PART THIRD.

Original Communications.

ART. I.

Pathological Report of the Middlesex Hospital; being un Analysis of the Principal Morbid Appearances observed in 180 Post-Mortem Examinations, from the 1st October, 1855, to the 1st October, 1856, By PHILIP J. VAN DER BYL, M.D. Edin., Licentiate of the Royal College of Physicians, Lecturer on Histology at the Middlesex Hospital, &c.

DURING the first year that I conducted the post-mortem examinations at the Middlesex Hospital, 180 cases were examined. Of these, 98 were males and 82 females. The chief object of this report is to exhibit the relative frequency of the principal morbid appearances observed, and the connexion of individual diseases with certain morbid conditions. In the general index which I have made to our postmortem register, every morbid appearance is entered, and under each heading are placed numbers referring to the cases in which that particular lesion occurred. From this index the headings and the numbers of the cases are taken, so as to exhibit the occurrence of individual morbid appearances, not of separate cases of fatal disease. Thus, for example, one fatal case may be noted in three, four, or five different places, according to the number of well-marked lesions it exhibited. The arrangement is entirely anatomical, that is, founded on the physical changes observed in the organs; and not nosological, or having reference to symptoms, causes, &c. Remarks, in the shape of short notes, have been made upon most of the headings, and these doubtless might be extended; but being limited in space, I was obliged to confine my remarks only to a very brief statement of facts, and must defer for the present all deductions. In a practical point of view, the usefulness of a pathological report would probably be much increased by giving a brief history of the cases before death; but this plan was abandoned by me, as it was thought that even a very brief notice of this kind would detract from the interest of a nosological report at present in course of preparation by our medical and surgical registrars.*

After stating the number of cases under each heading, I have given the post-mortem register number of each case. I resolved upon doing so, because these numbers really occupy very little space, and an opportunity is thus afforded of tracing the relations of diseases beyond what I have done, and of satisfying one's self as to the existence of certain morbid conditions along with any particular disease. Thus, for ex* I wish to acknowledge my obligations to Mr. Balding for his kind assistance on many occasions.

ample, the numbers under adherent pericardium will show in which cases there was hypertrophy of the heart; the numbers under fatty heart will show in which cases there was granular disease of the kidneys, and so forth. References have been given to all cases or specimens of which any account has been published; also to those specimens which are preserved in the museum of the hospital. arranged my present materials under fourteen sections-viz.,

I have

1. Brain and its Membranes. 2. Spinal Cord, its Membranes, and the Nerves. 3. Heart and Pericardium. 4. Blood vessels. 5. Air

passages, Lungs, and Pleuræ. 6. Alimentary Canal. 7. Liver, Gallbladder, and Biliary Ducts. 8. Spleen. 9. Kidneys and Urinary Passages. 10. Genital Organs and Mammary Glands. 11. Lymphatic and Lacteal Glands. 13. Bones and Joints. 14. External Appearances, Skin, &c.

I. BRAIN AND ITS MEMBRANES.

1. Cancer of Dura Mater, communicated from Cranial Bones, 2 cases: Nos. 480, 498.-In Case 480 (a man aged forty-five) the cancerous growth commenced in the antrum, and extended to the base of the skull and the bones of the forehead and face, and thence to the dura mater. The bones forming the anterior half of the base of the skull, and the other bones just named, also the petrous portion of the temporal bone, were quite soft, and easily cut with the knife. In the antrum and sphenoidal sinuses, the cancer presented an exuberant nodular appearance. On squeezing sections of this growth, it yielded a thick creamy stuff, which contained many compound nucleated cells. The anterior half of the dura mater on the right side was about half an inch thick, and presented a uniform firm medullary appearance. Some juice scraped from this part exhibited large compound nucleated cells, with several nuclei. The internal surface of the base of the skull was comparatively smooth; the brain was not affected, but there was much sub-arachnoid serous effusion.-In Case 498 (a man aged twentyeight), the primary disease was scirrhous cancer of the liver, which weighed twelve pounds. (See VII. 5.) There was cancer of the spleen, lung, and lumbar vertebra; a cancerous tumour about the size of two fists involved the upper part of the sternum, the half of it projected into the chest. It was firm, nodulated, and elastic, exhibiting a radiating fibrous appearance on section; a similar tumour, about the size of half an orange, was situated over the occipital bone, and sent long spiculæ inwards, which involved the dura mater, below the left lateral sinus, in the growth, and produced yellow softening of the brain and breaking up of the cerebellum. The lower half of the humerus was surrounded by cancerous growth.-Museum, V. 2, IV. 36d, 43b.

