary congestion com-
bined with atrophy.  General congestion I have seen combined—
with thickening of Glisson's capsule, and a bright yellow colour of
the whole liver; the  bile distending the minute ducts,  and exuding
from their orifices when divided;—in other cases with a  dark green
tint of the whole viscus.
   Diseases of the biliary ducts and gall-bladder.
  a. The ductus communis choledochus is liable to become ob-
structed by inflammation, either rapidly or slowly. In  the former
case the symptoms are rapid;  as in a man mentioned  by Andral,
who had acute pain  followed by jaundice, and a pyriform swelling
rising up  from under the margin of the ribs.  On the fifth day he
was suddenly attacked  with peritonitis, and died in twenty-four
hours.  The ductus communis  was found much contracted, and at
one place obliterated.   The gall-bladder and the hepatic  and cystic
ducts bore, marks of having been much distended;  the rupture had
taken place in the hepatic duct, and much bile was found in the pe-
ritoneal cavity. In another case the symptoms of obstruction  to the
passage of bile had been going on for between two and three months 
THE DIGESTIVE ORGANS.
297
before the fatal attack ; and in this case both the cystic and common
ducts were found much contracted.
  b. Tho diseases of the biliary ducts are mostly caused by the pre-
sence of gallstones.
  Gall-stones, according to Chevreul, are composed of the  yellow
colouring matter of the bile  and cholesterine; the latter  predomi-
nating, and sometimes forming the entire concretion.  Gall-stones
sometimes contain a portion of inspissated bile.   In some rare in-
stances the cholesterine is  entirely wanting, [r. 100 to 110.]
  The passage of a gall-stone through the duct is characterised by
severe but vague  pain in the right hypochondrium, and by vomit-
ing: and is often  attended with jaundice.
  In a lady aged  fifty-eight, (attended by Mr.  North,) who had be-
fore been occasionally jaundiced, sickness  and excruciating pain
suddenly supervened; which continued with alternating abatements
and exacerbations for a fortnight, when an oval gall-stone was pass-
ed,  which weighed two drachms and a half: its length was an inch
and a third, and  its thickness at the broadest  part nearly an inch.
During this attack there was no jaundice.
  c. When the gall-stone is too  large to  pass  the common duct, it
sometimes causes all the symptoms of intestinal obstruction.
  A lady, aged sixty, had  been for several years liable to attacks of
acute pain in  the  right hypochondriac region, which generally con-
tinued in great severity for a few hours, and then subsided suddenly.
On Wednesday, 14th January, 1824, she was seized with pain cor-
responding to her former attacks, but which did not subside as usual.
It continued through the night, accompanied  by frequent vomiting
and constitutional disturbance.   On the 15th there was fever, with
frequent vomiting and obstinate costiveness, and the pain was more
extended, being referred to a considerable space on the right side of
the abdomen. Belly tense and rather tumid. The case had assumed
the character of ileus, and all the usual means  were employed with
little relief. 16th. There was some discharge from the bowels after
a tobacco injection, but it was very scanty.  Severe pain continued,
with every expression of intense suffering.  Her strength sunk, and
she died on the morning ofthe 17th.
  Inspection.—Every  part  of the  intestinal  canal was perfectly
healthy, except the upper  part of the  duodenum,  where there was
considerable appearance of inflammation, with remarkable soften-
ing, so that it was very easily torn.  A large irregular calculus was
found sticking in  the ductus communis, and the parts were so sof-
tened that it came through  the side of the duct when it  was very
slightly handled.  In the texture  behind the duodenum there was
considerable appearance of inflammation.  No morbid appearance
could be detected  in  any other organ.
  d. If the gall-stone is too  large to pass, rupture ofthe duct may
take place, followed by fatal peritonitis.
  e. A gall-stone  may escape through the sides ofthe duct, after the
union ofthe latter by adhesive inflammation to the part adjoining. 
298
MAYO'S OUTLINES OF PATHOLOGY.
  Several cases are on record,  in which large calculi,  after pro-
ducing jaundice, and the other symptoms indicative of having been
impacted in the duct, have worked their way  outwards, and  have
been extracted from an opening in the parietes. In a case of this kind
mentioned by Dr. George Gregory, after the gall-stone was extract-
ed, the ulcer healed up, the jaundice  went off, and the patient, who
had suffered excessively for several months, rapidly got well. Seve-
ral cases of the same kind  are mentioned by Morgagni and Haller.
In one of them the abscess speedily healed ; in another it continued
open, discharging a yellow fluid ; in a third  it discharged calculi at
intervals.   I have seen, along with Mr. Lizars, a man, about fifty,
who has had a biliary fistula discharging for nearly four years. The
complaint began with pain in the region of the liver, accompanied
by  vomiting and jaundice.  After these symptoms had continued
about three weeks, a tumour formed in  the region of the gall-blad-
der, which was opened, and discharged much fluid of a mixed green
and yellow colour, and some small  biliary calculi.  This  opening
closed, but another soon took place, which has continued to dis-
charge ever since.  The discharge varies in quantity, but is  often
so profuse as in  a very short time to wet his clothes  as far as his
knee, and in the night  to soak through his bed to a  great extent.
Mr. Lizars at  one time collected,  in  the course of a  visit not ex-
ceeding fifteen or twenty minutes, about four ounces of fluid, which
on chemical examination exhibited  all the properties  of pure bile.
The man  has  every appearance of good health, and, except the fis-
tulous opening, there is no appearance of disease in  the region of
the liver.  His appetite and digestion are good, his bowels are  regu-
lar, and the evacuations of a natural  appearance.  A case occurred
to the late Dr. Graham, of Dalkeith, in which a very large  calculus
was extracted  from an abscess in the parietes ofthe abdomen; and
I believe ultimately did well. It has been doubted whether  the very
large biliary calculi, which are sometimes discharged by the bowels,
had really passed through the duct, or whether they had worked
their way by a process of  ulcerative  absorption into the  duodenum
or the colon.  But I have described a case, in which a large calculus
produced fatal ileus after it  had passed as far as the middle of the
small intestine.  The common duct  was found so dilated as to ad-
mit a full sized finger, but without any other appearance of disease.
  It has been  disputed, whether biliary calculi  are ever formed in
the substance of the liver, or in the gall-bladder only.  But Mor-
gagni mentions several instances in which  they were found in the
liver, and even of great size ; and therefore there is no doubt of ano-
ther point which has been disputed, namely, that they may produce
jaundice by sticking in the hepatic duct.
  /. The  coats ofthe gall-bladder are liable to be perforated by ul-
ceration, without the presence of bilious concretions.
  A man mentioned in the Nouveau Journal de Medicine for  1821,
had been affected for more than a month with pain in  the abdomen
and fever, which had various remissions and aggravations.  On the 
THE DIGESTIVE ORGANS.
299
thirty-seventh day of the disease, he was suddenly seized with symp-
toms ofthe most violent peritonitis, and died on the following morn-
ing, after suffering inexpressible agony.  On inspection, there were
found marks of most extensive peritonitis. The inner surface ofthe
gall-bladder presented numerous small circular  ulcers from one to
three lines in diameter; two of them had entirely perforated its coats,
so as to allow the escape ofthe bile into the peritoneal cavity.
  XIII. Jaundice.—An ordinary attack of jaundice is characterised
by yellow suffusion  ofthe skin, impaired appetite, nausea, the urine
being high-coloured, the stools white. The following is perhaps the
true account ofthe pathology of this affection.
  The  yellow  colour, which  pervades all the tissues and  most of
the secretions in jaundice, is  proved to be owing to the presence of
bile in them ; while the white colour of the feces evidently  results
from the want of bile in the alimentary canal. The  bile has not its
proper ven^, and is distributed in new places. What is the mecha-
nism of this error loci?
  Secretion is the separation  of one or more  elements  from the cir-
culating blood.  That separation may be owing,—either to a power
in the secerning organ of extracting or drawing from the blood the
secretion, previously not existing  as a separate substance in it,—
or to the secerning organ  allowing the matter of the secretion, al-
ready formed in the blood, to strain  through and find vent,—or to
both these causes conjoined.
  The result obtained by MM. Prevost and Dumas, in some expe-
riments made upon  pigeons, favours the second  supposition.  They
found,  that, when the kidneys  were removed, the blood  became
loaded with urea.  This single fact would lead us to conclude ana-
logically, that the elements of all the  other secretions are evolved in
the blood in the course of  the general circulation, and that the or-
gans in which they are commonly thought to be formed only give
them passage. The bile we may thus conclude to be formed, not in
the liver, but in the mass ofthe circulating blood.
  Again, secerning organs are liable  (to use indeed a doubtful ex-
pression,) to be palsied; in other words, their secretions are liable
to be suppressed.  The best instance of this phenomenon occurs in
the pathology of the kidney: suppression of urine forms a well
marked and Very formidable complaint. In this instance another re-
markable feature makes its appearance. The secretion being stopped,
and the usual vent  for the elements of the urine being obstructed,
they appear in other places: urea has thus been found in the peri-
toneal serum in cases of suppression of urine.
  Reasoning from the above premises, I am disposed to believe  that
ordinary cases of jaundice depend upon suppression of bile—that the
bile, abnormally accumulated in the blood, finds vent  in the secre-
tions of other parts, which thence  become coloured  yellow.  Addi-
tional  circumstances  might  be mentioned, which corroborate this
view.  Bile  is detected in the blood of jaundiced persons; while the 
300
MAYO'S OUTLINES OF PATHOLOGY.
liver in those who have died of jaundice is generally pale, and with-
out bile.
  But there are instances of rapid invasion of jaundice, in which the
preceding explanation is not sufficient.  Mr. North assures me that
he witnessed a case, in which an unmarried female, on its being ac-
cidentally disclosed that she had borne children, became instanta-
neously yellow.  Now it is not reasonable to suppose that the blood
is generally so loaded with  bile, or  that bile is generally forming so
rapidly, that its suppression should produce an immediate sensible
effect in colouring  the skin.  I am therefore disposed  to conjecture,
that such instances are  produced through a new cause—through
bile being suddenly formed in unusually large quantities in the blood,
owing to some influence propagated along the nerves. When a per-
son labouring under an inflammatory attack  is bled for it, and hap-
pens to become faint from apprehension ofthe operation, the blood
which flows during the faintness is  not sizy, while that which fol-
lows  as soon as the nervousness is worn off, presents the strongest
inflammatory crust.   If mental emotions  can  convert  sizy into
healthy  blood,  why should they not  be sufficient to render healthy
blood bilious?
   The parallel  above drawn between suppression of urine and jaun-
dice (viewed as suppression of bile) admits  of being rendered ex-
tremely close ;  for although jaundice in general is not a serious dis-
ease, while suppression of urine is commonly  fatal, (the bile being
probably  a less noxious element when dispersed in the blood than
the urea,) it nevertheless sometimes proves so.  There are many in-
stances on record, where jaundice has run an exactly similar course
to the most rapidly destructive suppression of urine.
   A young man, mentioned by Morgagni, was seized with jaundice
after agitation of mind.  It was attended with pain of the stomach
and vomiting, but no fever. On the second day he was dull and for-
getful, on the third he was convulsed and then comatose, and he
died on the fifth.  The liver was found only flaccid and pale; there
 were some red  points on the mucous membrane of the stomach, and
turgid glands in the abdomen.  In the head there was slight effusion
on the surface of the brain, and a considerable quantity about  the
spinal cord.  Another young man, mentioned  by the same writer,
 was very much frightened by having a musket pointed at his breast.
 Next day he was jaundiced; soon after delirious;  then convulsed;
and  he died in  twenty-four hours from the first appearance of the
delirium.  No disease could be detected, except turgescence of the
vessels on the surface of the  brain.  Dr. Marsh also mentions two
 cases in which jaundice came on  suddenly during the use of mer-
cury, and was  filial with delirium  and coma.
   c.  Obstruction to the escape ofthe bile, such as that produced by
gall-stones, by the pressure of external   tumours, by spasm of the
ducts, or by chronic  inflammation and thickening of Glisson's cap-
sule, may be supposed to operate  in producing jaundice, much ar
retention of urine  produces diminished secretion of urine.  Eithes 
THE DIGESTIVE ORGANS.
301
there is a sympathy between the excretorv apparatus and the secret-
ing organ, or a mechanical effect produced by distention ofthe for-
mer upon the action ofthe latter, which in both the cases adverted
to diminishes the quantity ofthe secretion.  But when the urine is
the secretion diminished in quantity, there is no sensible evidence
in the system ofthe accumulation of urea in other organs ; while, if
the bile is the secretion repressed, there is plenty of evidence ofthe
fact in the pervading bilious tinge.
                         SECTION IX.

                          Pancreas.

   1. Inflammation.  Dr. Baillie found an abscess of the pancreas
in a young man who had a good deal of pain in different parts of
the abdomen, with spasms of the  abdominal  muscles, but did  not
complain of any fixed pain in the region of the pancreas: there was
sickness with distention ofthe stomach, especially after eating, and
a tendency to diarrhcea, and at length he became dropsical.  A gen-
tleman mentioned by Dr. Percival had jaundice and bilious vomit-
ing; a tumour appeared at the epigastrium; his strength  failed;
blood and fetid  pus were discharged by stool; and he died exhausted
in three mouths.  The  pancreas was found greatly enlarged, and
contained a considerable, abscess : the  ductus communis was obliter-
ated by the pressure.
   Inflammation of the pancreas.   A lady, aged twenty-one, when
between five and six months advanced in pregnancy, lost her usual
healthy appearance,  and gradually became very pallid.   She was
singularly troubled  with thirst, and drank cold fluids  in such large
quantity, as to lead  her mother to represent to her that she feared
the circumstance might prove injurious to the child.   She also suf-
fered much from pain in the epigastric region, which was sometimes
so severe as to  oblige her to retire to her apartment.   Her mother,
in mentioning this circumstance, afterwards drew her hand across
the abdomen on the seat of her daughter's sufferings, and pointed
exactly to the  situation  of the pancreas.   After her  delivery the
thirst remained, and  the  weakness and paleness increased.  Her
state and symptoms were like those of persons who have  lost large
quantities of blood.   About five days before death the  stomach  be-
came irritable, and nothing but rennet-whey in small quantities was
retained.   She died exactly five weeks after delivery.
   Upon inspecting the body, the viscera generally were found pale
and bloodless;  but  there was  effusion  on the membranes of the
brain, the  cellular texture around the  pancreas and duodenum,
the great  and  small omentum, the root of the mesentery,  the
mesocolon, and the appendicis epiploicae ofthe arch of  the colon,
were loaded with serous effusion.   The pancreas was throughout 
302
MAYO'S OUTLINES OF PATHOLOGY.
 of a deep and  dull red colour, which contrasted very remarkably
 with the bloodless condition of'other parts.   It was firm to the feel
 externally;  and when an incision was  made into  it, the divided
 lobules felt  particularly firm and crisp.  The texture was other-
 wise healthy.   The part was left wrapped up in  a cloth for nearly
 forty-eight hours after its removal from the body, the weather being
 then very cold. At the end of this time the hardness was gone, and
 the gland even appeared rather  soft.—Lawrence.
  2.  Tuberculous disease of the pancreas.  W. M., aged thirty-
 eight, [under the  care of Dr. Wilson in the Middlesex Hospital,]
 became ill sixteen weeks before  his death : in seven weeks he was
 confined to his  bed. The first symptoms were pain in the abdomen,
 extending along the right hypochondrium to  the spine.   Twenty-
 eight days before  death he  became  jaundiced, stools white, urine
 high-coloured; for some time he could lie on the right side only:
 often obliged  to  sit  upright to draw breath.  A large abdominal
 tumour had been  felt immediately above the umbilicus some time
 before death; and the right  arm and side of the  neck had become
 oedematous.
  Inspection.—Upon  opening the abdomen, the liver was found to
 occupy the epigastrium and part of the right  iliac region.  It was of
 a dark colour from bilious and venous congestion, but not enlarged;
 its position resulted from effusion of serum into the  right cavity of
 the chest.  The gall-bladder was  distended to a great size, so as to
 contain eight ounces of fluid.   The distention  arose from an en-
 largement of the pancreas, the  head of which formed an  irregular
 sphere four inches in diameter, which had compressed the gall-duct:
 the rest of the  gland was likewise enlarged.   In  parts it preserved
 its natural texture and colour: at  other parts it was infiltrated with
 tuberculous matter, which at two or three points  had softened, and
 formed  thick pus.  One  or two lacteal glands were softened, and
 contained tuberculous matter.   Three or  four small scrofulous tu-
 bercles were found in each of  the kidneys.   The left  pleura was
 coated with recent lymph: the fluid which it contained was a dark
 amber-coloured serum.  The thymous gland was  enlarged  to a
 considerable size, and  formed with the adjacent lymphatic gland a
 mass, which was extensively infiltrated with tuberculous matter,
 which at the posterior part had softened.   The  upper cava passed
 through  the mass, and divided in it; the right vena innominate
 was greatly compressed by it; the left less so : nodular projections
 of the tumour pressed upon and had caused  thinning of the vein,
 and projected into it.
  2. Malignant disease rarely  attacks the pancreas alone, but in-
 volves in common with it either the  stomach, or liver, or both.
  A gentleman, aged  thirty-five, died after an illness of about eigh-
 teen months' duration, in which it was to the last impossible to say
 what organ was the seat of the disease.  His complaints began with
a febrile attack, which left him  weak; and from  that time he was
liable to dyspeptic symptoms, with variable appetite,  and undefined 
THE DIGESTIVE ORGANS.               303
uneasiness in the  epigastric region.   He gradually lost flesh and
strength ;  and when he  consulted Mr. Newbigging, in January,
1822, he was found thin and weak: but Mr. N. was particularly
struck with his remarkable paleness, even  his lips and the inner
surface of his mouth being entirely without colour. About this time
he had some  vomiting, and was feverish for a day or two; but these
symptoms soon subsided, and left him in his former state : appetite
variable and capricious ;  bowels sometimes  costive and sometimes
rather loose; he had frequently perspirations in the night-time, and
appeared at all  times languid and faint, but his pulse was natural;
he took a  good  deal of food, and there was  no symptom  that ac-
counted for  his emaciated appearance.  In  February he  became
rather worse, with some diarrhoea and scanty urine ; but these symp-
toms soon subsided, and he afterwards complained chiefly of throb-
bing in the head, and a constant noise in the left ear.  When I saw
him in the middle of April, he was reduced to the  last degree  of
paleness and debility, but  his pulse was full, strong, and  regular.
He took a good deal of food, and complained of nothing except the
painful  pulsation in his left ear. The action ofthe heart was rather
strong, and  he  felt a sensation  of throbbing  over his whole body.
He di<>d in the end of April, without any change ofthe symptoms,
except that his pulse became frequent a few days before death.
   Inspection.— All the  internal parts were found remarkably pale,
and void  of blood ;  the  heart was sound, but remarkably empty.
The pylorus was thickened and firmer than  natural, and had con-
tracted  an  adhesion  to  the  pancreas.   The pancreas was con-
siderably  enlarged, and  of nearly cartilaginous  hardness, except
some spots which  were soft, with the appearance of the medullary
sarcoma.  No  other disease could  be detected in  any part of the
body.
   Dr. Bright has  given, in the eighteenth volume of the  Medico-
Chirurgical Transactions, some interesting cases of  malignant dis-
ease of the pancreas, in which the passage of an oily substance  or
fatty  matter with the feces had been a prominent symptom  ; and  he
evidently leans to  the opinion, that disease of the part of the pan-
creas adjacent  to the duodenum, and of the duodenum itself, has to
do with its production.   In a case given by Mr. Lloyd in the same
volume, where fatty matter was passed both with the digestions and
by vomiting, "the pancreas was healthy, except at that part more
immediately connected with the  duodenum,  where it  had under-
gone some "slight degree of induration, as if it had  been inflamed.
Its duct, at  the termination in the duodenum, was  completely ob-
structed :  in the rest of its course  it was not only pervious, but it
was larger than natural,  and contained a brownish fluid of rather a
yellowish tint,  resembling in some respects the fatty matter in  the
state  that  it was when it'passed from the intestine.   As it  escaped,
however,  at the time the duct was opened, the opportunity was lost
of particularly  examining it."                            .
   Some remarks upon this subject by Dr. Elhotson, contained  in 
304            MAYO'S OUTLINES OF PATHOLOGY.
the same volume, seem to disprove a connection of morbid phe-
nomena, or the dependence ofthe formation of oil in the feces upon
the state of the pancreas.  The general organic derangement with
which this formation is coupled appears to be jaundice and disease
ofthe liver.   The most remarkable case which Dr. Elliotson gives
is  narrated  by Mr.  Pearson.  Mrs.  W.,  aged seventy-nine,  was
labouring on the 28th of March, 1829, under a severe attack of gall-
stones, a  disorder to which  she had  been occasionally subject  for
some  years.  She complained also of a dull pain  in the region of
the liver, that had been felt for some months in a slighter degree.
She had  suffered frequent pain in the head, and  giddiness, which
latter came in a  paroxysm  daily about five o'clock,  before dinner.
She also suffered in an almost insupportable degree from prurigo
pudendi.   Her  constitution  was gouty, but on  the whole pretty
good till  within the last two years.  She  had always led  a very
sedentary life.  For some months the fecal evacuations  had been
scanty, and almost free from fecal odour.  The  urine was pale, and
in proper quantity.   She recovered from the attack;  but about a
month afterwards  observed in her evacuations a thin, concreted,
fatty-looking  substance, and the stools were, as  above  described,
without the least appearance of bile.   She observed, that oil also
passed the bowels in a  liquid state, and quickly concreted ; and that
a similar oil passed with the urine, and floated upon its surface; but,
when removed, concreted into the same appearance as the fat from
the intestines.   The quantity of oi! which escaped from the bowels
was such, as to oblige her constantly to wear a  napkin.   The bow-
els were  generally irregular, and each evacuation was usually pre-
ceded by some pain.   Without any other particular symptom the
patient became more and more emaciated, and  died on the 29th of
October.
   The quantity of fat  and oil from the bowels averaged about an
ounce and a  half  daily when  they were  relaxed,  and  from  the
bladder  about the third of  an  ounce.  The oil and fat from both
patients readily inflamed in the fire; and, when mixed with alkali,
formed a good soap.  In this case no post-mortem examination was
allowed.   The appearance ofthe oil in the urine  would lead to the
impression, that, in  this case, a general failure  of  the  powers of
assimilation had taken  place.
   Dr. Elliotson, however, in another case where oily fat was voided,
found (the other abdominal bowels being sound) the pancreatic duct
and the  larger lateral branches crammed  with large calculi.  So
that, upon the whole, connected as the pancreas  is with the liver,
the pathological connection indicated  by Dr. Bright remains of
considerable interest.
   8. Calculous concretions.   De Graaf found seven or  eight cal-
culi, of the size of small peas,  in the pancreas of a  man who had
been  long  liable  to vomiting  and  diarrhcea, and died, gradually
exhausted,  at the age of thirty.  Portal found  the pancreas much
enlarged, and containing twelve calculi, some of them the  size of 
THE DIGESTIVE ORGANS.
f,305
nuts, in a man who died of disease of the aorta.  In a case men-
tioned by Dr. Baillie, calculi from the pancreas were about the size
ofthe kernel of a hazel-nut, with  a very irregular surface, and were
found to be composed of carbonate of lime.
                          SECTION x.

                           Spleen.

   1. Laceration of the spleen maybe produced by a blow upon the
left hypochondrium.  The symptoms are the same with those of
rupture of ihe liver.  Death takes place either from hemorrhage or
from peritoneal inflammation.
   2. Hypertrophy of the spleen.  Simple enlargement of the spleen
occurs chiefly as the result of intermittent and remittent fevers.  It
is also said to occur from other causes; as in young women  in con-
nection with  suppression  of the  menses,  and in  persons more
advanced in  life from  the suppression  of long  continued  hemor-
rhoidal discharge.   The spleen in this state sometimes reaches the
weight of eleven  to twelve pounds.  The  texture of the gland
appears natural, or even firmer than usual.  In section iii. a case is
referred to of rapid diminution of enlarged spleen  through  hemor-
rhage  into the stomach.
   3. Inflammation ofthe substance ofthe spleen.
   A gentleman, aged  fifty-two, who had enjoyed  previously very
good health, was affected, in January, 1821, with cough and slight
feverishness  like  a common cold.  After a short confinement the
cough  disappeared, and he felt otherwise much better; but after
some time he was confined again, though without any defined com-
plaint  except weakness.  When closely questioned, he sometimes
mentioned an undefined uneasiness across the epigastric region, but
it was  slight and  transient: his appetite was variable and capri-
cious, but upon the whole not bad, and he had no dyspeptic symp-
tom ;  his bowels were rather slow, but easily kept, open ;  his
breathing was natural;  and every other  function was in a  healthy
state, except that his pulse continued a little frequent,  and  that he
was becoming progressively more weak  and emaciated.   In this
manner the complaint went on during the remainder ofthe  winter:
in the  beginning of summer he went to the country, where he made
no improvement.
   He was now greatly  reduced in  flesh and strength: his pulse was
from 96 to 100, and  weak; his nights  were generally good, but
sometimes feverish; his appetite was bad, but he still took  a good
deal of nourishment, and never complained of his stomach; there
was no cough and no pain ; the urinary secretion and bowels were
natural;  but the debility and emaciation continued to increase pro-
gressively.  On the 2d of July he was seized with diarrhcea, and 
306
MAYO's OUTLINES OF PATHOLOGY.
 died  on the 5th.   Before  the attack of diarrhcea, there had been
 little change for several weeks:  he had been able to be out of bed
 the greater part of the day, and occasionally out in a carriage or in
• a garden chair.
   Inspection.—The  spleen was somewhat enlarged,  and in the
 centre of it there was an irregular cavity containing several ounces
 of purulent matter: the surrounding substance was soft, and easily
 lacerated.   The liver was pale, but otherwise healthy ;  the kidneys
 were pale, with a peculiar degeneration of some parts of them into
 a firm white  matter.  After  the most  careful  examination,  no
 appearance of disease could be  detected in any other  part of the
 body.—Abercrombie.
   4.  Cysts containing serous fluid occasionally form in the spleen,
 which grow to an enormous size.-The peritoneal coat in such cases
 is commonly thickened.
   5.  Tuberculous matter is liable to be deposited in the spleen.
  6.  Medullary sarcoma and melanoma are met with in the spleen,
 when either of their diatheses prevail.
  7.  I  am at a loss whether to  include the grumous and softened
 state ofthe spleen in its pathology.   Does the softening occur ante-
 cedently to  death, or  is  the condition of the organ the  result of
 commencing decomposition ?  Many other organs of the frame are
 met with occasionally in a state  of degenerative  atrophy, softened
 so that the finger may be thrust through their texture. Is the spleen,
 too, susceptible of a similar change;  and are the appearances which
 follow, the compound result of a change during life and of cadaveric
 decomposition ?
  A lady, aged sixty, had been for several months affected with loss
 of appetite, dyspeptic symptoms, and occasional vomiting.   Dr.
 Abercrombie  attended  her for about a month  before her death,
 during which she had much nausea, and generally vomited three
 or  four times a day; she had little or no appetite, tongue loaded;
 bowels rather costive, but easily regulated ; pulse natural.  She did
 hot complain of any pain, and nothing could be felt on pressure that
 could account for  the  disorder.  She died,  gradually exhausted,
 without any other change in the symptoms.
  Inspection.—No  morbid appearance  could be  discovered, after
 the most careful examination, except in the spleen, which was of a
 very dark colour, and the whole  substance of it was broken down
 into a soft mass like grumous blood.
  A  gentleman, aged  about  forty-five, consulted  me in  summer,
 1827, on account of a deep-seated painful swelling in the left side.
 On  examination, it was  found to be exactly in  the region of the
 spleen : it was  well defined, and  very painful;  and no  cause could
 be assigned for it.   His general health was considerably impaired;
 and the functions ofthe stomach  were a good deal deranged. After
 a variety of treatment, he regained pretty good general  health ; and
 the swelling was very much reduced.  I then lost sight of him for
 a year, during which I learnt  that he  enjoyed  tolerable  health, 
                   THE ABSORBENT SYSTEM.               307

though  he occasionally felt uneasiness  in his  side.  He  died in
August, 1828, after an illness of about three weeks, which  had the
characters of continued fever.  I did not see him in this illness, but
was present at the examination ofthe body.
  Inspection.—The spleen was very much enlarged, probably to at
least ten or twelve times its natural size.   When first taken out, it
had a remarkably soft and fluctuating appearance, as if its peritoneal
coat  contained a large quantity of fluid.   But on cutting into it,
this appearance was found to  be owing to its whole substance being
reduced to a  soft black mass, like grumous blood.  The liver was
of a remarkably dark green colour, but without disease of its tex-
tu re. —Abercrombie.
                        CHAPTER X.

                 OF THE ABSORBENT SYSTEM.

   The  affections of the absorbent system are referable to three
 classes; being either inflammatory, tuberculous, or malignant.
   I. The inflammatory affections of the absorbent system attack
 the lymphatic vessels and glands alone ; and of these not all indis-
 criminately,  but those only which have  a superficial  situation.
 They present the following features, some trivial, others of serious
 moment.
   a. A gentleman, about thirty years of age, after exposure to cold,
 had slight fever, attended with the formation of thirty to forty small
 painful  tubercles dispersed  over the back of the  neck and  head.
 After a few days these tumours subsided:  they were inflamed sub-
 cutaneous lymphatic glands.   The patient belongs  to a  family in
 which scrofula exists.
   b. A groom, aged thirty, struck himself  in the groin against  the
 step of a carriage: one ofthe inguinal glands immediately swelled
 and  became  painful, and  matter formed around it.  The abscess
 was  opened, and he was kept in bed and  a poultice applied:  the
 inflammation and swelling subsided, and the part healed in three to
 four weeks.
   c.  A young man of  a scrofulous habit, after some fatigue and
 exposure to cold and wet, had glandular  swellings  form in both
 groins and in one axilla : after some weeks the swelling in one groin
 and that in the axilla went on to suppuration, and broke.  The indo-
 lent sinuses which  remained were, as it frequently happens, several
 months in healing.
  d. Inflammation ofthe superficial lymphatic glands is liable to be
produced by sympathetic irritation.  Thus irritable hemorrhoids, or
a gonorrhoea, occasionally lead to sympathetic bubo in the groin ; 
308            MAYO'S OUTLINES OF PATHOLOGY.

the course of which is the same as that of inflammation ofthe lym-
phatic glands from direct irritation.
  e.  The lymphatic system is liable to become affected in some of
the cases in which poisons  are supposed to be introduced into the
system.  The principal varieties of these cases are wounds received
in dissection, and ulcers following venereal infection.   The conse-
quences of inoculation with the fluids of a decomposing body are
referable to two  classes; they  generally do not occur in combina-
tion, but one or other train of symptoms separately manifests itself.
In the more rapid and dangerous ofthe two seizures, the  lymphatic
system is not involved.  The patient in a  few hours after inocula-
tion  is seized with pain (generally unattended with swelling) ofthe
part, with shivering,  and  fever.    The  fever  has  a tendency to
assume  a typhoid character:  it  is attended in two or three days
with swelling of the cellular membrane of the axilla and beneath
the  pectoral  muscle,  or  upon the side and back.   When  these
swellings  contain  a sensible quantity  of  fluid, or are  tense, the
patient experiences the greatest relief upon their being freely opened.
Cases of this class often terminate fatally in from two days to a fort-
night after the  first seizure:  to their production a wound is not
necessary: it is sufficient, where the habit is vitiated, that the fluids
of the decomposing body should have come in contact with the skin
ofthe patient. The cause of such an attack, therefore, occasionally
escapes  early detection: the  patient complains of no  punctured
wound or-local inflammation.  Nevertheless, where there has been
no wound, it sometimes happens that two or  three vesicles form
upon the infected  skin, unattended indeed with inflammation, yet
sufficient  to direct the surgeon to the true nature of the malady.
The tissue on which the poison exerts its power of irritation in this
class of cases appears to be the cellular :  the symptoms produced
are those of diffused cellular inflammation.  Some account of the
disorder has been already given.  In the  mildest  form of cellular
inflammation, the attack is confined to the  immediate neighbour-
hood ofthe part  inoculated : a  finger thus is alone swollen, red, and
painful.   The complaint in this subdued  form generally produces
anchylosis of the nearest joint,  and frequently sloughing of the
tendons passing over it.
   It is in the more trivial and common kind of disorder, following
wounds received in  dissection, that the   lymphatic system is in-
volved.   The wound, after two, three, or four days, inflames: if it
was  a puncture, a circular pustule forms;  if an incision, the whole
length opens and suppurates.  At the same time the lymphatics  of
the limb become inflamed and tender, and their course  is marked
by red  lines upon the  skin.  Often, likewise, a lymphatic gland
inflames.  After a few days, under ordinary treatment, these symp-
toms subside: during their progress, there is little  or no constitu-
tional disturbance.
   These two effects of poisoned wounds or surfaces are  commonly
produced  by different states of the decomposing body.  The first 
THE ABSORBENT SYSTEM.
309
and more serious attack generally follows a poisoned wound from a
body dead only from twelve to forty-eight hours, and in which some
serous surface has been found in a state of acute inflammation.  The
slower attack commonly proceeds  from inoculation from part of a
body advanced in putrefaction.  The first therefore mostly occurs
to medical  men  in  practice accidentally examining a  body after
death: the second is more common among medical students. It has
happened, however, that two persons have been affected, each with
the different seizure, from examining the same body.
   After inoculation with the venereal poison, the lymphatic system
frequently becomes affected.  The process appears to be the follow-
ing. The poison resting upon the skin is imbibed by it, or becomes
incorporated with it.  The part of the skin loaded with the poison
is next carried away by the absorbents, and  then an ulcer is pro-
duced.    The  lymphatics  which conveyed  away the  poisoned
particles,  irritated through this cause, become inflamed:  they may
be felt as hard  and tender lines below the skin ; and the gland to
which they  lead swells, is painful, and may become the centre of a
suppuration.  If the disease  is allowed to  pursue its course un-
checked by proper medicine, the skin covering the inflamed gland
ulcerates; but the escape ofthe matter previously confined does not
relieve the part:  on the contrary, the ulcer spreads in breadth and
depth ; the surface foul, greenish, or gray, with a tint of deep red ;
the surrounding skin raised, thickened, dark red ; the edge irregu-
larly eaten away, angry,  painful.
   The lymphatic glands are liable to become simply enlarged and
hard, without much  vascularity, and  with  a degree of hardness
approaching to the character of cartilage.  The disease seems to be
a primitive enlargement of the glands, not  the result  of irritation
propagated to them from other diseased textures.   Dr. Hodgkin, in
the 17th volume ofthe Medico-Chirurgical Transactions, has given
some good instances of this affection ; the nature of which, however,
is by no means  satisfactorily made out.
   II.  Tuberculous affections of the absorbents manifest themselves
in the glands alone, but the glands of both systems; that  is to say,
in the lacteal as well as  in the lymphatic, and in the deep-seated
as well as in the superficial glands.  Practically, however, the latter
division may be used to establish two classes of cases.
   a. In superficial tuberculous affections of the absorbent glands,
the glands slowly enlarge without pain; their texture becomes infil-
trated with  tuberculous matter, which  is deposited either in their
serous canals or their cellular  tissues, or in  both.   After existing
for a  certain length of time in a solid state, the enlarged glands
soften, and matter forms within and around them, the process being
attended with chronic inflammation, slight tenderness and redness
of the skin over the glands gradually supervening.  The steps on
the spontaneous process of restoration are the separation and elimi-
nation ofthe tuberculous matter with the suppuration, then healthy
       21—c                                   21 may 
310
MAYO'S OUTLINES OF PATHOLOGY.
 granulation and cicatrisation.  The points deserving of attention in
 this course of disordered actions are the following:
   1. The common seat of scrofulous enlargement of the lymphatic
 glands is the neck, about  the parotid and supra clavicular regions.
 The disease is  generally at  once recognisable by the number  of
 glands simultaneously affected.
   h. When the disease has advanced to the suppurative stage, the
 part affected presents a well-marked character.  There are one or
 more ulcerated  openings through the  skin, which is red, soft, and
 undermined:  the discharge is thin and serous, with flakes of albu-
 minous or  tuberculous  substance  in  it.   The ulcerated surface
 seen through the openings ofthe skin is of a light pink, or consists
 of pale half-organised granulations.   The skin, being extensively
 undermined, ulcerates to  a great extent when the healing process
 is about to  begin; from  this cause  are produced the ragged and
 unsightly seams and scars ofthe neck of scrofulous persons.  WThen
 it is certain  that a chain of enlarged  glands are  filled with  tuber-
 culous deposit, it becomes a  question whether they should not be
 removed by an  operation.  The wounds  thus  made  heal very
 kindly:  and the patient is saved the slow and tedious suppurative
 process, and the disfigurement.  Iodine is  occasionally of great use
 in dispersing clustered glandular swellings ofthe neck.
   c. Scrofulous enlargements of the internal glands,—ofthe mesen-
 teric for instance, or the bronchial,—rarely lead to suppuration:
 but their effects  are not the less fatal.   In the former case nutrition
 is obstructed,  the  belly is large and hard, the patient wastes and
 sinks; tuberculous disease commonly developing  itself at the same
 time in other parts, in the intestinal glands, or in the lungs.
   In the latter case, the enlarged glands pressing upon the wind-
 pipe have produced in children difficulty of breathing with convul-
 sions, that have  proved fatal.  Tuberculous disease ofthe bronchial
 glands often coexists with tuberculous disease of the lungs.
   III. The malignant  diseases in  which the lymphatic  glands
 partake are carcinoma, medullary sarcoma, melanoma, and  mam-
 mary sarcoma.
  a. In  the neighbourhood  of a scirrhous breast, the  lymphatic
 grands commonly become carcinomatous.  This circumstance does
 not necessarily render the  removal of the breast unadvisable.   This
subject will  be discussed in connection with disease ofthe mamma.
  b. Medullary  sarcoma  is  liable to originate in  the  lymphatic
glands; as well as to follow, secondarily, the same  disease in  a
neighbouring organ.
  Anne Cook, aged sixteen, admitted into the Middlesex Hospital
October 19,  1835, three  years ago, received a violent blow with  a
bar of iron on the inner and upper part ofthe thigh.  The part was
bruised and  black and painful for two or three days: it was swelled,
with a sense  of crepitation,  from blood effused  into the cellular
membrane.  About  two  months afterwards there  formed,  three
inches below the groin,  a  lump of the size of a walnut, which was 
THE ABSORBENT SYSTEM.
311
 ^horh^^^T^V0  Pain  initforthe first  three months,
 although  it grew fast, and was  uneasy on pressure.   By this time
 having attamed the size of a large Grange, the tumouJ ceased to

 fast  for ™ I n°W, ^ '"f8 fdt f Shu°0ti^ Pain in if' which would
 oa i   For t" i  , an h°Ur a"f a ,ha,f-   lf She k,lelt> il *»ve her
 pain   For the last seven months the swelling has been enlarging:
 and  there has been more pain,  which is increased by  pressure  In
 the tumour, the  inner surface  of  which is  tender,  with a slight
 blush upon the skin.  The saphena vein  is full and  large at this
 part.                                                 &
   This tumour I removed on the 23d  of October.  It formed a
 flattened spherical mass about six inches in  its thickest diameter
 which  externally rested against the sheath of the femoral vessels'
 and  internally extended underneath the  adductor lon<nis and gra-
 cilis.   The tumour was a mass of brain-like and grumous matter
 contained in a strong membranous cyst, with irregular membranous
 processes extending through it.  It appeared to be medullary sar-
 coma of an  inguinal  gland.   The case went  on  at first very
 favourably; and  the wound  for some  time  had all  but healed
 when, in the beginning of January, a diffused hardness began  to
 show itself round partsof the cicatrix, which  threatens  a return  of
 the disease.
   c.  Melanoma, in  conjunction with  medullary sarcoma  of the
 inguinal glands, is exemplified in the case described, ch. viii. sec. 1.
   d.  Mammary sarcoma.   A girl, aged  thirteen, was admitted,  in
 1833, into the  Middlesex Hospital, under my care,  with a large
 nodular and deep-seated tumour  of the left groin, which had been
 slowly forming for many months. The skin covering  part of it had
 a  bluish tinge:  part was hard, part elastic: the elastic part  being
 punctured, gave vent to some matter which was thought to be brain-
 like.  Partial inflammation and suppuration followed; but the rest
 of the tumour enlarged, the skin ulcerated at two or three of the
 most  prominent parts, and a thin discharge took place from the
 openings.  This process was attended with great  pain,  the child's
 strength gave  way, and it died  in  three or four  months after its
 admission.   The disease had been confined to the groin: it pene-
 trated between the adductor muscles, the fibres of which were pale
 and tensely stretched over the nodular mass;  the latter, when cut
 through, was of a light grayish brown colour, and firm, consisting
 of several  tumours  adhering  together, with  membrane  between
 them.  They were judged to be diseased  lymphatic glands:  their
appearance resembled the texture of udder, and agreed with Mr.
 Abernethy's description of mammary sarcoma. 
312
MAYO'S OUTLINES OF PATHOLOGY.
                       CHAPTER XI.

                 ORGANS OF THE CIRCULATION.

  The pathology ofthe organs ofthe circulation maybe described
under the following heads :—the capillaries, the veins, the arteries,
the heart, the blood.
                          SECTION I.

                       The Capillaries.

