cover the color-evidence of the real change? In this connection, the reader will do well to turn to Dr. Lewis's remarks (Chap. VI., Sect. I.), not known to the editor when the above was written. Both authors are writing of the disease of 1843 at Mobile.] Dr. John Harrison, in his Remarks on the Yellow Fever of New Orleans, says: "The liver sometimes contains less blood than we usually find in the viscus, and in those cases it is paler and drier than usual. At other times, however, it is engorged with blood, and bleeds freely when cut; but these appearances it is subject to in common with all the organs, and the existence of one or the other appears to depend much upon the condition of the patient at the time of the attack, and the treatment he has undergone. In cases where the lancet has been used freely, we shall generally find a pale yellow liver." The interests of science not only justify here, as in all similar circumstances, but they demand a single criticism. Where results merely are given-and these only in general terms— where cases of disease are observed in a hospital by extensive practitioners, constantly and busily occupied with their private practice, and where these cases are not reported in detail, there must inevitably occur, and this not unfrequently, errors of diagnosis. That this error was sometimes committed in the Charity Hospital, no one can for a moment doubt who reads the following statement by Dr. Harrison. He says: "In some cases of a low typhoid type, in which there existed before death a low nervous delirium, we found sometimes ulceration, and at others hypertrophy and softening of Peyer's glands." These were unquestionably cases of true typhoid fever; such, at any rate, is the conclusion which, in the absence of any detailed histories of the cases themselves, we are justified in adopting; and if, under such circumstances, cases of typhoid fever could be confounded with those of yellow fever, how much more readily might this happen with the more closely allied forms of periodical fever, bilious remittent, and congestive? In the Gibraltar epidemic of 1828, a case was reported to Louis by Mr. Frazer as one of yellow fever, where the yellow liver was wanting, and in which there was ulceration of Peyer's glands. A careful study of the case shows manifestly that there had been an error of diagnosis, and that the disease was typhoid, and not yellow fever.3 In regard to the causes and nature of this peculiar condition of the IN. O. Med. and Surg. Journ., vol. ii. p. 138. 2 Ibid., p. 139. liver, it is quite idle to speculate. We can only call it peculiar or special, and plainly and frankly admit that we know little more about it. Clearly enough, it is neither inflammatory nor congestive, and this is about as far as we can go. It constitutes one of the pathological elements-a very common, though not a constant one—in a specific disease, the result of a specific cause, the nature and action of which are yet hidden in absolute darkness. Dr. Richard D. Arnold, of Savannah, has reported a case of yellow fever in the American Journal of the Medical Sciences, for October, 1842. The liver was pale and ash-colored on its entire surface, and throughout its whole structure; and it was very destitute of blood. Dr. Arnold says: "Dr. Waring, in 1827, pointed out to me, in the dead body, as the peculiar characteristics of yellow fever, the pale appearance of the liver, its deficiency of blood, amounting to a comparative dryness, and the entire absence of all biliary secretion. Dr. Barrington, in his account of yellow fever on board United States vessels in and near the Gulf of Mexico, in 1828, 1829, and 1830, speaks of the liver in two cases as of a light color.1 Dr. Ashbel Smith made seven autopsies at Galveston, Texas, in 1839. In three cases, the liver was of a very light drab color, externally and internally, and destitute of blood; in one, of a dark claret color, and congested with blood; in the others, of its usual appearance, and containing a moderate quantity of blood. In all cases, there appeared to be a suspension of the biliary secretion; no bile could be squeezed from the substance of the liver. M. Catel says there were one hundred and fifty yellow fever autopsies, at the Hospital of St. Pierre, in Martinique, between October, 1838, and September, 1839; and that the liver was always deprived of its color-décoloré-and yellow; and the gall-bladder generally empty.3 [The liver in Dr. Bache's fourteen cases had more or less markedly the yellow color in all. "Its internal structure was of gamboge color in one; mottled yellow and orange red in twelve, and pale yellow in one." On the exterior it was more or less yellow in every case, but this color was associated with purple, and brown, each in one; with ecchymotic spots in one; with bronze in two; with red in seven, and was unmixed yellow of different shades in the remaining two. The bronze color in these cases appears to 1 Amer. Journ. Mel. Sci., Aug., 1833. Rapport, &c. Par N. Chervin, p. 12. 2 Ibid., Feb., 1840. have been on the "inferior surface" and "anterior portion;" and as the interior structure was yellow, this must have been the common surface-stain, from the intestinal gases. The size of the liver is reported normal in twelve, large in one, and small in one; the consistence natural in thirteen, and soft in one. Congestion of the hepatic venous system was present in two, and absent in two; of the portal vein, present in three, and absent in two; the condition of the veins in the others is not mentioned. The hepatic ducts contained bile in two. Dr. Blair gives no details of his hundred post-mortem examinations, but has evidently seen "the dark purple, or slate color" after yellow fever. He speaks also of the "yellow condition of the enlarged liver," remarking: "It is no doubt true that the liver is often found dry and anæmic, from having been drained by hemorrhage, and from vital or physical determination to some neighboring organ" (or, the editor would add, from the mechanical obstruction of the oil accumulated in its tissue); and he asks: "Of what does this yellow or ochre enlargement consist ?" The answer to this question will be found in the next paragraph. Here it is only necessary to add, that the slate color of the liver seen after yellow fever, in Demerara, eminently a miasmatic country, confirms the conjecture just hazarded regarding Dr. Nott's cases. What causes the yellow color of the liver in yellow fever? Dr. Blair himself came very near