ARTICLE III.

LESIONS OF THE ABDOMINAL ORGANS.

SEC. I.-Stomach. The mucous membrane of the stomach is more or less altered in a pretty large proportion of cases. Louis and Trousseau found it of natural thickness, consistency, and aspect, with the exception only of slight changes of color in five, of twentythree cases; in the remainder it presented evident traces of previous inflammation. Its color was quite natural in only three cases; in several it was more or less deeply red, sometimes over its whole surface, and at others only over circumscribed portions; in eight cases, instead of a red color, there was an orange, or a slight rose tint, or a color of onion parings, varying in extent; in two cases there was a ruddy or bistre hue, and in two others the membrane was greenish or yellowish. The thickness of the membrane was natural in half the cases; in the other half the thickness was increased; in some universally, and in others partially. Its consistence was natural in only two subjects, in all the rest it was more or less diminished. The softening was general but moderate in five; partial and but rarely to a remarkable degree in the others, so that in no region, not even in the great cul-de-sac, was the membrane reduced to the consistence of mucus. Well marked and more or less extensive mamellonation was found in two-thirds of the subjects; and it is important to remark that this lesion was always accompanied by thickening, or softening of the membrane, or by both, and by alterations of its color. Dr. Ashbel Smith has published a history of the appearance of the abdominal organs in seven cases of yellow fever, occurring in Galveston, Texas, in 1839. He found the mucous membrane of the stomach of a whitish pearl color, much thickened and softened. In four cases, these lesions were limited to certain portions of the membrane, while the remaining portion, in the cardiac extremity, was the seat of a very intense, uniform, red injection, but was neither thickened nor softened.' Subsequent observations, by other physicians, have led to the same general results, in regard to the condition of the stomach. Dr. Josiah C. Nott, of Mobile, in sixteen cases, examined in 1843 and 1844, found the mucous coat of the stomach free from any appreciable change in seven; in the remaining nine it was more or less reddened, softened, thickened, and mamellonated."

'Amer. Journ. Med. Sci, Feb., 1840.

2 Ibid., April, 1845.

The contents of the stomach are thus minutely and particularly described by Louis. In four subjects, the stomach contained only a small quantity of flocculent mucus, or a little grayish, yellowish, or dark-colored liquid; in all the others, eighteen in number, the contents of the stomach were red, more or less inclining to black. This red or black matter varied in quantity, from four to twenty ounces; and its quantity was in proportion to the depth of the red color; the mean quantity where the color was bright red being nine ounces, and fourteen ounces where it was entirely black. The consistence of the red and the black matter was about the same; in some it was quite liquid, in others it was like porridge. It separated on standing into two portions; the upper more liquid than the lower, and of a bistre color; the lower less abundant, and formed as it were of blackish parcels.' [Dr. Bache found the material of black vomit, varying in color, dark, dark coffee color, dark chocolate, and dark green, in all his fourteen cases.] This matter of black vomit was formerly supposed to be derived principally from the liver, and to consist of vitiated bile, mixed with the fluids of the stomach. Dr. Rush says that he at one time believed this matter to consist of vitiated bile, but that subsequent dissections by Dr. Stewart and Dr. Physick, convinced him that it was derived from the stomach; although I find in the report of the dissections, made by Dr. Physick and Dr. Cathrall, and quoted by Dr. Rush, the black liquor found in the stomach and intestines referred to an altered secretion from the liver. This opinion is now, I think, generally if not universally abandoned; and it seems to me quite clear that the matter of black vomit consists of blood, mixed with the fluid secretions of the stomach, and derived directly from the mucous membrane. Dr. Nott, and Dr. P. H. Lewis, of Mobile, have made some interesting experiments for the purpose of ascertaining the nature of this substance. Dr. Nott believes it to consist of blood, exhaled in its natural state from the capillaries of the stomach, intestines, and even the bladder, and changed black by the secretions with which it comes in contact; this chemical change. being produced by one or more acids. He says that the matter of black vomit is always acid, turning litmus paper red; and he supposes that the acrid property of the liquid may depend upon the presence of these acids. Dr. Nott found, further, that the matter of black vomit can be very exactly imitated, by adding to a few

Louis on Yellow Fever, p. 79, et seq.

drachms of blood four or five drops of muriatic acid, and a little gum water, or flaxseed tea, to represent the mucus of the stomach. No one can distinguish, he says, the artificial from the natural black vomit; although he admits that the small coffee-grounds coagula are more difficult to imitate. A very small quantity of blood, he thinks, oozing gradually in a minutely divided form, and mingling slowly with the secretions of the mucous membrane of the stomach and bowels, will make a large quantity of black vomit.1 The opinion that the coloring matter of black vomit consists of blood, is strengthened by the fact that, in some instances, pure blood is found in the stomach. It is probable that, as a general rule, this matter is derived exclusively from the mucous surface of the stomach, and not from that of the intestines; although the observations of Louis lead to the conclusion that it may sometimes be furnished by the latter. It is important that a single additional remark should be made here. We have no right to assume that the appreciable inflammatory lesions of the stomach are the essential cause and condition of the presence of the matter of black vomit; and this for the obvious reason that the latter is not unfrequently found where the former do not exist. All that we can do in the present state of our knowledge is to refer the productions of this substance to some special but unascertained pathological action or condition of the mucous membrane of the stomach, or of the fluids of the body; or, as is more probably true, of both; the inflammatory lesions of the gastric mucous membrane being also one of the results or complications of this same action or condition.2

[The views here expressed regarding the nature of the black vomit are confirmed by the late chemical and microscopical study of that

Amer. Journ. Med. Sci., April, 1845.