  The coats of the capillaries are so fine, that the vessels them-
selves are not visible. But their existence is demonstrable in trans-
parent parts of living animals through  the motion of the particles
of the blood: the latter (when  the part is examined in  a micro-
scope) are seen to move in  unchanging  currents, that branch from
larger divergent currents, (which are contained in minute arteries,)
and terminate in larger convergent currents (which are contained
in minute veins).  The intermediate channels, which  are of one
dimension, and cannot much exceed in diameter a particle of the
blood, and have reciprocally frequent reticular anastomoses, form
the capillary system.
  In health, the capillaries perform two offices at the least; they
regulate  the  quantity of blood distributed in  each part, and they
give passage through their coats to the materials of growth and
secretion.  We may suppose  there  is an average tone for the ca-
pillary vessels of the body, which they  habitually maintain: some-
times, however, that tone is heightened, as in sudden paleness from
mental emotion, when the cutaneous capillaries ofthe face contract
and  admit less blood ;  sometimes, on  the  other hand, the tone is
lowered,  as in blushing, when  the facial capillaries are relaxed,  so
as to yield a larger passage to the blood. In health again the quan-
tity and quality ofthe different secretions is variable : in  hot wea-
ther, for instance, the urine contains a less proportion of water than
in cold weather, the  perspiration the reverse.  The two classes of
phenomena admit of separate study in disease.   We have to in-
vestigate the relative capacities of the capillaries in disease, and the
nature of their products.
  I. a. Anamia.  Emptiness of the capillaries is  liable to be pro-
duced by hemorrhage, when there is a general lack of blood in the
system—by local compression,  which  may prevent the  blood en-
tering a  part, as, for  example, the brain in some cases of  hyper-
trophy—or  the liver,  through thickening of Glisson's capsule.
Whether there be an active anaemia in disease, a spastic state of the 
ORGANS OF THE CIRCULATION.
313
capillaries, which contracts their channels  and resists the entrance
ofthe blood, is unknown.  In  the pale and  shrunken skin at the
commencement of a febrile rigor, one might suppose such a state
to exist.
   6. Hyperamia, or  congestion.  The minute vessels may  be
unusually distended with  blood, either through obstruction upon
the veins—as in a limb to which  a  bandage  is applied previously
to venesection—or through strong action of the  heart, as upon the
skin  during the hot stage of  inflammatory fever; or,  finally,
through a change in the state of the capillaries, enabling the blood
to enter  them with greater facility and in greater  quantity than
before.   The cases  in pathology in which  the vessels  display a
lowered tone, or yield a freer passage than natural to the  blood, are
referable to three heads.  1. Irritation, as, for instance, in the suffu-
sion of  the conjunctiva, when a foreign body gets within the eye-
lids, or  in the state ofthe mucous membrane ofthe small intestines
in Asiatic cholera.  2. Vascular nasvi, or, as they are often termed,
erectile tissue.   3. Some kinds of malignant tumours.
   c. Inflammation.   In  inflammation there  is an afflux of blood
to a part,  and something more.  Not only are the minutest vessels
in the inflamed part larger than before, and  hold more blood, but
the  blood which they contain, in  some is  perfectly stagnant, in
others moves very slowly;  and where it is stagnant,  or nearly mo-
tionless, is changed in  quality,  the  distinction of  a transparent
liquid and particles suspended in it being lost. These appearances,
which  have been observed by many, I have repeatedly  produced
by irritating the membrane of the foot  of  frogs under the  micro-
scope.
   II. The morbid products, which I shall  alone notice on the pre-
sent occasion as liable to be abnormally separated from  the blood
in the capillaries, are serum,  lymph, pus.  Capillary hemorrhage
has  been already spoken  of  on more  than  one occasion.  The
formation of tuberculous matter will be adverted to  in connection
with the pathology of the lungs, and that of the malignant tumours
with the diseases ofthe breast and testis.
   1. a.  The most frequeut cause of effusion of serum is retarda-
tion of the progress  of the blood in the veins.  The effect in this
instance is perhaps entirely of a mechanical nature.   The capilla-
ries being gorged, the thinnest part of the blood  transudes through
their coats.  When  the  axillary vein is compressed by enlarged
and  indurated lymphatic glands, serum thus escapes  into  the cellu-
lar membrane, or the limb  becomes oedematous.   When the upper
vena cava is obliterated by  inflammation, or obstructed by the pres-
sure of a tumour,  the face, throat, and arms, are loaded with
anasarca.   When the inferior  cava is obstructed, the legs become
anasarcous.  When the cavity of the femoral vein is  obliterated by
inflammation, the same result lakes place.  When the hepatic cir-
culation is obstructed by thickeningofGlisson's capsule, abdominal
dropsy, or ascites, follows.   When the inferior cava  is compressed 
314
MAYO'S OUTLINES OF PATHOLOGY.
near the diaphragm,  by induration  of the  pancreas or adjacent
lymphatic glands, dropsy with anasarca of the legs ensues.  When
there is valvular disease of the heart, allowing the stroke of the left
ventricle to tell backwards  and  impede the propulsion ofblood
through the lungs, and even  its passage through the right side of
the heart, the lungs and the whole body are  liable to become infil-
trated  with serum.  Finally, the pressure of ovarian tumours, or of
dropsy, on the iliac veins will render the legs oedematous.
  b. It is probable there may be a condition  of the blood—such as,
for  instance, extreme attenuation from repeated hemorrhage—which
may dispose it  to part with  serum readily,  and so  to  give rise to
oedema.  A thin blood and a weak heart are  capable of occasioning
anasarca and dropsy.
  c. Chronic inflammation of the kidney, impeding the secretion
of urine, may be productive of anasarca.  This is one ofthe causes
of  the anasarca which follows scarlatina.   Dr.  Bright discovered
and described the influence of this cause in determining effusion in
persons who have lived intemperately ; and showed  its connection
with albumen in the urine.
  d. General  effusion of serum  partakes sometimes of an  inflam-
matory character.  In young and not otherwise unhealthy persons, •
oedema of the legs, of the arms, and face, with ascites, will  some-
times supervene after exposure to cold, being  attended with slight
tenderness ofthe swollen parts, and often with albuminous urine.
  e. Serous effusion is a constant attendant  of ordinary inflamma-
tion, exuding equally into the  interstitial cellular membrane,  into
the cellular tissue of organs, upon serous and mucous surfaces,  and
upon the skin.  Its  source in these instances  is again probably
mechanical, and attributable to the obstruction of blood  in the in-
flamed capillaries.  The softening common to all fleshy textures
at the  outset of acute inflammation is in  part at least produced by
their infiltration with serum.
  2. Lymph, in  its  chemical  composition,  resembles coagulated
albumen or the fibrin of the blood. It is probably the latter element
exuding in a liquid slate, and  then  coagulating.  The colourless
part or size, which in two or  three minutes separates and floats
upon the surface of liquid inflamed blood, Hewson has shown to be
fibrin  unusually attenuated:  but if there  exists in inflammatory
blood  a portion of unusually attenuated fibrin—and if that fibrin
can be shown to have a disposition to separate from  the rest of the
blood—and if its tenuity would render its mechanical escape from
the containing vessels the more facile—and if from vessels in in-
flamed parts a liquid fibrin is  found to escape—we  seem to be al-
ready  in possession of all the elements of this phenomenon.
  3. Pus is an opaque, straw-coloured liquid, ofthe specific gravity
1051),  which does not spontaneously coagulate.  The  colour is
owing to a prodigious number of minute particles.  Upon compar-
ing thein with the particles ofthe blood, (streaks of both fluids being
drawn side by side upon a glass micrometer, and  examined  in a 
ORGANS OF THE CIRCULATION.
315
 microscope by Carey, with achromatic object-glasses by Dollond,) I
 found the shape of the particles of each to correspond accurately.
 The particles of the blood were discovered  by Dr.  Young to be
 flattened discs, resembling pieces of money, but having rounded
 edges, and a shallow central depression on their flat surfaces.  The
 particles in pus are precisely of  the same shape.  They  are, how-
 ever, considerably larger than the blood particles;  the latter being
 aoV^of an inch, while the particles in pus are ^^ only  in diame-
 ter.  If we  may rely upon the observations of M. Gendrin, the
 production of  pus bears a considerable analogy to the separation of
 serum  and of lymph as above  described.   He  states  that he has
 $een in the capillaries of the frog's foot, when in a  state of inflam-
 mation, the  blood particles  put on the appearance of particles of
 pus, and afterwards exsude as  pus upon a wounded surface.  The
 reader  will desire to see the words of this remarkable statement;
 they occur at  the close of an elaborate account ofthe separation of
 a slough following a burn on a frog's foot, of which  the following is
 a translation.
   " If we  cauterise a point of a frog's foot under the microscope, by
t the solar rays, and then concentrate a less heat in the part, but suf-
 ficient  to  provoke inflammation in it, at the expiration of six to
 eight minutes, numerous distended capillaries  are seen  about the
 eschar: the circulation is as yet accelerated in the largest of these
 vessels, but in  the lesser ones  it is slower, and entirely arrested in
 the smallest, which are full  of motionless  red blood,  in which
 globules are  not  distinguishable:  twenty-five  to thirty minutes
 later, the circulation is slower in the principal capillaries, in which
 alone it is  now going on.  At two lines from the eschar the capil-
 laries are  very  much  dilated,  and display a rapid  circulation of
 blood rich in globules.
   "After twenty hours, numerous  capillaries  gorged  with stagnant
 blood are seen  in the neighbourhood ofthe eschar; in some of them
 the colour of the blood  is altered to a reddish yellow, in others it
 remains perfectly red : the texture ofthe skin has  become slightly
 opaque,  and infiltrated ; red  molecules of no  determinate  form
 [lymph] are disposed in the interval between  and  on  the coats of
 the vessels.
   "At  the expiration of thirty hours, all the inflamed  texture is
 opaque, and of a uniform yellowish red.   The area  ofthe inflam-
 mation  is enlarged, and  the  distended vessels containing stagnant
 blood are spread over an increased surface.
   " From  the fiftieth to the fifty-sixth hour, the capillaries begin to
 lose their colour ; the fluid which fills them is of a yellowish red;
 they are less dilated: the inflammation becomes circumscribed, and
 at the margin ofthe eschar a yellow  matter fills the capillaries and
 their interstices, and infiltrates even the edges ofthe eschar, so that
 nothing is  discernible but an homogeneous granular matter.
   " Towards the seventy-fifth hour the circulation is  re-established
 in the distended capillaries at  the circumference of the inflamma- 
316            MAYO'S OUTLINES OF PATHOLOGY.
tion, and the blood moves with rapidity.   There is so little interval
between the globules, that it is difficult to distinguish them.  The
eschar begins to detach itself; the texture adjacent to it is opaque,
and evidently softened;  the  largest dilated capillaries of this tex-
ture are distinguishable: some of them  are of a grayish red, dis-
tended, and without apparent motion in   them ; the others are of a
grayish yellow, filled with a  fluid of the same colour, which moves
slowly in a direction towards the  eschar.  This fluid  contains be-
sides  globules of a grayish  yellow, others inclining to red, with a
red spot in the centre.
  " Between the fourth to  the fifth day, the little eschar separates;
it leaves a  solution  of continuity, at the edges of which tortuous
vessels are seen gorged with pale grayish yellow fluid.   The tissue
has become so opaque, that these  capillaries are  only distinguish-
able by the movement, slow  indeed, but  incontestable, of globules
in their cavity.  At some distance from  the little wound the circu-
lation is entirely restored, but it is slow, and the fluid in the vessels
has globules larger and more numerous than  healthy blood.
  " On the  sixth day the little solution of continuity is covered
with a  layer of yellowish gray fluid, which appears to be without
globules, but in the middle  of which are mixed little striae of a
liquid  substance, containing tolerably large globules; the  fluid of
which these little  striae consist dees not  appear to differ from that
which is slowly moving  in  the capillaries.   These striae are evi-
dently,  indeed, continuations of the capillaries, for  the movement
of the fluid in the capillaries is seen to be continued  with, or pro-
gressive upon their fluid.
  " The process  of cicatrisation  is completed towards the tenth
day.  The circulation  is then re-established up to the edge of the
wound  ; it is still  slow, but  the vessels have  returned to their ori-
ginal  size.   The striae are very numerous, but they are no longer
formed  of a  yellowish gray and evidently purulent fluid, but of a
pinkish yellow, globulous, half-coagulated substance.  The  pro-
gress  of globules may be followed from the adjacent capillaries into
the completing cicatrix:  on entering its bounds they move more
slowly, become paler, but move in determinate tracks.   Their pro-
gress  is very slow ; small red striae without globules or motion arc
likewise to be seen.  When  the cicatrisation is perfected, the capil-
lary circulation is established in  the cicatrix itself;  it is still, how-
ever, at first slow  on the vessels of the cicatrix, and some globules
may be observed to lose their colour in traversing it."
  The  complement of  this interesting statement is the following
passage.
  "Si Ton passe un se'ton au travers de la pate d'une grenonille,
aussitot que la suppuration est etablie, on peut ais^ment en suivre
les  progres.  En introduisant une lancette sous le bord de la plaie,
en souleve une lamelle excessivement fine, dans laquelle on peut
voir s'operer la circulation assez lente  de pus  vers la plaie.  Ainsi
le  sang relentit sa marche  en approchant de l'areole, et  avance 
ORGANS OF THE CIRCULATION.             317
d'autant plus lentement, qu'il se decolore progressivement davan-
tage ;  il vient sortir de la plaie sous !a forme de pus."
  The observations which  I have quoted from M. Gendrin, when
taken  in connection with the facts  previously stated, simplify the
theory of inflammation, and satisfactorily explain  the  alliance of
all its leading phenomena.  The initiatory effusion of serum and of
lymph, dependent upon the visible obstruction ofthe circulation—
the lymph the same substance with  attenuated inflammatory fibrin
—the  consequent occasional mixture of blood  with lymph__the
formation of pus secondary  to and later than the secretion of serum
and lymph, being the result of protracted inflammatory action—the
solid particles in pus, although larger, yet of the  same remarkable
figure with those of the  blood, and doubtless the same enlarged—
the occurrence of blood  in pus mixed  with  it in  streaks, or gene-
rally diffused through  it—the organisation of lymph by extension
of vessels, some at first containing pus, others a thick red  liquid—
and lastly, inflammatory gangrene proceeding from the  vessels be-
ing in certain  cases  irrecoverably obstructed—are phenomena,
which may be declared to be now grouped under one law.
                          SECTION II.

                          The Veins.

   The affections of the veins may be classed under  the following
 heads:—inflammation ; active dilatation ;  passive dilatation ;  ossi-
 fic degeneration; malignant growths.
   I. Inflammation of the veins presents itself in two well-marked
 gradations, which may be called, to distinguish them, subacute and
 acute.
   a. Subacute inflammation.  With slight general  indisposition,
 and  little local pain and  tenderness, the vein affected  becomes firm
 and  hard, as if it contained solid matter: more or less oedema of
 the limb commonly follows.
   The inward changes which produce these symptoms are, slight
 thickening of  the coats of the vein, and coagulation of the blood
 within it, which adheres to the lining membrane, so as permanently
 to plug the cavity.
   There are two phenomena with  which the  coagulation of the
 blood in  inflamed veins deserves to be associated.  The first is, the
 formation of fibrinous excrescences in the  lining membrane ofthe
 heart in endocarditis.   There is little doubt that the contact of the
 inflamed serous surface, in the latter as well  as  in the former case,
 immediately determines more or less coagulation of the blood flow-
 ing over  it.  The second phenomenon, which seems to  have some
 alliance with the facts before us, is the immobility of the blood in
the capillaries  in the centre of an inflammation.   May not this cir- 
318            MAYO'S OUTLINES OF PATHOLOGY.
cumstance  be  attributed to an  influence exerted by the irritated
capillaries  corresponding in its nature to that which causes the
coagulation of the blood in an inflamed vein?
  The disease termed  phlegmasia dolens, in its mild form, is sub-
acute phlebitis.
  I have in a considerable number of cases applied  caustic or
caustic paste over the trunks of the subcutaneous veins of the leg
for varix.   In  some few instances, on the healing of the ulcer left
by the separation of the eschar, no effect on the vein  has been ob-
servable ; but  in much the greater proportion the vein has been
found firm  and hard, and its  cavity obliterated at the part where
the issue has been made.  I have little doubt, that, in the successful
cases, the  irritation upon the vein has  caused local subacute in-
flammation, as a  consequence of which the blood has coagulated in
its cavity, and plugged it.  The vein is often tender, during several
days, for the extent of three or four  inches above the place at which
the caustic is applied.  The obstructed part does not exceed more
than half an inch to an inch in length.   I have never known acute
phlebitis supervene in employing this practice.  In one case occur-
ring in a young woman, an inexperienced dresser made a circular
eschar two inches in circumference, and deep in proportion, over
the  saphenic  vein  immediately below  the  knee:  it opened the
saphena, and  within six  hours there  was violent  venous hemor-
rhage : this of course stopped on pressure being  applied.   During
the next few days  there was tenderness of the saphena extending
half the length ofthe thigh, over which leeches were applied once:
the case did perfectly well,  no other unfavourable symptom occur-
ring.  The best  material to form a caustic in  this instance is a
paste made with soft soap and quick-lime.
  The veins commonly attacked with subacute  inflammation are
those of the lower extremities.
  A patient, in the Middlesex Hospital for another complaint, com-
plained of  pain  of the inside of the leg: the skin at that part was
mottled with red;  the redness followed the course ofthe trunk and
branches ofthe saphena major vein, which felt thickened and firm.
There was  little  constitutional disturbance, and the redness and
uneasiness ofthe leg subsided.
  A lad, aged nineteen, was attended by Dr. Watson and myself
for fever with suppurations in many parts, under  which he sank
after upwards of two months' illness.  A few  days before he died,
the left leg became oedematous.  On examining  the body, the left
femoral vein  was found plugged  up with-  coagulum  throughout
its whole extent: the coagulum was firm, and of a  reddish brown
at the upper part ofthe vessel, looser and darker  towards the ham.
   I attended,  with  Mr. Andrews of Stan more, an  elderly woman,
who  had  been confined to her  bed for  some time  with pain and
tenderness at  the lower part of the belly, and slight symptomatic
fever : the belly had been  extremely tense from distention of the
bowels with wind.   I have no doubt that the disease was subacute 
ORGANS OF THE CIRCULATION.             319
 inflammation of the uterine veins.   At the time that I saw the pa-
 tient,  the abdominal pain was  less: but pain and oedema of the
 right thigh and leg had supervened : the pain lay in the direction
 ofthe femoral vein, which was hard, and tender on pressure.
   b.  Acute inflammation of veins has  a much more serious  char-
' acter than the disorder last described.  The greater part of the vein
 or veins attacked with acute phlebitis  is indeed always found in
 the state just mentioned ; but at other parts inflammatory products
 are present, lymph coating the inflamed lining membrane, and pus,
 either diffused or in a chamber circumscribed by lymph and coa-
 gulated blood.  The attendant fever is of the typhoid character,
 and the complaint is probably always fatal.  Acute phlebitis is
 liable to occur after compound fractures and dislocations, after am-
 putations, in puerperal fever  commencing in  the uterine veins, in
 malignant disease ofthe uterus,  and as a consequence of injuries of
 single venous trunks—for example, after venesection, or tying  veins
 that are varicose.
   The most remarkable feature of  this destructive complaint is its
 connection  with what  may be  termed  the  suppurative diathesis.
 Where suppurative inflammation exists in a vein, matter  is gene-
 rally formed in several other organs,—in the muscles, in the joints,
 in the serous cavities, in the different viscera—and with all the ap-
 pearance of having been spontaneously and easily eliminated from
 the vessels, the customary vascularity and thickening attending
 ordinary suppurative inflammation not being present.
   This subject,  although not  altogether overlooked by  former
 pathologists, (Dr. John Clarke in 1793, and Mr. Wilson in 1805,
 having noticed  and described inflammation of the uterine veins,)
 yet has been but  recently developed in all its bearings.   Dr. D.
 Davis, in 1823, pointed out the dependence of phlegmasia dolens
 on phlebitis ; and, in  1826, M. Dance attributed the typhoid  form
 of puerperal fever to this cause, and pointed out the connection of
 venous inflammation with suppuration in other parts.  The sub-
ject has been since investigated and extended by Dr. Robert Lee
and Mr. Arnott in this country, and by M. Tonnelle and others on
the continent.
   Of the attempts to  explain the relation  between acute phlebitis
and the deposition and  formation of matter in other parts, the  most
mechanical conjecture is, that the matter deposited in other parts is
pus that has been first formed in the inflamed veins, and has thence
been carried in the circulation to new places.   The  most original
notion which has occurred to  reasoners  upon this question is, that
the mixture of pus with the blood causes  the blood as it circulates
to form more pus ; as the absorption of venereal virus causes a part
to form more ofthe same poison.  Gendrin's remarkable although
inconclusive experiments, showing  the  rapid conversion of a clot
into pus, favour this idea.   The most cautious view may be to sup-
pose, that, when one part ofthe serous surface of  the vascular sys-
tem is inflamed and suppurating, remote parts of the same surface 
320            MAYO'S OUTLINES OF PATHOLOGY.
—such as the capillaries of different organs—may  with unusual
readiness fall into inflammatory and suppurative action, and, with-
out thickening the parts around, convert the blood circulating
through them into pus.
  III. Active dilatation.  Growth of veins attends every case of
sustained local determination of blood.  It forms one of the most
serious features in obstinate chronic diseases of joints, marking the
degree of the internal action: it attends  the  increase of vascular
and  malignant  tumours;  and is  always  conjoined  with arterial
hypertrophy.  In varicose aneurism the enlargement ofthe vein is
ofthe same nature.
  IV. Passive dilatation of veins.  Varix.  In persons of a lax
fibre, or in  persons habituated to  stand  a length of time, and in
pregnant women, the pressure of the blood on the veins  of the
lower extremities causes them to yield.  The trunks become larger,
elongated, tortuous, and at the same time often thicker and more
rigid.  When examined, they are found irregularly sacculated, and
have an appearance of transverse  rugae or fibres  prominent inter-
nally.  Sometimes one  venous  trunk is so affected,  sometimes
several ; sometimes the veins of both limbs, sometimes of one only,
are varicose.   In some,  the minute cutaneous veins alone are dis-
tended,  which show  like blue streaks mottling the surface:  in
others, all the varieties  are combined.   Varicose veins of the leg
are attended with a sense of weight and pain in the limb, and often
lead  to the formation of obstinate ulcers.  They are  likewise liable
to burst,  when a  large  quantity of blood may be  suddenly lost:
such an hemorrhage may even prove fatal.  It has been observed
that  varicose veins, from their  firmer texture, are  not  disposed to
collapse, a circumstance which must encourage hemorrhage when
they give way.
   I have already mentioned by what means the canal of a varicose
vein may be partially closed.  The same practice should be used
to the minute veins, when they bleed or threaten to do so: in the
latter instance the surface destroyed by caustic  should be very in-
considerable.
  IV. Ossific degeneration.  The texture of the  large venous
trunks sometimes, but rarely, is the seat  of phosphate of lime de-
posit.
  V. Malignant growths.  It  is  not uncommon to see medullary
sarcoma extending into  the interior of the venous trunks.
                         SECTION III.

                         The Arteries.

  The pathology  of the arteries may be treated of under  the fol-
lowing heads:—reparation; the hemorrhagic tendency;  hypertro-
phy;  inflammation; degeneration of tissue; morbid  growths. 
ORGANS OF THE CIRCULATION.
321
  I.  Reparation.  A wound of an artery is as capable of uniting
by adhesion, as a wound of a vein or of the integuments.   That
adhesion seldom takes place of the sides of a  wounded artery is
owing to the force with which the blood is driven along its chan-
nel,  a force sufficient' to  overcome any common pressure.   The
temporal is nearly the only artery which admits of being kept so
compressed as completely to stop the circulation  through it.  Situ-
ated between the integuments and a bony surface, the flow of blood
through the temporal may easily be prevented by a bandage: in
this manner the  vessel is  usually treated after it has been opened
in arteriotomy.  In less than twenty-four hours after being opened,
the vessel in this case is found to have healed;  and if the bandage
is removed, the blood again passes  along the vessel  as before.  It
is necessary, however, to  keep the bandage  applied for a longer
period, in order  that  the cicatrix of the vessel  may acquire firm-
ness; otherwise it gradually yields to the force ofthe blood, and an
aneurism is produced.
   In ordinary wounds  of arteries,  direct reparation is not looked
for; but a circuitous kind of  restoration takes place, which com-
bines two elements—the obliteration  of the wounded  artery, and
the enlargement of collateral channels.
   A  wound of an artery  may be either a puncture, or complete
division : unless the artery is superficial, and  lies upon a bone, the
former is a more dangerous injury  than the latter.   A divided ar-
tery may close spontaneously, a punctured artery [of any size] pro-
bably never does so, but necessarily requires for the suppression of
bleeding from it the ligature or division.
   A small artery, when divided, at  first throws  out its  blood per
saltum: after a few  seconds  the  blood only oozes from it, then
stops.   The cessation of bleeding is produced  by the  contraction
ofthe circular fibres at the extremity ofthe vessel.
   An artery of the size of a crow-quill,  if divided by a clean  sec-
tion, continues to bleed, unless means are used to stop it, till the
patient faints.   On his  recovery, hemorrhage does not commonly
recur for some hours or days: the extremity of the artery has con-
tracted, and its cavity is internally plugged up, and the end ofthe
vessel externally compressed, by coagulated blood.
   When a limb is torn off  by machinery, or by a shot, the main
artery is observed to hang out, but not to bleed; the violence done
to the vessel leads it to contract with unusual force and quickness.
The arm of a young girl  is preserved  in a preparation in King^s
College museum, which was torn off, with the scapula, by machi-
nery : she was brought to the Middlesex Hospital,  and recovered.
There was no hemorrhage from the torn axillary artery.
   "A soldier of the  Portuguese  artillery  was wounded  in the
breaching-battery,  at Ciudad  Rodrigo, by a large piece of shell,
which carried away his arm,  splintering the  humerus  to its tube-
rosities, and grazing his side severely.   Part of the long muscles of
the arm remained,  and the humeral artery  hung down two inches 
322            MAYO'S OUTLINES OF PATHOLOGY.
and a half below the ridge of the pectoralis major, which retained
its attachment to the shattered bone: it was independent of or un-
accompanied by the veins or nerves, and pulsated so forcibly to its
very extremity, that, being wet, it felt  inclined to slip from a loose
hold of my fingers.  The last eighth of an inch was contracted in
diameter so much as nearly to close the orifice ofthe vessel, which
was ofthe size of a common pin's head, and that shut up by a little
blood, a very thin layer of which covered the extremity ofthe ves-
sel.  On compressing the artery, and  again permitting its action,
and this frequently, the impulse given to the blood thus advanta-
geously failed to remove the obstruction to  its issue.  This was
about an hour after the accident, and the remains of the arm were
removed without delay."—Guthrie.
  When a large artery is divided  by a  clean incision, or opened
laterally, the hemorrhage, unless artificially stopped, persists till the
patient faints and death ensues.
  The temporary  arrest  of hemorrhage  may be effected mechani-
cally, as when pressure is applied in various ways, by  the hand, the
tourniquet,  and the like.  Its  permanent  suppression must  turn
upon pathological principles, and depend upon the resources ofthe
part  called into operation by  proper methods.   The means which
we possess for permanently arresting hemorrhage are, the  ligature,
torsion, pressure, and astringent applications.
  When a ligature is tied tightly upon  an artery, the serous and
fibrous coats are cut through, owing to their  brittleness, and re-
tract: the knot thus encloses  the cellular coat of the  vessel alone;
but the violence done to  the  artery irritates the serous coat ofthe
artery, throwing it into a  state approaching towards inflammation.
Under this influence, the  blood in the part of the vessel  near the
ligature coagulates, and,  adhering to the inner membrane, forms a
plug from half an inch to an inch in length.   The ring of mem-
brane enclosed in the ligature now sloughs, and separates before or
with the ligature ; which comes away, from a small artery in about
eight days, from a large artery in about fifteen.   When the ring of
membrane has separated, the  compressed and thickened end of the
cellular coat cicatrises; the cicatrix is guarded against the impulse
ofthe blood by the adhering clot behind it.
  Torsion of  an artery is performed  by drawing out the divided
end with forceps, applying a second pair of forceps half an inch or
more from  the first  to fix the  vessel, and twisting the portion so
drawn from the  wound  by the first.  The first effect of torsion is
mechanical, the bruised and twisted vessel has not elasticity enough
to untwist.  The next effect is vital, the  irritated inner membrane
causes the blood in the extremity of the vessel to coagulate.  It is
as yet  uncertain to what  extent this method is  safely available in
human surgery.
  Pressure as  a permanent means is rarely available, from the in-
terruption of the circulation which  it causes: but there are cases in
which partial compression may be  employed, and is found efficient. 
ORGANS OF THE CIRCULATION.            323
 In hemorrhage from a deep wound  of the palm of the hand, pres-
 sure may be directly applied to the bleeding vessel by means of a
 piece of sponge  inserted into the wound, a raised compress being
 laid over it.  If  a similar compress is  applied to the back of the
 hand, and  a paper-knife laid upon each compress transversely to
 the hand ;  then  by tying together the ends of the paper-knives on
 each side of the hand sufficient pressure may be  made on  the
 sponge in  contact with the bleeding vessel to restrain the hemor-
 rhage, without affecting the freedom of the general circulation  in
 the part.   Under this treatment, the wound inflames without  much
 swelling, and  suppurates;  the extremity of the artery becomes
 plugged with effused  lymph or coagulated blood, and the sponge
 becomes loose  and comes away at the expiration of ten  or twelve
 days.   Bleeding  after lithotomy is similarly stopped, by introducing
 a catheter through the  wound into the bladder  with lint fastened
 round it at  the part which is to  lie against the plate of the ischium.
 Bleeding again  from  cysts of the  thyreoid  gland  injudiciously
 opened,may be similarly arrested.
   Of astringent applications, the simplest is cold from exposure.
   In a  case in which  I amputated the cervix uteri,  very profuse
 and alarming hemorrhage took place a few  hours after the opera-
 tion, which  only ceased on keeping the  vagina distended with a
 speculum uteri.  .
   Saturated solutions of alum and of acetate of zinc are the most
 efficient liquid styptics.   These means appear to act by exciting
 contraction of the bleeding ends of the  vessels.  The most violent
 styptics are the nitrate of silver and the actual cautery;  the latter,
 applied by means of a red-hot fork or knitting-needle,  is of peculiar
 value in bleedings from ulcerated malignant tumours.
   The  pathological principles,  on which  the  treatment of hemor-
 rhage is founded, may be further brought out by considering he-
 morrhages as of three classes: the first, those which follow ampu-
 tations; the  second, those which attend  wounds  without loss of
 limb; the third, inward bleedings.
   After an amputation, all the arteries that bleed or can  be distin-
 guished should be tied with ligatures proportionate to their size.  If
 the ligatures are  laid straight  in  the wound,  they do not  interfere
 with the adhesive process ; but, on the contrary, serve as conveni-
 ent drains for any partial collections of matter that may form within
 the wound.
   Secondary hemorrhage following an amputation is liable to occur
 at two periods.  The first is within the first six or eight houis.  The
 vessels, from which it proceeds,  are such as, having contracted and
 temporarily  closed during the depression and chill ofthe operation,
 had not  been secured ; such vessels, on the patient recovering heart
and warmth, occasionally become relaxed and  allow the escape of
blood.  If the hemorrhage is considerable, and flows through the
dressings, the wound must be opened and the vessels  tied.   The
time for the second kind of hemorrhage ranges from the seventh or 
324            MAYO'S OUTLINES OF PATHOLOGY.
eighth day to the tenth week: it is produced by ulceration of some
large  artery divided in the operation, which  had been temporarily
secured by ligature.   This accident  can hardly happen  but in a
stump:  in that case the last resource  is to cut down  upon and tie
the trunk of the artery at a little distance from the end of the stump.
In a patient who had undergone amputation of the leg above the
knee,  and in whom  the wound healed  favourably all but a sinus
which extended to some depth along the side of the  bone, violent
hemorrhage supervened at the tenth  week,  for which I tied the
common femoral artery: the patient did  well, but partial sloughing
of the stump followed.  When arterial hemorrhage of this kind has
taken place  from a stump, it sometimes  happens  that without any
means being used, it does not recur.
  Hemorrhages from wounds casually inflicted, or in which the part
supplied by the punctured or divided  vessel is not amputated, pre-
sent more complicated features. It often happens in such wounds,
that there is at the time furious bleeding, when  the patient faints,
and the hemorrhage stops.  If the  bleeding has been arterial, and
in such  quantity and direction as to make its source from a large
artery probable, the wound should  be  enlarged if necessary, the in-
jured artery exposed, and  both ends tied.  It is not sufficient to tie
one end only: hemorrhage may return from the distal end.  Nor is
it safe to  wait for a  return of hemorrhage, giving  the  patient a
chance of its not returning.  The common period in such cases for
the secondary bleeding is a week or eight days from the first: the
parts at that time  are probably inflamed and thickened, in  a state
therefore in which it is hardly possible to expose the extremity of
the vessel that bleeds.   The only resource  in that case is to secure
one extremity of the vessel by tying the trunk nearer the heart, leav-
ing the  distal end unsecured;  and what is  worse,  tying a vessel
during the presence of an inflammatory  and  suppurative diathesis,
when the operation is not unlikely to  be followed  by inflammation
of remote serous membranes and purulent deposits in  other  parts.
In'a patient  in whom  I tied the common carotid for hemorrhage en-
suing at eight days after the division ofthe external carotid, suppu-
ration took place upon the surface ofthe brain.  The recurrence of
such hemorrhage at a week's interval  from the wound, in a case of
compound fracture ofthe leg, may on  the same principle necessitate
the amputation ofthe limb, and  that  at an unfavourable time;
which might have been prevented by enlarging the original wound,
and tying both ends ofthe artery on the day ofthe injury.
   When arterial hemorrhage proceeds from sloughing or ulceration
of a part, there is no resource  but  to tie the  branch from which it
proceeds, or,  if that is inaccessible or  uncertain,  the  neighbouring
trunk.  In  a case of repeated arterial hemorrhage from venereal
sloughing of one side ofthe fauces and pharynx, I tied the common
carotid, and the patient recovered.
   In the application of ligatures upon arteries, it is of the last mo-
ment  not to  place  the thread immediately beyond  the  origin of a 
ORGANS OF THE CIRCULATION.
325
branch; inasmuch as the flow of the blood through that branch will
interfere with the formation ofthe clot in the vessel behind the liga-
ture, on which the security ofthe cicatrix ofthe vessel depends.3
  Hemorrhages  which flow from rupture of inward  vessels, (in the
lungs for instance,)  require other principles for their suppression.
These are, rest,  which keeps down the action of the heart, the pro-
motion of (or the not interfering with) the faintness that supervenes,
for that faintness disposes the blood to coagulate in and around the
ruptured vessel: the use of inward styptics, such as  Ruspini's styp-
tic, or the  subacetate of lead,  or the  acetate of zinc, which are
thought to have a tendency, when taken  by the stomach into the
system, to cause the open vessels to contract.
  When arterial hemorrhage is stopped by the application of a liga-
ture on an artery, the  following changes additionally take place.
The ends  of the artery,  which was divided by  the  ligature, are
united by a strong cord of coagulated lymph ; the cord of course is
solid, not a tube: the ends which it joins, instead of communicating
through it, become, in  the lapse of a few months, shrunken and im-
pervious for some distance from the place, where the ligature was
applied. The arterial tissue wastes by absorption on each side ofthe
primary point of obliteration.
  As if nature  anticipated the occasional obliteration of  arterial
trunks, there is a provision for supplying their place. This is found-
ed on the same principle which  determines their  closure when di-
vided; namely, on their irritability: through this endowment on the
one hand, a torn artery may contract: on the other, the collateral ar-
teries may become relaxed and  allow the blood  to flow in fuller
streams through them to the distal part ofthe limb.  It is not indeed
their relaxation alone which accomplishes this efl- ct: the effect be-
gins in relaxation, but it is completed by growth. The collateral ar-
teries, which at first give by relaxation, afterwards consentaneously
grow to a larger dimension.
   The hemorrhagic tendency.  There are persons who are  in dan-
ger of bleeding to death from the slightest wound;  and cases are on
record, in which the amputation of a  limb, the removal of a tumour
from the rectum, the extraction of a tooth, have been fatal:  the mi-
nute vessels in such cases, instead of closing, continue open. There
are, however, degrees of this tendency.  A child to which I was call-
ed for continued  bleeding from the gum and alveolar process, that
had persisted for several days, recovered through  the continued or
frequent application of ice to the mouth and face.   On what does
the hemorrhagic  tendency depend? It evidently results from the in-
disposition ofthe small vessels to contract; they want or have less
than usual  of their proper irritability.
  III. Hypertrophy.   During utero-gestation the arteries  of the
womb become more capacious,  and longer and therefore tortuous.
The object of their increased capacity is to allow a larger quantity
of blood to flow into the growing part:  their greater  length and tor-
tuousness is probably in part accidental, and may be a collateral and
       21—d                                   22 may 
326
MAYo's OUTLINES OF PATHOLOGY.
even useless result ofthe process which dilates them.  That process
I believe to begin  in their relaxation.  Their tonic resistance I sup-
pose to be lowered below its former standard, and below the resistance
ofthe coats of other arteries in their vicinity; as a consequence, the
impulse of the heart drives proportionably more blood  into them:
they yield, and are fuller and larger than before; but the yielding of
a tube from lowered tone (as  I have experimentally shown  in  my
treatise on physiology) necessarily takes place in its length as well
as breadth: the artery  yielding to the blood becomes longer, and
therefore tortuous, as well as larger. The dilatation thus beginning
is supported by increased growth ofthe part; which as it grows con-
tinues still relaxed  in tone, and becomes therefore more and more
elongated  and tortuous.  The increased growth in this instance is a
physiological hypertrophy, and comparable to the  enlargement of
the bones  and muscles of a blacksmith's arm.
  A similar hypertrophy occurs as a  pathological phenomenon in
more  than one instance.
  Aneurismal varix occurs when an artery is punctured through
a vein; the outer wound of the vein closing, a communication is left
between the arterial channel and the venous. In this case the artery
above the communication becomes more capacious, and at the same
time slightly tortuous:  it becomes first relaxed, then enlarged by
growth, or hypertrophied. The effect may be viewed as an effort of
nature to allow a  double quantityof blood  into the limb, to make
up  for the loss of that  which directly returns to the heart  by the
vein.
  Another instance of arterial hypertrophy occurs in the affection
described  by Mr. John Bell under  the  name of aneurism  by anasto-
mosis. A patient labouring under this disease died from other causes,
under my care, in the Middlesex Hospital.  He had a raised pulsa-
tory tumour on one side ofthe head, for the cure of which Mr. Bab
ington had tied the temporal, and Mr. Wardrop the common carotid
artery, with temporary benefit; but the pulsation of the tumour, with
disposition to gradual increase,  had returned.  On examining the
part, the arteries having been  injected  with wax, the middle tempo-
ral  artery was found to enlarge and become more and more tortuous
in its ascent; opposite to the tip of the ear it gave  off a branch of
three  times its own  diameter, which  lay coiled  upon itself  with a
similarly hypertrophied vein : together they had constituted  the tu-
mour. The surrounding cellular membrane was slightly thickened,
but the skin did not adhere with inseparable firmness to the tortuous
vessels; and the bone below,  although thinned  by absorption, was
healthy, and covered with a healthy periosteum.
  In the fifteenth volume ofthe Medico-Chirurgical Transactions,
Sir Benjamin Brodie describes a tumour of the same nature, (but
which, as is more commonly the case, was formed of several tortu-
ous vessels,) that had orginated on the forehead of a  child four years
of age, in consequence of a blow.  At  first it was not larger than a
pea, for many years it remained stationary in size,  although it pul- 
ORGANS OF THE CIRCULATION.             327
sated.  Twelve years afterwards pressure  was tried, which gave
pain, and was followed on its discontinuance by the increase ofthe
tumour.  Four years afterwards, at four different times, Sir Astley
Cooper tied  each of  four arteries which supplied the tumour, and
each time with  temporary benefit.   But the tumour again grew
larger, and the pain returned with redoubled violence, attended with
a constant sense of weight over the eyes, and excessive depression
of spirits.  Three years afterwards the tumour had become bigger
than a large double walnut.  The skin covering it-was thin ; and on
some occasions,  as in coughing, when the  vessels  were unusually
distended, it appeared as if on the point of bursting.  When the scalp
was shaved, large and tortuous arteries were to be seen, even from
a considerable distance, passing into the basis of the  tumour in every
direction, from each  temple,  from the orbit ofthe right eye, and even
the crown ofthe head from  the occiput. The tumour was success-
fully  removed by means of  a ligature tied  round two steel needles
introduced at right angles to each other below the tumour, produ-
cing strangulation ; which, however, being  found not to have been
quite perfect, was completed three days afterwards by arming  one
ofthe needles with a double  ligature, and tying it round each half of
the tumour.
   It is evident that tumours of this description are instances of arte-
rial combined with venous hypertrophy; the elements ofthe change
the same, only misplaced, with those by which, in the healthy state
ofthe economy, the uterine arteries enlarge in  pregnancy.
   In cases in which a pulsating tumour of this description has been
so situated (either spread over  the side ofthe face and ear, or grow-
ing on the orbit) as to preclude the  ligature or excision, the main
artery of the part has  been tied with success:  and although  the
chances must always be against its efficiency, the  operation is  cer-
tainly to be  recommended in this class of cases.
   The tumour called vascular naevi, I am disposed to view as hy-
pertrophied  capillary tissue,  rather than as erectile or  hypertrophied
venous texture, which is perhaps the commoner  idea entertained of
this structure.   The vivacity with which  arterial  blood is poured
out from the entire cut surface when they are divided,  the absence
of enlarged venous trunks about them,  and what  I have  been  able
to make&out of their texture  through specimens very imperfectly in-
jected, lead me to this conclusion.  The subject has been  already
noticed.                                                .
   IV.  Inflammation of the arteries is considerably less  trequent
than inflammation ofthe veins ; but it presents the same varieties.
   a.  Subacute arteritis, like subacute phlebitis, produces coagula-
tion of the blood in the vessel attacked, followed by obliteration ot
its cavity.   The consequence, if the vessel is  the  principal one in
the limb, is  easily calculated.   When the main  venous channel is
obstructed, the  return of the blood is impeded, and oedema ensues ;
but in that case arterial blood pervades the limb, and it retains sensa-
tion and vitality. When the maiu artery is obliterated by inflamma- 
328            MAYO'S OUTLINES OF PATHOLOGY.

tion, (involving in a greater or less degree the branches,) the pass-
age of blood into the limb is impeded,"and mortification threatened.
  In a person of not very advanced age, who died of gangrene of
the foot, 1 found the  posterior tibial  artery plugged  with fibrin,
which adhered to  the inner coats of the vessel: the texture of the
artery was thickened, and  serum was effused  in  the  sheath sur-
rounding it. The coats ofthe artery were not ossified.
  A lady, under the middle age, was  seized with violent  pains in
the hand and arm, and impaired sensibility. There was no  swelling
of the arm or hand, but tenderness was observed in  the course of
the brachial artery. No pulsation was felt in the course of that ves-
sel, or of the radial or ulnar arteries.   She suffered great pain for
several days, indeed till the circulation was restored by the collate-
ral vessels. It was at first apprehended she would have lost the tops
of her fingers, which however was  not the case. A very small por-
tion ofthe extreme point ofthe ring-finger was alone lost.  She re-
covered completely the  use of her  hand and fingers, has  had two
children since the attack, and has  enjoyed  the  best possible health.
This capital example of a rare disease was communicated  to me by
Mr. Keele, of Southampton.
   b.  Acute arteritis.  A soldier aged twenty-two, died eighteen days
after cutting his hand severely to escape military service,  with low
fever and local inflammation.  Matter had formed around the palmer
tendons and among the  muscles ofthe fore-arm ;  the lower half of
the  external aspect ofthe radius was denuded of periosteum, and
rough.  The radial and  ulnar arteries, from the wrist to the middle
ofthe fore arm,  were full of pus; their lining membrane was thick-
ened, here,and there eroded, and in  part covered with coagulable
 lymph.   The veins for the  same extent presented similar appear-
ances, but less in degree.— Gendrin, vol. ii. p. 21.
   Arteries are also subject to chronic inflammation.   This is prin-
 cipally observed in thickened  and ossified  arteries, particularly in
 aneurismal subjects.   In some instances it may be regarded as the
 effect of pre-existing  disease, but  it is possible  that in others the
 inflammation leads to  these deposits.  The inner coat of ossified
 arteries is often  found  soft, thickened, and of a deep red colour,
 which is not uniform, but irregularly disposed  in the vicinity of the
 calcareous depositions.
   The  internal surface of arteries  often exhibits  a red appearance,
 which does not arise from inflammation.  The internal coat is of a
 deep scarlet colour, sometimes throughout the whole extent of the
 system; in  other instances,  this appearance  is observed only  in
 circumscribed  patches.   It  is  attended  with  no  deposition   of
 lymph  or thickening of the vessel; and if the inner coat be  re-
 moved, the  middle  coat  generally  presents  the natural  appear-
 ance.   The colour  is  probably a cadaveric  stain  produced  by
 transudation.
   V. Degeneration of tissue.
   a. The internal coat  of arteries  is sometimes thickened and con- 
ORGANS OF THE CIRCULATION.
329
verted  into a substance resembling cartilage.  If the coats  of the.
vessel are separated, the disease is found to occupy the internal coat
alone;  which,  having  lost its  elasticity,  sometimes cracks, and
forms lamina? or scales  that hang into the cavity of the  vessel.
This alteration of structure generally takes place to a considerable
extent, and is frequently accompanied with a deposition of calca-
reous matter.
  b. The internal  surface of arteries  frequently exhibits  a  thick-
ened and pulpy structure, which, like the former, is confined to the
internal coat.  Sometimes the appearance is that of small  flattened
tubercles, and at others the whole surface is  irregular and somewhat
fleshy.
  c. 0:ie of the most frequent appearances of disease in the coats
of arteries is produced by a deposition of atheromatous or  puriform
matter, in the cellular coat that  connects  the internal and middle
coats of the  vessel.  The diseased part is of an opaque yellow-
colour, and is generally somewhat elevated from ihe surrounding
surface.  Sometimes  these elevations  are  considerable,  and very
extensive;  whilst at  others they are  circumscribed, and have a
pustular or tuberculated appearance.   If punctured, matter may be
pressed  from  underneath the internal coat, varying in consistence
from that of  cheese to common pus.  Ulceration sometimes takes
place on the  surface of these elevations.   The  deposition of this
matter sometimes proceeds to  such  an extent as  to obliterate the
arterial cavity.   Calcareous matter is  frequently deposited with it.
  d. The deposition of a calcareous matter is so  frequent an occur-
rence in the  arteries of subjects advanced  in life, that Bichat esti-
mates its existence  in seven out of ten subjects  above the  age of
sixty; and Dr. Baillie says, that at that age  it is more  frequently
found to have taken place, than  that the arterial system  possesses
its  original healthy structure.  The appearance which it gives to
the surface of an artery depends entirely upon the extent  to  which
the deposition has taken place.   Sometimes the  internal coat pre-
sents numerous white specks of great minuteness; whilst, at other
times, the calcareous  matter is  mixed  with a curdy deposit,  which
produces a swollen  and earthy condition ofthe internal coat. More
generally, however, it forms a brittle scale or crust, which crackles
under the finger  like the shell of an egg.  Such incrustations do
not observe any peculiar shape in their formation, but are irregular,
and deposited both in a longitudinal and circular direction.  Some-
times they form spicula, or eminences, projecting into the  cavity of
the vessel, and diminishing its calibre; and not unfrequently in the
arteries  of the lower extremities they occupy the whole circumfer-
ence of  the  tube,  forming distinct rings, which are  connected
together by the intervening membranous portions ofthe vessel.  In
the early stage of their formation they are often  accompanied with
a deposition of atheromatous or  curdy matter  underneath the inter-
nal  coat, and  they are frequently surrounded by extreme ulceration.
In old  subjects, however, they sometimes exist without  any other 
330
MAYO'S OUTLINES OF PATHOLOGY.
morbid  appearance in  the coats of the arteries.   In some cases
they are probably detached from the  sides of the vessel by ulcer-
ation, and falling into its cavity, have produced those instances in
which loose calculi are reported to have been found in the heart
and arteries.
  These incrustations appear always to commence in the substance
of the internal coat, and generally on the external surface of that
membrane ;  for  there is almost constantly a delicate  pellicle con-
tinuous with the internal coat, extending over the calcareous matter,
and separating it from the blood passing through the vessel.  This
pellicle  is sometimes deficient, or hangs into the cavity of the vessel,
arid the blood is in contact with the calcareous matter.  In other
instances  all the coats of the vessel are involved in the disease, and
are converted into a bony cylinder, in which  no  remnants of the
original structure can be traced.—Hodgson.
  The chemical analysis of the calcareous concretion in arteries,
according to an analysis made by Mr. Brand, for Mr. Hodgson, is
the following:
     Phosphate of lime       ....   65.5
     Animal matter       -                             34.5
100
  The deposition of calcareous matter principally takes place in the
arteries of the trunk, and in the branches of the carotid  and iliac
arteries, and more frequently in the second and third orders of ves-
sels than  in  their  ramifications.  It seldom  exists in  the upper
extremities; and it is remarkable, that although so frequent in the
aorta, it is extremely rare  that  the  pulmonary artery or its valve
exhibit this morbid appearance.'  Disease is seldom met with in the
coats of the pulmonary artery, or  in any parts of the system situ-
ated on the right side ofthe heart.
  The  consequences of the changes which have been described,
occurring either  separately, or in combination, are of the most
serious import.   They are referable to two  heads, the first, im-
paired  nutrition—the  second,  mechanical  deterioration  of the
vessel.
  1. The cases of impaired nutrition, attributable to this cause, are,
  a. Atrophy  of the muscular substance ofthe heart dependent on
ossification ofthe coronary arteries.
  b. Ulceration.  An old man of a hale florid  complexion was ad-
mitted into the Middlesex Hospital, with a deep ulcer on one instep;
the  ulcer  was nearly circular, about two  inches  in diameter, and
nearly an  inch in depth at  its centre ; it was eating through every
texture, and had exposed several of the tarsal joints; there was little
discharge  from it, or pain attending it.  After he had been  a few
weeks in the hospital,  he lost his appetite and  healthy complexion,
when the limb was amputated below the  knee.  The stump went
on favourably for a few days,  then began to slough, when the 
ORGANS OF THE CIRCULATION.
331
patient sank and died.   The arteries ofthe leg were ossified to  an
unusual degree.
  c.  The  ordinary cause of senile gangrene is ossification of the
arteries.   This disease varies  in some degree in its  character in
different  instances.  In some  cases  it is  rapid and  preceded  by
little inflammation, and the morlified part shrinks and dries.  In
other instances there is a deep redness, and considerable  inflam-
matory swelling attended  with  severe pain, antecedent to the gan-
grene, and spreading as the latter spreads and  the mortified part
putrefies.
  In  either case, the mortification will occasionally stop; the dead
part  having separated,  the  surface which  has thrown  it off will
temporarily heal;  the disease being likely to return  after a  short
interval.
  The mechanical deteriorations of  the vessels, which follow the
changes above described, are  dilatation ;  rupture; and aneurism,
which originating in one or other, or both of these  lesions, may
pathologically be enumerated as a third alternative.
  a. Dilatation.   The commonest seat of dilatation is the arch of
the aorta.
  A stout man about sixty years of age had long complained of
difficulty of breathing, great oppression of  the chest, and frequent
palpitations of the heart.  He was occasionally subject to syncope,
and preferred a recumbent posture.  His  pulse was very small, fre-
quent, and intermitting, and his  physician suspected that  he had
hydrothorax, or some organic disease of the heart.   In this state,
whilst walking across his room, he suddenly fell, and  instantly ex-
pired.  The right ventricle of the  heart was very much enlarged
and flabby.  The aorta was dilated from its origin to the commence-
ment of the descending portion into a large bag, which would ad-
mit four fingers and a thumb with great  ease.  It had a gradual
termination, and the lining membrane was thickened, and covered
throughout with earthy scales and atheromatous  depositions.  The
semilunar  valves were thickened, and separated from each other.
The left ventricle  was large but healthy.   The aorta and left ven-
tricle were gorged with recently coagulated blood, but  there was no
lamellated coagulum on the surface of the dilated part.—Hodgson.
  The common carotid artery is occasionally the seat of irregular
dilatation.
  I have  seen the basilar  artery enlarged into a fusiform dilatation
an inch in length,  and half an inch at its greatest thickness.
  In  a patient in whom I tied the external iliac  for inguinal aneu-
rism,  and  afterwards the common iliac to suppress  a secondary
hemorrhage, a lenglh of about  four inches  of the lower part of  the
superficial femoral artery was enlarged to twice the natural diameter.
The artery was uniformly diseased, with  minute  lines of deposit
between the fibres.
  In dilated arteries a whizzing  or blowing is present,  which has
more or less roughness, according to the abruptness of the opening 
332            MAYO'S OUTLINES OF PATHOLOGY.
and  contraction  of  the  vessel, and  the condition of the inner
surface.
  b.  Rupture.   The most frequent instances of rupture of arteries
from ossification  occur in the  enkephalon.   It may be presumed
that their natural thinness and weakness renders these vessels more
liable to give way.  Such  instances produce sanguineous apoplexy.
  Primary rupture of the  vessels of the trunk and  limbs  is gene-
rally partial, and is usually spontaneously remedied  by the conden-
sation  of the adjacent  tissues, giving rise to aneurism.   Primary
ruptures of the large arteries of the  trunk  to an extent  and in a
situation to be rapidly fatal, are comparatively infrequent.  The
two following cases exemplify this occurrence.
  E. Robinson, aged 65, admitted into the Middlesex  Hospital under
Dr. Watson, Feb. 26, 1833.   Ill three days : was attacked  before
breakfast with  loss of consciousness;  on  recovery fell pain  at the
back of the head, with numbness of the right arm and leg; can
only lie on  the right side for  palpitation.  Systolic sound of the
heart  less; impulse  greater than natural.  After going on favour-
ably to that time, on the  6th of March she was suddenly  attacked
with convulsions, and  remained insensible, breathing without ster-
tor, pale, the  pulse small  and weak, till  her  death at two  p. m.  on
the 9th.                                              ,
  Inspection.—Sanguineous  effusion  on the surface of the hemis-
pheres, and softening of  the under part of the cerebellum.  The
pericardium  filled with a firm coagulum, which  formed  a bag
enveloping the whole heart, and admitting of being removed entire.
It adhered slightly  to the auricles.  The blood  of which  it was
formed appeared to  have  got in through a slit in the pericardium,
at the  angle of its reflection from the aorta.  A little  above  this was
a clean transverse rent upwards of a inch in length through  the front
of the aorta;  at this part a  large coagulum of blood lay  between
the middle and outer coats of the vessel.  The latter had  probably
first given way, and afterwards the outer coat had been rent through
into  the pericardium.  The inner surface of the aorta was covered
with opaque yellowish spots, some bony;  there was dilatation.
  Dec. 19,  1835.   Nine  o'clock,  p.  m.   A  cold night, and east
wind.—A gentleman, aged 35—tall, muscular, thin—countenance
and lips pale, his body very cold, and especially his right  arm and
fingers cold as marble.   The limb is not sensible to touch,  but he
complains of pain and cold in  it.   It is paralysed ;  he moves it by
the shoulder.   The  fingers and  wrist are  usually half bent, but
will remain in the position in which they are placed.   The elbow
joint  is nearly straight; he once bent it slightly.  No pulse in  the
radial, ulnar,  or  brachial  arteries; immediately above  and below
the clavicle the artery throbbed perceptibly.   Pulse in left wrist
small—SO.  He is lying  on  a  bed, covered  with blankets,  and is
perpetually moving.  He  complains of feeling uneasy all over,  but
of no  pain  excepting  in  his arm.  He  breathes easily, yet often
gapes and yawns.  He becomes  confused when he attempts to speak 
ORGANS OF THE CIRCULATION.
333
at any length, but makes short answers without any hesitation or
mistake.  The systolic  sound and  the  impulse of the heart are
natural.   The  diastolic  sound not distinguishable—in its place a
sort of blowing noise.
   His account is, that about  half an  hour ago he felt a "sort of
revulsion;" meaning by  this term sudden pain, extending from his
throat down his chest and belly, and a sensation as if he were dying.
His left arm and leg  then became very numb and cold, and he could
not move  them : they shortly recovered, and  his right arm was
affected as described. He had  been previously perfectly well.  The
servant says that he  complained of headach  in the afternoon.
   Dec. 20.  Eight o'clock, a.  m.—He  had been dead about three
quarters of an  hour.  Thin blood  trickled  from a puncture made
in the right external jugular vein.  The pupils are dilated.   Body
warmer than it was last night.  It is very pale, but not in the least
stiff.
   He had not  slept during the night.   About 12 he vomited the
medicine he had taken.  Subsequently he had one stool.  He had
talked and remained  much as he was in the evening until 7{ o'clock,
a. m. ; when the servant,  who was in the next room at the moment,
heard a great gurgling in the throct, chest, and belly, and thought
at first  that his bowels were suddenly purged.  He never moved
after that time.
   Inspection.—Dec.  21.  10^, a. m.—The  body stiff and pale, not
quite  cold yet.  Maculae mortuae on  all depending parts.   The
radial, ulnar, and brachial arteries of the right arm were fiat, thin,
and seemed to be deficient in elasticity, and  contained a  small
quantity of fluid blood,  and  the  veins  did not hold more.   In
dividing the cartilages of the  ribs on the left side, the pericardium
was pricked, and serum of a  straw colour  spirted out, 3iij or iv.
The cavity of the left pleura  was full  of  fluid blood, and the lung
dark-coloured, heavy, and compressed.  The right lung appeared
healthy.   The  pericardium  contained  about §vj of clotted blood.
The heart  hard, and  very large. A considerable ecchymosis (under
the pericardium) was observed around the the origins of the aorta
and pulmonary artery, and about the right auricle.   On slitting up
the aorta  from  below, several patches of opaque, yellowish and in
some  parts bony substance, appeared between the inner and middle
coats.  The aorta was large, and  especially the first portion of the
arch.  Th,; cellular  membrane around the  arch of the aorta con-
tained clotted  blood, by which  also the external coat of the aorta
was separated from the middle tunic, or at least from most of it, for
a  few circular fibres were attached  to the interior of the cellular
coat.  This separation extended to the origin ofthe aorta, where it
ended in a transverse slit  in the inner and middle coats, immediately
above the valve which has no corresponding coronary artery.   No
distinct opening could be  traced into the pericardium from this slit,
but in two or three places the  membrane seemed so thin, that pro-
bably  the aperture was concealed  by the distention with blood  of 
331            MAYO'S OUTLINES OF PATHOLOGY.