2. Osseous Growth in Falx Cerebri, 1 case: No. 463.-A man aged thirty-five, who died of phthisis and tubercular meningitis. The growth measures an inch and a half long, half an inch broad, and about a quarter of an inch thick; it is situated in the lower border of the falx cerebri, near its anterior extremity, and presents a nodulated surface with thin edges (Museum, V. 1°.) This man had a diverticulum of the intestine. (See VI. 13.)

3. Laceration of Dura Mater and of Brain, 2 cases: Nos. 518, 521. Both these occurred in cases of fracture of the skull.

4. Congestion of Membranes of Brain, 9 cases: Nos. 387, 391, 455, 461, 493, 527, 530, 534, 541.-Of these, 2 were cases of typhus, 2 typhoid fever, 1 cerebral hæmorrhage, 1 tubercular meningitis, 1 erysipelas of the head, 1"congestive apoplexy," with great serous effusion beneath the arachnoid, and 1 cerebral hemorrhage and softening of brain.

5. Excess of Serum beneath Arachnoid, 14 cases: Nos. 384, 395, 405, 419, 436, 447, 449, 460, 461, 470, 480, 483, 523, 541.-These occurred as follows: in typhus 2, typhoid fever 1, erysipelas 1, carditis and softening of brain 1, hypertrophy of heart 2, drowning 1, tubercular peritonitis 1, chronic hydrocephalus 1, "congestive apoplexy" 1, cancer of antrum and dura-mater 1.

6. Excess of Serum in Ventricles of Brain, 10 cases: Nos. 384, 387, 405, 410, 419, 460, 483, 523, 527, 531.-In Case 483, a man aged sixty, who died of chronic hydrocephalus, the lining membrane of the ventricles presented a dotted appearance; in the anterior part of the ventricles, this punctated appearance was most distinct, and a few specks of lymph were seen; about three drachms of turbid serum were contained in each ventricle. There was softening of the septum lucidum and of the anterior boundary of the left ventricle.-In Case 410, a woman aged fifty-three, the convolutions of the cerebrum were very much flattened and very pale; the lateral ventricles were much enlarged, and contained six ounces of clear serous fluid. This woman had aneurism of the basilar artery, (See I. 16)-Museum, V.

7. Opacity of Arachnoid, 8 cases: Nos. 436, 445, 449, 456, 461, 480, 483, 498.

8. Effusion of Lymph beneath Arachnoid, with Tubercles in Pia Mater, 3 cases: Nos. 463, 492, 530.-These occurred with tubercle of the lungs and softening of the brain in Case 463; with tubercle of the lungs, tubercular peritonitis, and tubercular ulceration of the intestines in Case 492; and with Tubercle in the bronchial glands (not in the lungs) in Case 530.

9. Cysts in Choroid Plexus, 1 case: No. 489.

10. Cerebral Hæmorrhage ("Apoplexy") 3 cases: Nos. 387, 410, 493.-In Case 387, with aneurism of posterior cerebral artery; in Case 410, with aneurism of the basilar artery; and in Case 493, the hæmorrhage was in the substance of the pons Varolii, and filled the fourth ventricle.

11. Hæmorrhagic Spots in the Pineal Body, 1 case: No. 461.This occurred in a woman aged twenty-four, who died of typhoid fever. The Pineal gland was twice the usual size, and was marked by five or six hæmorrhagic spots the size of a pin's head. (See VII. 19.) 12. Softening of Brain, 9 Cases. Red, 5: Nos. 463, 483, 493, 530, 531. Yellow, 4: Nos. 387, 419, 498, 505.

13. Disease of Cerebral Arteries, 1 case: No. 436.-A man aged twenty-five. The large arteries at the base of the brain exhibited thick fibroid patches, which on section were found to project into the vessels, and at some places nearly to obliterate the anterior and middle cerebral arteries.

14. Calcification of Minute Cerebral Arteries, 1 case: No. 505.— A man aged fifty-four. When the upper portion of the cerebral hemispheres was sliced off, only a few bloody points were seen in each centrum ovale, but numerous sharp points projected from the surface, like very short bristles. These on being seized with a forceps and drawn out, were found to be calcified vessels, which were quite rigid, and were easily broken up into several pieces by slight pressure. They were rather tortuous, and generally not half so thick as a pin. At the anterior part of the left hemisphere was a small patch of yellow softening.