2 The true character and origin of the matter of black vomit were clearly stated a long time ago. Dr. Bancroft quotes Dr. Henry Warren, who wrote on the yellow fever of Barbadoes, in 1740. Dr. Warren says: "I ought here to observe, that the fatal black stools and vomitings are vulgarly supposed to be only large quantities of black bile or choler, which false notion seems to be owing to that fixed unhappy prejudice that the fever is purely bilious. But let any one only dip in a bit of white linen cloth, he will soon be undeceived, and convinced that scarce anything but mortified blood is then voided, for the cloth will appear tinged of a deep bloody red, or purple, of which I have made many experiments."-Bancroft's Essay, p. 28. Sir John Pringle, Dr. John Hunter, and Sir Gilbert Blane, amongst others, entertained similar views. Mr. Pym says he is convinced that the matter of black vomit is blood in a dissolved state, poured forth from the small vessels, abraded by the separation or disease of the villous coat, and acted upon by the gastric fluid.

Prof.

fluid. Dr. La Roche has collected these recent observations. R. E. Rogers has furnished Dr. La Roche with an analysis of six specimens. He found in them all albumen; earthy phosphates; and iron; hydrochloric acid in a free state; and sulphuric acid, chlorine, and alkaline bases in a state of combination. All these substances, he remarks, except the hydrochloric acid, are constituents of the blood; and the albumen, the iron, and the sulphuric acid, he thinks, can have no other origin than the "altered blood." Dr. John Davy's "examination of a single specimen confirms the most important of these results. The specific gravity of four specimens examined by Prof. Rogers was, A, 1.010; B, 1.005; C, 1.004; and D, 1.003. One specimen, examined by Prof. Hume, which was remarkably black, had a specific gravity as high as 1.032.”

Both Dr. Davy and Dr. Blair noticed a considerable amount of muriate of ammonia in black vomit. The latter, finding how scanty the urea was apt to be in the urine during the advanced stages, was disappointed in his search for it in the vomit. The doctrine of Frerichs at length suggested the tests for ammonia, instead of those for urea and uric acid. Both liquor potassa and heat produced this gas in abundance. "The presence of ammonia in black vomit," he says, "is universal, that is, it has always been found when looked for, and may be considered one of its tests; while vomit also contains it in notable quantity." This elimination is regarded as vicarious, and however grave the lesions which produce the vomit, is considered one of the means of relieving the system from the equally grave uræmic poisoning.

The microscopical characters of black vomit, Dr. La Roche remarks, have been examined "by Dr. John Davy; Drs. Hayne and Michel, of Charleston; Dr. Riddell, of New Orleans, Dr. A. Clark, of New York; Dr. Hassell, of London; and, at my request, by Dr. Leidy of this, city" (Philadelphia). All but Hassell agree in ascribing the dark hue of the vomited matter to the presence of "altered blood." They find that the coloring substance exists in various forms; granules extremely minute, frequently aggregated in small masses; globules of all appreciable sizes less than the diameter of a blood disk, held by all to be blood corpuscles altered in size and form by the secretions of the stomach; and bodies having the size and shape of blood corpuscles (or only a little altered), some colorless, and some of a yellowish brown hue, the color not remov

1 [Am. Journ. of Med. Sci., July, 1854, and La Roche on Yellow Fever, vol. i. p. 314. ]

able by water and other fluids which promptly imbibe hematin from the unchanged blood. These substances are all supposed to have been derived directly from the blood. The granules, whether dif fused or clustered, are considered by the editor and by Prof. Leidy as in part the coloring matter of the blood, discharged from the corpuscles and converted into hematoïdine,' and in part the broken. down corpuscles. The brown coloring of the bodies which still retain the shape of blood-corpuscles, and of many which are dwarfed and globular, is believed to be due to the convertion of hematin into hematoïdine, within the capsule of the blood-cell, thus, so to speak, dyeing it indelibly. Some of the blood-corpuscles appear to be in a state of disintegration (Clark), or degradation (Leidy), thus becoming converted into granules of the same dark yellowish brown color as those formed from the hematin. Opaque black scales, having no uniform shape, and susceptible of fracture, were seen in some of the specimens, and were regarded by the editor as having the same origin as the brown material which chiefly gives color to the black vomit. Beside these essential constituents of black vomit, most observers notice epithelial cells both from the lining membrane, and from the crypts of the stomach, in greater or less abundance. These are colorless, and most of them highly granular. Their presence is thought to be important only when they are numerous. Then they probably indicate unusual vascular action. in the mucous lining of the stomach. Oil globules, crystallized margarine, and other remains of food also noticed, deserve no mention here. The same may probably be said of certain cryptogamous productions, which were discovered in some of the examinations. The variety of forms in the microscopic plants described, their entire absence in many specimens, and their evident production, after the vomit was exposed to the air in others, conspire to show that they are not essential constituents of this discharge.

Dr. Blair' has just published a letter addressed to Dr. John Davy, in which he states that he has detected hepatic cells in the matter vomited in yellow fever.]

As to the nature of these lesions of the stomach, it seems to me there can be no reasonable doubt. Where they are well marked, and especially where the membrane is reddened, softened, and

[For the nature of this hematoïdine, so far as it is known, see the section on the Bronze Liver in Remittent Fever.]

2 [Brit. For. Med.-Chir. Rev., July, 1856.]