the cellular membrane  beneath;  or the blood may be supposed to
have transuded.  A similar yet smallar transverse slit, appeared at
the commencement of the arteria  innominata.  The sides of the
left ventricle were enormously thick, and its cavity enlarged—it
contained a small clot.   The mitral valves very large and thick-
ened at parts, but to no great extent.  The  auriculo-ventricular
orifice large.  All other parts of the heart healthy.
   The vessels  of the scalp contained a good deal  of fluid blood.
The brain was perfectly healthy.   In  the arteries at its base were
a few opaque spots.
   The small intestine was gorged with blood.  An immense quan-
tity of clotted blood was effused behind  the peritoneum, along  all
the extent ofthe abdomen, aorta, and especially around the kidneys.
On slitting up the aorta, two or three transverse slits were observed,
similar to those mentioned to have been found in the thoracic ves-
sels, with a  like separation of  the arterial coats.
   A gonorrheal discharge appeared at the orifice of the urethra.
Connected with this circumstance it may be remarked, that he was
making water at the time he felt "the revulsion."
   It is remarkable  that the  blood in the cavity of the  pleura had
not clotted, nor had that contained in the vessels, whilst that effused
into the pericardium and  into the cellular  membrane,  and  what
little was found in the heart, was  perfectly clotted.  But no light-
coloured fibrinous masses were, found, as is sometimes the case.
   c. Aneurism An aneurism is a sac filled with blood, fluid or
coagulated, and communicating with an  artery, through the rup-
ture or dilatation of which it has been produced, and of the coats
of which, or of the adjacent cellular tissue, it is  formed.
   Aneurism may arise  either  from disease, or from an injury of an
artery.   The degenerations of tissue, which have  been above  de-
scribed,  and that may  lead, as  it has been  mentioned,  to general
dilatation of an artery,  may likewise  lead  to its partial dilatation;
one side-of a diseased vessel being weaker than  the rest for a small
extent, may become sacculated, all its coats yielding and concurring
to  form a  sac.  This variety is called true aneurism; the  blood
found in it is in a fluid state.   But as such an aneurism increases,
it commonly happens that the inner coat or coats give way at one
or more parts; at which parts the dilatation proceeds more rapidly
than before: the blood in contact with the new and abraded surface
coagulating, forms  a stratified  clot  of several layers.   Such an
aneurism is called  a mixed  aneurism.   Again, it fully as often
happens, that the aneurismal sacculation primarily results from the
giving  way of the inner coats of the artery at some  point  where
they have  been weakened either by the thickened inner membrane
splitting off in laminae,  or through its being partially absorbed over
a flake of phosphate of lime, which thus has become detached :  the
sac is then formed of something external to the tunic immediately
diseased.   This  kind is called a false aneurism: it contains two
varieties ; for the sac may be formed either of the outer coats of tho 
ORGANS OF THE CIRCULATION.
335
vessel, or that having additionally given way, of the neighbouring
cellular  membrane.  In either case  the  sac contains more or less
stratified coagulum.   Arteries, again, which are not diseased,  are
liable to become aneurismal in consequence of injuries.  Aneurisms
of this kind  are called  traumatic.  They  present three varieties.
To exemplify the first,  when the temporal artery has been opened,
if the bandage is removed too soon, within twenty hours for instance,
the wound  is found indeed to have united by adhesion;  but  the
artery is weak at the line of adhesion, and its texture that required
support  gives at that  part,  and an aneurismal  sac  is  formed.
Secondly, if an artery in a fleshy part is punctured, although  the
wound  of  the  integuments  may admit of being  healed through
pressure, the wound of  the artery is  kept open  by  the force of the
blood which  issues  from it, and drives against the cellular mem-
brane, and dilates and condenses it into an aneurismal sac.   Third-
ly, an artery may be completely divided or torn asunder,  with  the
same result: only that  in this case the end of the artery, not  the
side, opens  into the sac.  I have seen this case happen in two ways.
As  an instance of  the  first—a lady fell upon the nates, against
the edge of a step, and ruptured the gluteal artery; a tumour of
the size of  an orange immediately arose at  the part, and there was
ecchymosis  from  the heel to the head;  the patient recovered with
rest and cold.  The other case was the following: the profunda,
in an amputation ofthe thigh, was not tied  cleanly, but  the ligature
was applied  round  some  fibrous and muscular substance, which
was supposed to include the artery: but instead of this happening,
the artery slipped back and eluded the ligature ; the ligature being
thus tied before, not on the vessel, blood was poured from the vessel
into the muscular  and cellular tissues, which gave  way about
seven days  after the amputation, and  the hemorrhage destroyed the
patient.   The last form of traumatic aneurism is the aneurismal
varix, in which the  artery having been punctured through a vein
and the external  wound healed, leaves a communication between
the two  vessels: the blood rushes from the artery into the vein, and
dilates it into a sac over the point of communication.  In the aneu-
rismal varix, as in  true aneurism, the  blood  is in contact with  a
surface natural to it, and does not coagulate.
  The ordinary progress of aneurism is the following: the sac gradu-
ally yields, and becomes partially filled with stratified clot, of which
the  oldest-formed  layers  may be distinguished by their  lighter
colour;  the sac again partially yielding, often throws out additional
sacs.  The  soft parts become displaced, and the bones are absorbed
under the pulsating pressure.   At length the sac gives  way.  The
result is likely to be immediately fatal, if the aneurism burst upon
the pulmonary surface, into the pleura, pericardium, or peritoneum,
in the cranial cavity, or through the  integument or intestine.  But
the rupture of the sac is not even then necessarily fatal at the in-
stant: the patient fainting, the aperture may be plugged with coa-
gulum, or the opening may be among tense parts, which will form 
336            MAYO'S OUTLINES OF PATHOLOGY.

a second sac.  The patient thus may rally, to perish by a return of
hemorrhage.  Or the aneurism may open into a vein ; if such an open-
ing be from an aortic aneurism into the cava, tumultuous disturbance
of the  circulation and instantaneous death ensue.  If the opening
be from a membral  aneurism into a vein, as from a popliteal aneu-
rism into the popliteal vein, no immediate disturbance is observed.
But,  as  in the case recently communicated by Mr. Perry, the blood
now returning in part by the vein, imparts to the venous circulation
ofthe limb a "peculiar thrill, while the artery  above the communica-
tion  enlarges to allow a  freer passage of the blood, to make up for
what is thus lost to  nutrition ;  and the vein dilates from increased
pressure.   In Mr. Perry's case, the femoral artery  was of three
times the natural diameter, its coats uniformly thin, but smooth and
regular.
  The  diagnosis of  aneurism is  not  difficu't in general  in  the
limbs, or in the neck or axilla.  There is  a pulsatory  tumour, of
which the growth has been rapid, which is diminished by pressure,
when the artery leading to it is  compressed, and  on the pressure
being  removed  fills with a  peculiar  thrill.  In  general, but not
always, a blowing sound is heard in the aneurism.
  Internal aneurisms are often difficult of detection at  their  com-
mencement;  when  of any size, if at  the  areh of the aorta, they
simulate disease of the  valves of the  heart with hypertrophy, and
are with difficulty identified.  When the aneurismal tumour, press-
ing on the adjacent internal parts, causes pain under the sternum, or
in the  throat, extending to the arm, sometimes with numbness, dif-
ficulty of swallowing or  breathing, and when the patient experiences
an unnatural beating in  the upper part ofthe chest, the disease may
yet  not distinguish itself from tumours of other kinds which  may
produce these symptoms.  But when an impulse is felt  under, or a
little to the right ofthe sternum, greater than that felt in the region
of the  heart, and especially  if the impulse be accompanied by a
single loud sound, whether this sound be grating or not, there can
be  little doubt of there  being  aneurism, or considerable dilatation
of the aorta.
   It is interesting  to investigate the methods by which aneurisms
are sometimes spontaneously cured.
   1. By sphacelation.
   An  athletic dragoon,  thirty-five  years of age,  ascribed to great
exertions during a very severe field day, the origin of an aneurism
in his right groin.  The tumour increased rapidly: in a few weeks
it was  as large  as  a melon, and  extended several inches above, as
well as below, Poupart's ligament. It pulsated violently; its parietes
were very thin, and its surface was inflamed.  He was placed upon
the  lowest diet, and repeatedly bled from the arm, more particularly
and largely when the pulsation in the tumour was much increased.
On visiting him some time after he had been under this debilitating
treatment, during which the tumour had acquired a greater degree
of solidity, the  integuments on  its apex  were observed  to  have 
ORGANS OF THE CIRCULATION.
337
 become very livid, and were covered with numerous vesications
 containing dark-coloured  serum.  The pulsation about  he same
  mie  ceased, and the surface of  the tumour became black and flac-
 cid.  Ihe mans  death was  momentarily expected.   The  parts
 became more discoloured, until  at length a small opening formed
 in their centre  from whence issued a large quantity of dark, partly
 coagulated fond blood.  The sloughing became more general, par
 ticularly around the circumference of the tumour.  It extended in
 the  perineum  to the raphe, to  the spine of  the  ilium, upon the
 abdominal muscles, and down  the thigh.   When the sloughs sepa-
 rated, many pounds of coagulum were  discharged, until the whole
 cavity was cleared.  The sloughing sac was gradually cast off,
.and,  after  a  most  tedious process, the  sore assumed a healthy ap-
 pearance;  the  edges began to  granulate and discharge healthy
 matter   During this process, nature was left almost  entirely to
 work the cure.   The patient was extremely low ; so much so once
 or twice, as to excite considerable alarm for his safety.   His pulse
 could scarcely be felt, and he had frequent attacks  of syncope.  He
 was allowed wine  and cordials.  The immense chasm in his groin
 gradually filled up.   The edges were approximated with adhesive
 straps ; but it was more than twelve months before  it had cicatrised.
 At the end of that  time he was perfectly well, and  remained in the
 hospital many  months after the cure, during which time his health
 was good, and  he suffered nothing from the remains of the disease
 but the inconvenience of so large a cicatrix.—Hodgson.
   2.  By reflection  of the enlarging sac upwards in such a manner
 as to  press upon, and obstruct the flow of blood in  the artery above
 the aneurism.
   A  gentleman, about thirty years  of age, after a day's hunting,
 felt a pain in  his  thigh, which  he considered  as rheumatic.  A
 month afterwards  he perceived  a small pulsating tumour in the
 course of the femoral artery, about  four inches below Poupart's
 ligament.   The tumour increased, and  the leg  and thigh became
 oedematous.  He was bled copiously, and adhered to  a low diet.
 Compresses were applied above  the tumour  in  the course of the
 femoral artery, as  high  as Poupart's ligament, and the limb was
 rolled equally and tightly from the foot to the groin.  The application
 of the roller  increased the pain,  and he suffered much from  fever.
 This  plan was  continued for some months, when  on a sudden the
 whole limb became extremely cold and benumbed, the tumour and
 upper part of the  thigh  put on a livid  appearance,  and serious
 apprehensions were entertained  for  the  safety of the  limb, which
 was hourly expected to become gangrenous.  On the morning sub-
 sequent  to  this alarm, the pulsation in the tumour had ceased, but
 the livid colour and defect of sensation continued.  The pain was
 abated, his  fever was less, the warmth of the limb began to return,
 and the tumour to diminish.  From this time he  continued to re-
 cover  ; but it was long before the limb regained its natural sensation,
or the oedema subsided.  At the  end of six months he suffered no 
338            MAYO'S OUTLINES OF PATHOLOGY.
inconvenience from the remains of  the  disease,  except  that the
upper part of the thigh was four inches more in circumference than
the opposite limb in the same situation.   In this state he remained
twelve years, when the swelling began to enlarge, and was attended
with a dull pain after violent exercise.
  From  this time  the  tumour gradually increased ;  when Mr.
Hodgson saw him, twenty years after the commencement of tho
disease, it had grown to an immense size, but did not possess any of
the characters of an aneurism.  It had a firm fleshy feel,  was void
of pulsation, and no fluctuation could be discovered in it.  It con-
tinued to increase for two years, when its apex  sloughed, and a
quantity  of brown sordes was discharged, mixed with clots which
had very much  the appearance of lamellated coagulum in a putrid
condition: no hemorrhage took place.  A large cavity was thus
exposed,  the surface of which assumed a sloughy aspect, and he died
in consequence  of the fever  and irritation with which it was ac-
companied.  Upon  dissection, the sides of the  tumour, consisting
of a firm fleshy substance, were found to be in a sloughing condi-
tion,  but no large  blood-vessels communicated with the cavity.
The femoral artery, before it penetrates the tendon of the triceps,
was obliterated  for the space of three inches.  The body of the sac
was reflected upwTards upon the obliterated portion of the artery,
which must have been compressed between the sac and the femur.
Below the obliterated part the coats of  the artery were remarkably
diseased; and were dilated into a small  sac in the ham.  In this
case it appears probable, that the cure ofthe aneurism was the con-
sequence of the  obliteration of the upper part of the artery, which
was compressed  between the tumour and the  femur:  a diseased
action seems after some years to have commenced  in the remains of
the sac, which became a sarcomatous tumour, containing a grumous
fluid  mixed with clots, very like lamellated coagulum in a putrid
condition.
   The pressure of an aneurismal sac has been known to obliterate
an  adjacent artery.  Sir Astley Cooper has mentioned an instance
in which the cavity of the common carotid artery was obliterated
by  the pressure of an aneurism of the aorta, which extended  up
the neck by the side of the trachea.   Mr. Hodgson met with a case
in which the cavity of the left subclavian artery was obliterated by
the pressure of an aneurism ofthe arch ofthe aorta.  At the origin
of the subclavian artery there was also  a small aneurism,  in which
the process of  spontaneous  cure by the  deposition of lamellated
coagulum had  commenced in  consequence of the obliteration of
that portion of  the vessel which communicated with the humeral
extremity of the sac.
  3. By the blood in the sac clotting, and  converting  it into a
solid  tumour.
  A miller, about fifty years of age, had  for  five years before  his
death  been  afflicted with severe symptoms of asthma.   Various
medical  men considered  him as  labouring  under that peculiar 
ORGANS OF THE CIRCULATION.
339
asthma to which those who follow his occupation are subject.  His
symptoms, however, were  always relieved  by copious bleedings.
The above was all the information which could be procured relative
to his disease, when the body was examined.  The lungs were per-
fectly healthy.  A small aneurismal  sac originated from the poste- '
rior  part of the arch of the aorta close to the root of the  arteria
innominata.  This  sac was about the size of a common  walnut,
and  the coats of the aorta were deficient at its base for the space of
about the size  of a sixpenny piece.   The cavity was completely
filled with very firm layers of coagulum, resembling more  the ap-
pearance of boiled muscle than any other substance.  The opening
by which the sac  had  communicated with  the aorta was blocked
up  by the base of the coagulum, but the cavity of that vessel was
not  in the least diminished.  The tumour adhered posteriorly to
the  trachea,  which  was  thrust out of its natural position, and had
assumed a very remarkable curve, by which  its calibre was reduced
to one half  of the  natural dimensions.  The coats of the aorta
were thickened, and covered with steatomatous and earthy deposi-
tions.
  The two latter  instances, for the  first is  too hazardous, and in
nature's  hands too commonly fatal to be imitated, contain the prin-
ciples of medical and surgical treatment of aneurism.
  As regards medical treatment,—an aneurismal  patient should be
lowered  by  repeated bleedings and  restricted diet, and  be kept
tranquil  and undisturbed in body and mind.  These conditions at
once retard the enlargement of the sac, and increase the tendency
of the blood to coagulate in it.
  The surgical treatment  which is to be  resorted to, when not
contravened by the co-existence of  internal aneurism, or an  un-
fitting state of health, or the situation  ofthe aneurismal vessel, con-
sists in tying  the artery on the cardiac side of the tumour;—not
too  near  to "it, lest the  ligature should be  applied on a part more
diseased than the rest,;—not  too far from it, lest the collateral cir-
culation  should restore the direct current into the aneurism;—not
to a point of the artery immediately beyond the giving off a con-
siderable  branch, lest  the  blood  passing along that branch should
prevent the  formation of the  clot necessary for the security of the
operation.  In the  single instance of aneurism of the common ca-
rotid, the  operation of tying  the artery on the distal side of the
aneurism (supposing the cardiac side inaccessible) is to be practised.
 That operation is  inadmissible,  unless you can be sure  that no
branch intervenes between the ligature and the aneurismal tumour.
   s. 60.] Hypertrophied artery.
   s. 65. 66. 67. &c] Degeneration of tissue.
   s. 70. <fec]  Aneurism.
   VI. Jules Cloquet gives a  remarkable instance of disposition to
true aneurism in a subject aged fifty.  Numerous sacculi were
found in all the second sized" arteries. The  aorta and  primary
branches had fewer.  There  was no  alteration of tissue;  but the 
310
MAYO'S OUTLINES OF PATHOLOGY.
sacculi  were thinner, as if produced  by simple dilatation.  The
same  author quotes a case of arterial hypertrophy occurring in
the common and external and internal  iliac trunks.   These vessels,
for their whole  length, were  elongated, sacculated, tortuous: the
middle coat had  lost its yellow colour, and in many places looked
like a thin  layer of fibro-cartilage:  it was supple and elastic in the
direction of the breadth of  the vessel.
                        SECTION  IV.

                           The Heart.

   I propose to treat ofthe pathology of the heart under the following
heads:—affections of the pericardium ;  affections of the valves and
lining membrane;  affections  of the muscular texture;  functional
derangement;  malformations.
   It may be useful to prefix a short account ofthe natural size and
position of the heart, and of the causes which produce the sounds
that attend its healthy action.
   a. Size. The heart, comprising the auricles, ought to have a size
either  equal to, or a little  less, or but  little larger than, the fist of
the subject.  The walls of  the left ventricle ought to have a thick-
ness a little more than double that of the walls of the right:  they
ought not to collapse when an incision is made  into the cavity.
The walls of the right ventricle should collapse when cut through.
The four cavities of the heart have nearly an equal capacity ; but
those of the right side  rather exceed  those of the left, and often
appear greatly to  surpass them, in consequence of distention  with
blood.
   b. Position.  A straight line  drawn across  the  breast bone,
uniting the lower edges of the cartilages of the third ribs  at  their
sternal insertions, passes before the valves of the pulmonary artery
a  little to  the  left of the mesial line:  the valves of the aorta are
situated directly behind the  pulmonary  valves.
   From  this  point  the aorta and pulmonary ar,tery ascend, the
former inclining forwards  and to the right;  so as, upon emerging
from  behind the pulmonary artery, to come in  contact  with the
sternum, and to the right of the mesial line:  the  latter, which is
from the  first in contact with the sternum, inclining more consider-
ably to the  left, till  it  arrives at the margin of the interspace be-
tween the insertions of the second and third ribs.
   A vertical line coinciding with the  left margin of the sternum
has about one third of the heart, consisting of the basial portion of
the right auricle and  right ventricle, on its right, and the remain-
ing portion of  the right ventricle  and the whole of the left on its
left.   The left auricle is situated deep behind, and to the left ofthe 
OftGANS OF THE CIRCULATION.              341
heart  at  its upper part, opposite to the interval between the carti-
lages of the third and fourth ribs.
  The apex of the heart beats against the cartilage of the fifth rib,
or ^against the interval between the fifth and sixth.
  The heart rests on the tendinous centre ofthe diaphragm, which
is stretched  horizontally to form  the floor of the chest, at or a little
below the level of the lowest part of the fifth  rib.
  The lungs  descend along the margin of the sternum about two
inches apart, and overlap the base of the heart slightly on the right
side and more extensively on the left: then receding from each
other, they leave a  considerable portion of the  right ventricle and
a less extent of the lower part ofthe left in immediate contact with
the sternum and fourth and fifth  costal cartilages.
  c.  Sou?ids attending the action of the heart.   The sounds pro-
duced during the natural action of the heart are two, which bear
the following relation in time to each other and to the interval
between  two beats: when the pulse is sixty in a minute the first
sound lasts half a second, the second sonnd'a quarter of a second,
the interval the remaining quarter of the second.
  The  first sound  is duller and prolonged,  the second smarter.
The first sound corresponds with the systole of  the ventricle, the
second with its  diastole.  This was ascertained  by experiments
made by Dr. Hope,  some of which I witnessed.
  The first sound  is probably  caused by the  flapping to of the
mitral valves  and protracted vibration of the cordaj tendineas, the
second by the flapping  to  of the sigmoidal  valves.  It was found
by Dr. Hope, that  preventing either valve from closing, by wires
passed into the heart, put an end to or impaired the sound attributed
in the normal state to its shutting.
 , The first sound  is to be  heard by the stethoscope applied over
the ventricles, the second by the stethoscope applied either over the
ventricles or over the aorta or pulmonary artery.
  I. Pericardium.
  a. Acute inflammation of the pericardium produces immediate
effusion.  The appearances observed relate to modifications of the
effusion, not to the condition ofthe membrane itself.  The latter is
not thickened: and when  there is most effusion,  the colour of the
pericardium is often natural; and when redness is seen, the redness
seldom  is  spread over  the whole  surface,  but  has a dotted  or
mottled character, or presents numerous small scarlet specks upon
a ground of the natural colour.
  The effusion  consists of lymph and serum,  or pus.   The two
first  are the most common.   When first effused, they are probably
nearly pure  liquor  sanguinis,—the blood  without the coloured
particles.   The  lymph  then coagulates;  the serum  remains fluid.
The latter is generally transparent, and of a faint  yellow or fawn-
colour;  sometimes turbid and semi-opaque or wheyey, sometimes
bloody.   The quantity, though variable, is in general considerable
within the first two, three,  or four days of the  disease, and may
       21—e                                    23 may 
342
MAYO'S OUTLINES OF PATHOLOGY.
amount to five or six ounces;  but it frequently amounts to more
than a pint.  Corvisart once found four.  It is speedily diminished
by absorption, when the  first  violence of the inflammation  begins
to subside; and after the lapse of a few days, the serum is in the
majority of cases not more abundant than the lymph.  Sometimes
in those who  have died of very  acute  inflammation, no  serum
whatever  is  found; while a copious exudation of thick  concrete
lymph fills and agglutinates the  whole cavity.
   The lymph which coagulates on the opposite pericardial surface
assumes, upon its  free surface,  a variety of forms.  Sometimes  it
has a cellular arrangement, and, according to the fancy of different
observers,  is thought to resemble lace-work,  or a sponge, or a
honeycomb, or some specimens of coral, or the interior of a calf's
stomach :  sometimes it bristles  with a multitude of small short-
pointed papillae ; less frequently it is softer and shaggy ;  always  it
is rough or uneven,  [t.  21. 22. 23. 24. 25.]
   Sometimes partial  adhesions  take place, which by the motion of
the heart become elongated,  [t. 26.]
   In general (the patient surviving) universal  adhesion ensues.
When the fluid has been sufficiently absorbed, the depositions of
lymph on the opposite surfaces of the pericardium come in contact,
unite, and  gradually become organised by vessels presenting them-
selves  under the successive appearances of blood-stains, straggling
lines, and,  lastly, of uniform purplish vascularity susceptible of in-
jection from the vessels of the heart.  The depositions are thus
converted  into perfect cellular tissue, by which the contiguous sur-
faces are more or less firmly, closely, and extensively agglutinated.
   When  adhesion is of recent standing, the  lymph is generally
thick, and  separable by  mere tearing into two layers, one adhering
to each pericardial surface.   In proportion as the disease is older,
the false membrane is thinner and firmer, consisting, in cases that
date several  years back, of the finest layer of dense cellular tissue.
[t. 28.]  In some, the removal ofthe thickness ofthe uniting layer
is so complete, as  to give the idea of direct union having been
effected.
   Purulent matter is not  common in pericarditis, and appears to
depend upon the protraction of the acutest form of the inflammation.
It is met with  diffused  through the whole cavity, or in circum-
scribed chambers between the adhesions.
   The muscular structure ofthe heart is rarely invaded by inflam-
mation.  Dr. Latham, however, met with  a  case of  carditis (in
which death took  place  after an illness of only two days), when
"the  whole  heart was  found deeply tinged with dark-coloured
blood, and  its substance softened;  and here and there, upon the
section of both ventricles, innumerable  small  points of pus oozed
from among  the muscular fibres."   Mr. Stanley records another.
It is probable that alterations in the colour and consistence of the
flesh of the heart occurring with pericarditis are results of lesser
degrees of inflammatory action that  has spread  from the membrane. 
ORGANS OF THE CIRCULATION.
343
   1 he occurrence of inflammation of the lining membrane in con-
 junction with pericarditis will be afterwards adverted to.
   In general, the symptoms of pericarditis  are  sufficiently pro-
 nounced—acute inflammatory  fever—pain in the  region of the
 heart, extending to the left shoulder and arm—hurried breathing-
 palpitation—the expression distressed and anxious.  But there "are
 cases in which these symptoms are not manifested; and the disease
 is liable to be  overlooked, and difficult, when looked for, to be iden-
 tified.  A symptom, however, may generally be detected, to which
 the  attention  of physicians has beeu  drawn  by Dr. Watson, that
 furnishes a certain ground of diagnosis  in many of the most ob-
 scure as well  as in the otherwise best marked cases.  The symptom
 referred to is  a murmur heard equally during the  systole and dias-
 tole of  the ventricle:  it appears to be superficial, and is produced
 by the  motion on  each other of the surfaces  of  the pericardium
 roughened by lymph.  Dr. Watson  uses the term to and fro sound,
 to denote this sign.  The sound is not, however, always to be per-
 ceived with equal  distinctness: it is heard at the commencement of
 pericarditis, and continues audible as long as there is no  great
 quantity of serum; it  then nearly disappears, but is heard again
 later in tho disease, when, from the serum being absorbed, tire sur-
 faces again touch  over a larger extent.   It is likewise not always
 distinguishable from valvular murmurs that attend  both the sys-
 tolic and diastolic sounds.
   A  systolic  murmur is generally heard in  pericarditis: this is
 supposed  to be often  produced by an accompanying roughened
 state ofthe valves from inflammatory vegetations adhering to them.
 But it is not. impossibe  that an increased and smarter action of the
 ventricle may alone be sufficient to produce it.
   When any  considerable quantity of fluid is forced out into the
 pericardium, other signs make their appearance.  A dulness of the
 fore part of the chest  on percussion, arising from the lung being
 pressed aside by the distended pericardial sac, which takes its place;
 and  sometimes a peculiar tremor perceptible to the touch from the
 undulation of the liquid in which the heart is beating.
   Pericarditis is not commonly fatal at the first attack: by bleeding
 and calomel the inflammation is generally arrested, and the absorp-
 tion  of the effused  lymph and serum  promoted.  What the practi-
 tioner apprehends  for his patient, is the gradual invasion  of hyper-
 trophy from the adhesion of the pericardiac surfaces, and of valvular
 disease  commencing  in  thickening of the valvular membranes
determined by coexistent endocarditis.   It is probable, however, that
 both of  these dangers are considerably overrated.
  6. Deposit of flakes of phosphate of lime is liable to take place
 below the pericardium.
  c.  Melanoma and medullary sarcoma, separate or mixed, [t. 35.]
are occasionally found in tubercles below the pericardium.
  2.  Affections of  the inner or lining membrane.
  Valvular disease of the heart consists in  the formation of deposits 
344
MAYO'S OUTLINES OF PATHOLOGY.
or growths in or upon  the  fibro serous membranes of which the
valves are framed.  The mechanical consequences of these forma-
tions are, permanent narrowing ofthe valvular openings on the one
hand, and on the  other imperfect  action of the valves when they
should close.  The valves of the  left side of the heart  are more
frequently diseased than those of the right;  and when the two are
simultaneously affected, those of the left side are commonly the
most disorganised.  WThen the system and the circulation  are tran-
quil, there may be contraction and immobility of the  valvular ori-
fices without prominent symptoms:  when, on the  contrary, the
circulation is strong aud excited, dyspnoea, palpitation, and a long
train of distressing sensations, make their appearance.
   The sources of valvular  disease are twofold; being either in-
flammatory growths and thickening, or ossific degeneration.
   a. Inflammatory action, which is to the full as often determined
to the inner as to the outer membrane of the heart, in consequence
of the rheumatic diathesis, produces two effects on the fibro-serous
texture of the valves.  This texture becomes internally thickened
by infiltration with lymph, so as  to resemble a close fibrous or even
fibrocartilaginous tissue; and externally covered with little fleshy
vegetations or excrescences, which are found either  isolated or in
clusters, and are of a yellowish-white or reddish colour, and of dif-
ferent degrees of firmness; in figure sometimes nodular, sometimes
like fine  serrae jagging  the  free edge of the  valves, [t. 40. 41.]
These little  warty excrescences consist of  adherent and  finally
organised fibrin, which has either exuded from the inflamed surface,
or has coagulated  from the blood flowing over it.  In an experiment
upon an ass, in which I assisted Dr. Hope, the aortic  valve,  which
had been held aside by a wire  passed into  the vessel, was  found,
when examined a few minutes afterwards, to be studded with these
warty excrescences, which admitted of being easily scraped off
from the irritated membrane.
   b. Ossific  degeneration, resembling the like change  in the arterial
tissues, is liable to occur in the  valves of the heart; irregular con-
cretions  of  phosphate  of lime, often joined  with   atheromatous
matter, being deposited underneath the serous membrane, and pro-
ducing its partial  absorption.  The rough masses of phosphate of
lime  project from the valves in various sizes and figures  in the
stream of blood flowing through the cardiac cavities,  [t. 45.  to 48.]
   The two  forms of  disease continually  occur in  combination.
Phosphate of lime is often deposited in the thickened semi-cartila-
ginous valve;  and, on the other hand, the  membrane covering a
primary deposit of bone frequently becomes the seat of a secondary
inflammatory vegetation.   When disease of this nature  has  once
commenced,  it is evident that it must be progressive: the diseased
valve is never relieved of the constant friction and pressure of the
blood.   At parts, the thickening of the valve goes on increasing,
and the  edge becomes  irregularly fissured : at other  parts the val- 
ORGANS OF THE CIRCULATION.
345
vular membrane becomes  thinner and extenuated, and is finally
ruptured through or torn from its adhesion.
  Diagnosis of valvular disease of the heart.   When the aortic
valve (alone) is thickened to that degree, with or without fissure or
laceration, that it cannot rise and fall so as alternately to leave  the
passage into the artery free, and to close it, it will follow, first that
the second  sound is small  or imperfect; secondly, that the passage
ofthe blood over the roughened valve at the time ofthe first sound
will  produce a  vibration of the valve which will cause a murmur
of greater or less sharpness (I have heard it musical, like the cooing
of a dove); thirdly, that the refluent passage of the blood into the
ventricle will produce a less degree ofthe same murmur; fourthly,
that the pulse will be sudden or jerking, the fulness of the artery
not being sustained during the diastole of the ventricle by the aortic
valves.
  Similar disease occurring in the mitral valves (alone) leaves the
second sound ofthe heart distinct and clear, and does not materially
interfere with the first;  but the passage of the blood over the valve
produces a  murmur both  at the time of the first sound and of the
second, which is principally to  be distinguished from the murmur
of diseased  aortic valves through its  situation—that is to say, by
its not being heard by the stethoscope  applied over the aorta, while
it is heard  satisfactorily when the instrument is applied over the
ventricle.  Disease ofthe mitral valve produces intermission ofthe
pulse: if the left auricle discharges  a small  volume of blood into
the ventricle, the latter in  its systole throwing half the  quantity or
more back  into the auricle, the quantity propelled into the aorta is
not sensibly felt at the wrist.   The  same thing may happen at the
ventricular systole, the pulse being then only felt at the wrist when
the left auricle is full enough to prevent material regurgitation into
it from the ventricular contraction.
   Disease of the valves ofthe pulmonary artery is stethoscopically
distinguished by  its place and superficialness.  Disease  of the
tricuspid valves is of extremely rare occurrence, but may be iden-
tified in a similar manner.
   The extreme interest of this subject, into which  my limits  pre-
vent  my entering at any length, may be exemplified  by pursuing
the following train of morbid sequences.  Suppose the mitral valve
to be thickened  and contracted, the auricle must labour doubly; in
its systole  it has to force the  blood  through a rigid  and narrow
passage, in its diastole it has no protection against the systole ofthe
ventricle.   The  auricle being distended with blood,  and acting
forcibly, the pulmonary vessels must  become gorged;  hence op-
pressed breathing,  spitting of  blood,  pulmonary apoplexy, serous
effusion into the lungs being loaded, the right ventricle must exert
unusual force to drive its  blood into the pulmonary artery ;  hence
it will  become dilated, and at the same time probably hypertrophied:
the ventricle dilating,  its auricular  opening  will gradually yield,
and the blood be forced backward into the ventricular systole; from 
346
MAYO'S OUTLINES OF PATHOLOGY.
the right auricle of course the refluent pressure tells upon the sys-
temic veins, and a systolic pulse  is thus produced in the veins of
the neck:  at the same time oedema may be produced ;  or, to follow
the retarded column of blood along the inferior cava, hepatic con-
gestion  and ascites, venous obstruction and oedema in  ihe  lower
extremities may ensue.  The heart at the same time, overwrought
and  irritable, is the  seat of pain  and palpitation  alternating with
syncope.  This instance may serve to illustrate the use of patho-
logical  knowledge: a few principles justly laid down, the explana-
tion  of an immense  assemblage of complicated  phenomena is
naturally and easily deduced from them.
   The  inner membrane of the heart, where it is reflected over the
muscular  structure, is often the seat of inflammation, which  leaves
patches slightly thickened or covered with adherent vegetations.
The same part of the membrane sometimes gives  attachment or
origin to  pendulous  tumours, which, if of gradual  formation, and
not of considerable magnitude, only produce symptoms  when they
happen to be so placed as  to interfere with the action ofthe valves.
   [t. 55.]  Is a  tumour  as large as a walnut, firm, and in a section
resembling a clot  of blood, growing from the left side ofthe septum
of the heart, and projecting into Ihe left auricle.   It  probably inter-
fered with the  closure of the mitral  valve,  towards which it pro-
jected:  and I am assured, that, during life, the first  sound of the
heart was wanting,  and  the  diastolic attended  with a murmur.
The  tumour  was either  medullary sarcoma,  or an instance of
slowly-forming polypus.  It seems now sufficiently established,
that the blood will  occasionally clot  in the cavities of the heart
during life, and form  adherent tumours.   The clots  that are sup-
posed to form during life are distinguished by being of much  firmer
consistence, more opaque, and less charged with serum than the
coagula which form after death.   Their texture  is  more distinctly
fibrous; they are often arranged in concentric  layers: they are
commonly found  on the left side of the heart.   In some of them
a cavity is found containing blood, or matter like the lees of wine,
or pus.  M. Laennec thinks that polypi of considerable  magnitude
(of sudden formation) may be recognised by the following physical
signs.  When in a patient  who till then may have presented regular
pulsations of the heart these suddenly become so anomalous, con-
fused, and obscure, that they can no longer be analysed, we may
suspect the formation of a polypous concretion; and if this  disurbance
takes place on one side only, the indication is almost certain.
   III. Alterations of the  muscular structure of the heart may be
classed under  the heads  of  inflammation,  hypertrophy, atrophy,
steatosis, cysts, and morbid growths.
   a.  Inflammation.
.   1.  Acute.  This rare affection has  been  already adverted to in
connection with pericarditis.
   2.  Chronic.  To  this head  may be referred induration  of the
heart.   The muscular substance  is hardened so as to present unu- 
ORGANS OF THE CIRCULATION.
347
  octZThn    °, thGr SCa,peV *e CO,our  unaltered.   It generally
  STL   Wh°leofa ventricle, but sometimes only a  portion ;
  rjL?78!00"^7 ^y state  of the organ  as  to size, though
  most commonly it is conjoined with hypertrophy              &
    b. Hypertrophy is an augmentation ofthe substance ofthe heart
  from excess of growth.  It presents  three  varieties : hypertrophy
  of the valves  without alteration of the cavity;  hypertrophy with
  enlargement ofthe cavity ; hypertrophy with contraction.
    1 he muscular  substance in hypertrophy is usually firmer and
  redder than natural.  The augmentation  of growth mav be con-
  lined to a single cavity, or it may affect several"and  even the whole
  simultaneously.   Sometimes one cavity is thickened while another
  is attenuated.   The  ventricles  are more frequently hypertrophied
  than the auricles.  When all the cavities are hypertrophied, and at
  the same time dilated, the  heart attains a  volume,  two, three, and
  occasionally even  four times greater than natural: its form instead
  of being oblong is spherical, its apex is hardly distinguishable, and
  it encroaches so  far upon the loft cavity of  the chest" as sometimes
  to raise the lung as high as  or  higher than the  fourth rib; some-
  times even it occasions a preternatural prominence  at the prsecor-
  diarregion.—Hope.
   The left  ventricle is  more prone to thickening,  and not less to
 dilatation, than the right.  The valves of the left ventricle,  the na-
  tural thickness of which averages  about half an  inch in the adult,
 may be increased  to the extent of one or  one and a half to two
 inches.   The cases are rare in which  it  exceeds  an inch and a
 quarter.  The situation of the greatest thickening is  usually a little
 above the middle of the ventricle, where the columnae carneae take
 their  origin.  Thence  the  thickness decreases  rather suddenly
 towards the  aortic  orifice, and gradually towards the apex, where
 it is reduced to less than half.  When  hypertrophy maintains these
 proportions in the  different parts of the ventricle, the state is  only
 an exaggeration of the natural  form.  The case  is  different when
 the hypertrophy  takes place inwards, and  diminishes the cavity;
 for then the whole ventricle is nearly equally  thickened,  and its
 form  is unusually globular.—Hope.
   Hypertrophy of the heart, we may presume; is produced by all
 the causes which promote increased action of the muscular fibre of
 the heart  in persons of a strong  frame and  sanguine temperament.
 These causes are either  general or local:  the general are either
 mental  or physical—strong  excitement  or  bodily  exertion; the
 local, obstructions to  the passage of the  blood  calling for unusual
 effort  (so  hypertrophy of the left ventricle is produced by contrac-
 tion of the aortic opening, of the right ventricle  by disease of the
 mitral valve, or by any impediment to the pulmonary circulation,)
or embarrassment ofthe free play of the heart by adhesions  of the
 pericardium,  necessitating in another way unusual force.
   Protracted rheumatic fevers are said to have given rise to hyper- 
348
MAYO'S OUTLINES OF PATHOLOGY.
trophy, when  there has  been apparently no inflammation  of the
heart or its membranes.
  The symptoms  of simple  hypertrophy of the left ventricle, are
such as result from its  increased force : a strong impulse is felt at
the ventricular systole, which is of unusual duration, heaving up
the chest, and prolonging the pulse.  If the hypertrophy is unat-
tended with dilatation, the natural systolic sound  is distinct and
dull; if attended with  dilatation, the sound is loud and smart. The
direct tendency of the disease is to induce apoplexy.  Hypertrophy
of  the  right  ventricle tends to produce  pulmonary congestion,
spitting of blood, pulmonary apoplexy.  The capillaries oppressed
by  a too powerful impulse  from the heart, give  passage  to the
serum, and anasarca ensues.  The heart, irritable from the violence
of its action, is easily excited to fits of palpitation.
   The relation of hypertrophy to valvular disease is complicated
and curious.   Hypertrophy  in some instances is caused by, and
corrects the latter.  Suppose the aortic aperture narrowed,  and  its
valvular  structure too rigid  to close ; the  left ventricle has double
work in  impelling the blood through it, and at its diastole is op-
pressed by regurgitation.  Called upon for unusual exertion, the
left ventricle in a strong heart becomes under  these circumstances
hypertrophied ;  and it will  sometimes happen  that  the  increased
force it thus obtains will for a time only  and  sufficiently balance
 the impediment at the aortic valve.   In other cases, hypertrophy
 may produce valvular disease, and its effects be aggravated through
 the latter cause.
    3. Atrophy ofthe muscular structure of the heart presents three
 accidental varieties of feature.
    a. Simple atrophy.  The heart collapsing by its own  weight,
 its texture soft, and rather of a darker red than usual, or of a faint
 yellow, or fawn colour.  The  symptoms, probably a quick, feeble,
 and  faltering pulse, and disposition  to  syncope.   Death might be
 produced, I presume,  in this case, through continued syncope; or
 even by  rupture of one of the parts of the heart that are naturally
 the feeblest, the appendage,  for instance, of the left auricle.  This
 accident I have known to happen in a healthy heart under excite-
 ment.
    b. Dilatation with attenuation of the muscular structure.  The
 symptoms the same as in the preceding case, with the aggravation
 of a  retarded circulation, and consequent anasarca.
    Dr. Hope mentions a  case of this affection in a gentleman seventy
 years of age, in  whom, when upon  the night-chair, the ventricle
 gave way by a fissure an inch in length.
    c. Aneurism of the heart means  partial dilatation, with thin-
 ning ofthe parietes.   The  seat of this  disease is the left ventricle.
 Though probably, in general, a consequence of atrophy, it must be
 liable to  be produced by ulceration of the inner  surface,  or by a
 cyst breaking into the ventricle. 
ORGANS OF THE CIRCULATION.
349
  Atrophy of the heart is liable to occur in  those whose hearts are
originally  preternaturally  thin  and feeble.  Excitement in such
cases, instead of strengthening weakeus the organ.  Atrophy again
results from  insufficient nutritive energy: it is promoted by ossifi-
cation ofthe coronary vessels.
  4.  Steatosis.  In atrophy the heart is often loaded with fat de-
posited between  the pericardium and the muscular texture.   The
heart is likewise susceptible of steatosis, in which its flesh is found
soft and  pale-coloured and greasy, as if its texture was infiltrated
with an  oily matter.  Steatosis has only been found  partially af-
fecting the ventricles.
  5. Cysts and other tumours of small size occur in the substance
of tiie heart, without sensibly deranging its action.
  IV. Functional disorder.  The  most distressing feelings which
arise  in organic  disease of the  heart, have been  grouped together
under the name of angina pectoris ; they consist of a sense of pain
and constriction at the pericardial region, accompanied with numb-
ness and thrilling of the left arm, sometimes of both—oppression
of breathing, palpitation of the heart, congestion in the head, and
followed perhaps by syncope and convulsions.   Paroxysms of this
nature are  liable to take place in any form of organic  cardiac dis-
ease.   They result,  it  appears to me, directly from  extreme irrita-
bility ofthe heart, brought on by working under the disadvantages
of impaired organisation.   They may therefore be expected to flow,
though  less frequently, and in a form less severe, from excitement
of the heart without organic disease; and this is frequently found
to be  the case.  Pain  in  the cardiac region, palpitation, pain and
numbness  extending down the left arm, and affecting particularly
the ulnar nerve,  are features of daily occurrence, where  organic
disease  certainly does  not exist.   Their recurrence  may be pre-
vented or mitigated by attending to the cause which may have pro-
duced them—whether over-exertion of  mind or body—excess or
incautiousness in  diet—or plethora, requiring  the occasional ab-
straction of blood.
  In  hysterical  females, and perhaps generally in persons of a
nervous  temperament, these uneasy  sensations are  liable to be
coupled with a symptom that at first  gives  the  impression of or-
ganic mischief.  A murmur is often distinctly heard attending the
ventricular systole, conveying the  idea that  the  aortic valves are
diseased.   But this  murmur comes and goes,  and  whatever its
cause, it is  independent of any change of structure.  The pulse at
the time  is quicker than natural, and jerking, and it is  possible that
a suddenness of expulsion of the blood through the aortic orifice
may be sufficient to give rise to this sound.  Dr. Hope is of opinion
that in such  cases  something may be  attributed  to an attenuated
state of the blood ;  and the experiments upon which  he grounds
this conjecture are extremely curious, and  seem strongly  to  bear
out his ideas.  He  found that  if he  subjected  dogs  to  repeated
bleedings, the heart  became irritable, the pulse frequent and jerk- 
350
MAYO'S OUTLINES OF PATHOLOGY.
 ing, and the blood greatly attenuated : at the same time a systolic
 murmur became audible.
   V. Malformations.  The following enumeration  is given by
 Dr. Hope.
   a. The heart single, like that of a fish, consisting of  one auricle
 and one ventricle, from  which springs a trunk that presently di-
 vides into the aorta and  pulmonary artery.
   b. Two auricles and one ventricle.  In one case the patient at-
 tained the age of twenty-two.
   c. The foramen ovale  remaining  open.  This is the  most com-
 mon malformation, and is found at all ages, sometimes  even at the
 extreme period of senility.
   d.  The foramen ovale and  ductus arteriosus  both  remaining
 open.
   e. The foramen ovale and ductus arteriosus open, and the pul-
 monary artery obliterated at  its origin.  In one case the cavity of
 the.  right ventricle was nearly obliterated, and  in two others the
 septum ofthe ventricles was perforated.
  /. Ventricular septum deficient; auricular imperfect.
   g. Ventricular septum deficient at the aortic orifice, so as to leave
 a common opening into  that vessel  from both ventricles.  This
 malformation is generally accompanied with contraction of the
 pulmonary  artery, frequently with an open  state of the foramen
 ovale, and occasionally with obliteration of the pulmonary artery,
 and palescence ofthe ductus arteriosus.
   h. Ventricular septum perforated towards  the base;  associated
 with  contraction of the  pulmonary  artery, and palescence of the
 base.
   i. Foramen ovale  open ;  and  pulmonary  artery arising from
 both ventricles ; and giving off  the descending aorta, while the as-
 cending rises  in the usual way.
   k. Aorta  rising from the right  ventricle, and pulmonary artery
 from left, the foramen ovale, and sometimes ductus arteriosus re-
 maining open.
   I.  The right auricle opening into the left ventricle instead of into
 the right, and the ventricles communicating by an aperture imme-
 diately below  the aortic valves.  The foramen ovale open.
   The  common feature resulting  from such  malformations is the
 admixture ofthe black blood with  the arterial.  When this is  con-
 siderable, the  lips are  blue, the countenance and extremities livid;
 the power of resisting cold small ;  breathing  hurried on  bodily ex-
 ertion, and liability to palpitation  and syncope.  When the com-
 munication  is inconsiderable,  no sensible result ensues from it.
 Free communication of the two sides of the heart  is almost  con-
 stantly  accompanied  with hypertrophy  or dilatation of the right
cavities,  whereas the  le"t  are very rarely affected.   This circum-
stance is probably attributable on the  one hand to the  direct force
of the left cavity acting against the  right—on the  other hand, to
the effort to maintain a vigorous pulmonary circulation. 
ORGANS OF THE CIRCULATION.
351
                          SECTION  V.

