mamellonated, we are obliged to consider them the result of inflammation. If we refuse to do this, merely because some of the ordinary phenomena of simple acute gastritis are wanting, there is at once an end to all rational or positive conclusions. At the same time it must be admitted that the inflammation of the gastric mucous surface is a peculiar or specific inflammation; it is in some way modified by the general disease; it derives from the latter some special and unknown element, which does not exist in other forms of gastritis, whether these latter are primary or secondary.

Dr. Ashbel Smith concludes from his observations, that the softened, thickened, and mamellonated condition of the membrane is always preceded by an intense sanguineous engorgement, differing in its nature from inflammation, and resulting in the production of the matter of black vomit, and the lesions of the membrane which it precedes.1

Ulceration is of very rare occurrence. In regard to the volume of the stomach there is nothing constant: sometimes it is contracted, sometimes distended, and at others natural.

SEC. II.-Intestines. The mucous membrane of the small intestines is, in a considerable number of cases, quite natural throughout its whole extent; or it is the seat only of slight and unimportant alterations. Its thickness and consistence are rarely changed; in a certain proportion of cases there are patches or sections of redness, mostly within a few feet of the cæcum. Redness, softening, and thickening of the lining of the larger intestine are more frequent. Louis and Trousseau found universal softening in fourteen of twenty-three cases. The latter lesions are probably the result of inflammation. [Dr. Bache noted the appearance of the intestines in twelve cases. The mucous membrane of both the large and small intestines was variously discolored in most, red, or slate color, or purple, &c. It was marked with ecchymotic spots in the small intestines three times. There was no softening in any case, even in the colon, that he noticed, but in one there was a fibrinous patch at the sigmoid flexure, and in another the plates of Peyer were unusually distinct.]

The upper portion of the small intestine usually contains the same kind of reddish, brownish, or blackish matter that is found. in the stomach; and the same substance is found also in the large

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

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intestine.' It is thicker and more consistent especially in the large intestine than it is in the stomach. Pure blood has occasionally, though rarely, been found in both the stomach and bowels. The volume of the intestines is not often altered.

Louis and Trousseau found the epidermis which lines the oesophagus perfect in only five cases; in all the others it was more or less completely destroyed. Dr. Nott, of Mobile, thinks it probable that this destruction of the epidermis of the oesophagus depends upon the acid acridness of the matter of black vomit. [The condition of the oesophagus was noted by Dr. Bache in nine cases. The mucous membrane was injected in four, slate colored in one, spotted red in two, spotted and striped black in two, softened in one, partly divested of epithelium in all, and sphacelated (?) in one.]

SEC. III.-Liver. Since the publication of the researches of Louis and Trousseau upon the yellow fever of Gibraltar, in 1828, the attention of pathologists has been turned particularly to the condition of the liver in this disease; and the result of subsequent observations in regard to the state of this organ in periodical, or marsh fevers, has imparted to the subject new interest and importance. The following, I believe, is a full and fair summary of the present state of our knowledge in relation to this question.

Louis and Trousseau, in all the subjects examined by them at Gibraltar, found a very striking and uniform change in the color of the liver. They describe the liver as being sometimes of the color of fresh butter; sometimes of a straw color; sometimes of the color of coffee and milk; sometimes of a yellowish gum color, or a mustard color, and, finally, sometimes of an orange or pistachio color. "This discoloration," they say, "was not the same throughout the whole extent of the liver; more marked in the left than in the right lobe; it was also more uniform. In cases where the color was uniform in the left lobe, there was in the right lobe a mixture of gum yellow, orange, or red points, larger or smaller; or else we found in the right lobe a rose tint, which did not exist in the left lobe. The cases in which the color of the liver was formed by the mingling of different colored points were rare; and this disposition was somewhat remarkable in one of them, where the liver presented a mixture of yellow and green points. This change of color extended

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

2 Louis on Yellow Fever, p. 100, et seq.

3 Nott on Path. of Yellow Fever.

throughout the whole of the organ, in all but three cases; in these, it was limited to the left lobe, or to the left and a part of the right, the latter preserving its natural color throughout, or in its obtuse edge only."

"With the discoloration of the liver, are found a more or less marked paleness, and a diminished quantity of blood, so that wherever this appearance of the liver was well marked, the sections of it were dry, and of an arid appearance in the left lobe. This appearance reminded us at first of the greasy transformation of the liver, a transformation always accompanied by a softening, more or less marked. In the cases now under consideration, the cohesion of the liver was not at all diminished, even where the organ was of a clear coffee and milk color, or of a straw yellow, or of the color of sole leather." The cohesion of the liver, and the resistance of its tissue to the knife, or to the hand, on attempting to break it, were increased in five cases, and diminished in five others.

