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stage was severe and prolonged, the quantity of blood was often large, and so intimately mixed with the masses of shreds and flocculi as to give the evacuations a remarkable appearance, especially when the amount of fluid was small.

5th. Columnar and scaly epithelium, rarely to any amount, and even generally not readily discoverable. On this point our investigations confirm the observations recorded by Dr. Parkes* in opposition to those of Böhm during the last epidemic, and whose accurate descriptions apply rather to the contents of the intestines after death, than to the evacuations during life.

6th. On evaporation by exposure to the air, a large number of crystals of chloride of sodium in cubes and octohedra, and occasionally also some crystals of urate of ammonia and urate of soda, and, when decomposition had commenced, prisms of triple phosphate.

The state of the spleen is noted in 23 cases fatal in the Spleen. algide stage. Of these, in 3 it was of the natural size, in 18 it was small, or very small; namely, in 2 it weighed but two ounces, in 2 others two ounces and a half, and in 3 three ounces, &c. In most cases there was no obvious change in the tissue, beyond that arising from a want of blood, giving its capsule rather a wrinkled appearance, and enabling it to resist laceration, the texture being often described as pale, firm, and dry. Of the above 23 cases, in one the tissue was mottled by effusions of blood, and by dark red congested portions; and in one only is it stated that the white corpuscles were distinct.

Niemeyer found the spleen small, flaccid, and bloodless in 19 out of 20 cases, the exception occurring in a person who had ague. According to Reinhardt and Leubuscher, "The spleen presented no constant change in respect to volume; sometimes, particularly in old persons, it was very small, but in the majority of cases it was normal in size. There were cases in which it was very notably increased. . . . . The capsule was sometimes, especially in children and young individuals, smooth and distended, but for the most part it was more or less wrinkled. The tissue was normal in color and consistence, the white corpuscles in most cases distinct. In one instance where the spleen was of very large size, they were equal to bemp-seeds, of a yellowish white color, and of such consistence as to admit of isolation from the surrounding splenic tissue. . . . In those who

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Op. Cit., P. 495.

died in the cold stage, it was not rare to find spots of hyperæmia and solid exudation, of a reddish brown, or blueish red color from extravasated blood. These masses (hæmorrhagic infarctions) were of different sizes, from a hazel nut upwards. Under the microscope they presented amorphons fibrin and blood corpuscles... In the later stages of the discase these infarctions were either in the condition here described, or were more or less changed as follows: they commonly retained their consistence, but lost their color, becoming yellowish red or yellow. Not rarely the exuded matters, after losing their color, softened, to a variable extent, into a greasy puriform mass from a detritus of broken up fibrin and blood corpuscles. In one instance these nodulated masses were very firm, compact, dry, and obviously contracted, the surface of the spleen over them being drawn in."

Briquet and Mignot report as follows:-" The spleen is mentioned in 25 of our observations;-seven times we noted a slight ramollissement, and six times it seemed voluminous, and perhaps hypertrophied. In the other cases there was on the contrary a state of atrophy (?) the organ being shrivelled like the surface of a fruit when the juices have evaporated. The consistence of the splenic tissue was increased; it had a tint of lighter red disposed in patches of irregular size upon a violet ground. In one subject there were spots of apoplexy."

Rület found enlargement of the spleen only twice in 16 postmortem examinations.

Leudet says, "The spleen was generally small, the mean length was 123 centimetres (4.8 inches), the breadth 73 millimetres (2.8 inches), and the thickness 13 millimetres (inch). I generally found the tissue firm, exsanguine, and tough. Sometimes the corpuscles of Malpighi were apparent. In only one case was there interstitial apoplexy."

In a report of 70 cases examined by Virchow he states that he arrived at no definite results as to the morbid changes in the spleen. He found acute enlargement of this organ in so many instances, and under such variable circumstances, that he could not refer it to mere accident. During life he had repeatedly, by percussion, been able to determine that it was decidedly enlarged; and in some cases patients had complained of pain in the left side. In old persons no enlargeOp. Cit., p. 410. + Medicin. Reform, No. 15.

Ibid., No. 10.

ment was ever observed; but in almost all other cases the spleen was so flaccid and shrivelled that one was obliged to admit a previous enlargement, or rather so recent and rapid a reduction of volume, that the capsule had not yet accommodated itself. The change of color in the tissue, from altered blood, led him to infer a previous hyperæmia.

After death, in the algide stage, the liver was generally diLiver. minished in bulk, the tissue flaccid, and the capsule finely wrinkled. The larger veins, both the hepatic and the portal, but especially the latter, were often full of dark viscid blood. The lobular appearance of the secreting structure was indistinct, and the whole tissue of rather a lighter red than usual. Exceptions were not, however, wanting to this general rule; thus in a male, æt. 25, who died in collapse, after severe symptoms of 21 hours' duration, the liver was of the natural size, but very full of blood; its structure distinct, firm, and of a dark color. In another case, a girl aged 8, who died very rapidly, the whole duration of the attack not being more than nine hours, "the hepatic tissue was dark on section, with much blood in the large vessels, especially in the hepatic veins. Injection around some of the lobules, apparently portal." In a third case, a male aged 34, who died after about 20 hours of acute symptoms, the liver is reported to have been of natural size and structure, with some dark parts in which the centres of the lobules were black with blood.