                          The Blood.

  a. Causes that excite the circulation, make the blood slower of
coagulating.  By loss  of  blood, its  tendency to  coagulate  is in-
creased.  Mr.  Hewson, who ascertained this to be fact by observa-
tions  on slaughtered animals,  introduces  the following remark,
which is not without interest, as exemplifying the  half perception
of a principle, which generally precedes its true knowledge.
  "I recollected," says Mr. Hewson, "a remark  that 1 had heard,
particularly from  Dr. Hunter, which is—that the faintness, which
comes on after hemorrhages, instead of alarming the bystanders,
and making them support the patient by stimulating medicines, as
spirits of hartshorn and cordials, should be looked upon as salu-
tary ; as it seems to be the method nature takes to give the blood
time to coagulate."
  Loss of blood reduces the specific gravity ofthe blood in propor-
tion to its frequency ;  the  red particles and  the fibrin are repro-
duced with more difficulty than the serum or the  salts.  The serum
also becomes lighter from a gradual diminution of its solid con-
tents.   The blood sometimes  loses its tendency  to  coagulate, and
has the  appearance of serum and  red  particles.  Mr.  Hewson
describes a case of fever where the blood presented this character,
but the patient dying a few days afterwards, coagula were found in
the great vessels.
  6. The blood in the  veins in some instances has the colour of
arterial  blood.
  A man was admitted into the Middlesex Hospital, who had been
stabbed  in  the belly j the  bowels protruded, and  were  wounded in
several places ;  I sewed the wound  with a continued  suture, and
returned the intestine.  Twelve hours afterwards, severe pain in
the abdomen having supervened, I bled him to thirty ounces.  The
pulse  became irregular.  The pain was slightly mitigated.   The
blood  was  bright and  florid, like arterial blood.   He  died within
thirty-six hours of the  injury.   The appearance of the  peritoneum
barely indicated co.nmencing inflammation.
  A man was admitted into "the hospital, who had received  a vio-
lent blow on the lower part ofthe abdomen :  he was faint and sick
at the time of his admission.   The next day there was pain and
tenderness  of the belly at  the part which had been bruised ;  the
countenance  pale and  anxious, the pulse not remarkable.   I bled
him to eighteen ounces, and he felt relieved.  The blood was  florid,
like artenal blood :  no  further treatment was tried, but rest and low
diet, and he  recovered.   A third  similar case will be given after-
wards.                                         .      .      . *
  c. General anaemia,  or a deficiency in the quantity of circulating
blood,  whether induced by natural  or artificial causes, is highly 
352
MAYO'S OUTLINES OF PATHOLOGY.
detrimental  to  health.  The symptoms are general pallor, weak
circulation, languor,  syncope with palpitations, oppressed respira-
tion, flatulency, general oedema, and, in extreme cases, effusion
into all the serous cavities.
  In chlorosis nothing is more constant than an impoverished con-
dition of the blood, which is  thin, light-coloured, and weakly coa-
gulablo, being deficient in  fibrin, and still more so  in the propor-
tions of the red particles.   To the latter cause is  to be attributed
the diminished temperature of the surface, together with  the uni-
versal  pallor and waxy appearance, which  those who are  the
subjects of this disease exhibit.   The deficiency of colour  in the
catamenia, and the  pale stain which hemorrhages from  the nose
leave on  linen are referable to the same cause.  In two well-marked
cases of chlorosis, wherein  an analysis of the  blood was  obtained
by  Mr. Jenkins,  the blood contained 871  and 852 parts  water,
instead of 780  parts, the natural standard ; and  colouring  matter
48.7 and 52, instead of 133.   The  albumen and salts  were in the
usual proportions.
   d. Blood may be excessive in quantity,  constituting  plethora,
whereby the circulating system is supplied  more  abundantly than
is needed for the due performance of the functions of nutrition and
secretion.
  A tendency  to accumulation  in  the  capillaries  and in the dif-
ferent  internal  organs is hence induced, and congestion with its
consequences, or actual  rupture of the blood-vessels, are liable to
result.  Drowsiness,  vertigo, headach,  epilepsy,  apoplexy, mark
this state as existing in the head ; dyspnoea, and a livid or  purple
hue of the  skin, as  affecting the lungs; palpitation and  irregular
action, with syncope, mark the struggle of the overloaded heart to
propel its contents.
   Hemorrhages from the  mucous  membranes of the  nose, the
lungs, or the intestines, are often consequences of congestion ofthe
vessels which ramify on their surface ; while  indigestion,  torpor,
xmd biliary redundancy, are  connected  with a plethoric condition
ofthe abdominal viscera.
   d. Inflammatory  blood is  characterised by a colourless crust or
size upon  the  upper surface of the  clot, which in the acutest in-
flammation is ofthe  depth of a quarter to a third of an inch, and is
strongly contracted or cupped.
   The  principal facts which are known upon this subject, were
observed by Mr. Hewson.  They are the following:—
   1. In inflammatory  blood the  process of coagulation is slow, but
the red particles begin to subside immediately, as may be seen in
the bluish cast which  the surface assumes,  from  which a transpa-
rent liquid can be taken that coagulates.
   2. The subsidence ofthe red particles depends upon attenuation
ofthe fibrin.
   In two phials, one of inflammatory serum, one  of uninflamma-
tory serum, a teaspoonful of  serum loaded with red particles (from 
                ORGANS OF THE CIRCULATION.             353

uninflammatory blood) was poured.   They  subsided  with equal
slowness in both.  Two teaspoonfuls, one of serum with  red par-
ticles from  inflammatory  blood, one of serum  with red  particles
from uninflammatory blood, were poured into two phials of unin-
flammatory  serum.  There was no  difference in  the  time of the
subsidence of each.
  3. The disposition to form a size is capable of being modified in
a very brief period, by the condition of the nervous system.
  A young  man of an athletic habit, was bled  in an attack of in-
flammatory  fever.  Upon  opening the vein, the blood  flowed very
slowly.   The  pulse in the other wrist was low, and  he admitted
that he had  been afraid of the operation : it was four minutes be-
fore an ounce and a half could be drawn into another cup.  The
orifice was then stopt till  a second cup was  brought, into which
three ounces were drawn in a full stream, in two minutes. A third
cup was then substituted, into which the blood'flowed in  less than
two minutes.   By this time  the  patient began to  be faint; the
bleeding was  stopt till he lay down on the  floor, and then about
three drams more  were received into a fourth cup : this came very
slowly, and  the bleeding stopt of itself.   Upon this blood Mr. Hew-
son adds the following remarks.
   "That which was  taken away last  was first  coagulated, and
completely  too,  by the time I had tied up his arm, which was in
three minutes  from the blood's first running into the cup.
   " The blood  which  was  received  into the first cup coagulated
next, and, as I observed by my watch, in twelve  minutes from its
being set down on the table.
   " That which was received into the second cup  was the third in
order as to coagulation, and was considerably later in jellying than
the first; for in fifteen minutes it was not thoroughly  coagulated ;
nay, even in twenty-two minutes a small part of it was still fluid.
It was remarkable that none of these three had any size.
   " But the blood in the third cup differed  considerably from that
in tho others ; for in five  minutes it began to appear transparent
on its surface, an  indication of a future size, and it  was later in
coagulating than  that  in  the other  cups ; for even at the end of
twenty-six minutes a great part of the coagulated lymph was still
fluid, as appeared on removing the pellicle that covered it; but in
thirty-five minutes it was  completely jellied.  The size in this blood
was very thick and tough."
   Milky serum.  The oil or unctuous soft solid which is  now as-
certained to be one of the constituents of healthy blood, is liable to
morbid increase under various  forms of disease.  Morgagni cites
twocases of malignant fever in which the serum was  milky.  Hew-
son, besides enumerating instances to be met with  in authors, gives
three cases  sent him by'medical friends: one of amenorrhea with
dyspepsia and vicarious discharge of blood by vomit and stool;
another  of  violent and continued epistaxis,  and a third of dys-
pepsia with  slight asthma.  In all three cases there were symptoms 
354
MAYO'S OUTLINES OF PATHOLOGY.
 of plethora; but milky serum is by no means necessarily connected
 with this state.   The most marked instance that Dr. B. Babington
 has met with, was in a case of diabetes, where bleeding was several
 times repeated at long  intervals, and on each occasion  the same
 morbid condition of serum was observed.  This was quite opaque,
 and nearly as white  as milk ;  and on standing for a few hours, a
 film of matter resembling cream covered the surface.  The clot
 could not be seen when it was scarcely a tenth of an inch beneath
 the surface.   It had a firm, very thick, white coat of fibrin, and the
 red particles were almost diffluent beneath.   The patient, a female,
 could not be called plethoric, having been the subject of her ema-
 ciating complaint more than  a year and a half.
   An instance, of which I have kept a note, is that of a gentleman
 who was seized  in  the night with feelings of nervous excitement
 and alarm, with a hurried  circulation, proceeding from indigestion.
 I bled him to  fourteen ounces;  the blood exhibited a milky serum.
   In disease of the kidney.   In those organic diseases of the kid-
 ney which are characterised by anasarca, and the passing of urine
 coagulable by heat and acids, the  albumen ofthe blood is more or
 less deficient in proportion ;  and this is marked by a corresponding
 diminution in the specific  gravity of the serum.  The two follow-
 ing instances are from notes  of cases by  Dr. G. H. Barlow, who
 has devoted  much attention  to the  examination of the blood and
 urine in this disease.
   From a patient affected with general anasarca—the urine was
 copious, clear, pale,  coagulable by heat and  nitric acid; specific
 gravity 1.011.  Blood cupped  and  buffed, serum milky; specific
 gravity 1.019. The healthy specific gravity of serum 1.028.
   From a man aged 48, affected  with  anasarca—the urine was a
 dingy brown ; natural in quantity, and coagulable : specific gravity
 1.003.  Blood cupped and buffed: specific gravity of whole blood '
 1.037.
   These notices are contained in an excellent account by  Dr. Ben-
 jamin Babington, ofthe morbid condition of the  blood, in the fifth
 number of Dr. Todd's Cyclopaedia, from which having already
 largely borrowed, I likewise extract the following.
   In the cases of diseased  kidney referred to, a result analogous to
 that which follows extirpation occurs ; for  while that organ is  per-
 mitting albumen  to pass through it unchanged,  the urea  which it
 should separate is very generally if not always found in the  blood.
 This has been  proved by Dr. B. Babington in repeated instances,
 and it is now so generally admitted from the experiments of Prout,
 Christison, and others, that it is scarcely worth while to cite cases.
 Dr. Bright, vol. ii, p. 447,  alludes to several specimens of serum
from patients under this disease, which were submitted to exami-
nation, in some of which urea was detected, in others not.   In one
very remarkable instance of a young  woman,  the albuminous state
of whose urine constantly  existed for above three years, the urine
contained less than  one-third of the normal proportion  of urea, 
ORGANS OF THE CIRCULATION.
355
 while about one per cent, of albumen supplied the deficiency.  The
 serum of the blood was, as it has  been  already  remarked to be
 usual in this disease, of very low specific gravity, being only 1.021
  rhe quantity of albumen in 1,000 grains amounted, after careful
 drying, to only 50 grains instead of 78, (Lecanu's healthy standard,)
 and it contained fully as much urea as the urine itself, the 1,000
 grains yielding nearly 15 grains of that principle.
    Diabetes.  The  blood in diabetes is remarkable for the length
 of time that it can resist putrefaction ;  but hitherto no other differ-
 ence  has been determined  in  its  qualities from those of healthy
 blood.   Dr. B. Babington remarks, with equal ingenuity and pro-
 babi ity, that the failure of chemical analysis in this instance may
 result  from venous, not arterial blood, having been used.   The
 kidney may be vent enough for the abnormal ingredients.
    Cholera.   In the stage of collapse the blood  is  thick and dark,
 resembling treacle or tar. Specific gravity high ;  the serum vary-
 ing from 1.040 to 1.045 at 60 Fahr.; the solid matter, according to
 M. Lecanu, double that of the healthy  proportion.  Cholera  blood
 contains less  water and more albumen  and haematine than healthy
 blood,  and its salts are  in  unusually small quantity, or  almost
 entirely  wanting.   Dr.  O'Shaugnessy detected urea  in  cholera
 blood.
    Fever.  In those fevers which  arise from  marsh miasmata or
 from contagion, it is an opinion held by Dr. Stevens, and supported
 at great  length in his work on  the blood, that a diseased condition
 of that fluid is the first in the train of symptoms which occur, and
 the immediate cause of those which follow.  The blood itself, says
 Dr. Stevens,  is  both black and diseased  even  before  the attack.
 During the cold  stage it is very dark.  When first drawn  it has a
 peculiar smell, and coagulates almost invariably without any crust.
 There  are  black spots on the  surface of  the crassamentum;  the
 coagulum is so soft that it can easily be separated by the  fingers,
 and during its  formation a large quantity of the black colouring
 matter falls to the bottom of  the cup.   In the hot stage it becomes
 more red, and, in some cases, it is even florid for a time, but during
 the remission  it is darker in colour than the blood of health, and
 decidedly diseased in all its properties.  In milder  cases, the  blood
 which is drawn may coagulate  without a crust on its  surface ; but
 in  the more severe forms of this fever, when the blood was drawn
 at an advanced period ofthe disease, a part ofthe albumen coagu-
 lated on  the surface of the  fibrin, and formed a  diseased mass,
 which in appearance had a greater resemblance to oatmeal gruel
 than to blood  drawn  from a healthy person.  The serum which
separated was also diseased; it had a brownish  colour, and in
some cases  an oily  appearance, which is  never met with in the
clear serum of healthy blood.   In  the  climate or seasoning  fever
ofthe West  Indies, which is not considered contagious, but a  fever
of excitement, tjie blood  drawn in  the first stage  flows from the
vein with great force, but is  neither  cupped nor buffed.  It is so 
356            MAYO'S OUTLINES OF PATHOLOGY.
florid, being charged with salts which ought to have been removed
by the organs of secretion, that  it resembles arterial  blood.  The
fibrin coagulates firmly, and in some cases the serum which sepa-
rates from it has a bright arterial colour, the colouring matter being
not merely diffused through, but combined with the serum.  Dur-
ing the progress of  this kind of  fever the blood loses a  large pro-;
portion of its fibrin  and albumen, and becomes so thin that it oozes
from the mucous membranes without any abrasion of surface, and
in the last stage turns quite black from a diminution in the propor-
tion of its salts.
  Such are the appearances which the  blood  presents in the more
severe fevers  of hot climates.   In  this country, at the commence-
ment or stage of depression the blood is dark and tarry, coagulates
quickly, and forms  a large clot with but little serum.  As the stage
of excitement advances, the blood becomes thinner and more florid,
and flows more freely.   Coagulation  takes place  more slowly, and
a buffy crust  is frequently formed on the  surface of  the clot.  In
the latter stage, when the powers are giving way,  the blood be-
comes thinner, darker, and more dissolved.  It scarcely  coagulates
at all, and is deficient in saline matter, and probably also in fibrin,
thus  nearly  resembling  menstrual blood,  or  the  fluid mixture of
serum and red particles, already mentioned as often found in  the
larger vessels after death.  Such  are  the alterations  which  the
blood usually undergoes in the different stages of simple continued
fever, but in its more  malignant forms, as in typhus, the  blood is
generally very watery, even from the commencement.  As the dis-
ease advances, it gradually loses its power of coagulation,  and in
the last stage seems almost entirely deprived of fibrin.
   Magendie has artificially produced an analogous  state of blood
by injecting putrid liquids into the veins of animals, and the speed-
ily fatal disease which he thus caused had a strong  analogy with
typhus fever.
   To Dr. Stevens  belongs the merit of having especially  directed
general attention to the circumstance, that the saline  matter of the
blood  gradually disappears in the progress of fever, and is almost
entirely lost  in its  last stage.   This he ascertained  by direct ex-
periment, and his  facts have since  been  confirmed  by Jennings,
who in the interesting report already alluded to, gives an analysis
ofthe blood in six cases  of continued fever, in which the alkaline
salts  were found diminished in the following proportions:—
In  healthy serum, according to  Lecanu, salts.....8.10
In  the serum of a male, aged 31, first day of fever, salts  .  .  4
Ditto                   aged 34, first day  of fever, salts   .   .5
Ditto           female,  aged  14, fourth day of fever,  salts  .  4.2
Average of three other cases...........4.4

   Jaundice.  In jaundice the blood, both arterial and venous,  is
tinged with bile, and this  is  apparent not only in the  serum, but
still more strikingly in  the crassamentum, provided  it  be covered 
THE RESPIRATORY ORGANS.
357
n^nln "f    LSUJfaCe' , If thlS be removed and  d"«* in a state of
tension, it exhibits a deep yellow hue, particularly when viewed
by transmuted  light.   Although  the  bile is^  hus^^ndere^ ve^
men Vinih'dfl ^ ye!' ^ to itS -mbinatfontith aTbu"-
men, which defends it from the action  of acids, it is difficult of de-
tection by chemical  reagents, so that many chemists  of eminence
have sought in vain to ascertain its presence. Lassaigne, however.
succeeded in demonstrating that the colouring matter of the bile is
really  to be  found in the circulation, and Berzelius tells us that
Collard and Martigny pretend to have discovered even the resin of
bile in jaundiced  blood.  M. Lecanu has more  recently confirmed
these facts, and Mr. Kane has verified his results.   To  the medical
inquirer who does not follow the minutiae Manimal chemistry, the
identity of  the colouring matter in the serum  of jaundiced  blood
with that of the bile itself  will be  rendered sufficiently evident by
adding to it an equal quantity  of sulphuric  acid diluted with twice
its bulk of  water.   The serum will thus change its yellow hue for
the characteristic green colour of acid bile.  Experimentalists have
failed in producing this effect, being probably  misled  by having
found that the small proportion of acid which is required to strike
a green colour with urine  charged with bile,  produces no such
effect when added to jaundiced serum.
     CHAPTER XII.

THE RESPIRATORY ORGANS.
  The organs of respiration will be treated of in the following
order:—the pleura; the lungs and trachea:  larynx; thyreoid and
thymus glands.
                          SECTION I.

                            Pleura.

   The cavity ofthe pleura extends upwards to the first rib ; down-
wards, in front, to the cartilage of the seventh rib: and, laterally,
to an inch and a half from the margin of the chest.  The level to
which the lungs descend may be  found  by a line drawn from the
angle between the ribs and xyphoid cartilage to the eleventh dorsal
vertebra.  Upon the right side in a healthy  chest the correctness of
this rule may easily be verified by  percussion, the hollow sound of
the lungs contrasting strongly with the dull sound of the liver.
      21—f                                    24 may 
358
MAYO's OUTLINES OF PATHOLOGY.
Below the line indicated, the pleura  costalis and pleura diaphrag-
matica are naturally in contact.
  The alterations of which the pleura is susceptible are, inflamma-
tion   and its  ordinary  consequences—empyema,  pneumothorax,
pneumothorax with liquid effusion, haetnothorax, hydrothorax, ma-
lignant disease.
  1. Pleurisy.  Acute inflammation of the pleura, like acute peri-
carditis,  produces  an immediate  effusion of fluid lymph more  or
less diluted with serum.  Part of the lymph coagulates, and forms
a thin, spongy, fibrinous layer, which adheres to the surface ofthe
pleura, and becomes organised,  [u. 89.]  When the inflammation
subsides  early, and the quantity of effusion is not great, the part
which remains liquid is entirely absorbed.  The surfaces covered
with lymph then come into contact, and adhere.  After a time the
medium  of union degenerates into a filamentous tissue, the threads
of which are drawn into lengths by the motions of the chest and
lungs, [u.  91.]  When the effusion is considerable  in  quantity,
amounting to nine, ten, or eleven pints, it appears to  be incapable
of absorption, and requires to be let out by the operation of paracen-
tesis thoracis.   The  wound thus made heals.   The fluid does not
reaccurnulate.  The air, which has got in, is absorbed.  The lung
is again  dilated.   The fluid effused  at the commencement of pleu-
risy  is probably pure liquor sanguinis—the blood  without the
coloured particles.   It has been  observed, that the tendency of the
blood to  coagulate  is restrained by the contact of a  living surface.
The same holds with liquor sanguinis.  Accordingly, when, upon
the chest being punctured, fluid  which has been  some  weeks  in
that cavity is evacuated,  a considerable  filmy coagulation takes
place in  it.  The liquid and fibrin  of  pleuritic effusion are some-
times tinged with blood.
  The symptoms  of pleurisy are, inflammatory fever  ; pain on in-
spiration or a stitch, the ordinary seat of which is just below and
without  the nipple, the stitch being commonly on the side diseased,
but sometimes on  the other; disposition to lie on the  affected side;
dyspnoea.  When  the effusion is  considerable, the patient can only
lie on the  side  affected, which appears fuller and larger than  the
other; the  intercostal spaces are prominent;  the  ribs motionless.
At the commencement of  pleuiisy, or when  the effusion is small
in quantity, a rubbing sound may sometimes be heard by the ear
applied to  the chest, or even felt; which is supposed to arise from
the motion of the  opposed surfaces roughened with lymph  against
each other.   But the characteristic stethoscopic sign  of pleurisy is
one, which depends upon a thin stratum of liquid intervening be-
tween the lungs and the walls ofthe chest.  In that case the voice
ofthe patient, when heard through the  instrument, has a squeaking
tone resembling that of Punch; or a shrill sharp tone  seems vibrat-
ing upon the surface of the lung, echoing, or rather accompanying
the voice of the patient.  This sound is termed oegophony.' It dis-
appears as  the quantity of fluid increases:  at the  same time the 
THE RESPIRATORY ORGANS.
359
chest is dull on percussion, and the lung being compressed, respira-
tion  is totally extinguished in it.  When in the ordinary precis of
recovery the liquid is in  great part reabsorbed, the cegophony be-
comes again audible.   At this period the affected side becomes less
than  the other;  the lung being slower in expanding to its original
size  than the water in being absorbed.
   Chronic inflammation  ofthe pleura displays various features;
or, under this head, several dissimilar affections have been grouped.
   One of these is attended with the formation  of a general" layer of
adherent lymph upon the  pleura, and immense serous effusion, but
is without the characteristic pain or fever of pleurisy.  This affec-
tion  existed,  masked  by other disease, in  the  case of tuberculous
affection of the pancreas given in sect.  ix.  ch. ix.
   A less effusion, with partial deposition of lymph depending upon
partial inflammation, is of frequent occurrence.
   Thickening ofthe pleura without adhesion [u. 93.], the membrane
sometimes approaching cartilage in hardness and crispness, is an-
other consequence of chronic inflammation.  Phosphate of lime is
sometimes deposited in pleuritic lymph.
   Empyema.  Suppuration in the  pleura is less a consequence of
chronic than of protracted acute inflammation, [u. 90.]  This com-
plaint may  be surmised  to exist, when  the  symptoms  denoting
pleuritic effusion, instead of gradually lessening, persist, the patient
falling at the same time into hectic fever.   In tbis case paracentesis
thoracis is again necessary.  In a boy, upon whom I performed that
operation, for empyema ensuing from fracture of the ribs, complete
recovery followed: the discharge of matter slowly  lessened; the
parietes of the chest on the injured side sank down  upon the com-
pressed lung; the wound healed ; respiration  of the lung was re-
established.
   The  following is a brief account of another case, at present
under my care.
   George Bussel,  aged twenty-one, at eight became subject  to
epileptic fits.  Four years ago the fits used  to supervene every three
weeks, or  oftener.   At that time the moxa was repeatedly applied
by my advice behind  each ear for a period of three months.   The
recurrence of the fits was suspended  through this treatment for two
years and upwards.   During the last  year  the fits have  returned.
In one of them,  which occurred about the  beginning of August, as
he was  bathing  in  the Serpentine, he dropt under the water unob-
served ; but  another bather happened to catch his foot against him,
which led to his being taken out and resuscitated.   His mind was
not collected for forty-eight hours.   The  next day he felt pain  in
the left side  on  drawing  his breath, with symptomatic fever, and
disposition to lie on the left side.  After a few days the pain declined
in severity; but he continued confined to his bed for fourteen weeks,
with dyspnoea, and profuse night sweats. He eat, however, heartily,
dining on meat and porter.
  At  the time of his  admission, November lltb, the left side was 
360
MAYO'S OUTLINES OF PATHOLOGY.
o&dematous, and the chest was dull on percussion.  No respiration
was  audible in the left lung.  The heart beat  on the right side,
where he had observed it to "beat since the first week of his illness.
On the following  day I  punctured the side of this patient with ^
hydrocele trochar, between  the fifth and sixth  ribs, selecting thi3
point from the peculiar tenderness on pressure there, and a suspicion
that the sixth  rib had been fractured, which however was not the
case.  Twenty ounces of matter were drawn away, and the wound
was closed. The following day thirteen more were allowed to flow,
and the wound was again closed.   Three days after, twenty-eight
ounces more were drawn,  and a portion of elastic catheter was
fastened in the wound.  A few days afterwards the portion of ca-
theter was removed, and the wound has continued fistulous.  The
discharge is still very profuse, and he is greatly emaciated.  There
is respiration in the upper part of the left lung; the heart has not yet
returned to its proper place, although situated less to the right than
at first.
   Pneumothorax.  The cavity of the pleura is liable to become
filled with air alone; either through  fracture of a rib and laceration
of the  lung;  or  through air secreted to take the place of absorbed
serum.  Where the lung is remote from  the side of the chest, pneu-
 mothorax may be distinguished  by a hollow sound on percussion,
combined with the absence of respiratory murmur.  Where pneu-
 mothorax arises from the first of the causes mentioned,  it is com-
 monly coupled with subcutaneous emphysema.   The distention of
 the affected pleura may be so great as to press the mediastinum to
 the opposite side, and so to embarrass the sound lung. In this case
 an  opening with a grooved needle or small trochar is necessary to
 evacuate the air.
   Pneumothorax combined with liquid effusion.   Air in the chest
 may coexist with various liquids; with  blood from a wound of the
 king, or  of an intercostal artery; with the  pus of empyema, after
 a fractured rib and wounded lung, or  after tuberculous ulceration
 extending through the pleura:  the admixed air may again result
 from the partial decomposition of liquid effusion, or may even have
 been a primary secretion  into the pleura.   A characteristic sound
 attends the act of respiration when liquid and air coexist  in the
 pleura, which often bears a close resemblance to that produced by
 wind blowing down a gunbarrel.  A common variety ofthe sound
 produced by the same cause is aptly denominated metallic tinkling
 Qn percussing the side, an abrupt alteration  ofthe sound may often
 he observed, indicating the transition from the part under which tbfl
 liquid lies to the part containing air.
    Hamothorax.   The  causes of hemorrhage into the  chest are,
 wounds  of the  intercostal arteries, or  of the lungs.   Dulness on
 percussion supervening immediately after an injury of the chest,»
 diagnostic of one or other of these lesions; for  the relief of which,
 when the effusion is so great as to embarrass respiration, it is neces- 
THE RESPIRATORY ORGANS.              361
7Z!° puncture the thora*-  Aneurisms sometimes burst into the
pieura.

ni.ll tnCw.Vh?r ?'e ^ °f Pr- Ha*ttn», at the Middlesex Hos-
pital  n which the breathing of one lung had been suppressed, and
 he pleura of tnat side was  conjectured to be filled with solid sub-
stance, its cavity was found occupied by strata of coagulum, which
had  been deposited at different  times from blood that had flowed
from an intercostal artery ulcerated over a rough and carious rib.
  Hydrothorax, like ascites, is rather an effect of disease, than a
disease itself: it commonly results either from some obstruction to
the circulation,  or from attenuated blood and vascular atony   The
Symptoms are dyspnoea, orthopnoea, livid countenance, dulness of
the chest on  percussion.
  Malignant disease. In a preparation presented by Dr. Chalmers,
of Croydon, in which the lungs were the seat of fungus haematodes,
both the pleurae costalis  and pulmonalis had given origin to masses
of medullary sarcoma, [u. 100.]
  In a patient who died  in the Middlesex Hospital of cancer ofthe
breast, the pleurae pulmonalis and reflexa were studded with smooth,
firm, white, circular, convex tubercles, from a line to half an inch
in diameter,  [u.  101.  102.]
                          section n.

                          The Lungs.

   Under the head of affections of the lungs, it is convenient to
 include those  of the filamentous texture of the  lungs, of the air-
 vessels, and of the smaller air tubes.  Hypertrophy, atrophy, pneu-
 monia, gangrene, pulmonary hemorrhage, oedema of  the  lungs,
 emphysema, phthisis, malignant tumours, hydatids of the  lungs,
 are the subjects treated of in the present section.
   I. Hypertrophy.   When one lung is destroyed  by disease,  the
 other becomes hypertrophied, or grows, to serve its doubled function.
 The lung increasing in  volume becomes firmer, more elastic, and
 more compact.   In place  of collapsing, when the chest is laid open,
 it sometimes protrudes from it, as if the space that contained it had
 been too small.
  II. Atrophy.  The pulmonary tissue is  liable to  waste, when
tubercles or other accidental products are developed in it.
  III. Pneumonia.   Inflammation of the substance of the lungs
presents three  well-marked stages—inflammatory congestion, hepa-
tisation, purulent infiltration.  The  inflammation may stop at either
the first or the  second, in which cases simple resolution takes place.
The anatomical characters of the three stages of pulmonary in-
flammation are the following:—
  1. The  lung  externally livid or  violet-coloured,  increased  in 
362            MAYO'S OUTLINES OF PATHOLOGY.