15. Obstruction of Middle Cerebral Artery by a Fibrinous Plug, 2 cases: Nos. 413, 419.-Case 413, a woman aged thirty-seven, suffering from cancer of the uterus, was seized with a pain in the left temporal region, which lasted half an hour; she then suddenly lost the use of her right side, but retained her consciousness; she was able to move the mouth, but could not speak for eight days. She became quite listless, and died twenty-two days after the sudden headache and paraplegia. The middle cerebral artery was obstructed at its very origin by a triangular-shaped fibrinous plug, its greatest length being about a quarter of an inch. About an inch from its origin, where a large branch was given off, another little plug was found; the trunk of the artery beyond this was filled with a slightly-coloured fibrinous clot, nearly half an inch long, which was connected with the little plug, but presented a less dense appearance. The space between the two plugs was empty, and there was no adherent lymph about the arteries involved. The substance of the brain felt rather flabby, but was not softened. The heart was flabby and enlarged; warty vegetations, the size of peas, were found on the aortic and mitral valves; they were rough, pointed, and not very adherent. The spleen presented three or four purulent spots, and adherent lymph occurred in the iliac veins from the pressure of a cancerous growth of the uterus and lumbar glands.*

In Case 419 (a female, aged sixteen), partial obstruction of the left middle central artery occurred along with fibrinous deposits in the spleen and kidneys. A thin fibrinous clot, not nearly filling the vessel, was found to run from its origin for about one inch and a-half; here the artery bifurcated, and a dark black clot filled and plugged up the two branches; on tracing these two branches, they were found to proceed to a depressed, softened patch, about the size of a crown-piece, situated near the middle of the external surface of the left hemisphere. The heart weighed nineteen ounces; the valves were healthy, but the lining membrane of the left auricle was thickened, and covered by fibrinous layers, which could be peeled off. The axillary and left common femoral arteries were found plugged by fibrinous coagula about one inch long, which were adherent to the lining membrane, and of a reddish-yellow colour. It appears doubtful whether the obstruction in any of the arteries was produced by fibrinous particles carried direct from the heart, and it seems altogether more probable that the blood was, as it were, overcharged with fibrin, that a spontaneous coagula

For sketch of the artery and further particulars by the author, see Transactions of Pathological Society, vol. vii. p. 118.

tion took place in the larger as well as in the smaller arteries, and that this was followed by decoloration of the clots. The axillary and femoral arteries may also have been more or less inflamed at the points where the coagula were situated.

This patient was first seized with a pain in the head and face, and a few days after she awoke in the morning and found she had lost all power in the right hand and arm, and could only drag her right leg along the ground. She had also lost her voice, but was not aware that she had any kind of a fit; her mental powers seemed entire.-For ticulars see Trans. of Pathological Society,' vol. vii. p. 168.

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16. Aneurism of Cerebral Arteries, 2 cases: Nos. 387, 410.-Case 387, aneurism of the posterior cerebral artery occurred in a man aged fifty-six. The tumour was about the size of an egg, and was situated in the posterior part of the right ventricle; the surrounding brain-substance was softened. On section the tumour presented a laminated appearance, the sac was thick and firm, the opening into the vessel distinct (Museum V. 35).-Case 410, aneurism of the basilar artery occurred in a woman aged fifty-three, who died of rupture of the aneurism. There was a considerable amount of coagulated blood around the pons Varolii, and at the base of the brain. The aneurism was about the size of a hazel-nut. The lateral ventricles were very large, and contained six ounces of serum (Museum V. 36).*

II. SPINAL CORD, ITS MEMBRANES, AND THE NERVES.

1. Softening of Spinal Cord, 2 cases: Nos. 452, 483. 2. Spinal Arachnitis, 1 case: No. 511.

3. Cancer of Phrenic Nerve, 1 case: No. 425.-This occurred in a case of cancer of the breast; the disease extended inwards, and involved the pleura and pericardium, and a few cancerous nodules were seated upon the phrenic nerve in its course across the pericardium. (See XI. 6.)

III. HEART AND PERICARDIUM.

1. Serous Effusion into Pericardium (Hydropericardium), 4 cases : Nos. 387, 417, 420, 537.-In Case 420 there were ten ounces of turbid fluid in the pericardium, and the heart weighed twenty-six ounces.

2. Serous Effusion with recent Lymph in Pericardium (Pericarditis), 12 cases: Nos. 395, 398, 412, 419, 426, 450, 458, 459, 470, 498, 513, 516.-In Case 513 only is it noted that the patient had acute rheumatism.

3. Adherent Pericardium, 7 cases: Nos. 393, 407, 426, 484, 506, 513, 550.

4. Cancer of Pericardium, 2 cases: Nos. 425, 431.-In both cases the cancer was propagated from the breast, and also involved the pleura. 5. White Patches on Heart, 18 (well-marked) cases: Nos. 387, 389, 395, 411, 412, 423, 425, 426, 433, 435, 449, 473, 482, 491, 512, 516, 537, 547.

6. Thickening and Opacity of Endocardium, 2 cases: Nos. 389, 546.

These two cases are more fully described by the author, in the Transactions of the Pathological Society, vol. vii. pp. 122 and 129.