The secreting structure on a microscopical examination presented nothing abnormal.

Briquet and Mignot report as follows:-"In general the parenchyma of the liver appeared reduced, rather than increased in volume. On section but a very small quantity of blood escaped from the tissue; this chiefly depended upon its coagulation and density. In 8 cases out of 32, a certain degree of venous congestion was obvious, from the violet tint of the hepatic tissue."

According to Reinhardt and Leubuschert, "The liver was, in the first stage of the disease, devoid of blood. . . . . The consistence of the parenchyma was normal. It was pale yellow, or yellowish brown; and the so-called red substance either not at all, or only faintly visible. In the latter stages of the disease this became again evident, and the liver was dark and more full of blood than usual.” Niemeyer states, as the result of 20 post-mortem examinations, Op. Cit., p. 409. † Op. Cit., p. 493. Medicin. Reform, No. 19.

the greater number of the subjects being young and strong soldiers, "that the liver on section appeared bloodless; the larger vessels contained thick and dark blood. The gall bladder was always distended, and contained mostly dark bile of variable consistence."

Leudet writes thus,-" The liver presented no change of volume, 12 times in 26 its color was very deep, the texture uniform, without the appearance of yellow granulations (yellow substance of lobules); capillary congestion was very rare. I found in one case only a little blood under Glisson's capsule. The biliary vessels were empty."

Virchow says, "The liver was but little altered; it was for the most part pale and flabby. Only the large vessels contained blood. Not rarely the volume of the organ appeared to be diminished. The parenchyma was deeply colored with bile."

Gall Bladder.

The gall bladder was usually distended with dark bile, generally viscid, but sometimes more watery than natural. In most cases, the gall ducts were not obviously affected. The mucous membrane of the gall bladder and ducts was healthy, except in some rare cases, where it was the seat of morbid changes, similar to those occurring in the intestinal mucous membrane. For example, in one case occurring under our observation, a male, æt. 41, who died in collapse, after 22 hours of acute symptoms, "the gall bladder was distended to three times the natural size. It contained four ounces of semi-transparent, slimy, pale orange-colored fluid, sp. grav. 1007, rendered turbid by boiling, and by nitric acid. It contained cylindrical epithelium, free nuclei, and blood discs. The ducts were full

of thin, colorless, mucous fluid." In the following section on the morbid appearances found in the secondary fever, it will be seen that the gall bladder and ducts were occasionally the seat of diphtheritic exudation, like that described above as occurring on the intestinal mucous membrane.

According to Briquet and Mignott, "The gall bladder was for the most part distended with a large quantity of bile, the excreting ducts being, however, always free. In one case, the lining membrane of the gall bladder was inflamed (?) and covered by a yellow purulent (?) fluid. The color of the bile was variable, its density apparently increased."

Reinhardt and Leubuscher state, that "with rare exceptions, in patients who died during the cold stage, the gall-bladder was distended • Med. Ref., No. 12. † Op. Cit., p. 410. Op. Cit., p. 493.

with bile, and by gentle pressure the contents could easily be made to flow into the intestine. The bile was in general watery and brownish, but in some cases, where the cold stage had been of long duration, it was greenish."

The kidneys were of the natural size, their surface was Kidneys. mottled by arborescent venous injection, and, on section, the same venous hyperæmia gave a dark color to the cones. The secreting structure rarely presented any obvious morbid change. In one case, that of a girl æt. 8, who died very rapidly, the whole duration of the attack not being more than nine hours, the kidneys were of a reddish brown color, and the larger vessels full of blood. On a microscopical examination, the epithelium of the tubules was for the most part normal in form, but exceedingly granular. At different points there were irregular masses, consisting of yellowish granules, and transparent oval globules (exudation cells and nuclei ?).

The contents of the pelves were mostly turbid with exfoliated epithelium and free nuclei. The mucous membrane was generally pale, but in some instances it presented patches of venous injection.

The urinary bladder was empty, or contained but a small quantity of turbid fluid like that in the pelves of the kidneys, coagulable by heat. The mucous membrane was occasionally hyperemic.

According to Reinhardt and Leubuscher*, "The kidneys had frequently, even in the first stage of the disease, undergone a change. They were not much increased in volume. The vessels, especially the veins, were slightly hyperæmic, but there was never the same extent of capillary engorgement as in the latter stages. Even in those who died in the asphyctic (algide) stage, we not rarely found portions of the secreting structure whitish or yellowish white from an exudation into the tissue. This change, as Virchow has proved,. began at the apices of the pyramids, and extended thence towards their bases. The papillæ, and a greater or smaller section of the pyramids, were compact and of a whitish color. Before the infiltration had become extensive, similar changes usually began in the cortical portion, sometimes near the surface, but more commonly at the bases of the pyramids, thus surrounding them with a layer of a grey or whitish yellow color. The exudation did not follow a continuous course from the apices of the papillæ to the periphery of the organ, but took place simultaneously in the pyramids and in the cortical Op. Cit., p. 496.

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