weight, not collapsing, but pitting on pressure;  still crepitant, but
not as much so as in health.   When cut into, it appears of a livid
or blood colour,  and injected with a frothy serous fluid,  more or
less sanguineous, which  flows from it abundantly.
   2. The  lung has lost its crepitant feel, and has acquired a con-
sistence and weight resembling those of the liver.  The surface of
a  section varies in colour from a violet gray to blood red; and is
marbled by the bronchial tubes, the blood-vessels, specks  of black
pulmonary matter, and  the  white membranous partitions of the
lobules.  The cells of the lungs  are obliterated, being filled with
reddish coagulated lymph, so that when the texture is torn it com-
monly presents  a granular aspect,  as if composed of small  red
grains, oblong, and somewhat flattened.
   3. In this stage the substance of the lung at first preserves the
firmness it has acquired ; gradually it softens, becoming of a yellow-
ish pale or straw  colour.  At first the pus appears in small detached
yellow points, mottling  the surface with  a new colour.  These
points gradually combine, and the whole finally assumes an uniform
straw  or lemon-yellow colour; and when incised, exudes in greater
or less quantity purulent matter.   In this state the pulmonary sub-
stance has become more humid  and soft:  the granulated texture
gradually disappears as the purulent softening advances; and even
before this latter stage has attained its acme, the parenchyma of the
lungs  breaks on pressure.
   VVhen the  lung contains  much black  pulmonary matter, as is
commonly the case in adults and old persons, both the pus and the
pulmonary substance assume an ash-gray colour.
   These  different  stages are frequently found in the same lung,
dividing it into as many zones, that are strongly contrasted, although
insensibly shading into one another.
   The lower  parts of the lungs are the most frequent seat of pneu-
monia ;  and  when  the  disease involves  the whole  viscus, it is
almost in the inferior part that it commences. Such is the observa-
tion of Laennec,  with which the impression of several of our most
scientific London physicians concurs.  Dr. Forbes, however, in his
valuable notes to  his translation of Laennec's immortal work, brings
a  body of evidence from Andral and Cruveilhier, to show that the
upper lobes are very frequently the seat of pneumonia.
   The formation of abscess in the lungs, as a consequence of pneu-
monia, is of rare  occurrence, [m. 60.  61.]
   The lining membrane  of the  bronchi  is commonly  red,  and
occasionally swollen.
   When near the surface, the first stage of pneumonia is recognised
by a  peculiar crepitation on crackling, as  of salt thrown into the
fire, resulting from the air bubbling through the liquid in the cells
and  minute bronchial tubes.
   In  the  second  stage, the chest over the inflamed  lung is dull on
percussion: no crepitation is heard;  but the motion of the air and 
THE RESPIRATORY ORGANS.
363
mucus in the large bronchi is distinctly audible, being conveyed
through the solidified  lung.
  The disease is characterised  by obtuse and deep-seated pain in the
chest, quick  respiration, dyspnoea,  cough; the  sputa  are  viscid,
tenacious, glutinous, and contain some diffused shade of red, being
either tawny or rusty.
  An abscess of the lungs is attended with definite physical signs.
When great part empty of fluid, it gives rise to pectoriloquy  ; or, in
speaking, (if the stethoscope is applied over  the cavity,) the voice
seems to issue directly from the chest of  the speaker.   When air
and liquid are present together, metallic  tinkling or amphoric re-
sonance  is heard,—just  as when air and liquid are mingled in the
pleura.
  The combination of pneumonia and pleurisy with large effusion,
produces each complaint in a modified form.   The tissue of the
lung under these  circumstances has the colour and consistence of
flesh, is no longer  crepitant, and presents no traces of the vesicular
structure.
  Pneumonia probably never takes place  without some degree of
pleurisy coexisting with it.
   The  duration of the different stages of pneumonia, when the
disease runs its full  course, is as follows:—The first usually lasts
from twelve hours to  three days before complete hepatisation super-
venes :  from one  to  three days then  pass  before spots of purulent
infiltration  make  their appearance; and the period of suppuration
(from the  time when the concrete purulent infiltration is distinctly
perceptible until this  is completely  softened to a  viscid fluid) varies
 from two  to six days.  The engorgement, however, or first stage,
 will  sometimes continue for seven or eight days,  and affect the
 whole lung and part  ofthe other, and prove fatal, before the occur-
 rence of any very distinct hepatisation.  And  oa  the other hand,
 particularly when  the disease has  attacked debilitated or very old
 subjects, or supervened in the course of another  severe malady, the
 inflammation has reached the stage of purulent inflammation  in
 the short space of thirtv-six or even twenty-four hours.
   IV. Gangrene.  Sphacelus of the lungs does not occur  as a
 consequence of pneumonia; it is met with in two forms, uncircum-
 scribed.
   a. Uncircuinscribed  pulmonary gangrene   may be reckoned
 among  the  rarest of organic affections.   It  presents the following
 characters;—the  pulmonary  tissue, more  humid and less  cohesive
 than in the sound state, has the same degree of density as in the
 first stao-e of pneumonia, cedema of the lungs, or in serous engorge-
 ment occurring after death,—its colour  varies from a dirty white
 or slightly greenish hue to a deep green approaching to black, with
 a mixture occasionally of brown or of earthy or yellowish brown.
 These different shades are  mixed irregularly in different parts ot
 the lun<rs; in which  are likewise observed some portions of a livid
 red colour more humid than the rest.  Some points here and  there 
364
MAYO'S OUTLINES OF PATHOLOGY.
are softened, and converted into a putrid deliquum; and from these,
when cut into, there flows a turbid  sanies of a greenish gray colour,
and of an insupportable gangrenous fetor.
  The gangrenous affection occupies at least a great portion of one
lobe, and occasionally the greatest  part of one lung: it has no defi-
nite boundary.   In some places pulmonary substance, altogether or
nearly sound, blends insensibly with the gangrenous parts; in other
instances these are separated by a  portion of lung inflamed in the
first  degree, and in still rarer instances by a hepatised portion.  If
the disease is at all extensive, the  progress of the symptoms is ex-
tremely rapid.  The patient's strength  is prostrate from  the very
beginning: the oppression becomes all at once  extreme; the pulse
is small, compressed, and frequent;  the cough  is rather  frequent
than strong; the expectoration is diffluent,  of a very peculiar green
colour, and exhaling  an extreme  fetor, precisely similar to that of
a sphacelated  limb.  This expectoration is copious for a time, but
soon ceases through loss of power, and the patient dies suffocated.
  b. Circumscribed gangrene.  Partial gangrene may occur in
any part of the lungs.  It exists  in three different states; that of
recent mortification  or gangrenous eschar, that of  deliquescent
sphacelus, and that of an excavation produced by the softening and
evacuation of the  sphacelated spot.
   When the sphacelated substance, of a dirty greenish-gray colour,
occasionally bloody, and horribly fetid, separates and makes its way
into the neighbouring bronchi, an ulcerated excavation  is left, which
for a long  time retains something of  the gangrenous  character.
Sometimes  the gangrenous  eschar, in a  state  of  decomposition,
makes its way through the pleura, and excites a pleurisy, usually
accompanied by pneumo  thorax,  either from the gas exhaled by
the putrid  eschar, or from a simultaneous communication  with the
bronchi.
  Gangrene occasionally takes place of the walls of a tuberculous
excavation.
  V. Pulmonary hemorrhage may arise from rupture or ulceration
of a vessel [u.  69.], or  from an aneurism bursting into the lungs
[s. 73.]:  but these accidents are rare;  and bleeding into the lungs
commonly  proceeds, like epistaxis  or hemorrhage of the stomach,
from  exhalation or secretion of blood by the vessels of the mucous
membrane, [u.  70.]
  There are two  varieties of pulmonary  hemorrhage,  which are
comparatively  of little moment, but which throw  light upon the
nature of this affection.
  a. On mountains sufficiently elevated to occasion a considerable
diminution of the  atmospheric pressure, most  persons spit blood.
This arises from the pulmonary vessels  being gorged with blood in
consequence ofthe contraction of the air-cells, which follows upon
the diminution of the force that naturally expands them.
  6.  In women, haemoptysis  is not unfrequently vicarious of the
catamenial  secretion, being the result of the entire  or partial sup- 
THE RESPIRATORY ORGANS.
365
 pression of the latter.  In this  case, the complaint is but another
 mode  of relieving  the vascular  system.  As a general rule, there-
 fore, hmmoptysis is a less alarming occurrence in women than in
 men.  Dr  Clarke  has remarked, that the  application of leeches
 occasionally produces pulmonary hemorrhage. This observation is
 consistent  with the fact, that the application of leeches  in  many
 women brings  on uterine sanguinolent secretion.
   The ordinary causes of pulmonary hemorrhage  are, phthisis,
 and disease of  the mitral valve of the heart.
   c. Andral gives  the following statement as the result of his own
 observations upon the connection of haemoptysis  with phthisis.  Of
 the persons whom he had known to die of phthisis, one in  six never
 spat blood at all.  Three  in six, or one half of the whole number,
 did  not spit blood until the existence of tubercles in the lungs was
 already made certain by unequivocal symptoms.  In the remaining
 two sixths, the haemoptysis preceded the other symptoms  of tuber-
 cular disease, and seemed to mark the period of its commencement.
 Of those individuals whom Andral had known to spit blood at some
 period or other of their lives, there was only one in five whom he
 did not also know to have tubercular phthisis.
   d. Disease of the mitral valve occasions a congested state of the
 pulmonary veins.   Pulmonary hemorrhage is the mechanical relief
 and natural consequence of this  condition of the pulmonary circu-
 lation.
   e. In patients recovering from  bronchitis, the sputa are not un-
 frequently  streaked with blood.
  /. Pulmonary hemorrhage sometimes takes place  from none of
 the above  causes.  Andral  relates the case of young a man, who
 suffered  profuse hemorrhage from the lungs on  four several occa-
 sions, between  the  age of twelve and eighteen, without any appa-
 rent detriment to his health, which remained  excellent.   I  am
 acquainted with a gentleman, now forty-five years of age, and in
 perfect health,  who fifteen years ago had two attacks of spitting of
 blood in one year :  bolh seizures were preceded by a sense of con-
 striction around the lower part of the chest.  A year afterwards he
 spat blood a third time, in a violent fit of coughing excjted by the
 smell of fresh  paint.  He  has, I  believe, neither  pulmonary nor
 cardiac disease; and his only complaints are occasional indigestion
 and  irregular  action of the bowels, which he  attributes to  the
tegetable diet which he adopted for several months after the spitting
 cfcblood.   He  is  thin  and spare, with a well-formed chest, and of
 a sanguineo-nervous temperament.
  The blood of haemoptysis is commonly florid, often frothy, some-
 times clotted; the clot occasionally stringy and  like  fibrin, some-
 times black.
  The immediate danger attending pulmonary hemorrhage is two-
 fold.  On the  one hand, the loss of blood  may be so great as to
 destroy life: on the  other hand, it may lead to an  infiltration of the 
366
MAYO'S OUTLINES OF PATHOLOGY.
lungs with blood that may be followed by its own train of serious
consequences.
  Laennec observes, that he  had known ten pounds of blood lost
in forty-eight hours by a young man who died under the hemor-
rhage ; and that, in cases of less acute character, he had seen  about
thirty pounds lost in a period  of fifteen days.  Haemoptysis is often
attended  with vomiting of blood, that, when  previously coughed
up into the pharynx, had been swallowed.
  The appearance  produced  by the infiltration of the lungs with
blood is called pulmonary apoplexy; the discoloured portion  ofthe
lung  is commonly from one  to four inches in diameter, of a dark
blood or  brown red, sometimes spotted with lighter granules. The
coarser parts of the pulmonary tissue alone can be distinguished;
and  even these partake of the same tinge.  Unless the effusion is
recent, the consistence ofthe  part is firm from the absorption ofthe
serum.   Sometimes there  is  an  obvious detritus  in  the  centre,
formed of grumous blood alone, in which no texture can be traced;
and  in the most severe cases  of pulmonary apoplexy, in which the
hemorrhage  has been  directly fatal, the whole affected portion of
the  lung is found lacerated and broken up by the effusion of blood
into it.  In  general, the blood thus diffused is absorbed:  in other
cases, the affected part of  the lung becomes softened and resolved
into pus.
   Dr. Watson  has placed the nature of pulmonary apoplexy in its
true  light.   He holds, that it is an  accident of pulmonary hemor-
rhage, upon the evidence  furnished by a remarkable case already
adverted to.   A patient in the  Middlesex Hospital was suffocated
by blood pouring down the windpipe from an ulcerated lingual
artery.  The lungs contained, in various situations, solid dark red
masses,  precisely resembling those described  by Laennec as con-
stituting pulmonary apoplexy.
   VI. (Ederna.   (Edema  ofthe lungs is rarely idiopathic: it most
frequently accompanies organic diseases of the heart of long dura-
tion, and humoral catarrh, in which cases it is often the immediate
cause of death.  It often coexists with the general anasarca which
sometimes succeeds to febrile affections, particularly the  exanthe-
mata : and  is the cause of the dyspnoea occurring after scarlatina,
 rubeola, &c.
   Serous effusion into the  filamentous tissue of the lungs  produces
to the ear a kind of humid crepitation like the sound of a liquid io
gentle effervescence.
   An oedematous lung does not collapse on opening the  chest: it
feels weighty, and pits on  pressure, but is still  crepitant.  The
vesicular texture is less perceptible than usual.  When cut into, it
exudes a clear yellowish serum, scarcely frothy, which appears to
proceed  from all parts equally.
   VII. Emphysema.   This term  is given to two conditions; one
of which consists in dilatation of the smaller air-tubes, the other in 
THE RESPIRATORY ORGANS.
367*
rupture of the pulmonary cells, and diffusion of the air through
the interstitial cellular membrane.
  a. Dilatation of the smaller air-tubes is liable to be produced by
any cause which  obstructs them.   The  ordinary cause is  a gluti-
nous secretion attending one or  other of the forms of bronchial in-
flammation, which will afterwards be noticed.   When the outlet of
a lobule of  the lung, as it often happens, is  blocked up by a little
pearl-like concretion of tough  mucus,  each  expiratory effort  in
coughing compresses the vesicular structure, and strains the air-tube
into which  it opens; both are liable to  be injured, the air-cells  to
become larger and irregular,  the bronchial tube to  be dilated.  The
enlargement of the air-cells and bronchial tubes takes place at tho
expense  of  the blood-vessels, which,  being habitually compressed,
some of  them are obliterated, and most are contracted to less than
their natural calibre.   An emphysematous lung, when examined,
appears  to be less vascular than another: it is less crepitant,  more
elastic, and does not  collapse.  The surface is often irregular, from
the dilatation or rupture ofthe vesicular structure having produced
bullae of different sizes immediately below the pleura, hi. 74. 75.]
  When the circulation is tranquil, the atmosphere  dry and of a
moderate temperature, and bronchitis not present, the patient labour-
ing under vesicular  emphysema often breathes freely.  But when
any of these conditions are reversed, a paroxysm of embarrassed
respiration, or asthma supervenes.
  The sign of the disease obtained on percussion  is. an unusually
loud drum-like sound ;—on  auscultation, the absence of the ordi-
nary vesicular murmur.
  b. Interlobular  emphysema  is  liable to  be produced  by the
giving way of dilated  air-passages.  Or it may likewise  be the
result of rupture of the air-cells in healthy lungs through violent
muscular exertion, as during labour : in the latter case, the air has
been known to make its way into the cellular membrane of the
neck and chest.   This  kind of  emphysema disappears  readily
through the absorption of the air which has escaped.
  VIII. Phthisis.  This disease, of which  one fourth of the popu-
lation of this country dies, originates in the deposition of tuber-
culous matter in the  lungs.
  a. Nature of  tubercle.   By  the  terms  tubercle,  tuberculous,
strumous, or scrofulous matter, pathologists denote a yellowish un-
organised substance of different  degrees of consistence ;—the two
first terms referring to the form  which it commonly affects, the
latter to the  diatheses in which it prevails.
  The relation of this substance  to the blood is not yet established:
its deposition is unattended by symptoms of general or local inflam-
mation.  Nevertheless, tubercle is frequently present in combination
with effused lymph.   In one form of general peritoneal adhesion,
for  instance, among the granules of firm  lymph, which stud the
accidental filamentous tissue, pallets of tubercle are not unfrequently
met with.  Tuberculous matter  is likewise occasionally found in 
368
MAYO'S OUTLINES OF PATHOLOGY.
parts of malignant tumours: in medullary sarcoma of the tibia and
ofthe testis I have seen tuberculous matter; in the first infiltrating
the bony cells, in the second disposed in amorphous masses in the
septa dividing the lobes of the medullary tumour.
   The substance to which in appearance and other relations tuber-
culous matter bears the closest affinity is, the flaky, curdy matter
which floats in the serum of chronic abscesses.
   Andral describes  tuberculous  matter as a secretion  originally
semi-fluid, which acquires solidity through the absorption of the
liquid  part.   He recognises its deposition  on mucous surfaces [in
the pulmonary cells],  upon serous surfaces [in the cavities of ab-
sorbent vessels],  upon the interstitial cellular membrane  [in the
interlobular  pulmonary substance], in the cellular  membrane of
organs [in the brain, and between muscular fasciculi].
   Tuberculous matter may be formed in  the majority of the vas-
cular textures: it has been found in  every vascular part except
tendon, ligament, cartilage, the skin, the eye, the veins and arteries.
   When  the  disposition  to form tuberculous matter is strong, the
entire texture of a part becomes  infiltrated  with it.  When  the dis-
position is  less,  partial deposits take  place, which, when in the
parenchyma of organs, are spherical  from the  equal pressure to,
which the effusion  is  subjected; when upon a surface, they are
moulded to its shape.
   When  tuberculous  matter has been secreted a certain length of
time,—which varies from a few weeks to years,—it softens.  The
softening is the result of infiltration with  liquid exuding from the
part which contains the tubercle.  The stage of softening leads to,
or is produced by—at all events is accompanied by—inflammation
and ulceration and suppuration.  These actions, under favourable
circumstances, are followed by restoration ; the tuberculous matter
 being expelled, the ulcer contracts and heals.
   Those in whom the tuberculous diathesis  prevails, are often dis-
 tinguishable  by  certain external signs.  Either they are  of a re-
 markably fair skin, the veins  showing through it; the eyes  blue;
 the upper lip full;  the frame  thin  and  delicate;  the expression
 placid; the mind often unusually intelligent: the disposition touched
 with a high degree of sensibility and gentleness.  Or they are of
 a dark and  coarse complexion, the iris an  opaque brown, the mind
 often  dull and slow.   Sometimes they exhibit a delicate dark skin
 and lucid eye, the sclerotic glistening and pearl coloured.
   In infants of the scrofulous diathesis, the digestion is weak, the
 skin harsh and dry, or subject to cold perspirations, particularly of
 the hands and feet;  the  nose is generally dry, or discharges thick
 mucus in large quantity ; and epistaxis occasionally occurs.   The
 eyelids are subject to chronic inflammation ; and eruptions behind
 the ears and on the scalp, or other parts, are  frequent.
   The tuberculous deposit is most liable to attack particular organs
 at the following  periods.
   In infancy and early childhood it  attacks the lymphatic glands, 
THE RESPIRATORY ORGANS,
369
either  the  subcutaneous, and  principally  the cervical;  or the
mesenteric, producing tabes mesenterica; or the bronchial.
  In  more  advanced  boyhood, and  after  puberty till  the age of
twenty, and then in a  diminishing  ratio to the age of thirty, the
cancellous structure of  the  round bones, and of certain of the flat
bones already specified,  and of the articular ends ofthe long bones,
are liable to be affected.   From  puberty to five-and-twenty or five!
and thirty the lungs are especially obnoxious to tuberculous disease
  In  thus signalising certain epochs as particularly perilous to
particular organs, it must be  at the same time stated, that each of
these  organs is liable to be  affeeted at other periods of lire.  Upon
the whole, the  determination  of strumous action upon  one organ
may be viewed as rendering the  others less liable to it.
  b. Pulmonary tubercle. "In  the lungs, tuberculous matter occurs
either  in minute spheroids, or in larger masses, or in general infil-
tration, [u. 76.]
  Andral attributes to Magendie and Cruveilhier the origination of
Ihe opinion, that tuberculous  matter  may be formed in the extre-
mities  of the bronchial tubes.  This view, confirmed  by Andral
himself, is well illustrated in  the drawings of Dr. Cars well,  from
specimens in which the air-cells and minute bronchial tubes were
filled  with  tubercle.  Sometimes numerous detached tuberculous
granules are seen:  sometimes all the air-cells of a lobule are filled
with a common  infiltration.  The larger spheroids of tuberculous
matter in the lungs, as in the  liver, and kidneys, and on the brain,
appear to be interstitial.
  The lungs are rarely the seat of tubercle alone : two other de-
viations from the natural state commonly are found combined with
it.
  One of these consists of little grayish spheres, of different degrees
of consistency, that were  originally described  by Bayle, who con-
sidered them as a formation sui generis, and constituting their own
species of consumption.  Andral determined  the  true nature of
these  bodies, detecting  them  in their different stages;  in one of
which they are soft, gelatinous of a reddish colour;  in the second,
white,  firmer,  almost cartilaginous.  These gray tubercles  were
supposed, by Laennec, to be the  matrices of true tubercles.  Andral
has shown,  that this is not  their history:—not  leading  to true
tubercles, though often  coexisting with them, they are products of
a partial inflammation occupying a few of the air-cells, and filling
them with lymph.
  The other occasional attendant is the yellow jelly-like matter,
the "infiltration  tuberculeuse, gelatiniformc,"  of  Laennec;  who
believes it to be only a more liquid state of the  tuberculous matter
poured into the parenchyma ofthe lungs.
  The ordinary situation of tubercle is the upper part of the lungs;
and the left lung is  more commonly affected than the right.
  I must refer  the  reader to  Dr. Clark's scientific  and practical
Treatise on Consumption, for an account ofthe progress and symp^ 
370            MAYO'S OUTLINES OF PATHOLOGY.

toms of the disease, to which  tubercles in the  lungs give rise;—
from the first period, when a slight diminution of strength, a pulse
easily excited, occasional flushings, imperfect rest, slight but  fre-
quent cough, irritable mucous membrane ofthe bowels, first awake
suspicion :  and when  on  examining the chest, one side may sound
duller  on percussion  than  the other, and the voice  may be more
resonant on that side.—To the second period, when the figure  has
become emaciated, the cough more frequent, the frothy fluid which
had  been  before expectorated  colourless,  now  containing  small
spjeks of opaqoe curdy matter, of a pale  yellowish  colour, some-
times streaked  with blood ;  the respiration hurried, the pulse  fre-
quent, with afternoon flushes and night sweats ;  the sound on per-
cussion duller;  crepitant rhoncus heard,  and  bronchophony; or
even in one or  more points of  the clavicular, or scapular regions,
pectoriloquy.—To the concluding stage, in which to an aggravation
of the previous symptoms, dyspnoea threatening suffocation, distress-
ing muscular pains about the chest, colliquative diarrhcea, close  the
scene.
   IX.  Cysts, hydatids, and phosphate of lime deposit, arc met
with in the lungs.
   X. Medullary sarcoma and melanoma, separately or  together,
are liable to form in masses in  the lungs.  In the case from which
the specimen  [u. 86.] was obtained, the only pulmonary symptom
was frequent haemoptysis.   The lung  is  studded with spherical
masses of medullary sarcoma.
                         section m.
                         The Bronchi.
   The subjects to be considered are,—foreign bodies in the bronchi;
bronchitis;  pituitous catarrh; suffocative catarrh;  dry catarrh;
pertussis; ulcers; hemorrhage ; dilatation ; polypus.
   I. Foreign bodies. The impalpable dust, which we occasionally
inhale,  is thrown  off  with  the phlegm, which  it  causes  to be
secreted.  But in those  who are habitually exposed to breathe dust,
among  miners,  leather  dressers,  china  manufacturers,  needle
grinders, and the like, marked consequences are produced  by it;
the bronchial membrane  being  perpetually  irritated, bronchitis or
consumption supervene.
   Solid bodies sometimes  remain in the bronchi without producing
irritation.  More frequently a fatal result ensues.
   A boy, aged about twelve, who was  travelling in  a carriage,
happened to have an ear  of rye in his mouth:  the carriage  being
jolted, the ear of rye disappeared:  it had dropped into the lungs,
where  it  produced abscess.  The abscess extended through the
diaphragm into the liver.  On inspection, the ear of rye was  found
sticking, part in the liver, part in the lungs, [u. 62.] 
                   THE RESPIRATOY ORGANS.               371

   Any quantity of liquid  introduced  into the bronchi produces
 instant suffocation.  A case has been already adverted to, m which
 Dr. Watson and myself witnessed the instantaneous ex inction of
 life, through a gush of arterial blood down the trachea.   Corvisar
 mentions  the  case  of a steward,  who, being suddenly  sck  a
 stomach  made a violent effort to  repress the vomiting; Uen he
 fell  to the ground  and expired.   On  examining  the bodv, the
 food"*'         °   bronchi, were found filled with half-digested

   II.  Bronchitis.
   a-Aci'le bronchitis.   Inflammation (ordinarily following cold  in
 the  head) of the lining membrane  of  the trachea and  bronchi,
 which become red and slightly thickened, sometimes firmer, some-
 times softer than natural; attended with a sense of dryness or rough-
 ness behind the  sternum, and extending into one or both lungs •
 cough at first  dry, soon accompanied  by a serous expectoration!
 which is saltish and slightlyglutinous, but not distinguishable from
 the saliva with which it is intermixed. As the disease advances, the
 expectoration becomes thicker and more yellow, and is mingled with
 particles of an opaque whitish colour: by degrees the whole becomes
 opaque, of a pale yellow or slightly greenish hue, viscid, enclosing
 air-bubbles, tasteless or somewhat saltish, and occasionally marked
 with dots or small specks of blood.  When the sputa are  very large,
 they frequently leave,  after  expectoration, a  dull pain  about the
 root of the bronchi, indicating the place whence they have been
 detached.   The cough  occurs in fits, on waking, after a meal, and
 on lying down  to rest.
   The place and extent of the disease may be determined by the
 sound  received through the stethoscope: at first a sonorous rhoncus
 like the deep sound of snoring, or  the scrape of a bow over a large
 violoncello  string; afterwards, when  the  mucous secretion in-
 creases, the sound of guggling is heard.
   The vesicular sound  of the lungs is sometimes at one part defi-
 cient,  (the passage  leading to it being plugged with mucus,) then
 suddenly again audible.
   When the rhoncus exists  in  the whole of one lung,  or in  the
 greater part of both, the disease is always severe.   When  it exists
 over the  whole of both, (which  is the case only when  catarrh
 supervenes  upon severe idiopathic  fever,) death  almost  always
 follows, except in very young subjects.
   6.  Chronic bronchitis.  Anatomically, the membrane  more  fre-
 quently of a violet colour, and irregularly marked  here and there
 with spots of a paler or darker hue ; while in the acute, the red is
 brighter, and verging more towards purple or  brown.  The expec-
 toration sometimes precisely similar to that ofthe latter stage ofthe
 acute;  but most commonly less glutinous, more opaque, and nearly
 puriform.   Occasionally it is  of a  dirty-grayish or greenish hue,
from an admixture of the black pulmonary matter.  It is usually
inodorous; but sometimes becomes more or less fetid, and assumes 
372
MAYO's OUTLINES OF PATHOLOGY.
 the  smell  as well as the other physical qualities of the different
 kinds of pus.
   This disease frequently follows acute bronchitis ;  and it is liable
 to persist,  with  remission, for  years.  During  the  remission, the
 appetite and strength return; but the patient commonly loses a little
 flesh, and remains paler than usual.
   During  repose, there is no oppression on the chest, but exercise
 soon brings on dyspnoea.  The complaint remits in the summer,
 and returns in the winter, frequently attended with fever.
   In some rare cases, hectic fever comes on, with rapid emaciation;
 and the disease  terminates fatally with all  the  usual symptoms of
 phthisis  pulmonalis.  In fact, the  most  perfect similarity exists
 between  the two diseases; as far as regards the expectoration, the
 emaciation, and  all the other  general symptoms.   Percussion, in
 this case, cannot remove the difficulty, as the chest sounds quite
 well in  many consumptive patients.  The indications afforded by
 the stethoscope are much more to be depended on.   In such cases,
 if upon  properly examining a  patient at different hours, and  for a
 certain length of time, we find neither pectoriloquy, nor the  gug-
 gling produced by softened tubercles, nor the cavernous respiration
 of tuberculous excavations, nor  the permanent  absence of respira-
 tion in certain places from tuberculous indurations  of some extent,
 we have a strong presumption that the  disease is  merely chronic
 catarrh; and if the same  results uniformly present themselves  after
 an attendance of some time, (say two or three months,)  our  pre-
 sumption is converted  into certainty.  In these cases, the stetho<
 scope gives no other signs than a mucous rhoncus ; sometimes in-
 deed pretty loud and  abundant, but very  rarely continuous, and
 still more rarely general  over the  chest.   Very commonly we can
 hear distinctly the  sound of respiration, notwithstanding the rhon-
 cus  ; and  there  is hardly ever  observed that total suspension of
 respiration which occurs in  the acute disease, unless indeed there
 should happen  to coexist  with the chronic a dry or pituitous catarrh
 with intense congestion of some  portion ofthe mucous membrane.
 It even frequently happens, that the  respiration becomes puerile
 over nearly the whole lungs  in these chronic catarrhs, while at the
 same time there exists a continued dyspnoea, occasionally aggra-
 vated to violent paroxysms even in a state of quietude.  This  con-
 stitutes the humid asthma of practitioners.—Forbes's translation of
 Laennec.
   c. Pituitous catarrh.  The anatomical characters, a middling
degree of swelling, and a slight softening ofthe mucous membrane,
with slight redness here and  there.   The expectoration  colourless,
transparent, ropy, frothy on the surface, and underneath like white
of egg diluted with  water.  The chest sounds well on percussion:
the sound of respiration is weaker during the fits of coughing  than
in the intervals :  it is attended by a sonorous rhoncus, flat or  sibi-
ious, imitating the chirping of  birds, the  note of a  violoncello, or
the cooing of a wood-pigeon. 
THE RESPIRATORY ORGANS.
373
  The disease may be either acute or chronic.
  The acute  is characterised  by an extreme oppression, attended
by copious pituitous expectoration.  It sometimes begins as a com-
mon cold; but after a few hours, or even  minutes, its severe cha-
racter is declared by the violence of the cough, lividity ofthe face,
coldness of the extremities, cerebral congestion.   In  children it is
sometimes mistaken for croup.   The attacks, however violent, are
usually transient.
  The chronic form is common in gouty subjects, when the gout
has become less distinctly marked. Two elderly patients are men-
tioned  by Laennec, one of wrhom,  aged seventy, had  expectorated
during the last ten or twelve years, in two daily paroxysms,  about
four pounds of a  colourless, ropy, and  frothy fluid.   Of two cases
given by Andral, the one, an  old  man, was carried off after five
months by the daily expectoration of about two pints of a serous
fluid :  the other, aged forty-five, died after bringing up three pints
ofthe same kind every day during three successive years.  In nei-
ther of these  two cases was there found any other  cause of death ;
and in the one last mentioned, the mucous membrane of the bronchi
was found extremely pale.
  Something  similar occurs as a temporary feature during the re-
solution of peripneumony ofthe lungs.
  d. Suffocative  catarrh.  The  name given to bronchial inflam-
mation, with  large mucous secretion, that mechanically clogs the
air  passages, and suffocates : common in elderly persons  from cold,
or after injuries of the chest;  met with in adults and in children,
and liable to be confounded with croup.
  e. Dry catarrh.  Anatomical  characters;  swelling, together
with an obscure redness or violet hue of the mucous membrane ;
the swelling  particularly remarkable in the smaller branches. Se-
cretion glutinous,  occurring in pearl-like  globules, completely ob-
structing several of the smaller tubes.   The chest  resonant on per-
cussion.   No respiratory murmur.
  This disease, when existing in a middling degree, frequently re-
mains altogether latent for a long course of years, the subjects of it
being  only more  short-breathed than  others when they make any
unusual bodily exertion. When the bronchial tumefaction becomes
more extended, dyspnoea is then experienced even in a state of quie-
tude,  and  particularly after  meals.  After a  time the dyspnoea
comes on in  fits,  which last usually several days, and  obtain the
name of asthma.  It is  presumable,  that spasm of the muscular
fibres  of the small bronchial tubes contribute  to  the difficulty of
breathing.                                         ...
  /. Hooping-cough holds the middle  place between the pituitous
and mucous catarrh, as far as regards the nature of the  expectora-
tion and  the bronchial  congestion.   The  sonorous cough and
crowing inspiration depend upon spasm of the glottis.   1 he dura-
tion of the hooping-cough is from a few weeks to  several months.
It seldom occurs twice in life.
       2l_g                                   25 m*y 
374
MAYO'S OUTLINES OF PATHOLOGY.
  III.  Ulcers of the mucous membrane of the bronchi occasionally
attend  phthisis.  Dr.  Hastings, in describing chronic bronchitis,
observes, " it is  not  uncommon to find this membrane ulcerated.
This happens more particularly when the disease has arisen from
the irritation  of mechanical  substances.  The ulcers  are  always
superficial, and generally small; but occasionally, in the larger
bronchial cells, they are of considerable magnitude, and oblong or
oval in shape.   In the leather-dressers of Worcester, who have died
of chronic bronchitis, the mucous membrane is always ulcerated."
  IV. Hemorrhage.  See Pulmonary Hemorrhage.
  V. Dilatation ofthe bronchi.  See Pulmonary Emphysema.
                         SECTION IV.

                        The  Trachea.

  The place of foreign bodies that slip through the larynx into the
trachea, and are large enough to be detained in it, is discoverable
by the pain or local uneasiness which they produce.   They admit
of removal by tracheotomy.
  The affections of the  trachea are, croup, chronic  inflammation,
small-pox, ulcers.
  I.  Croup.   An inflammation of the  air-passages,  in which the
mucous membrane, of a deep vivid  red, and slightly thickened, is
lined with an exudation of coagulable lymph.   The  trachea is the
principal seat ofthe most common  form ofthe malady;  which ex-
tends, however, over the inner surface of the larynx, and into the
first  division of the bronchi, only in diminished intensity, [u. 46.]
It sometimes extends to the fauces and tonsils, and at other times is
most severe ih the  bronchi.  The false membrane, when coughed
up, is reproduced,  but in a less cohesive state.   The disease  com-
bines two elements of danger—fatal pyrexial  action, and mecha-
nical suffocation.  The latter may, if necessary,  be remedied by
tracheotomy.
  When the disease begins in the larynx, in its onset it frequently
resembles a common  cold ;  but  after the lapse of some hours—
sometimes only after  one or two days—the cough  becomes more
violent, resounding in the larynx and trachea as in a metallic tube,
and with a peculiarity of character which has been compared to
the crowing of a cock.
  There is a spasmodic croup which exactly simulates this disease,
and  which depends upon an inflammation confined  to  the  upper
opening  of the larynx.   On the same  coexisting with ordinary
croup, the spasm and peculiar crowing inspiration of that disease
immediately depend.
  II. Chronic inflammation of the trachea  is  a  part of chronic
bronchitis. 
THE RESPIRATORY ORGANS.
375
  III.  Small-pox pustules are found in the upper part of the tra-
chea as well asof the larynx, and in the soft palate.
  IV.  Ulcers   The ordinary seat of tracheal ulcers is the lower
part of the tube.   Their size varies from a few lines to an inch and
a rialt: they are of a grayish dirty colour, covered with  a puriform
mucus, with edges  somewhat swollen, the surrounding membrane
red.                                              °
  In a case given by Andral, the trachea, from its origin to a little
ahove the bifurcation, was like a sieve, from an immense quantity
of minute  ulcers, so numerous and close indeed that  the space oc-
cupied by them exceeded the sound portion ofthe membrane. The
disease had been attended by a sensation of habitual heat rather
than pain in the trachea; and inspiration was attended by a laryn-
geal hissing.   In another an ulcer opened into the oesophagus, but
was productive of no further inconvenience than a little  uneasiness
and cough when the patient swallowed.
  V.  The trachea is liable to become contracted by thickening of
its membrane  from chronic  inflammation, forming  one or more
narrowed rings, as  a consequence of the irritation following the
establishment  of a  permanent opening  after tracheotomy.  The
contraction occurs a short distance below the opening.
                          section v.

                          The Larynx.

   The affections ofthe larynx derive importance from the effect of
 spasm of its muscles.  The arytaenoids have in health the office of
 closing the larynx during deglutition.   When disease or irritation
 ofthe larynx is present, these muscles are liable to close the open-
 ing of the  tube  suddenly, and  keeping it closed to produce or
 threaten suffocation.
   The affections of the larynx may be classed under the heads of
 spasm, inflammation, ulceration,  polypi.
   I. Simple spasm ofthe larynx is met with in the fits of children
 attended with crowing inspiration, in hysteria, in hydrophobia.
   II. Inflammations about the larynx present four varieties.
   a. Acute laryngitis, with effusion of croupy membrane or lymph
 on the mucous  membrane, rapid prostration, suffocative seizures,
 death in  two to four days. [u. 45.]
   b. Erysipelatous  inflammation of the mucous  membrane ofthe
 epiglottis and  lips of the glottis, with  effusion of serum into the
 subjacent cellu'ar membrane, producing oedematous narrowing of
 the opening, and spasm—sometimes fatal in two or three  hours.
   c. Inflammation of a similar  character but with  less oedema;
not alarming  till suppuration is  established  below  the mucous
membrane. 
376
MAYO'S OUTLINES OF PATHOLOGY.
  In  each of these cases, bronchotomy, or laryngotomy, are re-
quired to prevent immediate suffocation.
  d. Subacute inflammation of the mucous membrane attends the
latter stages of three cases out of four of phthisis, aggravating the
cough and dyspnoea.
  III.  Ulcers of the larynx are of frequent  occurrence, and are
often  combined  with phthisis.  Alone  they  constitute  phthisis
laryngeal  they  generally commence upon the chordae vocales,
often exposing and rendering carious  the thyreoid cartilage.  The
voice at first rough, then a harsh whisper, cough with purulent ex-
pectoration tinged  with blood, local pain, and  tenderness on pres-
sure, mark the disease.   The affected surface maybe reached from
the fauces, and the suffocative spasm may be relieved by broncho-
tomy. [«. 48. 49. 50. 51.]
  1. Polypi.  Mr. Charles Mayo, of Winchester, favoured me with
a preparation from the  body of an  elderly lady, in which a firm
whitish elastic  polypus grew by a pedicle from the  root  of the
epiglottis.  It had  produced occasional suffocative seizures,  in one
of which the patient died.  [u. 54.] Such tumours are not extremely
unfrequent.  They would probably  admit, when of any size, of
being identified and removed during life.
  Andral describes in the larynx of a phthisical patient a wart on
one ofthe lips of the glottis,  formed of several small pedunculated
white nodules ofthe same nature probably as the above.
                         SECTION VI.

                Thyreoid and Thymus  Glands.

  The basis of the diseases of the thyreoid gland is  hypertrophy,
with which a great variety of morbid alterations may  be combined.
The enlargement is  called a bronchocele.  It principally attacks
young persons; girls much more frequently than boys.
  In simple hypertrophy the natural structure of the gland becomes
coarser and firmer, its size increasing to an enormous  extent.  The
gland often enlarges unequally; sometimes one lateral lobe exceeds
the other;  sometimes this is so in appearance only, an  enlarged
lymphatic gland being attached to one lobe :  sometimes the isthmus
ofthe gland is principally enlarged, and  attains the size of an egg,
exceeding the  bulk of either  lateral lobe.  It has appeared to  me
that this enlargement produces more dyspnoea and laryngeal irrita-
tion than lateral enlargement.
  The tumour, when growing rapidly, is  soft, and generally tender
on pressure.
  The influence of one  medicine on this  complaint is remarkable.
Iodine in general either permanently reduces  the enlargement to a
supportable size, or at all events temporarily diminishes it. When 
                   URINO-GENITAL SYSTEM.                377

the disease makes head, if the isthmus alone is enlarged, the tu-
mour admits  of easy removal.  I have once assisted at this opera-
tion, and once performed it myself.  The best way to restrain the
hemorrhage is to pass strong double ligatures on each side of the
tumour which  is to be removed, and tie them before cutting it out.
I have never seen a case of lateral enlargement that required an
operation to be  performed.
  The introduction of a seton, though in many cases successful, in
some has proved fatal; the ligature ofthe thyreoid arteries for this
complaint is a pathological  mistake.
  The varieties ofthe disease are,
  1. Serous or  glairy cysts in  the gland, which may be punctured
and healed.
  2. Tuberculous matter, which  is likely to go into suppuration.
  3. Cysts, containing blood.   These cysts are sometimes of large
size: one that  I punctured continued  to pour out blood profusely,
and kept filling.  The lancet opening, however, which I had made
was closed without trouble by a compress and a piece of sticking
plaster.  When a larger opening has been  made, the cyst requires
to be filled with lint, the pressure of which stops the bleeding, and
excites inflammation and suppuration ; after which the cyst granu-
lates and closes.
  d.  Phosphate of lime deposit is frequent in bronchocele, as in all
chronic fleshy growths.
   The thymus gland I have once only seen diseased, when it was
enlarged to a considerable  size, and formed a mass with the adja-
cent lymphatic glands, infiltrated with tuberculous matter.
                      CHAPTER XIII.

                   URINO-GENITAL SYSTEM.

  Many points in the pathology of this system are common to both
sexes.  These common points are found in the diseases of the kid-
neys, ureters, bladder.   But even the complaints of these  parts,
although essentially  the  same in both  sexes, have a character of
ao-oravation in the male, owing to  their complication with other
organs, and greater liability to obstruction in  that sex.   The patho-
logical outline which I purpose to offer cf this system, is to be con-
sidered as  taken from, or applicable  to, the male  subject.   The
shades of difference  which  belong to the pathology of the  female
urinary system, will be pointed out in their place in the following
sections.   The affections of the uterine system will be treated of in
a separate  chapter. 
378
MAYO'S OUTLINES OF PATHOLOGY.
  The male urino-genital organs may be studied under the sepa-
rate heads of the  kidneys, ureters, bladder, the prostate gland, the
urethra, the testes.
                          SECTION I.

                         The Kidneys.

  It will be found convenient, first, to consider the various struc-
tural alterations of which the kidney is susceptible ; and afterwards,
the different morbid conditions ofthe urine.
  The morbid appearances of the kidney may be thus enumerated.
  1. Hypertrophy and atrophy.  Neither of these conditions forms
a prominent feature in the pathology of the kidney.  Hypertrophy
takes place in  those  cases in which one kidney alone has been
formed :  the single kidney is of unusual magnitude, but ofthe nor-
mal shape, [x.  40.]  Atrophy of the cortical substance is liable to
be  produced by any cause that mechanically obstructs the flow of
the urine; the backward  pressure ofthe urine in such cases upon
the pelvis and infundibula of the  kidney, produces dilatation, and
a wonderful expansion of the cortical substance, which gradually
spreads into a thin  loculated membranous sac. [x. 42. 43.]  It oc-
casionally  happens, when the kidney has been for some time ex-
panded into a membranous sac, through  a calculus obstructing the
pelvis, and the calculus is not got  rid of in  any way, that after a
time, the urine which distends the kidney is absorbed;  the mem-
branous sac at the same time wastes and  shrinks, and  is finally re-
duced to a  mere capsule containing the stone.
  2. Anamia, or paleness  of  the  kidney, and hyperamia, or a
dark and loaded state of the  vessels, attended in extreme cases with
spots of extravasation, are common appearances.
  3. Acute inflammation.  I have never had an opportunity of
seeing the appearance which  this disease  presents upon a post
mortem inspection.   It rarely terminates  fatally.   Increased vascu-
larity, with softening and brittleness of texture, would, I suppose,
characterise it.   The symptoms  are  fever,  vomiting, pain in the
loins, colicky pains of the belly, the urine scanty, the bladder irri-
table.
  4. One of the most important varieties of chronic inflammation
was discovered, and its true pathological  value determined, by Dr.
Bright, in  whose reports the practitioner may see faithful delinea-
tions ofthe different stages of the complaint.   The cortical part of
the kidney at-first mottled with  interstitial deposit of fibrin ; then
indurated and granulated from the consolidation ofthe renal lobuli;»
and finally, entirely  converted into a yellowish  white seemingly
homogeneous substance—form  the progressive steps of the morbid
alteration. 
URINO-GENITAL SYSTEM.
379
  5. Abscess of the kidney is ordinarily the result of protracted
common inflammation, originating in whatever cause.  It is how-
ever most  frequently a secondary consequence of mechanical or
sympathetic irritation, propagated reflectively from  the bladder.
Dr. G. H. Barlow mentioned to me a case that he had witnessed,
in which the ureters of both kidneys were obstructed through lithic
acid calculi.  One kidney adhered to the colon, and communicated
with its cavity by an ulcerated aperture.   A lady mentioned by Sir
Benjamin Brodie, had frequent desire to void the urine, and com-
plained of a cutting pain at the neck ofthe bladder; the urine con-
tained  a muco purulent secretion ; afterwards true pus.  Things
had gone on thus for  two or  three years, when the  patient, with
the usual symptoms, passed a large renal calculus, and the original
symptoms  were relieved.  Abscesses of the  kidney  depending on
calculi, have pointed in the loins, and when the calculi have been
discharged,  have closed.
  6. Serous cysts.  Small cysts containing a transparent liquid
are common in  the  kidney, [x. 45.]   Their growth is supposed to
be slow, and they generally produce no derangement of the func-
tion of the  gland : they  have  been  termed  spurious hydatids, in
contradistinction to  true hydatids, which form in, and  are occasion-
ally discharged in great numbers with the urine; the patient some-
times recovering.   I shall quote two  unusual cases of renal cysts :
the first communicated to the  Medical and Chirurgical Society,  by
Mr. Caesar Hawkins, and  remarkable for  its  rapid formation ;  the
second, which  is  described in Sir  Benjamin Brodie's Lectures  on
the Urinary Organs, exemplifies likewise subacute inflammation  [of
the mucous tissue?] ofthe kidney.
  A child, six years of age, was struck down and run over in the
street,  which caused considerable  swelling of the belly and pain :
these symptoms subsided in a few days.  The accident occurred at
the end of  September, 1832.   Four or five  days afterwards  the
swelling returned ;  it was now confined to the right side : the child
suffered from feverishness, and became emaciated.   The swelling,
which  in a short time was determined to  contain fluid, diminished
temporarily  with calomel.  It  then increased anew, with  marked
change for the  worse  in  the  child's health.   On the first of De-
cember the  cyst was  punctured through the abdominal muscles,
when eighteen ounces of  clear fluid  were drawn off,  with relief to  K
the child : the fluid was nearly transparent, and evaporated almost
entirely, leaving a small residuum of  muco-extractive  matter, with-
out any trace of albumen.  The cyst filled  again, and the child
sank, and died on the  25th.  The tumour was found to consist of
a single cyst, which held  four pints of fluid, the greater part clear
and transparent, the remainder contained a good  deal of white
semi-purulent matter.  The tumour  reached  upwards to the loin,
raising the ribs and pushing the liver towards the left  side and into
the chest • downwards the cyst had protruded slightly below Pou- 
3S0            MAYO'S OUTLINES OF PATHOLOGY.

part's ligament, through the femoral  ring.  The cyst appeared to
have formed on the surface ofthe kidney.—Casar Hawkins.
  A  gentleman, in November, 1833, complained  of voiding his
urine frequently, and in quantities varying from an ounce to an
ounce and a half.  Always after making water he had a severe
pain  lasting a few minutes, and extending along the course of the
urethra.   The urine was pale, semi-opaque, of an acid quality, and
when tested with  heat and nitric acid, it was found to.be highly
albuminous.  Occasionally small masses of a substance resembling
coagulating lymph were found floating in it.     He made no com-
plaint of pain in the loins; he was able to empty his bladder by his
own  efforts; and the urethra was free from stricture.  There  was
no calculus in  the bladder, nor had sand or gravel ever been ob-
served in the  urine.  These symptoms  had begun to exist in the
preceding February, since which time  they had  gradually in-
creased.   For a short time during the month of March the urine
had  been tinged with blood.  In addition to these  local ailments,
the general health was much impaired:  the patient had lost flesh,
was  languid, dejected, and of a pallid countenance.  Soon after-
wards the urine became again tinged  with blood, the bodily powers
continued to fail, and  the local symptoms became more urgent.
There was a total loss of inclination for food, the  extremities be-
came cold, the  pulse feeble, and he died at the end of February,
1834.
  Inspection.—The  kidneys were found to be of a dark colour
from excessive  vascularity, and of a soft and somewhat  brittle con-
sistence ;  the distinction between the cortical and tubular portions
being less  marked than  under ordinary circumstances.  The in-
vesting membrane of the kidney had a very slight  adhesion to the
kidney itself, but  it adhered very closely to the adipose  substance
ofthe loins.  On the surface of each kidney, and partly imbedded
in its substance, were four or five membranous cysts, each of the
size  of a large pea; and in one of them there was a similar cyst,
but as large as a  nutmeg, completely imbedded in the cortical sub-
stance.  The pelvis, infundibula, and ureters  were  not more capa-
cious than under ordinary circumstances: but on their being slit
up, their internal  surface presented the appearance  of considerable
inflammation.—Brodie.
  7.   Tubercidous disease, occurs in  two forms ; in one the tuber-
culous matter  is  deposited in  spherical  masses in the cortical sub-
stance of  the kidney [x. 50.]; in the other it lines as an exudation
the mucous surface of the infundibula, pelvis, and ureter, and is
commonly combined with  dilatation  of  the cavities of the kidney
and expansion of its cortical substance, [x. 51.]
  8.  Fungus hamatodes ofthe kidney is unfrequent.   The gland
affected enlarges   indefinitely; haematuria is generally present.
The countenance in the latter stages exhibits  the striking expres-
sion  which inward malignant disease usually gives  rise to"! 
                   URIN0-GEN1TAL SYSTEM.                381

  9. Calculi in the kidney are found either as small fragments im-
pacted in the tubuli uriniferi, or part in a  tubulous part projecting
into an  infundibulum, or as larger masses free, or  by their figure
fixed in the infundibula, or in the branches ofthe pelvis, or in acci-
dental  dilatations ofthe cavities, [x. 60. 61.]
  In diseases of other organs, the local or sympathetic pain, and
the attendant fever, are the  prominent symptoms: but all diseases
of the  kidneys are liable, while  many are certain, to produce pain
in the  loins, in the course ofthe ureters, and in the  bladder, in the
spermatic cord and testis; and fever without diagnostic local symp-
toms is of little use to the pathologist.
  One striking  relation of renal  disease has,  however, been ob-
served and recently described by Mr. Stanley,  in the 18th volume
of the  Medico-Chirurgical Transactions, which  although not often
in activity, deserves from its importance full illustration.
  A man was admitted into St. Bartholomew's  Hospital, with para-
plegia  and retention of urine.   On examining the spine, tenderness
was discovered at the third lumbar vertebra: an issue was applied.
and considerable  improvement  followed.  Afterwards the general
health  failed, and the  patient gradually sank.  No disease could be
discovered in the vertebral  column :  the bones, fibro cartilages,
spinal  cord, and nerves were perfectly sound, as were the brain and
its membranes.  In one kidney there were numerous small abscesses.
The other kidney was gorged with blood, and  its substance was
softer than natural.  The mucous lining of the ureters and  of the
bladder was very vascular; and the muscular coat of the bladder was
thickened.
  A man, aged thirty-five, had a partial loss of motion in his upper
and lower limbs, which had commenced a month previously, and
was supposed to originate in disease of the cervical  vertebrae.  He
suffered  besides from  irritation ofthe  bladder, with occasional ina-
bility to  expel the urine,  which was  mixed with some puriform
fluid.  His health declined and he died in six weeks.  Both kidneys
were found  gorged with blood.   In  the substance  of one  kidney
there were small depositions  of  pus.   The muscular  coat  of the
bladder was thickened, and  its  mucous coat very  vascular.  No
morbid appearance was discovered in the brain or spinal cord.   The
vertebrae and fibro-cartilages were perfectly healthy.
  Two cases  are then mentioned by Mr. Stanley, in wdiich similar
conjoint  affections of  the spine and kidneys occurred after injuries
of the  back.
  The explanation, which it would have been natural to  offer of
these concurrent phenomena, is,  that in the latter case, the injury of
the back, in  the former, some nervous affection of the spinal marrow,
determined  simultaneously  both  results,  the paraplegic affection,
namely, and the renal disease; but other cases  follow in Mr. Stan-
ley's paper, which appear to me completely to establish the justness
of his conclusion, that renal disease may cause paraplegia.
  A man aged twenty-two, had retention of urine, in consequence 
382            MAYO'S OUTLINES OF PATHOLOGY.

of stopping a severe gonorrhoeal discharge by injections.   The blad-
der then lost its expulsive power.  The sphincter ani became para-
lytic, and the  lower limbs were incompletely paralysed.   He com-
plained of severe pain at the fifth lumbar vertebra.   He  sank, and
died in a fortnight.  The kidneys were found  larger than natural
and of a very soft consistence.   Sections of them displayed general
vascular turgescence,  and numerous minute  depositions of pus
throughout  both the cortical and tubular parts.  The infundibula
and pelvis were filled  with pus mixed with a thick ropy mucus.
The mucous membrane lining the bladder was very  vascular, and
in part covered by coagulable lymph.  There was no morbid appear-
ance discernible in any part ofthe brain or spinal cord.
   A  man, aged thirty,  had gonorrhoea with phymosis, which was in
progress  of cure.  The inflammation of the uretha had subsided,
but the discharge continued.   Whilst in this state,  as far as local
disease was concerned, and without any particular derangement  of
the general health, he was suddenly seized with paraplegia, which
extended as high as the umbilicus.  The loss of motion  was com-
plete—that of sensation nearly so.  The celebral functions were un-
affected.   He stated that he had been suffering for a day or two from
pain in the loins.  The pulse was 85,  and rather  full.  He was
cupped on the loins and free action ofthe bowels obtained by pur-
gatives, but with no benefit.  The urine flowed spontaneously, and
in considerable quantity.   As,  however, it  was  thought the bladder
was  distended,  a catheter was  introduced, and  three pints of urine
evacuated.   In sixteen hours from the attack of paraplegia, the man
suddenly fell back in his bed, and died.  Both kidneys were found
of so dark a colour as  to be almost black; they  were remarkably
flaccid, and on sections being made of them,  were  found to bo  in
every part gorged with blood.  The mucous lining  ofthe infundi-
bula and pelvis was dark-coloured from the turgescence  ofthe ves-
sels.  There was enlargement and induration of the liver, and some
turgescence ofthe vessels  ofthe spinal marrow.
   It is in alterations ofthe quantity and quality of the urine, that
the symptoms are found which are our guides in measuring the ex-
tent and the kind  of  renal lesion or disease.   The phenomena  of
this description may be arranged under the following heads,—sup-
pression, excessive secretion, haernaturia, albuminous urine, excess
of urea, diabetes, amorphous sediments, gravel,  renal calculi.
   1. Suppression of urine may be complete or incomplete—that is
to say, the secretion may not take place at all (or to the quantity  of
a table spoonful only in twenty-four hours); or the secretion may
be less than the natural quantity by one  half or two-thirds only.
   Complete suppression of urine may result from various  causes.
   a. From the prostration of the vital  forces which attends Asiatic
cholera.
   b.  From acute inflammation of both  kidneys, of which it forms a
symptom. 
URINO-GENITAL SYSTEM.
383
   °i a   i™ ?bstruction lo the discharge ofthe  urine already se-
creted ;  which obstruction acts either mechanically or by sympathy.
   A gentleman, aged sixty-four, who had been subject to the for-
mation of renal calculi, which had afterwards come away by the
urethra, was seized  with one of his usual attacks, indicating that a
calculus had escaped from the kidney.  Instead, however, of termi-
nating in the usual manner, the pain  continued  unaltered, and he
ceased to void his urine.   In the supposition that there might be
urine in the bladder, the catheter was introduced several times, but
no urine flowed.  The patient became comatose, and died in a fit
of convulsion eleven or twelve days after the commencement ofthe
attack.
   On examining the body after death, no urine was found in the
bladder.  In one kidney there were several calculi: there were none
in the other.  In  the ureter belonging to the latter, and in the upper
part of that canal, a calculus ofthe size of a horsebean was wedged.
It appeared, therefore,  that  the circumstance of one ureter  being
completely obstructed by a calculus,  had caused a  suppression of
the secretion of urine in both kidneys.—Brodie.
   d.  During the subsidence of scarlatina, the secretion of urine is
sometimes deficient for two days and upwards;  the cause of this
symptom is probably the same with that ofthe anasarca which fre-
quently follows scarlet fever.
   e. Suppression of urine  may take place either as a functional dis-
order ofthe kidney, or through the influence of disease in some dis-
connected organ or organs.
   A middle-aged man, in a London  brew-house, had felt indisposed
on the evening ofthe 7th November, 1818; on the 8th he returned
to his employment, and was engaged in hard bodily exertion,  strip-
ped to his shirt.   Becoming fatigued, he drank a large draught of
porter, upon which he felt as if he was taken ill;  he therefore went
home : towards evening he remarked that he made  no water.   He
sweated profusely during the night, and the next morning felt better:
still  he   made no water.  He then  came to the Middlesex Hos-
pital, when though no distention of the bladder was apparent a ca-
theter was introduced, and a  table-spoonful of water was drawn off.
He complained of no pain, but his tongue was furred, his pulse fre-
quent, his countenance anxious: his bowels were relaxed: there was
tenderness ofthe epigastrium on pressure.   On the 10th he appear-
ed worse; on the 11th another table-spoonful  of  urine was drawn
off through the catheter: the breathing was laboured : in the even-
ing coma supervened, and he died at ten at night.
   The vessels ofthe  brain were distended with blood, and there was
serous effusion on the surface and in the  ventricles.   The  right
lung was in a state of congestion : the liver was studded with nume-
rous small abscesses about the size of peas, some larger, some smaller,
containing a thick matter.
   The kidneys were externally lobulated:  on dividing them the
tubular part appeared darker than usual, the cortical paler; the tex- 
384            MAYO'S OUTLINES OF PATHOLOGY.