The singular change in the color of the liver, thus particularly and specially studied by Louis and Trousseau, is regarded by the former as the characteristic anatomical lesion of yellow fever-the only lesion constantly found after death from this disease. Louis's conclusion, so far as his own facts are concerned, and he carries it no further, is legitimate; but these facts were not sufficiently numerous and various, finally and definitively to determine the question. These facts were gathered in a single locality, and during the same epidemic season; and although analogies drawn from some other forms of fever, and especially from typhoid, might seem to favor the probability, or in some degree to justify the conclusion that this lesion of the liver would prove to be constant and characteristic, still, such analogies are never to be trusted, and the settlement of the question must be referred to further and more extensive observations. But before giving the results of these observations, so far as they have yet been made, it may not be wholly without interest to notice some of the allusions to the condition of the liver made by the older writers upon yellow fever; from which it appears that this change of color had not entirely escaped their notice, although they generally describe the organ as natural or congested, or corrupted, and so on. "Dr. Hume," says Dr. Rush, "in describing the yellow fever of Jamaica, informs us that, in several dead bodies which he opened, he found the liver enlarged and turbid with bile, and of a

Louis on Yellow Fever, p. 117, et seq.

pale yellow color." Dr. Chisholm made five autopsies, in the yellow fever of the West Indies, towards the close of the last century, and he describes the liver as being "of a color nearly approaching to buff, or a mixture of yellow and that of ashes." Arejula, in his account of the yellow fever of Cadiz, in 1800, says: "In many subjects the liver was enlarged, and its consistence so much altered as to appear as if it had been macerated; and this organ, as well as others, was found tinged of a different color, approaching to the hue between yellow and black." Dr. Rand and Dr. Warren, in their account of an autopsy made in Boston in 1798, describe the liver as appearing to be much inflamed, both on its convex and concave surface; its substance much indurated, and, on cutting, resembling in color a boded liver. Mr. John M'Colme, whom John Hunter calls a man of veracity and observation, and who served as a regimental surgeon in the West Indies, in the years 1741 and 1742, has given an account, in a letter to Sir John Pringle, of the appearances on dissection in the bodies of twenty-three officers and soldiers, who died with yellow fever. He begins his letter in these words: "In all the cases, the liver was changed in part, and sometimes almost the whole-to be more pale and hard than natural; and, in such parts, there was a less proportion of blood than in those of a more natural color."

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Dr. Burnett reports a case in which the substance of the liver was of a yellow color; and he quotes from Mr. Whitmarsh the account of two cases of the Gibraltar fever of 1813, in which the liver was found of an ash color."

Mr. Doughty has published, quite in detail, the appearances on dissection in eight cases, examined at Cadiz, in 1810. In some, the liver is called natural; in some, dark and engorged; in one, the color is described as between a light and dark yellow; and in one as a light yellow. Dr. Hume made some examinations before the middle of the last century. He says: "The liver, which is naturally of a dark red color, frequently appears on dissection in the yellow fever to be pale and yellow.”7

The observations of O'Halloran upon this point, made in 1821, are very interesting. In his first reported case, the liver is described as extremely yellow externally, hard and dense when cut into-the

flow of blood inconsiderable; in the second, the liver was yellow, hard, and deficient in blood; in the third, hard and yellow, without blood; in the fourth, thick, hard, compacted, dry, and pale, with no flow of blood when cut into, and crumbling between the fingers; in the fifth, pale externally, hard to the feel, internally destitute of blood, and gritty, so as to be easily crumbled into small pieces; in the sixth, large and hard, crumbling between the fingers; in the eighth, pale yellow externally, internally hard, destitute of blood, and easily broken into small pieces; and in the ninth, considerably enlarged, hard and yellow externally, internally destitute of blood, and easily crumbled. In three cases, it is described as either healthy or inflamed. He quotes a letter from Dr. Salvador Campany, who says: "The liver presented a saffron color, sometimes with obscure stains in its concave part."

Dr. Nott, of Mobile, in his interesting paper on the Pathology of Yellow Fever, describes the liver as it appeared in sixteen cases of the disease. Of eight cases examined during the epidemic of 1843, the livers in two only corresponded with the description of Louis, being pale, and when torn resembling very closely gingerbread, or new leather; in the six others, the liver was of a dark blue or a dark chocolate color, presenting different shades, and excessively engorged with blood. Of eight cases examined in 1844, the liver in four corresponded with the description of Louis; in two the color was a dark olive, and in two there was no alteration. Dr. Nott says, further, that he has twice met with the straw-colored liver after death from other diseases. [The inquiry arises here whether these organs described as "dark blue," "dark chocolate," "dark olive," &c., might not still have given evidence of the fatty degeneration soon to be described. These are the colors of remittent fever, and it has been already shown that this dark hue of the liver may remain for at least one or two years after recovery. Besides, in highly miasmatic regions, there is reason to suppose that the poison may produce some of these dark hues in the liver, without the full development of remittent symptoms, not to mention the recognized difficulty, in particular cases, of distinguishing between remittent and yellow fever. May not the liver in Dr. Nott's cases have been colored by the miasmatic influences common about Mobile, previous to the attack of yellow fever, so as to obscure or

O'Halloran on Yellow Fever, p. 186, et seq. 2 Amer. Journ. Med. Sci., April, 1845.