answering the question; for he says: "I have found that, in these cases, a small portion of the parenchyma scraped off, and submitted to the microscope, showed an abundance of oil-globules." In the N. Y. Med. Times, May, 1853, the editor has recorded the result of an examination made by him in the latter part of 1852. The liver was one in which the yellow color was well marked. It was not, however, materially enlarged; and on close examination the lobules of Kiernan could still be distinguished on its surface and section, by the minute vessels which surrounded them. The marked change in its structure, demonstrated by the microscope, was a fatty state of all the secreting tube-cells, and such an abundance of free oil-globules, of large and small size, as to cover and obscure every thin section which was made of the liver. The whole hepatic tissue was thoroughly infiltrated with oily matter; and scarcely a cell could be seen that was not literally loaded with these globules. The condition of the cells was in all respects identical with that observed in extreme fatty degeneration, in its chronic form; but the oil infiltrated into the general hepatic tissue exceeded greatly that ordinarily noticed in chronic fatty liver. The paper concludes with the question: "Is not the change so constantly observed in the livers of those dying of yellow fever, an acute fatty degeneration?" Dr. La Roche, in his unparalleled book on Yellow Fever, after referring to the fact that he witnessed and confirmed some of the observations, on which this inquiry was founded, says (p. 404, vol. i.): "Scarcely a few months had elapsed when we had in this city (Philadelphia), the fullest opportunity of confirming these observations; for in all the examinations made during the epidemic of 1853, the peculiar change to which he (Dr. Clark) called attention, was discovered." These examinations were fourteen at the Pennsylvania Hospital, and several at other hospitals. To these he adds six observed the succeeding year, and remarks that, "in every instance, without a single exception, in both seasons, the result was the same." The observers were Professor Leidy, in nine cases; Dr. T. H. Bache and his hospital associates in fourteen cases already cited, and in several others to which Dr. Bache refers in his paper (Am. Journ. of Med. Sci.), as among the victims of yellow fever not admitted into the hospital; and Dr. La Roche himself. Dr. Riddell, of New Orleans, however states, with "opportunities of examining about fifty human yellow fever livers," that "fatty degeneration, well marked, occasionally appears, but not constantly." -(La Roche, vol. i. p. 406.) These statements render it at least highly probable that the cause of the yellow color in the yellow fever liver, is an extraordinary and rapid deposit of oil in the cells and tissue. But the most important question is still to be answered: "What is the state of the system, and of the liver which causes this deposit ? Conjecture may be based on analogy; conclusions require the broader foundation of direct observation, or positive proofs. Analogy in this case suggests, that a main exciting cause of the oily deposit, is a hyperæmic state of the organ during the fever. The chronic fatty disease in the drunkard's liver, is supposed to depend on the irritating effects of the alcohol in the capillaries of the organ; and the enlargement which attends this degeneration will hardly admit of explanation, if hyperæmia, in some form, be not assumed. True cirrhosis, involving Glisson's capsule, implies a moderate. inflammatory hyperæmia, and this is always attended by free deposit of fat in the hepatic cells; while atrophy from the contraction. of false membrane investing the liver, leaves the cells free from any unnatural accumulation of this substance. Metastatic and single abscesses of the liver, are marked by fatty degeneration of the neighboring cells. Fatty degeneration of the kidneys, in albuminuria, occurs after congestive, perhaps, inflammatory hyperæmia of those viscera. Inflammatory softening of the cerebral, spinal, and nerve matter, is attended by an abundant deposit of oil-globules. These, and many similar facts, seem to establish a general relation between hyperemia and morbid oily deposits, that is suggestive in the present inquiry. Dr. Blair, in summing up two thousand and six cases of the first fourteen months of his second epidemic in Demerara, expresses a confident opinion that an active hyperæmia really exists. He says: "On the liver there seems to have been induced an irritant effect. The suppression of bile in the last stage, had always been preceded by an erethism of that organ-as indicated by the copious secretion of bile-and there was frequently tenderness toward the right side, in the early stage, before it could be occasioned, as it no doubt is, in the last stages, by the distension of the capsule. The kidneys and lungs, therefore, seemed to suffer passively, while the liver suffered from active congestion." Congestion is really found after death, in many cases, and in some enlargement; while an anæmic state of the organ at the autopsy, as has been already said in this note, is no evidence that hyperemia has not existed, even to a late period during life. But still, again, supposing congestion or hyperæmia, in some form, were admitted, there are nearly the same reasons for appealing to a similar condition, to account for the deposit of hematoïdin in the bronze liver of remittent fever. In the latter, there is a deposit of oil in the cells, as in the yellow fever liver, though the quantity is notably less. If in one case hyperemia produces hematoïdin, and a moderate amount of oil; and in the other, a large amount of oil, and little or no hematoïdin, there must be still other agents at work to produce a difference so nearly constant. These may, perhaps, be found in the yet undiscovered changes which the different poisons of remittent and yellow fever effect in the blood itself.] SEC. IV. Gall-bladder and its Contents. Most of the older observers, and some few amongst the moderns, describe the contents of the gall-bladder as nearly or quite natural. Thus, Dr. Physick and Dr. Cathrall, in their account of "several dissections," made in Philadelphia, in 1793, say that the bile in the gall-bladder was quite of its natural color, though very viscid; and Dr. Harrison, in his account of the yellow fever of New Orleans says that the gallbladder in most cases contains its usual quantity of bile, which is |