ture was softer and moister than common, as if it had been slightly
oedematous; the kidneys had a urinous smell.
  Diminution of  the secretion of urine is common during urethral
retention, the cause of which must  be partly mechanical; and in
dropsy, when it  may be either a cause or  an  effect of the serous
effusion.
  2. Excessive secretion.  In hysteria the urine is often  large in
quantity, pale, of a low specific gravity, and contains a large portion
of saline ingredients.
  Sir Benjamin Brodie mentions an  instance in which he examined
the kidneys after death, where for some years there had been a large
flow of urine of a pale straw colour.   Both kidneys were of a very
pale colour; the glandular structure ofone of them was much dimin-
ished in  bulk, the pelvis being at the  same time considerably dilated.
  3. Hamaturia.  The existence of blood in the urine is undoubted
when coagula are voided with it, or when being of a dark colour its
expulsion is followed by drops of pure blood.
  Blood uniformly diffused through  the urine, imparts to it either a
bright red  or a brown,  or nearly black colour : its presence may be
decided by adding water to the urine, and placing the diluted fluid
in a tall glass vessel, when  the colouring  matter of the blood sub-
sides to the bottom—or by  boiling it,  when  a brown coagulum
is obtained, and the rest of the liquid regains the natural colour of
urine.
   The blood in  haernaturia may proceed either from the kidneys,
the ureters, the bladder, the prostate, or the urethra.
   a.  Blood from the kidney may pass in  clots, or uniformly diffused
through the urine.
   The first is generally the result of hemorrhage from a mechanical
cause.
   When there are calculi in the kidney, rupture of a vessel or ves-
sels may be produced by any sudden jolt: the  blood that passes in
that case occasionally comes away in  theshape of worm-like coagula,
which have been shaped in the infundibula or ureters.  These are
sometimes externally gray, like fibrin, and  internally red, like a re-
cent clot.  Cullen states, that he had sometimes observed the blood
come away in an almost dry state, resembling the half-burnt wick of
a candle.  I once found a black charred mass shaped to  a part of
the pelvis ofthe kidney contained in that cavity; it was extremely
light; it was laid aside for more careful examination, and  lost.
   A blow  upon the loins is liable to rupture the kidney to a greater
or less extent, producing bloody urine : the kidney may even be in-
jured by pressure from the fore part ofthe belly.
   Ann Sullivan, aged  twenty-five,  was  admitted into the Middle-
sex Hospital in February, 1836, having been pinned  by the shaft
of a rubbish cart against a railing.  She  was  retained  in that posi-
tion nearly a minute:  the pain was severe, and she vomited.   The
belly was bruised to the left ofthe umbilicus, and  tender on pres- 
                   URIN0-GEN1TAL SYSTEM.                385

sure.  She was directed to be kept perfectly still, and without food,
in the apprehension that the  intestines might be ruptured; in the
afternoon sixteen ounces of blood were taken from the arm.  This
blood drawn nine hours after the injury was of the colour of arterial
blood.  On passing urine in the evening, there was no pain, but the
urine contained two small clots  of blood : the urine voided  after-
wards-was natural in appearance.  For several days great tender-
ness remained at the left side ofthe belly and left loin, which, under
the usual treatment, gradually went away.
  Blood, however, from the kidneys, when proceeding from a me-
chanical cause, more often forms a liquid mixture with the urine.
In that case, Dr. Prout observes, that it is generally equally diffused
through the whole urine.
  The most  frequent cause of  renal haernaturia  is the presence of
renal calculi, which often exist without causing any other symptom;
the rarest cause, malignant disease of the kidney, in which case Dr.
Prout has noticed the presence of a peculiar and characteristic red-
dish sediment.   It has been already shown that mechanical injury
will produce renal hemorrhage.  In  inflammation, or in  vascular
congestion ofthe kidney, blood  is liable to be poured out by exha-
lation.
   The varieties of the latter case are periodical and vicarious haerna-
turia, which are stated to have occurred.
   The exhalation of blood in the kidneys is sometimes attended with
shivering.
   A patient under the care of Dr. Watson, in the Middlesex Hospi-
tal, had haernaturia of an obscure kind ; the discharge of blood was
always marked by a smart rigor.  Dr. Prout mentions an instance
of obstinate haernaturia, in which the bleeding was constantly pre-
ceded by a shaking fit.   Dr. Elliotson gives an account of a case of
intermittent haernaturia,  in a patient who had  formerly had the
 Walcheren fever.  He  was admitted  into  St. Thomas's  Hospital
with  ague, and he discharged from the urethra every time the cold
fit came on a quantity of pure blood.   He was cured by quinine, los-
ing the cold fit and the haernaturia together.
   The origin of haernaturia in the kidney is rendered probable  by
the presence of pain in one loin, and by the absence of those symp-
toms which indicate disease in the other parts  ofthe urinary appa-
ratus.
   b.  Hemorrhage from the ureters occurs in consequence of lace-
ration ofthe lining membrane by the  passage of gravel or calculi.
   c.  Vesical hemorrhage.  Dr. Prout observes, that when blood is
derived from the bladder, it for the most part  comes away at the
termination only of the urinary discharge, the  urine  having previ-
ously flowed off nearly pure.   If poured  out in any quantity, it is
likely to clot in  the bladder and form a coagulum, which will take
several days to loosen and be discharged with the urine.   Mr. How-
ship mentions a  case which occurred to Mr. Heaviside, of an old
E ' st Indian, who died after what was thought to be retention of 
386
MAYO'S OUTLINES OF PATHOLOGY.
 urine, but no urine had flowed on the introduction of the catheter.
 The  bladder was found distended by a very large coagulum of
 blood, which had come from the diseased mucous membrane.
   M. Renault describes an obstinate haernaturia, which affected num-
 bers  of the French troops in  Egypt, and particularly the cavalry.
 It was attended with pain in the bladder, extending  along the ure-
 thra to the extremity ofthe glans penis,  and with frequent urgency
 to make  water.   The last drops excreted were frequently of pure
 blood.  M. Renault had opportunities of examining the bladder, and
 found its  inner membrane inflamed.
   d.  Prostatic hemorrhage is generally small in quantity, but some-
 times it is abundant and alarming.  A gentleman laboured under
 disease of the prostate: he was in the habit  of introducing the ca-
 theter himself.   One evening he observed  that blood  flowed with
 the urine.  In the night Sir  Benjamin Brodie found him with  the
 bladder enormously distended, prominent in  the abdomen as high
 as the navel, and blood still flowing from the urethra.  A large ca-
 theter was introduced, but no  urine escaped :  the  bladder was dis-
 tended, not with urine but with blood.  The patient was directed to
 lose blood by cupping on the loins, and to remain quiet: under this
 treatment the hemorrhage ceased—not, however, until  a very large
 quantity of blood had been lost.  The catheter was afterwards in-
 troduced three or four times daily.   The blood by degrees became
 dissolved  in the urine, and after two or three weeks the latter was as
 clear  as it had been before the  attack of hemorrhage took place.
 But the pulse was frequent, the skin hot, the tongue dry and brown,
 and the patient survived the hemorrhage only about a month.  In
 the post mortem examination, the mucous membrane of the bladder
 was found extensively inflamed ; a large tumour ofthe prostate pro-
jected into the bladder ; and the exact spot seemed to be discernible
 at which the vessels ofthe tumour had given way, and from  which
the hemorrhage had proceeded.
  e.  Urethral hemorrhage.   A young  man came to the Middlesex
 Hospital, with hemorrhage from the urethra, and said that he had lost
a considerable quantity of blood in this manner in the course of a
few hours, inconsequence of excessive  indulgence in sexual inter-
 course the preceding  night.  The  bleeding was permanently ar-
rested by the introduction of a bougie, which was allowed to remain
a short time  in the urethra.
  4. Albuminous urine.   Albumen is contained in scarcely appre-
ciable quantities  in healthy urine, but in some states of disease it ap-
pears  in considerable proportions.
  The best mode of detecting its presence is the application of heat,
and.the addition  of nitric acid.   When the urine upon being heated
to the boiling point is  rendered opaque by a white precipitate, which
is not re-dissolved by the addition of nitric acid, the presence of al-
bumen may  be certainly inferred.   The addition of the nitric acid
is, however,  a necessary precaution, as specimens of urine are  not
unfrequently to be met with, which, upon being boiled, give a white 
URINO-GENITAL SYSTEM.
3S7
flocculent precipitate closely resembling albumen, but which is proved
not to be that substance, by its being immediately re-dissolved upon
the addition of a few drops of nitric acid.   There can be little doubt
that the use of heat alone, as a test, has given rise to much error
upon this subject.
   Of those specimens of urine which  are rendered turbid by heat,
it is probable that not much more than one-half contain albumen.
The cause, of this phenomenon is at present involved in some ob-
scurity ; it appears in many cases to depend upon the precipitation of
the phosphates, caused by the ammonia generated by the decompo-
sition of the urea through heat, as stated by Dr. Bright, on the autho-
rity of Mr. Rees, in the Gulstonian Lectures for 1833.  There are,
however, cases to which this solution of the difficulty will not apply.
   But further experiments are wanting upon the subject.  Albumi-
nous urine  is of  light specific  gravity,'seldom  exceeding 1.015:
Dr. G. H. Barlow  has met with one or two specimens in which its
specific gravity has been 1.005.  This circumstance, which appears
to depend upou a deficiency of urea, is  perhaps of no less importance
in the etiology ofthe diseases which have been observed in connection
with albuminous  urine  than is the presence of the albumen itself.
The mode which Dr. Prout uses to estimate the proportion of urea, is
to put a little of the urine into a  watch glass, and add to it carefully
nearly an equal quantity of pure nitric acid, in such a manner that the
acid shall subside to the lower part ofthe glass.  Healthy urine yields
crystals of nitrate of urea after an interval of two hours ; but Dr. G.
II. Barlow has examined specimens of albuminous urine, which,
even when concentrated by gentle evaporation to one fourth of their
bulk, yielded scarcely any crystals at the end of that time.
   It was remarked by  Dr. Blackall, that albuminous urine is cha-
racteristic of certain kinds of dropsy accompanied with inflammatory
symptoms; and that physician expressed his belief that these symp-
toms had their origin in inflammation of some internal organ.  It
was, however,  reserved for Dr. Bright to ascertain the seat of the
disease.  According to his observations,  albuminous urine  is ac-
companied by certain forms of disease of the kidneys which  have
been already adverted to, of which it may be considered a diagnostic
symptom;  which  disease, on the other hand, is productive of drop-
sical effusions, of  hypertrophy of the left ventricle ofthe heart, of
inflammation ofthe serous membranes, and of apoplexy.
   5. Excess of urea. The deficiency  of urea has been shown  to be
an important circumstance in those cases of disease  of the kidneys,
which have been adverted to  under the head of albuminous urine.
There is, however, a disease noticed by Dr. Prout, as characterised
by an excess of that substance.   This derangement of the urine has
not as yet been connected with any organic disease; and there ap-
pears to be a considerable want of uniformity in its nature, though
the symptoms have in  several  cases closely resembled those of dia-
betes in which Dr. Prout believes, that,  if it be checked, it will
eventually terminate.  In these  cases  the  urine is  very abundant; 
388
MAYO'S OUTLINES OF PATHOLOGY.
and characterised by its great specific gravity, and the readiness with
which it crystallises upon the addition of nitric acid.
  6. Diabetes.  This term is restricted, by Dr. Prout, to disease in
which a saccharine state ofthe urine is the characteristic symptom.
  Diabetic urine is almost always of a pale straw or greenish colour.
Its smell is commonly faint and peculiar, sometimes resembling sweet
whey or milk.   Its taste is  always decidedly saccharine in a greater
or less degree.   Its specific gravity  has been stated  to vary from
1.020 to 1.050.  Dr. Prout has seen it higher than this, but  never
so low.  The quantity of "urea, according to Dr. Prout,  is almost
always very much diminished : it contains,  for the most part, little
or no  lithic acid.   The usual saline matters existing in healthy
urine are met with in diabetic urine  in  nearly  the same relative
proportions, but their absolute quantity is  very much diminished.
Sometimes diabetic urine contains a little blood; and, not unfre-
quently, albuminous matter analagous to that of chyle.
  Diabetes  is ordinarily connected  with diuresis.  Cases are on
record, in which the  enormous quantity of  thirty pints  has been
discharged every  twenty-four hours  for weeks and  even months
together.  The quantity of saccharine matter contained in diabetic
urine is not less surprising.  From a table calculated by Dr. Henry
it appears that ten  pints of  diuretic urine, of  the specific gravity of
1.040,  contain upwards of a pound and a quarter of solid extract.
  The constitutional and other affections usually accompanying a
saccharine state of the urine are- summarily enumerated by Mr.
Watt as follows:—
  The appetite usually better than  in health ; uneasiness in  the
stomach after meals;  thirst urgent; the mouth  dry and  parched;
tongue white and  foul, sometimes unnaturally clean and red ; tough
disagreeable mucus in the throat; depraved taste; skin dry and
unperspirable; considerable emaciation; weariness and aversion to
exercise ; loss of strength ; pain and  weakness in the region of the
kidneys; irregular, generally costive, state of the bowels ; some de-
gree of inflammation and uneasiness about the external  orifice of
urethra; loss of virility; chilly state of body; cold feet; tendency to
cedema; heat and  uneasiness in stomach and bowels; acid eructa-
tions; flatulence; eyes muddy and painful; indistinct vision; vertigo;
headach;  dyspnoea  on the  least exertion;  gums  spongy and
ulcerated; weight  and tenderness about the praecordia ; listlessness;
mind weak and peevish ; spirits exhausted.  The breath, and  fre-
quently the person of the patient exhales a peculiar hay-like smell.
The pulse variable, but generally in the latter  stages weak, and
sometimes irregular.
  The proximate  cause of this disease is unknown.  It is  occasion-
ally combined with tubercles in the lungs.   Its source probably lies
in disorder either ofthe digestive  organs, or of some other part of
the assimilating apparatus.   Diabetic kidneys are generally large,
soft, and v..soutar. 
URINO-GENITAL SYSTEM.
389
  7. Amorphous sediments.  These are divided by Dr. Prout, into
yellow sediments; red or lateritious ; and pink sediments.
  a. The yellow consist essentially  of lithate of ammonia tinged
with the colouring principle of the urine ; but usually contain more
or less of the  phosphates, and sometimes  a little of the lithate of
soda.  This class  of sediments  Dr. Prout terms the sediment of
health, being such as are produced in the urine of healthy or slightly
dyspeptic persons by errors of diet, unusual bodily or mental exer-
tions interfering with digestion, and the like.
   b.  Red or lateritious sediments vary in tint from nearly white,—
in which state they are with difficulty distinguished from the last
variety, to a deep brick red or brown.  They consist essentially of
lithate of ammonia, or lithate of soda, tinged with a large proportion
of the colouring principle  of the  urine,  and more or less  of the
purpurates of ammonia and soda.  When the purpurates exist in
the urine (indicating,  as Dr. Prout conceives, the  secretion by the
kidney of nitric acid), feverish or inflammatory  action  is  almost
constantly present.  This law is so general,  that Dr. Prout has
never seen a  decided  exception to it.   The lateritious  sediment,
therefore, denotes fever, and that generally  of an inflammatory
nature ;  not however as attacking or at its height, but  on  the turn
and declining : thus it  is found, not in the cold, but in the  sweating
stage.
   c.  Pink sediments consist of the lithate of ammonia, tinged by
the purpurate only,  the colouring matter of the urine which gives
the lateritious its yellow being away.  They indicate general fever
of an irritable nature, or hectic.   The most perfect specimens which
Dr. Prout has seen of pink sediment  were obtained from the liver of
dropsical persons:  they are  produced in certain  chronic visceral
obstructions, especially ofthe liver.
   Besides these amorphous sediments, Dr. Prout  has seen two or
three instances in which large quantities  of perfectly white lithate
of soda were  deposited from the urine.  In one case in particular,
the quantity was immense; and voided not only mixed with urine,
but in a state  of consistency  like  mortar, especially during the night,
so as to produce considerable difficulty in passing the urine.
   8. Gravel.  The urine under different circumstances deposits  a
red sand and  a white.
   a. Red sand. Healthy urine turns litmus paper red. This effect,
according to  Dr. Prout, is not produced by a free  acid, but  by  the
lithate of ammonia.   But another  acid (the muriatic, according to
Dr. Prout) may be  formed in the urine, which will decompose the
lithate of ammonia, combining with the ammonia, and  throwing
down the lithic acid.  The red sand is lithic acid.  When  the urine
contains superabundant acid, it is usually bright  and transparent,
and of a copper colour, or resembles Madeira wine.
   Lithic acid gravel is formed in a sthenic habit, the result of stimu-
lating food not qualified by exercise and free perspiration.  It occurs
in gouty diathesis, combined with lithate of soda deposit about  the
       22-a                                    26 may 
390
MAYO'S OUTLINES OF PATHOLOGY.
joints, and psoriasis of the skin.  Alkaline medicines, temperance,
exercise, the sulphur bath, correct it.
  b. White sand.  The urine,  under ordinary circumstances, con-
tains in solution the phosphate  of magnesia, a highly soluble salt.
But according to Dr. Prout, in some cases of disease the urea be-
comes decomposed in the kidneys, and ammonia is evolved, which
combines with the phosphate of  magnesia so as to make a triple salt.
But the triple salt is insoluble, and therefore is precipitated in the
form of a white sand.  Dr. Prout observes also, that the same state
of the system which leads to  the decomposition of urea and the
evolution of ammonia, leads also  to a more abundant formation of the
phosphate of magnesia; and hence arises the  immense deposition of
white sand which occurs in some cases.
  The white sand, which the triple phosphate constitutes, in general
marks an asthenic habit: the system has been lowered, and must be
strengthened;  the alkaline quality corrected by the use of the mine-
ral  or vegetable acids.   But sometimes other causes will  produce
the same diathesis.   The urine  in this case  is alkaline, of a pale
colour like whey;  the  odour  remarkably unpleasant, sometimes
ammoniacal.
  Certain symptoms of a mechanical origin are  common to both
kinds of gravel:  pain in the loins, pain in the course of the ureters
and in the testis, pain down  the thighs, irritability of the  bladder;
but the extent and even the existence of these symptoms are capri-
cious.
  Phosphate of lime is met with in the urine, either with or without
the triple phosphate.  A  small quantity of this salt seems to be
occasionally generated by a diseased kidney;  but in general  it is
derived from another source.
  9. Renal calculi are the results of the same diathesis, and consist
for  the most part of the same chemical elements as gravel.   Calculi
are thus formed of lithic acid,  or of the triple phosphate, or of the
two in succession.  The cause why at one time gravel is formed, at
another calculus,  is to be sought in the presence or  absence of an
additional element, some glutinous substance secreted with the salt,
which when present joins the crystals into a coherent mass.
  The lithic acid, or the triple  phosphate, may form indifferently
calculi or sand : on the other hand, another salt, the oxalate of lime,
never appears as sand,, but comes away in small or large concrete
masses.
  a. The commonest variety of calculus is that which is composed
of pure lithic acid. These are generally of around or oval form, of a
light brown colour, and commonly smooth on the surface.
  b. The next in order  of frequency are those composed of oxalate
of lime.   These are of a dark colour, and usually of an  irregular
figure, with a number of small prominences on  the surface ; having
something ofthe appearance of a mulberry, and hence denominated
mulberry calculi.
  c. The triple phosphate of ammonia and magnesia is sometimes 
URINO-GENITAL SYSTEM.
391
but rarely deposited in the kidney, so that it may form  the nucleus.
of a calculus. The triple phosphate is commonly found asan external
layer (separated from  the urea in the bladder) upon a nucleus either
of lithic acid or of oxalate of lime.
  d. Calculi of phosphate of lime are occasionally found in a dis-
eased kidney, probably not proceeding from the urine, but from other
secretions of the affected organ.   In the collection belonging to Sir
Benjamin Brodie there are two kidneys completely filled  with calculi-
of this description.
  Calculi may  form  in the kidney, and exist unsuspected for an
indefinite length of time, or they may produce  hemorrhage, or
inflammation, or abscess, with or without obstruction to the flow of
urine from the  affected kidney; with or without pain  in the loinSj
pain in the ureters and bladder, fever, and extenuation.
                          SECTION II.

                         The Ureters.

  The ureters are liable to participate eiiher in inflammation, or in
tuberculous action  originating in the kidney:  they are  liable to
become enlarged from distention with urine, alone,  or mixed with
pus, in consequence of obstruction either from inflammatory stricture
following irritation, or from calculi filling and being stopped in their
cavities.   In general, calculi that cannot  pass  are  arresled  at  the
upper part ofthe canal [x. 70]; but it has  happened that a calculus
has stuck in the vesical termination ofthe ureter, and has produced
fatal disease ofthe kidney, when a fortunate movement of a sound
in the bladder might have displaced it.  The ureters will bear, or
wi 11 grow to, a wonderful degree of d ilatation, so as to attain a diameter
of three-quarters of an inch, in consequence of stricture of the ure-
thra.   Sometimes when the ureter has been long distended with a
calculus, an abscess  has formed in the loins, the ureter has ulcerated,
and the calculus has passed by the opening,  [x. 71.]
  The principal affections of the ureter are thus dependent upon the
passage of calculi.   Even sand in passing generally produces some
disturbance; pain is  felt in the loins, and in the course ofthe ureter.
But the progress of a calculus causes more severe distress.
  But  this rule  has its exceptions.  The following case, which is
one, exemplifies at the same time the effect of accidental concussion
in placing a pelvic calculus in such a position against the com-
mencement of the ureter as to lead to its expulsion by that canal.
  A gentleman somewhat  advanced in years, who had  observed
occasionally that his urine was tinged with blood,  was overturned
in a carriage, and  severely  jolted."  When, after the delay  which
this necessarily occasioned, he reached home, he found his bladder
much distended, and experienced a violent desire to void his urine. 
392      f      MAYO'S OUTLINES OF PATHOLOGY.

On his making the attempt, however, no urine flowed, there being
evidently a mechanical impediment.  He strained and strained, and
at last the impediment gave way.   A renal calculus, which seemed
to have the form of one of the infundibula of the kidney, was pro-
jected with no small degree of violence into the  chamber pot, and
then the  urine flowed  in a full stream.—Brodie.
   One ureter may become obliterated.  In a patient in whom the
bladd.-r  was extensively ulcerated (a  stone had escaped  into an
ulcerated cavity of the perineum,  from which Sir Everard Home
extracted it), one kidney  was found, after death,  reduced to a third
of its natural size: it contained a considerable quantity of pus.  The
ureter on this side had its cavity entirely obliterated ; it was nothing
more than a ligamentous cord extending from  the kidney to the
bladder.
                         SECTION III.

                        The  Bladder.

  The affections  of the  bladder are almost all  secondary ;  that is
to say, they are brought on  either by extension of disease from
other parts, or by the consequences which such disease provokes.
They are, palsy,  irritability,  neuralgia, hypertrophy, sacculation,
inflammation, abscess, ulceration, sloughing, fungus, calculus.
  1. Palsy ofthe bladder presents the following varieties :—
  a.  Vesical paralysis combined with general paraplegia, from
injury or disease ofthe brain, or spinal marrow, or nerves.  Vesi-
cal paralysis depending upon lesion ofthe spinal marrow, or nerves,
is followed by chronic inflammation, and  secretion of ropy mucus,
as it has been already mentioned.   The bladder requires to be
regularly relieved by the catheter,  and in some  cases to be washed
by injecting tepid water.
  b. Hysteric paralysis.  The general rule in this case is, not to
draw off the urine for fear of encouraging the complaint.  Yet care
must be used in withholding  this  relief.  A patient was admitted
with  hysteria into St. George's Hospital, and  retention  of  urine,
which had been long neglected : forty ounces of urine were drawn
off  by the catheter.  The patient ultimately died.   The bladder
was of a  very large size, as if it had been for  a long time unusually
dilated.   It was throughout of a dark colour, almost black.  There
were only some slight vestiges of its natural  structure left;  the
muscular fibres  being very much  wasted, and  the internal  mem-
brane presenting  the appearance  of a very thin film, which was
readily separated  from the parts below.  The dark  colour of the
bladder  did  not  seem to arise from  mortification, since there was
neither foetor, nor any other mark of mortification.—Brodie.
  c.  Paralysis of the bladder sometimes occurs  in men from inat- 
URINO-GENITAL
SYSTEM.
393
tention probably, like the costiveness which supervenes after the
impulse to pass the feces has  been  disregarded.   A gentleman of
sedentary habits, and of a nervous disposition, observed that he had
not the usual desire to void his urine ; and that, when he did void
it, it was in a very slow stream, and  in small quantity.   On the
following day he voided none at all; but he had at the same time
no inclination to do so, and therefore did not suffer.  Another day
acceded,  and being still in the same condition, he thought it prudent
to consult a surgeon; not because he experienced either pain or
inconvenience, but  because  he knew, as he expressed it, that all
could not be  right.  The  surgeon introduced a catheter, which
entered the bladder without the smallest difficulty, and drew off a
large wash-hand  basinful of urine. The urine  soon again collected
in the bladder, and the catheter was again had  recourse to.  At the
end of a  few days, the patient regained the power of making water.
—Brodie.
   c. After an  attack of prostatic retention of urine, the bladder is
commonly paralysed for a period varying from twenty-four  hours
to three or four weeks.
   2.  Irritable bladder.   Frequent urgency to pass the urine, with-
out vesical disease, is sometimes the result of mere nervousness: it
may be produced by an altered state of the urine, or by sympathy
with  disease  of  the kidneys, and  is a frequent attendant upon
advanced age.
   A gentleman who suffered from a most severe irritation of the
bladder,  in consequence of  disease of the  kidneys, discovered the
following method of giving himself relief.  Once a day he intro-
duced an elastic gum catheter, through which  he injected into the
bladder as much  tepid water as it was capable of containing.  At
first the bladder would admit a small quantity  only, perhaps an
ounce, but  by degrees he was able  to inject a larger quantity,
amounting at least to  half a  pint or more.  And now,  instead of
voiding urine every twenty or thirty minutes, he was able to retain
it for two hours, or even longer.  As soon as he omitted the use of
the injection,  the bladder returned to its former habits.— Brodie.
   3.  Neuralgia.  The bladder is sometimes the seat  of pain nei-
ther dependent on  disease in it, nor  of the viscera with which it
directly sympathises.   A gentleman whom I attended had constant
neuralgia of the  bladder,'and  in  the eye-balls  : he suffered besides
occasional severe attacks of spasm of the sphincter am.
   The bladder is sometimes the seat of sympathetic pain when the
disease is  in the kidneys.  "A  patient,"  says  Morgagni  "corn-
plained of very little pain in the region of the kidney:  while he
was tormented with pain in the bladder so excruciating that five
or six physicians who attended him entertained  no doubt that the
seat of the disease was in that organ.  On dissection, however, no
morbid appearance was discovered in the  bladder,  but there were
laro-e and ramifying calculi ofthe kidney.
   I.  Hypertrophy of the bladder.  The muscular coat of the blad- 
394
MAYO'S OUTLINES OF PATHOLOGY.
der, when called upon or excited to repeated and forcible action
through stricture of the urethra, or prostatic enlargement, or calcu-
lus, becomes firmer, thicker, and of a darker colour:  it sometimes
attains a thickness exceeding  half an  inch.  In this state it does
not dilate as before, and is incapable of holding more than a few
ounces of urine, [x. 100.]
   5. Sacculation of the bladder is a hernia of the mucous  and
submucous  coats, a fold of which is  pushed out between the  mus-
•cnlar fasciculi, whereby a sac is formed external to the bladder, but
communicating with it.  Such sacs are never formed, unless there
is obstruction to the escape of urine from the bladder.  I have seen
as many as  five sacculi upon one bladder,  [x. 105.]  The principal
pathological relation of these  sacs is to calculi:  they have occa-
sionally given rise to great ambiguity in cases of stone, from the
temporary or permanent disappearance of the symptoms, on the
stone happening to slip into one of them.
   6. Acute  inflammation ofthe mucous lining of the bladder occa-
sionally supervenes in  gonorrhoea.  The  symptoms are, pain  and
weight, and  frequent  and painful micturition : the  appearances, a
bright red colour  of  the  membrane, principally upon the  promi-
nences ofthe rugae.  I have seen a specimen of this disease follow-
ing the abuse of injections in gonorrhoea, where death ensued.  It
is attended wilh inflammatory fever, and is liable to excite vesical
ulceration and suppuration.
   7. Subacute inflammation of the bladder is commonly the result
of stricture of the urethra, of enlarged prostate, or of calculus, or
paraplegia.   The inner membrane reddened, and secreting a thick
tenacious mucus, of a grayish  brown colour, and of an ammoniacal
«mell,  are the characteristic features of the disease.  Effusion of
lymph,  ulceration of the mucous lining, and suppuration, are liable
to follow.
   The tenacious mucus, which belongs to this state ofthe bladder,
deposits, as  Dr. Prout pointed out, phosphate of lime.  When phos-
phate of lime from this source coexists, as it often happens, with
the triple phosphate in the urine, a combined salt is formed, which
will be presently described.  I  introduce the remark  in this place
to lead to the mention of an important improvement in practice by
Sir Benjamin Brodie in cases of subacute inflammation ofthe blad-
der, where tenacious mucus is present with or without  the calcu-
lous matter.  In the  second case, a weak  solution of nitric acid
(beginning with a drop, gradually increased to two, of concentrated
nitric acid to two ounces of distilled water), injected into the blad-
der, acts as  a salutary astringent; in the first, this menstruum at
the same time dissolves the vesical  concretion ; and  may even be
employed to reduce a calculus, when its surface is composed  ofthe
phosphates,  to a size in which  it can be voided with  the urine.
   8.  Ulceration of the  bladder  presents  various  appearances;
sometimes the whole lining membrane is absorbed, and the muscu-
lar fibres have the appearance of being cleanly dissected: at other 
URINO-GENITAL SYSTEM.
395
times the bladder is covered with numerous circular ulcers.  The
pain attending the passage of the urine, and continuing for some
time afterwards,  appears to be ofthe most severe character.
  9. Sloughing of the bladder is  the  consequence  of long-con-
tinued  retention : it commonly occurs towards the fundus, [x. 110.]
It is the danger of this contingency that renders it sometimes neces-
sary to puncture the bladder in retention.
  10. Abscess of the bladder.   In  some cases of stricture of the
urethra, when the disease has existed for a great length of time,
abscesses  form in the  cellular membrane of the bladder; which
eventually point in  the groin  or  above the pubes,  discharging
putrid  and offensive pus, and afterwards urine.
  11. Fungus hamatodes.   In a case which I examined with the
late Mr. Wilson, in  which the  existence of  stone had been sus-
pected from pain in the bladder and occasional discharge  of blood,
a fungus  was found attached by a narrow pedicle to the mucous
membrane:  the texture of  the fungus was  soft, and its surface
shreddy and ragged.
   In a patient wHo died  in the Middlesex Hospital, with medullary
sarcoma affecting the uterus and neighbouring part of the vagina,
the bladder was studded with  little  white tubercles, about the size
of  peas, which had formed behind  the mucous coat,  but  projected
inwards.   They appeared, when cut through, of the  same medul-
lary texture with that which grew from the uterus and vagina.
   Local uneasiness, frequent micturition, blood in the urine, reten-
tion, if, as in a case of Mr. Stanley's, the accidental growth of the
fungus towards the ureters  plugs  the orifices of the latter,  are
symptoms ofthe disease.
  ' 12.  Vesical calculi may be considered in reference  to their che-
mical composition, to their symptoms, and to  the modes of getting
rid of them.
   a. Varieties of vesical calculi.
   1. Lithic acid calculi. Generally of  an oval form, and slightly
flattened : of a brownish red colour, approaching that of mahogany;
rather smooth on the surface, but not  polished, except occasionally
from friction when there are two or more calculi in the same blad-
der.  If broken, the lithic acid calculi split into concentric laminae.
   2. Oxalate of lime, or  mulberry calculi;  of a dark brown
colour, rough  and tuberculated on  the surface,  very hard,  and
imperfectly laminated.                                 .
   3  The triple phosphate  of ammonia and magnesia^  1 his
salt forms a fragile calculus; and when broken, it does not, .ike  the
lithic acid calculus, split into concentric laminae.  The  surface is
uneven, covered with  minute crystals.
   4. Phosphate of lime.  Calculi  composed of this substance, un-
mixed with other calculous  matter,  are rarely found in the bladder;
and when they are.  there is reason  to suspect, from Dr. I rout s
observations, that they  have their origin  in the  secretion of  the 
396            MAYO'S OUTLINES OF PATHOLOGY.

bladder itself, and not in the urine.   These calculi  are of a  pale
brown colour, and of a laminated structure.
  5.  Although it is rarely that we find a bladder calculus composed
altogether of phosphate of lime, we frequently find this salt existing
in combination with the triple  phosphate of  ammonia and mag-
nesia.  The mixed calculus is of a white colour ; friable, not un-
like a mass of chalk in appearance ; not in general  laminated.  It
melts into a vitreous substance, when exposed to heat in the flame
of a blow-pipe ; and hence it has received the name  of the fusible
calculus.
  6.  Lithate of ammonia.  This variety of calculus is  of a clay
colour: sometimes it is smooth, and at other times tuberculated on
its surface:  it is composed of concentric layers.  Dr. Prout regards
it as  being almost peculiar to children.
  7.  Lithate of soda.   This is a rare  calculus of a white colour,
like  the chalk-stones of gout;  probably formed where  a patient,
having a lithic acid diathesis, takes large quantities of soda.
  8.  Cystic oxide.   A rare kind of calculus  of  a  white  colour;
and,  when broken, found not to be laminated, but appearing as one
mass confusedly crystallised throughout its substance.
  9.  Calculi are  sometimes composed of carbonate of lime ; but
these are of very rare occurrence indeed.  The carbonate of lime,
however,  is frequently blended  in small quantity with other ingre-
dients.
  10.  Dr. Marcet  has also described a variety of calculus  under
the name  of xanthic oxide; and another under that ofthe fibrinous
calculus.
  11.  The fibrinous calculus appears to be composed of the fibrin
of the blood.   Sir Benjamin Brodie, from whose Lectures on the
Diseases of the Urinary Organs I have taken the above enumera-
tion, states, that he has met with one instance only of this kind.
It was of an oval shape, about the size  of a  horse-bean, yellow,
semi-transparent, not very unlike amber, but  less  hard.   When
dried it shrunk to a small size.   Its  existence in the bladder had
not  been  suspected  during life.  The kidneys were in  the state
connected by Dr. Bright with the formation of albuminous urine.
  Some calculi are found composed throughout of one  of the sub-
stances which have been described nearly pure.   In others we find
the different substances  disposed in  layers, the lithic acid distinct
from the  oxalate  of lime; the  oxalate of lime distinct  from the
triple phosphate,  and so on ;  while  in others they are  intimately
blended together.   As Mr. Brande  long ago  observed, the centre,
or nucleus,  is generally either the lithic acid or oxalate  of lime.
In many cases the addition to the calculus are of the same chemi-
cal composition with the nucleus; in other cases we find  the  lithic
acid  deposited  on the outside of the  oxalate of lime ; and  more
rarely, the oxalate of lime is deposited  on the surface of the  lithic
acid.   The deposit of lithic acid, or oxalate of lime, may take place 
URINO-GENITAL SYSTEM.
397
 in the bladder, where there is no evident disturbance of the general
 neaun.  it  the general health becomes affected, and the bodily
 powers ot the patient are impaired, either from the irritation of the
 stone  in the bladder, or  from any other cause, the urine becomes
 alKaline, and, in consequence, the subsequent additions of the cal-
 culus  are formed ofthe triple phosphate of ammonia and magnesia.
 When the calculus has existed for some  time in the bladder, it fre-
 quently happens, and indeed it always happens sooner or later, that
 the  mucous  membrane becomes inflamed, and adhesive tenacious
 mucus is secreted, which contains phosphate of lime; and this
 being  blended with  the  triple phosphate,  constitutes the fusible
 calculus.   Calculi found  in the ducts of the  prostate gland, are
 composed of phosphate of lime, pure, or nearly so.   But whatever
 may be the condition of the bladder, it is a very rare occurrence to
 find a simple phosphate of lime calculus in it.  In cases of chronic
 inflammations ofthe bladder, the phosphate of  lime is deposited by
 the mucus in small masses;  but these nuclei being exposed to the
 contact of the urine, and the health becoming impaired, as always
 is the  case under these circumstances, the triple phosphate is added
 to the  phosphate  of lime, so as to constitute the fusible calculus.—
 Brodie.
   Dr.  Prout, with whom the latter observations originated, has
 furnished us also with a knowledge of the following most import-
 ant  and interesting facts  in the history of calculous formations.
 There are but few cases in which the phosphates form the nucleus
 of a calculus ; but being once deposited,  they continue to be so, and
 are not followed  by other  depositions.   The phosphates may suc-
 ceed the lithic acid or the oxalate of lime, but neither of these can
 succeed the phosphates.   If the external surface of a calculus  is
 composed either of the  lithic  acid  or of the oxalate  of lime, you
 may be certain that there are no phosphates in the interior; where-
 as if there are the phosphates on  the outside, the general rule,  to
 which there are but few exceptions, is, that some  other substance
 lies underneath.
  b. The symptoms of vesical calculi are, pain in the bladder, fre-
 quent  urgency to make water, increased  pain  at the close  of mic-
 turition (when the bladder presses against the stone), that originates
 in the  bladder, extends along the urethra, and  is felt with aggrava-
 tion  at its under part  immediately within the orifice.  Pain  in the
 loins,  bloody urine, and  increased vesical pain after riding  on
 horseback or in a carriage.  In the history of  the case, the period
 of the descent of the calculus from the kidney is  often marked.
 The patient remembers having experienced pain in the loins, ex-
 tending down one ureter,  which lasted a couple of days, and was
 followed by a clot of blood in the urine, and relief of the pain ; but
 the bladder may have continued irritable for a week: after which
 the stone  may have produced  no further irritation  for months or
years ;  at  length its increased  weight, or  continued presence, gives
rise to  inflammation and its sequelae. 
398           MAYO'S OUTLINES OF PATHOLOGY.

  All the  symptoms of stone  in the bladder which have been
described may be fallacious.  To be sure of the existence of stone
in the bladder, it must be.felt with the sound;  which, however,
occasionally fails  of detecting the stone, unless the  patient is ex-
amined in every variety of posture, and with every shape of instru-
ment.
  There is a mechanical symptom which  is highly diagnostic.
The urine is liable to be suddenly stopped as it flows from the
bladder, by the stone falling  against  the  vesical orifice  of the
urethra.
  Where  there is even a small  calculus in the  bladder, it rarely
happens that the  urine retains its natural clearness  and transpa-
rency.  A slight cloud is perceptible in it as  soon as it begins  to
cool, and a mucous deposit takes  place afterwards.
  Sometimes the progress of the  symptoms is slow, and it may be
four to ten years before the patient is driven to apply for surgical
relief.  In the common course of events they reach a  height which
renders the patient a great sufferer in  the course of  two or three
years.   At first his general health is  unaffected; but  at  last the
health begins to  suffer, the urine becomes alkaline, and the triple
phosphate is  deposited on the original  stone.   Now all the symp-
toms are much aggravated.  The alkaline urine  is more  stimulat-
ing to the bladder than healthy urine.   Inflammation of the mem-
brane follows; the  pain  is greater; the  desire to void  the urine
almost constant;  the urine voided  is  offensive, soon  becoming
putrid and ammoniacal, and depositing the  usual thick tenacious
mucus streaked with blood.
  A patient with a simple lithic acid calculus suffers  less than one
with a calculus composed externally of the  triple phosphate; and
the latter less than a patient with a fusible calculus.   The oxalate
of  lime,  or mulberry calculus composed externally of the triple
phosphate; and the latter less than a patient with a  fusible calcu-
lus.  The oxalate of lime,  or mulberry calculus, on  the whole,
occasions more distress than the lithic acid  calculus, from the irre-
gularity of its shape.
  There are certain spontaneous  changes which occasionally take
place, and relieve the patient of  half or all  his sufferings.  The
most tender part of the bladder  is its  neck.   Enlargement of the
third lobe ofthe prostate, by pushing the stone away from the neck,
and fixing it behind it, has removed all the suffering.  A stone that
falls into, and is retained  in a cyst by sacculation of the bladder, is
equally out ofthe way of irritating.
  c. Removal of calculi.  When a calculus is sacculated towards
the  rectum, so as to be felt prominent and almost projecting into
that viscus, it should be extracted by an incision from  the  rectum.
When the  prostate is greatly and  irregularly enlarged, and the suf-
ferings  from stone  intolerable, the high operation should  be per-
formed.   In  a child, lateral lithotomy is unattended with risk.   In
an  adult, suffering under great irritation of the  bladder, from the 
URINO-GENITAL SYSTEM.
399
presence of a stone, the  kidneys and other viscera sound, lateral
lithotomy should be performed.   If the stone  or  stones are  small,
they may be removed by  forceps through the urethra.
  But in the majority of  cases  there is  no doubt that, when  sur-
geons become familiar with the use of the instrument for crushing
with a screw the stone in the bladder, it, or improvements upon it,
will supersede every other method.
                          SECTION IV.

                        Prostate Gland.

   The prostate gland  is liable to be affected with acute inflamma-
 tion, chronic inflammation,  abscess, ulceration, hypertrophy, cal-
 culi.
   1. Acute inflammation of the prostate  is produced by extension
 of gonorrhoea!  inflammation: the complaint is marked by a sense
 of weight in the perineum  and  at the  neck of  the  bladder, by
 increase of pain and heat at the latter part on making water.  The
 bladder is more or less initable, and  generally partakes in a greater
 or less degree in the inflammatory action.   Retention of urine
 occasionally supervenes.  Rest, the recumbent posture, cupping in
 the perineum, with other obvious remedies, are certain to allay the
 disorder,  if so treated early.
   2. Chronic inflammation may follow the acute stage, the patient
 not  being sufficiently cautious during recovery.
   3. Abscess is the result  either  of acute or chronic prostatic
 inflammation : a prostatic abscess naturally breaks into the urethra,
 sometimes into the rectum.   The latter case gets well  readily, the
 former  is often  extremely troublesome from  urine entering and
 keeping up irritation in  the abscess.  The existence of prostatic
 abscess is often first discovered  through  the sudden discharge of
 pus  with  the urine.  The complaint is  to be  suspected when in-
 flammation of the gland continues obstinate: examination by the
 rectum  will often decide its presence ; and even when its presence
 is uncertain, if there is much constitutional disturbance, with  rigor,
 and  fulness of pain  about the prostate, a  lancet should be pfcinged
 deep into the perineum to endeavour to give vent by a harmless
 channel to the pus.
   Cases of abscess of the prostate in young men and adults are of
 not unfrequent occurrence—they are rare in old age and in infancy.
 Sir Benjamin Brodie mentions three cases of the former  class,
 where the disease was  combined with chronic, enlargement.  An
 infant, two years  of  age, came under my  own care, with retention
of urine, which  required  the  repeated  use of the  catheter.   The
catheter when introduced sometimes drew off pus, at other times
urine ; by care in the management of the instrument,  he bladder, 
400
MAYO'S OUTLINES OF PATHOLOGY.
however, could always be relieved.   The infant died, and a large
abscess of the  prostate was found opening into the urethra by a
considerable orifice, into which the catheter had passed on those
occasions when matter flowed instead of urine.
  4.  Ulceration of the vesical  surface of  the prostate is an occa-
sional attendant upon chronic enlargement; it greatly aggravates
the patient's sufferings, causing the most agonising pain when the
bladder acts.
  5.  Hypertrohy, or chronic  enlargement of the prostate, is  a
change to which the part is liable, when the frame is beginning to
feel the effects of age.  [x. 119. 120.]
  The enlargement in general is unattended with  alteration of
texture;  sometimes the gland  is softer than usual, sometimes in
parts it is remarkably hard ; it never, I imagine, becomes  circiuo-
matous.
  The enlargement occupies either  both lateral lobes equally, or
one  more  than the other,  or  the  third  lobe less or more than
either.  The enlargement varies from a trifling increase of hulk to
twenty times the natural  size of the gland.  The suffering which
attends the disease is from retention of urine, and is at  first the
mechanical distress of the bladder  and  kidneys.   The frequency
and severity of the fits of retention bear no relation to the absolute
enlargement ofthe gland.  However, when there  is much enlarge-
ment, the bladder can never be completely emptied ; several ounces
of urine remain after its seeming evacuation, the parts  of  the en-
larged prostate  coming together and impeding the escape of more.
It is  not easy  to  account  for the fits of  retention, wlrch have a
character of spasm.  They supervene unexpectedly, but are com-
monly attributable to exposure to cold.   The urine, which flowed
tolerably freely the day before, is  completely  obstructed.   Relief
can only be given  by the catheter, which either is to be retained in
the bladder, or  passed twice a day  for a period, varying  from forty-
eight hours to three weeks: the bladder becomes  temporarily pal-
sied by each of these attacks.
  The form and kind of catheter must be determined by the form
of the prostatic enlargement, and  that is only learned  by the trial
of different forms and kinds of instruments.  The most generally
useful are silver catheters, with a long curve and point well turned
up, and elastic  catheters,  which have been  long kept upon a stilet
of this shape.
  An  hypertrophied  prostate,  after being divided in  lithotomy,
commonly lessens.
  A prostatic enlargement is sometimes formed of a thick cyst con-
taining mucus, [x. 125.]
  Calculi of  the prostate are round, of a reddish colour  externally,
and composed cf phosphate of lime. 
URINO-GENITAL SYSTEM.
401
                          SECTION V.

                           Urethra.

  The urethra is liable to acute and chronic inflammation, to stric-
ture and ulceration, to obstruction with calculi.
  1. Acute inflammation of the membrane of the urethra may be
produced  by mechanical  injury; but  the ordinary cause of  the
complaint is the contagion of gonorrhoea.  In the latter case  the
complaint begins at the external  orifice with a mucous discharge,
commonly attended with tenderness of the inguinal glands on one
side.  After three or four  days the discharge becomes a thin pus,
and the urine  produces a sensation of scalding in passing: in two
or three days  more the discharge  is a thick greenish  matter, occa-
sionally tinged with blood, and the membrane is acutely sensible.
The disease then spreads down the urethra, extending about half
an inch each day.   The pain is greatest in the portion last affected,
subsiding towards the orifice: when the disease occupies the ure-
thra in the middle ofthe spongy body, chordee is produced. When
the inflammation has arrived at the membranous part of the urethra,
after existing  there a  few days in  considerable severity, it often
returns to the  commencement  of  the urethra, and  the same stages
are repeated.  If the disease  is neglected, it occupies the whole
urethra with virulence, or attacks the prostate and  bladder, or  one
or both testes.  Gonorrhoea has  some relation not understood to
syphilis :  it is  capable of producing inflammation of the joints and
ofthe mucous membrane and internal structure of the eye, and is
the common cause of stricture.
  Chronic inflammation  of the  urethra is  a common sequela of
gonorrhoea ; when seated near the orifice, it gives rise to a  trans-
parent discharge, occasionally coloured yellow.   When remaining,
as it frequently does, at the junction ofthe spongy and membranous
portions of  the  urethra, it is the immediate cause of permanent
stricture.  A subacute  inflammation of the urethra lasting a  week,
frequently occurs as an accidental attendant  upon  stricture of the
urethra; and  is  liable  to occur  in some habits without any very
obvious reason.
  2. Stricture ofthe urethra is either spasmodic or permanent.
  a. Spasmodic  stricture  I have never met  with, except at  the
point where the  urethra passes through Camper's ligament.  It is
by no means ascertained upon what texture the temporary obstruc-
tion depends.  It is liable to  be brought on  by cold, or by excess,
in cases where the  patient before and  afterwards  experiences no
inconvenience.  It  yields always to  the  pressure of a properly
directed silver catheter.
  Permanent stricture  of the urethra begins in opacity and loss of
extensibility of part of the lining membrane from inflammation.
[x.  130. 131.]   The ordinary length of a stricture  is about two
lines ; but it varies from half a line to an inch and  a half. [x. 135.] 
402
MAYO'S OUTLINES OF PATHOLOGY.
 The ordinary place of stricture is the passage through the ligament
 of Camper; but sometimes stricture occurs in the middle of the
 urethra, sometimes at  the orifice ;  it never occurs  in  the  mem-
 branous part of the urethra, or in the prostate.  Generally there is
 but one stricture;  sometimes there are several: in that case the
 first and the narrowest is situated at Camper's ligament.  Some-
 times the  whole length of the  urethra contained in the corpus
 spongiosum is narrowed, and  at particular  points more  especially
 contracted.  Sometimes the orifice  is alone contracted.   A  linear
 stricture is sometimes oblique, [x. 132. 134.]
   When the channel  of the urethra  is constricted at any  part seve-
 ral local consequences follow.
   a.  The  texture surrounding the  membrane becomes condensed
 by an extension  of inflammation.
   In a gentleman from a hot climate, who died after the  cure of a
 stricture, which was attended by, and left considerable firm gristly
 induration at one  part of the urethra,  the tumour was  found to
 have been caused  by a deposition of lymph into the cells of the
 corpus spongiosum.   Immediately behind the stricture  there was
 an orifice  leading  into a long narrow sinus, extending  from the
 urethra forwards  into  the  gristly  substance of  the tumour.—
 Brodie.
   b.  The  urethra behind the stricture becomes more or less dilated.
 In the following case the dilatation was extraordinary.
   In a gentleman,  who laboured  under stricture, the canal behind
 the obstruction was  so dilated, that whenever he made water a
 tumour as large as  a  small orange, and affording a distinct fluctua-
 tion,  could be felt in the perineum.—Brodie.
   c.  The  surface of  the distended part is liable to inflame, and to
 be covered with  an exsudation of coagulable lymph, [x. 137.]  This
 circumstance will cause pain in the expulsion of the urine.  Some
 pain  and  heat in the  urethra are generally present from irritation
 of the surface posterior to the stricture, in every case  of  consider-
 able contraction. The pain is felt less at the part than at the ex-
 tremity of the urethra.  It  appears  situated in the lower part of
 the urethra, half an inch behind the  orifice.
   The danger as well as chief distress arising from stricture, are in
 the state of the bladder and kidneys, which are liable, from the force
 necessary to the  expulsion of the urine, to  chronic inflammation,
 ulceration, and  abscess—the bladder even to slough,   [x.  110.]
 Some of the  local consequences  of stricture  may be viewed as
 efforts of nature to save the more internal organs from one or the
 other of these lesions.
   d.  Stricture of the  urethra sometimes disappears by ulceration:
 at any rate, it is difficult on any other supposition to account for the
 phenomena ofthe following case.
   A gentleman,  who had laboured under stricture  of  the urethra
 for a great  number  of years, now voided his nrine with the greatest
difficulty:  the  stricture was rigid and unyielding; but  a catgut 
URINO-GENITAL SYSTEM.
403
 bougie was introduced, which enabled him  to  make  water  in a
 small stream.  Under these circumstances he was seized with  pain
 in the act  of making water, which lasted  for some minutes after-
 wards,   j. he pain became more severe: it was referred to the  situ-
 ation of the stricture in the posterior part  of  the  urethra, and the
 patient described it as  intolerable.  He  said,  he  could  compare it
 to nothing but the  pain which he supposed would be produced if
 melted lead were poured into the urethra.   Every half hour he had
 a desire to make water, and  his screams and groans could be heard
 not only over the  whole  house,  but even  in the street.  In  the
 course of a few days these symptoms began gradually to abate, and
 the urine flowed in a much larger stream.   When the  attack  had
 completely  subsided, the condition  of the  patient was much  im-
 proved, for  he made water more freely than he had done for many
 years.—Brodie.
   e. Sometimes abscess forms deep in the perineum, and close upon
 the membranous portion ofthe urethra, [x.  140.]   Such an abscess
 is attended with fever, brown tongue,  and great prostration,  and
 should be opened as soon as suspected.  When opened, the urine
 either at first, or in a day or two,  flows through it; the inflamma-
 tion subsides, and a fistulous channel is left, opening  behind the
 stricture, through which the  urine passes, [x.  142.]
   /  Sometimes the urethra  gives way by ulceration  behind  the
 stricture, and the urine is forced  into and infiltrates the cellular
 texture ofthe perineum, scrotum,  and penis.
   The symptoms of stricture  ofthe urethra are, difficulty in expel-
 ling the  urine, the urine flowing in  a small flat stream, which
 twists or is  divided (coming out at the corners of the orifice, being
 not strong enough to distend the centre), frequent micturition from
 distention ofthe ureters and irritation ofthe kidneys, mucus in the
 urine, attacks of complete retention, or the  urine flowing  continu-
 ally away by drops, rigors, wasting fever.
   The local treatment of stricture comprises four different methods
 —dilatation, the caustic, puncturation, incision.
   a. Dilatation is applicable to, and the best method  in the great
 majority of cases.
   6. The caustic is  often of great utility, when the stricture is firm
 and linear.
   c. Puncturation, or division from within, I have employed suc-
 cessfully, and recommend  in  impervious stricture, situated in  the
 first four  inches of the urethra—that is to say, in the part which
 admits of being drawn into a  straight line.  At the common situa-
 tion of stricture, this method is dangerous and uncertain, if the con-
 traction is otherwise impervious to instruments;  it is less danger-
 ous, but unnecessary, when a small bougie can be  passed through
 the stricture.
   d. Division of a stricture of the urethra from the perineum is to
 be practised  only in  cases of rupture of the urethra behind a stric-
ture, and  of urinary fistula,  with extensive sinuses and  general 
404
MAYORS OUTLINES OF PATHOLOGY.
thickening of the perineum, the strength threatening to fail from
the urinary irritation, [x.  150.]
  In rupture of the urethra with impervious stricture, a free inci-
sion is to be made in the perineum towards the urethra, a full sized
staff is to be passed  down to the stricture, the urethra is  to  be
opened upon the groove  of the staff  immediately anterior to  the
stricture; the staff being then drawn back, the scalpel is to be car-
ried in the direction of the urethra through the stricture, dividing
it;  a catheter is finally passed into the bladder, and retained there.
Incisions are to be made into the integuments of the swollen scro-
tum and penis, to allow the escape of the infiltrated urine, and so to
lessen the extent of sloughing.
  In  complicated urinary fistula,  with stricture impervious to in-
struments, the best practice is to  perform the same operation, hav-
ing previously dilated the urethra to behind the scrotum.  After
free division  of the parts, the general  induration of the perineum
disappears in forty-eight hours; and a free channel  being given to
the urine through the catheter,  the  vesical and  renal irritation
quickly subsides.  Granulations  soon  grow up in the wound, and
closing in upon the catheter, the incision gradually cicatrises. The
catheter should be changed every day;  and the patient never al-
lowed to make water  without the instrument till all is  healed.
  This operation I have several times performed, and twice under
circumstances  in  which  I would not repeat it.  The cases were
impervious stricture, with vesical irritation, but unattended with
rupture ofthe urethra or fistula.   One of these cases did perfectly
well.   Another surgeon  had tried to perform the operation on this
patient a week before ;  and, after protracted ineffectual attempts,
had relinquished  it.  I set to work upon the old wound,  and  the
operation was successfully finished.  In  the  other case referred to,
all  went on well for a week: the catheter then unfortunately dur-
ing the night slipped  out, and the patient made water without it:
the result was, infiltration of the  parts about  the wound, followed
by  inflammation, and an abscess, which opened into the urethra
anteriorly to  the scrotum, arid has  left there a permanent fistula,  the
perineal wound having closed.
  The accident which occurred in this case has determined me not
again  to divide a  stricture from without, merely for retention  un-
attended with rupture ofthe urethra, or unless exhausting urinary
fistula is present likewise.
  In  cases of otherwise  irremediable retention from aggravated
stricture, with  danger of sloughing of the bladder, puncturing the
bladder from the rectum or above  the pubes is to be resorted to.
  3. Calculi that have escaped from  the bladder are liable to be-
come impacted in any part ofthe  urethra :  if in the membranous
part, they may be cut down upon, and  extracted with safety.  If
in  the corpus  spongiosum, they are  generally within  reach of
forceps introduced at the external  orifice   Under urgent retention,
and impossibility of extracting the calculus by forceps, it would be 
URINO-GENITAL SYSTEM.
405
better to push it back towards the membranous part, and cut upon
  from the perineum, than open the urethra  anterior to the scro-
tum, which is apt to leave irretrievable fistula
                          SECTION VI.

                             Testis.

   The diseases in  which  the testis is  concerned are referable to
 three  heads:—diseases  of the testis; of the tunica  vaginalis: of
 the cord.
   I. The testis is liable to acute inflammation,  chronic inflamma-
 tion,  tuberculous disease, atrophy,  medullary sarcoma,  hydatid
 disease.
   Every disease of  the testis is liable to be attended  with pain in
 the loins, which is lessened by supporting the testis, and by the re-
 cumbent posture, and aggravated by the reverse.
   1. Acute inflammation ofthe testis is characterised by  pain and
 swelling, usually commencing in the epididymis : by pain stretch-
 ing along  the cord  to the back ;  by inflammatory fever, often at-
 tended with vomiting; and  by tenderness of the abdomen resem-
 bling  acute peritonitis.  Acute  inflammation terminates either  in
 resolution, or in chronic inflammatory  enlargement, or hydrocele,
 or in both.   The common  causes of this disease are, local violence,
 or  metastasis or direct  continuation of gonorrhoea!  or simple in-
 flammation along the spermatic cord.
   2. Chronic inflammation of the testis presents great diversity of
 feature : sometimes it occupies the body ofthe testis, sometimes the
 epididymis  which becomes hard and knotted, occasionally  both.
   Chronic inflammation of the testis occasionally occurs as one of
 the direct consequences of syphilis.   There is a patient now in the
 Middlesex  Hospital  under my care, in  whom this affection super-
 vened  upon chancre, and  was shortly followed  by psoriasis upon
 the back, and arms, and head.
   Chronic inflammation of the testis is often accompanied by effu-
 sion of serum  into the tunica vaginalis : in that case  considerable
 pain is generally experienced from  the pressure  ofthe fluid on the
 gland.   The pain is relieved  upon letting out the fluid, [x.  161.]
  Chronic inflammation ofthe testis may terminate in  abscess.  To
 this head I  think should be  referred some of the cases (some to
 which  the subsequent description  applies  being certainly tubercu-
 lous) which Sir Benjamin  Brodie speaks of as scrofulous  disease.
 The patient, says Sir Benjamin Brodie,  describing this disease, ex-
periences a slight pain at one  part of the testicle, and you feel there
a little  enlargement, generally at one end of the epididymis.  He
then experiences  pain at another part, and you find there  another
enlargement, and this is generally also on the epididymis.   These
      22—b                                   27  may 
406            MAYO'S OUTLINES OF PATHOLOGY.

little tumours  increase in size, becoming gradually more painful.
Sometimes as many as three or four of these tumours are found on
the surface of the epididymis.   The skin  becomes  adherent to
them, and one of them becomes an abscess, which bursts  through
the external skin.  A similar abscess forms in another, and runs
the same course.  These abscesses  discharge very little matter,
and they do not  heal like healthy abscesses.   When you introduce
a probe into one of the sinuses thus formed, you  find that it passes
down into the centre  of the tubercle or tumour in which the ab-
scess  originated. The  disease will go on in some  instances until
the whole ofthe testicle  becomes disorganised. Sometimes it is con-
fined  to one testicle ; sometimes both are affected in the same  man-
ner.   Sometimes it will completely destroy one  of the  testicles;
but more  frequently the  testicle is  only partially injured, and a
great  deal of the glandular  structure remains in a  natural state.
[x. 160.]
   The following instance, which Sir Benjamin Brodie appears to
have  considered a morbid growth, was possibly chronic inflamma-
tion of the testicle.
   A man was admitted into St. George's Hospital with one testicle
enlarged and hard.   There were certainly not exactly the symp-
toms  of chronic inflammation of the testicle ; but it was treated at
first as if of this nature, and mercury was  administered, but with-
out making any impression upon it.   Other remedies having been
tried,  Sir Benjamin Brodie thought it would be  safer to amputate
the testicle, and the operation was performed.   When the testicle
was examined, its structure gave  the idea of cellular  membrane
condensed into a firm solid substance.  It was of the consistence
of ligament, without its  fibrous structure.  Between six and twelve
months after the operation, the man returned to the hospital, having
a disease apparently similar just begun in the other  testicle.  One
part had become hard, somewhat enlarged, and the feeling commu-
nicated to the fingers was exactly similar  to that which had been
given by the testicle  formerly affected.   As an experiment,  iodine
was given internally,  and the iodine ointment was probably rubbed
on the  part.  The hardness not only did  not increase, but it be-
came in some degree diminished ;  at any rate the progress of the
disease was stopped, and the  patient left  the  hospital with the
greater part of the remaining testicle in a sound state.
   3.  Tuberculous disease begins in the deposition of tuberculous
matter at one or more places in the substance of the testis or epi-
didymis.   Sometimes on examining a tuberculous  testis, two or
three nodules of yellow cheesy matter are found [x.  165. 166];
sometimes the whole structure of the testis seems to have disap-
peared, and to  be replaced by tubercle, [x. 167.]  Sir  Benjamin
Brodie conjectures, that  the primary seat of this deposit is the mu-
cous  surface of the tubuli testis, having observed it in the canal ol
the epididymis.   It is probable that  both the mucous and intersti-
tial membranes  of the testis can secrete it. 
URINO-GENITAL SYSTEM.
407
   The disease begins without pain.   There is slight nodular en-
 largement, which increases;  after a while, general uneasiness or
 pain in the gland, extending after standing or walking to the back,
 as in other affections of the testicle.
   The disease sometimes ends in the form of abscess, to which the
 description given under the  head of chronic inflammation, applies :
 at other times, the  suppuration and discharge of the tuberculous
 matter is attended with another  feature.   The skin  inflaming over
 a prominent part of the tumour, and ulcerating, gives issue at first
 to matter alone ; then, in addition, to  a  slow  fungous  protrusion,
 firm, of a pink colour, irregular and channelled on its surface, some-
 times insensible, sometimes with the  ordinary sensibility of the
 testis.   This fungus consists of  inflamed and swollen tubuli testis.
   The  inflammation  and suppuration  are efforts to throw out the
 tuberculous matter.   The extent of the  fungus depends upon the
 quantity ofthe tubuli implicated in the  disease.  After the tubercu-
 lous matter has been expelled, the fungus shrinks, the surrounding
 cutaneous inflammation lessens,  the ulcerated orifice contracts, the
 wound  heals; the testis is left free from  disease, but more or less
 reduced in volume, through  consolidation of the tubuli to a greater
 or less extent, but generally  considerable.
   Atrophy.   Wasting of the testis, it is said, has been produced by
 the continued use of iodine.   Sometimes  atrophy takes place with-
 out any apparent cause, or from excess.  Partial atrophy often
 follows  chronic inflammation or tuberculous disease.  Sometimes
 the same effect follows acute inflammation.
   Mr. S----, when nineteen years of  age, received a blow on the
 testis from being thrown on  the pommel of a saddle.  In  the even-
 ing of that day he was seized with  excruciating pain in one testis,
 which swelled to a great bulk in a week:  then the inflammation
 and swelling began to subside;  but its decrease did not stop at the
 natural size of the testis, but the absorption  proceeded until the
 gland disappeared.  The spermatic cord  was much smaller on the
 diseased side than on the other.   The  vas deferens was much less
 than  natural.  A small  portion of  the epididymis  could be  felt;
 but the testis was not larger than a pea: it had feeling, but less
 than the healthy testicle.—Cooper.
  A gentleman died, who had had inflammation of the  testis from
 a gonorrhoea  twenty years  before ; after which  the testicle was
 smaller  than  the other, and  a  part of it remained considerably in-
 durated.   On  inspection, about  two-thirds of the  tubuli  testis re-
 mained in their natural condition : while the remainder had become
 converted into a white substance, having the  consistence, but not
 the fibrous structure of ligament.—Brodie.
  4. The form of malignant disease which infests the testis is me-
 dullary sarcoma.
  The complaint cannot be  mistaken when  uncomplicated.  Ihe
gland slowly  swells into a  large, even,  weighty, elastic tumour,
seldom attended with  much  pain or tenderness on pressure.   But 
403
MAYO'S OUTLINES OF PATHOLOGY.
the weight is distressing, and causes aching and pain in the loins.
On puncturing it with a grooved needle, medullary matter escapes
with blood.
   The tumour when cut into is found to consist of a pulp, which
varies  in  character  from a close resemblance  to  cerebral  matter
(which is  the least usual) to  a grayish soft and  almost  diffluent
texture, from which, on the least pressure, a  thick whitish fluid
exudes with blood and  serum.  There  is some variety in different
instances in the external characters ofthe disease, arising from the
greater or less thickening and  adhesion of, or effusion in, the tunica
vaginalis;  from the  place of the medullary sarcoma, either central
or near one  side of  the testes ; from the greater  or less degree of
thickening and induration ofthe septa ofthe testes involved in the
disease; and from the  occurrence or not of cysts in the tumour.
[x. 170.]
   The part is to be  amputated if the patient is otherwise in  health,
and there is no evidence of the existence of medullary sarcoma in
any other organ.  The disease, however, almost always reappears
in the lumbar lymphatic glands.
   5. Hydatid disease.  Under this name  Sir Astley Cooper  has
described enlargement ofthe testis with  cysts filled  with  serum or
mucus, or a clear water containing  little animal matter, and not of
a malignant character.  The disease is not  of common occurrence
   A young  man  twenty years of age,  without any obvious cause
for it,  found  a tumour at one extremity  ofthe testis.  It was at first
unattended with pain ; was usually  soft to the feel.  It grew larger,
and was at one time soft, at another hard ; generally attended  with
little pain, sometimes extremely painful.  It was  extracted after a
twelvemonth.
   On cutting into the  testicle, it was found to be composed of nu-
merous cysts, of different sizes and forms, containing a serous  fluid
in some parts: at others it was like  the  white of egg.   In one part
 the testis was very compact, and at  that part there was a tendency
 to suppuration.—Cooper.
   II.  The tunica vaginalis  participates in the acute inflammation
 of the testis; is liable to chronic inflammation,  thickening, adhe-
 sion, hydrocele, hematocele, malignant  disease.
   1. Hydrocele is a sac containing water  connected with  the tes-
 ticle or the cord.   It presents  two  varieties—hydrocele  of the
 tunica vaginalis, and encysted hydrocele.
   a. Hydrocele ofthe  tunica vaginalis is so called  from the liquid
 effused being contained in  that cavity.   The  fluid  is of an amber
 colour, and quite transparent.  A  large portion of it coagulates
 with  heat, and on  the addition of  nitric acid.   It  resembles very
 nearly the serum ofthe blood, both  in its appearance and chemical
 composition ; the chief difference being, that it contains rather less
 albumen. Every now and then a number of small greasy particles
 of a yellow colour, with something of a metallic lustre, are found
 in it, which are probably adipocire.  [x. 180.] 
URINO-GENITAL SYSTEM.
409
   The  tunica  vaginalis often  remains  unaltered in  hydrocele.
Sometimes, however, especially in old hydroceles, it becomes thick-
ened.   Occasionally, conjointly  with thickening, the inner  surface
is  found honeycombed, the  result  of effusion of lymph  upon it.
Occasionally, little bodies, like the loose cartilages of a joint, grow
from its free surface, [.r. 162.]
  The sac which contains the water often exhibits an hour-glass
contraction at its middle: at this part the walls of the sac some-
times adhere and grow  together, converting the one sac into two.
In a  case  of hour-glass-shaped hydrocele, Sir  Benjamin Brodie
drew off all the water  through one  opening at the lower part.  A
year afterwards, the hydrocele having filled again, the lower part
was again punctured;  but the upper did not empty itself as before,
but required to be separately opened.
  Hydrocele generally  forms slowly and without pain, or apparent
cause.   Sometimes it seems to depend upon  inflammation of the
testes and  tunica  vaginalis;  and sometimes  the irritation of the
little cartilaginous bodies in the  cavity may cause the disease.  Sir
Benjamin Brodie gives the case of a gentleman with hydrocele,
who, as soon as the water was  drawn off, used to lie down and
groan with agony for a quarter of an hour.  When he died, a loose
cartilage was found in  the sac.
  A common cause of hydrocele is strain of the loins.  A groom
was admitted into the  Middlesex Hospital with hydrocele, which
had come on a few days before.  It contained  about six ounces of
Water.  The patient declared that the swelling had come on within
half an hour  after he had made an effort beyond his  strength in
pushing a carriage into a coach-house, which sensibly  strained his
back.   In general the effusion into  the tunica vaginalis follows the
strain ofthe loins at a longer interval and more slowly.
  Hydrocele in  adults  seldom goes away spontaneously.  When
this event happens, it is probably caused by some degree of inflam-
mation ofthe membrane supervening, which stops the tendency to
secrete water.   Sometimes the  sac  spontaneously suppurates, and
on  being punctured, granulates and becomes  obliterated.  The
common  practice of injecting equal  parts of port wine and water to
cure hydrocele, acts by altering the mode of action, not by  causing
general adhesion  of the membranous surfaces  and closure of the
sac.
  Hydrocele is common  in  infants ; it generally spontaneously
goes away.   Sometimes the distention is so  great as to cause pain
or uneasiness : in that  case the tumour had  better be punctured.
The fluid occasionally has a free passage to and from the abdomen,
the peritoneal canal remaining open : in that  case a truss should
be worn to prevent hernia.  In time the liquid  is absorbed,  and the
canal closes.
  Hydrocele is often combined  with  chronic  inflammation of the
testes, and the patient  suffers considerable pain from  the  pressure 
 410            MAYO'S OUTLINES OF PATHOLOGY.

 ofthe liquid on the inflamed gland. The pain is relieved by letting
 off the water.
   b.  An encysted hydrocele is a thin membranous cyst, ordinarily
 containing a transparent water, which contains no coagulable mat-
 ter :  held in a spoon oyer the flame of a candle, it nearly all evapo-
 rates, leaving the  smallest possible residuum  of animal  matter.
 Occasionally, however, the contents  are  a yellow serum, like the
 fluid of common hydrocele.  Encysted hydrocele occurs in the
 cord, upon  the epididymis, when it lies between that tube and the
 tunica vaginalis ; upon the body ofthe testis, when it is  contained
 between the tunica vaginalis and the tunica albuginea.  [x.  175.]
   This kind is  commonly of slow growth, and forms a tumour of
 small size,  which  remains without  changing  for years.  When
 punctured, it is more likely not to  reaccumulate than common hy-
 drocele.
   2.  Hematocele.  This term is given to two affections—one, effu-
 sion  of blood, the other,  of  sanguinolent serum into  the tunica
 vaginalis, [x. 1<8.]
   The latter, I believe, may alternate with hydrocele, the secretion
 being from an accidental  cause dark and turbid at one time, clear
 and serous at another.  It may likewise arise  from blood being
 mixed with the serum of the hydrocele, in consequence  of a bruise
 on the testes,  or from a vessel having been punctured in tapping a
 pre-existing hydrocele.
   The former is the direct consequence of  mechanical injury to
 the  part; if the  effusion of blood  is small, it will be partially or
 wholly absorbed.  If of any  quantity, it should be evacuated, lest
 its pressure should excite disease or absorption of the testis.  The
 proper method is to make an  incision into the  sac, allow  what is
 disposed to  do so to come away, and then to apply a poultice, into
 which the effused blood will gradually be discharged.
   3.  Malignant disease ofthe tunica vaginalis.
   Mr. T. aged sixty, affected for fifteen  months with swelling of
 the testes, went through repeated mercurial courses for its removal,
 under the  advice  of Sir Benjamin  Brodie,  Sir Astley Cooper,
 attending in consultation.  The  remedies proving fruitless, it was
 at length agreed that the diseased part should be removed, if,  upon
 puncturing, the quantity of fluid  should be found inconsiderable.
 On passing  a lancet into the part in three different places, although
 the  fluctuation  was  apparently decreased, no  water was found.
 The  testicle was then removed by Sir Benjamin Brodie, and  upon
 dissection the appearances were as follow :—The testis was per-
 fectly sound.  The cavity of the tunica vaginalis was occupied by
 a spongy effusion, which  was thought to have .all the character of
 incipient fungus.   The tunica vaginalis was thickened, and had a
piece of ossific  matter in  it.  The patient died of  erysipelas.—
 Cooper.
  III. The cord  is liable to inflammation, to be the seat of encysted
hydrocele, and to the complaint next described. 
THE BREAST.
411
   Varicocele, is varix occurring in the spermatic veins,  which
forms a large soft nodular compressible mass, of a conical or pyra-
midal shape, stretching from the testes to the  groin.  The com-
plaint is attended with a sense of weight and dragging, and pain in
the loins.   It is more frequent on  the left side than on the right,
owing to the position  of the sigmoid flexure of  the colon over the
left spermatic veins.   For the same reason it is often benefited by
purging.  The use of a suspender and cold astringent  lotions are
generally sufficient to prevent this complaint being  very trouble-
some.   In  one case,  Sir  Benjamin  Brodie divided  the cluster of
veins on the cord with a pair of scissors:  a little bleeding took
place, but none of any  consequence ;  pressure  for a few minutes
stopped it, the wound healed, no inconvenience  followed the opera-
tion, and  the patient was entirely relieved of  the pain which he
suffered previously.   In a case of varicocele of so much severity
as to require any operation of this  kind, I should be disposed to re-
commend the application  of potassa fusa to the  plexus  of veins,
having first exposed them by dividing the skin.
   The  cord and  testicle  are liable to be the  seat  of neuralgia.
When a renal calculus is descending the ureter, the same parts are
sympathetically tender and swollen.
                       CHAPTER XIV.

                         THE  BREAST.

  The diseases ofthe breast fall under the following heads—acute
inflammation and abscess, chronic inflammation, neuralgia, hyper-
trophy, atrophy, tuberculous  disease, malignant tumours, encysted
tumours.
  I.  Acute inflammation ofthe breast rarely occurs except during
lactation : the swelling and shooting pain, with tenderness on pres-
sure, are sufficiently declaratory ofthe nature of the disease.  By
a timely  application of leeches, joined  with repeated fomentation,
and cooling medicine, the formation of matter may  be often pre-
vented.   When  suppuration  has taken place, and distinct fluctua-
tion  can be felt, the  abscess should be  opened.   When such an
abscess  is  in progress of granulating and contracting, the matter
secreted sometimes  has the"appearance of being mixed with milk.
  II.  Chronic inflammation  of  the breast is liable to occur at any
period of life,  from  puberty  till  the complete degeneraiion ofthe
gland- it generally attacks one  or more  lobules only: but some-
times the whole of the  breast,  and sometimes both mammae are
simultaneously affected.   The inflamed part is firmer than the rest,
and tender on  pressure,  and  is the seat of constant  uneasy sensa- 
412
MAYO'S OUTLINES OF PATHOLOGY.
tion, often shooting and lancinating.  The sensation communicated
by touching the inflamed part is very characteristic ; it feels a firm
inelastic  substance, with numerous  nodules of the  size of millet
seeds in it.  This  complaint rarely goes to suppuration : but it is
extremely  troublesome, often  continuing  for  years,  belter and
worse ; the pain  generally aggravated  before and about the cata-
menial period.   I never saw this affection lead to  malignant dis-
ease.  I believe, however, that it has often been mistaken for it.
  The following case, which was treated by Mr. Johnston, of Mor-
timer Street, with  myself, when we first saw  it, and for some time
afterwards, had much the character of carcinoma.   I give it as an
exception to the common history of this affection.
  Anne Bankes, aged fifty, mother of two children, had  not suckled
with the  left breast, because the nipple had been naturally retracted,
and the infants never took  to it.   Six years ago, dating back from
November, 1830, she  had observed under  the left breast a  small
lump, which was stationary for two  years;  when she fell, and
struck the breast against the banister, upon which the lump began
to enlarge, but very gradually.  In August, 1830, the swelling be-
gan for the first time to be the seat of pricking and shooting pains.
In the November following, when I first saw this patient, who was
of a full person, the whole ofthe left breast was affected: the gland
was  large, and  hard, and weighty, with a knotted irregular surface.
The left  axilla and left supraclavicular region (which  was tender
on pressure) were  fuller than the right, depending, as I conceived,
upon enlargement of the lymphatic glands.   She complained  of
loss of appetite, and being out of health. Six  leeches were ordered
to be applied every five days,  to the breast or neck; intermediate
days, a  spirit lotion ;  a dram of liquor potassae (which  was gradu-
ally increased to two drams) to be taken twice a day.
  Jan. 11.—Health improved ; the mamma decreased in size, pain
gone: fulness in the axilla  gone: enlargement above the clavicle
rather increased, aching pain extending from thence to the occiput.
To continue as before.
  March  7.—The breast,  has become extremely hard.  She  is
weakened, and  experiences sickness and disordered stomach.   To
take twice a day a dram of tincture of gentian and half a dram of
sal volatile, in lime water.   With this  her  stomach  symptoms left
her in a few days.
  In May she complained of pains at  the lower part of the right
breast, which went away on the application of leeches.
  June 29.—The left breast much softer than  it  has yet been; not
larger, but  generally firmer than  the right;  occasionally  only
shooting  pains  in  it;  the tumefaction at the  suprascapular region
almost gone.
  Some months afterwards, when I saw this patient, she continued
in the same state, thinking herself, as I suppose she  really  was,
cured.
  III. Neuralgia.  The breast extremely painful, tender on pres- 
THE BREAST.
413
sure, occasionally swollen—unattended  with inflammation or al-
teration of structure.   This complaint is frequent in young women,
and is singularly unmanageable.  Local applications in general do
harm; but I  have known a  belladonna  plaster, and ice, and a
blister, temporarily remove the pain.   Tonics in general, especially
steel, are of most use in irritable breast.
  IV. Hypertrophy ofthe glandular structure of the breast is sup-
posed to take  place occasionally.  What is  commonly considered
to be this complaint, is an hypertrophy of the interstitial mammary
fat
  Adipose tumour.   A woman was admitted into Guy's Hospital
for a tumour of the breast, which was of great size, and felt as if it
were composed of an  increase of the  different lobes, of which the
glandular structure of the breast consists.   But upon  making an
incision for its removal, it was found that the different lobes of fat
only which enter into the composition of the breast had become
enlarged, and  that  the glandular structure itself was free from dis-
ease.  The different branches of which the swelling was composed,
were easily drawn out from between  the different portions of the
gland, so as to leave cells in which the lobulated fat had been con-
tained.—Cooper.
  V. Atrophy.  The mamma  naturally wastes sooner or later after
menstruation  has  ceased.  The adipose tissue about the gland is
absorbed : the glandular  structure diminishes in  volume, and be-
comes  firmer  and  grayer, losing  its  opaque milky colour, and be-
coming of a dirty white.  The tubercular  structure,  however, is
not obliterated ;  a viscid serum can often be  pressed from the atro-
phied gland.  Sometimes the gland wastes early in life, particularly
after children  have  been borne, and not  nursed.   Otherwise the
mammary structure is fuller, and persists longer in married than in
single women.
  VI. Scrofulous disease. I have not seen an instance of tubercu-
lous deposit in the breast; when  occurring in this organ, it is pre-
sumable that it would  lead to  chronic abscess, which after a time
would contract and get well.
  VII.  Malignant disease.   I had  reserved for this place the
general consideration  of  malignant  diseases affecting soft  parts,
partly hoping  that before  I reached the present chapter the result
of Mr. Kiernan's inquiries would have been published, partly be-
cause the organ under consideration is the most frequently and
remediably their seat.  Being,  however, in some degree acquainted
with Mr. kiernan's unpublished views,  I must now limit myself to
the description  of the  external character of these disorders, and
their general appearance upon anatomical  inspection.   The basis
of the division  which  I  follow, the reader will find in  an  account
of some cases given in the Medical and Physical Journal for Janu-
ary, 1830.
  The malignant diseases of the breast are  carcinoma, medullary
sarcoma, gelatiniform sarcoma, melanoma. 
414
MAYO'S OUTLINES OF PATHOLOGY.
  1. Carcinoma.  This disease, which forms forty-nine fiftieths of
malignant diseases of the  breast, when examined after death, pre-
sents three distinct morbid appearances, which are often met with
combined in the same part, although sometimes, but rarely, they
are met with separately.
  a. A tumour, the whole of which nearly resembles cartilage in
structure, dense, of a grayish  or bluish white, with  a slight  ap-
proach  to transparency, elastic, cutting with the same sound as
cartilage. [Y. 1.]
  6. A tumour, cutting crisply, like the texture of an unripe pear,
of a gray colour, succulent, with yellowish  or whitish lines, con-
taining an inspissated substance, probably tubuli lactiferi. [Y. 2.]
  c. A softer texture, more  vascular, or red  with partial  vessels,
and succulent, not without some crispness when cut through, when
squeezed giving out fluid  partly serous, partly opaque and white.
[Y. 3.  4.]
  There is  evidently a close  alliance between these appearances.
The first I met with constituting the mass of a tumour of  the size
of a small orange flattened, involving  the  whole breast,  which I
removed from an elderly  woman in the cancer  ward of the Mid-
dlesex Hospital; at one  part  only  the softer character to  a very
small extent was found in it. A beautiful model of a section of this
tumour is in the King's College Museum.   The second is the com-
mon appearance found in  carcinomatous tumours that are early
removed.  The third, mingled with the  second,  is the ordinary
appearance  where carcinoma of the breast  has  grown rapidly, or
the operation has been long  delayed.  The first is  rarely found
constituting any large portion of a carcinomatous tumour of the
breast; the second and third  are common  appearances, the third
marking, I think, an advanced  stage ofthe disease.
   If the whole gland is not implicated, the  excepted part  is some-
times healthy, sometimes it is yellowish, hard, coarsely granulated,
firm, and not unlike  the pancreas in appearance.  The  enlarged
lymphatic glands in  the  neighbourhood present two characters;
they are either  uniformly firm and of a grayish white, or softer,
more succulent, gray and bloodshot, like the third form of carci-
noma ofthe breast above specified.
   To  exemplify combinations of the  above appearances,  I shall
quote some  post mortem  inspections from the paper of my own
already referred to.
   A woman, about forty-five years of age, had been afflicted seve-
ral months with scirrhusof the mammary glands and of the integu-
ments.  The right breast  was  nearly flat, the nipple retracted ; the
integument  immediately covering the gland, as well as the  adjacent
integument  upon the right side and front of the  body, was thickly
studded with hard nodules.  These nodules were a little elevated;
most of them were about a third of an inch in diameter, one or two
an  inch, one an inch and  a half; the largest among them were
covered with a crust or thick scab.  There were several lymphatic 
THE BREAST.
415
 glands  in  the axilla  enlarged and indurated; the right arm was
 oedematous and greatly swollen.
   The oedema was temporarily diminished, as I have seen happen
 m other similar cases, by the application of a blister to the swollen
 arm.  The patient  complained of darting  pains and a sense of
 burning in the right  breast.   The left  breast was harder than na-
 tural, and the  surface  of the gland felt coarsely granulated; the
 nipple was not retracted.
   Inspection.—The gland of the  right  breast, when divided, was
 of a gray  colour, and presented a texture like that of an unripe
 pear, cutting with a  characteristic resistance and sound.  Tubuli
 lactiferi were seen upon the surface of the section, both in the
 gland and nipple, containing a thick white  secretion.   The right
 pectoral muscle, to which the breast  strongly adhered, had two or
 three large, firm, white tubercles in its substance.
   The  structure of the left breast was different  from  that of the
 right: the gland was greatly hardened, but  had  preserved its na-
 tural colour;  its surface was  exceedingly  irregular, being raised
 into innumerable little  knots; and, when divided, the section had
 a corresponding character, and bore some resemblance to the sec-
 tion of an indurated pancreas.  The left breast was readily separa-
 ble from a thick  layer of cellular membrane, which intervened
 between it and the pectoral muscle:  this layer of membrane was
 studded with numerous small, white,  hard, flattened nodules, vary-
 ing from two to three lines in diameter.
   The  lymphatic  glands that were affected were hard, white, and
 dense :  when they were divided, the appearance of the cut surface
 was the same.
   The  smaller nodules upon the skin  were hard and firm:  they
 had  the colour of the skin, which seemed to have become thickened
 and  hardened, and distinctly laminated,  to form them.   The larger
 nodules differed from  the rest in this, that the cellular membrane
 beneath them was converted  into  a like substance, a  thin layer of
 fat partially intervening between  it and them.   On lifting off the
 crust from the  largest, the surface was found to be soft and vascu-
 lar, with something superficially of a villous  appearance.
  A lady, aged sixty-six, was attended  by Mr.  North  for a  small
 tumour in the inner and upper part ofthe left breast, of the exist-
 ence of which  she had been aware about seven  months.  It was
 tender when pressed :  it was not hard,  but felt like a common in-
 flammatory thickening of a lobe of the  breast.  In July, 1829, Sir
 Astley Cooper saw this patient with  Mr.  North,  and prescribed a
 mercurial alterative at night with a bitter and aperient draught  in
 the morning; the part to be bathed with a spirit lotion.   This plan
 was  pursued for a few weeks, during  which the complaint con-
 tinued stationary.
  The following August I saw this patient  with Mr. North: the
part had become painful, and had increased in size, and there was
fulness  of  the glands of the axilla.  It was agreed that leeches 
416            MAYO'S OUTLINES OF PATHOLOGY.
should be occasionally applied, and the mercurial alterative used
again.   The  symptoms improved under  this treatment,  and the
breast ceased to be painful.
  The lady now left town : on her return, about the beginning of
October, the symptoms had changed for the worse.  The  swelling
of the breast, although not much larger than before, had  now the
character of scirrhus ;  at the same time, subcutaneous tumours had
formed in  different parts of the body.  Her breathing became
affected;  she was unable to  lie down in bed.  She sank rapidly,
and died on the 1st of November.
  Inspection.—The lump upon  the inner edge of the left  breast
was prominent, so as to raise the integuments: it had to the touch
the peculiar hardness of a scirrhus.  Two other parts ofthe breast
felt indurated, but not in  the same degree.  On making a section
of the gland, the lump at the  inner edge presented the following
appearance:  it was nearly spherical; its substance was particularly
hard and dense, slightly elastic and crisp, mottled gray and white,
the white  predominating:  the margin was  here and  there of a
softer texture, and, for the depth  of a third of an  inch, vascular or
bloodshot.   The morbid structure ended abruptly.
  The other two indurated parts had a different character:  the indu-
ration began insensibly, so that it was difficult to determine exactly
where the natural structure of the breast ended.   The central part
of each was dense, slightly elastic, of a dull white colour ; and, in
one of the  indurations alone, the white was  partially mottled with
a transparent gray.  In the  condensed  substance  at one  part, and
at another in the soft and natural substance of the breast, there was
a body, ofthe size of a pea,  that was internally soft and bloodshot,
and resembled, in some degree, the margin  of the  lump first de-
scribed.
  The right breast had partaken of the same affection : it was in-
durated in two places, so that, deducting from  the preceding de-
scription of the left breast the account  of the more  advanced and
maturer tumour, the rest might stand as a sufficiently exact account
of the condition of  the right.
  The tumours in the subcutaneous cellular membrane were about
as large as middle-sized peas:  there were from twenty to thirty dis-
persed about the  abdomen,  immediately below the integuments, to
which  they did  not adhere;  a  considerable group was situated
below  the  right  breast,  and there were a few,  individually of a
larger size, about each clavicle; and  at  least a  dozen upon the
back, between the shoulders.  Almost  all these tubercles had one
character ;  when entire, they felt firm and tense ; when cut through,
a quantity  of fluid escaped,  in some serous, in others thicker and
whitish.  The parenchyma ofthe tumours was a soft, gray, spongy
flesh, highly vascular or bloodshot, and exactly resembling the pea-
like tumours in the substance of  the breast.  Two or three only of
the little tumours about the  right breast, when cut  through, were 
THE BREAST.
417
of that dense white substance, which is the commonest state of the
glands about a scirrhous breast.
  In the substance of each lung, and in the liver, there were seve-
ral tumours of a dense, white, elastic substance.
  Cavities containing a viscid transparent  fluid  are occasionally
met with in carcinoma of the breast.
  Mrs. Fuseli, aged sixty-eight, had a tumour of the breast, which
had  been two years  in  forming.  It had  not  been attended with
lancinating pains,  and there  was an evident collection  of fluid in
it, to the outside of the nipple, but elsewhere the tumour felt like a
scirrhus.  I removed the breast, in the presence of Mr. Cartwright,
in May, 1829.  On examining it, the structure was found to be the
ordinary crisp gray scirrhus, with a cavity containing about  two
ounces  of liquid,  partly serous,  partly viscid, of a dirty  yellow
colour.   Mrs. Fuseli died  two years afterwards of apoplexy.   The
disease had begun  to reappear.
   Scirrhus of the  breast commonly exists as an indolent tumour,
either  on the surface of the gland,  or  deeply  seated, for from six
months to two years before it causes much  uneasiness; the lump
is not at first tender  on  pressure, although occasionally the seat of
lancinating pains.   At length the tumour begins to enlarge,  and,
at the same time, it becomes sensible to pressure, and darting pains
are felt in it, the pain often extending to the  subclavian region, and
down  the arm.  In its  progress, the complaint in different cases
assumes different features, of which the following are the principal
which I have remarked.
   a. The skin, not participating in the disease, becomes  inflamed,
and ulcerates over the most prominent and tender part or parts of
the tumour: two  or  three such ulcers forming in succession, at
first circular, red  round the  edges, but soft, the substance of the
tumour is exposed, covered with firm granulations, which are of a
pale red, and but partially organised, so that thin lines or patches
of yellow lymph-like substance intervene among them.  The ulcers
of the skin enlarging, run  into one.  The carcinomatous tumour
ulcerates, and the  cavity so formed extends  to  a great depth, with
most severe pain and suffering.  The skin at length at a few points
becomes tuberculous, and around the ulcer is  brawny,  hard,  and
red.  The edge of the ulcer  is irregular, but without either much
eversion or inversion.
   b. It sometimes  happens in the preceding  form of the complaint,
that sloughing supervenes, which destroys with rapidity great part
of the diseased structure.   A lady, whom I attended, after very ex-
tensive mortification of  a  scirrhous breast, temporarily recovered:
the surface cleaned and cicatrised, drawing the skin  together to-
wards a  hard  irregular cicatrix, which had the firmness,  and, I
have no  doubt, the structure of carcinoma.  After a few months
ulceration began again, and the disease ran its usual fatal course.
   c. At the period when the  disease  in  the  gland  becomes active,
it sometimes happens that atrophy or wasting of the surrounding 
418
MAYO'S OUTLINES OF PATHOLOGY.
parts takes place.   The adipose tissue  is absorbed,  the  breast be-
comes much less in size than the sound mamma: the skin comes
into immediate contact with the scirrhus, and adheres  to it, and
participates in the same action ; the scirrhus adheres to the pectoral
muscle;  and round the firm flat lump to which the part  is reduced
the skin of the neck is studded with little hard tubercles, the near-
est of which as they enlarge coalesce in patches.  Sometimes par-
tial atrophy of the gland itself takes place.  [Y. 8.]  The mode in
which  such a tumour ulcerates is peculiar.  It seems as if the
cuticle were merely separated  from some of the groups of carcino-
matous tubercles: they remain raised, and red, and smooth, but
are moist and discharge.  In time the  ulceration goes deeper, and
destroys  the raised part; and if the patient's strength bears  up, a
great part of the chest presents the appearance of a flat discharging
ulcer, the surface of which is red and covered with firm, flat, red
granulations, based upon a thin layer of almost cartilaginous firm-
ness; the edge is irregularly eaten  away,  slightly raised, part in-
verted, part everted.  [Y. 9.]
   d. Sometimes, as a modification ofthe preceding variety, atrophy
taking place of the fat upon the fore part of  the  tumour, the skin
comes  into contact with it, adheres to it, becomes red ; and there is
presented the appearance of a dry, red, hard, rounded tumour, pro-
jecting out of  the partly-wasted breast: the skin around healthy,
only having become incorporated with the tumour, where it has
been drawn into contact with it; the tumour  being movable on the
pectoral  muscle.  The dry surface begins to  discharge at different
points, then the lump ulcerates or sloughs.
   e.  When the neck  has been previously full,  and the adipose
tissue has been less absorbed than the gland  has been  atrophied,
the integuments and fat form large irregular folds, the furrows be-
tween  which converge to  a  point often near  to  the nipple, where
ulceration is commencing.
  /.  In a lady of a remarkably full person, whom I saw  in consult-
ation with Dr. Langmore, of Finsbury Square, the  affected breast
had attained a great magnitude: the skin was firm, and  not merely
distended,  but uniformly thickened,  the natural pores and irre-
gularities of its surface being rendered more distinct: the integu-
ments  of the side  underneath the arm were in the same condition.
There was slight redness upon the under part of the  breast and
upon the side.   The termination ofthe case I did not see; but Dr.
Langmore tells me,  that  eventually superficial  ulceration  took
place, attended with the peculiar smell of carcinoma.   The ulcer
never  became deep,  or  sloughed;  the  enlargement  gradually
lessened ; the breast  became hard, and immovably fixed to the
ribs.                                                      ■■&
   The enlargement of the  subclavian and axillary glands, espe-
cially of the latter, contributes to aggravate the features  of cancer.
With the local swelling,  there is an extension of pain, aching or
lancinating;  and the arm becomes oedematous. 
THE BREAST.
419
  One case of carcinoma, which was recently under my care, I
may take this opportunity of mentioning;  the mamma was  free
from disease, which was confined to the subclavian glands,  that
formed a large, hard, rounded mass.
  The important question now presents itself, whether carcinoma
is a disease only to be  palliated, or whether it admits of extir-
pation.
  After amputations of a scirrhous breast under the most favour-
able circumstances,—that is to say, when the operation is performed
at the earliest period at which the structural character of the  dis-
ease has declared itself in the gland, no other part being yet in-
vaded by it, and the diseased structure being entirely removed,--
I believe,  that, in ninety-nine cases out of a hundred, the  disease
returns  either  in the  cicatrix,  or  in  the  axillary or subclavian
glands.   The operation, therefore, cannot be performed with any
reasonable prospect of saving  the patient eventually  from  the
disease.
  But the period of the  return of scirrhus varies from six months
to two or  three years, or even longer.   The  interval may be one of
health and hope; and  even when the disease reappears, it does not
in general return in a character of such formidable suffering as in
its ordinary character it presents.   The worst suffering in cancer
arises from the destructive ulceration of the  original  scirrhus: the
changes which supervene in the  secondary scirrhus, whether in
the  cacatrix or the lymphatic glands, are generally mild, compared
with the former.  The constitution likewise sinks more rapidly on
the  return of the disease, being by that  time more completely un-
dermined than at the first invasion of scirrhus.
  It is not equally advisable  to remove every scirrhus of the breast.
If the skin is extensively implicated,—or the surrounding adipose
tissue and cellular tissue,—or if the gland is firmly adherent to the
pectoral muscle,—or if any extent of ulceration has already taken
place,—or if the disease in the breast is much  less in degree than
coexistent scirrhus of the adjacent  lymphatic  glands,—the patient
would not derive sufficient benefit from the operation to compensate
for the suffering attending it.   Of course such an operation is al-
ways out ofthe question  if the general health is so impaired as to
show that the constitution  is   fast giving  way  under  the local
scirrhus, or sinking under other accidental disease.
  2. Medullary sarcoma.  In the paper already referred to, I  had
introduced the following remark:—" The fungoid growth, which
often supervenes in  scirrhus of the breast, commonly resembles in
texture the firmer part of a  fungus haematodes.   Occasionally it
partially retains nothing of that fibro-cartilaginous  texture which
belongs  to scirrhus."  Ofthe  alliance of the  two diseases there  can
be no doubt.  On the other hand, pure medullary sarcoma, entirely
abstracted from scirrhus, is of very rare occurrence.  I witnessed
the following case of the complaint.
  A young unmarried woman, aged nineteen, was admitted into 
420            MAYO'S OUTLINES OF PATHOLOGY.

the hospital, under the care of Mr. Cartwright, in March, 1819.
Six years before, a tumour,  unattended with pain, formed  under
the right breast: the whole of the breast gradually became involved
in the disease.  In the course of another year  the  left  breast be-
came affected.  At  the time of her admission, both breasts were
considerably enlarged ; the right, however, was a third larger than
the left.  The colour.of the left was natural;  that ofthe right dark,
resembling the colour of old mahogany.  Both  breasts were to the
touch firm,  but with a consistence  like dough.  The surface be-
tween the breasts was hard and prominent; the skin thickened and
nodular.  At this part there  were two ulcerated holes, an  inch  in
diameter: the surface of the ulcers  was  dark.  This patient had
not experienced much pain : that which she had  felt  had been
rather smarting than  pain, and  had been  confined to the right
breast and to the ulcerated part.  She died  soon after  her admis-
sion.
   The  left  breast  (the smaller)  was of a hard, white,  firm, and
fibrous, but doughy substance;  here and there a calcareous con-
cretion  was found  in it:  in parts the texture was softer,  more like
the substance of brain, and slightly bloodshot in parts.
   The  right breast was generally softer,  and great  part of it con-
sisted of brainlike substance, here and there streaked with blood.
   The  substance  between the breasts and  the lymphatic glands
appeared upon a section white and firm; a thick  white  pulp or
viscid fluid exuded from it on pressure.
   The right pectoral muscle was pale and wasted.  The  interstices
between the fasciculi were studded with numerous small tubercles,
which,  when squeezed, yielded a white pulpy substance.  This
white, doughy, or pulpy formation was  found  both in  the pleura
costalis and the pleura pulmonalis, on the right side.  There was
a large  quantity of water in  the cavity ofthe right pleura.
   In  a  lady, whom I saw in consultation with Dr. Langmore  of
Finsbury Square, about three months before her death by medul-
lary sarcoma of the breast, the appearances bore some resemblance
to those last described.
   The neck was full:  the skin soft and healthy, except at one part.
Over the middle and lower part of the sternum there was a swell-
ing, which extended to the inner part of the  left breast:  the  lower
and inner part of the left breast had a slight blush upon  it. On
the upper part of the  neck two or three  large blue veins were pro-
minent.  At the left part of the sternal swelling, over the insertion
of the cartilage of the fourth rib, was a  round ulcerated opening,
something larger than a sixpence, with soft red drawn-in edges,
which led into  a cavity two  inches in depth, from which a great
discharge of ichor,  without  any disagreeable  smell, took  place
daily.   Below this opening, the fulness bulged into a soft,  smooth,
red shining tumour, of the size of a nonpareil apple.  A probe in-
troduced in a direction downwards and inwards from the ulcerated
opening, passed  between the sternum and this swelling.   Upon 
THE BREAST.
421
puncturing the swelling with a lancet, making an aperture half an
inch long, a smart stream of arterial blood flowed from the cut sur-
faces, but stopped on introducing a slip of lint into the wound, and
making light pressure with the finger.
  3. Melanoma of the breast is extremely rare.  A patient, aged
forty-nine, mother of a family, was operated on nine months ago
for a scirrhus of the breast.   The tumour contained several black-
nodules about the size of peas.  The subjacent pnrt of the pectoral
muscle was studded with similar growths.  This part Mr. Earle
removed in the same operation.   The patient has  enjoyed  good
health from that time to the present; but during the last few weeks
a small lump has appeared in the cicatrix.
  4. Gelatiniform sarcoma.  The  following case I suppose to
exemplify this rare disease.
  A lady, fifty-eight years of age, married,  but never having borne
children, had observed for the first time, about six years before, a
hardness at one part of the right breast.  About two years after this
she had a fever, during which the tumour  disappeared.  In 1S27
the tumour returned ; but no remedies were made use of till March,
1828, when she  placed  herself under my care.  Mr. Brodie saw
her at  that time, in consultation.
  The right breast was enlarged, and formed a flat oval cake, five
inches in length, four in breadth, and about two in thickness.  To
the touch, the tumour was  firm, and  slightly elastic; its surface
was even, or very slightly lobulated.   It was  easily movable  upon
the pectoral muscle.  The nipple was slightly retracted. The skin
over the tumour was  not tense;  the subcutaneous veins  were en-
larged.   At times shooting pains were felt in the breast, and  there
were two points at which the tumour was tender on pressure : one
internal to the nipple, the other at the upper and outer part.   This
lady is of a pale complexion and relaxed habit, liable to occasional
attacks of erysipelas of the face, and continually required aperient
medicine to move the bowels.
  R. A dram of liquor potassae to be taken  three times  a day in
table-beer.  A dram of the ointment of hydriodate of potass to  be
rubbed upon  the tumour  night and morning.
  The adoption of this plan was of temporary service.  At the ex-
piration of two months,  the general health had considerably im-
proved :  the bowels no longer needed medicine : the shooting pains
in the breast had entirely gone away.  The tumour had not en-
larged, and had become less tender on pressure.
  The lady now went into the country, with directions to continue
taking the liquor potassae, in a dose increased to a dram and a half
three times a day.
  Towards the winter this lady returned to London, having steadily
pursued the plan laid down in all  but the constant use of the oint-
ment, which at one time  irritated  the skin.   About the middle of
December, 1828, the changes that had taken place were the follow-
ing:—The breast had enlarged considerably; the shooting pains
       22—c                                   28 may 
422            MAYO'S OUTLINES OF PATHOLOGY.

had recurred ;  and there was some tenderness in the axilla, but no
enlarged gland could be felt  there.  I directed the application of
leeches  to the axilla, and frequent fomentation, upon which the
tenderness in the axilla went away.
  It appeared to me, however,  that no  time was to  be lost in re-
moving the tumour.   Sir Astley Cooper, who saw the patient in
consultation,  concurred in the same opinion.   I amputated  the
breast early in January, 1829.
  Upon examining the part after its removal, the disease, it  ap-
peared,  had not involved the  whole breast, part (or the whole) of
which lay as a flat white cake, compressed and  condensed  to  the
right ofthe tumour towards the axilla.  The nipple adhered partly
to the unchanged breast, partly to the tumour.   The  tumour was
about three inches in thickness, five in length, four in  breadth.  It
was weighty and  tense.   On cutting it through, the texture gene-
rally had a crispness like unripe fruit: the surface of the section
was of  a light gray colour,  glistening, and  semitransparent;  the
interior texture succulent, in the softest parts tearing, when  a little
force was used, into gelatinous strings: at the  circumference, the
texture  became more dense, and approached more nearly, in  colour
and consistence, the character of scirrhus.  There was no cavity
in any part ofthe tumour, [y.  35.]
  On the fourth day after the operation, the patient complained of
pain at  the lower  and inner angle ofthe wound.  The wound was
dressed: adhesion seemed to  have taken place  along  the greater
part, and there was no inflammatory tumefaction, or unusual ten-
derness, where the uneasiness  was felt; yet, when she drew in  her
breath,  there was some pain at this point which suddenly checked
the inspiration.  This symptom had  come on during the preceding
night.   The pulse was  ninety;  the skin something  heated,  but
rather moist than otherwise; the tongue neither furred nor dry.  I
thought it  right,  under these circumstances, to take away some
blood:  when she had lost fourteen ounces she  became faint, and
said that the pain had nearly left her.  The blood showed  that it
would have a  size.   In less than an  hour  the pain  recurred more
severely than before.  She was again bled to sixteen ounces, when
she became faint again,  and the pain was scarcely felt.  She then
fell into a doze, and, on awaking, declared  herself entirely relieved
from the pain  and oppression of breathing.
  Every thing now went on favourably, and the wound had  healed
in a fortnight after the operation.  There has been no return ofthe
disease.  The lady is now in good health.
  VIII. Encysted tumours of the breast present the following va-
rieties :—Sometimes the  tumour is a portion of a galactophorous
duct which  has become obstructed, and,  milk  accumulating in it,
has dilated it  into a  globular sac.  Sometimes the cyst contains
serum only, or a  transparent  viscid liquid; and, instead of one,
there  may  be several.  This  kind probably  arises in the same
manner as the first.   Cysts, again, containing  transparent liquid 
THE BREAST.
423
are often met with in carcinomatous tumours of the breast: while,
on the other  hand, cysts that were simple originally, after great
and continued  distention,  occasionally give  origin to medullary
tumours that grow from their internal surface.
   1.  Mrs. R., aged thirty, had a swelling ofthe right breast, which
had existed twelve months, and appeared one month after the birth
of her last child.  The skin was undiscoloured, and  her general
health good.  The swelling was of the size of an orange,  and
attended with occasional trifling pain.  It was punctured, when a
saucerful of  milk,  like curd or clouted cream, was  discharged.
The discharge continued for three days, and then ceased.—Sir
Astley Cooper.
   2.  A young  woman  was  admitted  into Guy's  Hospital for a
tumour on the breast, which had existed several months.  As there
was an obscure  fluctuation in it, a lancet was introduced, when a
discharge of serum took place from the opening.  A small piece of
lint was introduced into the orifice, which brought  on  an adhesive
inflammation: the sides of the  cyst  adhered, and  the patient did
well, having  no return  ofthe complaint.—Sir Astley Cooper.
   A young lady had a tumour in her right  breast.   In its centre
there was a distinct fluctuation surrounded by some hardness.   A
lancet  was introduced,  when a quantity of clear serum gushed from
the opening.  Adhesive plaster was applied, and the wound healed.
The hardness remained for a length of time, and pain and swelling
of the other breast supervened ;  but by taking alterative medicine,
by bathing in the sea, by the application of soothing plasters upon
the part, the  swelling disappeared, the uneasiness ceased, and she
is now perfectly recovered.— Sir Astley Cooper.
   Mrs. H., aged forty-five, had a tumour in her breast after lying-in.
It was opened by means of a seton; and discharged  a mucilaginous
fluid.   In the year 1800 the whole breast had become involved  in
the disease.  There were several tumours in it: some felt like peas,
others were as large as a  marble; some  had ulcerated and  dis-
charged a mucilaginous fluid, and  then healed.  There was occa-
sionally slight pain.  The breast was removed on the  5th of May,
1800;  and, when  examined, was  found full of cells  which con-
tained a serous glairy fluid.  One  cyst was larger  than the rest,
and the membrane which formed it was highly vascular.  In 1804
she had experienced no return ofthe disease, but was quite healthy.
At the time of the operation  there  was in each axilla  an enlarged
gland, which disappeared after it, and never returned.—Sir Astley
Cooper.                                              ,     ,
   The following case is one of the  most interesting, and  at the
same time the most satisfactory in its results that I have witnessed,
anion" diseases of the  breast partaking of a malignant character:
it combined  an encysted tumour  with  medullary sarcoma:  the
latter grew in the  interior of the cyst,  and was  probably an acci-
dental consequence of the long-continued distention and irritation
it had undergone. 
424
MAYO'S OUTLINES OF PATHOLOGY.
  Mrs.----, aged  sixty-one, consulted Dr. Chalmers, of Croydon,
for an immense enlargement of the right breast, in March, 1832.
Twelve years before, she had first observed some  uneasiness and
fulness of the neck.  The pain had never been very acute, and had
never much disturbed  her,  and her  health  was  good; but  the
swelling had  gradually become so large, that the breast formed an
immense bag, stretching from the clavicle to below  the edge of the
ribs from the side to the sternum;  and measuring in length four-
teen inches, and weighing, it was conjectured, about twenty pounds.
She supported it habitually on the right forearm.  The parietes of
the sac seemed attenuated  in  several  places, where superficial ab-
scesses had at different times existed and healed.  Fluctuation was
distinctly perceptible in every part of the tumour, and several irre-
gularities of substance could be felt within it.  The integuments
were apparently oedematous, having a doughy inelastic feel.  The
patient's health was impaired: there was  fever and irritability of
the stomach, which Dr. Chalmers was endeavouring to allay before
any thing further should  be attempted ;  when, on.the night of the
12th, the skin  gave way at three points, and about a gallon of thick
brown  fluid was discharged: in the  course of a few hours about
another gallon was discharged.  Between the 12th and the 2lst
from six to seven gallons  more came away,  so  rapidly was this
fluid reproduced.   On the 21st I  saw this patient  in consultation
with Dr. Chalmers;  and, concurring with  him in opinion that the
tumour should  be removed,  was present  during the operation,
which  he performed with  great dexterity and boldness.  A large
portion of skin was removed, and the  immense and thickened cyst
was  dissected from the  front  of the chest.   The part removed
weighed four pounds and a half.  The cyst was about a quarter of
an inch in  thickness: from two or three parts of its internal aspect
masses of fungus haematodes projected into the cavity.   The pa-
tient recovered without any untoward symptoms, and is  now alive
and well, February, 1836.   Some obscure threatenings of a return
of the complaint have been recently observed by Dr. Chalmers,
who thus speaks of them in a letter to me.
  " I saw Mrs.----this  afternoon.  She  had enjoyed an almost
uninterrupted  good state of health ever since the operation in
March, 1832.  She has quite recovered the use of the arm, notwith-
standing the destruction of the tendon and the removal of nearly
the whole of the pectoralis major.  She can  cross  her breast with
the arm ;  but, in raising her hand to touch the left shoulder or ear,
she needs the  elbow to be  raised by  the left  hand.   For two or
three months past she has experienced an  unpleasant tingling sen-
sation stretching down  the inside of the arm, commencing at the
insertion of the heads of the tendon of the pectoralis; and though
the cicatrix is  quite healthy, and  slides  over  the ribs without un-
easiness, and  there is not  the slightest vestige of irregularity or
tumefaction, yet I discovered  in  the  margin  of the axilla (appa-
rently the extracted termination of the tendon) a hard tumour of 
THE UTERINE SYSTEM.
425
irregular shape, not very movable, but without  pain even when
handled roughly.  Time will show what the nature or termination
of this may prove: it has been there, she says,  ever since the ope-
ration ; and, perhaps, after all, it may only be a bundle of consoli-
dated fibres of the muscle." [y. 40.]
CHAPTER XV.
THE UTERINE SYSTEM.
  The affections which will  be enumerated under this  head are,
disorders of the urethra and vagina ;  of the unimpregnated uterus ;
ofthe ovaries :  extra-uterine foetation.
                          SECTION I.

                     Urethra and Vagina.

  a. The female urethra is very rarely the seat of stricture: when
that complaint has occurred, it has been  situated immediately
within the external  meatus.  Sir Benjamin Brodie describes an
instance, in which he had an opportunity of examining a stricture
which was quite at  the extremity of the urethra, and  occupied
about half an inch ofthe canal.
  A vascular excrescence is liable to grow from the female urethra.:
it is of a bright scarlet colour, and possessed of great sensibility: it
varies in size from that of a large pin's head to the size of a horse-
bean.  It requires to be cut off, and the surface cauterised.
  6. The external parts of the vagina are liable to  hypertrophy, or
indurated enlargement, (such tumours often require to be removed
with the knife,) to inflammation, abscess, ulcers.
  In infants, the nymphae are sometimes found adherent;  a  little
pressure separates them.
  Congenital  imperforation  of the vagina is liable to occur at the
orifice/Yimperforate hymen,] when it  should be perforated  with a
trochar; or in the middle of the vagina, obliterating its cavity for
the Ieno-'th of half an inch or more, when it  should  be  carefully
divided with a scalpel, lancet-shaped, and bent upon the flat.
  Obstruction ofthe vagina is liable to occur from inflammation.
  A woman who had borne several children had a premature  con-
finement  at the seventh  month.  Severe inflammation followed ;
and the vagina, which had, perhaps,  partially sloughed,  was nar- 
426
MAYO'S OUTLINES OF PATHOLOGY.
rowed.  To remedy the constriction, a surgeon divided the part
with a knife having  several blades.  Fresh  inflammation was set
up  by this operation,  and the canal  became  entirely obliterated
through the adhesion of its sides.   Three or four years afterwards
this patient consulted me: she was at  that time suffering periodi-
cally with epileptic fits, from suppressed menstruation.  They were
mitigated by bleeding.  The uterus, when examined by the rectum,
was found  of the natural size.  In this case I restored the vagina
by dividing the  substance which intervened  between the bladder
and rectum.  I did not, however, succeed in reaching the uterine
cavity, as I had hoped.  I suspect that it was obliterated; for  I
certainly divided the cervix uteri obliquely,  as  I judged from the
gristly texture of the part, and the sickness which  the patient ex-
perienced.  She lived  many  years  afterwards; and her vicarious
epileptic  seizures were less frequent and severe  after the opera-
tion.
  Laceration of the vagina through the sphincter into the rectum,
during labour, I have successfully treated,—following a suggestion
of Mr. Copeland's,—by dividing  the sphincter laterally on both
sides, and preventing the new wounds closing by the introduction
of a few threads of lint.  The laceration was then  encouraged to
close by constant cleansing, and keeping the sides in apposition by
bandaging the knees together.  After the laceration had healed, the
lateral incisions were allowed to unite.   The part was perfectly re-
stored, and the patient has  borne two  children  since  without
renewed laceration or inconvenience of any kind.
                          SECTION II.

                          The  Uterus.

   The affections of the  unimpregnated  uterus are, disordered se-
cretion ;  tumours in its substance;  polypus ; chronic inflamma-
tion,  and enlargement  and ulceration  of  the  cervix ; malignant
disease.
   I. Disorders of secretion are, suppressed or incomplete menstrua-
tion, menorrhagia, leucorrhoea.
   II.  Tumours in the substance of the womb.  Tumours are form-
ed between the fibres ofthe womb, which present accidental diver-
sities of structure, but  belong to one genus.  Their form is sphe-
roidal ; their diameter  from half an  inch to six or eight inches ;
their ordinary structure well  expressed  by the term fibro-cartila-
ginous; firm, crisp, opaque, gray, or yellowish white, tearing  into
strong fibres or laminae,  often disposed  concentrically; sometimes
more granular; sometimes with cavities containing a brown or
eddish gelatinous fluid.   These  tumours often  contain and some- 
THE UTERINE SYSTEM.
427
times are incrusted with calcareous matter, which Dr. Bostock has
shown  to consist principally of phosphate of lime, with small quan-
tities of the carbonate and  sulphate.  The calcareous  matter is
generally soft and porous, li.ke pumicestone; but instances  have
occurred in which it has admitted of being polished like ivory or
marble.  These tumours, when in the substance of the uterus, are
easily unshelled, and turn out without much adhesion to its fibrous
structure : but  they are organised, and when they project on the
peritoneal aspect of the womb, their surfaces are furrowed by the
large veins belonging to them.   The uteius often contains  more
than one such tumour.
  These tumours are not malignant: they have  no  disposition to
ulcerate, nor lead to similar disease in other organs.
  When of a  small  size, they  produce  no inconvenience; when
larger, they are  liable mechanically to interfere with labour, to
form weighty  and troublesome abdominal tumours, to  protrude
towards the vagina as a form of polypus.
  In a paper on this subject in the nineteenth volume of the Medico-
Chirurgical  Transactions,  Dr. Robert  Lee observes, that when
fibrous  tumours  are imbedded in  the proper tissue of the uterus,
women are frequently barren ; or, if they become pregnant, abortion
takes place in  consequence  of the uterus being incapable  of the
necessary developement in the latter  months of pregnancy.   When
the ovum is not prematurely expelled, death may take place in such
cases from uterine hemorrhage  soon  after delivery.  M. Chaussier
saw a woman  die from flooding soon after giving birth to a full-
grown child, when there was a large fibrous tumour on the posterior
walls of the uterus.   This tumour was not so situated as to present
an obstacle to the passage ofthe child through the pelvis; but soon
after delivery, it was perceived that the uterus had not the power of
contraction.  Profuse hemorrhage took place from that  part of the
uterus in which the tumour was lodged: the flow of blood could not
be arrested, and the patient died.
  Sometimes these tumours are expelled by the contraction of the
uterus after labour.
  Fibro-cartilaginous tumours formed at the fundus of the uterus,
beneath the peritoneum, rise into  the abdomen, and may  be felt
movable in that cavity. One of these weighing about eight pounds,
Dr. Granville showed me, which he  had removed: it was attached
by a short  peduncle an inch in diameter, and  had contracted no
adhesions.   The case was therefore, if any such case can be, favour-
able for the operator : the patient, however, died,—I  think within
forty-eight hours.
  Ill  Polypus.  One sort of polypus ofthe womb arises from the.
accidental  growth  of a fibro-cartilaginous tumour immediately
behind or near  the mucous lining of the uterus, whereby, as it grows,
it projects first  into  the cavity of the uterus, then into the vagina,
then externally. 
428
MAYO'S OUTLINES OF PATHOLOGY.
  Another resembles, except that it is firmer, polypus of the nose:
this kind has a light yellow tint, with a shade of green.
  Another tumour forms under the lining membrane of the uterus,
the structure of which is different from.that of either of the preceding.
It consists of a congeries of small vesicles or cysts, filled with a clear
yellowish coloured ropy fluid,  which cysts are imbedded in a  soft
fibrous substance situated under the lining membrane of the uterus.
  A fourth  variety of polypi  consists of  obstructed and enlarged
muciparous  follicles.  These are liable to form cysts, which some-
times attain  the size of an egg, and are attached to the cervix.
  The three first kinds of polypi  should be tied at their peduncle,
not too close to the uterus.  Mr. Beaumont, of Manchester Street,
has invented an excellent instrument for this purpose.  The last
probably require only to be punctured.
  Polypus ofthe uterus becomes dangerous through the serious and
repeated hemorrhages which it gives rise to.
  The cervix uteri is liable to chronic inflammation, through which
it becomes swollen and elongated.  It is likewise liable to ulcerate:
the ulceration spreading, destroys the cervix uteri, and extends  into
both the bladder and rectum.
  IV. Malignant disease.  The os uteri  is liable to scirrhus; or
the texture of the cervix or entire womb may become of cartilaginous
hardness : after which ulceration  commences at the cervix, leading
to the same  extent of destruction as the preceding case.
   Medullary sarcoma of the uterus is more frequent than scirrhus:
it generally commences at the cervix  uteri, a soft  fungus growing
from which is often for a time  the whole extent of the disease.
Afterwards the vagina and bladder become involved.
                         SECTION III.

                         The  Ovaries.

  The ovaries are liable to enlarge into ample cysts, containing a
thick, viscid, brown fluid, which commonly  occupies, not a simple
cavity, but a series of loculi, separated by soft membrane.
  The  ovaries  are  occasionally  the  seat  of fibro-cartilaginous
tumours, and of medullary sarcoma.
  This subject has occupied the attention of Dr. Seymour, who has
illustrated it by a series of beautiful engravings. 
THE UTERINE SYSTEM.                429
                        SECTION IV.

                   Extra-uterine Fatation.

  The embryo, when it does not reach the uterus, may be developed
either in the Fallopian tube, or in the ovary,  or in  the peritoneal
cavity.  In the first instance, the distended Fallopian tube ulcerates,
and fatal hemorrhage takes place about the sixth week.  In the two
latter, the foetus usually attains complete developement; but at the
expiration of nine months it dies.   An effort is then  made to throw
out the dead foetus.  This is sometimes attended with a favourable
result; the bones  either passing by the bowels, or through an abscess
pointing through  the walls of the abdomen. The process,  however,
is extremely slow, occupying many months ; and, in  the majority of
instances, the patient sinks under it.   It is  probable that the removal
of the foetus  might always be practised with safety,  the time being
properly chosen, in those cases in which the conception lies before
the bowels.
   In the following case,  a dead foetus  was removed with complete
success.  The statement, as it is  here printed, is taken from the
Medical Gazette for November 7, 1835 ; to which it was sent by Mr.
Hutchinson, of Farringdon Street, Blackfriar's Bridge, who had the
good  fortune  to bring to a successful termination  this important
case.
   "Mrs. J----. aetat. twenty-eight, living  at 5, Butcherhall Lane,of
an active disposition  and healthy  constitution, has been married
eleven years  without having borne a child, and was always perfectly
regular in regard to the catamenia until August 4, 1834, when that
discharge appeared for the last time.   In consequence of its suspen-
sion, she considered herself pregnant, and was confirmed in that
opinion as well by the declaration of the medical gentleman to whom
she applied for advice, as by her own feelings.  His statement was,
' that she had every symptom attendant on such occasions.'  From
the beginning of September she states, that the  breasts enlarged
considerably,  and that a milky fluid was secreted in such quantity
as to be readily squeezed out  on the application of pressure: the
areolae around the nipples also were  deeply  shaded.   Her person
enlarged more rapidly than  is usual in early pregnancy; so that by
the middle of September she  had  acquired considerable bulk.  It
was remarked that the  abdomen was  more prominent on the left
side than on the  right.   She now became the subject of occasional
spasmodic pains  in the back and the region ofthe stomach : and so
viojent were these attacks as  to produce syncope, and deprive her
of all consciousness while they lasted.  During the  month of October,
she believed  that she felt the movements of a child distinctly.   Her
increase in size  was regularly progressive : but so  quick, that she
was represented to have been as large by the end of January  as the
generality of women are at the full period of gestation.  After th 
430            MAYO'S OUTLINES OF PATHOLOGY
                                                     ft
month of December had passed, she felt the movements ofthe child
continually, and it seemed to become daily stronger: the enlargement
continued to be greatest on the left of the linea alba.   At the end of
April she was seized  with periodical uterine pains, attended with
much  expulsive effort.   She  then  considered herself  in  labour,
especially since (according to her own  calculation) the ninth month
of her pregnancy  had expired.   The pains continued for nearly
three weeks, accompanied with a discharge from the vagina of clear
fluid, sometimes mixed with blood, and at other times  assuming a
yellowish appearance, amounting altogether, she believes, to about
two quarts; and after the passage of two or three stringy substances,
they gradually subsided. She suffered at intervals, during this period,
great agony from the restlessness ofthe child ; after which it ceased
to move, and she has not felt it since.  Still, however, her abdomen
continued to enlarge, and  her  legs  became oedematous.  From the
latter  part of May, she gradually wasted; her breasts and lower
extremities shrank to less than half their former  dimensions :  her
appetite failed and general debility ensued. The size ofthe abdomen,
however, remained nearly stationary.
   "The preceding statement constitutes  the history and symptoms
of the case until the  14th June, 1835, when Mrs. J. first called at
my house.   The symptoms then present  were as follows :—She was
much emaciated, but her general aspect was not unhealthy.  Pulse
100 ; tongue clean ; bowels indolent, unless their action was excited
by purgatives.  Her sleep was sound, and appetite good ;   but  she
felt afraid of taking solid  food, in consequence of its producing pain
in the stomach  accompanied  with flatulence.  She  complained of
pain in the lower part ofthe back when  in the erect position, and a
dreadful sense of suffocation when recumbent.
   "  On an  examination  per  vaginam, that canal was found to be
shorter than natural, and its sides were compressed  by  the  pro-
trusion of a large tumour, occupying a portion ofthe pelvis between
it and the rectum.   The os uteri was  indistinctly felt, conveying to
the touch an impression  that the fundus was turned downwards
and  backwards,  and the mouth forced up behind the pubes.
   " I did not see the patient again till  July 8th.   I found her much
altered for the worse, and considerably more reduced than when the
former observations  were made.   The  pulse was now 115;  the
respiration laborious ; tongue dry and  furred ; there was a disagree-
able taste in the mouth, and the bowels were constipated ; there was
also  frequent vomiting of a white frothy fluid ; pain  in the back;
constant desire to pass urine which was  voided in small quantities,
and its evacuation  afforded  only temporary relief from the painful
sense of distention.  She suffered frequent forcing and bearing down
pains, with cramps in the legs; and her  nights were disturbed and
sleepless.
   " Dr. Ramsbotham visited her  with me on July 9th, the symp-
toms being then  as just described.  After examining the  tumour
externally, and by  the vagina, he was  of opinion that the case was 
THE UTERINE SYSTEM.
431
 one of ovarian disease, and that paracentesis abdominis ought to be
 adopted.
   Dr. F. H. Ramsbotham saw her, in company with his father,  on
 the 12th ; and from the distinct sense of fluctuation communicated
 to the hand on examining the abdomen, considered that there was
 ascites complicated with ovarian enlargement.  He  concurred in
 the propriety of letting out the fluid, and thought that as little time
 as  possible should be lost before the operation was performed.
   " On the  15th, in the presence of Dr. F. H. Ramsbotham, and Mr.
 Margetson,  I introduced a large-sized trocar through the abdominal
 parietes, in  the linea alba, about two inches above the umbilicus,
 where the tumour was most prominent.   About six pints of a thick,
 sizy,  chocolate-coloured fluid escaped, possessing  an unpleasant,
 though not highly fetid, odour.   This proceeding afforded  con-
 siderable and almost instantaneous relief to the suffocating sensations
 the patient had previously experienced.  On the discharge of the fluid
 Dr. F. H. Ramsbotham expressed surprise atits character, having been
 previously impressed with the conviction that it was contained  in
 the peritoneal cavity.   The aperture did  not heal, and a fluid con-
 tinued to be discharged  daily, which  at first resembled that let out
 by the trochar, but became by degrees more offensively fetid, until
 a fortnight after the operation, when  a small lock of foetal hair was
 observed in  it.   From this date pieces of the same kind of hair passed
 repeatedly,  as well as globules of oil, and  portions of putrid skin,
 with  some  membrane,  which was  described  by the patient  as
 resembling  foetal intestines,  and which could be drawn out by the
 fingers to a considerable length.   A  hard circumscribed substance
 could now be distinctly  felt  through  the abdominal parietes, in the
 left hypochondrium, evidently the head of a child, and  no doubt
 remained in the mind of either  Dr.  F. H. Ramsbotham or myself
 as  to the true nature  of the case.   She remained much in1 the
 same  state throughout August; but before the middle  of September
 all  the  symptoms  became  aggravated.   She suffered much from
 constitutional irritation ; the pulse rose to 120 : there was great thirst,
 and her appetite was impaired, which she attributed to  the offensive
 effluvia that arose  from  the putrid discharge.
  " On September the  21st  Dr. F. H. Ramsbotham again  met me,
 and I proposed making  an incision sufficiently large to remove the
 child.   To this measure he objected, thinking putrefaction had gone
 on  to  such an  extent that the body could not be extracted entire,
 and that Ihe frequent introduction of the hand would be required for
 the purpose  of emptying the cyst in  which it lay ; but he  thought
 it would be desirable to enlarge the aperture to the extent of an inch
 or two, that  the fluid might have a more ready exit,  and  that an
 opportunity  might be afforded us of examining more accurately the
 degree of decomposition  that had taken place.
  "Accordingly, on the  next day, in the presence of that gentleman
and Mr. Margetson, by means of a director and bistoury, 1 made an
incision about  two inches in  length downwards, below, and rather 
432
MAYO'S OUTLINES OF PATHOLOGY.
to the right of the umbilicus.  A small artery  was divided, the
hemorrhage from which,  however, was  easily checked  by gentle
pressure ;  a considerable quantity of fetid matter escaped.  The
finger could be introduced toils whole extent into the cyst, upwards,
downwards, and laterally; and it was  ascertained that tbe foetal
body still retained much greater firmness and solidity than had been
anticipated.   We were yet not perfectly  agreed as to the propriety
of extending the opening, and it was determined to seek the advice
of a consulting surgeon.   On the day after, therefore (Sept. 23d),
we obtained the  opinion  of Mr. Mayo ;  and as he concurred with
me, Dr. F. Ramsbotham  withdrew his objection, and it was agreed
that the body of the child should be removed without delay.  Besides
the gentlemen just named,  Mr. Margetson was  present, and his
opinion was also favourable for the operation.
   "The grounds upon which we resolved  to remove the dead foetus
were the following:—
   " 1st. The body had so much consistence and  firmness, that we
conjectured it would probably be several months  before it would be
sufficiently softened to come away piecemeal in the discharge ; but
the state ofthe mother's health was such, that we could not expect
her to hold out many weeks longer unrelieved.
   "2dly.  The original risk  arising from  opening the cavity of a
peritoneal  ovum was already got over, as far as  the irritation of
puncturing and admitting air into such a cavity could be prejudicial;
the operation had been tried, and had not  injured this patient.  A
freer opening might get  rid of the existing source of irritation in
the abdomen, but was not likely to add another.
   "3dly.  It was evident, from examination by the finger, that the
cyst enclosing the foetus lay before the bowels, and behind the
abdominal parietes ; and that the existing wound  might be enlarged
upwards and downwards in the direction ofthe linea alba, without
risk of  opening  the  peritoneal cavity, or dividing any part of the
reflected peritoneum, which was not adherent to the outer membranes
ofthe ovum.
   " The operation was performed in the following manner :—
   "I  enlarged the aperture both above and below, to the extent of
about five inches.  Mr. Mayo then introduced his  hand, and grasped
the left  upper extremity, which he brought out of the wound ; but
the transverse position of tho foetus prevented its being extracted by
that member; the arm  was therefore separated at  the shoulder.
The part  that was next  taken hold of was a foot; this was then
drawn out,  and  the trunk afterwards extracted without difficulty;
the head,  however, was too bulky to come away  entire, and on the
suggestion of Dr. F. H. Ramsbotham, the  cranium was punctured
with a scalpel in the lambdoidal suture ;  a  quantity of offensive gas
instantly escaped ;  the bones collapsed and passed readily.
   " The removal of the child was followed by a  flow of the same
kindof offensive, brown, putrid fluid, which we had before remarked.
The  funis  was  divided ; a  portion of it, with  some  membrane, 
THE UTERINE SYSTEM.
433
was  left  hanging  out  of the  wound.  Upon  gently  pulling the
maternal  end ofthe funis, the placenta was felt to be still adherent:
no attempt was therefore made to remove it.  The wound  was
dressed with a strip or two of  adhesive plaster, and poulticed, an
opening being left at the lower  part to allow the escape of the fluid
still within the cyst.
  " The  operation did not occupy much more than five minutes,
and  was  borne by the  patient with the greatest fortitude.   No
vessel was divided that required to be secured ; but a slight faint-
ness came on soon after its completion.   The foetus was as large
as an ordinary one at full time, and the cuticle was perfect except
on  the scalp, whence it had entirely separated, and over the verte-
brae and  the joints of the fingers and toes, which were denuded.
   "Sept.  24th.—Met  Mr. Mayo and  Dr. F. H. Ramsbotham, the
latter of  whom has continued to attend with me three or  four times
a week from this period.  She has passed a good night;  expresses
herself much relieved ; the countenance is cheerful; pulse 115, but
evidently excited by seeing  us.  There has been no rigor or sick-
ness; no  pain or tension on any part ofthe abdomen.   The bladder
 has acted two or three times;  one motion of a natural appearance
 has passed:  a  larger portion of membranes than was apparent
 yesterday is hanging out at the lower part of the wonud  : she com-
 plains of being hungry : the dressings were not disturbed.   It was
 not  thought  necessary to administer  any medicine; but she was
 allowed a little broth.
   "25th.—Another comfortable night; we found her eating some
 flounders.  Pulse 100, no pain,  and the bowels and bladder had acted.
 The fluid discharge  since yesterday  has been trifling;  but a con-
 siderable part ofthe placenta is offering itself at the aperture.  The
 whole of this  organ  was drawn away  most easily by a pair of
 forceps;   it was  perfectly putrid: the cellular web having  been
 entirely  destroyed, and the vessels separated from each other, hung
 down like strings.  It had the appearance, indeed, of having been
 a long  time macerated in water.  It was smaller than a uterine
 placenta.   About a  pint  of   fetid fluid followed  its extraction.
 Dressed  as before.
   " From this time she continued improving, the discharge varying
 daily from about  four to eight ounces, but  still very fetid in cha-
 racter.   Not a  single bad symptom  appeared until Oct.  2, when
 she complained of slight gastric uneasiness, which she attributed
 to  having eaten some"turnips.  To relieve this, a mild dose of the
 compound decoction of aloes  was administered: it produced, how-
 ever, so  much relaxation, that it was thought necessary to order an
 astringent.  The purging was soon checked, and she became again
 free from uneasiness.  "The wound is now very much contracted,
 and the  edo-es granulating:  she has sat up two or three times.  She
 continued Win to improve  till  the  8th, when she was attacked
 with constant pain  on the right side of the abdomen extending
 from the ribs to the spine of the ilium,  and the least pressure 
434           MAYO'S OUTLINES OF PATHOLOGY.

caused an aggravation ; there was also sympathetic fever. The dis-
charge from the wound  has  become changed,  both in colour  and
smell: it is yellowish, as though bile was mixed with it, and  pos-
sesses a  slight fecal  odour.   Pressure  on  the  right  side of the
abdomen produces an increase of discharge, and an evacuation of
gas:  the bowels continue to act naturally;  tbe size of the aperture
is much diminished.   Fomentations relieved the pain, and saline
medicines  seemed  to  allay the fever.  From  this date,  the  8th
October, the general  symptoms have remained much  the  same,
although upon the whole the aspect of the countenance  has  im-
proved ; the discharge has been occasionally fecal.  Upon our visit
yesterday we found her in good  spirits:  pulse 98, rather  small.
She sleeps well; her  appetite much improved.   The bowels have
acted daily once or twice.  At the  bottom, and on the edges of the
wound, healthy granulations  have sprung up,  which  have con-
tracted the opening to the size of about  half an inch.  The  dis-
charge consists almost  entirely of pus from the granulating surface,
and  that in moderate  quantity. The  flaccidity of the  abdominal
parietes,  consequent on  the extraction of the child, has, Oct.  26,
entirely disappeared; she has  been able to sit up, dressed, for two
or three hours every day, since Thursday last, without fatigue;  can
walk without pain, and she seems in a fair way to  be eventually
restored to health."
   March, 22, 1836—I am happy to add  to the preceding details,
that  this patient is now  perfectly well.  The wound  has  entirely
closed.  The periodical uterine secretion has returned.
THE END. 
CONTENTS.
 CHAP fL_. ..  ^he Bones,   .
         Reparation of Bone,
         Hypertrophy of Bone,
         Atrophy of Bone,
         Inflammation of Bone,
         Abscess in Bone,
         Necrosis,
         Caries,  ....
         Malignant growths of Bone,
         Hydatids in Bone,
 CHAPTER II.—The Joints,
         Synarthroses,
         Diarthroses,
         Diseases of Bursse Mucosae,
 CHAPTER III.—Voluntary Muscles and their
         The  Muscles,
         Affections of Tendons,
 CHAPTER IV.—Cellular  Membrane : Fasciae
         I. Cellular Membrane,
         II. Aponeuroses and Fascise,
         III. Adipose Tissue,
 CHAPTER V.—Of the Nerves,   .
         Ofthe Nerves as Organs ofConsci
 CHAPTER VI.—Of the Spinal Cord,    .
 CHAPTER VII.—Of the Enkephalon,
         Pathological Anatomy,   .
         Classes of Cerebral Disorders,
 CHAPTER VIII.—The Skin,   .
         I. Tumours, &c.
         II. Eruptions,
         III. Syphilitic and other Ulcers,
 CHAPTER IX.—The Digestive organs,
         § I. Tongue, &c.
         § II.  Pharynx,  .
         § Oesophagus,
         § III. Stomach,
         § IV. Duodenum,
         § Jejunum and Ileum,
         § V. Great Intestines,
         § VI. Peritoneum,
         § VII. Hernia,
         § VIII. Liver,  .
         § IX. Pancreas,
        § X. Spleen,
CHAPTER  X.—The Absorbent System,
CHAPTER  XL—Organs of the Circulation,
        § I. Capillaries,
         § II.  Veins,
        § III.  Arteries,
        § IV. Heart,
        § V. Blood,   .
Tendons,


 Adipose Tissue, 
vte.
436
CONTENTS.
CHAPTER XII.—Respiratory Organs,
        § I. Pleura,   .
        § II. The Lungs,
        § III. The Bronchi,
        § IV. Trachea,
        § V.  Larynx,
        § VI. Thyreoid Gland, &c.
CHAPTER XIII.—Urino-Genital System,
        § I.  Kidneys,
        § IT. Ureters,
        HH- Bladder,   .
        § IV. Prostate Gland,
        § V. Urethra,
        § VI. Testis,
CHAPTER  XIV. The Breast,   .
CHAPTER  XV. The  Uterine System,
        § I.  Urethra,  Vagina, &c.
        § II. Uterus,
        § TIL The Ovaries,
        § IV. Extra-uterine Foetation,
  N. B.—The numerical references in this volume are to specimens in the Museum of
King's College;  the small letters to preparations; the capitals to wax models.
Pa*
 35,
  ib.
 361
 370
 374
 375
 376
 377
 378
 391
 392
 399
 401
 405
 411
 425
  ib.
 426
 428
 429 
 
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